Postdischarge telephone calls by hospitalists as a transitional care strategy.

Objectives: To determine whether treating hospitalists can identify and address early postdischarge problems through a structured telephone call.

Study Design: Prospective cohort study.

Methods: We studied patients insured through a managed care program who were discharged from a general internal medicine service of a university-affiliated public safety net hospital (Denver Health Medical Center) between March 1, 2012, and October 31, 2013. The hospitalist who treated the patient during their hospitalization contacted them 48 to 72 hours after discharge and completed a structured telephone assessment. We assessed the type and frequency of problems identified, the proportion of calls in which problems were independently addressed by the hospitalist, the proportion referred for additional managed care services, and the duration of calls and subsequent care coordination.

Results: Treating hospitalists identified 1 or more problems in 74 of the 131 patients (56%) contacted. The most common categories of problems were: new or worsening symptoms (41%), difficulty accessing recommended follow-up care (21%), and medication issues (20%). Hospitalists independently managed the problems identified in 68% of the calls; additional services were required in 32%. Median time spent per call was 8 minutes (interquartile range, 5-12).

Conclusions: Treating hospitalists identified problems in over half of patients contacted by telephone shortly after discharge, the largest proportion of which were new or worsening symptoms. Hospitalists were able to address the majority of problems identified through the single, brief telephone encounter without utilizing additional resources.