St. Rose makes a follow-up call after a patient’s doctor appointment. This makes patients accountable for going and taking notes.
We originally made follow up phone calls 1-3 days after discharge to see how patients were doing, see if they had any questions about their care, and encourage them to make an appointment with their primary care physician if they hadn’t yet. Patients seemed to appreciate those calls and often asked whether we would check in on them again. We also realized that without another follow up phone call, we didn’t know whether patients actually went to their appointments or if they got their questions answered by the doctor.
St. Rose is a non-profit hospital in Hayward, CA. It has 217 beds and serves a diverse, low-income population including Spanish, Hindi, and Tagalog speakers. Their transitions program began in 2012 and is influenced by Project RED.
What We Tried
We started making several follow-up calls at different points after discharge. On each call we asked how they were doing, what progress had been made from the last call, and if they had any questions about their care. We’ve found that the more regularly we check in with patients, the more attentive they are to their care. We know timely appointments with their PCP are critical to reducing readmissions, so we call patients beforehand to make sure they schedule their appointments, compile their list of questions for the doctor, and remember to go. We also tell patients we’ll call them back the day after the doctor’s appointment to see what the doctor said about their questions and anything else they learned about their care. This encourages patients to take notes during the appointment and makes sure that they get answers to their questions. Each patient receives at least these two calls.
These follow up phone calls have been the cornerstone of our success. Patients are much more diligent about their plan of care because they know we are watching out for them and will check in on them for regular updates. They take notes during their doctor’s appointments because they know we’ll ask them exactly what the doctor said. It’s funny because we don’t really do anything for them, we’re more like life coaches, asking them how they’re doing, encouraging them to keep working hard, and praising them for any progress they make.
For many of our elderly patients, we’re the only support network they have and they really appreciate it. Patients will even call us just to check in and let us know how they’re doing if we haven’t talked in awhile.
When patients are in the hospital we give them a simple notebook to take notes in. It’s a small gesture, but we can tell them to write questions down for their doctor in the notebook and take notes in it during their appointments. They really appreciate it.