By Dorothy Brooks
Follow-up calls to patients after they have been discharged may be far down on the priority list for busy EDs. However, new data suggest such calls can ensure patients understand their discharge instructions and prevent repeat visits.
Investigators considered the cases of more than 8,000 patients who had been seen in a large, urban ED and discharged home over a 10-week period in 2018. Patients were divided into two groups: 2,958 patients received an automated phone call two days after discharge from the ED, and 5,152 patients did not receive these calls. All patients received an automated call at 14 days after discharge to assess for some secondary outcomes.1 The automated call that went to intervention group participants two days after discharge asked whether patients wished to receive a call-back from a clinician to review their care plan. If patients replied affirmatively, then an advanced practice clinician tried up to three times to reach the patient by phone on the same day as the automated call. Patients could indicate whether they wanted to ask questions about their discharge instructions, follow-up plan, prescribed medications, or other subjects.
Investigators reported patients receiving automated calls were much less likely to return to the ED for care within seven days of their original encounter. Further, these patients were more likely than the patients who did not receive the automated calls to understand their discharge instructions, to put follow-up plans in place, and to successfully obtain prescribed medications.
Automated calls offer savings from a resource standpoint, but some EDs prioritize a live, person-to-person approach, noting there are advantages to connecting in real time with patients. With a little creativity, some EDs have pulled this off without stretching the staff too thin. For instance, in the call-back program at Massachusetts General Hospital (MGH) in Boston, a nurse oversees trained volunteers to help make the calls, using a patient list and a script so callers ask appropriate questions.
“The target population is from our non-acute area because those patients get discharged quite a bit and they seem to have the most questions,” explains Inez Luciani-McGillivray, BSN, RN, CEN, a nurse in the department of emergency medicine at MGH and the lead author of a study of the effects of the call-back approach.2
Typically, calls are made two or three days following the patient’s ED visit, but they can take place up to seven days after. When a call is made, a nurse or trained volunteer will review the patient’s discharge instructions and determine whether he or she wants to ask any additional questions. “We really try to deal with any barriers and help patients get the resources they need,” Luciani-McGillivray says.
For example, if a patient is struggling to contact neurology to make an appointment that was recommended during the ED visit, the nurse or trained volunteer will take steps to facilitate that connection.
All the volunteers understand a key part of their job when making these calls is to stress the importance of seeking follow-up care after the ED encounter. “There are so many people who leave the ED with mounds of paper, and they really don’t know what to do,” Luciani-McGillivray shares. “We always encourage them to contact their primary care provider ... we have a whole script on why this is so important.”
In some cases, patients just need to contact their provider’s office to let them know they have been to the ED and why. The provider may determine an in-person visit is not needed, but he or she will be there as a resource should there be any questions or concerns. In other instances, patients may need ongoing monitoring or someone to remove stitches, tasks that do not require a return ED visit.
“Patients often don’t realize that they don’t have to come back to the ED for follow-up. That is the most important thing that I stress,” Luciani-McGillivray says. “We never tell patients not to come back. We always say they are more than welcome, but we give them the pros of being able to check in with their own provider ... and we try to explain how the ED works.”
Further, speaking one on one with someone in real time gives patients assurance their concerns are heard. “I can’t tell you how many people really appreciate having a live person on the other end of the phone to talk with and try to figure out what they need to do next,” Luciani-McGillivray says.
Data show the post-discharge calls affect return visit rates. Luciani-McGillivray and colleagues found only 4% of patients who received call-backs returned to the ED vs. 9% who did not receive call-backs.2 This makes a big difference to an ED that routinely sees hundreds of patients per day. “We are overcapacity, and this has been going on for years,” Luciani-McGillivray says. “If we can help people stay safe and healthy with good, quality discharges so that they don’t need to come back here, that is a big incentive.”
How might a busy ED create an effective call-back program that makes use of volunteers? First, gather support from nursing leaders and other administrators. Show data to demonstrate the difference call-backs can make. Luciani-McGillivray says it is critical to involve at least one experienced nurse. “I have been here 37 years. I know the resources, I know how the ED works, and I still work on the unit when I have to. I am very involved with the everyday things that go on,” Luciani-McGillivray says. “To make a [call-back] program as successful as it has been here, you have to have that experience.”
At MGH, two experienced nurses train volunteers with script readings, simulations, and role-playing. Nurses work side by side with volunteers as they make calls to intervene if a situation arises that they cannot handle alone.
Volunteers do not always stay with the program long term, so it is important to provide ongoing training. Luciani-McGillivray notes she has seen older volunteers thrive. “I have three volunteers who are in their 70s, and they are so good,” she says. “They understand the system, they know what to do, and they have been with me for a very long time.”
The Cleveland Clinic is a long-time proponent of live call-backs. Erica Shields, RN, BSN, MBA, NE-BC, and Joanne Socausky, RN, DNP, NE-BC, both senior nursing directors of nursing there, jointly answered questions about their approach.
They noted their call-backs happen two days after ED encounters. These calls can be made by a wide variety of staff. “Most physicians do try to call patients they have seen. Often, they will keep a list of patients they want to follow up with personally,” Shields and Socausky explain.
The goal is to reach 70% of all patients who have been discharged home from the ED. “Our exclusion subset includes some behavioral health diagnoses and sexual assault patients who are called by a forensic nurse instead,” Shields and Socausky say.
As with the MGH call-back program, callers at Cleveland Clinic aim to answer any questions patients may ask, ensure patients schedule a follow-up appointment with their provider, and reduce unnecessary return visits. Staff also ask patients if they would make recommendations to improve service and if they want to recognize specific staff for providing excellent care. If patients cannot be reached, clinicians leave messages about the purpose of the call, indicating there is no need to call back unless there are questions or concerns. There will be no repeated attempts to reach patients unless there is a concern.
The EMR contains records of call-back responses so clinicians can see who has been contacted and their responses. Administrators monitor call-back information and correlate that data with other metrics, such as increases in patient satisfaction.
Busy staff may not have the time or inclination to learn a customer service role like this, but making scripts available can ease the transition. Successful roll-out hinges on an education plan, support for staff, and a process that works for the department. “As with any new project, it is important to move to the goal of sustainment,” Shields and Socausky say. “To get there, you have to have consistency. This will only happen with the support and drive of the entire team.”
REFERENCES
1. Fruhan S, Bills CB. Association of a callback program with emergency department revisit rates among patients seeking emergency care. JAMA Netw Open 2022;5:e2213154.
2. Luciani-McGillivray I, Cushing J, Klug R, et al. Nurse-led call back program to improve patient follow-up with providers after discharge from the emergency department. J Patient Exp 2020;7:1349-1356.
Follow-up calls to patients after they have been discharged may be far down on the priority list for busy EDs. However new data suggest such calls can ensure patients understand their discharge instructions and prevent repeat visits.
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