Secondary Logo

Journal Logo

Feature: QUALITY IMPROVEMENT

Impact of NP follow-up calls on reducing 30-day readmissions in patients with stroke

Hwang, Pauline J. DNP, AGACNP-BC

Author Information
doi: 10.1097/01.NPR.0000827056.81217.5b
  • Free

FU1-9
Figure

Patients with stroke as well as their families endure a lifelong recovery period following stroke, as well as complications which often delay the recovery process and require hospital readmissions. The 30-day hospital readmission rate is an important indicator of the quality of care.1 Readmissions within the first 30 days after hospital discharge can result from a progression of the patient's disease, inadequate care of the underlying problem, or inadequate coordination of care after discharge.2 Patients with stroke have been identified as a group at risk for readmissions due to complications of stroke, such as infections, and recurrent stroke, which are highly associated with increased mortality, healthcare costs, and decreased quality of life.3-10

Understanding the most common causes of 30-day readmissions can assist in the development of interventions to target those causes. In a systematic review and retrospective claims analysis, recurrent stroke was the most common cause of 30-day readmissions in patients with ischemic stroke.5,9 On the contrary, a case-control study found that patients were readmitted within 30 days after discharge due to stroke-related complications as the most common causes of 30-day readmissions.11 In addition, two cohort studies identified stroke-related complications as the most common cause of readmissions, and recurrent stroke as the second most frequent cause.3,12

Regardless, 30-day readmission is highly associated with increased mortality. One study found that patients readmitted within 30 days have a 2.5 times greater mortality during readmissions than for index admissions.3 Patients readmitted for recurrent stroke or transient ischemic attack (TIA) were more likely to expire during readmission than patients readmitted for other reasons (P = .006).3 Patients with stroke who are of advanced age and have comorbidities often experience more complications than other patients, resulting in various levels of functional limitations and increased 30-day readmissions. Complications from a stroke, during and after hospitalization, are an especially significant predictor of 30-day readmissions.3,4

Readmission is also highly associated with increased healthcare costs. The nationally estimated annual cost of stroke in the US is $34 billion.13 The average readmitted inpatient cost per person was $12,000 between 2008 and 2013.5 Some of the costs are avoidable because more than 50% of readmissions for patients with stroke and other cerebrovascular diseases are considered preventable.14,15

Practical requirements for ongoing care are addressed and provided upon hospital discharge to patients with stroke in order to prevent complications, avoidable readmissions, and recurrent stroke. To reduce readmission rates, current literature supports a variety of successful pre- and postdischarge interventions including discharge planning, patient education, follow-up telephone calls, home visits, and transition coaching.16,17 Specifically, postdischarge telephone follow-up by nurses, trained coaches, interns, and NPs have shown positive outcomes for reducing readmission rates in patients with stroke.18-22 A cohort study emphasized the importance of timely follow-up calls to reduce 30-day readmission rates; the critical window for readmission is the first 2-3 weeks after discharge, with a median time of readmission at 11 days.20 Additional studies revealed successful outcomes of 7- to 10-day postdischarge phone calls.18,20,22 Given the significance of 30-day readmissions in relation to increased mortality and healthcare costs and decreased quality of life of individual patients and families, implementing postdischarge telephone follow-up calls within 7-10 days of discharge is essential.

Currently, our organization has a follow-up call team conducted by an RN and pharmacist. Although the project organization demonstrated readmission reduction within the stroke population, there are three gaps in the current practice of postdischarge follow-up calls to be addressed: lack of inclusion of providers in the process, lack of follow-up when a patient is discharged to sites other than home, and lack of data on patients readmitted to outside facilities. NP follow-up calls could provide detailed education on stroke symptoms and counseling, increase the postdischarge sense of security, and improve the transition of discharged patients to the next level of care. Therefore, the purpose of this quality improvement project was to evaluate the impact of adding NP participation to the follow-up telephone call program on 30-day readmission rates for all patients discharged from an accredited stroke center after stroke into various environments.

The project aimed to (1) determine if readmission rates prior to implementation of NP calls differed from readmission rates after NP calls; (2) expand follow-up calls to include all discharged participants, not only those who were discharged to their homes; and (3) capture 30-day readmission data for participants readmitted to other hospitals.

Methods

Setting

The setting for this project was a Joint Commission-certified Comprehensive Stroke Center within an academic medical center in south-central Pennsylvania. The organization has 548 inpatient beds and a telestroke network with 14 local and regional hospitals, some of which are rural, community hospitals. The organization has consulted on more than 5,000 patients for potential neurovascular interventions and further stroke treatments since 2012.

Intervention

The intervention included adding an NP to the established discharge call program. Data were collected for 3 months before and after start of the intervention. The preproject implementation group received usual care, which included RN care manager and pharmacist calls to patients discharged to home. The postimplementation group received a follow-up telephone call from the NP at 7-10 days and 30 days after discharge, in addition to the standard care.

The project was completed by a single project leader. The population for this project included all patients diagnosed with ischemic stroke or TIA and discharged from the project organization during the 3-month implementation period. The selection procedure in this project was a convenience sample of all discharged patients with ischemic stroke or TIA during the defined project time frame.

Recruitment. After approval for this project from the organization's Neuroscience Research Committee and Institutional Review Board, the project leader accessed the patient database of those admitted with stroke daily from the electronic medical record (EMR). Data including the patient's name, medical record number, diagnosis with stroke etiology, admission date, current medications, stroke deficits, and primary caregiver's name and phone number were recorded in the demographic sheet. During hospitalization, the project leader met with each patient and their primary family caregiver to introduce the project and request their participation. For patients with the capacity to make their own decisions, the project leader visited the patient's room at their convenience. However, the project leader contacted the primary caregiver if patients were unable to make their own decisions due to residual stroke deficits, such as cognitive or speech issues, or if patients preferred for their family members to be called first due to their planned discharge to somewhere other than home, such as an acute rehabilitation facility or skilled nursing facility. The benefit of follow-up calls by the project leader as an additional postdischarge resource for recurrent stroke prevention was discussed. Patients and caregivers were assured that all healthcare information would be discussed only with the patient's healthcare team and only when necessary. Preferred days and times were discussed with patients and caregivers during the meeting. At the time of discharge, patient information was obtained from the discharge summary in the EMR. The final discharge date and destination as well as discharge medications were updated in the demographic sheet, which was organized in a tabular manner arranged by discharge date and stored on the server, secured by a two-step password. Patients who were in hospice, died prior to discharge, had severe deficits from stroke and lacked family member participation, or were discharged prior to the project leader's visit were excluded.

- Patient demographics
Preproject implementation n = 173; n (%) Postproject implementation n = 60; n (%)
Age
20-39 8 (4.6) 4 (6.7)
40-59 43 (24.9) 13 (21.7)
60-79 87 (50.3) 27 (45.0)
80-99 35 (20.2) 16 (26.7)
Gender
Male 97 (56.1) 29 (48.3)
Female 76 (43.9) 31 (51.7)
Race
White 150 (86.7) 52 (86.7)
African American 10 (5.8) 7 (11.7)
Asian 5 (2.9) 1 (1.7)
Hispanic 8 (4.6) 0
Discharge destination
Home 79 (45.7) 32 (53.3)
Acute rehab facility 65 (37.6) 21 (35.0)
SNF 13 (7.5) 7 (11.7)
LTAC facility 5 (2.9) 0
Hospice 6 (3.5) 0
Expired 5 (2.9) 0
Note. SNF = skilled nursing facility; LTAC = long-term acute care

- 30-Day follow-up call responses
Answered at 30 days 28/60 (46.7%) Did not answer at 30 days 32/60 (53.3%)
Mean age 65.2 years 69.3 years
White race 23/28 (82.1%) 29/32 (90.6%)
Discharge destination Home 14/28 (50.0%) Acute rehab facility 11/28 (39.3%) Home 18/32 (56.3%) Acute rehab facility 10/32 (31.3%)
BE FAST knowledge at 30 days postdischarge Full or partial 27/28 (96.4%) Poor 1/28 (3.6%) Full or partial 24/32 (75.0%) Poor 8/32 (25.0%)

Phone follow-up. Discharge follow-up calls were made by the project leader to participants within 7-10 days of discharge at their preferred phone number, day, and time on weekdays. A total of two calls were made: one at 7 days and another at 30 days postdischarge. The tools for collecting project data were the demographic datasheet and the stroke follow-up form, which includes four categories: medication, assessment, education, and follow-up care. During the first call at 7-10 days, the educational section was emphasized, including monitoring for recurrent stroke symptoms and signs by teaching the BE FAST (Balance, Eyes, Face, Arm, Speech, Time) mnemonic. Secondary stroke prevention and risk factor modification based on the individual participant's comorbidities were addressed, which was not a standard part of the follow-up call procedure. The importance of taking medications prescribed for stroke prevention was discussed. Follow-up imaging; labs; and physical, occupational, and speech therapies for enhancing functional outcomes were discussed, if needed. The project leader addressed all patient concerns and questions during the first phone call. The duration of each call was 5-10 minutes. The second call was placed at 30 days, asking whether they had been readmitted to a hospital since discharge, and if so, the reason for the readmission.

Measures, data management, and analysis

This project was conducted and evaluated by a single project leader. All participant information was stored at a server in the project organization which was secure and password-protected. All findings obtained by using statistical analyses including Excel spreadsheets and 30-day readmission data from the Quality and Safety Committee at the project site were password-protected and anonymized.

Quarterly 30-day readmission rates in the project organization were the main outcome measure and analysis of the data from before and after project implementation was completed to determine if the difference was significant. Information on 30-day readmissions to the project organization and demographics for both pre- and postproject implementation groups was collected via EMR chart reviews. Information on whether postproject implementation participants were readmitted to other organizations was collected via 30-day follow-up calls. Readmission data were divided by the total number of participants to calculate the postimplementation readmission rate. In addition, the number of ED visits before and after project implementation was tracked.

The preproject implementation group data were collected for the third quarter of 2018 (July 1 to September 30). Postproject implementation group data were collected for the fourth quarter of 2018 (October 1 to December 31). The project ended on the last day of January 2019, as the 30-day follow-up calls were made at the end of January for patients discharged on the last day of December 2018. The data were analyzed at the beginning of February 2019.

Results

Sample description

The preproject implementation group included a total of 173 patients with ischemic stroke and TIA who were discharged during the third quarter.

The recruiting goal for the postproject implementation group was 100 participants for the 3-month period. A total of 163 discharged patients with ischemic stroke or TIA during the project period were reviewed for inclusion. A total of 76 of the 163 did not meet eligibility criteria and therefore were excluded. The remaining 87 agreed to participate. Twenty-seven (31.0%) of the 87 did not answer their phones at 7-10 days (of these, 55% were discharged to acute rehabilitation and 37% to homes), even after a follow-up attempt, and were removed from the project. Therefore, the final number of participants successfully contacted 7-10 days after discharge was 60 (69.0%; 29 patients, 31 primary caregivers; see Patient demographics). Of these 60 participants, 28 (46.7%) were able to be reached at 30 days. Patients who did not answer the 30-day follow-up calls had an older mean age (69 versus 65 years), were more likely to be White (90.6% versus 82.1%), and were more likely to have poor knowledge of stroke symptoms (25.0% versus 3.6%) (see 30-Day follow-up call responses).

- 30-Day readmission data
Preproject implementation Postproject implementation
Dates July 1-September 31, 2018 October 1-December 31, 2018
Discharged patients 173 60
ED visits 7 2
Proportion of patients with ED visit 4.0% 3.3%
30-Day readmissions 14 4
Proportion of patients with 30-day readmission 8.1% 6.7%

Of 60 participants who had successful follow-up calls initially, the majority (85%) of participants reported understanding stroke signs and symptoms; 13 participants (21%), mostly patients rather than caregivers, were fully aware of signs and symptoms of stroke and were able to verbalize them. Thirty-eight participants (64%), including patients and primary family caregivers, displayed partial knowledge of signs and symptoms of stroke but could not describe them. The remaining nine participants (15%), mostly sons and daughters who did not live with patients, had heard about BE FAST but did not understand or were unable to verbalize its details.

Readmissions and ED visits

Of the 173 discharged patients in the preproject implementation group, there were 14 with readmissions and 7 with ED visits. Of the 60 patients successfully contacted at 7-10 days in the postproject implementation group, 4 (6.7%) were readmitted (to the project organization) within 30 days after discharge with an average of 10 days to readmission. Two other participants visited the ED (3.3%). There was no significant difference in 30-day readmission rates between pre- and postproject implementation groups (see 30-Day readmission data).

Among the 28 participants who answered at both 7-10 days and 30 days, no readmissions to other facilities were reported. For the 6 patients in the postproject implementation group with a readmission (4) or ED visit (2), the most common reasons were stroke complications or stroke-related symptoms including vertigo, sepsis, numbness, weakness, seizure, and pseudoaneurysm. One of the four readmitted patients expired during readmission. Ages ranged from 54 to 92 years, with a mean of 71.5 years; 4 (66.7%) were male, and 2 (33.3%) were female. The majority were White (83.3%). These patients had been discharged to home (n = 5; 83.3%) and acute rehabilitation facility (n = 1; 16.7%).

The average number of days to readmission or ED visit was 11, with a range of 3-22 days. Two readmissions and one ED visit occurred within 3-5 days after discharge, prior to receiving the project leader's 7- to 10-day follow-up call. The remainder had received the 7- to 10-day follow-up call.

Discussion

Literature findings of the most common cause of 30-day readmissions are recurrent stroke and stroke-related complications.3,9,12 All six patients who were readmitted or visited the ED did so because of preventable or nonpreventable stroke-related complications. Although no patients were found to have recurrent stroke, this result supports literature findings on 30-day readmissions due to stroke-related symptoms or complications. Thirty-day readmission also was a significant concern because of increased mortality during readmissions and higher mortality (20%-25%) in 1 year.3 Of the four patients readmitted within 30 days in this study, one died due to complications, supporting the findings in the literature of increased mortality among readmitted patients.

Literature supports postdischarge telephone calls as a strategy to prevent 30-day readmissions. Follow-up calls by healthcare providers such as NPs were especially associated with reducing 30-day readmission rates and healthcare costs.11,18,19 Even though this project did not demonstrate a statistically significant difference in 30-day readmission rates of patients with ischemic stroke and TIA between preproject and postimplementation groups, it yielded several useful clinical findings. First, consideration can be given to placing NP follow-up calls closer to discharge dates, which may reduce readmissions and ED visits. Of 60 participants, two of four readmissions (50%) and one of two (50%) ED visits occurred before the 7- to 10-day follow-up calls. The presenting symptoms for these readmissions and ED visit included acute onset left-sided weakness, unresponsiveness, and vertigo. It is difficult to determine whether those symptoms could have been addressed in a follow-up call without the patient needing to come to the ED. If the two early (3-5 days postdischarge) readmissions and one early ED visit were due to late effects of stroke symptoms, they might have been preventable. A benefit of earlier follow-up calls by NPs includes the ability to assess/recognize the patient's signs and symptoms before they worsen, which may prevent readmissions. This may also have helped connect patients at high risk to physicians via telehealth videoconferencing before readmission or ED visit, which could have helped cut costs and improve quality of life. One of two early readmissions due to unresponsiveness might have been prevented by a follow-up call because the patient's seizure may have been provoked by multiple factors such as a urinary tract infection and medication overdose. It is possible, therefore, that earlier follow-up calls within 2-3 days could reduce rates of 30-day readmissions and ED visits.

Secondly, to further reduce readmissions and complications among the stroke population, patients and caregivers need to be educated by expanding follow-up calls to all patients discharged after a stroke, including those discharged to an environment other than home. The majority of patients in the study rated themselves as understanding the reasons for hospitalization and knowing who to call with problems and symptoms before their discharge. However, the initial follow-up calls showed that only 21% fully understood their diagnosis and were aware of BE FAST. Undoubtedly, stroke education needs to be reinforced after discharge to enhance knowledge. Expanding NP outreach in the form of telephone follow-up calls or telehealth videoconferencing could be one way to narrow the knowledge gap and reinforce stroke education to patients and caregivers. Stroke education can help prevent recurrent stroke, reduce readmission rates and mortality, and improve quality of life by teaching patients and caregivers to recognize complications and signs and symptoms of stroke and helping them to understand recommended lifestyle modifications and medication regimens.

Thirdly, although there was no significant change in the 30-day readmission rate for the postproject implementation group, the results do suggest potential revisions to the system of follow-up calls: (1) placing calls earlier, (2) adding NP calls to the existing follow-up call procedure, (3) expanding the existing RN calls to contact more patients, (4) utilizing paramedicine to focus on those who are sicker, or (5) implementing methods to improve call response rates. Patients discharged to environments other than their own homes are usually more impaired and need more medical attention. In total, 47% of follow-up calls were made to participants who were discharged to acute rehabilitation facilities and skilled nursing facilities during this project—a group of patients and family caregivers who may not have otherwise received postdischarge stroke education. Therefore, expanding NP outreach in the form of follow-up calls or telehealth videoconferencing could help recognize complications and stroke signs and symptoms early, which may reduce readmission rates and improve quality of life.

Limitations

Several limitations within this quality improvement project were identified that may have affected the outcome. The project time frame was limited to only 3 months. To acquire a more accurate understanding of the impact of NP follow-up calls on 30-day readmission rates, data should be collected over a longer period of time. A second limitation of the project was the small sample size. A larger and more diverse sample size would be needed in order to generalize the results.

- Recommendations for program revision and rationales
Recommendations Rationales
Place calls earlier than 7-10 days after patient discharge
  • Identify preventable potential causes of readmission earlier

  • Expedite follow-up appointments if needed

  • Connect patients to telehealth video conferencing if symptoms need to be evaluated in real time

Include NP in the follow-up call program in addition to current calls by RN and pharmacist
  • NP can focus on patients with significant deficits from strokes and comorbidities

  • Provide quality stroke education

  • Minimize knowledge gap among patients and family caregivers

Expand NP and RN follow-up calls to all patients with stroke discharged to various environments
  • Narrow the knowledge gap and reinforce stroke education to more patients and their families

  • RN calls should also reach patients discharged to places other than their own homes

Utilize EMS to examine patients
  • EMS can check on patients who live alone, lack caregivers, have an impaired memory, or have more serious deficits from strokes

  1. Implement methods to improve call responses

    • Schedule an appointment for a follow-up call prior to discharge

    • Send a reminder text message prior to calls to confirm phone call appointment

    • Provide business card with the phone number that follow-up calls will use before the calls so patients are not confused when they see the number in their caller ID making them more likely to answer

    • Leave a clear voice message with the next follow-up call time and date

EMS, Emergency Medical Service

Thirdly, a major limitation of follow-up calls was that many participants did not answer the phone. Of the 87 participants who agreed to receive follow-up calls, only 60 were able to be contacted by phone. Of the nearly one-third who did not answer the initial 7- to 10-day call, more were discharged to acute rehabilitation (55%) than to home (37%). This could suggest that many discharged patients have reduced phone accessibility due to being in a rehabilitation facility; caregivers were contacted in cases where patients were very sick or had severe aphasia. Of participants who answered the initial call, only 47% answered at 30 days, much lower than answered the initial calls (69%). This may show that longer waits to call patients after discharge reduce the likelihood of receiving an answer.

Lastly, newly adapted stroke community paramedicine home visits could have affected results. Paramedicine home visits in the project organization area started after August 27, 2018. Home visits to patients with stroke begin within 48 hours after discharge and as needed for patients who are discharged to their homes; with the existence of the standard calls and paramedicine visits, the project leader's call may not have been essential to improve the 30-day readmission rates of patients discharged to their homes.

Recommendations

The findings and limitations identified in this project will be useful in developing future studies. One identified opportunity for improving future projects is follow-up calls earlier than 7-10 days. Earlier follow-up calls within 2-3 days could help identify problems and arrange follow-up appointments sooner or connect patients to telehealth videoconferencing, if available. We identified several recommendations and rationales for program revision based on the experience gained during this project's implementation (see Recommendations for program revision and rationales).

Secondly, the rationale for using an NP in future follow-up call procedures is that an NP can act as an educator and provider. NPs can focus on patients with multiple comorbidities for further stroke education to prevent recurrent stroke and readmission and can connect patients to telehealth videoconferencing if symptoms need to be evaluated in real time. NP participation in this follow-up call procedure would utilize an NP's leadership abilities by educating patients and family members, supporting the organization, and sharing a common vision and direction for change. The outcomes of the project can be evaluated by patient satisfaction and can financially benefit the organization. Therefore, further data need to be collected to evaluate the impact on patient satisfaction levels and organizational financial savings based on reduced 30-day readmission rates.

Conclusion

Stroke has an immense impact on patients and the healthcare system. Thirty-day readmission after stroke is an indicator of reduced quality of care and increased mortality and healthcare expenditures. Studies have shown the impact of postdischarge follow-up calls on reducing readmissions. This project was both important and essential for improving care in order to reduce readmissions of patients with stroke. Although the result of this project did not demonstrate a statistically significant relationship between NP follow-up calls and readmission reduction, the lessons learned are valuable and provide an outline for improving future quality improvement projects within this population of patients.

REFERENCES

1. Brown CS, Montgomery JR, Neiman PU, et al. Assessment of potentially preventable hospital readmissions after major surgery and association with public vs private health insurance and comorbidities. JAMA Netw Open. 2021;4(4):e215503.
2. Chandra A, Takahashi PY, McCoy RG, et al. Use of a computerized algorithm to evaluate the proportion and causes of potentially preventable readmissions among patients discharged to skilled nursing facilities. J Am Med Dir Assoc. 2021;22(5):1060–1066.
3. Nouh AM, McCormick L, Modak J, Fortunato G, Staff I. High mortality among 30-day readmission after stroke: predictors and etiologies of readmission. Front Neurol. 2017;8:632. doi:10.3389/fneur.2017.00632.
4. Wen T, Liu B, Wan X, et al. Risk factors associated with 31-day unplanned readmission in 50,912 discharged patients after stroke in China. BMC Neurol. 2018;18(1):218. doi:10.1186/s12883-018-1209-y.
5. Johnson BH, Bonafede MM, Watson C. Short- and longer-term health-care resource utilization and costs associated with acute ischemic stroke. Clinicoecon Outcomes Res. 2016;8:53–61. doi:10.2147/ceor.s95662.
6. Tsai Y, Vogt TM, Zhou F. Patient characteristics and costs associated with COVID-19-related medical care among Medicare fee-for-service beneficiaries. Ann Intern Med. 2021;174(8):1101–1109.
7. Andrews AW, Li D, Freburger JK. Association of rehabilitation intensity for stroke and risk of hospital readmission. Phys Ther. 2015;95(12):1660–1667. doi:10.2522/ptj.20140610.
8. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6–e245. www.ncbi.nlm.nih.gov/pmc/articles/PMC5408511/.
9. Rao A, Barrow E, Vuik S, Darzi A, Aylin P. Systematic review of hospital readmissions in stroke patients. Stroke Res Treat. 2016;2016:1–11. doi:10.1155/2016/9325368.
10. Haynes HN, Gallek MJ, Sheppard KG, Drake KW, Ritter LS. Transitions of care for stroke and TIA. J Am Assoc Nurse Pract. 2015;27(10):558–567. doi:10.1002/2327–6924.12219.
11. Loebel EM, Rojas M, Wheelwright D, Mensching C, Stein LK. High risk features contributing to 30-day readmission after acute ischemic stroke: a single center retrospective case-control study. Neurohospitalist. 2022;12(1):24–30. doi:10.1177/19418744211027746.
12. Bjerkreim AT, Thomassen L, Brøgger J, Waje-Andreassen U, Næss H. Causes and predictors for hospital readmission after ischemic stroke. J Stroke Cerebrovasc Dis. 2015;24(9):2095–2101. doi:10.1016/j.jstrokecerebrovasdis.2015.05.019.
13. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association [published correction appears in Circulation. 2017 Mar 7;135(10 ):e646] [published correction appears in Circulation. 2017 Sep 5;136(10 ):e196]. Circulation. 2017;135(10):e146–e603. doi:10.1161/CIR.0000000000000485
14. Bushnell CD, Kucharska-Newton AM, Jones SB, et al. Hospital readmissions and mortality among fee-for-service Medicare patients with minor stroke or transient ischemic attack: findings from the COMPASS Cluster-Randomized Pragmatic Trial. J Am Heart Assoc. 2021;10(23):e023394.
15. Nahab F, Takesaka J, Mailyan E, et al. Avoidable 30-day readmissions among patients with stroke and other cerebrovascular disease. Neurohospitalist. 2012;2(1):7–11. doi:10.1177/1941874411427733.
16. Tahereh N, Hossein B, Mahboobeh K, Ahmad K. The effect of post-discharge telephone follow-up on the inherent dignity of patients with heart failure. Avicenna J Nurs Midwifery Care. 2021;29(2):91–101.
17. Jayakody A, Bryant J, Carey M, Hobden B, Dodd N, Sanson-Fisher R. Effectiveness of interventions utilising telephone follow up in reducing hospital readmission within 30 days for individuals with chronic disease: a systematic review. BMC Health Serv Res. 2016;16(1):403. doi:10.1186/s12913-016-1650-9.
18. Condon C, Lycan S, Duncan P, Bushnell C. Reducing readmissions after stroke with a structured nurse practitioner/registered nurse transitional stroke program. Stroke. 2016;47(6):1599–1604. doi:10.1161/STROKEAHA.115.012524.
19. Fischer K, Hogan V, Jager A, von Allmen D. Efficacy and utility of phone call follow-up after pediatric general surgery versus traditional clinic follow-up. Perm J. 2015;19(1):11–14. www.thepermanentejournal.org/issues/43-the-permanente-journal/original-research-and-contributions/5777-pediatric-general-surgery.html.
20. Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. The impact of postdischarge telephonic follow-up on hospital readmissions. Popul Health Manag. 2011;14(1):27–32. doi:10.1089/pop.2009.0076.
21. 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(1). doi:10.3402/meo.v20.26701.
    22. Coskun S, Duygulu S. The effects of nurse led transitional care model on elderly patients undergoing open heart surgery: a randomized controlled trial. Eur J Cardiovasc Nurs. 2022;21(1):46–55.
    Keywords:

    30-day readmissions; hospital discharge; postdischarge follow-up calls; quality improvement; stroke

    Wolters Kluwer Health, Inc. All rights reserved.