The past 2 years have turned the healthcare industry upside down. The COVID-19 epidemic has impacted the industry in ways no one could have imagined. Rapid change in the healthcare environment meant switching from in-person work to remote work where case managers led the way by engaging patients as they transitioned through the delivery system from inpatient through the next level of care. One standard that has remained the same throughout the pandemic is the post-hospital transition calls. These calls have traditionally been completed 48-72 hours post discharge to home or another home care setting such as assisted living facilities or adult family homes.
The post-hospital discharge call process provides an early warning system that the patient did or did not transition smoothly or successfully to their home setting. The transition call provides an opportunity for the case manager to identify patient needs and earlier outpatient follow up if the transition did not go smoothly. The identification of unmet patient needs and early intervention potentially reduces the risk for readmission to the hospital by providing needed support at a lower level of care. The aim of the transition calls is (1) patient education including information regarding health condition, red flags, teaching self-monitoring of the chronic condition; (2) medication reconciliation and confirmation of new and discontinued medications; (3) ensuring timely patient follow up including scheduling of appointments if necessary; (4) providing a patient-centered approach that may include referrals to complex case management, home health or other services as identified. These four aims are based on the Transition of Care Model developed by Eric Coleman, MD, and are commonly called the four pillars (2013).
In an ideal world, all patients discharging from the hospital to home should receive a transition call. The case management department at Kaiser Permanente of Washington completes transition calls for patients who have been identified as high risk for readmission. Patients are stratified by color pathway during their hospitalization: orange – high risk, yellow – moderate risk and blue – low risk. At time of discharge, orange pathway patients have follow-up appointments scheduled within 7 days of discharge; yellow patients are informed to contact their provider to schedule their appointments within 7-14 days of discharge. Blue pathway patients are considered low risk for readmission and are most likely planned surgery patients who have pre-scheduled appointment for post-operative follow up prior to admission.
The case management team receives a list of all the patients discharged within the past 48 hours. This list is sorted by readmission risk. The nurses attempt to reach the patient three times over a 24 to 48-hour period to review the four pillars. They make two attempts on day 1 with the third attempt on day 2. The nurses have a successful reach rate of between 85-90%.
With the influx of COVID-19 patients into the hospital over the past 2 years, with the potential for readmission being higher in this population, a need was identified to contact these patients post discharge to complete a transition call. The discharge call list was further stratified to identify patients discharged home with a primary discharge respiratory diagnosis including the diagnosis of COVID-19. The determination was made to include all respiratory diagnoses, as patients may have an underlying respiratory condition which necessitated the admission, and COVID-19 became the secondary diagnosis. It had been noted over the initial year of the pandemic that patients discharged with a diagnosis of COVID-19 with hypoxia and discharged home with home oxygen were at increased risk for readmission. The transition call nurses contacted these patients per their regular transition calls and performed the four pillars, which identified patients discharged home on oxygen.
The team developed a second process to follow the patient discharged home on oxygen. The rationale for this was to provide ongoing care and education and identify additional care needs during the initial transition home. These patients were contacted daily for 5 days after the initial transition call for ongoing monitoring. The nurses reviewed their status including current symptoms, temperature, oxygen liter flow, oxygen saturation, appetite and energy level. Patients were also asked if they were wearing their oxygen continuously. Education included review of the red flags and who to contact including provider or consulting nurse if after hours. Patients were also instructed when to contact 911 or return to urgent care or the emergency department. The development of the ongoing follow-up process was based on the CMSA Standards of Practice including client selection, client assessment, identification of care needs and monitoring (2022).
Once the team developed the process for ongoing transition monitoring, education was provided. The ongoing monitoring of COVID-19 patients being discharged on home oxygen began on May 3, 2021, and continues currently. The additional follow-up calls were voluntary and the transition nurses asked permission to contact these patients over the next 5 days. Most patients were receptive to the program and welcomed the additional support. Patients identified their concerns regarding the virus and were anxious to receive education. One concern the patients voiced was the inability to see their provider in person. Ongoing education was provided to the patient with encouragement via virtual or phone visits with their provider. Patients were receptive when it was explained to them that in-person visits could place them or other patients at risk.
The transition team continued with their regular post-hospital transition calls, incorporating the additional daily calls to the patients on home oxygen into the work. The team recognized the importance of this work in the ever-changing world of COVID-19. As new variants became evident, the teams educated patients regarding the variants as well as their recovery plan. Initially, patients were concerned about which COVID variant they were diagnosed with; however, the nurses were skilled with educating them regarding the overall treatment and recovery plan.
When the Delta COVID variant became most prominent, hospitalizations increased during the summer and into the fall of 2021. As Omicron became the dominant variant, hospitalizations decreased; however, most of the hospitalizations were among patients who were not vaccinated. Hospitalizations remained elevated throughout the winter of 2022; however, the primary diagnosis of COVID-19 did not dominate admissions.
Since May 2021, the transition team has followed a total of 500 patients through June of 2022. There have been six readmissions related to hypoxia during that time, which is a 1% readmission rate. The overall goal readmission rate is 5%. The increased focus for hypoxic patients with a primary diagnosis of COVID-19 has impacted the readmission rate. The ongoing follow up has identified potential issues earlier, and the transition nurses have been able to redirect the patients to their providers for additional intervention including earlier follow up.
The transition team identified the overall of value of this program as patient centered, providing post-hospital touches for at-risk patients on home oxygen in reduction of readmission. Barriers identified during these transition calls were discontinuing oxygen with or without physician involvement and patients declining to continue with the follow-up calls either verbally or by not answering the phone. As noted above, the calls were voluntary. One last barrier was having an accurate phone number for patient outreach.
As the COVID-19 pandemic transitions to endemic status, it is important that these patients continue to have this follow up as this has demonstrated a strategy to decrease readmission risk. This follow up will be critical in identifying patients who may be at risk for long-haul COVID.
In closing, the overall transition call program for patients discharged to home-on-home oxygen is the right care at the right time and right place.
CMSA Standards of Practice for Case Management 2022 Edition.
Evaluation of a modified community-based care transitions model to reduce costs and improve transitions, https://www.ncbi.nlm.nih.gov › articles › PMC3848703 September 2013.
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