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Lack of understanding and errors can then be rectified with further directed teaching and reevaluation of comprehension. Some points to keep in mind include:. Before the phone call, obtain the patient's hospital discharge summary, the after hospital care plan AHCP , and the DE's notes. If the discharge summary is not complete or if an AHCP was not generated for the patient, you will need to collect this information from other sources.
These may include the hospital medical record, notes from the clinician who discharged the patient, the inpatient clinicians who cared for the patient, and the ambulatory medical record. You will need to be familiar with the patient's health history and discharge plan before you make the followup phone call.
Review the discharge summary and AHCP to find out about:. While the patient was in the hospital, the DE should have completed medication reconciliation.
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The goal of inpatient medication reconciliation is to produce a correct and consistent list for the patient and clinicians, where the medication lists are identical in the discharge summary, inpatient medical record, AHCP, and, if possible, the ambulatory medical record. In certain cases, however, this may not have happened e. To check whether the patient has been given an accurate medicine list, compare the list of medicines on the hospital discharge summary with the medicines listed in the AHCP.
If medication reconciliation was done correctly at discharge, these lists should match. Doublecheck the medicine list for potentially harmful drug interactions. This should have been done as part of the in-hospital medication reconciliation process but may not have been completed for the reasons discussed above. If you identify any drug interactions, speak with the hospital team starting with the discharging physician to get clarification and make any necessary changes to the patient's medicines. Changes in medicine regimens can be particularly confusing to patients returning home.
Note changes such as discontinuation of medicine taken prior to the hospital stay or a change in the dose. Any medicine with complicated instructions can also be a source of confusion. Pay special attention to medicines for which the adverse consequences of taking them incorrectly are severe.
Familiarize yourself with commonly known drug-food interactions and side effects prior to the call. This will enable you to actively elicit this information from the patient, as well as educate him or her on possible side effects. The DE should have noted on the contact sheet go to the Contact Sheet whether an interpreter is needed for the phone call. If an interpreter is needed and your hospital has not documented that you are proficient in the language, arrange for interpreter services before the call. You can use a qualified hospital interpreter by using a speakerphone in a private location or a three-way phone system.
You may also use a telephone interpreter that your hospital contracts with. Notify your interpreter services department in advance of when you will need an interpreter, for how long, and in what language.
You may have an unanticipated need for interpreter services. This can happen if a patient or caregiver's English skills are sufficient for in-person communication but not for telephone communication, or if the need for interpreter services was not accurately recorded. Know the procedure to access immediate interpreter services. More detailed information about using an interpreter, developing cultural and linguistic competence, and reducing disparities in health care communication is described in Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital.
Before discharge, the DE will have collected contact information from the patient to facilitate reaching the patient or caregiver via phone within 72 hours of discharge. This information is found in the Contact Sheet. It includes:. When you plan your calls for the day, note that calls will vary in length, from approximately 20 to 60 minutes.
The type of patient population you target can affect the length of calls. Patients taking more medicines will require longer calls. Start your calls 48 hours after discharge. If the patient has delegated the phone call to his or her legal proxy the person with legal authority to act on behalf of the patient or his or her caregiver, call that person first. This toolkit contains a patient call script developed by the RED team to provide guidance for completing the call. Some hospitals, however, have found the call script too time consuming.
Adapting the call script for your hospital and your RED patient population will focus the call and make efficient use of your time. A data collection sheet for documenting the call also is available. The script is just a guide. The phone calls will require flexibility and creativity. You will problem solve with patients and caregivers and refer any issues that require further intervention to the appropriate clinical team member. This toolkit portrays a fictionalized followup phone call , in which Brian, a nurse at the hospital, speaks with Mrs.
Smith, a patient with congestive heart failure. This script, designed to be used at a training session for staff performing followup phone calls, gives you a sense of how a conversation might go. After introducing yourself, ask if it is a good time to talk. If it is not, get a precise time when you can call back. If the person says he or she only has a limited amount of time available, try to prioritize and tailor the call to meet the needs of that person. Even if the contact sheet indicates that an interpreter is not necessary, you should independently assess the need for an interpreter.
The DE may have assumed that people who could speak English without an interpreter at the hospital could comfortably complete the phone call in English. The telephone, however, presents another hurdle as it removes context, body language, and lip movement. If you have any sense that the patient or caregiver is not proficient in English and you are not documented as proficient in the preferred language, let him or her know that you would like to use an interpreter. If an interpreter is not immediately available, schedule a time to call back.
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Try to establish an open communication style so patients or caregivers share their hesitations or problems they are having with the discharge plan. Ask them to locate and bring the AHCP and all medicines, supplements, and traditional remedies to the phone. If the patient's health status has deteriorated, a plan of action may be needed. Interventions for patients reporting feeling worse since discharge due to primary discharge diagnosis, adverse drug event, or other symptoms may include:. The medicine check involves making sure patients or caregivers understand what the patients' medicines are for and how to take them.
This part of the phone call can be lengthy, since each medicine needs to be reviewed: name, when they take it, how much they take, how they take it, why they take it, and any problems or side effects. There are many potential barriers to adherence. Your job is to encourage the patient to share the most accurate information regarding what interferes with his or her willingness or ability to take the medicine.
You might find it helpful to think about three sources of nonadherence:. Intentional nonadherence. When a patient has chosen not to take a medicine that is part of the discharge plan or insists on taking medicine in a manner other than prescribed or that is contraindicated. Reasons for patient's intentional nonadherence include:.
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