Phone-based transitional care program has high engagement among surgical patients

For patients undergoing complex abdominal operations in the United States, poor transitions from the hospital to home contribute to hospital readmission rates ranging from 13 to 30 percent. To address this situation, a research team used the framework of a successful phone-based transitional care program adapted to the needs of surgical patients, based on a systems engineering approach. The researchers found the program was feasible for hospital staff to implement and provided a positive experience for patients, according to study results published as an "article in press" on the Journal of the American College of Surgeons website ahead of print publication.

In 2012, the Centers for Medicare & Medicaid Services (CMS) began reducing Medicare payments for hospitals with excessive hospital readmissions under the Hospital Readmissions Reduction Program. In an effort to reduce readmissions, health care systems studied the impact of transitional care programs and whether they improved the postoperative health of patients with chronic medical conditions, study authors wrote. Physicians at William S. Middleton Memorial Veterans Hospital, Madison, Wisc., previously demonstrated that implementation of a transitional care program for hospitalized patients led to a reduction in readmissions and cost savings. However, no evidence-based transitional care program existed for surgical patients, according to lead study author Sharon Weber, MD, FACS, professor and chief of the division of surgical oncology, department of surgery, University of Wisconsin School of Medicine and Public Health, Madison.

Therefore, Dr. Weber and her team relied on the infrastructure of the original program as well as information from interviews with patients about what contributes to poor care transitions. Patients mentioned factors including inadequate patient education, hurried discharge, failure to retain pertinent recovery information, and unclear plans for follow-up care.

"We clearly identified a gap in patient care during that transition between their inpatient stay and return to full health," Dr. Weber said. "We realized there were a lot of things we didn't understand about factors that might lead to readmission." Dr. Weber's coauthor, Amy Kind, MD, PhD, was part of the group that originally implemented the Coordinated Transitional Care (C-TraC) Program for medical patients at the VA hospital.

To implement the adapted surgical program, known as sC-TraC, University of Wisconsin Hospital hired new nurses who underwent a five-week intensive training that prepared them to counsel patients on postoperative recovery. The nurses met the patients before they were discharged from the hospital. The pilot study was conducted from October 2015 through April 2016, and included 212 patients enrolled after complex abdominal procedures, defined as colorectal, hepatobiliary, or other gastric or small bowel resections.

After they were discharged from the hospital, nurses contacted patients within 24-72 hours to review four focus areas: medication reconciliation, any symptoms that would warrant direct contact between the nurse and patient, scheduling a follow up appointment, and ensuring the patient had the nurse's contact information. The nurses initiated phone calls every three to four days as needed. The program was completed once the patient and/or caregiver and the sC-TraC nurse mutually agreed that no further follow-up was needed, the patient had been discharged for six weeks, or the patient was readmitted to the hospital within 30 days after discharge, study authors wrote.

Ninety-five percent of patients participated in the post discharge protocol for at least one phone call, which Dr. Weber called a huge success. "Patients were so unbelievably happy to have someone that they could reach directly on the phone and they didn't have to go through a phone tree," she said. "There's something about that direct access to the health care system that's immensely gratifying to patients and their caregivers." Among the engaged patients, 72 percent ended the program after mutual agreement that no further follow-up was necessary. A small percentage refused further follow-up or were readmitted to the hospital. Of all 212 patients, 17 percent were readmitted within 30 days of discharge.

Researchers also found that 46 percent of patients had medication reconciliations (meaning the patients weren't taking medications correctly) noted on the first phone call. Study authors said this finding was concerning because it is the hospital's routine practice to have a pharmacist-led medication reconciliation before the patient leaves the hospital. "It reiterates that what we are providing at discharge in a routine way is not enough to meet patients' needs," Dr. Weber said.

Dr. Weber said this study was the first to show data about medication discrepancies in postoperative patients. Study authors wrote it demonstrates a clear need to study the impact on readmission and recovery for these patients.

Study authors hypothesized that there was high patient engagement because of the early incorporation of patient-identified needs as well as a non-intrusive follow-up program. The sC-TraC nurses fit in well with the hospital's existing infrastructure and established rapport with patients. Additionally, the phone-based program allowed for an increase in the scale and breadth of follow-up care with minimal increase in staffing, study authors wrote. A multi-center randomized controlled trial in the future would assess the impact of this program on post-discharge health care utilization.

Dr. Weber said the interviews with patients were particularly important in conducting this study. "It's not just about ER use, or cost, or readmission. It's about whether patients feel like we are providing them with what they need."