Hospital-to-home care program that includes direct phone calls increases patient engagement

A phone-based transitional care program helped improve patient engagement post-discharge, according to study results published in the Journal of the American College of Surgeons.

Researchers at Madison-based University of Wisconsin Health implemented an adapted version of an existing transitional care program. The organization hired nurses, who then underwent a five-week training course on counseling patients in the postoperative period. The nurses met with the patients before discharge and then contacted them within 24 to 72 hours of discharge. The nurses called every three or four days. The transitional care program was deemed complete when both the nurse and patient decided there was no need for follow-up; the patient had been discharged for six weeks; or the patient was readmitted to the hospital within 30 days.

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Researchers conducted the study from October 2015 through April 2016. They included 212 patients who underwent complex abdominal procedures.

The study shows that 95 percent of patients participated in the phone-based transitional care program for at least one phone call. Among these patients, 72 percent ended the program because they agreed with their nurses that no further follow-up was necessary. Around 17 percent were readmitted within 30 days of leaving the hospital.

Additionally, the study found that 46 percent of patients weren't taking their medications correctly when nurses discussed it with them on the first phone call.

"Patients were so unbelievably happy to have someone that they could reach directly on the phone and they didn't have to go through a phone tree," said lead study author Sharon Weber, MD, professor and chief of the surgical oncology division at University of Wisconsin School of Medicine and Public Health. "There's something about that direct access to the health care system that's immensely gratifying to patients and their caregivers."

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