Phone-Based Transitional Care Pilot Sees Success in Surgical Patients

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Researchers from the University of Wisconsin devised a phone-based intervention to assist patients during the transition from hospital to home following complex abdominal surgery and reduce readmissions.

Poor transitions from hospital to home following complex abdominal surgery can cause a spike in hospital readmission rates. To address this issue, researchers from the University of Wisconsin devised a phone-based intervention to guide and assist patients during the transition period.

Under the Hospital Readmission Reduction Program, launched in 2012, CMS penalizes hospitals that have a higher readmission rate beyond a predetermined benchmark—an effort to ensure hospitals have a more active follow-up role with patients after their discharge. Previous research conducted at the University of Wisconsin demonstrated that implementing a transitional care program for hospitalized patients not only reduced readmissions, but also saved costs.

To formalize a transitional care program, the authors of the current study, led by Sharon Weber, MD, FACS, professor and chief of the division of surgical oncology, department of surgery, University of Wisconsin School of Medicine and Public Health, used the infrastructure of the original program, called the Coordinated Transitional Care (C-TraC) program, and conducted interviews to document the patient perspective on what contributes to poor care transitions.


The intervention included follow-up phone calls by trained C-TraC nurses to address medication management, clinic appointments, operation-specific concerns, and identifying symptoms that could be red-flagged. The participating patients had either had a pancreatectomy, gastrectomy, operative small bowel obstruction or perforation, ostomy, discharge with a drain, in-hospital complication, or were referred by the clinician. The first phone call was within 48 to 72 hours of discharge, with a call scheduled every 3 to 4 days after. A mutual consensus between the surgical C-TraC nurse and the patient established the completion date for the follow-up, unless the patient was readmitted.

Amy Kind, MD, PhD, coauthor on the study, said, “We clearly identified a gap in patient care during that transition between their inpatient stay and return to full health. We realized there were a lot of things we didn’t understand about factors that might lead to readmission.”

Of the 212 patients enrolled in this pilot between October 2015 and April 2016:

  • 46% had colon surgery
  • 16%, small bowel
  • 12%, pancreas
  • 9%, multivisceral
  • 4.5%, liver
  • 4.5%, retroperitoneum/soft tissue
  • 4%, gastric
  • 2%, biliary
  • 1.5%, appendix

The engagement rate, the study found, was 95%. Nearly half (47%) the patients presented with at least 1 (range, 0 to 6) medication discrepancy during the initial call, and there was an average of 3.2 calls (median, 3; range, 0 to 20) from provider to patient in this cohort.

“Patients were so unbelievably happy to have someone that they could reach directly on the phone and they didn’t have to go through a phone tree,” Weber said. “There’s something about that direct access to the healthcare system that’s immensely gratifying to patients and their caregivers. It’s not just about [emergency department] use, or cost, or readmission. It’s about whether patients feel like we are providing them with what they need.”

Identifying medication management as a prominent issue post discharge, the authors recommend additional studies to assess the impact of surgical C-TraC on healthcare use following hospital discharge.


Acher AW, Cambell-Flohr SA, Brenny-Fitzpatrick M, et al. Improving patient-centered transitional care after complex abdominal surgery [published May 23, 2017]. J Am Coll Surg. doi: