Chinese hospital determined when to make follow up calls based on their readmissions data and best practices found in the literature.
We knew follow up calls were an important intervention to prevent readmissions, but didn’t have guidelines for when those calls had to be made. We decided to look at our readmissions data and conduct a literature review to determine the best times to make follow up phone calls.
Chinese Hospital is a non-profit hospital in San Francisco, CA. It has 54 beds and serves a primarily elderly (average age of 76) monolingual population with most patients speaking only Chinese. Their transitions program began in 2008 and is influenced by IHI’s Transforming care at the Bedside and the Care Transitions Program.
What We Tried
We looked at the hospital data and saw that 48 percent of our readmissions occur within the first week and 28 percent occur in 8 to 14 days. Many literatures also indicate the readmission rate is high within the first week of discharge. We believed that seeing a PCP within the first week of discharge would reduce those numbers significantly, so we scheduled the first follow up phone call for 48 hours after discharge. On the call, we check to see if they had an appointment to see their doctor and help them make one if they didn’t. We scheduled our second follow up call for 1 week after discharge to check in after their doctor’s appointment or further encourage them to make the appointment.
More of our patients are going to follow up appointments and readmissions have gone down, but it has been challenging getting appointments for patients within the first week of discharge because doctors are so busy. We have started working with our clinics to help get patients follow up appointments within the first week of discharge if patients are unable to get an appointment with their PCP and/or other specialists.
We keep reviewing our data to adjust our follow up call schedule. At first we called 72 hours after discharge, but after a few months the data revealed that we should shift to 48 hours.
We try to focus on self-care as much as possible. So rather than make appointments for patients, we teach them the language to use when speaking to their doctor’s office.