There have been tremendous success stories of facilities following up with patients via discharge phone calls as they transition home.
However, not everyone is getting these same positive results. Why is that and what can facilities do to best position themselves for success when implementing a discharge phone call program?
1. Inform the patient. Let each patient know he or she will be receiving a follow-up phone call. It is important for patients to understand the purpose of the follow-up call is to help them as they transition home because the facility cares and is committed to their continued recovery. Knowing the facility is genuinely concerned and not simply completing an obligation will carry a lot of weight when it comes to establishing a trusting relationship. Finally, often when patients see the hospital is calling they may assume it is the billing office. When they are informed beforehand that the facility will be calling to inquire about their well-being, this will help to take away that concern.
2. Equip the caller with scripting and reporting tools. Whoever is doing the calling—a transitional care coordinator, a coach—make sure he or she asks specific questions and gathers answers in a reportable data format. This is beneficial advice even for seasoned clinicians and coaches. If you look at any nursing, case management or doctor notes regarding patient care, one knows there is great variation. For this reason, scripting and discrete data collection fields allow for consistency. Consistency builds trust in the system, trust between the individuals and trust in the data.
3. Educate the caller on listening for clues. One of the biggest advantages of having a live person as opposed to an automated caller is the ability to listen and follow up if the caller senses a patient is not being completely forthcoming in his or her response; Nurses and case managers have been taught these skills, which include framing questions in such a way as to elicit a more detailed response. For example, “I believe you had some prescriptions that you needed to fill. How did that go?” If the response is a brief “Fine” or “Okay,” the care coordinator should follow up with confirming questions to ensure the patient was, in fact, able to obtain all of his or her medications. As an example, the caller may ask, “Great, so the pharmacist had all of the medications and you were able to pick all of them up?”
4. Provide the caller with the time and resources. Transitional care coordinators and coaches need time to develop a conversation with the patient. If the call is rushed or robotic it will be ineffective and the process will be unsuccessful. Some patients will not have the energy or desire to talk for long; however, if they do not feel rushed they will leave the conversation feeling that someone sincerely cared. It is also imperative that transitional care coordinators and coaches have the community resources available to assist patients.
5. Prepare the decision-making team for innovation growing pains. The need to take care of patients once they leave the facility is a new one, meaning facilities will need to address certain questions such as who will call, how often, whether to use live or automated calls, what to do when a patient is struggling at home, who will manage that patient and other aspects of follow-up care. It can be difficult to think about all of these variables and at the same time avoid scope creep. Remember, the new program may not fix everything right away, but given time the results are typically extremely successful. This new workflow needs to be piloted to prove concept for each facility and community; it is not one size fits all. Keep in mind that the process may take time and patience, but is worth the journey.
6. Remember: it is about the patient. As a facility crafts the discharge phone call process that best serves its needs, it takes discipline to keep the focus on caring for the patient. A patient who feels cared for will be more compliant, more engaged and quicker to seek out help when in trouble.
About Nexus Health Resources:
Nexus Health Resources (http://nexushealthresources.com) is a leading provider of transitional care software, services and patient engagement for acute and post-acute care organizations facing the challenge of reducing unnecessary hospital readmissions and total medical spend. Through Nexus Health Call Center and our proprietary transitional care software platform, NexusConnexions®, we assist providers with ensuring coordinated, quality health care during the important transition period from hospital or rehabilitation facility to home in order to mitigate the risk of readmission. Additionally, Nexus Health Academy® promotes patient engagement with condition-specific health literacy for patients and care givers to assist in guiding recovery at home
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