P092

Digital Post-Discharge Outreach: A Value-Driven, Accessible Approach to Improving Care Transitions


Purpose: The purpose of instituting a digitized post-discharge outreach is to create a more efficient, consistent, patient-centric, and data-driven approach to care transitions. This transformative initiative addresses the critical aspects of post-discharge care, improves accessibility to a broader population, and captures valuable data to assess patient outcomes.

Description: Post-discharge outreach plays a crucial role in ensuring seamless care transitions, enhancing medication adherence, and providing early detection of medical complications after hospitalization. It empowers patients and caregivers by offering education and support, instilling confidence for self-managed care, and fostering trust in care teams. Additionally, it serves as a valuable data source for quality improvement and value-based care initiatives. In 2015, Stanford Health Care (SHC) introduced a centralized tele-triage call center, clinical advice services (CAS), aimed at enhancing patient connectivity and improving transitions of care. One of CAS’s core services includes outreach calls within 72 hours of discharge from the hospital or ED or following outpatient procedures. Patients are asked 9 questions related to their discharge instructions, pain control, follow-up appointments, home health services, and prescriptions. The initial call is handled by a non-licensed administrative specialist who escalates to a co-located registered nurse (RN) if clinical needs are identified. Standard work is utilized to resolve unmet needs.

Evaluation/outcome: From June 1, 2021, to July 30, 2022, SHC had 34,377 discharge encounters. Of these, 25,872 patients met the criteria for receiving a post-discharge call. Of the 25,872 patients, 10,943 were successfully reached by CAS within 24 hours of hospital discharge. While the calls helped identify patient needs, an analysis of the 10,943 patients found several opportunities for improvement. First, data revealed a reach rate of 42.3%, suggesting that not all patients were reachable by phone, potentially leaving gaps in follow-up care. Second, over half of the patients had an unmet need related to medications (19.6%), follow-up appointments (28.2%), or new/worsening symptoms (12.2%). Lastly, the existing process had no significant impact on reducing 30-day hospital readmissions.

To address these gaps, CAS initiated several enhancements to the post-discharge outreach process. First, CAS implemented a digital questionnaire focused on analysis’s top unmet needs: worsening symptoms, medications, and timely follow up with a healthcare provider. The digital questionnaire was launched on MyHealth, ensuring an accessible and user-friendly experience for patients and creating streamlined data collection for value-based care teams. The change from a manual phone call to an automated and interactive digital interface expands access to virtual points of care. In addition, the outreach exclusion criteria were updated to ensure CAS reached a broader and more representative pool of discharged patients in the community. The questionnaire engages with patients at risk for readmission by sending multiple touchpoints at 24 hours, 72 hours, 1 week, 2 weeks, and 3 weeks after discharge.

Conclusion: CAS plays a central role in ensuring seamless transitions from the hospital to home. The post-discharge outreach redesign reflects CAS’s commitment to providing exceptional patient care, furthering digital health efforts, and improving patient outcomes in a way that sets SHC apart in the healthcare industry.

Speaker

Speaker Image for Joan Slagle
Joan Slagle, DNP, RN, CNL

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