Implementing a Discharge Follow-up Phone Call Program Reduces Readmission Rates in an Integrated Health System.

Area of Science:

• Healthcare Quality Improvement
• Patient Outcomes Research
• Health Services Research

Background:

• Unaddressed patient concerns post-discharge are linked to increased care complications and hospital readmissions.
• Effective discharge planning and follow-up are critical for reducing preventable readmissions.
• Proactive patient contact after hospital discharge can mitigate risks.

Purpose of the Study:

• To evaluate the impact of a large-scale, nurse-led discharge follow-up phone call program on hospital readmission rates.
• To assess the effectiveness of timely post-discharge patient contact in a major academic health system.
• To determine if proactive outreach influences 7-day and 30-day readmission rates.

Main Methods:

• An observational quality improvement project conducted across 22 hospitals from April 2020 to January 2022.
• Implementation of a scripted, nurse-led phone call program to contact patients within 72 hours of inpatient discharge.
• Tracking and comparison of readmission rates before and after the program's implementation, analyzing contacted versus non-contacted patients.

Main Results:

• Over 137,000 calls were made during the 21-month study period, with a 57.92% patient contact rate within 7 days.
• Contacted patients had a lower 7-day readmission rate (2.91%) compared to non-contacted patients (4.73%).
• Contacted patients also showed a reduced 30-day readmission rate (11.00%) versus non-contacted patients (12.17%).

Conclusions:

• A systematic, nurse-led discharge follow-up phone call program effectively decreases hospital readmission risk.
• Proactive patient engagement post-discharge is a valuable strategy for improving patient outcomes and reducing healthcare system burden.
• The findings support the scalability and effectiveness of this intervention in integrated health systems.