Background: Discharge from the hospital can be overwhelming for patients. Prior to May 2016, discharge phone calls were made by inpatient bedside nurses who seldom had the resources or time to resolve patient’s unmet needs. Patients/families were often referred to the outpatient clinics for assistance.
Purpose: To provide seamless connectivity to patients after discharge from the hospital using discharge phone calls, and resolve any unmet needs.
Description: Since May 2016, a centralized Clinical Advice Service (CAS) has been making discharge phone calls at our institution. Patients are called 24-48 hours after discharge. A clinical assistant initiates the call, and if a clinical need is identified, the call is escalated to a co-located nurse. We aim to identify patients unmet needs using 9 standard questions regarding discharge instructions, appointments, prescriptions, red flag symptoms, pain control, medical equipment/home health services, and provider contact information. We utilize standard work to resolve any unmet needs.
CAS is currently making discharge phone calls to patients discharged from 11 inpatient units. We have made 10,198 successful calls so far, with an average of 48 calls per day. Over 98% of the unmet needs are nonclinical, the majority being questions on discharge instructions, inability to pick up new prescriptions, or unclear on how to make a follow up appointment. An average of 7% of the patients reported an unmet need on these discharge calls.
Conclusions: A shared seamless connectivity vision, multidisciplinary ownership of the problem, and synergistic enterprise improvements have contributed to this success of CAS. The discharge phone calls has also provided an opportunity for our institution to identify the needs of our patients and barriers after discharge from the hospital.