Follow-up Vigilance Improves Discharge Experience

Follow-up Vigilance Improves Discharge Experience
Text messaging and other forms of communication are among tools used in the ongoing effort to reduce readmission rates.

Vanderbilt University Medical Center discharges more than 40,000 patients annually from its adult hospital. To ensure that as many as possible have a safe and high-quality experience, Vanderbilt Discharge and Transitions (VDAT) works strategically to optimize discharge and post-discharge care.

Among VDAT’s initiatives is the Discharge Care Center (DCC) that provides text messaging and other forms of two-way communication between discharged patients and hospital clinical staff, extending the reach of transitional care to reduce hospital readmissions and address other metrics of concern.

“VDAT is an expansive program; there are many improvement initiatives going on at the same time,” said Neesha Choma, M.D., executive medical director of quality and safety for Vanderbilt University Hospital and Clinics. “No single tactic alone can reduce readmissions.”

This multipronged approach seems to be working.

“Since we have more robustly scaled our VDAT tactics including the DCC over the past year, we have seen a reduction in our readmission rates by approximately 5 percent, and we’re pleased with these early results,” Choma said.

Coordinated Discharge Workstreams

The VDAT initiative comprises three workstreams: high-quality discharge and care transitions; two-way communication and follow-up appointments; and post-acute care for high-risk patients. A leader of the communication initiatives is Marcella Lupica, R.N., an associate nursing officer at Vanderbilt.

Lupica notes that the process begins while the patient is still in the hospital, when the discharge nurse adds a patient contact number to the EHR and gives the patient a flyer with the DCC’s contact information.

One important goal is to ensure all patients admitted for an unplanned hospitalization leave with a scheduled follow-up appointment within seven to 14 days of discharge, she said.

“We will follow them for 30 days post discharge, sending a total of 12 messages in 30 days to cover medication and clinical signs and symptoms, in addition to durable medical equipment such as oxygen,” Lupica said. The outgoing messages have a reach rate of more than 85 percent, she added.

The DCC now offers text automation and phone call access for most patients discharged from the hospital, with an option for patients to forego the program. However, many (62 percent) continue to participate for the full 30 days.

“Since we have more robustly scaled our VDAT tactics including the DCC over the past year, we have seen a reduction in our readmission rates by approximately 5 percent.”

Patient and Caregiver Benefits

Two-way communication can facilitate a smooth transition to home and provide ongoing education and support for patients, caregivers and families post discharge, Choma said.

“We wanted to make it easy for patients to have questions answered and get the help they need once they leave the hospital,” she added. “The DCC is a multidisciplinary center, staffed with nurses, case managers, care coordinators, social workers, pharmacists – all with access to the provider who was responsible for that patient during hospitalization.”

Patients can call the DCC at any time, including nights, weekends and holidays.

“And they do call,” Lupica said.

In addition, the DCC team proactively reaches out to communicate with higher-risk patients during the post-discharge period.

Improving the Process

Approximately a quarter of patients require some post-discharge intervention by staff, including triage and support of clinical symptoms, patient and medication-specific education, pharmacist support and prescription coordination, and administrative and scheduling assistance.

The DCC also provides feedback to individual Patient Care Centers (PCC) at Vanderbilt.

“We measure the care gaps and the interventions,” said Lupica, “and give each PCC a scorecard: what’s going well, what care gaps we’re seeing, what interventions are needed most for their patients.”

“It’s a mechanism to keep ourselves accountable,” Choma added. “We can figure out how to improve the process upstream so that it gets better over time downstream for our patients.”