Context and purpose: The Centers for Medicare and Medicaid Services (CMS) monitor hospital 30-day readmissions to improve healthcare quality and reduce costs. Our organization prioritizes efforts to monitor patients discharged from our hospital to prevent and manage potential complications. Registered nurses (RNs) in care management and primary care (PC) play vital roles in transition care management (TCM) to ensure patient safety across the continuum of care. PC RNs perform discharge follow-up (DCFU) calls to patients with moderate or high risk for readmission scores to ensure that patients and/or caregivers understand the discharge plan of care. Key elements of the DCFU call include medication review, education to support self-management, assisting patients and/or family to access necessary care and services, and facilitating follow-up appointments. When CMS instituted new guidelines for TCM coding in 2017, PC RNs updated DCFU workflows to incorporate requisite TCM elements. We discovered that CM discharge RNs were intermittently contacting mutual patients to assess DCFU needs. To improve patient satisfaction and reduce duplicative efforts, we collaborated with CM RNs to revise DCFU/TCM processes.

Background: In 2020, CM RNs partnered with an external vendor to utilize DCFU robocalls for all hospital discharges. With a focus on improving patient care, PC and CM RNs joined forces to enhance nurse-to-nurse communication and leverage resources. Mutual goals were to streamline our DCFU processes, optimize inpatient to outpatient care transitions, and ensure that patients’ needs were being met.

Implementation strategies: Robocalls began 48 hours post-discharge. Our CM partners agreed to move the initial call to 24 hours post-discharge to meet CMS requirements. Patient responses to robocall questions are recorded. If patients indicate they feel worse than at discharge, have questions regarding discharge instructions or medications, need home health services or medical equipment, and/or would like to speak to the care team, a CM RN calls the patient. We agreed if CM RNs identified PC patients with concerns, a direct call and handoff to a PC RN would occur via our electronic medical record communication platform.

Three PC RNs were designated to perform all DCFU calls for a 6-month pilot period. Training on access and review of robocall information was provided. A smartphrase for ease and standardization of documentation was created. PC nurses reviewed daily DCFU reports and accessed robocall logs. If patients indicated they were doing well and did not need follow-up, TCM documentation was completed. Monthly workgroup meetings were held to discuss workflow issues, review call volumes, and identify opportunities for improvement.

Learning outcomes: Patient engagement with robocall technology was impactful in streamlining DCFU efforts. Patient robocall response rates remained consistent at 88% pre-pilot and 89% post-pilot. Patient concerns requiring callback were relatively unchanged at 28% pre-pilot and 29% post-pilot. Average number of DCFU calls per day by PC RNs decreased from 15 per day pre-pilot to 4 per day post-pilot. TCM smartphrase utilization helped to reduce documentation time. Collaboration and coordination among CM and PC nurses are essential for safe transitions of care.

Mary Sue Dumas MSN, RN, AMB-BC

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