A Quality Improvement Project to Improve Hospital-to-Home Transitions Using Discharge Televisits

Patients were eligible for inclusion in the study if they were discharged from the pediatric unit between November 1, 2020 and August 31, 2021. Patients were excluded if transferred to another institution or discharged to a long-term care facility.

The improvement team included pediatric residents, hospitalists, outpatient pediatricians, and QI specialists. Additional stakeholders included clerical staff who helped build the discharge televisit template in the EHR and schedule the follow-up appointments.

The model for improvement was used as QI methodology and a key driver diagram to guide improvement efforts (Fig 1).

The following change ideas were developed and tested using plan-do-study-act cycles between November 2020 and August 2021:

1. Discharge televisit appointment template: We designed an EHR visit template for the discharge televisits. The template included a total of ten 20-minute slots per week. The televisits were initially conducted on 2 weekdays with 5 slots per day. After receiving feedback from the residents that 5 slots per day interfered with other patient care tasks, the template was changed to 2 visit slots per day, 5 days per week (Monday to Friday at 14:00 and 14:20). The inpatient clerical staff were available to schedule patients for discharge televisit appointments. Although appointments were scheduled for 14:00 and 14:20 in the EHR system and residents were encouraged to stick to these times, there was some flexibility in when the televisits were conducted based on patient or caregiver and resident availability. For example, if the patient or caregiver stated they were only available after 15:00, the residents could schedule them for 14:20 but make a note to call them after 15:00 as long as this worked within their schedule.

2. Criteria for allocating discharge televisits: Since only 10 televisit slots were available per week, discharge televisits were not available to every patient. The improvement team developed criteria for prioritizing patients for discharge televisits: going home on antibiotics or new medications, high-risk social situations requiring inpatient social work consult, 1 or more subspecialty follow-up appointments, need for durable medical equipment or home nursing services, and diagnostic test results that were pending at the time of discharge.

3. Discharge televisit workflow: The study team developed a protocol for conducting discharge televisits. To emphasize the continuity of care whenever possible, the pediatric intern who discharged the patient was responsible for conducting the discharge televisit. This was not always possible given scheduling conflicts (eg, continuity clinic), and another intern on the team conducted the televisit in these cases. The visits were conducted in the resident workroom using a hospital landline phone. The team was instructed to conduct the televisits between 14:00 and 15:00 to ensure enough time to round in the morning and get patient care tasks done before and after the televisits. If there was no answer after 3 attempts to contact the patient or caregiver, the residents were instructed to leave a message for the patient and to document this in the EHR. The residents conducting the televisits were supervised by the pediatric attending on service who was available either in person or on the phone to precept and answer any questions.

4. Resident training on discharge televisit workflow: The pediatric residents were taught how to conduct discharge televisits during the monthly orientation to the pediatric inpatient unit. Additionally, project champions were available during the first few days of each inpatient cycle and on an as-needed basis to help the inpatient team troubleshoot the discharge televisit workflow.

5. Previsit planning worksheet: The improvement team designed a previsit planning worksheet for providers to complete at the time of discharge. The planning worksheet included patient contact information, discharge date, discharge diagnosis, patient summary statement, a list of the discharge medications, follow-up appointments, pending diagnostic studies, and a question about whether the patient portal was activated at the time of discharge. The pediatric residents were instructed to fill out the previsit planning worksheet at the time of discharge after informing the patient or caregiver of the upcoming televisit. A folder was placed in the resident room to store completed previsit planning worksheets for use later during the discharge televisits.

6. Discharge televisit note template: An EHR note template was created to facilitate documentation during the discharge televisit. The template included documentation of whether the call was successful, patient or caregiver concerns, any fever, and the quality of intake and output since discharge. Additionally, providers were prompted to ask whether all prescriptions were picked up, whether the patient was experiencing any medication side effects, and whether all the subspecialty follow-up appointments were scheduled, if applicable. Providers were also prompted to review any diagnostic studies that resulted since discharge and share these results with the patient or caregiver. If the patient portal was not activated at the time of discharge, providers were encouraged to help interested patients or caregivers activate the patient portal during the televisit.

7. Ongoing project feedback: Project champions continuously elicited feedback from inpatient providers to identify any barriers to conducting the discharge televisits and to improve the workflow. The following changes were made throughout the project after provider feedback: (1) template change, (2) addition of the previsit planning worksheet, (3) change from 1 assigned televisit intern to having the intern who discharged the patient conduct the televisits, and (4) addition of criteria for allocating televisits.

The outcome measure was the proportion of patients who had completed follow-up. Completed follow-up for patients with televisits was defined as a scheduled televisit encounter in the EHR and a visit note signifying visit completion. Completed follow-up for patients with in person visits was defined as having a scheduled in person encounter in the EHR and a visit note signifying visit completion. Patients who did not have a scheduled in person or televisit postdischarge encounter within our system were classified as unconfirmed follow-up since it was not possible to determine whether follow-up was completed. The process measure was the proportion of televisit appointment slots filled. The balancing measures were the 7-day ED visit and readmission rates. Postdischarge issues identified and addressed during each televisit were also tracked. Additionally, to help drive ongoing improvement efforts, all patient-caregiver dyads with completed televisits between December 21, 2020 and January 14, 2021 were contacted after the televisit and asked to respond to a 5-question verbal survey to elicit patient-caregiver satisfaction and feedback.

For all children admitted to the pediatric unit during the study period that met inclusion criteria, sociodemographic characteristics were summarized by medians and interquartile ranges or frequencies and percentages. Patients were grouped by follow-up type (discharge televisit, in person visit, unconfirmed follow-up). Sociodemographic characteristics were compared between patients with scheduled versus unconfirmed follow-up and televisits versus in person visits using the Kruskal Wallace test for continuous variables and the χ square test for categorical variables.

Statistical Process Control P charts were created in excel using QI macros to track completed follow-up for patients with televisits and in person follow-up visits over time. Simple logistic regression was used to determine the unadjusted association between visit type and completed follow-up. Odds ratios with 95% confidence intervals (CI) were calculated. Multiple logistic regression was used for the final model to adjust for sociodemographic variables. Stepwise elimination using backward akaike information criterion (AIC) was used to choose the most parsimonious model.

The proportion of available televisit shots that were scheduled was determined. Frequencies and percentages were used to categorize topics addressed during the discharge televisits and these were displayed visually on a Pareto chart. Seven-day ED visit and readmission rates were compared between visit types using the χ square test. Responses to the caregiver survey were described by frequencies and percentages. RStudio was used for the statistical analysis and a P value < .05 was considered statistically significant.

The study protocol was submitted to the university’s institutional review board and considered exempt from review.

There were 752 discharges between November 1 and August 31, 2021. Among these, 44 patients were excluded from the study because of transfer to another acute care institution or discharge to a long-term care facility. The remaining 708 (94.1%) patients were included in the study. There were 159 (22.5%) patients with unconfirmed follow-up since these patients did not have any follow-up encounter (televisit or in person) scheduled within the EHR. Patients with unconfirmed follow-up did not differ in age, sex, race, ethnicity, and preferred language (English versus non-English) from patients with scheduled follow-up appointments. Patients with scheduled follow-up appointments were more likely to be admitted to the general pediatrics service versus subspecialty service (97.4% vs 90.6%, P < .001), and more likely to have a primary care provider affiliated with the study institution (59.9% vs 32.1%, P < .001).

A little more than half the patients with scheduled follow-up had a televisit: 315 (57.4%). The sociodemographic characteristics of patients with televisits, in person visits, and unconfirmed follow-up are presented in Table 1.

Completed follow-up was 88.3% for patients with televisits and 63.3% for in person visits (Fig 2). Completed follow-up was 4.2 (95% CI 2.8–6.2) times more likely in patients with televisits compared with in person follow-up and remained significant after controlling for age and having a pediatrician affiliated with the study hospital (odds ratio 4.4, 95% CI 2.9–6.8, P < .001) (Table 2). Of the 434 available televisit slots, 315 (72.6%) were scheduled.

In approximately one-third (32.7%) of televisits, providers discussed with patients and caregivers the results of diagnostic tests that were pending at the time of discharge. In 19.8% of televisits, providers discovered and addressed issues related to medications prescribed at discharge, including insurance prior authorization needed or medication never picked up from pharmacy. Additional topics that providers addressed during televisits included issues scheduling subspeciality appointments and new or persistent clinical symptoms (Fig 3). There were 6 of 315 (1.9%), 7 of 234 (3.0%), and 4 of 159 (2.5%) readmissions within 7 days of discharge for patients with televisits, in person, and unconfirmed follow-up, respectively (P = .709). ED revisits within 7 days of discharge also did not differ between individuals with televisits, in person visits, and unconfirmed follow-up [18 of 315 (5.7%) televisit, 10 of 234 (4.3%) in person, 4 of 159 (2.5%) unconfirmed follow-up (P = .279)].

Of the 31 patient-caregiver dyads who received a post-televisit survey, 28 (90%) responded. On a Likert scale of 1 to 5, 23 of 28 (82%) patients-caregivers responded satisfied (4) or very satisfied (5) with the discharge televisit. The remainder responded neutral (3) and did not provide any additional feedback. All respondents reported their concerns being adequately addressed during the discharge televisits.

Using QI methodology to implement a discharge televisit workflow on a pediatric inpatient unit, we successfully increased completed postdischarge follow-up from 67.0% to 88.3%, achieving our desired goal. Completed follow-up was significantly higher in patients with televisits compared with in person follow-up visits during the study period. Overall, patients and caregivers were satisfied with the discharge televisits. Importantly, 7-day ED revisits and readmissions were low throughout the study period and not significantly different between patients with televisits, in person visits, or unconfirmed follow-up. This suggests that patients and caregivers were getting their concerns addressed during the televisits and did not need to seek further care.

Our study is unique from most prior studies because the discharge televisits were conducted by the pediatric residents. This method maintains continuity of care with providers who are most familiar with the discharge care plan and are therefore best situated to answer any questions and troubleshoot issues. The discharge televisits also allowed residents to learn about this unique application of telehealth as part of their residency training. According to a national cross-sectional survey, 71% of pediatric residency programs are using telemedicine with trainees.³⁴  Having residents participate in discharge televisits is one way for residency programs to provide trainees with supervised telemedicine experiences during residency.

Similar to Rhem et al, we found that the discharge televisits were a good venue to address postdischarge issues related to follow-up appointments and medications.³  These findings are important given the known risk for adverse events related to care transitions.^1–5  A study conducted at a pediatric hospital in the midwestern United States found that over a quarter of pediatric patients had 1 or more discrepant medications at the time of hospital discharge.⁵  Similarly, we identified a medication problem in 20% of the discharge televisits. An advantage in our study is that the providers conducting the discharge televisits had opportunities to intervene on the medication issues identified, for example, by providing additional clarification or interventions as needed, such as obtaining prior authorization.

It is known that certain patients are at a higher risk for adverse events during care transitions. In high-risk infants being discharged from the NICU, for example, medication errors by caregivers postdischarge occurred in two-thirds of patients.³⁵  Complex discharge instructions, and having multiple diagnoses, discharge prescriptions, and follow-up appointments have been associated with errors in caregivers’ ability to recite discharge instructions and with missed follow-up appointments.^36–38  Caregiver limited health literacy and low English language fluency are also associated with medication dosing errors and nonadherence after discharge.³⁹  In our project, we attempted to identify patients who would benefit most from the discharge televisits and use this to prioritize visit scheduling. Additional research is needed to better target patients who will benefit most from discharge televisits.⁴⁰ 

We also found that the discharge televisits were helpful to share and potentially act upon diagnostic tests that result after discharge. This aligns with one of The Joint Commission National Patient Safety Goals to report critical results of tests and diagnostic procedures on a timely basis.⁴¹  Studies conducted in the ambulatory care setting show that most patients prefer a telephone call by their physician or office visit to share diagnostic test results,⁴²  particularly when test results are abnormal.^43,44 

The findings of our study complement the growing body of literature on the application of telemedicine amid the COVID-19 pandemic.⁴⁵  Strengths of this study include efficient coordination between the inpatient and outpatient teams to drive improvement efforts and integration of the discharge televisits into the inpatient workflow for enhanced continuity of care. Although there are known disparities in telehealth utilization related to sociodemographic factors and lower odds of completing virtual visits in patients with lower household incomes,⁴⁶  we had high televisit completion rates for patients discharged from our study institution, which is part of a large public safety-net hospital system. Since we saw no significant difference in race or ethnicity between patients receiving in person versus televisits, this was not a significant confounding factor in this study.

Our findings should be viewed within the context of the following limitations. The average daily census on the pediatric unit was only 5 during the study period, with a high resident to patient ratio. Therefore, the televisit intervention may be less generalizable to institutions that are busier or have limited or no resident providers. Additionally, for a fifth of patients discharged during the study period, completed follow-up was unconfirmed. However, the sociodemographic characteristics of these patients were largely similar to those with scheduled follow-up, limiting potential selection bias. The study was conducted during the first year of the COVID-19 pandemic when televisits were rising in popularity. This may have contributed to the high follow-up rates we saw for discharge televisits and also to lower attendance for in person follow-up visits. Since this study used quality improvement methodology, there was no randomization to televisit versus in person follow-up. Patients were preferentially selected for televisits based on investigator-developed criteria to identify patients who would benefit most from the televisit follow-up model. It is possible this produced a “Hawthorne effect” where patients were more likely to attend televisit follow-up because the physician team invested more time in their care. Additionally, patients not meeting televisit follow-up criteria may have had less of a need for postdischarge follow-up, which may have contributed to the lower in person visit follow-up rates. Study investigators did not track the reasons why a televisit was assigned, so it is not possible to determine how strictly the criteria for assigning televisits was followed. Lastly, although the study team elicited informal feedback from providers throughout the study, a formal survey of providers was not conducted. Given these limitations, future directions should include taking a more systematic approach to assigning patients to televisits versus in person discharge follow-up, such as through randomization and through the blinding of providers assigning the visits to reduce bias.

Discharge televisits are an innovative way to increase timeliness and completeness of hospital discharge follow-up and may be preferable to in person follow-up visits in certain cases. Since the televisits were conducted by the inpatient resident team who discharged the patient, they provided superior continuity of care compared with traditional follow-up and allowed immediate intervention as needed. Televisits also offered opportunities to discuss clinically important topics, such as results of diagnostic testing and medication issues, which help promote safe-care transitions.