Strengthening Our CORE: Care Navigation Post-Discharge Outreach: It works

As part of Yale New Haven Health’s commitment to seamless high-quality care, a post-discharge outreach program that launched a year ago is now live across the health system. It is a key tool in reducing readmissions, boosting patient satisfaction scores and coordinating care back into the community setting.

Post-Discharge Outreach is a fancy way of saying that every patient cared for at any YNHHS hospital gets a follow-up call 24 to 48 hours after they go home. Call specialists record patients’ responses to questions about medications and other concerns listed in the electronic health record.

While follow-up calls are nothing new, this standardized, systemwide approach ensures people don’t fall through the cracks.

Call questions were crafted after a review of published literature on transitions of care. These include discharge instructions, medication changes and how they’re feeling since they got home.

“Patients have to absorb a lot of information right before they go home,” said Maribeth Cabie, executive director, Enterprise Ambulatory Care Management.  “We’re finding that a lot of people just want to cross check instructions and ask a few detailed follow-up questions, which can make a huge difference.”

For example, if a call specialist can clear up a patient’s confusion about when or how to take a vital medication, it could prevent a readmission. That patient might feel more satisfied with their care, which could be reflected in their patient satisfaction survey responses. These surveys are mailed to patients shortly after the post-discharge outreach calls.

“We saw a huge improvement in patient satisfaction scores at L+M Hospital when we first started this program, and we’ve seen that improvement consistently across all our hospitals,” Cabie said.

“We are constantly improving this program to make sure it’s efficient and effective,” said Ohm Deshpande, MD, YNHHS associate chief population health officer and vice president, Clinical Financial Services. “Readmissions are a key quality measure for our hospitals and ambulatory practices, so this program is tightly coordinated with the enterprise’s multi-pronged approach to improve performance.”

Using resources efficiently is critical, Cabie said. For lower-risk patients, non-clinical specialists make the calls, but they are trained to know when to triage the call to a nurse. Nurses call high-risk patients. The program also has a multi-disciplinary team that can intercede when needed, including health coaches, a behavioral health specialist, transition coordinators who follow patients in skilled nursing facilities, and a pharmacist. If a patient needs a visiting nurse, call specialists can help contact the primary care provider for a referral. They can also facilitate referrals to community health programs.

The lowest-risk patients receive automated messages which invite them to answer key questions through MyChart. If any answers are concerning, they quickly get a call from a nurse. Automation allows team members to focus on higher-risk patients.

“With these calls, I really feel a connection to people in the community,” said Dawn Dinuzzo, LPN, one of the call center specialists. “You touch people’s lives, and to make a difference means everything.”