Depression is a common mental health disorder. In 2015, 16.1 million adults age 18 or older had at least one major depressive episode in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). This number represents 6.7% of all adults in the United States (SAMHSA, 2016). Many people are hospitalized due to depression. In 2005, 2.9 million hospitalizations occurred among patients with depression (Russo et al., 2007). For 423,300 (15%) of these hospitalizations, depression was listed as the principal reason for admission (Russo et al., 2007). All-cause, which means any reason, hospital readmissions in the United States in 2011 were associated with approximately $41.3 billion in hospital costs (Hines et al., 2011).
The time immediately following hospital discharge is a crucial period, wherein patients are at risk for hospital readmission, adverse events, and suicide. In 2014, all-cause readmissions within 30 days for inpatient stays were 14%, with more than one third of these readmissions occurring within 7 days (Fingar et al., 2017). Approximately one in five patients experienced an adverse event after discharge from the hospital to home after general medical service (Forster et al., 2003). Patients with depression had the highest 90-day rate of suicide after hospital discharge (235.1 per 100,000 person-years) compared to patients with all other primary diagnoses of mental disorders (Olfson et al., 2016).
Solutions have been developed to help improve the continuity of care for patients from one setting to another, and these solutions are components of transitional care. The American Geriatrics Society defines transitional care as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location” (Coleman & Boult, 2003, p. 556). One example of a transitional care intervention is the implementation of telephone follow up after discharge. Telephone follow up allows providers to strengthen patient knowledge about discharge instructions, follow-up plans, and medications (Harrison et al., 2014). A nurse-led discharge telephone follow-up call may improve patient satisfaction, meet the information and communication needs of patients, and improve attendance for follow-up appointments (Woods et al., 2019).
Among patients discharged from an inpatient psychiatric unit for depression, how does the use of telephone follow up after discharge compared to the standard of care affect hospital re-admission rates and emergency department (ED) visits?
A literature review was conducted to determine whether telephone follow up after discharge helps improve health care use for patients admitted for depression and discharged home. This review aimed to synthesize telephone follow-up interventions and their effect on hospital use, depression symptoms, and care transitions after patients were admitted to an inpatient psychiatric unit for depression and discharged from the hospital. A total of 15 studies published between 2007 and 2019 were included.
The review included studies in which participants were adults age 18 or older and were in a discharge telephone follow-up intervention group or had been previously exposed to a discharge telephone follow-up intervention. Studies in which participants received a telephone intervention not related to discharge follow up were included due to the limited number of studies evaluating the effectiveness of post-discharge follow up. The intervention or exposure could have been a primary stand-alone intervention or part of a bundled intervention. The primary outcomes were hospital readmission rates and ED visits, and a secondary outcome was depression symptoms. Studies in which the samples did not have depression but were inclusive of all hospital populations were included.
Of the four studies in which hospital use was the primary outcome, three studies showed that a telephone intervention or exposure to a telephone intervention was associated with lower rates of hospital readmissions (Harrison et al., 2014; Harrison et al., 2011; Jack et al., 2009). Harrison et al. (2011) found a positive association between 30-day readmission and the following variables: older age when first admitted, male sex, and longer length of stay at initial admission (p < 0.001). Participants received a telephone call within 14 days of discharge. On Days 2 and 3 after discharge, the readmission rate was highest. The odds of being readmitted to the hospital within 30 days of discharge were 1.3 times greater in participants who did not receive calls than participants who received calls (p = 0.043) (Harrison et al., 2011). In another study, Harrison et al. (2014) found that the odds for readmission were lower in patients completing a telephone call 3 days after discharge (adjusted odds ratio [adj. OR] = 0.71; 95% confidence interval [CI] [0.55, 0.91]). However, after adjusting for the propensity score, which was based on the probability of a patient receiving a call, the researchers found no correlation between call receipt and readmission (adj. OR = 0.91; 95% CI [0.60, 1.20]) (Harrison et al., 2014). Similarly, researchers found that outpatient follow up, including telephone contact, within 7 days after hospital discharge may not improve readmission rates (Pfeiffer et al., 2012).
Ten studies evaluated the impact of a telephone intervention on depression symptoms. Of these studies, eight showed that depression symptoms were improved (Ashing & Rosales, 2014; Kargar Jahromi et al., 2015; Mohr et al., 2012; Pfeiffer et al., 2017; Rollman et al., 2009; van den Berg et al., 2015; Wenze et al., 2015; Zanjani et al., 2010). Kargar Jahromi et al. (2015) conducted a randomized controlled trial in which telephone follow up was completed 30 days after the last dialysis shift. The study resulted in statistically significant differences between the two groups (telephone follow up versus no telephone follow up) on Depression Anxiety Stress Scale scores. Similarly, for participants who received a telephone contact from either a family member/friend or a certified peer support specialist, Patient Health Questionnaire-9 (PHQ-9) scores decreased from a mean of 17.4 to 12.7 (p = 0.001) to 11.8 (p = 0.004) at baseline, 3 months, and 6 months, respectively (Pfeiffer et al., 2017). Among Latina patients with breast cancer, those who received psychoeducational telephone sessions twice per week reported a significant decrease in depressive symptoms on the Center for Epidemiologic Studies Depression scale, from a mean of 25.4 at baseline to 17.2 at follow up (p < 0.001) (Ashing & Rosales, 2014). van den berg et al. (2015) found that there was a significant decrease in depression scores for those who received a telephone contact compared to those who did not receive a telephone contact (p = 0.046). However, these results were yielded after the researchers conducted an exploratory sensitivity analysis that included 75% of patients with the highest symptom scores at baseline (van den Berg et al., 2015).
Although most of the studies compared a telephone intervention group to a usual care group that did not receive telephone intervention, Mohr et al. (2012) explored the effects of telephone-administered cognitive-behavioral therapy (CBT) compared to face-to-face CBT on treating depression and lowering the levels of attrition. Patients in both groups had improvements in depression outcomes at 6-month follow up. For the telephone CBT group, the change in Hamilton Depression score was −9.25 and change in PHQ-9 score was −10.12 (p < 0.001) (Mohr et al., 2012).
Overall, the level of evidence generated by the current review was moderate to high. The sources were rated based on the rating system for the hierarchy of evidence model (Melnyk & Fineout-Overholt, 2015). According to the model, the highest level is I and the lowest level is VII. The current review presented adequate evidence for the implementation of telephone follow up after patients are discharged from the hospital to reinforce discharge instructions and improve care transitions. The intervention was found to be acceptable among participants. Health care professionals, including physicians, RNs, clinicians, and paraprofessionals can implement the telephone calls.
The effects of telephone follow up were mixed; however, the interventions differed in each study. The timing of the telephone follow up after discharge is an important area for future research. Future studies need to be conducted that show whether structured post-discharge telephone calls improve hospital use among patients admitted to an inpatient psychiatric unit for depression and discharged home.
The purpose of the current evidence-based practice (EBP) project was to reduce recidivism, including readmission rates and ED visits, in patients with depression after acute psychiatric hospital discharge through implementation of a telephone follow up. The aims of reinforcing and improving patient understanding of discharge instructions were set in hopes that patients would avoid readmissions and ED visits related to lack of understanding of discharge instructions.
The project setting was a 20-bed adult inpatient psychiatric unit of a large metropolitan hospital attached to an academic medical center in Louisville, Kentucky. At the clinical setting, there was a general perception that readmission was a concern, but no data on readmissions had previously been collected.
The target population included adult patients who were discharged home from an inpatient psychiatric unit with a diagnosis of depression. The sample included adults at least 18 years old who could read and speak English, were discharged home, and had a telephone number listed in the electronic health record (EHR). Participants who had co-occurring severe psychiatric disorders (e.g., bipolar disorder, psychotic disorders), visual or hearing impairments that would prevent participation, cognitive disorders, and substance use disorders were excluded. Patients were informed that their participation was voluntary. Because this was a pilot project, a power analysis was not conducted. The sample comprised eight participants.
The intervention took place between January and April 2019. Patients who met inclusion criteria were called within 72 hours of discharge using a telephone script. The telephone follow up consisted of reinforcement of information provided in the discharge instructions. The discharge instructions included the following information: discharge diagnosis, medication reconciliation, follow-up appointments, and suicide prevention hotline number. The PHQ-9 was administered at the end of the reinforcement of discharge instructions to assess depression severity.
This project was submitted to the University of Louisville Institutional Review Board using the Non-Human Subject Research Determination form and was approved as a quality improvement project.
The PHQ-9 was used to assess depression severity. The PHQ-9 is a self-administered screening tool that is used by clinicians to diagnose depression and quantify depression symptoms and monitor severity in adults (Kroenke et al., 2001). A score of 0 to 4 indicates a depression severity of none to minimal, 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, and 20 to 27 severe (Kroenke & Spitzer, 2002). This tool has excellent internal reliability, with a Cronbach's alpha of 0.89 in the PHQ Primary Care Study (Kroenke et al., 2001) and 0.86 in the PHQ Obstetrics-Gynecology Study (Kroenke et al., 2001). Test–retest reliability was also good (intraclass correlation = 0.84).
All eight participants in the intervention group who were contacted by telephone agreed to participate in the project. The charts of these participants were reviewed for readmissions and ED visits within 30 days from the time they had been discharged. Data from the intervention group were compared with data in a historical control group. Access to historical controls was made available through a retrospective chart review. The control group included patients who met inclusion criteria and were discharged from the inpatient psychiatric unit from January to April 2018, exactly 1 year prior to implementation of the current project. This group never received a discharge telephone call.
The intervention allowed for patients to ask questions and express concerns related to discharge instructions at the end of the telephone call. A data collection form was used by the student project manager (H.S.A.) to note patient concerns about medications, provider follow up, diagnosis, and symptoms and challenges.
Data were stored on an encrypted and password-protected USB flash drive. All identifiers were destroyed when they were no longer needed for the project.
A pre-test was not available to compare baseline and follow-up PHQ-9 scores. The PHQ-9 score at follow up helped in understanding the findings of this project in relation to findings from other studies. For categorical variables, chi-square analysis and a two-sided Fisher's exact test were used for discharge telephone call status and readmissions and ED visits. The criterion for significance was set at p < 0.05. Quantitative and qualitative data regarding concerns from patients and challenges experienced by the student project manager were recorded. Data analysis was performed using SPSS version 22. Descriptive statistics were used to summarize demographic and clinical characteristics.
During the project period from January to April 2019, eight patients were eligible for a discharge telephone call; all received this call. Of the 97 patients who were discharged from January to April 2018, 16 met the eligibility criteria to be used as a baseline historical control comparison. Demographic and clinical characteristics are reported in Table 1.
Patient Demographics and Clinical Characteristics
None of the eight patients in the intervention group were readmitted or visited the ED within 30 days of discharge. In comparison, the control group of 16 patients had one (6.25%) patient who was readmitted and three (18.75%) patients who visited the ED within 30 days of discharge (Table 2). A chi-square analysis for both discharge telephone call status and readmissions and ED visits showed that two cells had an expected count less than five. Because of the small sample size, a Fisher's exact test was conducted. There were no statistically significant differences detected in discharge telephone call status (received or did not receive) and readmissions (p = 1.000) and ED visits (p = 0.526).
Readmission and Emergency Department (ED) Visit Outcomes
The following feedback was received regarding reasons for readmissions or ED visits in the control group. A patient who was readmitted after 23 days of discharge had visited the ED due to cellulitis. She was readmitted at another hospital in the same city as that of the project setting. One patient visited the ED after 7 days because he was “unable to go to the outpatient appointment due to having no transportation and his friend was working during the day” per the patient chart. Another patient visited the ED 13 days after discharge due to a urinary tract infection.
One patient visited the ED within 34 days due to alcohol intoxication and pseudo-seizure. Another patient visited the ED within 37 days due to self-harm. These visits were not included in the statistical analysis because the scope of the current project focused on readmission and ED visits within 30 days of discharge.
Only the intervention group completed the PHQ-9, with six of eight patients completing the questionnaire. The mean PHQ-9 score was 3.3, which indicated depression severity of none to minimal (Kroenke & Spitzer, 2002).
As part of the intervention, patients were given an opportunity to ask questions or verbalize concerns. One patient had the discharge paperwork available to review, whereas the others did not. One patient had outpatient electroconvulsive therapy (ECT) appointments in which the details in the EHR were not consistently documented. For example, the first ECT appointment was listed as “ECT,” whereas the second appointment was listed as “X Hospital Surgery OR.” Although this discrepancy posed some confusion, the patient stated that the second appointment was supposed to be for an ECT appointment. Some patients were familiar with their medications and follow-up appointments, but most wanted confirmation of their medication list, and one patient asked for clarification regarding her follow-up appointment. In her discharge instructions, there was a discrepancy between the follow-up appointment time and what the patient had thought was the correct time.
Readmissions and Emergency Department Visits
Patients in the intervention group received a discharge telephone call. Rates of readmission and ED visits were compared to that of the control group, which comprised patients from exactly 1 year prior to project implementation to avoid as many confounding factors as possible, especially those related to seasonal differences (e.g., seasonal affective disorder) that may impact patient clinical outcomes. Demographic and clinical characteristics between the two groups were somewhat similar, but equal similarity was difficult to assume due to differences in sample size. Based on frequency data alone, the rate of readmissions and ED visits in the control group were higher than that of the intervention group, because none of the patients in the latter group had a readmission or ED visit. These findings were consistent with studies that showed a telephone intervention was associated with lower rates of hospital readmissions (Harrison et al., 2014; Harrison et al., 2011; Jack et al., 2009). Because the results of this project were not statistically significant, there is insufficient evidence to indicate that discharge telephone calls affect readmission status and ED visits. Two patients had visits to the ED after 30 days of discharge. This finding may indicate that trends in recidivism rates may have differed if the project criteria included a longer window for readmission or ED visits.
In 2012, the average cost for initial hospital stay for mood disorders was $5,800 and readmission for any cause was $7,200 (Heslin & Weiss, 2015). No readmissions were noted in the intervention group within 30 days of discharge, which may have contributed to lessening the economic burden of hospital readmissions.
Acceptability and Feasibility
Discharge telephone calls were found to be acceptable among patients. All eight patients in the intervention group stayed on the call until reinforcement of discharge instructions, assessment of support person(s), and opportunity for questions and concerns were completed. All patients except two completed the PHQ-9 questionnaire. The feasibility and acceptability of the project were consistent with the findings of Ludman et al. (2007), in which a care management program including telephone outreach for patients with chronic or recurrent depression was found to be acceptable. Approximately all participants had accepted the care manager's calls and completed assessments related to their depression symptoms, medication adherence, and side effects (Ludman et al., 2007).
Six of eight patients completed the PHQ-9 with a mean score of 3.3. The highest PHQ-9 score recorded was 8, which indicates mild depression. The average PHQ-9 score of current participants was lower than that found in a telephone-delivered collaborative care intervention for patients who had depression following a coronary artery bypass graft, which was 13.5 (Rollman et al., 2009). The availability of research studies that measure PHQ-9 scores of patients who have been discharged from an inpatient psychiatric unit are limited. Although there was no baseline for the intervention group, which included patients who were admitted with major depressive disorder and met the criteria at that time, these patients showed depression levels of none to minimal after discharge.
Limitations of the current project include a small sample. The purpose of this EBP project was to implement evidence-based research into practice, which did not require a large sample. The completion of discharge telephone calls was dependent on the availability of the caller and the patient. The completion of the PHQ-9 was not a standard practice in the clinical setting in 2018 or 2019. Although the collection of baseline data for the PHQ-9 was not within the scope of this project, such data would have allowed for comparison of depression severity from admission to discharge and follow up. Administration and documentation of the PHQ-9 at admission and discharge may serve as quality indicators for the hospital.
Many patients did not meet eligibility criteria due to comorbid severe mental illnesses or substance use disorder. Further projects that include all patients who have been discharged from an inpatient psychiatric unit need to be implemented. Data collection in the EHR was limited to patients returning to the same hospital or a hospital within the network. Therefore, the data collected may not accurately represent the true recidivism rates.
Implications for Practice and Future Projects
Reducing recidivism and improving patient satisfaction may highlight the importance of implementing telephone follow up in patients with depression after discharge from an inpatient psychiatric unit. Discharge telephone follow up may help reinforce discharge instructions, improve patient understanding of discharge instructions and follow-through on outpatient appointments, and increase patient satisfaction. Robust quality improvement projects with larger samples may need to be implemented to show statistically significant trends in reduced recidivism rates.
The strength of the current quality improvement pilot project was its ability to demonstrate feasibility in an inpatient psychiatric setting. Patients were receptive to the reinforcement of their discharge instructions over the telephone. Patients expressed gratitude for the above and beyond customer service of a discharge telephone call that is not the standard of care currently. This project was novel in that recidivism rates were calculated for the first time for the Inpatient Psychiatric Unit. This quality improvement project helped address patient lack of understanding related to discharge instructions after being discharged from the hospital to home to impact the overall outcome of reducing recidivism. No patients in the intervention group had a readmission or ED visit.
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Patient Demographics and Clinical Characteristics
|Characteristic||Control Group (n = 16)||Intervention Group (n = 8)|
| Women||9 (56.3)||4 (50)|
| Men||7 (43.8)||4 (50)|
| White||11 (68.8)||7 (87.5)|
| Black||5 (31.3)||1 (12.5)|
| Single||9 (56.3)||3 (37.5)|
| Married||4 (25)||3 (37.5)|
| Divorced||2 (12.5)||2 (25)|
| Widowed||1 (6.3)||0|
| Family||11 (68.8)||8 (100)|
| Friend||2 (12.5)||0|
| None||3 (18.8)||0|
|Mean (SD) (Range)|
|Age (years)||49 (16) (19 to 73)||52.1 (19.8) (25 to 80)|
|Initial hospitalization length of stay (days)||11 (17) (3 to 73)||9.8 (4) (4 to 16)|
|Number of telephone call attempts||N/Aa||1.5 (0.9) (1 to 3)|
|Duration of telephone call (minutes)||N/Aa||4:09 (6:01) (2:06 to 8:07)|
Readmission and Emergency Department (ED) Visit Outcomes
|Variable||Control Group (n = 16)||Intervention Group (n = 8)|
|Patients with 30-day readmission(s) (n, %)||1 (6.25)||0|
|Number of days between discharge and readmission||23||N/A|
|Patients with 30-day ED visits (n, %)||3 (18.75)||0|
|Mean number of days between discharge and ED visit||14 (9.24) (7 to 22)||N/A|
|Mean PHQ-9 score||N/A||3.3a (3.08) (0 to 8)|