Study: Nurse phone calls reduce risk of readmission

( Weekly telephone contact with a nurse substantially reduced hospital readmissions for high-risk patients, according to a study.
In addition, healthcare costs decreased by about $1,225 for each patient enrolled in the program compared with similar patients who were not enrolled, reported researchers with the University of Wisconsin School of Medicine and Public Health.

The study measured the efficacy of Coordinated Transitional Care, a program used by 605 patients discharged over an 18-month period from the William S. Middleton Memorial Veterans Hospital in Madison, Wis.

High-risk patients were defined either as having dementia or some other impairment in memory, older than 65 and living alone or older than 65 with a previous hospitalization in the last year.

Patients in the program were a third less likely to be readmitted than similar patients who were not in the program. The patients were phoned by a nurse case manager 48 to 72 hours after discharge. The nurse met with each patient before discharge to make arrangements for the phone calls, and with each patient’s hospital providers to help ensure the patient’s transition home was as smooth as possible.

“The nurse engages the patient in an open-ended discussion,” Amy Kind, MD, PhD, the study’s lead investigator and an assistant professor of medicine at the UW SMPH, said in a news release. “They spend a lot of time talking about medications, follow-up and the appropriate response to any signs and symptoms that the patient’s medical symptoms could be worsening.”

Kind said most of these discussions involved the correct use of medications.

“Many patients, within two days of discharge, were not taking their medications properly,” she said. “They may have not understood what they should have been doing, or became confused about their medications when they arrived home. Our nurses can help them work through those issues and make sure they are doing things as they should.”

Kind said the patients received weekly phone calls for up to four weeks or until they were transitioned to a primary-care provider. That provider was updated at each step of the process and immediately informed if problems were detected. “Our role is not to complicate the process, but to more seamlessly bridge the patient’s journey from the hospital to the home and to primary care,” Kind said.

The study was funded by a grant from the VA. Kind estimates that during its first 18 months, the program saved the hospital $741,125 in healthcare costs.

Kind said C-TraC was very popular, and only five patients declined to participate out of more than 600 approached. She believes it could eventually be used in other clinical settings, and become a useful tool in lowering the cost burden on the healthcare system while minimizing re-hospitalizations of patients with high-risk health conditions. She said the program does need additional testing.

“This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act,” Kind said. “It provides an option to hospitals that previously could not access transitional care services, especially those in rural areas or other areas challenged by a wide geographic distribution of patients, or those with constrained resources.”

The study appears in the December issue of Health Affairs. The study abstract is available at