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. 2022 Mar 14:9:23743735221086756.
doi: 10.1177/23743735221086756. eCollection 2022.

Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities

Neeraj Bhandari  1 , Josue Epane  1 , Jerry Reeves  2 , Christopher Cochran  1 , Jay Shen  1
Affiliations

Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities

Neeraj Bhandari et al. J Patient Exp. .

Abstract

We explore whether the frequency of post-hospital discharge transitional care calls affects patients' adherence to their discharge plans. We reviewed 1,000 call records of a post-discharge transitional care program run by a large U.S. tertiary care hospital in 2018-2019 and generated binary outcomes capturing patient self-reports of (1) scheduling or completing follow-up appointments, procedures, or prescription fills, (2) missing a scheduled event, and (3) reporting a new adverse clinical event. Our predictor variables captured callers' success in completing the first and each subsequent call with discharged patients. We ran linear probability models (LPM) for each binary outcome after controlling for sociodemographic and clinical characteristics. Results indicate successful completion of the first two calls was associated with the increased probability of scheduling or completing follow-up appointment (15.5% points, p < 0.01) and follow-up procedure (13.5% points, p < 0.01), and reporting new adverse event (5.9% points, p < 0.05). Our findings suggest that making the first phone call to patients, while crucial, may not be sufficient for effective care transition; making two to three phone calls seems to be more optimal, while further calls may have limited value.

Keywords: discharge planning; transitional care.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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References

    1. Raso R. Value-Based purchasing: what's The score? Nurs Manage. 2013;44(5):28‐34. - PubMed
    1. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520‐8. - PubMed
    1. Jones CE, Hollis RH, Wahl TS, Oriel BS, Itani KM, Morris MSet al. et al. Transitional care interventions and hospital readmissions in surgical populations: a systematic review. Am J Surg. 2016;212(2):327‐35. - PubMed
    1. Kash BA, Baek J, Davis E, Champagne-Langabeer T, Langabeer JR, II. Review of successful hospital readmission reduction strategies and the role of health information exchange. Int J Med Inf. 2017;104(4):97‐104. - PubMed
    1. Wan TT. Strategies to Modify the Risk for Heart Failure Readmission: A Systematic Review and Meta-analysis. In: Population Health Management for Poly Chronic Conditions. Springer; 2018, pp.85–112.

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