Improving postop transitional care with phone-based program

Editor's Note

A phone-based transitional care program after complex abdominal surgery has high patient engagement and can be implemented using existing hospital infrastructure, this study finds.

For the program, nurses met patients before hospital discharge and then contacted them within 24 to 72 hours to review:

• medication reconciliation
• any symptoms that would warrant direct contact between nurse and patient
• scheduling a follow up appointment
• ensuring the patient had the nurse’s contact information.

The nurses initiated phone calls every 3 to 4 days as needed. The program was completed once the patient and nurse mutually agreed that no further follow-up was needed, the patient had been discharged for 6 weeks, or the patient was readmitted within 30 days.

Of 212 patients enrolled in the study, 95% participated in the postdischarge protocol for at least one phone call, 72% ended the program after mutual agreement that no further follow-up was needed, and a small number refused further follow-up or were readmitted (17%).

A key finding was that 46% of patients were not taking their medications correctly, which was noted on the first phone call.

Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol.