One Call, Right Time, Right Person

July 2016

​How a Single Phone Call is Improving Care Transitions

A team from University of Colorado Hospital (UCH) has launched a program that is reducing the incidence of readmissions for the patient population of AF Williams Family Medicine Center. 

When the Centers for Medicare and Medicaid began targeting readmissions rates as a quality indicator, Katy Boyd-Trull, MD​, was paying attention. Over the years she served as a family medicine practitioner in both inpatient and outpatient settings at UCH, and she had a hunch that she was seeing the same patients over and over. 


(Pictured above, left-right: Stratton, Boyd-Trull and Lyon)

“It was something that was talked about throughout the Family Medicine Residency Program,” she said. “So I started paying close attention to what other academic medical centers were doing. And very few were having any success in developing transitions curriculum.” 

Dr. Boyd-Trull, as director of inpatient services at UCH, decided to tackle the issue. Yet there was a problem: Data was lacking. But she knew transitions were something they could be doing better. So with little more than a hunch, she applied and was accepted to the Certificate Training Program through the Institute of Healthcare Quality, Safety and Efficiency (IHQSE). There she partnered with Corey Lyon, DO​, medical director for the AF Williams Family Medicine Center and associate program director of the Family Medicine Residency Program. With representation from both the inpatient and outpatient setting, they recruited psychologist Joanna S. Stratton, PhD​, to complete their team.

IHQSE Provides Framework for Improvement

“Physicians are problem solvers by nature,” said Dr. Lyon. “We’d identified the problem and we wanted to jump straight into a solution.” But how would the team create sustainable change in an organization as large as UCH? 

Through the systematic approach the IHQSE required. 

“The IHQSE forced us to go through every step—defining our questions, our barriers and problems, how we’d build on our solution,” he said. “The coaches walked us through the process improvement process, which included considering our patients’ voices.” 

The program also helped them define and track quality metrics. 

“When we started, we didn’t even know our readmission rate. It was through the data analyst in IHQSE that we got the initial data and found that nearly one in four of our hospitalized patients were being readmitted within 30 days. That’s where we got our burning platform,” said Dr. Boyd-Trull. 

They also learned that there wasn’t a single solution for improving care transitions. “It’s multi-factorial,” explained Dr. Boyd-Trull. “One intervention wasn’t going to change anything.”

Before they could even implement a care transitions program, first Dr. Lyon and his team at AF Williams had to adjust the workflow within their practice to ensure the ability to schedule appointments within seven days as required by CMS. On the inpatient side, Dr. Boyd-Trull and team had to improve the discharge process, which meant providing discharged patients with direct access to members of their team. 

Finding the Right Person to Make the Call

Once workflows and processes were enhanced, the team focused on implementing the CMS-required post-discharge contact that must be made within 48 hours to ensure patients are seen by their primary care provider within 7–14 days. 

They continued to research the transitions programs developed and launched by others, tracking what worked, and what didn’t. 

“There were all kinds of models about what this contact looked like,” explained Dr. Boyd-Trull. “Some were doing what I’d call a ‘robo-call,’ which makes financial sense. But I’ve been a patient. And when I’m sick and scared, I want to talk to a human—someone who is well-trained in transitions care.”

They also monitored the content and frequency of calls others made and billed as care transitions follow up. “We discovered that patients were getting multiple phone calls, from insurance, from clinicians, from hospitals. That’s when we decided it would be best for our patients to implement one quality phone call from someone who knows you, and knows the care you’ll need,” said Dr. Boyd-Trull. 

“We learned that the person making the call was even more important than the call’s content,” said Dr. Lyon. He explained how they chose a registered nurse who was well-trained in transitions to make the call using scripted templates developed by the team. 

“The launch wasn’t perfect, and we learned we can’t let perfection inhibit getting started,” said Dr. Boyd-Trull. “Much of our success has come from choosing the right person to do the job and from being willing to tweak our processes as we move forward.”

Before the interventions were implemented, 25% of patients were readmitted within 30 days, and only 57% saw their primary care physician post-discharge. Since AF Williams began calling patients in the fall of 2015, the readmission rate has dropped to 14%, and 80% of patients see their primary care doctor within 7–14 days. Pre-intervention, 23% of the appointments made at discharge were cancelled, but since they implemented the phone call, only 8% are canceled. 

Patient Confidence Improves

“Our patients’ reactions have been incredible,” said Dr. Lyon. “Many say they were confused and worried and our call made things better. They’re very grateful.” 

As a patient herself, Dr. Boyd-Trull knows it’s easy to feel lost in a giant system. “Once you’ve been on the patient side, it’s easier to see how complicated and overwhelming health care systems can be. And it’s made me, as a provider, an even stronger advocate for my patients.”

As for being part of the IHQSE, both doctors credit the program with their success. 

“I was afraid of not having enough time to commit to a year-long course. But it was worth it, both for the skills I’ve taken away and the success we’ve had,” said Dr. Lyon.

Dr. Boyd-Trull agrees. “It’s helped me understand what it takes to lead sustainable change.”​

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