Project BOOST 72-hour Telephone Follow-Up

Literature Review

Amit Patel, MD, FACP, SFHMChithra Perumalswami, MD

Objectives

• Your team will better understand:– The literature behind the follow-up phone call

process (benefits, greater context, etc.)– Who should make the calls.– What means of communication have been

studied.– Which diseases have been studied in this

context.

2

Benefits

What is the value of calls?

• Patients’ benefits: – Clarify any misunderstandings in the care

plan.– Reminders to adhere to follow-up plans and

treatment.– The ability to learn of labs which returned

after discharge.

4Nelson JR; American Journal of Medicine, 2001;111(9B):43S–44S.

• Hospital’s benefits:– Learn from patient and family/caregivers

about unexpected outcomes.– Early detection of treatment failures.– Re-establish/Reinforce patient-physician

relationship.– Learn whether patient complied with

outpatient services, home nursing visits, etc.– Learn whether patient complied with

discharge instructions, bought Rxs, etc.5

What is the value of calls?

Nelson JR; American Journal of Medicine, 2001;111(9B):43S–44S.

Potential Value of Calls

• A VA-funded study of psychiatric patients found that those receiving post-discharge calls were twice as likely to make their first follow-up appointment (88% vs. 43%.)

• There was a trend for increased function and less violence for those patients also.

• This suggests adherence to follow-up appointments can be improved by follow-up phone calls.

6Rosen CS, DiLandro C, Corwin KN, Drescher KD, Cooney JH, Gusman F. Community Mental Health Journal. 2006 Oct;42(5):501-8.

Who benefits?

• A Medicare Advantage Plan used a for-profit company to conduct RN-led phone calls to all of its members to determine if this would reduce readmissions.

• There was a 23% reduction in readmissions among members who received calls vs. those who did not (1.3 times more likely to be readmitted.)

• Caveat: The for-profit company prepared the manuscript and retrospective design. 7

Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. Population Health Management. 2011 Feb;14(1):27-32. Epub 2010 Nov 19.

Benefits of Telephone Calls

• Braun et al performed randomized evaluations of telephone follow-up in Haifa, Israel.

• They found improved medication and therapy compliance, along with improved patient satisfaction with the hospital and discharge.

• No change in 1-month readmissions and trend towards improved 3-month readmissions.

8Braun E, Baidusi A, Alroy G, Azzam ZS. European Journal of Internal Medicine. 2009 Mar;20(2):221-5.

Greater Context

• Balaban et al studied an intervention similar to the BOOST program at Somerville Hospital in Massachusetts.

• The intervention included:– Comprehensive Patient-Friendly Discharge Form.– Transfer of the form to the primary care RNs.– Telephone contact by a primary care RN after

discharge.– Confirmed PCP review and modification of the form.

9Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.

• The team studied readmissions, ER visits, incomplete outpatient follow-up appointments, and incomplete recommended outpatient workup.

• It was a single-center study conducted in a safety-net community teaching hospital with a culturally-diverse and linguistically-diverse patient population.

10

Greater Context

Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.

Greater Context

• Balaban et al reported the intervention group was ½ as likely to experience one of the adverse outcomes being studied vs. the controls.

• Similar or greater differences were found for many of the other categories as well.

• There was a trend towards improved weekend discharge follow-up and a benefit for patients over age 60.

11Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.

Greater Context

• Lawlor et al studied the use of a comprehensive COPD out-reach intervention in a large inner-city population including self-education, RN/PT home visits, and telephone follow-up in an early discharge intervention.

• They found reduced ED visits and readmissions at 6 months and 1 year.

Package deals are better!12

Lawlor M, Kealy S, Agnew M, Korn B, Quinn J, Cassidy C, Silke B, O'Connell F, O'Donnell R.. International Journal of COPD. 2009; 55-60.

Why use the telephone?

Telephone Use

• Deiker et al reported that the use of a “liberal” telephone policy during and after treatment lead to:– Significantly reduced readmissions (11% vs.

36% for experimental vs. control)– The population was a psychiatric state

hospital population. – Patients and family members had access to

call staff both during the stay and after.– This study was conducted in 1973.

Deiker TE, Villemarette TJ; Hospital and Community Psychiatry. 1973 Feb;24(2):7114

E-mail vs. Telephone

• The University of Pennsylvania conducted a large study of e-mail follow-up in comparison to telephone follow-up for patients discharged from the ED.

• Telephone use was 82% more likely to reach the patient compared to e-mail.

15Ezenkwele UA, Sites FD, Shofer FS, Pritchett EN, Hollander JE; Journal of Emergency Medicine. 2003 Feb;24(2):125-30.

Videoconferencing vs. Telephone

• A study performed by cardiothoracic care providers compared structured regular video conferencing with telephone use in a pediatric congenital heart disease population.

• Videoconferencing was preferred by providers and families by a wide margin, but costs were an issue.

• There were safety benefits to videoconferencing.16

Morgan GJ, Craig B, Grant B, Sands A, Doherty N, Casey F.. Congenital Heart Disease. 2008 Sep-Oct;3(5):317-24.

Text messaging

• A small (N=45) study from the Czech Republic found the use of surveys sent to patients and family members that were returned by text messaging could be directed to interventions by health care providers.

• The patients were found to have reduced admissions to the hospital in a psychiatric population.

17Spaniel F. et al. Schizophrenia Research. 2008; 312-317.

Who should make the calls?

Nurse-Lead Telephone Calls

• Riley reported in 1989 about a nurse-led call-back program which was structured to perform calls within 24 hours.

• Structured training/guidelines, structured documentation, and structured research using the information.

• This intervention improved patient satisfaction, improved care processes, and improved discharge planning.

19Riley, J.; Nursing Management.1989; vol. 20 No 9 ; 64-66.

Nurse-lead Telephone Calls

• Memorial Hermann Health System conducted a retrospective analysis of a single follow-up call from the nursing unit vs. no receipt of a phone call by patients.

• Those patients who received calls were more likely to return post-discharge surveys by mail and …

• If the patient had a follow-up appointment already made, there was a statistically significant reduction in readmissions. (p=0.04)

20D'Amore J, Murray J, Powers H, Johnson C. Population Health Management. 2011 Oct;14(5):249-55.

Safety of Follow-Up Calls

• A study from Western Canada evaluated the role of 24 hour follow-up calls in safely evaluating patients after ambulatory surgery.

• Patients had no adverse events and were not readmitted. They also reported higher satisfaction than patients who received a nurse visit within 24 hours.

21Fallis WM, Scurrah D. Canadian Journal of Surgery. 2001 Feb;44(1):39-44.

Costs and Staffing

• A quality improvement project at the NHS Birmingham Heartlands Hospital showed how to build the program for nursing to conduct the follow-up phone calls.

• The program was successful in maintaining or reducing costs associated with making those calls.

• They did not measure readmissions or ER visits.

22Lee L; British Journal of Nursing. 2004 Apr 8-21;13(7):412-21

Pharmacists

• Dudas et al found that using pharmacists to perform follow-up phone calls statistically reduced ER visits after discharge.

• There was a trend toward reduced readmissions but limited by small sample size.

• Calls took 30 minutes on average and was unsustainable for the pharmacists’ work-load. 23

Dudas V, Bookwalter T, Kerr KM, Pantilat SZ; Disease-a-Month. 2002; 48: 239-248

Outsourcing

• A lay article in Healthcare Benchmarks and Quality Improvement described a hospital in California “outsourcing” its follow-up calls and “Ask-a-Nurse” line to a Texas-based company with access to its EMR.

• Only 2% of calls were escalated back to the RNs in California.

• Consider the cost-benefit analysis of using your RNs vs “outsourcing” the calls.

24Healthcare Benchmarks and Quality Improvement. 2010 Oct;17(10):114-6.

Diseases which benefit from calls

CHF Follow-Up

• CHF readmissions are a great burden to hospitals and the health care system overall; CMMS has placed special focus on this condition as well.

• Harper University Hospital in Detroit showed that dedicated staff just for outpatient calls as part of a comprehensive care program reduced readmissions by 50%.

26Telephonic Program Cuts CHF Readmissions in Half. Hospital Case Management Newletter; Sept 1 2004

CHF Follow-Up

• Jerant et al showed that telephone follow-up was equivalent to home telecare device follow-up.

• This was a small sample size study (N=37) that showed reduced CHF-related costs/readmissions but not reduced all-cause costs/readmissions.

• There was no statistical difference between telecare and telephone follow-up.

27Jerant AF, Azari R, Nesbitt TS.. Medical Care. 2001 Nov;39(11):1234-45.

CHF Follow-up

• Brandon et al studied the effect of a single nurse practitioner (working with one cardiologist) performing follow-up calls in a rural eastern Alabama CHF population.

• Consistency, education, and learning lead to reduced HF-related readmissions, improved QOL, and self-care.

28Brandon AF, Schuessler JB, Ellison KJ, Lazenby RB.. Applied Nursing Research. 2009 Nov;22(4):e1-7.

CHF Follow-up

• A large non-concurrent prospective study of Chinese patients with CHF using a targeted home-based intervention emphasizing 48-72 hour follow-up phone calls and recurring biweekly phone calls lead by nurses found:– Reduced all-cause readmits, HF-related

readmits, length-of-stay, and costs!!

29Chen YH, Ho YL, Huang HC, Wu HW, Lee CY, Hsu TP, Cheng CL, Chen MF. The Journal of International Medical Research. 2010 Jan-Feb; 38: 242-252.

Gynecologic Follow-Up

• Caljouw et al studied structured telephone advice following discharge for gynecologic surgery patients targeting common post-op considerations.

• They found improved patient satisfaction with the follow-up.

• Medical conditions such as COPD, CHF, AMI, and Pneumonia may not be the only ones to benefit from telephone follow-up.

30Caljouw, MA, Hogendorf-Burgers, ME. Journal of Clinical Nursing. 2010; 19 (23-24):3301-3306

Other Populations

• Numerous studies conducted calls on specific populations of patients:– COPD patients– High-risk patients (prior hospitalizations)– Psychiatry patients– General medical service patients– Pediatric populations

31

Barriers and Caveats

What NOT to do: Unstructured

• Hodgins et al studied the effect of a 48 to 72 hour follow-up call performed by nurses for orthopedic surgery patients discharged from a Canadian hospital.

• The calls were added to the nurses regular work, there was no description of training or structured topics of discussion, and most calls were conducted within 24 hours of discharge.

• No significant effect on post-discharge outcomes.

33Hodgins MJ, Ouellet LL, Pond S, Knorr S, Geldart G. Applied Nursing Research. 2008; 218-226.

Calls do NOT reduce anxiety

• Roebuck conducted a study to determine whether telephone call-backs reduce patient anxiety after discharge from cardiothoracic surgery.

• There was no statistical difference in measures of anxiety and depression between those who received calls and those who did not.

• Single center, cardiothoracic surgery patients. 34

Roebuck A. Intensive Critical Care Nursing. 1999 Jun;15(3):142-6.

Barriers

• A large CDC-sponsored study showed a trend for increased re-hospitalizations amongst patients in Pennsylvania who received follow-up calls and were at higher readmission risk.

• The authors found that RNs reported increased collaboration/communication barriers with physicians as a deterrent to using guidelines in the calls.

35Bowles KH, Holland DE, Horowitz DA. The Journal of Telemedicine and Telecare. 2009; 157 (7) 344-350.

Caveats

• Rigorously structured analysis of the literature finds the following:– Highly variable studies– Poorly-designed or conducted studies– Variable outcomes reported– Small sample sizes– Increased heterogeneity

36

Mistiaen P, Poot E. Cochrane Database of Systematic Reviews 2006, Issue 4. Updated in 2008, Issue 3.Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Annals of Internal Medicine, 2011;155:520-528.

…One Last Thing

Verify Call Number

• Thibodeau et al conducted a study on verification of the call-back number.

• There was a significant difference between patients with HMO coverage (90%) vs Self-Pay (<75%) in success of call-backs after verification of the phone number.

• Simply ask: “What number can we reach you at to discuss lab or x-ray results?”

38Thibodeau LG, Chan L, Reilly KM, Reyes VM; Annals of Emergency Medicine. 2000 Jun;35(6):564-7.