Enhancing the effectiveness of follow-up phone calls to improve transitions in care: three decision points

Unavoidable rehospitalizations are frequent, costly, and burdensome for patients and families. The incidence of rehospitalizations within 30 days of discharge can be reduced by improving communication and coordination of care, including enhancing communication with patients and families. Postdischarge follow-up calls are often cited as a cost-effective intervention, yet there is little standardization on how they should be conducted.

A nonsystematic review of the literature focused on the use of telephone follow-up (TFU) to improve postdischarge processes and reduce avoidable readmissions. Its use was also examined as a component of postdischarge processes among hospitals and organizations participating in the STate Action on Avoidable Rehospitalizations (STAAR) initiative. THE THREE DECISION POINTS: (1) Who Should Make the Call? The decision about who should initiate telephone contact will involve multiple considerations, such as available staff time, level of clinical knowledge required, and financial and practical sustainability. (2) Which Information Is Essential? Care teams should define the follow-up calls' short- and long-term goals and then identify the information needed to achieve them. A standardized assessment sheet may help ensure that patients are always asked the appropriate questions to ascertain whether they require advice and/or intervention, changes in medication, or a visit to their physician or emergency department. (3) What is the Optimal Timing, Frequency, and Duration of Follow-up Calls? The frequency of calls should depend on the patient population, and the duration on the length of the standardized assessment or telephone script and on patient need.

TFU should continue to be explored as a cost-effective option to reduce readmissions.