Keywords

discharge planning, hospital readmission, quality improvement

Authors

1. Lukanski, Amy
2. Watters, Shelley
3. Bilderback, Andrew L.
4. Buchanan, Dan
5. Hodges, Jacob C.
6. Burwell, David
7. Triola, Amy
8. Marroquin, Oscar C.
9. Martin, Susan C.
10. Zapf, Rachel L.
11. Kip, Paula L.
12. Minnier, Tami E.

Abstract

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.