Johnson Marian Bihrle, Laderman Mara, Coleman Eric A
Institute for Healthcare Improvement, Cambridge, Massachusetts, USA.
Jt Comm J Qual Patient Saf. 2013 May;39(5):221-7. doi: 10.1016/s1553-7250(13)39029-1.
Unavoidable rehospitalizations are frequent, costly, and burdensome for patients and families. The incidence of rehospitalizations within 30 days of discharge can be reduced by improving communication and coordination of care, including enhancing communication with patients and families. Postdischarge follow-up calls are often cited as a cost-effective intervention, yet there is little standardization on how they should be conducted.
A nonsystematic review of the literature focused on the use of telephone follow-up (TFU) to improve postdischarge processes and reduce avoidable readmissions. Its use was also examined as a component of postdischarge processes among hospitals and organizations participating in the STate Action on Avoidable Rehospitalizations (STAAR) initiative. THE THREE DECISION POINTS: (1) Who Should Make the Call? The decision about who should initiate telephone contact will involve multiple considerations, such as available staff time, level of clinical knowledge required, and financial and practical sustainability. (2) Which Information Is Essential? Care teams should define the follow-up calls' short- and long-term goals and then identify the information needed to achieve them. A standardized assessment sheet may help ensure that patients are always asked the appropriate questions to ascertain whether they require advice and/or intervention, changes in medication, or a visit to their physician or emergency department. (3) What is the Optimal Timing, Frequency, and Duration of Follow-up Calls? The frequency of calls should depend on the patient population, and the duration on the length of the standardized assessment or telephone script and on patient need.
TFU should continue to be explored as a cost-effective option to reduce readmissions.
不可避免的再次住院情况频繁发生，成本高昂，给患者及其家庭带来负担。通过改善医疗护理的沟通与协调，包括加强与患者及其家庭的沟通，可以降低出院后30天内再次住院的发生率。出院后随访电话常被视为一种具有成本效益的干预措施，但在如何进行随访方面几乎没有标准化规范。
对文献进行非系统性综述，重点关注电话随访（TFU）在改善出院后流程及减少可避免的再次入院方面的应用。还将其作为参与“避免可避免的再次住院国家行动”（STAAR）倡议的医院和组织出院后流程的一个组成部分进行研究。三个决策要点：（1）谁应拨打随访电话？关于谁应发起电话联系的决策将涉及多个因素，如可用工作人员时间、所需临床知识水平以及财务和实际可持续性。（2）哪些信息至关重要？护理团队应确定随访电话的短期和长期目标，然后确定实现这些目标所需的信息。标准化评估表可能有助于确保始终向患者提出适当问题，以确定他们是否需要建议和/或干预、药物调整或看医生或去急诊科就诊。（3）随访电话的最佳时间、频率和时长是多少？电话频率应取决于患者群体，时长则取决于标准化评估或电话脚本的长度以及患者需求。
应继续探索电话随访作为降低再次入院率的一种具有成本效益的选择。
