In order to provide better support, a research team at University of Wisconsin School of Medicine and Public Health, Madison used the framework of a successful phone-based transitional care programme that was adapted to the needs of surgical patients.
The researchers found the programme was feasible for hospital staff to implement and provided a positive experience for patients, as reported in a paper in the Journal of the American College of Surgeons.
In the US attention has been focussed on the issue of re-admissions since 2012, when the Centers for Medicare & Medicaid Services (CMS) began reducing payments to hospitals with excessive hospital readmissions under the Hospital Readmissions Reduction Programme. That prompted health care systems to study the impact of transitional care programmes.
Doctors at William S Middleton Memorial Veterans Hospital, Madison, previously demonstrated transitional care programmes led to a reduction in re-admissions and cost savings. However, no evidence-based transitional care programme existed for surgical patients, according to lead study author Sharon Weber, chief of the division of surgical oncology, department of surgery, University of Wisconsin School of Medicine and Public Health.
Weber and her team relied on the original programme along with insights from interviews with patients about what contributes to poor care transitions. Patients mentioned factors including inadequate education, hurried discharge, failure to retain pertinent recovery information, and unclear plans for follow-up care.
“We clearly identified a gap in patient care during that transition between their inpatient stay and return to full health,” Weber said. “We realised there were a lot of things we didn't understand about factors that might lead to readmission.”
To implement the adapted surgical programme, University of Wisconsin Hospital hired new nurses who underwent a five-week intensive training that prepared them to counsel patients on postoperative recovery. The nurses met the patients before they were discharged from the hospital. The pilot study ran from October 2015 - April 2016, and included 212 patients.
After they were discharged from the hospital, nurses contacted patients within 24-72 hours and then initiated phone calls every three to four days as needed until the patient and/or caregiver and the nurse mutually agreed no further follow-up was needed, the patient had been discharged for six weeks, or the patient was readmitted to the hospital within 30 days after discharge.
Ninety-five percent of patients participated in the post discharge protocol for at least one phone call, of which 72 per cent ended the programme after mutual agreement that no further follow-up was necessary. A small percentage refused further follow-up or were readmitted to the hospital. Of all 212 patients, 17 percent were readmitted within 30 days of discharge.
Researchers also found that 46 percent of patients were not taking medications correctly on the first phone call. The researchers says this is concerning because it is the hospital’s routine practice to have a pharmacist-led medication reconciliation before the patient leaves the hospital. “It reiterates that what we are providing at discharge in a routine way is not enough to meet patients’ needs,” Weber said.
The phone-based programme allowed for an increase in the scale and breadth of follow-up care with minimal increase in staffing. A multi-centre randomised controlled trial in the future will assess the impact of the programme on post-discharge health care utilisation.
Weber said the interviews with patients were particularly important in conducting this study. “It’s not just about ER use, or cost, or readmission. It’s about whether patients feel like we are providing them with what they need.”
Improving Patient-Centered Transitional Care Following Complex Abdominal Surgery. Journal of the American College of Surgeons. http://www.journalacs.org/article/S1072-7515(17)30374-5/fulltext
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