Follow-Up Care

The emergency department at New York University Langone Medical Center (NYULMC) in New York City has developed a robust follow-up program to ensure high-quality care for all patients after they have been discharged from the ED. This follow-up is delivered by providing telephone communication between the patient and medical provider.

The program features a collaborative approach that utilizes an integrated team of RNs, nurse practitioners and physician assistants who work closely with the ED medical and nursing directors.

Background

The Follow-Up Center was created in 2012 and reflects NYULMC’s historical commitment to high-quality patient care. The goal of the program is to communicate with all patients and synthesize patient feedback, history and all test results to properly assess health status and treat and refer when necessary.

All patients seen in the ED receive a follow-up call from a team member. Patients are designated as high- or low-risk. The high-risk (HR) cohort is followed by an NP or PA. This protocol requires a follow-up call to be made within 24 hours of discharge. The low-risk (LR) cohort is followed by an RN, who makes calls within 48 hours of discharge.

The HR cohort is defined as:

• any patient aged 16 or younger;

• any patient with fever who is 21 or younger;

• any patient aged 65 or older who had a mechanical fall;

• patients with head trauma, headache, abdominal pain/flank pain; or

• patients who return to the ED within 72 hours.

All other patient categories are designated LR.

As part of the initial follow-up process, charts are auto-labelled according to risk category. High-risk charts are then reviewed by the NP or PA, and low-risk charts are reviewed by the RN. In addition to reviewing results in the chart already interpreted in the ED, the NP or PA reviews, interprets and addresses all results that arrive in an inbox after patient discharge. These include all cultures, pathology, serology and radiology studies. The NP or PA serves as the resource for questions from the RN. Utilizing the NP or PA in this fashion allows for less interruption of ED workflow. Should the NP or PA have further questions, the ED attending physician and collaborating specialists are involved.

The Follow-Up

NYULMC’s Follow-Up Program is unique in its goal to reach all discharged patients. To best meet this goal, the patient designates at registration a clinical contact (CC) and an emergency contact (EC), each of whom is authorized to be called to reach the patient in the event of outstanding issues. Personal health information may only be shared with the EC, whereas the CC serves as a bridge to reach the patient. Patients who cannot be reached at the first call attempt get a second call.

Messages requesting call backs will be left on voicemail when possible, including a return telephone number. Additionally, the follow-up center telephone number is visible on caller ID. The second call is considered a final attempt unless outstanding findings need to be addressed. Further attempts to communicate with the patient include utilizing the CC or EC, or sending a secure email or telegram. Care is taken ensure that no personal health information is disclosed to the CC.

At NYULMC, all patient documentation is accomplished via an electronic health record (EHR). The follow-up team relies heavily on the EHR for immediate visualization of all categorized patients, provider notes, radiology results and lab entries. In a designated staff message section, ED providers flag concerns about patients who need immediate follow-up after discharge. This area is accessible only to the follow-up team members and ED providers. Since team members work different days and shifts, the EHR is a constant that allows for continuity between shifts.

In addition to maximizing communication betweeen the multidisciplinary team, the EHR allows for provider-patient messaging and automatic posting of outstanding results, which are pushed to an EHR inbox. Because the EHR allows real-time tracking of patients in the ED, it enables the staff to track patient adherence with recommended returns and therapies. The EHR also automatically sends a summary of care, which includes any lab and imaging results, to the listed primary care provider after discharge.

Example

The following is an example of a typical ED visit and telephone encounter. Patient X comes to the ED with abdominal pain. He is evaluated, treated and released. Labs are collected, imaging studies are performed and surgical consultation may be obtained. After being evaluated, the patient may receive medication and then be sent home after stabilization and/or resolution of symptoms.

A typical follow-up telephone encounter facilitates patient comprehension of discharge instructions and clarifies discharge medications. At this time, the NP or PA can change medication therapies by e-prescribing to an outpatient pharmacy. The team member may refer the patient to social services or assist the patient with making post-discharge transportation arrangements.

Finally, the team member reviews imaging results with the patient and reports any incidental findings. An incidental finding is one that is discovered unintentionally and is not related to the patient’s current medical condition. For example, this same hypothetical patient with abdominal pain might have imaging that reveals lung nodules. The follow-up team also tracks any new findings outside of imaging. An example is a patient who is prescribed a narcotic for pain control at discharge. An outside pharmacist calls the follow-up team to report the patient is taking an opioid antagonist; the NP or PA then changes the prescription to a different class of pain medication.

If any incidental findings have been reviewed during the course of the ED visit, they are reinforced during the discharge follow-up. If they have been newly discovered and have not been reviewed during the ED visit, the patients are notified and advised accordingly. Concerning findings are also communicated to the patient’s primary care provider or specialist.

Patient Satisfaction

Patient satisfaction with ED care is also assessed during the telephone encounter. Should the patient complain about any aspect of ED care, we attempt “service recovery.” These efforts include calling the patient back after re-evaluating ED care by complete chart review.

Any unresolved patient concerns not addressed by the follow-up personnel are then referred to the attention of the ED nursing or medical director. The director will either personally call the patient or designate a staff member to do so.

The most frequent areas of patient dissatisfaction are with wait times for imaging and a perceived lack of communication by the treatment team to the patient of visit progress and updates. When warranted, such comments lead to corrective action with the staff, showing that accountability is taken by the ED.

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