Peri-discharge Care Coordination After Sepsis Hospitalization

Document Type

Conference Proceeding

Publication Date

5-21-2025

Publication Title

Am J Respir Crit Care Med

Abstract

RATIONALE: Patients experience high rates of readmission and mortality after sepsis hospitalization. Since peri-discharge care coordination may improve outcomes, we evaluated hospitals' peri-discharge care coordination practices to support patients after sepsis hospitalization. METHODS: We surveyed 69 hospitals in the Michigan Hospital Medicine Safety Consortium (HMS) Sepsis Initiative, a collaborative quality initiative sponsored by Blue Cross Blue Shield of Michigan. Each hospital's HMS representative completed the survey in fall 2023, with input from relevant hospital staff as needed. The survey included questions on three peri-discharge care coordination practices: mechanisms for patients to contact hospital clinicians for questions related to hospitalization or hospital discharge instructions, post-discharge phone calls, and scheduling of outpatient follow-up. RESULTS: Among 67 hospitals completing the survey (97% response rate), 44 (65.7%) had a mechanism for patients to contact hospital clinicians to discuss post-discharge questions (34 for all patients; 10 for some patients). Of these hospitals, 13 (29.5%) implemented the mechanism in the prior year; another 11 (16.4%) planned to institute a mechanism in the coming year. Hospitals most frequently had centralized care managers (n=20; 29.9%) or service-specific care managers (n=15; 22.4%) answer patient calls, or had hospital operators route patients to on-call physicians (n=25; 37.3%). 53 (79.1%) hospitals made post-discharge telephone calls to patients within 3 days of hospital discharge to follow-up on discharge instructions and/or to assess patient symptoms (10 for all patients; 43 for some patients). Of these hospitals, 7 (13.2%) implemented post-discharge calls in the prior year; 5 additional hospitals (7.5%) planned to implement post-discharge telephone calls in the next year. Calls were most frequently made by transitional care staff (n=31, 46.2%), PCP office staff (n=21, 31.3%) or inpatient staff (n=18, 26.9%). Seven hospitals (10.4%) used automated calls to follow up with patients, connecting to a clinician only if needed based on patient response. Among hospitals doing follow-up calls for some but not all patients, prioritization was most often based on diagnoses, discharge service, or readmission risk score. 31 (46.3%) hospitals had a mechanism in place to ensure patients discharged without follow-up scheduled were scheduled shortly after discharge. CONCLUSIONS: Most hospitals have mechanisms to facilitate, or plan to institute mechanisms in the coming year. However, there is substantial variability in how hospitals implement peri-discharge care coordination and prioritize patients for follow-up calls. Additional research is necessary to identify how these interventions impact patient outcomes.

Volume

211

First Page

1

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