Impact of Post-Discharge Follow-Up Calls on 30-Day Hospital Readmissions in Neurosurgery

Hospital readmissions occur when a patient is admitted to a hospital within a specified time after being discharged from an initial hospitalization.^[1] Unplanned readmissions that occur within 30 days of discharge from an initial hospital stay are costly and avoidable.^[2] As estimated by the Medicare Payment Advisory Commission, 12% of readmissions are potentially avoidable.^[3] Avoidable readmissions cost the federal government $17 billion annually.^[4] Despite efforts aimed at enhancing the transition of care from the hospital, readmissions have remained a challenge, dropping only by 0.1% from 2013 to mid-2016.^[5]

Across all service lines and age groups, adverse outcomes that occur post-discharge can lead to readmission; the risk is high in older patients because of difficulty in comprehending the discharge instructions.^[6–8] Other factors responsible for unplanned 30-day readmission include but not limited to incomplete treatment and inadequate coordination of services after discharge, and can be aggravated by quicker hospital discharges that tend to leave patients unprepared for what to expect or do after they are discharged from the hospital.^[9,10]

The Hospital Readmissions Reduction Program (HRRP) established in 2012 by the Affordable Care Act required the Centers for Medicare and Medicaid Services (CMS) to reduce reimbursements to hospitals with readmission rates that are higher than the national average estimated to be approximately 19% between 2007–2011.^[3,11,12] As such, readmission rate is increasingly becoming an essential indicator of the quality of patient care.^[10,13–15] Extending patients care after discharge from the hospital could save hospitals from penalties, increase the quality of care, and improve patients’ health outcomes. Conducting small-scale tests to improve daily medical practices has been shown to be effective in a variety of settings.^[16] Low-cost small-scale interventions such as follow-up calls post-discharge can provide a continued plan of care, improve clinical outcomes, enhance patients engagement and satisfaction, identify complications early, manage symptoms, and reduce costly readmissions.^[7,17–19]

In a study to identify deficiencies leading to readmissions in the neurosurgery service located in a large academic medical center, having a provider call discharged patients within 24–48 h post-discharge was one of the strategies implemented to attempt to reduce readmissions. Nurse practitioners were required to conduct post-discharge follow-up calls to identify and remediate red flags early.^[20] The authors implemented this study as a quality improvement initiative within a well-established interdisciplinary clinical and academic quality improvement program in the neurosurgery service. The aim of the study was to evaluate the effectiveness of nurse follow-up calls conducted in the neurosurgery service for discharged patients between October 2017 and February 2018 in reducing readmissions that occur within 30 days of initial hospital stay.

A Plan–Do–Study–Act methodology was used in this study.^[21] Initially, an audit was conducted to assess the nurses’ compliance with conducting follow-up calls in the neurosurgery service. Weekly discharge reports were used to check against medical charts if patients received a follow-up call within 24–48 h post-discharge. There was a provision in each patient’s chart for nurses to make a note of post-discharge follow-up call encounters. Follow-up call encounters including date and time of calls were extracted from the electronic medical records and recorded in excel sheets for analysis. Preliminary results revealed that nurses were not routinely conducting follow-up calls. To understand the current situation with follow-up calls including reasons for noncompliance to help with ideas for improvement, an anonymous survey was administered to the nurses. Mixed methods were used to analyze the survey data.

A retrospective chart review of medical insurance claims data was conducted and data were analyzed to assess if there was any difference in number of days from initial discharge to readmission between patients who received a follow-up call and those who did not receive a follow-up call within 24–48 h after they were discharged from the initial admission and before they were readmitted. Patients who were identified as having been readmitted within 30 days of their initial hospital stay based on the medical insurance claims data for October 2017 to February 2018 were included in the study; N = 83 patients.

A plan of study activities is provided in Table 1.

The response variable was number of days between discharge from initial admission and readmission, with the main explanatory variable being receiving a follow-up call. Data of all patients who were admitted were extracted and only patients who were readmitted within 30 days of the initial hospital stay from October 2017 to February 2018 were included in the study. The timeframe of interest considered the authors’ time and resources, the time to gather and implement the study to get initial data to assess the alignment of the aims of follow-up calls. This small-scale intervention or pilot study is a preparatory investigation yielding specific information for planning and guidance for operationalizing processes and interventions.^[22] Other variables collected from the medical insurance claims data for readmitted patients included age, sex, race (white or black/other), length of stay (LOS) at index admission, transfers from the emergency room (ER), disease severity (minor/moderate or major/extreme), day of the week discharged (weekday/weekend), and insurance provider (state or private). These variables were essential in helping to adjust the results to control for possible confounding effects.

Univariate summary statistics were described by calculating medians, minimum, maximum, and means based on a two- sample t test for continuous variables. Proportions were used to describe categorical variables. Pearson’s chi-square test (or Fisher exact test where the expected value of a cell in the contingency table was less than 5) of independence was used to describe the independence of two categorical variables. To account for heterogeneity and adjust for other potential risk factors and confounding covariates, a negative binomial multivariable regression model was used. Data were analyzed using Stata software.^[23]

In total, 83 patients were included in the analysis. Of these, 45% (n = 37) received a follow-up call after they were discharged from initial admission. Descriptive analysis (see Table 2 for details) using a two-sample t test indicated that the estimated mean number of days from initial discharge to readmission (±standard error [SE]) was higher for patients who received follow-up calls ( = 15.8 days ± 1.53), which is approximately 16 days on average, compared to 10 days for patients that did not receive a follow-up call ( = 10.2 days ± 1.22, p = 0.005).

After adjusting for all other covariates using a negative binomial multivariable regression model, patients who received a follow-up call after they were discharged from initial admission stayed out of hospital longer (incidence-rate ratio [IRR] = 1.54, 95% confidence level [CI] = [1.13, 2.10], p = 0.006) compared to those that did not receive a follow-up call (see Table 3 for details). The estimated average number of days out of hospital readmission was 16 days (SE = 1.77, 95% CI = [12.32 days, 19.26 days]) for patients who received a follow-up call, and 10 days (SE = 1.08, 95% CI = [8.13 days, 12.36 days]) for patients that did not receive a follow-up call.

The neurosurgery service had a total of six nurse practitioners. Five of the six nurse practitioners participated in a survey, a response rate of 83%. A summary of the survey results is provided in Figure 1.

Findings from the study suggested that receiving a follow-up call after being discharged from the initial admission increased the LOS out of hospital, (IRR = 1.54, 95% CI = [1.13, 2.10], p value = 0.006). These findings are consistent with the majority of studies that have shown that in addition to discharge instructions and education provided to patients and/or the patient’s legal caregiver, follow-up calls post-discharge can be effective at reducing readmissions.^{[9,17,18,24,25]} In the USA, readmissions make up $41 billion in health care spending.^[5] Implementing small-scale low-cost interventions in health care, such as follow-up calls post-discharge, could save hospitals from penalties, improve patient outcomes, and contribute to the reduction of health care costs.

In the neurosurgery service, conducting routine follow-up calls to all discharged patients particularly targeting patients at a higher risk of readmission could improve patients’ outcomes as well as social conditions such as lack of support at home, which could make following doctor’s instructions difficult.^[5] As the CMS plans to begin accounting for patients’ socioeconomic status in 2019,^[5] adhering to routine follow-up calls post-discharge may place the neurosurgery service a step ahead in understanding the patients’ socioeconomic issues.

The neurosurgery service is located in a large teaching hospital and of the over 3000 hospitals participating in the HRRP, those more likely to receive penalties were urban, major teaching, and larger hospitals.^[26] These hospitals with higher readmissions may be penalized based on the patients they serve.^[27] Social characteristics predispose certain patients to greater rehospitalization because they lack needed discharge resources such as social support or primary care.^[28] Controlling social characteristics is often outside the hospital’s influence, but if a facility is treating a large proportion of socially disadvantaged patients, then it may be necessary to devote more resources, like follow-up calls, to avoid the costs associated with readmissions.

More common hospital follow-up calls are primarily conducted by clinical staff such as nurses, physicians, or pharmacists.^{[9,19,24,25,29]} A recent review by Meek Clinical Partners, LLC, found that about 73% of the primary initiators of follow-up calls post-discharge are nurses.^[25] The problem with utilizing clinical staff to initiate follow-up calls post-discharge is that it adds to their list of responsibilities and many dislike making post-discharge calls with over 20% affirming that they would rather do any other task.^[25,30] Nurses and other clinical staff feel the amount of time to make the post- discharge calls is underestimated. On average, the initial post-discharge calls are 10–20 min.^[31] If an issue arises, that time is much longer and there is also extra time needed to summarize the issues for feedback to the care providers.^[32]

From the nurses’ survey, nurses indicated that other tasks such as follow-up on patients’ insurance issues take precedence over follow-up calls post-discharge. As such, continuing to require nurses to initiate post-discharge follow-up calls to all discharged patients in the neurosurgery service may not be a sustainable approach. Moreover, precaution must be taken to ensure that nurses in the neurosurgery service have ample time to perform their primary administrative duties and that they are not overburdened with additional tasks such as being the primary initiators of post-discharge follow-up calls. In this study, only 45% of patients discharged between October 2017 and February 2018 received follow-up calls post-discharge. This was indicative that more patients could benefit from avoiding early readmissions if the follow-up call process was optimized to ensure routine and timely follow-up calls were made to all patients who were discharged.

Accordingly, the authors of this study recommended optimizing the process of follow-up calls in the neurosurgery service to increase efficiency by redesigning the process to utilize trained nonclinical staff, specifically trained graduate interns within the neurosurgery quality improvement program as the preliminary initiators of follow-up calls post-discharge. The use of nonclinical staff to initiate follow-up calls and/or contracting the services to external vendors is a practice that some organizations are turning to with a goal to achieve high levels of engagement and satisfaction of patients post-discharge.^{[24,25,30,33]} As the neurosurgery service is in a large academic medical center, the strategy of utilizing trained graduate interns as initiators of the preliminary follow-up calls is believed to be sustainable and cost-effective compared to utilizing other categories of nonclinical staff.

Other proposed strategies for improving the post-discharge follow-up call process in the neurosurgery service included using a structured call script and a tracking log when initiating follow-up calls to ensure that the process was standardized, effective, and well documented. A call script written in a layman’s language was developed and tested with the neurosurgery patients. Patients identified to be at risk of early complications post-discharge were triaged to nurses for immediate action. A sample of the follow-up call script is provided in Figure 2.

As the primary role of the trained graduate interns in the neurosurgery service is to initiate follow-up calls post-discharge, it is expected that the number of patients followed up post-discharge would increase to at least 75%. Thus, reducing the chances of early readmission and contributing to the reduction of readmissions occurring within 30 days of initial hospital stay.

In the neurosurgery service, utilizing trained graduate interns to initiate follow-up calls post-discharge will ensure that routine follow-up calls are made to all discharged patients at low cost. The number of patients followed up will increase and nurses will only follow-up on complicated cases as opposed to following up on all discharged patients. In addition, the use of a structured call script and a tracking log when initiating follow-up calls will relieve nurses of post-discharge call tracking and documentation responsibilities. Measurable indicators captured using the call tracking log such as time taken to make follow-up calls will provide real-time evidence-based data for estimating the effort required to conduct follow-up calls post-discharge in the neurosurgery service. The recommendations identified in this study can be replicated in other similar services to improve patients’ health outcomes.

The study findings suggest that readmitted patients who received follow-up calls post-discharge had significant improvements in the length of time out of hospital compared to those that did not receive a follow-up call post-discharge. Reducing neurosurgery readmission can generate cost savings at a local level as well as help avoid future CMS penalties under the HRRP. Future development could include developing additional call strategies and identifying patients at higher risk of readmission. Further studies need to be completed because the results from this single-center cannot necessarily be generalized to other institutions.