Phone follow-ups smoothe transitions home

SURREY, BC – A recently published study from Fraser Health highlights the value of nurse-led post-discharge telephone interventions in reducing short-term emergency department (ED) visits among high-risk patients.

With unplanned ED visits and hospital readmissions posing ongoing challenges to patient well-being and healthcare efficiency, Fraser Health set out to examine how nurse-led phone calls from Fraser Health Virtual Care nurses – a practice that is still in place today – supports smoother transitions home.

“This study has given us very valuable insights into how this service is making a positive difference to patients and our healthcare system,” said Min Naruki-van (pictured), director of operations, Virtual Health. “The large datasets resulting from the study will also allow us to pinpoint which patients benefit most from nurse-led follow-up calls and focus our efforts on those who need this service most.”

Conducted between May and September 2022, the trial included over 7,000 participants, each at elevated risk for readmission.

Those randomized to the intervention group received a call from a Fraser Health Virtual Care nurse 48 hours after discharge. The calls focused on clarifying instructions, medication management and ensuring proper follow-up support.

The results were compelling. Fewer people returned to the emergency department within both a seven- and 30-day timeframe after the nurse’s call. After adjusting for other factors, the rates dropped by about 28 percent and 12 percent for each period. Importantly, during 40 percent of the calls, the nurse found at least one area where the patient needed more help or information.

“I always say research is care, and this project is a clear example,” said Dr. Kate Keetch, director, Department of Evaluation and Research Services. “Embedding research in the system is crucial – Fraser Health Virtual Care originated during COVID-19 and has integrated research and evaluation practices into their program from day one. Their approach exemplifies turning knowledge into action by implementing evidence-informed change.”

The structured nurse-led intervention not only contributed to reduced ED visits but also provided valuable insights into patient needs and potential barriers to recovery.

By proactively identifying gaps in patient understanding – such as confusion around discharge instructions or medication regimens – the team can intervene early, prevent complications and unnecessary return visits. This targeted approach aligns with Fraser Health’s commitment to person-centred care and continuous quality improvement.

The findings from the study show that low-barrier interventions like telephone follow-up aren’t just practical – they’re a step forward for equity in healthcare. Most patients reported increased confidence in managing their care and found the calls helpful.

“We’ve seen firsthand how a simple phone call can close the loop, answer questions, and ensure patients feel supported as they transition home from hospital,” said Min.

The study’s findings offer a pathway to strengthen Fraser Health Virtual Care, ensuring it makes a tangible difference for patients, while shedding light on areas where communication may break down during hospital discharge, providing valuable insights to improve acute care transitions.

“While meaningful evaluation doesn’t always require a randomized controlled trial, these types of studies offer strong evidence to demonstrate if a program or service is truly benefiting patients,” said Maria Montenegro, virtual health portfolio manager, Research Evaluation and Learning. “This study highlights the positive impact of Fraser Health Virtual Care, showing how nurse-led follow-up can make a real difference for high-risk patients.”

As the practice of Fraser Health Virtual Care nurses calling patients after they leave the hospital continues, the team is excited to know their work is making a difference in patients’ lives and looks forward to using the knowledge learned from the study to further enhance care transitions for our patients.