THE CURRENT and extensive focus on patient experience has posed many challenges for health systems, both internally and externally. Engaging with recently discharged patients to fulfill statistical requirements on reportable information has left organizations struggling to implement new processes, software, and departments. One activity new to many acute care providers is a postdischarge phone call, which is not simply initiated for the collection of data. Rather, it is a tool for continuation of the plan of treatment of an individual patient.
The postdischarge call provides a dual benefit for patients and hospitals. To deliver continued care and compassion, health care providers may choose to remain as primary resources for those who are transitioning from hospital to home. At the same time, by connecting with these individuals, the organization may reduce costly readmissions, intercept possible unfavorable incidents, and increase patient satisfaction with their care. When a patient perceives that a facility cares enough to initiate a telephone call to check on his or her progress and ensures that he or she understands discharge instructions, feelings of being cared for as an individual increase. The secondary result of this reaching out to patients has been shown to increase their satisfaction with the hospital experience as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores.
Postdischarge telephone calls are opportunities to extend care after the acute phase of an illness. They are especially important to the well-being of discharged patients when utilized to ensure an understanding of, or to re-explain the importance of discharge education or instructions. There are no precise methods to accurately assess patient's and family's (defined as his or her support system at home) understanding of written and verbal instructions communicated to them at the point of discharge. The postdischarge call is an additional step to reiterate this information and to answer questions that the patient may have once he gets home.
Primarily, registered nurses assume the role of initiating postdischarge telephone calls, but physicians and pharmacists may sometimes participate. Given the need to decrease costs while increasing quality, organizations should assess all of their processes for value. For postdischarge calls, a question that should be considered is this: Do postdischarge telephone calls require calls with clinical expertise, or can a trained nonclinical person demonstrate care for discharged patients, answer questions at a nonclinical level, and then proactively ensure that concerns identified during the telephone contact are addressed and transferred to a higher level of care when appropriate? In other words, can the value equation of quality and cost be well served through postdischarge calls initiated and conducted by trained nonclinicians?
CURRENT COMMON PRACTICES
The individual experiences related to the delivery of care in the health care setting can be measured by the patient's postdischarge retrospective evaluation. Subjective evaluation scores by independent health care surveyors are tied to reimbursement percentages. Therefore, acute care facilities must do what is required and in their best interest to maximize reimbursement, while providing their patients with personalized, quality care. One strategy that addresses both goals is the postdischarge phone call. Besides ensuring patients understand their postdischarge instructions, possible issues that were less than satisfactory in the acute care experience can be addressed with appropriate intervention, based on patient feedback.
Guss et al1 assessed the impact of the health care provider on patient satisfaction, after discharge from the emergency department. In their study, postdischarge calls were made by nurses, residents, or attending physicians, with no standardized script. The calls were done to notify patients of laboratory and imaging results, while checking on their status. In a second study, 4 nurses completed all postdischarge calls. Patients received a minimum of 2 phone call attempts within 72 hours after leaving the hospital. Between the 4 of them, the nurses utilized 20 hours per week (or 0.5 FTE [full-time equivalent]) to make the calls.2 Record et al3 have described a system in which medical residents engaged in postdischarge calls as part of their curriculum. In all of these articles, the postdischarge calls were made by high salaried, credentialed medical professionals.
While health care systems vary across the country, a review by Meek Clinical Partners, LLC, discovered that current methods for postdischarge phone calls consist of a few methods. The primary method (73.3%) was the use of registered nurses, assigned as a part of their regular duties, to make the calls during their scheduled shift (Meek Clinical Partners, LLC, unpublished data, 2017). Utilization of physicians making the postdischarge calls accounted for 13.3%, while the remaining varied among a dedicated call center team (6.7%) and the use of volunteers or navigators (6.7%) (Meek Clinical Partners, LLC, unpublished data, 2017).3
Although the approach for initiating the postdischarge calls may be similar for most organizations, monitoring the outcomes from these calls provides very little feedback to organizations, with 73.3% of those surveyed reporting that they do not have an integrated or centralized electronic process with their electronic medical record system.
A DIFFERENT APPROACH TO POSTDISCHARGE CALLING
The postdischarge programs and processes of many organizations fall short of delivering the benefits desired from postdischarge call program. As a result, some organizations are trying other models, including collaborations with third-party vendors to meet this need.4 They are utilizing trained nonclinicians to make their calls, with careful attention to key performance indicators to ensure quality procedures. These key performance indicators cover the issues of call timing, patient callbacks, objectivity, recording, supplemental items, and scalability.
Determining the opportune timing of postdischarge calls to patients is a key element of an effective program. The Studer Group indicates that calls placed within the first 24 hours postdischarge are most effective in not only being able to reach the patient for follow-up but also in creating a greater sense of satisfaction.5 This timeline can be challenging for many acute care organizations, especially for those with departments that are not open every day of the week.
Outsourced call centers operate 7 days a week and attempt initial patient contact within 24 hours of discharge. If they are unsuccessful in reaching the patient within 24 hours, they attempt to reach him or her at 48 hours, followed by an attempt on a Saturday or Sunday. By maintaining hours of operation beyond those of standard businesses, call center agents make calls in time periods that statistically report the highest connection with patients.6
Handling patient callbacks
One challenge with on-duty clinical staff members conducting calls is that, if they do not immediately connect with a patient, they leave messages letting the patients know that they were trying to contact them. Patients then try to return these calls to the number listed on their caller ID, which unfortunately is often the main hospital switchboard number. Operators are unsure of where to direct the calls, creating confusion and frustration for the patients. When clinical staff leave direct numbers for patients to return calls, staff members may be engaged in direct acute patient care. They are unable to take the discharged patient's phone call. Rather than increasing patient satisfaction, these situations lead to dissatisfaction for the discharged patient, the clinical staff, and hospitalized patients who may have received (as a result of the calls) interrupted care. Utilizing an outsourced program allows discharged patients to call back at any time and to be promptly connected with an agent who can handle their calls. Call center agents can make outbound calls on a dedicated line that is identified through state-of-the-art technology that makes the calls appear as though they are coming directly from the hospital. Agents answer incoming calls in the same manner as hospital-based switchboard operators. This service of patient callbacks provides a higher level of patient satisfaction by offering a first call resolution rather than a series of “phone-tag” calls. In addition, it allows for the hospital's clinical staff to remain focused on providing the highest level of care to the patients who are currently under their direct care.
Frequently, organizations report that they receive “great” feedback during their postdischarge calls but find that this feedback does not match what ultimately shows up in their publicly reported HCAHPS data. One factor that dramatically impacts a patient response is objectivity. When patients are asked by in-house clinical staff about their experience in the hospital, their responses can be influenced by the fact they may be speaking with the clinician who cared for them. People often withhold their negative responses in this situation and typically share a neutral or even positive response. When they complete an HCAHPS survey, in which they are talking to a nonhospital employee, they may respond differently.
Research shows that if a patient has expressed his or her negative experience to staff, it is often not documented, nor reported as a negative experience (Meek Clinical Partners, LLC, unpublished data, 2017). This may be due to feedback focusing on the clinicians themselves, or peer friends. It may even be due to an organization's attempt to improve patient care by comparing units or departments by their numbers of negative calls.
Professional call agents can make patients feel understood. They are able to empathize with the individual, as they elicit honest and true feedback on hospital experiences. Insuring objectivity offers organizations accurate feedback in a timely manner and the ability to respond appropriately. The organization can take this immediate feedback and follow-up with the patient to effectively perform service recovery prior to any formal negative survey responses from the patient.
Sharing original discharge call recordings with staff is a tremendous morale booster when positive feedback is received. Leaders can also use recordings to identify focused areas for improvement. Hearing the patients' own words, conveying firsthand experiences about their care, meals, room cleanliness, physicians, and other areas, has immense value. Because outbound calls from within an organization are not made through dedicated extensions that can record conversations, these benefits do not exist within internal call programs.
HCAHPS supplemental items and identifying system-wide opportunities for improvement
Many organizations gain additional value from their HCAHPS surveys by adding “supplemental items” to their surveys. These supplemental items are questions that organizations ask, in addition to the standard HCAHPS questions. However, the Centers for Medicare and Medicaid Services (CMS) reports that supplemental items lower the response rate of surveys by as much as 5.6%.7
One way to ensure that supplemental items do not lower the response rate is to remove them from HCAHPS surveys but ask these questions during discharge calls. If desired, organizations will need to have a centralized method for collecting and tabulating these data. In the Postdischarge Call Program survey, less than 5% of respondents stated that their organization collects and tabulates the data collected from postdischarge calls (Meek Clinical Partners, LLC, unpublished data, 2017). Outsourced call vendors could provide these data to organizations in a variety of formats for analysis.
An additional advantage of outsourced call centers is that volume does not affect response times or other assigned duties. Over any given period, call volumes could increase dramatically because of an increase in census, surgical procedures, or seasonal influx. As call volumes increase, the demand on staff also increases. This makes it extremely difficult to remain timely in postdischarge callbacks and creates stress on staff who are already trying to manage the increased patient care volumes. Outsourced call centers can flex-up during these peak times and handle wide shifts in volume, without affecting patient care or other areas of the organization. In addition, when volumes are low, outsourced call center agents are assigned to other organizations and the monetary impact to hospitals needing to schedule clinical staff on-site to make calls even when volumes are low is eliminated.
IMPROVING PATIENT AND STAFF SATISFACTION
A significant percentage (46.67%) of clinical staff report displeasure in making postdischarge phone calls, with 23% of those surveyed stating that they would rather do any task, other than making assigned postdischarge calls (Meek Clinical Partners, LLC, unpublished data, 2017). The Agency for Healthcare Research and Quality has developed a “tool kit” for organizations that includes role playing patient calls to help staff become less resistant and feel competent making postdischarge phone calls.8 Without proper training, clinicians may unintentionally reduce effectiveness of postdischarge calls and do little to improve patient satisfaction.
Because demands placed on clinicians are growing in today's changing health care environment, organizations must look at ways to reduce tasks and improve working conditions. Utilization of an outsourced call program is one way to ensure that the goals and objectives of the organization are achieved but not at the cost of staff retention and turnover. In addition, patient satisfaction should increase when calls are made by staff who have the training and time to address their concerns.
Few organizations have been able to develop successful internal postdischarge call programs. Clinical staff are most often being utilized to conduct these calls, even though many express their dissatisfaction in having to do so. This dissatisfaction leads to a diminished patient experience and lower satisfaction rates for patients and staff.
Establishing an outsourced postdischarge call program with well-trained call center personnel, able to escalate and transfer clinical concerns to clinicians as needed, can be a viable option for organizations looking to reduce costs, improve staff satisfaction, improve patient satisfaction, and provide the highest level of patient experience.
1. Guss DA, Leland H, Castillo EM. The impact of post-discharge patient call back on patient satisfaction in two academic emergency departments. J Emerg Med. 2012;44(1):236–241. https://doi.org/http://dx.doi.org/10.1016/j.jemermed.2012.07.074. Accessed August 15, 2017.
2. Harrison JD, Auerbach AD, Quinn K, Kynoch E, Mourad M. Assessing the impact of nurse post-discharge telephone calls on 30-day hospital readmission rates. J Gen Intern Med. 2014;29:1519–1525. https://doi.org/10.1007/s11606-014-2954-2. Accessed August 15, 2017.
3. Record JD, Niranjan-Azadi A, Christmas C, et al Telephone calls to patients after discharge from the hospital: an important part of transitions of care. Med Educ Online. 2015;20:26701. doi:10.3402/meo.v20.26701. Accessed September 2, 2017.
4. Willard M. Outsourcing
discharge follow-up calls keep nurses at the bedside. Health Leaders Media. October 5, 2009. http://http://www.healthleadersmedia.com
-discharge-follow-calls-keep-nurses-bedside. Accessed August 15, 2017.
5. Studer Group. Discharge phone calls deliver quality care, higher patient satisfaction. Hardwired Results, Winter 2006, Issue 5. https://az414866.vo.msecnd.net
/cmsroot/studergroup/media/studergroup/hardwired-results/issue05/hardiwred-results-issue-5.pdf. Published 2006. Accessed August 15, 2017.
6. NRC Health. Transitional care clinic and post-discharge calls boost patient-centered care effectiveness and cost savings [case study]. https://nrchealth.com
/wp-content/uploads/2017/04/Via-Christi-Case-Study.pdf. Published 2017. Accessed August 14, 2017.
7. Centers for Medicare & Medicaid Services. HCAHPS update training. http://http://www.hcahpsonline.org
. Published 2017. Accessed September 4, 2017.
8. Jack BW, Paasche-Orlow MK, Mitchell SM, et al An Overview of the Re-Engineered Discharge (RED) Toolkit. (Prepared by Boston University under contract no. HHSA290200600012i.). Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication No. 12(13)-0084.