Evidence-Based Practice Proposal Effects of Post-Discharge Follow-Up Calls


The problem with a high readmission rate is typical of many healthcare facilities. Surgical patients often need the continuous assistance and support during a post-discharge period because of high risks of complications. The lack of support can lead to hospital readmissions. Different types of interventions are proposed for surgical patients to prevent readmissions (Daniels et al., 2016). Thus, it is necessary to focus on interventions offered to address the problem in hospitals.

Many researchers and practitioners discuss post-discharge follow-up calls as an effective intervention to solve the problem and improve patients’ experiences (Chen, Li, & Lin, 2016). This post-discharge procedure can be applied to address the issue in the selected hospital. The presentation discusses the background of the readmission problem, explains the proposed evidence-based solution, describes the implementation plan, and concentrates on the appropriate evaluation plan.

What factors are associated with the problem?

Ineffective post-discharge procedures often lead to the development of adverse effects in surgical patients. They do not receive the appropriate care at home because of the lack of education in relatives. As a result, readmissions and hospitalizations rates among surgical patients are very high (Hoffman & Pelosini, 2016). The professional support and the adequate follow-up care are necessary at this stage (Crocker, Crocker, & Greenwald, 2012).

Thus, according to Lushaj et al. (2016), one patient in each five surgical patients is usually readmitted to hospitals because of inappropriate post-discharge strategies. As a result, numerous readmissions are associated with financial and administrative challenges. Therefore, the problem requires an effective solution to improve patient outcomes and decrease the readmission rate (Leppin et al., 2014). The purpose of this project is to find out whether post-discharge telephone follow-up calls can contribute to reducing the readmission rate for surgical patients.

PICO(T) Question

In surgical patients aged 21-75 years, will a 24/48-hour post-discharge telephone follow-up performed by an RN/MD/NP and compared to no call reduce the rate of hospital readmissions within 30 days over six months?

What is the proposed solution to the problem of readmissions?

To address the problem of high readmission levels for surgical patients aged between 21 and 75 years, it is necessary to propose an effective intervention. The evidence-based procedure is grounded on the idea that registered nurses (RNs), medical doctors (MDs), and nurse practitioners (NPs) perform post-discharge telephone follow-up calls during thirty days after discharging a surgical patient. This intervention is proved to be effective by many researchers. Clari et al. (2015) and Daniels et al. (2016) have found that those patients who receive follow-up calls have fewer reasons to be readmitted to hospitals. Lushaj et al. (2016) have found that the readmission rate tends to decrease because follow-up calls contribute to minimizing risks for surgical patients.

Implementation Plan

Implementation Plan

How to implement the solution?

The change model adopted for the process of implementing the intervention is Jeanie Daniel Duck’s change curve model (Melnyk & Fineout-Overholt, 2014). A change process includes such stages as stagnation, preparation, implementation, determination, and fruition. The project starts from determining the setting and participants with the focus on the surgical unit administrators, RNs, MDs, NPs, and surgical patients prepared for the discharge. Surgical patients are divided into control and test groups. The change project will last six months with the focus on the pre-implementation, implementation, and post-implementation procedures.

The post-discharge procedure includes the following steps:

  1. RNs, MDs, and NPs call patients within thirty days;
  2. if the initial call is not answered, specialists should attempt one more time;
  3. specialists ask questions and document the information;
  4. practitioners answer patients’ questions;
  5. if some risks are determined, specialists plan interventions (Daniels et al., 2016).

To monitor changes in test and control groups, it is necessary to use a protocol. The data will be collected with the help of questionnaires to document patient risks after performing a call. The information will be stored in computer files and evaluated by unit managers, nurse leaders, and administrators.

How to evaluate the intervention?

To evaluate project outcomes, it is necessary to use the digital data regarding readmission rates. The data should be collected during the second, third, fourth, fifth, and sixth months of the project. The next step is the evaluation of the documented information regarding the patients’ state (Clari et al., 2015). Chi-square tests and t-tests should be used to compare the results for control and test groups. The readmission rate observed after six months should be compared to the pre-implementation rate. The expected outcome is a reduction in readmissions for the test group.


The proposed solution is oriented to achieving a significant reduction in the number of readmissions associated with surgical patients. Thus, project outcomes are important to provide evidence regarding follow-up procedures and interventions that can be applied in hospitals to prevent readmissions. There is still a lack of data regarding the relationship between post-discharge telephone calls and readmission rates. Therefore, the discussed outcomes will have an impact on the patient-centered care. It is also possible to expect increases in the quality of care provided to the discharged surgical patients.


Chen, M., Li, P., & Lin, F. (2016). Influence of structured telephone follow-up on patient compliance with rehabilitation after total knee arthroplasty. Patient Preference and Adherence, 10(1), 257-264. Web.

Clari, M., Frigerio, S., Ricceri, F., Pici, A., Alvaro, R., & Dimonte, V. (2015). Follow‐up telephone calls to patients discharged after undergoing orthopaedic surgery: Double‐blind, randomised controlled trial of efficacy. Journal of Clinical Nursing, 24(19), 2736-2744. Web.

Crocker, J. B., Crocker, J. T., & Greenwald, J. L. (2012). Telephone follow-up as a primary care intervention for postdischarge outcomes improvement: A systematic review. The American Journal of Medicine, 125(9), 915-921. Web.

Daniels, S. A., Kelly, A., Bachand, D., Simeoni, E., Hall, C., Hofer, S. M., & Hayashi, A. (2016). Call to care: The impact of 24-hour postdischarge telephone follow-up in the treatment of surgical day care patients. The American Journal of Surgery, 211(5), 963-967. Web.

Hoffman, J. J., & Pelosini, L. (2016). Telephone follow-up for cataract surgery: Feasibility and patient satisfaction study. International Journal of Health Care Quality Assurance, 29(4), 407-416. Web.

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K.,… & Ting, H. H. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. Web.

Lushaj, E. B., Nelson, K., Amond, K., Kenny, E., Badami, A., & Anagnostopoulos, P. V. (2016). Timely post-discharge telephone follow-up is a useful tool in identifying post-discharge complications patients after congenital heart surgery. Pediatric Cardiology, 37(6), 1106-1110. Web.

Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Nurse talking on the phone [Image]. (2015). Web.

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