Implementing a Discharge Follow-up Phone Call Program Reduces Readmission Rates in an Integrated Health System.

ABSTRACT: In this study, we sought to determine the effect of implementing a large-scale discharge follow-up phone call program on hospital readmission rates. Previous work has shown that patients with unaddressed concerns during discharge have significantly higher rates of care complications and hospital readmissions. This study is an observational quality improvement project completed from April 17, 2020 to January 31, 2022 at 22 hospitals in a large, integrated academic health system. A nurse-led scripted discharge follow-up phone call program was implemented to contact all patients discharged from inpatient care within 72 hours of discharge. Readmission rates were tracked before and after project implementation. Over a 21-month span, 137,515 phone calls were placed, and 57.92% of patients were successfully contacted within 7 days of discharge. The 7-day readmission rate for contacted patients was 2.91% compared with 4.73% for noncontacted patients. The 30-day readmission rate for contacted patients was 11.00% compared with 12.17% for noncontacted patients. We have found that discharge follow-up phone calls targeting patients decreases risk of readmission, which improves overall patient outcomes.

Leading Nursing Excellence Through a System Magnet® Program Director Council.

American Nurses Credentialing Center Magnet® designation is prestigious to healthcare institutions. Setting the expectation for all hospitals within a system to be Magnet designated is a lofty but achievable goal. Nursing leaders at the University of Pittsburgh Medical Center set organization-wide designation as a goal in 2010. A robust system-wide Magnet Program Directors Council facilitated this effort by standardizing practices and supporting members through the journey.

Bridging the communication gap through implementation of a Patient Navigator program.

All healthcare providers working in an acute setting need to be empowered to provide an optimal patient experience with quality outcomes. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national standardized survey instrument designed to assess the patient's perspective of hospital care for public reporting purposes. These results are posted on the Center for Medicare and Medicaid Services (CMS) website for consumers to access comparison data related to a hospital's performance, create new incentives for hospitals to improve quality outcomes and enhance accountability through transparency (1). HCAHPS has 10 measures that evaluate the patient's recent hospital experience. Six of these are summary measures. One key measure, "communication with nurses," can directly affect both the patient satisfaction and patient safety scores (2). Patients tend to rate this domain based on the caregivers, and this rating can have a financial impact upon the institution. The skills and art associated with service are neither innate nor automatic. Communication skills are acquired and refined only through practice. The Magnet recognition program was developed to recognize health care organizations that provide nursing excellence and a vehicle for disseminating successful nursing practices and strategies (3). To assist the nurse in the patient's perception to care, a Patient Navigator program was developed to provide patients with the best possible hospital experience. The Patient Navigator program compliments the direct patient care that is provided on the patient care unit. HCAHPS is a national standardized survey instrument designed to assess the patients' perspective of hospital care for public reporting purposes. There are a total of 27 survey items that are divided into six composite measures, two individual items and two global ratings. The six summary measures and two global ratings are listed below.

Shared leadership: taking flight.

Nursing leaders are continually seeking ways to improve the work environment in their organizations. Instituting a shared leadership model supports a journey to promote a culture of nursing excellence. The author reviews key principles and how these principles were used as catalysts for change. Creation and implementation of the shared leadership model at the medical center have resulted in decreased nursing turnover, higher patient satisfaction scores, and enhanced patient outcomes.