Transition from Hospital to Home: Outbound Calling

Ontario Shores Centre for Mental Health Sciences, a 339 bed specialized hospital, has utilized multiple approaches, including Value Stream exercises and Kaizen events, to improve discharge planning while decreasing length of stay and enhancing the overall patient experience. Through these activities, patients and families provided important feedback related to the high stress and change caused by the transition from hospital to home, particularly in regard to problem solving and maintaining the recovery levels achieved in hospital. Specifically, family members identified the need to improve the discharge process. They wanted the process to include the transition from hospital to community, avoiding the finality of discharge or end of acute care services. As a result of a Kaizen event, an Outbound Call Centre was established, utilizing existing resources. The goal of the Outbound Call Centre was to decrease readmission within 30 days of discharge by 50%. In the days prior to discharge the intake and crisis nurse meets with the patients in order to obtain consent and to initiate the caregiver relationship. In the week following discharge, the nurse calls the patients providing telephone based coaching in the weeks immediately after discharge, which supports recently discharged patients, and engages patients by requesting feedback on their discharge experience. Utilizing intake and crisis nurses ensures that the patients receive the appropriate support and assistance in navigating community resources when needed. A standardized questionnaire is used during the call ensuring that all patients are being asked the same questions, and furthermore, ensures the organization is reflecting on the patients experience to improve the transition to the community and reintegration within the community. This process was launched in January 2012. To date, patients engaged in the Outbound calling process have a 0% readmission rate; compared to a 26% readmission rate for patients who consented to the process but did not complete the service; and compared to a 14% readmission rate for patients who were discharged prior to meeting with the nurse and patients who declined the service