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.

Telemedicine consultations: an alternative model to increase access to diabetes specialist care in underserved rural communities.

BACKGROUND: Diabetes care in rural communities often suffers because of physician shortages. When patients need to see an endocrinologist, long-distance travel to urban centers can constitute a barrier to care. OBJECTIVE: To address this problem, we tested whether diabetes telemedicine consultations would be acceptable to rural patients and their primary care providers as an alternative care model. METHODS: Twenty-five patients with diabetes in a rural, medically underserved community received glycemic management recommendations via videoconferencing-based teleconsultation with an endocrinologist at an urban center. At the rural site, a nurse trained in diabetes care assisted with the visits. Outcomes measured were patient and primary care provider satisfaction (measured by structured questionnaires) and glycosylated hemoglobin (HbA1c) levels. RESULTS: Patients and providers uniformly reported high levels of satisfaction and acceptability. Mean HbA1c decreased from 9.6% to 8.5% (P < .001). CONCLUSIONS: Teleconsultations are well accepted by users (patients and primary care physicians) and glycemic control seems to improve in patients with diabetes. This new model of care could potentially expand access to specialist care in isolated rural communities.