Postdischarge Telephone Calls by Hospitalists as a Transitional Care Strategy
Sarah A. Stella, MD; Angela Keniston, MSPH; Maria G. Frank, MD; Dan Heppe, MD; Katarzyna Mastalerz, MD; Jason Lones, BA; David Brody, MD; Richard K. Albert, MD; and Marisha Burden, MD
The period immediately following hospital discharge has been identified as a major patient-safety gap in which misunderstandings and medical errors frequently occur.1-3 Approximately 20% to 30% of medical patients experience an adverse event after discharge, resulting in a variety of suboptimal outcomes.4,5 The majority of these adverse events may be preventable, but they frequently occur early with respect to discharge and prior to patients being seen in the outpatient setting.4-8 Thus, managed care organizations are seeking feasible strategies to bridge this important safety gap.
Although telephone calls to patients following hospital discharge have garnered interest as a way to assist them with a variety of issues related to their hospitalization, the results of studies examining the effectiveness of such calls have been mixed.9-16 Very few of these studies have described calls made by the physicians who treated the patients during their hospitalization11,12 and, to our knowledge, none have described such calls to adult patients by treating hospitalists. We theorized that hospitalists may be well-positioned to recognize and assist their patients with problems and concerns arising shortly after discharge. Accordingly, we studied whether the same hospitalist who cared for the patient during their hospitalization could effectively identify and efficiently address early postdischarge problems through a structured telephone call.
METHODS Study Design and Setting
We conducted a prospective cohort study of patients who were discharged from a general internal medicine service by one of 19 participating hospitalists at Denver Health Medical Center, a 525 bed university-affiliated, urban public safety net hospital, between March 1, 2012, and October 31, 2013. We included English- or Spanish-speaking patients aged 18 to 89 years who were insured by Denver Health’s own managed care organization. We excluded patients who lacked telephone access, those with a physical or cognitive impairment precluding their participation in a telephone encounter, those who were incarcerated, known to be pregnant, and those discharged to a skilled nursing facility or hospice. The study was reviewed and approved by the Colorado Multiple Institutional Review Board with a waiver of consent.
Participating hospitalists assessed patients for eligibility and verified their telephone number prior to discharge on selected study days. Study days were selected such that the hospitalist knew they would be available to make the telephone calls 48 to 72 hours after discharge. Beginning at 48 hours post discharge, the hospitalists attempted to contact eligible patients by telephone. They were instructed to make 2 attempts to reach each patient, beginning at approximately 48 hours after discharge and making a final attempt at approximately 72 hours. Hospitalists either spoke with the patient directly or with a proxy selected by the patient. Telephone interpreters were utilized for Spanish-speaking patients.
A structured assessment based on key components of Project Reengineered Discharge17 was utilized by the hospitalist during the postdischarge calls (eAppendix, available at www.ajmc.com). Questions were organized within specific domains and prompts were used to encourage providers to perform “teach-back” at key intervals.18 Hospitalists also had access to the patients’ electronic health record (EHR), including information pertaining to their hospitalization, discharge instructions, and medication list. If the hospitalist determined that additional services were needed beyond what they could provide, then an electronic referral was sent to the Department of Managed Care at Denver Health Medical Center for resolution.
Within 2 weeks of the hospitalist call, patient navigators employed by the Department of Managed Care attempted to contact each patient who had received a hospitalist postdischarge call in order to evaluate their perceptions regarding the utility of the call and to determine whether the problem addressed in the initial call had been adequately resolved.
We collected demographic and clinical data from our EHR and assessed the following variables: a) the category and frequency of problems identified in the postdischarge call; b) the severity of the most significant problem, as perceived by the hospitalist, using a 100-point visual analog scale (with 1 representing the least serious problem and 100 representing the most serious); c) the proportion of calls in which a problem was identified that were independently addressed by the hospitalist; d) the proportion of calls for which additional managed care services were requested; e) the proportion of calls resulting in a recommendation to seek urgent/emergent care; f) the time spent by the physician on the call and any subsequent care coordination; g) each hospitalist’s a priori assessment of the likelihood that each patient would have postdischarge problems identified in the call (assessed at hospital discharge using the previously mentioned visual analog scale); h) the types of managed care interventions requested; i) patients’ perceptions regarding the usefulness of the call; and j) the navigators’ determination of whether the problem(s) identified by the hospitalist had been adequately resolved.
Data Collection and Statistics
REDCap, a secure Web-based application, was used to collect and manage all study data19; analyses were performed using SAS Enterprise Guide version 5.1 (SAS Institute, Inc, Cary, North Carolina). A Student’s t test or Wilcoxon Rank Sum test was used to compare continuous variables depending on the results of normality tests. Chi-square tests were used to compare categorical variables; P <.05 was considered to be statistically significant. We constructed a receiver operating characteristic (ROC) curve to evaluate the accuracy of the physician assessments in predicting postdischarge problems.
We assessed 200 hospitalized patients for eligibility, and 27 were excluded (Figure). Of the 173 eligible patients, 131 (76%) received a call from their treating hospitalist and agreed to participate in the survey. Assessments were completed on all 131 patients who received a call. We found no significant differences between any of the variables listed in the Table for patients who were successfully contacted versus those who were not.
A total of 107 problems were identified in 74 of the 131 patients (56%). A single problem was identified in two-thirds of patients while the remaining one-third had multiple problems identified. Forty-eight of these 74 patients (65%) initially denied having had any problems following discharge, but problems were subsequently discovered as a result of further questioning by the treating hospitalist using the structured survey.
Forty-one percent (44 of 107) of the problems identified were: new or worsening symptoms. The next most common categories were: difficulties obtaining follow-up appointments (23 of 107; 21%), medication issues (21 of 107; 20%), and problems understanding or executing discharge instructions (9 of 107; 8%). The remainder of the problems were related to home care services (5 of 107; 5%) and the capacity for self-care (5 of 107; 5%). Physician assessment regarding the severity of what they considered to be the most significant problem identified during the call was a median of 49 points (95% CI, 25-69) on a 100-point visual analog scale.
We found no statistically significant differences for any of the demographic or clinical variables assessed for patients in whom a problem was identified versus those in whom no problem was identified (Table). The hospitalist assessment at hospital discharge, regarding the likelihood of a patient subsequently experiencing problems, was a mean score of 67 of 100 (95% CI, 50-76) when a problem was reported versus a mean score of 49 of 100 (95% CI, 28-67) when a problem was not reported (both P = .002). However, the ROC curve depicting the accuracy of hospitalist assessment in predicting postdischarge problems had an area under the curve (ie, C statistic) of only 0.66.
Hospitalists were able to independently address the problems identified in the majority of calls (50 of 74; 68%), while the problems identified in 24 of 74 calls (32%) required referral to the Managed Care Department. The most common managed care services requested were: a nurse follow-up call (15%), transportation assistance (9%), and health coaching (8%). Eight patients—representing 11% of those in whom problems were identified—were referred to the emergency department (ED) or the urgent care clinic for evaluation as a result of the problem identified in the call.
Hospitalists spent a median of 8 minutes per call (interquartile range [IQR], 5-12) and a median of 10 minutes per case, including any subsequent care coordination (IQR, 6-16). Median time spent per call and per case when a problem was identified was 10.5 minutes (IQR, 7-16) and 13 minutes (IQR, 9-22) versus 6 minutes (IQR, 4-8) and 7 minutes (IQR, 5-10) when no problems were identified, respectively (both P <.001).
Eighty-four patients (64% of the patients who received a hospitalist call) were contacted by a patient navigator within 2 weeks and completed an additional survey. Of these, 77 (92%) believed the hospitalist call was “helpful” and 47 (56%) had problems discovered in the original call. Of the 47, 39 (83%) reported that they had “received the help necessary to resolve the problem(s) discussed” in the initial call. Navigators believed that the problem had been adequately resolved in 43 of 47 cases (91%).
Patients who received a hospitalist postdischarge call were less likely to be rehospitalized for inpatient or observation stays within 30 days (19 of 131; 15%) than those who were not able to be contacted (12 of 42; 29%) (P <.05). Patients who had problems identified in the call were more likely to have an ED or urgent care visit within 30 days of discharge (15 of 74; 20%) than those who did not (4 of 57; 7%) (P <.05).
Telephone contact with patients after discharge has been proposed as a way to address problems occurring in this period, but a large systematic review examining studies of postdischarge calls by a variety of healthcare providers found there was insufficient evidence to conclude that this intervention was effective.9 The results of several more recent studies have also been mixed.10-16 Most of these studies utilized nurses and pharmacists as callers. We know of only 1 other study describing postdischarge calls by treating hospitalists and it was performed in a pediatric population.12
Our study of postdischarge telephone calls by treating hospitalists revealed several important findings. First, hospitalists discovered problems in over half of the patients they contacted between 48 and 72 hours after discharge, and new or worsening symptoms accounted for the largest proportion of these problems. Second, hospitalists could not reliably predict which patients were likely to encounter problems. Third, the majority of problems identified were addressed by the treating hospitalist through the single, brief telephone encounter.
Many of the problems we identified were not trivial, and 11% of the patients in whom problems were discovered were referred to the ED or urgent care clinic as a result. The spectrum of problems we discovered is similar to previous studies; however, we identified a larger burden of new or worsening symptoms than in some previous studies describing calls by primary care nurses and unlicensed call center representatives surveying medical patients within a similar time frame.15,20 Although the reason for this difference unclear, it is possible that patients may be more comfortable discussing symptoms with their treating physicians or, conversely, that physicians are better at eliciting such symptoms compared with other types of providers, either because they are physicians and/or because they treated the patients during their hospitalization.
We had theorized that treating hospitalists might be able to accurately predict which patients were likely to experience problems following discharge, but our data did not confirm this supposition. Our results indicate that hospitalists’ predictions are marginally better than chance. However, we found that treating hospitalists were able to independently address the majority of problems they identified during the call without requiring additional managed care resources. Moreover, they were able to do so relatively efficiently (eg, median = 10 minutes per case), perhaps because the treating hospitalist was familiar with the patient and had firsthand knowledge of the discharge plan.
The frequency with which postdischarge problems occur, together with the fact that they are difficult for physicians to predict and often initially unrecognized by patients, suggests that early telephone contact with a healthcare provider after hospital discharge should be considered as a routine practice. Given the relatively high burden of new or worsening symptoms signaling possible deterioration in a patient’s condition, we would also suggest that the provider making the calls should possess the clinical acumen necessary to quickly and effectively evaluate such complaints. Although some of the problems we discovered could likely have been dealt with by allied healthcare providers, many were seemingly addressed more directly and efficiently because of the treating hospitalists’ implicit knowledge of the patient gained during their hospitalization.
Limitations and Strengths
Our study has several limitations. First, it was performed in a single university-affiliated public safety net hospital, such that the results might not be generalizable to other types of institutions and/or other patient populations. Second, because we studied patients who were insured through a managed care program, our patients may have had more resources available to them than would be typical of many patients cared for at a safety net hospital. Third, we did not design our study to compare the effectiveness of postdischarge calls by hospitalists with calls made by other types of healthcare providers or with no intervention, such that we cannot conclude that calls by hospitalists are superior to other strategies. Fourth, although fewer patients who received a hospitalist call were rehospitalized, this result may have been influenced by factors unrelated to the call (eg, patients may have been rehospitalized at the time of the call). Lastly, because our study is not a randomized controlled trial, the results may be confounded by unmeasured differences, such as variable health literacy or self-investment.
Our study also has a number of strengths. First, to our knowledge, it is the first study describing postdischarge telephone follow-up of adult patients by treating hospitalists. Second, we utilized a structured survey that included a “teach-back” style of interaction in order to facilitate patient learning and retention of information, and this may have aided our ability to detect and address patients’ problems. Third, we utilized a second call to evaluate patients’ perspectives regarding the usefulness of the call made by the hospitalists.
Our strategy represents a feasible method of detecting and alleviating early postdischarge problems, which, if unaddressed, may result in poor outcomes. Managed care organizations might consider partnering with hospitalists to enhance the postdischarge safety of their members. To determine whether our approach results in better outcomes than what can be achieved by calls from providers not involved in the care of the patients during their hospitalization would require a prospective randomized trial. Given the potential for improved outcomes, the results of such a trial could substantially alter the customary approach to patient care after discharge.