How Rush Uses Robocalls to Reduce Readmissions

The Chicago medical center has figured out how to get 80% of patients to answer automated calls after discharge, and uses the data to improve care, processes, and issues related to COVID-19.

This article appears in the September/October 2020 edition of HealthLeaders magazine. 

How is Rush University Medical Center reaching 80% of its patients post-discharge, with an innovation that has reduced its inpatient readmissions? With "robocalls."

The Chicago-based academic medical center has found a way to do the seemingly impossible: get most patients to answer an automated call once they leave the hospital. The technology provides a way to stretch limited staff resources, while addressing issues and escalating care for those who require further assistance.

According to the vice president in charge of the program, the patient engagement platform from New York City–based CipherHealth also improves internal processes, provides feedback to improve care to discharged COVID-19 patients, and contributes to greater patient satisfaction. Here's how they did it:

In the Beginning: Fighting Resistance

Before trying robocalls, Rush University Medical Center had launched a number of initiatives to reduce readmissions. "We know from research that post-discharge calls, in general, help to reduce readmissions," says Vanessa Roshell-Stacks, MHA, former vice president of care coordination, clinical documentation, and hospital operations at Rush. Confusion about discharge instructions or medications are among the driving forces behind readmissions, she says.

"We were struggling with who does those calls and how to scale those calls to reach a mass [number] of our patients," she recalls. "Once you reach the patients, how do you dedicate enough time to really triage and escalate their issues? It's very resource-intensive. We tried many different models to do this." Attempts included assigning this task to care managers as part of their role, as well as having nurses make the calls.

Rush's population health department was involved in a similar initiative, but only focused on a subset of patients. "We wanted the calls to get to all of our discharged patients," Roshell-Stacks says. "We tried all sorts of things with limited success."

The medical center had been using a patient rounding tool from CipherHealth since 2015. The platform also had the capability to handle outbound calls, but initially, the idea of conducting automated calls to solve the problem was not well received. "When we were deciding whether we wanted to do this, one of the concerns, honestly, was that people hate automated calls; they hang up," Roshell-Stacks says.

Yet since other efforts were not successful, in 2018, Rush decided to try the platform to reach out to patients discharged from the hospital and emergency department.  

"We did not think that patients would answer the robocalls," Roshell-Stacks says, "but that just proved not to be the case."

The Secret Formula: How to Get Patients to Answer Robocalls

A deeper look into the practices Rush put into place reveals clues regarding why so many of its patients answer the automated calls.

• Patients are informed before discharge that they will receive a robocall from Rush, and they are coached to answer it. "We spend time upfront to introduce this [concept] to patients while they are still in the hospital," Roshell-Stacks says. "We explain, 'You're going to get this call; please answer.' "
   
• The service is branded as Care Call. The name is mentioned to patients during their coaching session, and it appears that way on their caller ID. Patients understand that the purpose of the call is to check up on them; it is not a call from the business office.
   
• Two days after discharge, the system initiates a call to each patient, using contact information embedded in the Epic electronic medical record (EMR). Once the phone is answered, the caller is greeted by a recording from Angelique Richard, RN, PhD, vice president for clinical nursing and CNO. Richards explains that "she is the chief nursing officer at Rush Medical Center calling to check on you and ensure that you're transitioning [well] to home, says Amanda Devlin, senior vice president, enterprise sales & strategy for CipherHealth. Devlin says that the tone and language used in the greeting encourages callers to stay on the line.
  
  "That was very deliberate," Roshell-Stacks says, "because research shows that chief nursing officers are probably one of their most trusted executives in healthcare."

The personalization and education Rush conducts contribute to the success of the initiative, says Devlin. Rush has a higher rate of answered calls than any other health system using the platform, she says. 

No New Staffing Required

After the recorded introduction, callers are asked a series of questions, such as whether they understand their discharge instructions, how they are feeling, and whether they are experiencing any problems. Patients respond by pressing buttons on their keypad. For example in response to the question, "how are you feeling?" they would be instructed to "Press 1 for better, press 2 for the same, press 3 for worse."

The alerts are handled by a nurse triage team working out of Rush's Patient Placement and Transfer Center. "They call the patients back and dig deeper into [the patient's] issue," she explains.

The team is composed of the full-time equivalent of three staff members. No incremental personnel were hired for the initiative; one nurse was reassigned from another area of the hospital, and some care manager workflows in the Center were shifted to accommodate the new tasks.

If the nurse cannot resolve a patient's issue, they can escalate to other personnel including a pharmacist, social worker, or hospitalist, Roshell-Stacks says. These key stakeholder groups receive special training, but are not devoted to the program full time. Many frequent re-admitters are handed over to the population health department, and all patient interactions are recorded in the EMR.

Results

Rush has experienced numerous benefits from the program, says Roshell-Stacks, including reduced readmissions, as well as improved processes and enhanced patient satisfaction.

1. Reduced Readmissions

As a result of the program, "We've seen an improvement in our overall readmission rate," Roshell-Stacks says. From June 1, 2019, through May 31, 2020, the program experienced the following results for inpatients:

• The system attempted to reach 18,679 patients after their inpatient discharge.
   
• 80% of discharged patients answered the phone and listened to the messages.
   
• 57% of those who answered (10,559 patients) further engaged and answered clinically focused questions about their health status.
   
• Of those who engaged further and answered the questions, 7.9% (835 patients) had to be readmitted as compared to 14.1% (1,148 patients) that the system was not able to reach after three attempts. As a result, those who engaged in the automated calls had a significantly lower admission rate.

2. Actionable Data

The platform provides copious data points, which the hospital uses to improve processes, she says. For example, many patients reported they did not understand their discharge instructions. Before the robocall program, "we knew there were concerns," says Roshell-Stacks, "but that was the No. 1 data point that came out of those calls. The data that we're getting from these calls really helped inform where we need to focus our attention as an organization." As a result, Rush has formed a team, including frontline nurses, to address this issue and determine how to improve discharge instructions.

3. Improved Patient Satisfaction

"One of the metrics that we look at very, closely of course, is our patient satisfaction scores," she says. While Rush did not provide figures, Roshell-Stacks attributes a rise in scores since the robocalls began partially to the initiative. "We do a lot of things around patient satisfaction, but this is certainly a large component of what we do, as well rounding on patients, that we think is definitely a contributor to our great scores in terms of engagement."

To gain further insights, the medical center conducted an informal study with patients enrolled in longer term engagements with the program, such as congestive heart failure patients who are followed for 30 days post-discharge. "People really felt that Rush cares about them as patients," Roshell-Stacks reports.

4. COVID-Specific Improvements

More recently, the program has helped Rush better understand and respond to the needs of COVID-19 patients. Feedback from calls indicated that patients were having difficulty obtaining prescription drugs because many pharmacies were closed, not only due to issues created by the pandemic, but because of civil unrest in the Chicago area. To address this issue, "We asked our hospitalists and others to get the prescriptions to our pharmacy. Hours were expanded and a special area was set up for patients to wait while their prescriptions were filled. We were able to do that very quickly as an organization," she says.

The calls also revealed that patients were confused about COVID treatment and isolation protocols due to conflicting information from a variety of sources, including the media. Also, many other community resources were closed, and patients were having difficulty getting home healthcare services in certain communities. Others were having trouble accessing appropriate technology for televisits. The automated calls documented these problems and provided information Rush could act upon, she says.

The platform "allows us to quickly hear the voice of the customer and really understand their experience," says Roshell-Stacks. It enables "us to be agile and to adapt our processes to address the needs of our patients. As a healthcare organization, it helped us identify their needs and meet them where they were. That is the value the platform brings to us."

Editor's note: This story was updated on September 24, 2020.