One of the hardest times for a patient is when they leave the hospital and go home or to another care place. Patients can have trouble understanding discharge instructions, making follow-up appointments, and managing their medicines. These problems can make patients unhappy and lead to hospital readmissions soon after they leave.
Hospital managers and healthcare IT staff in the U.S. know that patients need organized and reliable support after they leave the hospital. Quick follow-up calls or messages can find and fix problems early. This helps avoid readmissions. This issue is very important, especially in states with many Medicare and Medicaid patients. Hospitals there may face penalties if patients are readmitted too often.
A team led by Michael Clarke from George Washington University did a study to improve how patients feel after leaving the hospital and to lower readmission rates within 30 days. The project included 713 adult patients discharged from certain nursing units in a U.S. hospital. They used the Plan-Do-Study-Act (PDSA) method and set up an automated follow-up system with phone calls and text messages sent within 48 hours after discharge.
PDSA is a cycle made for healthcare improvements. First, a change is planned (Plan), then it is tried on a small scale (Do). Next, the results are examined (Study), and finally, changes are made based on what is learned (Act). This process helps hospitals keep learning and improving.
The project had a 97% enrollment rate, showing most patients agreed to use the automated follow-up. Of those enrolled, 87.3% were successfully contacted by phone or text. This shows how automation can reach patients quickly and easily, which is harder to do with manual phone calls.
The system found that about 19% of patients needed extra help. These patients were called by a nurse manager. Almost half of these called patients (48.11%) said the main problem was making follow-up appointments. This shows many patients find it hard to schedule visits after leaving the hospital.
This information helps hospital staff understand where to focus their efforts. They could help patients set appointments before discharge or offer a central service to schedule visits. This can make care after discharge smoother for patients.
Patient satisfaction measures how good the healthcare experience is. The study showed a 13.99% rise in scores about Discharge Information. This means patients better understood the instructions given when leaving the hospital.
Scores about Care Transitions did not change much. But better discharge information means patients got clearer instructions and reminders after going home. This can help them take care of themselves and avoid problems that lead to readmissions.
The most important result was that no patients in the follow-up program were readmitted within 30 days during the study. Since readmissions cost money and show gaps in care, stopping them is a big success for hospitals.
For hospital leaders, this shows that automated follow-up plus nurse outreach may save money and improve the hospital’s reputation.
The program included a step where nurse managers called patients flagged by the system. These nurses were from the same units that discharged the patients, so they knew the patients well.
Using both automation and personal contact is important. Automated calls and texts find problems early. Then nurses can help with complex questions, schedule visits, and provide support during this tough time after hospital stays.
This study shows how PDSA helps improve healthcare quality. First, the team planned the project to improve patient experience and reduce readmissions. They tested the automated system on specific nursing units.
Then they studied results like how many joined, patient replies, issues found, satisfaction scores, and readmissions. The high participation and no readmissions showed the system worked well. Finally, they planned next steps such as expanding the program or fixing appointment scheduling problems.
Healthcare leaders in the U.S. can use this method for other projects too, like outpatient care, managing chronic illness, or preventive health checks.
New technology like AI phone systems and workflow automation helps hospitals communicate with discharged patients. Companies work on automating phone answering and call flows. This makes it easier to contact patients on time without extra staff work.
AI call systems can:
Workflow automation also helps by scheduling calls, recording interactions in health records, and sending alerts to care teams. This cuts down mistakes and paperwork delays common with manual steps.
In the U.S., where hospitals must lower costs and meet quality rules, AI systems provide solutions that can grow without needing more staff. Patients often like getting messages or calls when they want, which improves their involvement and satisfaction.
Medical practice managers, IT teams, and hospital owners thinking about similar programs should consider:
The study from George Washington University shows that projects mixing automation with clinical input can improve post-discharge care. Almost all patients joined the program, and many took part in follow-ups. Having zero readmissions during the study means the program worked beyond just theory.
Health administrators in outpatient clinics or hospitals across the U.S. might consider similar programs. States with readmission penalties or goals to raise patient satisfaction could use automated follow-ups based on their patient needs.
Using AI to support workflows fits with the ongoing digital changes in healthcare. It also helps meet national quality rules and payment programs like Medicare’s Hospital Readmissions Reduction Program.
This study gives a clear example of how a methodical approach, combined with automation and nurse support, can improve care during a key time after patients leave the hospital. As healthcare grows more complex, having these kinds of tools can help providers improve quality, lower costs, and help patients stay well after discharge.
The project aimed to improve patient satisfaction scores and decrease 30-day hospital readmissions among adult patients by implementing an automated phone call and text message post-discharge follow-up program.
A Plan-Do-Study-Act (PDSA) method was utilized for this quality improvement project.
The program had an enrollment rate of 97% of patients discharged from selected nursing units.
Of the enrollees, 19% (n=132) were flagged for a follow-up call by a nurse manager.
The most common reason for follow-up was ‘difficulty making follow-up appointments’ (48.11%).
There was a 13.99% increase in the Discharge Information domain score of the patient satisfaction survey.
No improvements were observed in the Care Transitions domain of the survey.
There were no hospital readmissions among patients enrolled in the program during the project timeframe.
Follow-up calls were conducted by the nurse manager from the discharging nursing unit.
The study concluded that an automated phone call and text message post-discharge follow-up program can reduce 30-day hospital readmissions and improve certain domains of patient satisfaction.
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