(P46) Post-SNF Follow-Up Calls and Appointments Trend Toward Decreased Readmissions

Objective/

Aim: To assess whether scheduled and attended follow-up appointments and follow-up phone calls after skilled nursing facility (SNF) discharge decrease 30-day readmissions post-SNF discharge, and subsequently improve patient outcomes and help decrease the strain on the health systems. Target population: patients discharged from one Michigan hospital to 4 SNFs. Goal: reduced hospital readmissions.

Background: Reduction in readmissions requires transitions of care coordination across various medical settings. Timely post-SNF discharge follow-up care can help avoid readmission.

Quality Improvement

Methods: As part of a collaborative quality initiative, we sought to determine whether follow-up calls and scheduled medical provider appointments decreased readmissions.
Patients discharged from SNF to home or assisted living facility from July 17, 2019 through July 29, 2022 were included. Interventions included scheduling a follow-up appointment within 14 days post-SNF discharge and making a follow-up call. Phone calls addressed home health needs, medications, equipment, and barriers to care. Multivariate logistic regression was used to assess for an association between interventions and readmission. The outcome was hospital readmission within 30 days of SNF discharge.

Results: Our sample included 437 patients. Interventions: 80% had post-SNF discharge follow-up appointments scheduled within 14 days, 71% had a follow-up call after SNF discharge, and 59% had both interventions; 65% of patients attended their scheduled follow-up appointment. The readmission rates for 1) those scheduled at 0-7d, 8-14d versus no appointment was 11.2%, 16.4%, 11.5%; p=0.465; 2) those who attended 0-7d, 8-14d versus no appointment was 10.9%, 9.7%, 14.9%; p=0.402, 3) those who had a follow-up call vs none 11.3% and 14.3%; p=0.379. In both multivariate models and logistic regression models, having a scheduled follow-up appointment within 14 days, attending a follow-up appointment, and having a follow-up call were each associated with lower odds of readmission compared to no intervention, however, was not statistically significant.

Conclusions: Decreasing readmissions is a high priority for patients, SNFs, and hospitals. Conducting post-SNF discharge calls focused on health care needs and scheduling and attending provider appointments trended toward decreasing 30-day readmissions after SNF discharge, however, showed no statistical significance. Limitations included small sample size and the potential effects of the COVID pandemic (not measured in this study) on access to outpatient visits. Larger studies are needed to confirm these promising findings.