In a previous post, I mentioned that I intended to expand on the idea of ED patient follow-up calls, and provide some tips on this process that I learned over 15 years making these calls. As I have often said, calling patients to follow-up on their visit to the ED was one of the most satisfying aspects of my practice in emergency medicine. I guarantee that if you begin doing this, you will find that it is more than worth the effort; and I know of nothing better to ward off burn-out in this very stressful and difficult practice.
There are many ways to do follow-up calls. Some EM groups favor having nursing or other ED staff make these calls; but as you will see from the suggestions below, many of the positive aspects of this process would be diminished or lost if these calls are left to non-practitioner ED staff, or to the physician who was not the treating provider in the ED. Probably better than not making any follow-up calls, but not my preference. The next question is whether these calls should be made from the ED, or from the provider’s home. The advantage of making these calls from the ED is that you may be able to forward the call to other services in the hospital if necessary, and that if the patient misses the call, they will often be able to identify the calling phone number, and call back. You also avoid some HIPAA issues (see below). If you call from home, or from your cell phone, unless you block your number, patients will then have your number and call you for all sorts of unrelated issues and advice. I made calls from my home, and later from my cell, without blocking the number, and to my surprise I only received two calls from patients unrelated to their ED visit, and completed an average of 12 calls a shift for fifteen years. Most cell phones (and landlines) allow you to block your caller ID and number temporarily if you feel this is necessarily. Making calls from home rather than the ED allows you greater flexibility to choose the time and date for your calls, which helps improve your ‘hit rate’.
How do you decide whom to make follow-up calls to? I tended to select patients in the following priority:
1) those patients (or families) who seemed less than pleased with their care in the ED (for service recovery, nothing beats a call-back)
2) patients with interesting problems I could not figure out during their ED visit, or whose diagnosis was more likely to become clear with time (learning opportunity)
3) patients for whom I had concerns about outcomes or care effectiveness following their ED visit (to reduce potential liability)
4) patients who needed close follow-up and might have problems getting this care
5) patients who I enjoyed talking with, or wish I had been able to spend more time with (this also had the side benefit of significantly improving patient satisfaction scores)
How many patients should you make these calls to? As I backed down on the number of shifts I worked over the years, I had more time to make these call-backs. If you are working 15 shifts a month, it is harder to devote an hour of free time to this effort, so be more selective, but don’t restrict your list too much. The harder you work, the more you need the positive feedback you will get.
When to make the calls? I tended to make these calls at around 7:30 or 8:00 PM, usually two to three days after the ED visit, depending on the reason for making the call. Most solicitation calls happen before then, and folks are more likely to answer. Depending on the reason for the call, I might call as many as three times over as many days to reach a patient before giving up.
What’s the best follow-up call process? The set up that facilitates this process is obviously important, and very dependent on the nuances of your ED (or any other) practice. HIPAA has made making these follow-up calls from home more complicated, unless you have password-protected access to hospital ED records from your personal computer. Prior to HIPAA, I used to just shred any paper I took home to use for these calls, but now I think it is only safe to make a list of patient names and dates as you work, and access the patient’s demographics and EMR in a password protected fashion prior to making the call. It is important to review the record briefly before making the call, so you can ask pertinent questions and make appropriate comments. If you do keep a running list on a smart-phone, keep it in a password-protected file. I suggest running any follow-up call process your group considers by the hospital’s compliance officer before implementing it. BTW, once your group begins making these calls, and you discover how often your patient registration process fails to get valid telephone numbers, this problem will get some well-deserved focus.
What if someone other than the patient answers the phone? It’s a bit tricky. Even the fact that someone visited the ED is protected information, and for some patients (like victims of abuse) this knowledge might even prove dangerous. First, if you think this might be an issue, don’t make the call. For example, don’t do follow-up calls on STD patients, or patients with early pregnancy. Second, do not speak to anyone besides the patient unless you know for a fact that they are immediate family, that the patient was unable to speak for themselves, and that you met this family member during the ED visit. Third, do not leave messages on the phone. If the patient is not available to take the call, just say it’s not important, and you will try to call back when the patient is likely to be available. Do not introduce yourself as a physician until you are certain the patient is available to take the call. You can, instead, use your first and last name. When I got the patient on the line, I always asked them if this was a good time to talk. Again, with care, I never ran into any problem here, but it pays to be careful and considerate.
What about making changes in your therapy on these calls. I made it a strict rule never to get between the patient and their primary care or follow-up care physician – never. If I did decide to modify MY treatment plan, for example if a patient could not tolerate an antibiotic, and I decided it was appropriate to switch and the patient was not able to see another physician for a few days (they often can’t); I would always call in and dictate an addendum to the ED record indicating what I had determined in the call, and how I was changing the treatment plan. You would not be surprised to learn that the best laid plans for follow-up often fall apart, and your intervention after the ED visit can make a world of difference for the patient, and even prevent the bad outcomes that sometimes end up in court. I must have made hundreds of such revisions to my treatment plans as a result of follow-up calls, and in my 34 years of practice (knock on wood), the only time I was named in a malpractice suit was by a patient I never saw, who was treated in a hospital I never worked in, in a county I never set foot in, and who was treated two years after I retired from clinical practice. In fact, besides dumb luck, follow-up calls may be most responsible for this result. Your ED group should decide if they are comfortable with these changes in treatment plans, and what process you need to use to document them.
How do patients typically respond to these follow-up calls? I imagine you can guess the answer to this question, based on my enthusiasm for placing them. Almost inevitably, patients are surprised that an ED physician would even bother to make these calls. As an ED physician, that bothered me a bit: it might reflect the fact that many ED patients do not believe that ED physicians care about them. EPs should be the first physicians to get on board with follow-up calls, which I suspect will eventually become commonplace amongst many providers with the advent of the medical home concept. Another thing that often happens is that you will discover important information for yourself and for your patient in the course of making these calls. You will become a much better physician because of this. You will also have an opportunity to explain, reinforce, and even expedite your post-visit care instructions and recommendations. On rare occasions, you may have the opportunity to drastically alter outcomes. Once or twice a year I sent patients back to the ED for urgent re-evaluation. Finally, it almost goes without saying that patients really, really appreciate these follow-up calls, and they express this freely in ways that often made my day. It is also true that sometimes you might get an earful from a very unhappy patient, which gives you another opportunity to apologize or straighten things out. This might be uncomfortable, but it is far better than facing a hospital CEO with a blistering missive in his hand. All in all, these follow-up calls have so much to commend them that they have caught on in EM practices throughout the country. Like they said in the Alka-Seltzer commercial: try it, you’ll like it.
If you have any questions about follow-up calls, please ask them in the comments option below, and I will be happy to answer them as best I can.