Put yourself in the slipper socks of someone who has just been discharged from the hospital. Maybe you just delivered a baby, or are recovering from a procedure or illness. You arrive home with a long list of instructions and educational materials. Now what? When were you supposed to take those medications? Is your incision supposed to look like that? What if you don’t feel well?
Patients often don’t realize the questions they have about recovery until they’re back home. When newly discharged patients don’t know where to turn for answers, or encounter problems, they’re at risk for return trips to the Emergency Department (ED), further hospital stays, and complications. Recognizing that a good discharge process isn’t always enough to head off all potential issues, Penn Medicine has over the last year invested in Penn Medicine Connects. This follow-up program gives care providers real-time feedback that can identify which patients need more help.
Phoning Home
Penn Medicine Connects employs a double-pronged effort to follow up on patients who go home after discharge from all six Penn Medicine hospitals (it’s not for patients who are discharged to other care facilities). Within 24 hours after discharge, every patient receives an automated call. (Postpartum patients receive text messages instead, as this population is more likely to respond to texts than to phone calls.)
Employing standardized scripts, the calls and texts ask a series of Yes/No questions to gauge how well patients’ transition to home is going, if they have all of the medication and supplies they need, and whether they have further questions or need to schedule follow-up medical appointments. When patients provide answers that indicate a need for further attention, or request a live follow-up, they receive one-on-one outreach from a nurse; any issues that can’t be easily resolved are escalated.
Post-Discharge Project in a Pandemic
The idea for Penn Medicine Connects was to bring post-discharge calls – previously handled independently by departments and service lines – under one umbrella, for quality control, cost savings, optimized results (reduced readmission, ED visit, and complication rates), and efficiency. For many staff who were previously tasked with initial check-ins, “It’s not their full-time job and they’re just trying to carve out enough time for outreach,” explains Project Manager Susan McGarvey, PMP. Taking these calls off their to-do list “allows these staff to focus on the rest of their job.”
Penn Medicine Princeton Health (PMPH) was the first site to adopt Penn Medicine Connects in March 2021. “I was excited with the possibilities of reducing readmissions, helping the patients to have a voice after they left the hospital,” says Chief Nursing Officer and VP for Patient Care Services Sheila Kempf, PhD, RN, NEA-BC.
By June, all six hospitals in the Health System were using the program. The collaborative aspect is key to the success of Penn Medicine Connects, Daniel Feinberg, MD, Pennsylvania Hospital’s chief medical officer, notes: “There was very focused effort by each entity, and incredible support from the Penn Center for Connected Care. We have all learned from one another during this rollout.”
Launching this effort in the middle of the COVID-19 pandemic might seem counterintuitive. But Penn Medicine Connects couldn’t have come at a better time, according to Kempf. For the past two years, patients haven’t been able to have many family members or visitors with them to be a second set of ears for discharge instructions: “It has helped us to place more emphasis on discharge instructions and then to validate that we did accomplish a successful discharge.”
Reaching Out for Care
Most Penn Medicine Connects calls and texts reach patients who are doing well and have everything they need; system-wide, about 26 percent are flagged for follow-up.
These cases are referred to PennLINKS, a team of 10 nurses who are part of the Center for Connected Care. Every day, working out of their homes, the team meets by video chat to discuss and divvy up the list of patients who need follow-up.
The majority of follow-up needs are medication-related; other common issues include general health status, discharge instructions, and scheduling appointments.
Most of these live calls involve issues and questions that are relatively simple to resolve, for example with additional education or a call to the patient’s pharmacy or care provider. Occasionally – about 4 to 5 percent of the time – a problem requires a higher level of intervention. The nurses draw on their training and established protocols to determine how to escalate the patient’s situation.
For example, Karen Trinidad, RN, one of the clinical leads PennLINKS, talks about a patient on oxygen who was sent home solo, so his wife wasn’t at his side to hear the discharge instructions. When his Penn Medicine Connects answers were flagged and Trinidad called to check in, the oxygen tank was empty; neither the patient nor his wife, both of whom were recovering from COVID, understood how vital the oxygen was, nor where to turn for a refill. On their behalf, Trinidad called the oxygen supplier, who promised to deliver it with an hour, thus preventing a possible bad outcome and return trip to the hospital.
Proof Is in the Progress
As it reaches the one-year mark, Penn Medicine Connects is planning to expand to four additional populations, including patients who visit Lancaster General Hospital’s ED but leave before being evaluated. As Feinberg puts it, this situation is “a significant indicator of quality and patient experience.”
And the team is beginning to tabulate the data that has been compiled, focusing first on the program’s effect on readmissions. “This has been helpful in showing us some areas for improvement in our current discharge process,” said Julia Karumathy, BSN, RN, case manager at the Hospital of the University of Pennsylvania. “Perhaps we can start fixing the problem before it even touches the patient.”
Qualitative data help expand on insights from the numbers: “The detailed event logs which chronicle the Penn Medicine Connects nursing phone contacts with the patients have proven to be the most actionable source of quality improvement data,” said Scott D. Crespy, PhD, LSSBB, senior improvement advisor with the Clinical Effectiveness and Quality Improvement team.
Preliminary findings from a patient survey at PMPH, where the program piloted, similarly suggest good outcomes and good experiences. “The response was overwhelmingly positive and also allowed us to identify some improvements we could make,” Kempf said.
Patient satisfaction surveys ask how prepared patients felt to return home from a hospital stay, notes Nancy Mannion, DNP, RN, CEN, nurse manager for PennLINKS. And that’s where Penn Medicine Connects really shines: “It gives the patient a sense of confidence that the hospital is still watching out for them. We also support the care providers by ensuring the patient has what they need to continue to heal in that critical first day at home.”
Trinidad and the other PennLINKS nurses know first-hand that patients are grateful for the outreach: “Every patient ends the call with, ‘Thank you so much for calling me.’”