The transition from hospital to home can expose patients to adverse events during the post-discharge period [1], [2]. Preventable harm may arise from medication errors [1], discontinuity in care, inadequate communication between inpatient and outpatient providers [3], or lack of follow-up of pending inpatient results that may impact management [2], [4], [5]. In addition, patients and primary care providers (PCPs) report negative experiences following discharge from hospital. Indeed, patients often experience a “voltage drop” in support once leaving the hospital, resulting in feeling unprepared for discharge, and have challenges transitioning to normal life and translating knowledge into safe, health-promoting actions at home [6], [7]. Contributing factors include inadequate patient and caregiver education prior to discharge, lack of in-home resources, and access to treating physicians.

A follow-up telephone call is a simple method to connect with patients following discharge to review and reinforce discharge plans. However, previous studies examining phone calls to patients returning home were frequently conducted by a pharmacist and focused on medication management. A Cochrane systematic review found a high degree of heterogeneity and low methodological quality across studies, hence limiting a meaningful conclusion [8]. There is inconsistent evidence that post discharge phone calls, alone or as part of a discharge bundle, can affect readmission rates [9]. However, the effect of post discharge phone calls on the patient experience and on perceived comprehension of discharge instructions remains unclear.

Our institution publically reports a measure of the patient's experience on continuity and transition through a validated standardized commercial post discharge survey instrument (NRCC-Picker) [10]. Consistently, reported scores have been below benchmark and those of peer comparator organizations. Root cause analyses indicated inadequate patient and caregiver engagement and education, and lack of post discharge follow up as contributors. To address these issues, a cluster-randomized control study was conducted on general medicine wards to determine the impact of post discharge phone calls on the patient experience, as well as reinforcing patient discharge instructions.

The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1 and Protocol S1.

Eligible patients were recruited between September 2012 and March 2013, from the GIM inpatient wards. (Figure 1) Recruitment ended when the sample size was reached. The mean age of participants was 64 years. About 60% were women, most had family physicians, and were in hospital for just under 8 days. The most common diagnosis was pneumonia. There were no differences between the two groups in terms of baseline demographic characteristics (Table 1).

Fidelity of the intervention was 69% (114 out of 165). The PNs attempted to improve fidelity by increasing the frequency of attempts (beyond 5) to contact patients but calls were often not returned. The majority of patients who responded to the intervention phone call were reached with less than 5 attempts. Reasons for not reaching patients in the intervention arm included loss to follow up (27), readmission to hospital (9), wrong phone number (5), deceased (2), declined (2), and other (6). Readmission to hospital accounted for 9 (18%) patients in the intervention arm who could not be reached for a post discharge phone call. The 30-day survey response rate was 65% (214 out of 328) (Table 2). CTM-3 scores for the intervention group was 73.1±19.5 and 71.3±18.8 for the control group. An intention-to-treat analysis revealed a small statistically significant difference in CTM-3 scores between the two groups (1.87 points, 95% CI 0.47–3.27, p = 0.01). On-treatment analysis and adjusting for geriatric unit assignment did not change the results.

Secondary outcomes of self-reported adherence to treatment plans and medications, and 30-day ED visit and readmission were similar between the two groups (odds ratio 0.57, 95% CI 0.13–2.45, 1.20, 95% CI 0.61–2.37, and 1.18, 95% CI 0.53–2.61, respectively) (Table 2).

We conducted a cluster randomized control trial comparing post discharge phone calls with usual care and found minimal improvement in CTM-3 scores in the intervention group over the control. However, the effect was small and may lack clinical relevance to clinicians and administrators. To our knowledge, this is the first study evaluating the effect of post discharge phone calls on a validated measure of the quality of care transitions, the CTM-3 score.

The association between suboptimal transitions of care and readmission rates [1] has stimulated great interest in post discharge efforts, such as phone calls, to support patients returning home. The results of our study are consistent with previous efforts that failed to demonstrate a meaningful effect of post discharge phone calls on readmission. However, several studies reported improved patient satisfaction scores. Dudas and colleagues conducted a randomized control trial of a pharmacist-led post discharge phone call intervention [17]. Outcomes measured were patient satisfaction scores, 30-day ED visits, and readmission. Implementation fidelity was similar to our study, with higher reported satisfaction with medication instruction and lower ED visit rates in the intervention arm. However, the study was limited by a small sample size and possible clustering effects. A second study used two phone calls to patients discharged from medicine one week and one month post discharge [18]. Although findings shared similar limitations, the authors found no differences in the primary end-point of readmission. A Cochrane systematic review examining the effects of follow up phone calls on patient outcomes found some evidence of improved effects such as adherence to post discharge appointments without evidence of adverse events [8]. However, heterogeneity, low methodology, and a risk of bias precluded a firm conclusion on the effects of discharge phone calls. In the majority of these studies, a hospital-based individual conducted the phone calls. It is unclear whether this contributed to the negative results and whether calls from outpatient-based primary care teams would be more effective. Finally, our intervention differed from previous studies in that a non-clinician conducted the phone calls, possibly reducing impact. A previous negative telephone study also involved a non-clinician caller [19].

Post discharge phone calls are but one component of “discharge bundles” that aim to prepare a patient for discharge. Over-reliance on this intervention to impact on the complex phenomenon of readmission may not be successful [20]. Our study showed that a single post discharge phone call had little impact on an objective measure of care transition. This observation supports the concept that care transition interventions may be most effective when delivered in a bundle where the effect on outcomes can be additive [9]. Other single intervention studies showed minimal impact on CTM-3 scores with absolute differences similar to our study [14], [21] whereas a study involving a multi-site, multi-faceted interventions resulted in greater improvement [22]. Although our intervention was simple and low cost (phone calls were incorporated into daily workflow), ideal post discharge care may require more intensive interventions such as repeated phone calls by a clinician or home visits as described in Project RED [23] and BOOST [24] to have a more appreciable effect. Finally, high resource-intensive interventions may be best targeted toward select patients with complicated discharge plans at risk of adverse events [20]. The decision to incorporate post discharge phone calls will require careful consideration of several factors. Patient factors such as complexity of disease and care plans, and poor social supports may warrant post discharge phone calls. How these calls fit into provider workflow, other discharge bundle interventions, and associated personnel costs need to be weighed against limited efficacy. Our next steps include evaluating discharge phone calls in select high-risk patients and in concert with other post discharge interventions.

Our study has several limitations. First, the implementation fidelity of the discharge phone calls was 69%, possibly reducing the effect of the intervention. This is however, consistent with other studies of post discharge phone calls [8] and an on-treatment analysis yielded similar results. Second, the primary outcome of CTM-3 scores was collected 30 days post discharge and may be subject to recall bias. Measurement of outcomes one month following the intervention was important to determine any long-term effects and sustainability of the phone calls on the patient experience. Given that readmission to hospital can occur throughout the 30-day period following discharge, it was important to capture the impact of the intervention during this time frame [25]. In addition, CTM-3 scores are frequently measured 30-days post discharge [8]. Third, we only measured self-reported adherence to treatment plans and ED visits and readmission rates. In addition, the study was not powered to detect secondary outcomes. However, we were able to confirm hospital utilization within our local health region through available electronic health records. Fourth, we enrolled all eligible patients rather than targeting those who may benefit most and/or require intensive support following discharge, possibly diluting the effects of the intervention. We plan to study our intervention in patients discharged with complex care plans at high risk of adverse events. Fifth, the provider teams and survey assessors were unblinded, potentially introducing bias. However, frontline staff frequently rotated to other facilities and was often unaware of the intervention. Sixth, patients lost to follow up represented the majority of missing data which cannot be assumed to be at random. This precluded imputation strategies to address missing data and may have introduced bias. Last, this study was conducted in a single academic medical centre and results may not be generalizable to other settings although our patient population and demographics are typical of many acute care facilities.

A single post discharge phone call for patients returning home from hospital failed to produce a meaningful impact on the patient's discharge experience. Our observations support a focus on higher intensity support in the post discharge period in select patients to aid transition to normal home life.