Transitions of Care: The Value of Post Hospital Discharge Calls

A major focus in healthcare today is the successful transition of a patient from one level of care to the next level.  NTOCC (National Transition of Care Coalition) was formed in 2006 to improve the quality of care coordination and communication when patients are transferred from one level of care to another.  A key focus is on successful discharges from an inpatient setting:   successful discharges occur where care is coordinated between the levels of care, and the member is not at-risk for complications from missing pieces of care or disjointed, delayed services.  Discharging from an inpatient setting presents many challenges, but also many opportunities, for safe, coordinated transition of care. 

Integra Health and Wellness programs have always addressed the discharge needs of enrolled members.  It has always been standard practice for our Utilization Review nurses to inquire about any discharge needs that require assistance.  They routinely make referrals to case management to provide assistance with these complex needs.

In 2007, case management implemented a focused quality improvement project targeting medication adherence for members enrolled in  member case management, which incorporated tools from national clinical sources to  help facilitate members having  a comprehensive, up-to-date list of medications, access to needed medication,  an  understanding of the reason  medications  have been  prescribed,  and  an understanding of  the side effects and safety issues related to the medication.  

As part of our continual improvement processes, any member discharged from an inpatient setting, that has not already been referred to case management, now receives  a call from an Integra Health and Wellness nurse to determine if they have the medications prescribed for them at the time of discharge, as well as any DME or home health services that  might  have been ordered. The nurse also verifies they have follow up appointments and understand basic safety related to their condition.  Often patients and family members experience increased anxiety once home and need support and education reinforcement on safe care.   They might not require case management services, but they do need a transitional bridge of care monitoring.  So what kind of questions or concerns might our nurses hear on that call? 

  • "Now that I am home, I am confused!  I don’t know what medications I am supposed to take – am I supposed to stop the ones not on this list from the hospital?" 
  • "They said to make an appointment with my primary care doctor as soon as I got home. I don’t have a primary care doctor – do you know who I can see?"  
  • "They didn’t tell me whether I can shower with this dressing on – can I?"
  • "I was supposed to get a wheelchair delivered, but no one has come yet. Do you think they forgot?”
  • "When we got to the pharmacy to pick up my prescriptions, they said we had to wait and mail order it. Should I go that long without this medication?"   

Integra Health and Wellness Director Leslie Roberts RN, BSN, CCM describes the impact of these calls: "Within the first week of implementing post discharge calls after inpatient hospitalizations, we realized just how powerful the impact of this program was going to be. We are able to assist members to obtain needed medication and equipment and avoid costly complications. We also are able to proactively help connect the member and their provider in collaborating on ways to make home care less anxiety-producing for the member and his/her family, and help facilitate communication to prevent missed discharge instructions for needed care.   The real impact was in cases that typically didn't meet standard case management criteria and there had been no discharge needs identified for the member by the provider at the time of discharge.  When those members received our calls, they were really grateful for that help. We found it is not just members with catastrophic illnesses that need assistance after discharge, but any patient who requires some kind of ongoing care or medication."  

For more information on Integra Health and Wellness programs, please contact us.