chan protocol#4. post hospitalization telephone calls

chan protocol#4. post hospitalization telephone calls

by Brian -
  1. Please complete and upload the following protocol assignment here:

    2. Describe the organizational and/or delivery system environment in which your intervention will take place.

 

Intervention would take place at SFGH ideally. SFGH does have vertical integration with hospital and outpatient clinic services. Would focus on medicine patient (non-surgical, non-psychiatric services).

3. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.

  • Quality performance. May encounter resistance if administration is concerned about the quality of the discharge phone calls, unintended worse quality outcomes due to intervention (ie. Maybe patients increase Ed/readmission visits because of phone call).

 

  • Patient satisfaction. One barrier to successful implementation of this intervention is that many patients do not have stable telephone access/lines to receive the intervention. Patients may not answer the phone for intervention as well.

 

 

  • Organizational learning. Who will actually conduct the calls (nurse practiceioners, nurses, MA) is an issue that may impede implementation.  Training these staff is a barrier. Supporting the downstream effects of discharge phone calls (how to deal with patient issues such as ordering meds/refills, active symptoms, questions for specific providers) is a barrier to implementation.

 

  • Financial performance. Cost of the intervention and activity is a potential barrier to limitation.


4. Using the same 4 domain model, describe how your intervention plan can take advantage of organizational strengths OR propose practical methods for addressing these barriers within your program.

 

 

  • Quality performance.
    • Use evidenced base strategies for phone discharge follow up
    • Measure outcomes- 30 day readmission rates, % make f/up appointments,

 

 

  • Patient satisfaction.
    • Measure this with care transitions measure survey
    • Measure satisfaction with phone call experience, subsequent advice given
    • Pt experience measures (hcahps scores)

 

 

  • Organizational learning.
    • Culture of innovations/research
    • Hospital is motivated to improve patient outcomes and experience
    • Bridge divide between inpatient and outpatient providers/staff

 

  • Financial performance.
    • Potential cost-savings to hospital 

Re: chan protocol#4. post hospitalization telephone calls

by Christina Mangurian -

Hi Brian,

Great study.  As you know, I'm quite interested in this work for many reasons, including the fact that I work at SFGH and really care about this vulnerable patient population.

Re: #2: I understand your reasoning for limiting to medical patients (non-surgical, and non-psychiatric), but I want to highlight the extent of co-morbidity at SFGH.  I’m pretty sure schizophrenia or Psychosis NOS is the #1 diagnosis….  I imagine this is already part of your plan, but I would strongly gathering information about psychiatric history (both diagnosis, PES visits, and inpatient visits). This comorbid psychiatric illness is likely to be a confounding variable. I think that there may be a lot of useful information to glean here in this age of integration of care.   In addition, if you are in the mindset to try to focus/limit your population, you might want to consider rolling out only in elderly patients at first.  Just an idea.  This might help with buy-in.  Most people want to help out the little old lady….

Re: #3/4:

--Agree with hospital’s concern that it might increase ED visits and your plan to monitor this.

--I’m not sure that patient’s don’t have cell phones.  I’d look into Dean Schillinger’s work with texting for DM self-management.  I’m pretty sure he used SFGH pop and vast majority had cell phones. 

--Who makes the call is critical.  I’d set this up as the same “class” of person being responsible for this.  One person from unit should be the dedicated caller. 

--I’d also consider using a text-based intervention (cheaper).

Re: chan protocol#4. post hospitalization telephone calls

by Brian -

christina/lisa

thanks for the feedback. i think definitely finding the right population for this intervention  is going to be crucial. I like focussing on the elderly vulnerable population vs some of the designations I had initially put. i think the issue of phone access can be tricky- some of our most high need patients have limited cell phone plans/unstable access to phones that make lisa's point about the completion of call vs attempted call very real concern. Balance this out with the "warm" handoff line that in theory our clinic in 1M has but those at risk for readmission do not utilize.

The text messaging idea is a really interesting one-- i'd like to be able to try something like this. Though the cochrane review on these interventions has some good conclusions that the "human voice" is an important factor in success of f/up calls/interventions.  

Re: chan protocol#4. post hospitalization telephone calls

by Lisa Thompson -

I think this is a high-need idea, but the delivery is tricky. I am sure at least some of us have been discharged from the hospital and felt we were being thrown into back into the wild, without provisions. For those who don't have a PCP to call, even a worse scenario. But the problem of 1) no answer, 2) wrong number, 3) language spoken requires translator, 4) unfamiliarity with what to do with information if there is a problem, 5) person with concomitant illnesses that limit their ability to communicate (elderly, people with mental illness) made me think of an alternative. Maybe there could be a centralized "red phone" number given to patients at discharge so that they can call in to the hospital and speak directly to a triage nurse, who can access the EMR and a translator? This could be texted to patients after discharge to remind them they can call. This could be measured with financial indicators (cost of staff vs re-admits/ED visits)

Re: chan protocol#4. post hospitalization telephone calls

by Victoria Tang -

Hi Brian,

Awesome stuff. 

1. I know you had wanted to aim this project at medical and not at surgical patients but many readmissions post-surgery are medical related. Even though surgical readmissions are usually medical conditions related, hospitals are still penalized for these within 30d readmissions. Let me know what your thoughts are about including surgical patients.

2. Good thoughts about the quality performance piece and it may be that patients will increase utilization of ER and be readmitted because there is greater amount of health care (being the telephone f/u call) whereas they might have just died at home (which wouldn't count against your current stated outcome) or dragged out long enough to not meet criteria for within 30d readmission

That's all I've got. :)