Called to C.A.R.E.: A Post-Discharge AMI Patient Care Initiative to Reduce Readmissions

Author: ORCID icon
Rodriguez, Larissa, Nursing Practice - School of Nursing, University of Virginia
Wiencek, Clareen, NR-Nursing: Faculty, University of Virginia
DeGennaro, Regina, University of Virginia
Ferguson, Barbara, Quality, Bon Secours Richmond
Hinton, Ivora, NR-Nursing: Faculty, University of Virginia

Background: Hospital readmissions after an acute myocardial infarction (AMI) are costly and avoidable with a thorough inpatient assessment and follow-up by a health care provider post-discharge. Prior studies indicate patient social support has a strong correlation to continued medication management and reduction of readmissions.
Purpose: The purpose of this Quality Initiative (QI) project was to measure the effect of the Called to C.A.R.E initiative, which was a series of four scripted follow-up phone calls focused on medication management, and its effect on reducing readmission rates in recently discharged AMI patients within 30 days following discharge. A second aim was to analyze the financial impact of conducting this initiative.
Methods: The calls were conducted by a Cardiology Nurse Practitioner (NP) at specific time points, to all eligible AMI patients admitted to the practice site. The first call occurred at 48 hours and every seven days thereafter for a period of 30 days. Data were collected between July 2020 to October 2020, and compared to prior year data for the same time period. The AHRQ post-discharge follow-up phone call script was modified and utilized for this initiative.
Results: Eighty nine patients were eligible to receive the Called to C.A.R.E initiative and 66 actually received between one to four of the follow up calls. The 2019 and 2020 comparison groups were demographically similar, as both were predominantly male, Caucasian, married, and had a mean age of 68-69.1 years. An average of 10 calls occurred per day, seven days a week, with the majority of the calls occurring in the afternoon between 12-3pm. There was a statistically significant difference in readmission rate (4.607; p=.032) between 2020 and 2019. In the 2020 group, readmission rates were reduced by 14.4% when compared to prior year data. The cost projections indicated that this reduction in readmissions could yield annual direct cost savings of $124,800.
Conclusions: Targeting a specific support person and the use of the Called to C.A.R.E. initiative had an impact on readmission reduction in the AMI patient population. The findings warrant further implementation to assess the impact of continued use of an Advanced Practice Registered Nurse (APRN) with prescribing privileges on readmission reduction.

DNP (Doctor of Nursing Practice)
readmissions, rehospitalization, acute myocardial infarction, heart attack, antiplatelet education , medication management , follow-up phone calls
Issued Date: