Talking Points

  1. Do phone intervention calls affect readmissions after an ED visit?
  2. What are the best resources to manage patients after an ED visit?
  3. What best practices worked…and which ones did not?

Data on 2,000 patients showed telephone follow-up for older adults following discharge from the emergency department did not affect readmission rates, researchers reported at the American Geriatrics Society’s annual meeting. The study found the nurse-led intervention also did not make it more likely that patients would follow-up with their physician.

Best Practice for Elder Patients Fails to Curb Readmissions

Having a nurse phone older adults discharged from the emergency department to help with medication use and appointment scheduling had no effect on readmission rates or on whether the patient followed-up with a physician, according to a study of 2000 patients.

A home visit — by a nurse or by a team that includes a nurse, physician, pharmacist, and social worker who can support the patient — might be a better use of resources, Dr Hanson said.

The intervention “did not work. It most emphatically did not work,” said lead investigator Kevin Biese, MD, a geriatrician and associate professor of emergency and internal medicine at the University of North Carolina at Chapel Hill.

Map of Barriers That Hinder Effective ED Discharge

“We felt that if healthcare systems on a wide-scale basis were going to implement a follow-up phone-call intervention, they were likely to do something similar to this — get their callback center to call patients using a scripted survey — he explained at the American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. This study shows that they might not want to invest resources in such an intervention, he explained.

The randomized controlled trial had the power to detect a 5% absolute decrease in 30-day readmission rates, which was the primary outcome of the study.

A nurse who worked at the hospital’s callback center was trained to phone patients 65 years and older who were discharged from the emergency department in the previous 1 to 3 days.

During the call, which took an average of 20 minutes, the nurse reviewed medication instructions, other instructions, such as wound care, and post-discharge instructions, and helped the patient make follow-up appointments.

Similar patients, who served as the control group, got a call from the nurse asking how they felt about their care.

The readmission rates were similar in the intervention and control groups. When Dr Biese showed a graph of the data, he quipped that “if I made those lines red and blue, you’d see purple.”

Secondary outcomes were whether patients had trouble getting medications or follow-up appointments in the 30 days after discharge.

“Were they more likely to see a doctor because of the call? No,” Dr Biese reported. “Almost 80% in each group saw a doctor within 30 days, and they were not more likely to see that doctor at any point in the time stretch.” In both groups, about 15% of patients said they had difficulty getting a new medication prescribed in the emergency department, he said.

Home Visits Could Be a Better Resource

Checking in to make sure that patients are getting their medications, that they understand the medical instructions, and that they schedule follow-up appointments “are all considered best practices, and that didn’t work,” Dr Hanson pointed out. It might be that “older adults need more than this to dissuade them from feeling that their only recourse is to come back to the emergency department or the hospital,” she explained.

A home visit — by a nurse or by a team that includes a nurse, physician, pharmacist, and social worker who can support the patient — might be a better use of resources, Dr Hanson said.

Currently, the rate of older people presenting to the emergency department is greater than the rate of growth of the population, so the situation is urgent, Dr Biese said.

And, a recent analysis determined that 57.3% of patients 65 and older admitted to the hospital came through the emergency department (Am J Emerg Med. 2016;34:943-947).

“Any older adult is more likely to find themselves in an emergency department today than 5 or 10 years ago,” he said. And they are being taken care of, for the most part, by physicians who don’t specialize in the complexities of older adults.

“In our current paradigm of care, whether we admit patients to the hospital or discharge them to the community, they are at high risk,” Dr Biese added. “We need to figure out ways to transition the older adults we take care of in the emergency department more safely.”

This work is supported by the John A. Hartford Foundation. Dr Biese and Dr Hanson have disclosed no relevant financial relationships. American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. Presented May 18, 2017.

Remington’s PAC Opportunities

What should your organization do now?

  1. Develop an ED Turn-Around/Triage model for chronic care management.
  2. Develop protocols with physicians managing chronic care patients.
  3. Develop a specific care coordination/care transition for ED discharges.
  4. Implement a team-based resource group to address patient needs.
  5. Track readmissions and ED visits.

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