Discharge Follow-up Phone Call Program

Study Overview
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Brief Summary
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The goal of this project is to quantify the impact of post-hospital discharge follow-up phone calls on hospital readmission, ED visits, patient satisfaction, and mortality in a general medicine inpatient population. We will obtain exploratory information on patient sub-groups at high risk for hospital readmission and on those experiencing high benefit from the follow-up phone call intervention. In addition, we will obtain data on discharge plan implementation assistance needed to support a successful transition from inpatient to outpatient care among those reached by the intervention phone call.

Detailed Description
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RATIONALE In the current medical literature, it is unclear how follow-up calls influence these outcomes in a general medical population. Some studies have attempted to address this question, but are limited in that they target very specific patient populations, are of insufficient quality, or evaluated follow-up calls as part of a larger care bundle. We will conduct a high quality, real-time clinical care study to determine the efficacy of a follow-up phone call program. STUDY DESIGN This is a single center, pragmatic, randomized, controlled clinical trial to investigate whether a structured post-hospital discharge follow-up phone call can improve patients' transition from in-hospital to outpatient care and improve satisfaction with their care. We will also identify the discharge implementation assistance given to those in the intervention (Phone Call) group. Outcome Measures Primary outcome for this study is readmission event rate within 30 days. Secondary outcomes include patient satisfaction which will be measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores, all cause VUMC emergency department (ED) visits, the need for assistance with discharge plan implementation, and 30 day mortality.

Official Title
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A Pragmatic, Randomized, Controlled Trial Examining the Effectiveness of a Hospital Discharge Follow-up Phone Call Program

Conditions
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Discharge Follow-up Phone Calls

Intervention / Treatment
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* Behavioral: Follow-up Phone Call


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: VUMC patients discharged after an inpatient status hospital stay on a general medicine service. Exclusion Criteria: patients who experience in-hospital death patient discharged to any post-acute care facility or inpatient hospice left the hospital against medical advice

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a single center, pragmatic, randomized, controlled clinical trial.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Phone Call Group (Intervention Arm)<br>Follow-up phone call intervention: Patients will receive the first call attempt within 72 hours of hospital discharge with a maximum of 3 call attempts by the study nurse made up until post-discharge day 7. The semi-structured script embedded within the program specific electronic health record Discharge Phone Call Starform is used to guide a conversation to obtain information on potential causes of hospital readmission that can be identified and addressed to improve each patient's transition to outpatient care. | Behavioral: Follow-up Phone Call<br>* Patients will receive a first call attempt within 72 hours discharge.<br>|
| No Intervention: Usual Care Group (Control Arm)<br>Patients assigned to the control group receive standard discharge planning and follow-up per the usual care of their medical providers. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With In-patient Re-admissions | Number of participants with in-patient re-admissions | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient Satisfaction: Experience | Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Higher scores indicate more patient satisfaction. Range is 0-9 with 9 being the most satisfied. | Within 60 days of Discharge | 
| Patient Satisfaction: Likelihood to Recommend the Facility (Top Box Rating) | Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Number of patients that reported a score of 3. Range is 0-3 with 3 being highest satisfaction. | Within 60 days of Discharge | 
| Patient Satisfaction: Hospital Experience (Top Box Rating) | Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Number of patients that rated the Hospital Experience as 9. Scale range is 0-9. Higher scores indicate more patient satisfaction. | Within 60 days of Discharge | 
| Patient Satisfaction: Likelihood to Recommend the Facility | Measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores. Scale range is 0-3. Higher scores indicate more patient satisfaction. | Within 60 days of Discharge | 
| VUMC Emergency Department (ED) Visits | All cause ED visits following discharge | 30 days | 
| Number of Patient Received Discharge Plan Implementation Assistance | Need for assistance in implementing discharge plan | 30 days | 
| Mortality | All cause mortality | 30 days |