Aged care patients at Caulfield Hospital are now less likely to be readmitted after they leave hospital thanks to a simple initiative that’s gaining world-wide attention.
Doctors Henry Yao and Jonathan Beavers have demonstrated that a phone call to a patient or carer within two days of discharge can prevent readmission.
“In our aged care wards, discharged patients have historically come back too often and it can be frustrating for the patient, their family and for the treating team who just want to see their patient doing well,” said Dr Yao.
During the phone call, the staff member asks about the health of the patient, checks that medication is being taken correctly and finds out if support services like home care have arrived.
“Our research found that it was relatively common for something unanticipated to occur within 48 hours of returning home,” said Dr Beavers. “And in many cases, if left unchecked, this would lead to hospital readmission.”
Problems identified by staff during the follow-up contact related to carers not showing up, miscommunications with GPs, incorrect medication use, or a misunderstanding by family or patient about the steps needed to stay healthy outside of hospital.
“A phone call from hospital staff can solve many of the problems by simply providing more information, clearer explanations and advice,” said Dr Yao.
The phone call trial has taken place across the aged care wards at Caulfield for the past year. Dr Yao has analysed the outcomes and found that readmission rates have fallen since staff started making the phone calls routine.
“Staff have an extra task but they see the benefits – they get satisfaction of being able to help someone who’ve they’ve sent home – they don’t want to see the patient back here,” Dr Yao said.
“Care for our patients doesn’t just finish when they leave the hospital’s front door,” Dr Beavers said.