ABSTRACT
BACKGROUND: Telephonic outreach programs (TOPs) can be an effective measure to improve 30-day readmissions and self-management behaviors. LOCAL PROBLEM: Our health care providers identified that patients admitted with heart failure (HF) were among those with the highest readmission rate, so we implemented a TOP specific to HF. METHODS: This project evaluated retrospective data from a convenience sample of adult patients admitted to our hospitals between January 2015 and June 2017, with a primary diagnosis of HF, and discharged home (N = 6271). Of those, 1708 patients also had at least partial TOP data, and a subset had timestamped TOP data (n = 1524). INTERVENTIONS: The TOP program included patient education and personal follow-up via an automatic voice calling system that employed a series of 4 phone calls over a 27-day period. RESULTS: Results showed that the TOP enhanced our hospital discharge process and contributed to program outcomes when the patients completed all 4 of the calls, with those patients having 11 times lower odds of having a 30-day readmission. CONCLUSIONS: The proportion of patients who completed the program reported more use of self-management behaviors compared with those who answered fewer than 4 calls. Our findings related to the lower frequency of self-management behaviors of patients who did not complete all vendor calls stress the important issue of vendor management.
