Issue: The Affordable Care Act, ACA Section III, encourages development of new transitional care models linking hospital reimbursements to improved quality, efficiency, and transparency in care delivery. Unplanned readmissions, a quality indicator, are costly under ACA and on the forefront of the Joint’s Commission effort to advance data utilization and improve care to stroke patients through the Comprehensive Stroke Center (CSC) certification requirements. Follow- up phone calls to patients discharged home from the hospital within seven days are embedded in the above requirements and can be a valuable tool in reducing unplanned readmissions and in improving support to stroke patients with complex psychosocial and medical needs.
Purpose: Phone calls initiated by a Nurse Practitioner (NP) to stroke patients after discharge to home in our CSC aimed at increased medication compliance, avoidable readmission rate monitoring, and comparison of outcomes to those reported in the literature. In investigating trends we pursued opportunities to enhance care delivery, establish long-term relationship with patients, and empower them to involve actively in their care.
Method: We utilized descriptive statistics in retrospective and prospective hospital data analysis extending our focus on development of quality improvement initiatives. Inclusion criteria consisted of age >18, primary diagnosis, and discharge disposition.
Results: Between June 2014 and June 2015, after the calls introduction, we achieved an absolute risk reduction of 4.1% in short-term readmissions within 30 days. Compared to the year before readmission rates decreased by 60% with number needed to treat of 25 and preventative fraction of 40%, similar to reduction rates cited in current literature. Patients expressed satisfaction with care and in discussions with the NP helped identify improvement areas for our program. Limitations of the study include single center observations and specific characteristics of our regional population.
Conclusion: When implemented as part of a transitional care model, telephone calls to stroke patients post hospital discharge to home conducted by an NP can be an effective tool in reducing unplanned readmissions and improve patient satisfaction with care.