Follow-up plan is key to continuum
Build bridges from inpatient to outpatient setting
Are hospitals doing a good job providing patient education in a seamless continuum of care? Not always, according to health care professionals in both the inpatient and outpatient setting. Sometimes patients go home not fully understanding their self-care instructions. Also, home health agencies and the clinics who work with patients after discharge have no idea what the patient has been taught about self-care.
The key to a seamless continuum of care is a good follow-up policy, says Carolyn Speros, MEd, MSN, RNC, a nurse practitioner at the University of Tennessee Family Practice Center in Memphis.
"The ultimate goal is to have patients clearly understand their role in self-care," Speros says.
That follow-up plan might include making a phone call to the patient or his or her caregiver to answer questions or providing a contact phone number so the patient can call if confused about self-care instructions. It also might entail coordinating teaching with home health agencies and clinics.
The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations does not mandate a specific follow-up method, but the agency expects health care organizations to follow through with the care whether handing off the patient to a home health agency or providing a contact for a patient providing self-care.
"What we are saying is that as part of the continuum of care function, hospitals want to make sure that the ball isn’t dropped," explains Ann Kobs, MS, RN, associate director in the department of standards at the Joint Commission.
There are many ways to keep from abandoning a patient upon discharge. Here are several suggestions:
• Provide a 24-hour contact.
Patients at the University of Texas M.D. Anderson Cancer Center in Houston are given written instructions on their discharge medication. Also, a pharmacist provides counseling whenever possible before discharge. Yet patients often don’t have any questions until they get home. That’s why the hospital provides a link to a pharmacist by giving patients an 800 number they can call 24 hours a day, says Sharon Bronson, MS, RPh, director of pharmacy academics program at M.D. Anderson.
• Develop criteria for follow-up calls.
Not all patients require a follow-up call after discharge, but those on complicated regimens often do have questions and concerns. Therefore, the case manager at Saint Joseph’s Hospital of Atlanta determines which patients to call on an individual basis. For example, those patients who are going home on intravenous antibiotic therapy with a family member as the caregiver will receive a call within 72 hours to one week, depending on the purpose of the call.
If the case manager believes the caregiver needs educational reinforcement, the call will be made within 72 hours. If the call is made to offer support and remind the caregiver that they can call if they have any problems or concerns, it would not have as much urgency, says Kathy Brandeis, RN, BSN, quality improvement coordinator at Saint Joseph’s. (For information on building a stronger inpatient-outpatient program, see the related story, p. 108.)
All patients are given a card with the case manager’s office number, so patients can call the hospital if they want to.
Time crunch often signals follow-up
Other situations that provide a "red flag" for follow-up calls include outpatient surgery and emergency department visits. There is not much time for discharge teaching in either case, explains Brandeis. Patients who have gastrointestinal surgery and outpatient cardiac interventions receive a phone call 48 to 72 hours following the procedure.
"We want to make sure there is no infection, they understand the discharge instructions and when they need to see the doctor next because they may have been a little groggy when taught," she says.
The call-back timeline of 48 to 72 hours was selected because patients are more rested after a couple of days and have had time to read through the materials they were given. That’s usually when questions develop, says Brandeis. Also, to provide continuity of care, the nurse who took care of the patient during outpatient surgery makes the phone call. The time frame fits the nursing staff schedule because nurses often work 12-hour shifts followed by two days off.
All patients who come through the ED receive a follow-up call within 24 hours. However, follow-up calls in any setting can create difficulties. There is no designated staff at Saint Joseph’s to make the calls; nurses must complete the task along with their other job duties. Also, ED staff often are given the wrong telephone number, or they reach an answering machine and can’t leave a message because of patient confidentiality. Time constraints for ED staff only allow one follow-up call.
• Reinforce teaching via telephone.
Patients who have cardiac interventions at Fairview-University Medical Center in Minneapolis receive a series of phone calls to reinforce the teaching they received in the inpatient setting. Often, they don’t remember much of what they are taught, says Paula Varhol, RN, cardiology aftercare coordinator at the medical center’s Riverside Campus.
Therefore, patients are sent home with a packet of written materials and are telephoned following discharge at 48 to 72 hours, one week, one month, two months, and six months. A teaching protocol is followed to help ensure patients understand their self-care instructions and are following them to reduce their risk of heart attack. (For details on this cardiac follow-up program, see story, below.)
• Copy instructions for handoff.
Make sure clinics and home health agencies receive the same instructions the patient was given, advises Jeannette Altenburg, RN, MSN, OCN, clinical supervisor for the City of Hope National Medical Center Home Health Department in Duarte, CA. The home health agency needs to know what the patient was taught and what occurred during the teaching session. For example, the patient may never have satisfactorily demonstrated a learning skill.
It would help if patients were told to bring their medication bottles, teaching sheets, and discharge instructions with them on follow-up visits to their physicians after discharge, says Speros.
"We are dealing with the same issues the nurses in the hospital are dealing with," she says. "We don’t have time to do a lot of teaching. Therefore, we shouldn’t duplicate efforts."
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