An Initiative to Change Inpatient Practice: Leveraging the Patient Medical Home for Postdischarge Follow-Up

The standard of care for hospital discharge planning includes arranging follow-up appointments, usually with a primary care provider. However, follow-up phone calls instead of face-to-face visits may be an appropriate alternative for some patients. This option was explored within the framework of the US Department of Veterans Affairs (VA) patient-centered medical home model of care, the Patient Aligned Care Team.

At a VA hospital, a pilot study was conducted on the use of phone calls from members of a patient's medical home as posthospital discharge follow-up rather than the traditional face-to-face provider model. Inpatient providers were educated about the phone follow-up alternative, and this option was standardized as part of discharge planning rounds.

During Phase 1 at one clinic over three months, 17 of 118 eligible patients received phone call follow-up (14.4% of discharges) instead of traditional face-to-face follow-up. During Phase 2, data from Phase 1 were analyzed, and staff at the other eight clinic sites were trained. After the expansion of the initiative to all regional clinic sites in Phase 3, 76 of 447 eligible discharges (17.0%) were scheduled for phone follow-up. As a balancing metric, there were no significant differences in rates of 30-day emergency department (ED) utilization (11.9% and 5.9%, (p = 0.47)) or nonelective rehospitalization (16.8% and 17.6%, (p = 0.93)) between these groups during Phase 1.

This initiative changed provider practices to use phone call follow-up for select patients instead of face-to-face provider visits after hospital discharge, without significantly increasing rates of 30-day ED utilization or rehospitalization.