- Considering the protocol you are developing: identify the process and outcome indicators associated with the program and briefly describe an approach to measuring each.
The motivating factor of the post-discharge follow up is to address any transitions of care “gaps” between inpatient-discharge and first follow up appointment which, if addressed, can decrease unnecessary readmission.
I followed our discussion in small group to develop a table of process/intermediate/long term and impact measures.
Goals: prevent readmissions using post-discharge phone call intervention
|
Process |
Intermediate/ |
Long-term outcome |
Impact (goal) |
|
% discharge who receive phone call
#/% of completed calls
#. Number of minutes spent on phone
|
- Content of the calls
- Did it change medical decision making (did it prompt appropriate call to primary medical team/outpatient physician, assess % providers aware of post-d/c needs/issues arising)
- Did it lead to change in care plan (documented in chart that in response to call, x/y/z was done)
|
- improve patient engagement/activation/satisfaction (HCAHPS scores, survey)
- improved adherence to care plan, medication, follow up appointments (pharmacy data, pill counts, % no-show rates to appts)
- did it lead to readmission or prevent readmission (readmission to hospital within 30 days) |
-Improve quality of care of patients -Improve transitional care quality - improve mortality - 30 day readmission rates could also be in this probably
|
2.
2. Define one or more “intermediate” outcome measures (reflecting changes in environment, organizational culture, systems of care, patient or public behavior, and/or clinician behaviors) that can inform you about the mechanism by which your intervention achieves its downstream effect on health inform you about the acceptability of your intervention
Some additional intermediate outcomes I came up with after the small group session.
- percentage of primary care providers/clinic aware of issues arising from post-discharge follow up call (if any) – assess via survey/ required documentation of phone call and action by medical home team.
- To the above end, a process measure might be % of “telephone encounters/e-documentation”/ discharges in chart for patients discharged from hospital reflecting receiving call and content of call.
- percentage of discharging physician aware of issues arising from post-discharge follow up call (if any) – survey.
- Content of the calls- NP or other clinical staff making phone call will document
- Able to reach patient
- Completion of call
- Time spent on call
- Content of call: 1) questions about meds- inability to fill rx, side effects, questions on dosing 2) problems arising after discharge 3) questions about medical condition/education; 4) issues arising from functional status (need for increased help/home health/OT evaluation; 5) acute issues requiring medical attention (new symptoms/unanticipated complications)
- Medical decision making/plan- document whether PCP was paged, covering PCP paged, clinic staff/nurse/nurse manager contacted, etc.
- Did it change medical decision making (did it prompt appropriate call to primary medical team/outpatient physician, assess % providers aware of post-d/c needs/issues arising)
- Did it lead to change in care plan (documented in chart that in response to call, x/y/z was done)