title: Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition.
abstract: BACKGROUND
  The post-hospitalization period is a precarious time for patients. Post-discharge nurse telephone call programs aiming to prevent unnecessary readmissions have had mixed results.
  
  
  OBJECTIVE
  Describe a primary-care based program to identify and address problems arising after hospital discharge.
  
  
  METHODS
  A quality improvement program embedding registered nurses in a primary care practice to call patients within 72 h of hospital discharge and route problems within the practice for real-time resolution.
  
  
  METHODS
  Adult patients with a primary care provider in the general internal medicine practice at the University of California San Francisco who were discharged home from the Medicine service.
  
  
  METHODS
  Patients reached directly by phone had a 'full-scripted encounter;' those reached only by voice-mail had a 'message-scripted encounter;' those not reached despite multiple attempts had a 'missed encounter.' Among patients with full-scripted encounters, we identified and cataloged problems arising after hospital discharge and measured the proportion of calls in which a problem was uncovered. For the different encounter types, we compared follow-up appointment attendance and 30-day readmission rates.
  
  
  RESULTS
  Of 790 eligible discharges, 486 had a full-scripted, 229 a message-scripted and 75 a missed encounter. Among the 486 full-scripted encounters, nurses uncovered at least one problem in 371 (76 %) discharges, 25 % of which (n = 94) included new symptoms, and 47 % (n = 173) included medication issues. Discharges with full-scripted and message-scripted encounters were associated with higher follow-up appointment attendance rates compared with those with missed encounters (60.1 %, 58.5 %, 38.5 % respectively p = 0.004). There was no significant difference in 30-day readmission rates (12.8 %, 14.8 %, 14.7 %; p = 0.72).
  
  
  CONCLUSIONS
  Our results suggest that centering a post-discharge phone call program within the primary care practice improves post-hospital care by identifying clinical and care-coordination problems early. With the new Medicare transitional care payment, such programs could become an important, self-sustaining part of the patient-centered medical home.
authors: Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
authors: Ning
authors: N
authors: Tang
authors: Jeffrey
authors: J
authors: Fujimoto
authors: Leah
authors: L
authors: Karliner
mesh_terms: D000359:Aftercare / Q000458:organization & administration; D002140:California; D003266:Continuity of Patient Care / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006760:Hospitalization; D006801:Humans; D010351:Patient Discharge; D059017:Primary Care Nursing; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D058996:Quality Improvement; D055817:Telenursing / Q000458:organization & administration*; D013689:Telephone