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Johns Hopkins Medicine Suburban - Patient Follow-up Calls Improve Communications, Reduce Readmissions

New Directions Summer 2013

Patient Follow-up Calls Improve Communications, Reduce Readmissions

Date: July 1, 2013

Clinical Director for Orthopedics Carol Stephens making follow-up call
Clinical Director for Orthopedics Carol Stephens, BSN, RN, ONC, is one of many nurses who make follow-up calls to patients after discharge.

The first 24 hours after discharge are key to a patient’s recovery. In February, nurses at Suburban Hospital initiated a telephone follow-up program that aims to prevent medication complications, patient anxiety and readmissions.

The nurses use Patient Call Manager System software that automatically alerts them within 24 hours that a patient has been discharged. Carol Stephens, RN, clinical director for orthopedics at Suburban Hospital, explains that the calls give her an opportunity to confirm a patient’s understanding of discharge instructions and answer questions that have arisen since the patient left the hospital.

“It’s not easy for patients to remember everything discussed when leaving the hospital,” she says. “Often, concerns come up in those first 24 hours.”

Thanks to the software’s information fields regarding medical information, admission and discharge dates, physician name and discharge comments, nursing staff are able to respond to situations quickly.

“After getting home there are questions, and sometimes confusion about medications and care instructions,” says Stephens, who notes that she and her team of nurses at Suburban make an average of 15 to 20 calls a day. Information obtained from each call is logged via computer. She says she’s prevented “near misses” with people taking new medications, and based on a telephone conversation has instructed someone to go to the emergency department for immediate treatment.

“The feedback on these calls is very positive. People feel it’s very helpful when we clarify things for them.”