By John Grochowski
Transitions of care have been uppermost in the minds of Margaret Emrick, BSN, RN, and Carla Graf, PhD, RN, for the past three years as they’ve worked on the California delivery system reform incentive payment program, designed to strengthen care delivery throughout the state’s healthcare system.
Emrick, the administrative coordinator of the discharge phone call program that is part of the innovations in population health program at UCSF Medical Center, and Graf, interim director for clinical programs in the office of population heath at UCSF Health, have focused on telephone follow-up as an important part of those transitions. Their poster presentation, “A Positive Discharge ‘Touch’: Implementation of a Centralized Nurse-Led Hospital Discharge Telephone Call Program,” earned first place in the transitions category at the national NICHE conference in Orlando, Fla.
“Transitions of care is an important topic for a quality and safety perspective,” Emrick said. “Because there are many different ways to implement this work, we wanted to highlight our particular model of having a nurse-led and centralized program that kind of hybridizes automated phone calls and specially trained nurses.”
In the UCSF program, two to three days after patients go home from the hospital, they receive an automated phone call asking if they have new or worsening symptoms, whether they were able to fill prescriptions and whether they have follow-up appointments.
“It’s basically a quick overview of clinical issues and whether they were satisfied with their experience,” Emrick said. “Their responses to that automated call trigger a phone call from one of our nurses from our centralized pool within 24 hours.”
Graf said this type of transitioning-back-home help benefits a broad patient base. “Thinking clinically, high-risk patients were those we were worried about,” Graf said. “But from a quality and patient satisfaction perspective, we realized following up after discharge was important for all patients, and that we couldn’t know when we were discharging someone who would come home and have questions or issues.”
Winning poster presentation
Turning what they learned into a winning poster presentation didn’t take long, Emrick said.
“Because it’s an implementation poster, the work had been done, and was continuing to be done,” she said. “From recognizing that I wanted to present the poster to completion took about a month, working about an hour or so a day.”
The poster resonated with conference attendees and judges in part because the work is translatable to different care environments, Emrick said.
“Follow-up phone care could be implemented in ambulatory care settings or as we do it, kind of in between the inpatient and outpatient settings,” she said. “Our presentation flows intuitively from the background stage through the next steps. Our images and other visuals add nice color to the poster and provide an alternate method to absorb the information, with text and diagram.”
Graf thought the whole package helped nurses visualize the issues involved in phone transitions.
“We’re all struggling across the nation with transitions, we’re struggling with many clinical issues, and as someone who’s been practicing either inpatient as a clinician or in this current work, it’s really helpful for me to go to a conference and see from start to finish, ‘This is how they did it,’” Graf said.