JMIR Publications

ABSTRACT

Background:

Unplanned emergency department (ED) visits and hospital readmissions following discharge contribute to patient distress, increased healthcare costs, and system inefficiencies. Early post-discharge follow-up can improve care transitions, yet evidence on the effectiveness of telephone-based interventions remains mixed. Telephone calls, a low-barrier form of digital health, may enhance equity and accessibility by reaching patients who face challenges with in-person or higher-technology follow-up.

Objective:

This study evaluated the impact of a nurse-led post-discharge telephone intervention delivered by Fraser Health Virtual Care (FHVC) on short-term ED visits and hospital readmissions among recently discharged high-risk patients. Secondary objectives included examining patient experiences with the service and identifying care gaps addressed during follow-up calls.

Methods:

A pragmatic quasi-randomized trial was conducted (May – September 2022). Participants were eligible if they were aged ≥18 years and classified as high-risk for readmission using the LACE index (≥10 or <9 and ≥45 years). Participants were allocated to either a post-discharge telephone intervention group or a standard care control group based on daily nurse availability. Intervention participants received a structured nurse-led call 48 hours after discharge assessing understanding of discharge instructions, medication management, follow-up appointments, and home supports. Primary outcomes were ED visits within 7 and 30 days post-call; secondary outcomes were hospital readmissions and patient experience. Negative binomial regression models were used to calculate adjusted incident rate ratios (IRRs).

Results:

A total of 7,091 participants were included (intervention: n = 3,911 of whom 1,752 completed the call; control: n = 3,180). Post-discharge calls significantly reduced ED visits at both 7 days (adjusted IRR = 0.719, 95% CI: 0.617–0.837; p < .001) and 30 days (IRR = 0.878, 95% CI: 0.783–0.983; p = .024). No statistically significant reductions were observed in hospital readmissions at either 7 days (IRR = 0.809, p = .128) or 30 days (IRR = 0.942, p = .536). Forty percent of completed calls (n = 701) identified at least one gap in discharge understanding or follow-up care. Most participants found the calls helpful and reported increased confidence managing their care.

Conclusions:

Structured nurse-led post-discharge telephone calls significantly reduced short-term ED utilization but did not impact readmission rates. These findings support the role of telephone-based virtual care as a scalable, low-barrier strategy to improve care transitions and reduce avoidable ED visits. Additional or ongoing interventions may be required to influence hospital readmission outcomes among high-risk patients. Clinical Trial: retrospectively registered: ISRCTN26233632