LAUSR

Background: As a Comprehensive Stroke Center (CSC), The Joint Commission requires post-discharge follow-up phone calls to be conducted within 7 days of discharge for all complex stroke patients. Purpose: To develop and sustain a feasible approach for Hospital Based Specialist (HBS) physicians to conduct follow-up phone calls within 7 days. Methods: A baseline evaluation of all post-discharge phone calls was conducted. It was determined that patients were receiving several phone calls already, therefore the team did not want to add an additional call to meet compliance. HBS calls were realigned to include a stroke-specific focus, reinforcing stroke education and secondary prevention. Calls were made within 7 days by the discharging physician. All stroke patient types discharged with a stroke diagnosis were contacted regardless of severity. Patients discharged to skilled nursing facilities, board and care, acute rehabilitation or other acute care hospitals were excluded. A templated note was developed to ensure all stroke-specific components were covered. All HBS physicians were trained. Telephone interactions occurred between the patient, family member, and/or caregiver. Those unable to be reached but had messages left or secure messaging sent were counted as compliant. Reminders were sent out to physicians to improve call compliance. Tracking occurred weekly for call compliance and note template utilization. Results: Between January 2018 and May 2019, 612 patients discharged home from the acute care setting. Of those, 55% (334) were contacted. Of those, 73% had the templated note documented. Several hurdles were encountered along the way, but utilization of the templated note and physician reminders improved compliance. Conclusion: Post-discharge follow-up phone calls initiated by HBS physicians and utilization of a templated note are a feasible means of meeting and sustaining the CSC requirement.