After going home from the hospital, patients are often still recovering, especially if they’re managing a chronic condition. A friendly phone call can help patients feel reassured about their recoveries and uncover any concerning symptoms, like trouble breathing, that need immediate follow-up. By moving follow-up tasks for care managers from a separate system to Epic, Baptist Health in Louisville, Kentucky saves these staff time so they can follow up with over 600 patients per day.
Call center nurses at Baptist follow up each week with patients who have a high risk of readmission for one of 8 chronic conditions. With the onset of the COVID-19 pandemic, additional surveys were developed to provide the patient with an intense, focused follow up to assure symptom management, needs met, and quarantine maintained as appropriate. The follow-ups last for a month after a patient leaves the hospital.
During the weekly calls, nurses see guidance in Epic for next steps based on a patient’s condition and how well the patient is recovering. For example, if the patient feels good this week, they might review patient education points together, or if the patient needs an update to medications, the nurse can send a request to a pharmacist.
Each call is tracked in Epic, so the care team knows how the patient’s recovery is going. Moving from the separate call center system to integrated tracking in Epic keeps all of a patient’s information in one place. After patients have been out of the hospital for a month, outpatient care managers take over regular chronic care management check-ins with them and track related tasks in Epic.
“With our notes and documentation visible to other providers, we can help patients recover at home and avoid readmissions or emergency visits,” said Chris Corkins, Baptist’s nurse call center director. “It’s the right thing to do for our patients.”