Introduction
On discharge, the discharging clinician provides a patient with a complete set of instructions to follow either on medication, diet, follow-up clinic, or other dos and don’ts. However, many patients do not fully adhere to the written discharge instructions, especially on medication, either because they forget, hate medicines, or just mere ignorance (Fagan, 2021). The former is the reason many discharged patients end up in readmission within a month of discharge.
The Medicare Payment Advisory Commission approximates that 12% of all hospital readmissions are potentially preventable and cost the federal government around $17 billion yearly. Despite various efforts to reduce the number of readmissions, they remain alarming (Fagan, 2021). This study hypothesizes that follow-up phone calls can greatly help in lessening the incidences of readmission and improving overall patient well-being.
Telephone Follow-up (TFU) calls can help remind patients who have a hard time remembering the exact time to take their medication. The calls can also come in handy for older patients who might struggle with reading the instructions. The calls can further aid in tracking client progress (Mars, 2018). The proposed study will be conducted to offer telephone follow-up calls and compare it with written instructions to measure the effectiveness of TFU after discharge.
Search Evidence and Literature Review Systematic Search Strategy
A systematic search will be conducted on CINAHL, Ebsco, PubMed, Quest, Google Scholar, and Cinch-Health databases. The key terms for the search will be ‘follow-up phone calls after discharge and written instructions after discharge. After this, the researcher will select studies that focus on the effectiveness of follow-up telephone calls after discharge and those that compare the impact of follow-up phone calls with written instructions after discharge. The search will target papers published between 2018 and 2022. The systematic review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) parameter for searching and configuring the findings.
The literature search also follows the PICO (population, intervention, comparison, outcomes) structure. The population of this study will be Emergency Observation Ward (EOW) patients. The intervention that will be offered will be follow-up telephone calls (verbal education), which will be compared with written instructions provided during discharge (written education). The outcome of this study will focus on the effectiveness of follow-up phone calls after discharge.
The research adopted the studies that included words like the effectiveness or impact of a call follow-up call. Investigations that compared the effects of follow-up calls and written instructions were also included in the study. The studies that will be incorporated in the investigation are those conducted in a hospital setting. Investigation with adults as the sample or population will be included, while those with children as the sample will be excluded. Studies examining the effectiveness or impact of follow-up phone calls after discharge will be adopted in addition to studies comparing the follow-up calls and adhering to written instructions. Studies that reviewed the use of follow-up phone calls without showing the impact of the approach will be excluded. Studies documented between 2018 to 2022 will be incorporated.
Systematic Literature Review
Yiadom et al., (2018) did a single-center pragmatic randomized and controlled clinical trial that examined the effectiveness of a discharge follow-up phone call to reduce 30-day inpatient readmissions. The basic endpoint of the experiment was inpatient readmission within 30 days of hospital discharge, censored for death, and analyzed with an intention-to-treat approach. The findings indicated that the program was effective in reducing hospital readmissions. However, they did not find its significant impact on mortality.
Technology has made it easier for clinicians to keep in touch with their patients, and phone calls make it easier to monitor the patients. Luciani-McGillivray et al., (2020) examined an existing nurse-administered call-back initiative implemented among emergency department patients within 24 to 48 hours following discharge. The findings revealed that the nurse-led, systematic post-discharge call-back program improved patient adherence to post-ED medical instructions and considerably lessened the incidences of patients revisiting the ED.
Clinicians have conducted experiments with follow-up phone calls to patients. Saba (2022) did a quasi-experiment on the quality and impact of the follow-up phone call on the 30-day readmission rate among adult psychiatric patients. The analyzed data revealed that there was no statistically significant improvement in readmission rates. However, the results showed that the approach reduced readmissions by 50.0% compared to the control, which reduced readmission by only 21.4%.
Oscalices et al., (2019) measured the effectiveness of the behavioral treatment of discharge guidance and telephone follow-up in medication compliance, readmissions, and death rates of patients with heart failure. The researchers employed a randomized clinical trial without blinding and incorporated 201 patients. The outcome of the study indicated that the treatment group had higher medication and non-medication compliance compared to the Control Group. Additionally, the intervention group demonstrated reduced re-hospitalization and mortality rates over time.
Every patient regardless of whether he/she will receive a follow-up call has to leave the hospital with medication instructions. Ramalingam et al., (2022) measured the effectiveness of phone call follow-ups over conventional verbal and written post-extraction instructions in terms of patient compliance in Riyadh, Saudi Arabia. The findings revealed that the group that received follow-up phone calls had increased compliance than the group that relied only on written instruction.
Nurses provide the instructions to be followed at home and also make follow-up calls most of the time. Mwachiro et al., (2019) measured the effectiveness of nurse follow-up calls among neurosurgery-discharged patients. The researchers conducted an audit on the telephone calls that had been made to discharge patients 24–48 hours post-discharge. The findings showed that patients who received a follow-up call after discharge from the first admission stayed out of the hospital longer compared to those who followed the written instructions.
Many researchers have conducted systematic reviews and primary research on this topic. Woods et al., (2019) assessed the quantitative and qualitative investigations on the effects of nurse-led post-discharge telephone follow-up (TFU) call approach on patient aftermaths. The results illustrated that nurse-led TFU approaches have the probability to enhance patient outcomes. Additionally, the outcome reported that patients’ fulfillment with TFU is one of the strongest positive outcomes from the approach.
Patient care managers are also sometimes involved in the follow-up programs for patients they take care of. Domoto et al., (2019) did a randomized control trial that measured patients’ post-discharge challenges via episodic phone follow-up calls from the hospital nurse to the homecare provider. The study targeted patients older than 65 years, using homecare managers to help with their conditions. The findings indicated that the follow-up calls helped the managers improve the care to the patients, it assisted in timely medication, monitoring for side effects, and dieting.
Many hospitals have patients who call services that are not well utilized. Taghinejad et al., (2018) exploited the effectiveness of nurses’ follow-up calls on the self-efficacy of caregivers of patients with stroke. The researchers engaged in a clinical experiment via the pretest and posttest design with the participation of 70 caregivers of patients with stroke. The outcome of the study demonstrated that the nurses’ follow-up phone call program improved the self-efficacy of caregivers.
van der Linden et al., (2021) did a systematic review of the literature that explored the impact of TFU by healthcare practitioners after ED discharge to an unassisted living facility. The study sampled two studies that had both an intervention and a control group of patients who received a scripted telephone intervention from a trained nurse and control patients. The outcome of the study showed no significant advantages of TFU on ED return visits, hospitalization, acquisition of prescribed medication, and compliance with follow-up clinic visits.
Fagan (2021) implemented an after-discharge TFU to ED patients to enhance their fulfillment scores concerning discharge instructions for at-home care and to lessen after-discharge problems. The initiative was executed over a period of three months in 2021 in the ED of a local hospital in Charleston, South Carolina (SC). An ED nurse called patients discharged to home 24 to 72 hours post-discharge to follow-up on guidelines and at-home care. Based on review and synthesis of the literature, the researcher recommended post-discharge phone calls in the ED to enhance the patient satisfaction and decrease post-discharge issues.
Research Pilot DesignResearch Question
This study proposes the use of telephone follow-up calls after discharge purposely to improve on the patients’ outcome and reduces the rates of readmission. To provide the evidence on why it is important to incorporate TOFU in the care process, the researcher will examine the effectiveness of TFU among patients. Hence the study will intend to answer the question: Are telephone follow-up calls after discharge effective in improving patient outcomes?
The literature reviewed in the above section has revealed that every patient discharged from the hospital has to take home written instructions. The instructions can be for medication, diet, or other does and don’ts to observe for their recovery or maintenance of their condition (Sheikh et al., 2018). Studies reviewed have also shown that the majority of patients are unlikely to completely adhere to the written instruction for various reasons including, inability to read, forgetfulness, or hate for medication (Luciani-McGillivray et al., 2020; Oscalices et al., 2019). Many researchers agree that follow-up phone calls are more effective when compared to written instructions (Mwachiro et al., 2019; Ramalingam et al., 2022). Patients who receive TFU have a high probability of acquiring positive treatment outcomes.
However, although many hospitals have follow-up call mechanisms in place, only a few hospitals make use of these resources. The majority of these studies have been conducted using the views of nurses and other clinicians who called the patients (van der Linden et al., 2021; Taghinejad et al., 2018; Woods et al., 2019). The researcher intends to address this research question from the patients’ perspective. The findings of this study will be helpful to both patients and clinicians. The information might encourage hospitals to apply them more often. The findings will also be informative to patients on the importance of the TFU approach.
Research Design
This study adopts the quantitative experimental research design particularly, the randomized control trial (RCT). The randomized control trial is a quantitative experiment kind of research where subjects are randomly assigned to either the experiment or the control group (Williamson & Lloyd, 2019). The experimental group is then taken through the intervention under investigation while the control group goes through a conventional group. In this study, the test group receives the follow-up calls while the controlling sect follows the written instructions provided to them after the discharge.
RCTs are potential investigations that explore the effectiveness of a new intervention or treatment. RCTs are largely adopted in clinical health studies because they reduce bias and offer a strong instrument to exploit cause-effect relationships (Twisk et al., 2018). The former is so because randomization balances participant features between the two groups permitting attribution of any variation in outcome to the intervention under scrutiny.
In RCT the investigators must judiciously choose the population, the interventions to be compared, and the outcomes of interest. In the case of this study, the researcher will select adults who have been recently discharged from the hospital emergency department. The intervention to be tested will be the follow-up calls compared to written instructions and the expected outcome is the effectiveness of the follow-up calls after discharge. Using the RCT method, the researcher has to ensure that at the time of recruitment, the participants do not get to know which group they will be allocated to (Hariton & Locascio, 2018). RCTs also engage the element of blinding respondents, doctors, nurses or other researchers do not know what intervention each participant is receiving, hence minimizing bias.
The two groups are monitored to assess whether there are any differences between them. The findings and subsequent analysis of the trial are utilized to measure the effectiveness of the intervention (Bhide et al., 2018). The outcome is measured in terms of the magnitude at which a treatment, procedure, or service causes patients more benefits than harm. RCTs have been greatly utilized for experiments in the healthcare sector to study different phenomena (Mulangu et al., 2019; Liu et al., 2020; de Rooij et al., 2019; Ramadurai et al., 2019). The above studies are just an affirmation that the randomized control trial is the suitable approach for this study.
Setting and Population
A hospital is the best location for this kind of study because it will provide data on patients who have been recently discharged and need follow-up services. Literature review has shown that these kinds of studies are best done in hospitals either among nurses, doctors, or patients (Saba, 2022; Yiadom et al., 2018; Domoto et al., 2019). This study will sample adults who have been recently discharged from the emergency unit and continuing their medication at home. The researcher will acquire data with the consent of the hospital management to follow up on the patients. The patients will be called from the hospital so the caller has to be a practitioner because hospitals cannot expose their patients to strangers.
Sampling Method
The study will adopt purposive sampling to select recently discharged patients from the emergency department continuing their medication at home. Purposive sampling is a non-probability sampling method where study respondents are chosen because they contain features needed in a sample (Campbell et al., 2020). This approach is also referred to as judgmental sampling because it relies on the researcher’s judgment to identify and select the persons, cases, or events that can offer quality data to answer research questions or accomplish the study’s objectives. The hospital discharge records will be utilized to access this information. The research will judge the information to pick patients that fit the study objective.
Inclusion/Exclusion Criteria
The study will include patients being discharged on a daily basis for about two weeks. The researcher will need patients being discharged so that the follow-up calls can begin within 24-48 hours after the discharge and continue for 30 days. The study will include adults discharged from the emergency department, the kind of sickness will not be considered, all the patients discharged from the department will be eligible for inclusion.
Recruitment
The hospital discharge records will be utilized in acquiring the participants. Individuals discharged in the span of two weeks and expected to continue with their medication for the next one to two months will be recruited. After confirming the discharge disposition, the phone call researcher will review the medical records to understand what is expected to occur to each patient after hospital discharge, including medication changes or follow-up appointments. The review will offer the caller a reference point from which to evaluate the patient’s understanding and ability to ‘teach back each element of the care plan. The patients will be conducted and informed about the study.
Ethics
The researcher will first acquire permission from the hospital administration to go ahead with the investigation. The researcher will ensure that the research question and objectives are designed in a way that will gather information that will be beneficial to the hospital and the patients. The researcher will conduct the patients and explain to them the purpose of the research and request for their consent. Participation in the study will be made voluntary, and so patients who will not be comfortable with the study will be permitted to quit even on the last day. The researcher will assure the participants of confidentiality, and the information collected will be used for research and the betterment of the patient’s well-being.
Data Collection
The study will engage a researcher who is a nurse calling patients to check on them and ensure that everything is okay with them. The phone call intervention will be structured to be similar to the current hospital program. It will be a semi-structured discharge phone call assessment delivered by a registered nurse. The researcher will need to have fulfilled the organizational education on discharge health coaching; interpreting discharge care plan documentation, and methods to contact discharge teams.
Specifically, the researcher will check on adherence to medication and remind the patients on taking their medication timely. The caller will also assess whether the patients are having adverse side effects from medication. Further, the investigator will also check on dieting in cases where a patient is supposed to be following a special diet. The caller will as well remind the patients of the scheduled checkup. The researcher will have structured a questionnaire for each patient to record each call and details of each patient. At the end of the data collection period, the researcher will review all the questionnaires and prepare them for data analysis.
Data Analysis
The researcher will utilize the Statistical Analysis System (SAS) version 9.4 which was used for data analysis. Additionally, the study will employ descriptive statistics, including frequency distributions for categorical variables, means, standard deviations, and ranges for continuous variables. Further, descriptive statistics will be adopted to describe demographic features of gender, race, ethnicity, age, and most common diagnoses. It will also illustrate the aspects handled during the follow-up call, such as pain, prescription status, follow-up appointment status, medication side effects, and any questions concerning discharge instructions. Chi-square tests, including Fisher’s exact tests, will be utilized to establish the statistical significance of responses of effectiveness and the combinations of responses that were not effective from pre-intervention and post-intervention data. The analyzed data will be presented through charts and graphs.
Dissemination and Implementation
The findings of this study will be beneficial to all medical practitioners. The findings will bring more insights into the advantages of engaging in making telephone follow-up calls because it promotes verbal communication with the patients. Verbal messages are well interpreted and understood as compared to written messages because written information is sometimes misinterpreted. When it comes to managing health, having clear information is very important otherwise, it can lead to serious consequences like readmissions. It will therefore be essential to get the information to the targeted audience.
After compiling the findings, I will make a leaflet that will intend to educate the stakeholders in the healthcare sector particularly doctors, nurses, and patients, on the existing facts about using follow-up calls after discharge. The flier will contain three major sections; the first part will contain information on various reasons why healthcare professionals need to make follow-up calls to their patients. The second part will highlight the benefits or the effectiveness associated with making follow-up calls after discharge. The third part will highlight the advantages of follow-up calls over written instructions. The last part will contain information on why patients should embrace this approach. The researcher will then prepare both soft copies and hand copies for distribution to various medical facilities.
After designing and printing the leaflets, I will distribute them in various places. I will target all the hospitals in my region to get this information. To the nearest hospitals, I will drop off the hard copies, and for the facilities that I cannot physically reach, I will email soft copies to them. Printed fliers are important as a patient can briefly go through them while waiting for a doctor, in a bus, and while relaxing at home. The brochures are important to remind the patient of the necessity of taking care of their health (Sustersic et al., 2019). Additionally, since everyone is using social media these days, I will post the leaflets on my various social media sites. Social media is a great way of disseminating health information these days, studies show that it is effective in reaching as many people as possible (Chan et al., 2020; Rosenberg et al., 2020; Wang et al., 2019). My friends and colleagues, and other people will be able to view and go through the leaflet through social media.
Further, I will also look to see whether I can get any print media platforms like newspapers or magazines that might be interested in publishing my findings. I am passionate about providing quality, accessible, and timely healthcare and following up on my patients to ensure they get well even after discharge. I intend, therefore, to ensure that people, particularly patients, understand the importance of this approach so that they will not feel as if their practitioners are disturbing them by calling after discharge. However, print media might not be effective because it is slowly being replaced by the use of new modes of communication and technology, and not many people spend time reading print media (Rosmani et al., 2020). Acquiring different kinds of information, just like the one provided by my proposal, is one way of achieving the former.
Conclusions
The literature review has revealed that many hospitals do follow up on their patients after discharge. The studies also revealed that many hospitals have patient call resources in place, but many facilities do not utilize these resources. Follow-up calls after discharge is one approach doctors use to monitor their patients. Studies have shown that hospitals that have utilized follow-up calls after discharge have achieved the benefits of reduced readmission and mortality rates among their patients. Follow-up calls have been demonstrated to be effective in medication adherence, dieting, and keeping scheduled appointments.
The comparison between the telephone follow-up and written instruction showed that the TFU was more effective in improving patients’ outcomes. Studies have revealed that many patients forget to take medication on time, some struggle to read the instructions while others just ignore to adhere to the doctor’s instructions. Patients greatly associate follow-up telephone calls with agency and importance, and it makes them take their medication and appointments seriously. TFU improves the overall well-being of the patients hence the need to provide more insight into this approach to stakeholders in healthcare. However, the majority of the past studies reviewed were done from the perspective of nurses and doctors, this study will focus on patients’ opinions on whether and how TFU has helped in their healing process.
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