Health and Disease Management
Hospital readmissions are common, costly and often preventable. Large numbers of cardiac patients are readmitted within 30 days of leaving the hospital. TelASK has collaborated with leading cardiac healthcare practitioners to develop a robust suite of follow-up systems that use IVR to monitor patient progress after discharge. These systems help patients to transition safely from hospital to home, and often prevent avoidable readmissions.
TelASK places calls to CHF patients every two weeks for six months with the initial call sent two days post-discharge. During the first call patients are asked questions that confirm they are following their discharge care plan. A “NO” response flags the patient for a callback from a clinician or “pushes” helpful information to the patient to educate them on the topic. For a more complete description of this program: Download CHF One-pager
Patients receive a series of calls that track their progress for one year after their heart event with the first call coming two days post discharge. Patients are asked if they have made follow-up appointments and filled their prescriptions. “No” responses are flagged for follow-up by a clinician to help the patient stay on track with their discharge care plan. In subsequent calls patients are asked about any significant changes to their health or their care since they left the hospital and about any symptoms they may be experiencing. Patients can also be screened for depression. If necessary, the patient will be triaged directly to a clinician for further intervention. Download ACS One-pager
Cardiac Surgery Program
In this program patients are called on day three and day 10 post discharge. They are asked a series of questions that detect minor problems as well as more serious issues. When a minor problem is reported, the system relays pertinent information to the patient about the next steps they should take. For more serious problems, TelASK flags the patient for a callback from a clinician.
Additional Patient Support
Appointment Reminder System
Patients receive important follow-up calls about their doctor’s referral to a treatment or rehabilitation program. They are asked about their readiness to enroll or their interest in receiving further information. If they wish, they can be connected to a clinician to discuss questions or concerns they may have. Once enrolled patients are called and reminded of the appointment date, time, place, any directions or parking instructions, and what to bring, including any medications they may be taking. Subsequent calls provide an opportunity for program evaluation and, if appropriate, relay any steps to be taken when the program ends.
TelASK provides education and motivation about lifestyle changes for women with Metabolic Syndrome. Participants received a series of IVR calls designed to support them as they take on new fitness and dietary goals. The questions help determine if participants are meeting their goals. If the system detects a participant is struggling, they are triaged to the appropriate resource (counselor, dietician or fitness coach).
TelASK supports patients discharged from hospital with undiagnosed diabetes. A series of IVR calls follow those at risk for developing diabetes and reminds them about the importance of regularly monitoring their blood sugar levels. The calls provide information about diabetes prevention, complications and the importance of following up with their primary care provider. If the system detects someone is struggling, it flags the call for follow-up from a clinician. In the case of a confirmed diabetes diagnosis, the system continues to monitor the patient and if necessary will refer them to a diabetes education program in their community.
TelASK has participated in randomized control studies that address the issue of medication non-compliance and the measures that can be implemented to improve patient compliance, especially in the crucial 30 days post-discharge. Results show that IVR reminder calls to patients regarding the maintenance of their medication schedule can make a significant and positive difference in compliance outcomes and contribute to a decrease in reported adverse events sometimes associated with non-compliance.
How TelASK Programs Help Clinicians
The data gathered by the interactive voice response (IVR) system provides clinicians with the ability to closely monitor the progress of a large volume of patients at the same time. To achieve similar results clinicians would need to proactively call all patients and manually document the results. Patient responses are documented in easy to read, printable reports available to clinicians on a secure web-based dashboard, 24/7. The system flags responses that indicate the patient may need one-on-one intervention. This ensures clinicians can focus their attention on patients who need their help the most.