A home health nurse is conducting a follow-up visit for a client who was recently discharged

Purpose of This Tool

The Re-Engineered Discharge (RED) aims to effectively prepare patients and families for discharge from the hospital, improve patient and family satisfaction, and decrease hospital readmission rates. The postdischarge followup phone call, the 12th component of the RED, is an essential part of supporting the patient from the time of discharge until his or her first appointment for followup care. Tool 2, "How To Begin Implementing the RED," discusses the options for assigning staff to conduct the call.

All RED patients should be called 2 to 3 days after discharge by a member of the clinical staff. This postdischarge followup phone call allows the patient's actions, questions, and misunderstandings, including discrepancies in the discharge plan, to be identified and addressed, as well as any concerns from caregivers or family members. Callers review each patient's:

• Health status.
• Medicines.
• Appointments.
• Home services.
• Plan for what to do if a problem arises.

This tool addresses the person who will make the followup phone call. After reading this tool, you will:

• Know how prepare for the phone call.
• Be proficient in completing a postdischarge followup phone call.
• Be able to conduct appropriate postcall actions.

Preparing for the Phone Call

Ensure Continuity of Care

If you are the discharge educator (DE) who provided the in-hospital RED components, you will be familiar with the patient. This will help you maintain continuity between the inpatient stay and the followup call. Still, you need to recognize that your patient is now in a different setting and you may need to tailor your communication style to the patient's current needs.

If your hospital has chosen to use a different person to provide the in-hospital RED components and to complete the call, you should:

• Communicate with the DE in order to have a smooth handoff and obtain important information about the patient and family that the DE has learned while working with the patient.
• Familiarize yourself with the patient by reviewing the information about the hospital stay thoroughly. (Go to Review Health History and Discharge Plans below.)

The remainder of this tool will instruct you as if you are not the DE.

Learn How To Confirm Understanding

Throughout the followup call, you will need to confirm that the person you are speaking with understands what you are discussing. One of the easiest ways to close the communication gap between patients and educators is to use the "teach-back" method. Teach-back is a way to confirm that you have explained to the patient what he or she needs to know in a manner that the patient understands. Patient understanding is confirmed when he or she explains the information back to you in his or her own words. Lack of understanding and errors can then be rectified with further directed teaching and reevaluation of comprehension.

A video demonstration of the teach-back method is available at: http://www.nchealthliteracy.org/teachingaids.html . Some points to keep in mind include:

• This is not a test of the patient's knowledge; it is a test of how well you explained the concepts.
• Be sure to use this technique with all your patients, including those who you think understand as well as those you think are struggling with understanding.
• If your patients cannot remember or accurately repeat what you asked them, clarify the information that you presented and allow them to teach back again. Do this until the patient can correctly describe your directions in his or her own words.

Review Health History and Discharge Plans

Before the phone call, obtain the patient's hospital discharge summary, the after hospital care plan (AHCP), and the DE's notes. If the discharge summary is not complete or if an AHCP was not generated for the patient, you will need to collect this information from other sources. These may include the hospital medical record, notes from the clinician who discharged the patient, the inpatient clinicians who cared for the patient, and the ambulatory medical record.

You will need to be familiar with the patient's health history and discharge plan before you make the followup phone call. Review the discharge summary and AHCP to find out about:

• Diagnosis and condition at discharge. You will ask the patient about his or her health status and discuss symptoms.
• Personal information, usual daily routines, relevant cultural practices, involvement of family, and relevant stressors and supports. This will help you make the call patient centered.
• Followup appointments. You will find out whether appointments have been completed and plans for future appointments.
• Home services and equipment. You will confirm that home services and equipment have been delivered as expected and discuss the need for additional home services.

Check Accuracy and Safety of Medicine Lists

While the patient was in the hospital, the DE should have completed medication reconciliation. The goal of inpatient medication reconciliation is to produce a correct and consistent list for the patient and clinicians, where the medication lists are identical in the discharge summary, inpatient medical record, AHCP, and, if possible, the ambulatory medical record.

In certain cases, however, this may not have happened (e.g., patient leaves against medical advice or sooner than expected, patient is discharged at a time when a DE was not available).

To check whether the patient has been given an accurate medicine list, compare the list of medicines on the hospital discharge summary with the medicines listed in the AHCP. If medication reconciliation was done correctly at discharge, these lists should match. If they do not match, resolve the issue before the followup phone call by talking to the hospital team (starting with the DE) and/or primary care provider (PCP),i depending on the nature of the inconsistencies or errors identified.

Doublecheck the medicine list for potentially harmful drug interactions. This should have been done as part of the in-hospital medication reconciliation process but may not have been completed for the reasons discussed above. If you identify any drug interactions, speak with the hospital team (starting with the discharging physician) to get clarification and make any necessary changes to the patient's medicines.

Identify Problems Patients Could Have With Medicines

Changes in medicine regimens can be particularly confusing to patients returning home. Note changes such as discontinuation of medicine taken prior to the hospital stay or a change in the dose. Any medicine with complicated instructions can also be a source of confusion. Pay special attention to medicines for which the adverse consequences of taking them incorrectly are severe.

Familiarize yourself with commonly known drug-food interactions and side effects prior to the call. This will enable you to actively elicit this information from the patient, as well as educate him or her on possible side effects.

Arrange for Interpreter Services

The DE should have noted on the contact sheet (go to the Contact Sheet) whether an interpreter is needed for the phone call. If an interpreter is needed and your hospital has not documented that you are proficient in the language, arrange for interpreter services before the call. You can use a qualified hospital interpreter by using a speakerphone in a private location or a three-way phone system. You may also use a telephone interpreter that your hospital contracts with. Notify your interpreter services department in advance of when you will need an interpreter, for how long, and in what language.

You may have an unanticipated need for interpreter services. This can happen if a patient or caregiver's English skills are sufficient for in-person communication but not for telephone communication, or if the need for interpreter services was not accurately recorded. Know the procedure to access immediate interpreter services.

More detailed information about using an interpreter, developing cultural and linguistic competence, and reducing disparities in health care communication is described in Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital."

Conducting the Phone Call

Whom and When To Call

Before discharge, the DE will have collected contact information from the patient to facilitate reaching the patient or caregiver via phone within 72 hours of discharge. This information is found in the Contact Sheet. It includes:

• Patient's desire to have a legal proxy or caregiver receive the phone call, if applicable.
• Preferred language and need for interpreter (for person receiving the call).
• Contact information for patient, proxy, and caregivers.
• Ideal time of day and day of the week to reach patient, proxy, and caregivers.

When you plan your calls for the day, note that calls will vary in length, from approximately 20 to 60 minutes. The type of patient population you target can affect the length of calls. Patients taking more medicines will require longer calls.

Start your calls 48 hours after discharge. If the patient has delegated the phone call to his or her legal proxy (the person with legal authority to act on behalf of the patient) or his or her caregiver, call that person first.

• Call the patient or legal proxy or caregiver designated to receive the call at the time of day listed as the best.
• If you cannot reach this person the first time, make several attempts over the next few days.
• If you still cannot reach this person, call the next contact on the list. If you cannot reach or do not get useful information from the contacts on the list, check the information on file at the hospital for additional contact numbers.

What To Say

The followup phone call consists of five components:

• Assessment of health status.
• Medicine check.
• Clarification of clinician appointments and lab tests.
• Coordination of postdischarge home services.
• Review of what to do if a health or medical problem arises.

This toolkit contains a patient call script developed by the RED team to provide guidance for completing the call. Some hospitals, however, have found the call script too time consuming. Adapting the call script for your hospital and your RED patient population will focus the call and make efficient use of your time. A data collection sheet for documenting the call also is available.

The script is just a guide. The phone calls will require flexibility and creativity. You will problem solve with patients and caregivers and refer any issues that require further intervention to the appropriate clinical team member. This toolkit portrays a fictionalized followup phone call, in which Brian, a nurse at the hospital, speaks with Mrs. Smith, a patient with congestive heart failure. This script, designed to be used at a training session for staff performing followup phone calls, gives you a sense of how a conversation might go.

Verify Availability To Talk and Need for Interpreter Services

After introducing yourself, ask if it is a good time to talk. If it is not, get a precise time when you can call back. If the person says he or she only has a limited amount of time available, try to prioritize and tailor the call to meet the needs of that person.

Even if the contact sheet indicates that an interpreter is not necessary, you should independently assess the need for an interpreter. The DE may have assumed that people who could speak English without an interpreter at the hospital could comfortably complete the phone call in English. The telephone, however, presents another hurdle as it removes context, body language, and lip movement.

If you have any sense that the patient or caregiver is not proficient in English and you are not documented as proficient in the preferred language, let him or her know that you would like to use an interpreter. If an interpreter is not immediately available, schedule a time to call back.

Try to establish an open communication style so patients or caregivers share their hesitations or problems they are having with the discharge plan. Ask them to locate and bring the AHCP and all medicines, supplements, and traditional remedies to the phone.

Assess Health Status

You will ask about the patient's:

• Comprehension of the reason for his orher hospital visit.
• Perception of any change in health status since discharge.
• Understanding of how to manage any medical changes or whether he or she needs to seek medical care for any concerns (either relating to the primary discharge diagnosis or any new problems).

If the patient's health status has deteriorated, a plan of action may be needed. Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse drug event, or other symptoms may include:

• Providing patient education.
• Checking whether the patient is taking medicine as directed.
• Checking labs and reviewing medicine list for cause of complaint.
• Advising the patient to attend an upcoming scheduled appointment with his or her PCP.
• Recommending patient action (e.g., take a medicine that was prescribed to take as needed, limit activity).
• Advising the patient to call his or her DE, PCP, or specialist.
• Advising the patient to go to urgent care or the emergency department.
• Consulting with the DE, inpatient physician/team, or pharmacy.
• Alerting the PCP.
• Arranging a same-day sick appointment.
• Determining the family's perception of the patient's status.

Check Medicines

The medicine check involves making sure patients or caregivers understand what the patients' medicines are for and how to take them. This part of the phone call can be lengthy, since each medicine needs to be reviewed: name, when they take it, how much they take, how they take it, why they take it, and any problems or side effects.

There are many potential barriers to adherence. Your job is to encourage the patient to share the most accurate information regarding what interferes with his or her willingness or ability to take the medicine. You might find it helpful to think about three sources of nonadherence:

• Intentional nonadherence.
• Inadvertent nonadherence.
• System/provider error.

Intentional nonadherence. When a patient has chosen not to take a medicine that is part of the discharge plan or insists on taking medicine in a manner other than prescribed or that is contraindicated. Reasons for patient's intentional nonadherence include:

• Personal, family, or cultural concerns regarding medicine.
• Concern regarding actual or feared side effects; and
• Difficulty filling prescriptions, including access to the pharmacy, insurance issues, and financial problems.

Inadvertent nonadherence. When a patient is not following the treatment plan due to difficulty understanding the plan or an inability to execute it. Examples of inadvertent nonadherence include:

• Failure to remove discontinued medicine from a pillbox.
• Inability to pay for or pick up medicines.
• Inability to understand instructions such as "take on an empty stomach" or "do not take with dairy products."

System/provider error. When the hospital did not do something it was supposed to. Examples of system/provider errors include:

• Conflicting information (e.g., the AHCP lists one type of antibiotic while the prescription was issued for another).
• Missing information (e.g., AHCP did not list when patient should take medicine).
• Missing pieces of the discharge plan (e.g., prescription was not issued at discharge).

Some nonadherence problems can be solved by providing education to fill in knowledge gaps. Others may require your contacting the patient's pharmacy, PCP, or DE or the inpatient physician who discharged the patient if there are any discrepancies between the discharge summary/AHCP and what the patient reports. If clarifying misunderstandings does not work with patients who are intentionally nonadherent, try enlisting the assistance of family members and spiritual leaders or traditional healers. Go to Tool 4, "How To Deliver the RED to Diverse Populations," for more on the family and community's role in patient treatment.

Once discrepancies are resolved, you will probably have to follow up with the patient with an additional phone call. Always conduct teach-back to confirm that the patient or caregiver understands how to take medicines. The box below illustrates how postdischarge phone calls can expose and resolve cases of intentional nonadherence.

Clarify Appointments

Check that the patient or caregiver knows about all followup appointments (e.g., primary care followup, lab test, specialist) and their dates, times, and locations; the purpose of the appointments; and that the patient can make it to the appointments. For example, if the patient has identified a support person to assist with transportation and other logistics, find out if the patient has sought and is receiving help from that person. You will need to problem solve with the patient if there are barriers to keeping appointments.

Coordinate Postdischarge Home Services

Check whether the patient has received home services and durable medical equipment that are scheduled and listed on the AHCP. You will need to intervene if services or equipment have not been received on time. Also check that caregivers have been available as expected. If a caregiver has not been available, explore alternatives, such as someone else who could help out or services available in the community (e.g., Meals on Wheels; spiritual leaders, clergy, or congregants).

Discuss What To Do If a Problem Arises

Always end the call by reviewing what the patient or caregiver should do if a problem arises at any time (any hour and day of the week). Make sure patients and caregivers understand:

• What types of emergency and nonemergency situations they may encounter.
• What to do in case of an emergency.
• How to call the patient's PCP, including after hours.

Documenting Your Call

You will need to document your calls, both for the patient's medical record and to allow hospital management to monitor the information for quality improvement purposes. For example, your hospital may identify common errors patients make and use this information to improve teaching to other patients with similar regimens or conditions. More detail for this process is included in Tool 6, "How To Monitor RED Implementation and Outcomes."

Documentation includes:

• Call attempts.
• Patient's health status.
• Problems with medicines.
• Appointment status.
• Patient's postdischarge actions.
• Followup actions you take.

This toolkit contains a sample of a data collection form you can use to document your followup phone calls.

Communicating With the Primary Care Provider

After you have completed a call, you may need to communicate with the patient's PCP. You can do this in a number of ways, such as via secure Email, flag in the electronic medical record (if the PCP is part of your hospital system), fax, or phone. If you call and cannot speak directly to a medical staff person within the PCP's office, you will need to follow up with another form of communication. Commonly, secure electronic communication is the most efficient means to transmit patient information. Below are two examples of Emails to alert providers.