ANAHEIM, CALIFORNIA—A postdischarge phone call to patients 24 to 72 hours after discharge from the acute oncology setting improved patient safety and satisfaction, according to program results presented at the Oncology Nursing Society (ONS) 39th Annual Congress.

Patients are most vulnerable during care transitions. Anxiety can be reduced and discharge instructions can be reinforced with a postdischarge telephone call. In this study, Molley Henneberry, RN, OCN©, and colleagues at the Billings Clinic in Montana identified a need to improve patient transition to home and sought to determine the outcomes of postdischarge calls to patients with cancer.

Patients were called 24 to 72 hours after discharge, and the following was assessed: pain, wounds, nutritional intake, bowel and bladder function, activity tolerance, medication adherence or questions, confirmation of follow-up appointments, and discharge education comprehension. The calls were made by the ADT nurse and recorded in the electronic medical record.

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The calls further enhanced patients’ transition from acute care to the home setting. More than 1,000 patients have received postdischarge calls. The program facilitated early recognition of uncontrolled symptoms, disease exacerbation, and lack of comprehension of discharge education. This early recognition prevented readmission and adverse events.

Henneberry described one phone call that resulted in a patient referral to a provider for excessive wound drainage, which led to an evaluation and emergency surgery. In another example, a postsurgical patient received timely education to initiate anticoagulation therapy immediately. The program has also increased referrals to other multidisciplinary team members including dieticians, diabetes educators, providers, and the symptom management team.

After these calls were first implemented, however, the data indicated that some patients were being readmitted to the hospital between the follow-up call and their next appointment with their providers. In response, an additional telephone call with the outpatient nurse navigator at approximately day 7 after discharge was added to the program.

As the discharge calls improved patients’ transitions, readmissions were reduced particularly for pain. By 2013, the unit had achieved no readmissions for pain. Further modifications have refined which patients receive a second call from the navigator, such as if they were not scheduled for a follow-up appointment with 10 days of discharge.

The call-back program is proven successful in safely easing patients’ transition back to their homes and improved patient satisfaction with their care. “Overall, we’re helping more of our patients spend their hard-earned birthdays at home,” reported Henneberry.


Henneberry M, Skogen K, Biggins B, et al. Discharge isn’t the end: We’re still watching. Presented at: Oncology Nursing Society (ONS) 39th Annual Congress, May 1-5, 2014; Anaheim, CA.