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

Area of Science:

Healthcare Management
Patient Care
Health Services Research

Background:

Standard hospital discharge planning typically involves arranging follow-up appointments with primary care providers.
Phone calls as a post-discharge follow-up strategy offer a potential alternative to traditional face-to-face visits for certain patient populations.
This approach was evaluated within the US Department of Veterans Affairs (VA) Patient Aligned Care Team (PACT) model, a patient-centered medical home.

Purpose of the Study:

To assess the feasibility and impact of using post-hospital discharge phone calls as a follow-up method within the VA's patient-centered medical home model.
To determine if phone follow-up could be integrated into standard discharge planning practices.
To evaluate the safety and effectiveness of phone follow-up compared to traditional in-person visits.

Main Methods:

A pilot study was conducted at a VA hospital, implementing phone calls from the patient's medical home team for post-discharge follow-up.
Inpatient providers received education on the phone follow-up alternative, and it was standardized in discharge planning.
The initiative was rolled out in phases, starting with one clinic and expanding to eight additional sites, with data collection at each stage.

Main Results:

During Phase 1, 14.4% of eligible patients received phone follow-up. This increased to 17.0% by Phase 3 after expansion to all sites.
No significant differences were observed in 30-day emergency department (ED) utilization rates between phone follow-up and traditional follow-up groups (11.9% vs. 5.9%).
Similarly, rates of nonelective rehospitalization did not significantly differ between the groups (16.8% vs. 17.6%).

Conclusions:

The initiative successfully shifted provider practices towards utilizing phone call follow-up for suitable patients post-hospital discharge.
This change in practice was achieved without a significant increase in adverse outcomes such as 30-day ED visits or rehospitalizations.
Phone follow-up represents a viable and safe alternative within the patient-centered medical home framework, enhancing discharge planning options.