Extending Care Coordination to Home: A Collaborative Intervention to Decrease Readmissions and Improve Patient Satisfaction

Kathleen Egan, MSW, LCSW, ACM, Jane Krivickas, BSN, LSSBB, Vanessa Roshell-Stacks, CHFP, MHA, Lynn Kasmer, MSN, RN, CNL, Sarah Johnson, MSN, RN, Jacqueline Sandkuhler-Kiel, BSN, RN, Shreya Gupta, MPH, Iman Perkins, MHA

Cipher Voice was launched in December 2018. All patients discharged from inpatient units, the observation unit, and the emergency department receive an automated Rush Care Call 48 hours post-discharge with the exception of Women and Children’s, Pediatrics, and Psychiatry. Heart failure patients receive additional weekly automated calls for four weeks.

The automated call is a recording of Chief Nursing Officer Angelique Richard asking patients several questions about how they are feeling and whether they have encountered any potential barriers since discharge.

If patients identify any issues, a Cipher nurse calls them back to triage clinical symptoms and address these barriers. If necessary, the Cipher nurses can escalate the issues to partners in pharmacy and care management, as well as patient navigators and social workers.

Early on, the Cipher nurses identified a gap in outreach to heart failure patients. A portion of these patients were not receiving the automated weekly follow up calls. In response, the Cipher nurses created and maintained a log of these patients and provided weekly calls to them.

Additionally, the Cipher nurses identified a knowledge gap. Bedside nurses did not know about these calls, which prevented them from encouraging patients to take them. Therefore, the Cipher nurses presented to nursing leadership and visited the nursing units providing education on this program to increase the percentage of patients that take the call. This resulted in a 27% increase in the reach rate. Of note, the readmission rate is approximately 4% lower in the patients that the Cipher nurses reach compared to the patients that they do not reach.

Cipher nurses have a unique opportunity to capture valuable patient feedback. To support efforts to improve care delivery and recognize care excellence, this data is distributed in weekly reports to nursing leaders as well as the patient experience team.

Most patients are grateful for these calls and we have heard several positive statements from them. Additionally, the percentages of both the ‘rate my hospital’ and the ‘staff worked together’ (care coordination) top box scores have increased since implementation of Cipher Voice.

Structural Empowerment-Extending Care Coordination to Home
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