Thanks to the Affordable Care Act and recent CMS pilot programs, healthcare is changing.
Quite a bit, actually.
Incentives have been placed on hospitals to move away from current fee-for-service and volume-based measures and adopt new care models that pay for quality care, not quantity.
To address this new reality, hospitals are realizing that the path to financial security lies in serving patients across the entire care continuum.
In short, hospitals are now coordinating patient care as they transition between healthcare practitioners and settings. To do this, many hospitals are looking to have registered nurses or other healthcare professionals connect with patients promptly after discharge via the telephone.
But before you start making calls, there are a few things to think through first.
Why are you making these calls?
Seems like a pretty obvious question, right? Well, frankly, it is.
But just because it's obvious, it doesn't mean it will be easy to answer. In fact, this is probably the most important question you'll need to ask yourself. The answer(s) you come up with will effectively drive your entire post discharge follow up strategy.
There are many potential answers as to why you would make follow up calls.
Some examples include*:
- Avoiding CMS financial penalties by reducing readmission rates for AMI, CHF, and Pneumonia.
- Identifying and fixing service issues that negatively impact your HCAHPS scores.
- Driving appropriate use of Emergency Services.
- Achieving NCQA Accreditation as a Medical Home and/or Accountable Care Organization.
Each of these goals will require your post discharge calling program to accomplish specific tasks and integrate with various healthcare systems, settings, and practitioners. By clearly stating why you are making these calls, you will be able to design and implement an effective follow up program.
(*These are not mutually exclusive – effective transitional care strategies focus on all of these objectives)
How will you measure success?
This is where being as specific as possible when answering question #1 really pays off.
To be successful, you need to constantly refine your program. And to do that, you need to know whether or not you are a.) achieving your program goals, and b.) which specific post discharge calling tactics have been the most effective in doing this.
And don't be scared to admit that success will be – in some respects – a moving target.
Your patient population is unique, and so is your health system. What works for some institutions may not work as well for you. As you begin connecting with patients after discharge, you'll learn a lot about how your program should operate and (I hope) start making adjustments as needed. As your program evolves, you need to make sure that your success benchmarks evolve with it.
Will you customize the outreach process for different patients?
It's all about patient-centered care, right?
It's pretty hard to be patient-centered when you're using the same outreach process for every patient regardless of demographics, current health status, or reason for admission.
Post discharge calling is most effective when used as a focal point for orchestrating necessary follow up care activities for the patient. And to do this, your interactions need to be customized for each patient. Depending on the sophistication of your operations team, this can include:
- Using custom calling scripts for different acute and chronic conditions.
- Medication reconciliation.
- Clinical or administrative escalation.
- Additional follow up determined by behavior based scoring.
Without customized interactions, you're going to have a hard time guiding patients to the right level of care, at the right time, and to the right place.
What actions will you take when issues are uncovered?
Your goal should be to resolve any and all health and service barriers identified during the follow up call.
Many of these issues can be addressed by the RN or discharge advocate who is making the call, but there will be times when other departments will need to take action in a timely way.
This means your post discharge calling program will need to be able to notify others within your healthcare system that a service or health barrier has been identified and action is required. Generally speaking, this can be accomplished by sending a secure text, email, paging, or fax alert as issues are uncovered during the post discharge call.
It should be noted that timely notifications are only the first step – you need to make sure that the resources you alert are capable of responding and resolving these issues as they arise.
Who's going to make these calls?
The last thing you want to do is to cannibalize other departments by pulling RNs away from their inpatient duties to make discharge calls. At best you run the risk of negatively impacting the patient experience (and your HCAHPS scores), at worst you put the patient's safety at risk by spreading your nursing staff too thin.
Not to mention the fact that discharge calling requires a certain skill set and specialized training to be successful. It's a better idea to utilize a dedicated team who can focus on connecting with patients within 24 hours of discharge and provide the support they need to recover successfully.
Key takeaway: While timely follow-up is critical, that alone isn't enough. To be effective, you need a care team that can connect, evaluate, and escalate patients to the appropriate care and/or administrative resources.