Project BOOST
72-hour Telephone Follow-Up
Literature Review
Amit Patel, MD, FACP, SFHM
Chithra Perumalswami, MD
Objectives
• Your team will better understand:
– The literature behind the follow-up phone call
process (benefits, greater context, etc.)
– Who should make the calls.
– What means of communication have been
studied.
– Which diseases have been studied in this
context.
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Benefits
What is the value of calls?
• Patients’ benefits:
– Clarify any misunderstandings in the care
plan.
– Reminders to adhere to follow-up plans and
treatment.
– The ability to learn of labs which returned
after discharge.
Nelson JR; American Journal of Medicine, 2001;111(9B):43S–44S.
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What is the value of calls?
• Hospital’s benefits:
– Learn from patient and family/caregivers
about unexpected outcomes.
– Early detection of treatment failures.
– Re-establish/Reinforce patient-physician
relationship.
– Learn whether patient complied with
outpatient services, home nursing visits, etc.
– Learn whether patient complied with
discharge instructions, bought Rxs, etc.
Nelson JR; American Journal of Medicine, 2001;111(9B):43S–44S.
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Potential Value of Calls
• A VA-funded study of psychiatric patients
found that those receiving post-discharge
calls were twice as likely to make their first
follow-up appointment (88% vs. 43%.)
• There was a trend for increased function
and less violence for those patients also.
• This suggests adherence to follow-up
appointments can be improved by followup phone calls.
Rosen CS, DiLandro C, Corwin KN, Drescher KD, Cooney JH, Gusman F. 6
Community Mental Health Journal. 2006 Oct;42(5):501-8.
Who benefits?
• A Medicare Advantage Plan used a forprofit company to conduct RN-led phone
calls to all of its members to determine if
this would reduce readmissions.
• There was a 23% reduction in
readmissions among members who
received calls vs. those who did not (1.3
times more likely to be readmitted.)
• Caveat: The for-profit company prepared the manuscript
and retrospective design.
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Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. Population Health Management. 2011 Feb;14(1):27-32. Epub 2010 Nov 19.
Benefits of Telephone Calls
• Braun et al performed randomized
evaluations of telephone follow-up in
Haifa, Israel.
• They found improved medication and
therapy compliance, along with improved
patient satisfaction with the hospital and
discharge.
• No change in 1-month readmissions and trend
towards improved 3-month readmissions.
Braun E, Baidusi A, Alroy G, Azzam ZS. European Journal of Internal Medicine. 2009 Mar;20(2):221-5.
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Greater Context
• Balaban et al studied an intervention
similar to the BOOST program at
Somerville Hospital in Massachusetts.
• The intervention included:
– Comprehensive Patient-Friendly Discharge Form.
– Transfer of the form to the primary care RNs.
– Telephone contact by a primary care RN after
discharge.
– Confirmed PCP review and modification of the form.
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Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.
Greater Context
• The team studied readmissions, ER visits,
incomplete outpatient follow-up
appointments, and incomplete
recommended outpatient workup.
• It was a single-center study conducted in a
safety-net community teaching hospital
with a culturally-diverse and linguisticallydiverse patient population.
Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.
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Greater Context
• Balaban et al reported the intervention
group was ½ as likely to experience one of
the adverse outcomes being studied vs.
the controls.
• Similar or greater differences were found
for many of the other categories as well.
• There was a trend towards improved
weekend discharge follow-up and a benefit
for patients over age 60.
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Balaban, RB et al. Journal of General Internal Medicine. 2008 Aug;23(8):1228-33.
Greater Context
• Lawlor et al studied the use of a
comprehensive COPD out-reach
intervention in a large inner-city population
including self-education, RN/PT home
visits, and telephone follow-up in an early
discharge intervention.
• They found reduced ED visits and
readmissions at 6 months and 1 year.
Package deals are better!
Lawlor M, Kealy S, Agnew M, Korn B, Quinn J, Cassidy C, Silke B, O'Connell F, O'Donnell R.. International Journal of COPD. 2009; 55-60.
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Why use the
telephone?
Telephone Use
• Deiker et al reported that the use of a
“liberal” telephone policy during and after
treatment lead to:
– Significantly reduced readmissions (11% vs.
36% for experimental vs. control)
– The population was a psychiatric state
hospital population.
– Patients and family members had access to
call staff both during the stay and after.
– This study was conducted in 1973.
Deiker TE, Villemarette TJ; Hospital and Community Psychiatry. 1973 Feb;24(2):71
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E-mail vs. Telephone
• The University of Pennsylvania conducted
a large study of e-mail follow-up in
comparison to telephone follow-up for
patients discharged from the ED.
• Telephone use was 82% more likely to
reach the patient compared to e-mail.
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Ezenkwele UA, Sites FD, Shofer FS, Pritchett EN, Hollander JE; Journal of Emergency Medicine. 2003 Feb;24(2):125-30.
Videoconferencing vs. Telephone
• A study performed by cardiothoracic care
providers compared structured regular
video conferencing with telephone use in a
pediatric congenital heart disease
population.
• Videoconferencing was preferred by
providers and families by a wide margin,
but costs were an issue.
• There were safety benefits to videoconferencing.
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Morgan GJ, Craig B, Grant B, Sands A, Doherty N, Casey F.. Congenital Heart Disease. 2008 Sep-Oct;3(5):317-24.
Text messaging
• A small (N=45) study from the Czech
Republic found the use of surveys sent to
patients and family members that were
returned by text messaging could be
directed to interventions by health care
providers.
• The patients were found to have reduced
admissions to the hospital in a psychiatric
population.
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Spaniel F. et al. Schizophrenia Research. 2008; 312-317.
Who should make the
calls?
Nurse-Lead Telephone Calls
• Riley reported in 1989 about a nurse-led
call-back program which was structured to
perform calls within 24 hours.
• Structured training/guidelines, structured
documentation, and structured research
using the information.
• This intervention improved patient
satisfaction, improved care processes, and
improved discharge planning.
Riley, J.; Nursing Management.1989; vol. 20 No 9 ; 64-66.
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Nurse-lead Telephone Calls
• Memorial Hermann Health System conducted a
retrospective analysis of a single follow-up call
from the nursing unit vs. no receipt of a phone
call by patients.
• Those patients who received calls were more
likely to return post-discharge surveys by mail
and …
• If the patient had a follow-up appointment
already made, there was a statistically significant
reduction in readmissions. (p=0.04)
D'Amore J, Murray J, Powers H, Johnson C. Population Health Management. 2011 Oct;14(5):249-55.
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Safety of Follow-Up Calls
• A study from Western Canada evaluated
the role of 24 hour follow-up calls in safely
evaluating patients after ambulatory
surgery.
• Patients had no adverse events and were
not readmitted. They also reported higher
satisfaction than patients who received a
nurse visit within 24 hours.
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Fallis WM, Scurrah D. Canadian Journal of Surgery. 2001 Feb;44(1):39-44.
Costs and Staffing
• A quality improvement project at the NHS
Birmingham Heartlands Hospital showed
how to build the program for nursing to
conduct the follow-up phone calls.
• The program was successful in
maintaining or reducing costs associated
with making those calls.
• They did not measure readmissions or ER
visits.
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Lee L; British Journal of Nursing. 2004 Apr 8-21;13(7):412-21
Pharmacists
• Dudas et al found that using pharmacists
to perform follow-up phone calls
statistically reduced ER visits after
discharge.
• There was a trend toward reduced
readmissions but limited by small sample
size.
• Calls took 30 minutes on average and was
unsustainable for the pharmacists’ workload. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ; Disease-a-Month. 2002; 48: 239-248
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Outsourcing
• A lay article in Healthcare Benchmarks and
Quality Improvement described a hospital in
California “outsourcing” its follow-up calls and
“Ask-a-Nurse” line to a Texas-based company
with access to its EMR.
• Only 2% of calls were escalated back to the RNs
in California.
• Consider the cost-benefit analysis of using your
RNs vs “outsourcing” the calls.
Healthcare Benchmarks and Quality Improvement. 2010 Oct;17(10):114-6.
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Diseases which
benefit from calls
CHF Follow-Up
• CHF readmissions are a great burden to
hospitals and the health care system
overall; CMMS has placed special focus
on this condition as well.
• Harper University Hospital in Detroit
showed that dedicated staff just for
outpatient calls as part of a
comprehensive care program reduced
readmissions by 50%.
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Telephonic Program Cuts CHF Readmissions in Half. Hospital Case Management Newletter; Sept 1 2004
CHF Follow-Up
• Jerant et al showed that telephone followup was equivalent to home telecare device
follow-up.
• This was a small sample size study
(N=37) that showed reduced CHF-related
costs/readmissions but not reduced allcause costs/readmissions.
• There was no statistical difference
between telecare and telephone follow-up.
Jerant AF, Azari R, Nesbitt TS.. Medical Care. 2001 Nov;39(11):1234-45.
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CHF Follow-up
• Brandon et al studied the effect of a single
nurse practitioner (working with one
cardiologist) performing follow-up calls in a
rural eastern Alabama CHF population.
• Consistency, education, and learning lead
to reduced HF-related readmissions,
improved QOL, and self-care.
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Brandon AF, Schuessler JB, Ellison KJ, Lazenby RB.. Applied Nursing Research. 2009 Nov;22(4):e1-7.
CHF Follow-up
• A large non-concurrent prospective study
of Chinese patients with CHF using a
targeted home-based intervention
emphasizing 48-72 hour follow-up phone
calls and recurring biweekly phone calls
lead by nurses found:
– Reduced all-cause readmits, HF-related
readmits, length-of-stay, and costs!!
Chen YH, Ho YL, Huang HC, Wu HW, Lee CY, Hsu TP, Cheng CL, Chen MF.
The Journal of International Medical Research. 2010 Jan-Feb; 38: 242-252.
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Gynecologic Follow-Up
• Caljouw et al studied structured telephone
advice following discharge for gynecologic
surgery patients targeting common postop considerations.
• They found improved patient satisfaction
with the follow-up.
• Medical conditions such as COPD, CHF,
AMI, and Pneumonia may not be the only
ones to benefit from telephone follow-up.
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Caljouw, MA, Hogendorf-Burgers, ME. Journal of Clinical Nursing. 2010; 19 (23-24):3301-3306
Other Populations
• Numerous studies conducted calls on
specific populations of patients:
– COPD patients
– High-risk patients (prior hospitalizations)
– Psychiatry patients
– General medical service patients
– Pediatric populations
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Barriers and Caveats
What NOT to do: Unstructured
• Hodgins et al studied the effect of a 48 to 72
hour follow-up call performed by nurses for
orthopedic surgery patients discharged from a
Canadian hospital.
• The calls were added to the nurses regular
work, there was no description of training or
structured topics of discussion, and most calls
were conducted within 24 hours of discharge.
• No significant effect on post-discharge
outcomes.
Hodgins MJ, Ouellet LL, Pond S, Knorr S, Geldart G. Applied Nursing Research. 2008; 218-226.
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Calls do NOT reduce anxiety
• Roebuck conducted a study to determine
whether telephone call-backs reduce
patient anxiety after discharge from
cardiothoracic surgery.
• There was no statistical difference in
measures of anxiety and depression
between those who received calls and
those who did not.
• Single center, cardiothoracic surgery
Roebuck A. Intensive Critical Care Nursing. 1999 Jun;15(3):142-6.
patients.
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Barriers
• A large CDC-sponsored study showed a
trend for increased re-hospitalizations
amongst patients in Pennsylvania who
received follow-up calls and were at higher
readmission risk.
• The authors found that RNs reported
increased collaboration/communication
barriers with physicians as a deterrent to
using guidelines in the calls.
Bowles KH, Holland DE, Horowitz DA. The Journal of Telemedicine and Telecare. 2009; 157 (7) 344-350.
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Caveats
• Rigorously structured analysis of the
literature finds the following:
– Highly variable studies
– Poorly-designed or conducted studies
– Variable outcomes reported
– Small sample sizes
– Increased heterogeneity
Mistiaen P, Poot E. Cochrane Database of Systematic Reviews 2006, Issue 4. Updated in 2008, Issue 3.
Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Annals of Internal Medicine, 2011;155:520-528.
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…One Last Thing
Verify Call Number
• Thibodeau et al conducted a study on
verification of the call-back number.
• There was a significant difference between
patients with HMO coverage (90%) vs
Self-Pay (<75%) in success of call-backs
after verification of the phone number.
• Simply ask: “What number can we reach
you at to discuss lab or x-ray results?”
Thibodeau LG, Chan L, Reilly KM, Reyes VM; Annals of Emergency Medicine. 2000 Jun;35(6):564-7.
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