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This script available for download in two formats:

• PDF - 100 KB
• Microsoft Word - 36 KB

This form reinforces the information provided to the patient at discharge. The patient's discharge information should be available to the interviewer at the time of this call.

CALLER: Hello Mr./Ms. _____________. I am [caller's name], a [type of clinician] from [name of hospital]. You may remember that when you left, the [hospital name] discharge educator, [DE name], mentioned you'd receive a call checking in on things. I am hoping to talk to you about your medical issues, see how you are doing, and see if there is anything I can do to help you. Do you mind if I ask you a few questions so I can see if there is anything I can help you with?

Is this a good time to talk? It will probably take about 15 to 20 minutes, depending on the number of medicines you are taking.

• If yes, continue.
• If no,CALLER: Is there a better time that I can call you back?

A. Health Status Diagnosis

CALLER: Before you left the hospital, [DE name] spoke to you about your main problem during your hospital stay. This is also called your "primary discharge diagnosis." Using your own words, can you explain to me what your main problem or diagnosis is?

• If yes, confirm the patient's knowledge of the discharge diagnosis using the "teach-back" method. After the patient describes his or her diagnosis, clarify any misconceptions or misunderstandings using a question and answer format to keep the patient engaged.
• If no, use this opportunity to provide patient education about the discharge diagnosis. Then conduct teach-back to confirm the patient understood.

CALLER: What did the medical team at the hospital tell you to watch out for to make sure you're o.k.?

• Review specific symptoms to watch out for/things to do for this diagnosis (e.g., weigh self, check blood sugar, check blood pressure, create peak flow chart).
• Measure patient's understanding of disease-related symptoms or symptoms of relapse (e.g., review diagnosis pages from AHCP).

CALLER: Do you have any questions for me about your main problem [diagnosis]? Is there anything I can better explain for you?

• If yes, explain, using plain language (no jargon or medical terms).
• If no, continue.

CALLER: Since you left the hospital, do you feel your main problem, [diagnosis], has improved, worsened, or not changed? What does your family or caregiver think?

• If improved or no change, continue below.
• If primary condition has worsened:

CALLER: I'm sorry to hear that. How has it gotten worse? Have you spoken to or seen any doctors or nurses about this since you left the hospital?

• If yes, CALLER: Who have you spoken with/seen? And what did they suggest you do? Have you done that?
• Using clinical judgment, use this conversation to determine if further recommendations, teaching, or interventions are necessary.
• Record any action patient/caregiver has taken and your recommendations on the documentation sheet.

CALLER: Have any new medical problems come up since you left the hospital?

• If yes:

  CALLER: What has happened?

  CALLER: Is there anyone else involved in your care that I should talk to?

  • If yes, Name: ___________________________

    Phone number: ____________________

    CALLER: Have you spoken to anyone about this problem? Prompt if necessary: Has anyone:

  • Contacted or seen PCP?
  • Gone to the ER/urgent care?
  • Gone to another hospital/provider?
  • Spoken with visiting nurse?
  • Other?
• Following the conversation about the current state of the patient's medical condition, consider recommendations to make to the caregiver, such as calling PCP, going to emergency department, etc. Record any actions and recommendations on documentation sheet.

B. Medicines

High Alert Medicines

Use the guide below to help monitor medicines with significant risk for adverse events.

Can you bring all of your medicines to the phone, please? We will review them during this call. Bring both prescription medicines and over-the-counter medicines, the ones you can buy at a drugstore without a prescription. Also, bring any supplements or traditional medicines, such as herbs, you are taking. Finally, could you also please bring to the phone the care plan that we gave you before you left the hospital?

CALLER: Do you have all of your medicines in front of you now?

CALLER: I'm going to ask you a few questions about each one of your medicines to see if there is anything I can help you with. We will go through your medicines one by one.

First of all, I want to make sure that the medicines you were given were the right ones. Then we'll discuss how often you've been able to take them and any problems or questions you might have about any of them.

Choose one of your medicines to start with.

• What is the name of this medicine? The name of it should be on the label. If the patient is using a generic, check that he or she understands that the brand and generic names are two names for the same medicine.
• At what times during the day do you take this medicine?
• How much do you take each time?
  • If the patient answers in terms of how many pills, lozenges, suppositories, etc. What is the strength of the medicine? It should say a number and a unit such as mg or mcg.
• How do you take this medicine? If there are special instructions (e.g., take with food), probe as to whether the patient knows the instructions and whether he or she is taking the medicine as instructed.
• What do you take this medicine for?
• Have you had any concerns or problems taking this medicine? Has anything gotten in the way of your being able to take it? Have you ever missed taking this medicine when you were supposed to? Why?
• Do you think you are experiencing any side effects from the medicine?
  • If yes, Could you please describe these side effects?
• Are you taking any other medicines? Repeat list of questions for each medicine.
• After patient has described all medicines, ask: Are you taking any additional medicines that you haven't already told me about, including other prescription medicines, over-the-counter medicines, that is, medicines you can get without a prescription, or herbal medicines, vitamins, or supplements?
• If patient has been prescribed medicines that the patient hasn't mentioned, ask whether he or she is taking that medicine.
  • If yes, go through the list of medicine questions.
  • If not, probe as to why not. If patient is unaware of the medicine, make a note to check with discharge physician as to whether patient is supposed to be taking it, whether a prescription was issued, etc.

CALLER: Have you been using the medicine calendar (in your care plan) that was given to you when you left the hospital?

• If yes, provide positive reinforcement of this tool.
• If no, suggest using this tool to help remember to take the medicines as directed. If patient has lost care plan, offer to send a new copy of AHCP by mail or Email.

CALLER: Do you use a pill box?

• If yes, provide positive reinforcement of using this tool.
• If no, suggest using this tool to help remember to take the medicines as ordered.

CALLER: What questions do you have today regarding your medicines and medicine calendar (if using)?

CALLER: Does your family or caregiver have any questions or concerns about your medicines?

**Please note on the documentation sheet any recommendation you made to the patient and followup actions you took.**

C. Clarification of Appointments

CALLER: Now, I'm going to make sure you and I have the same information about your appointments and tests that are coming up. You were given appointments with your doctors [and for lab tests] when you left the hospital. Can you please tell me:

• What is the next appointment you have scheduled?
• Who is your appointment with?
• What is your appointment for?
• When is this appointment?
• What is your plan for getting to your appointment?
• Are you going to be able to make it to your appointment? Is there anything that might get in the way of your getting to this appointment?
  • If yes, Let's talk about how we can work around these difficulties.
• If patient plans to keep appointment, ask, Do you have the phone number to call if something unexpectedly comes up and you can't make the appointment?
• If patient can't keep appointment, get the patient to reschedule: As soon as we hang up, can you call to reschedule your appointment? If patient is unable or unwilling to make the call to reschedule, offer to make the call: I can reschedule that appointment for you. What days and times would you be able to make an appointment? After you get several times, say, Thanks. I'll call you back whe I've been able to set up the appointment. If patient refuses to cooperate, consult the DE and hospital team.
• Do you have any other appointments scheduled? If yes, repeat the set of questions. If no, but other appointments are scheduled, ask, Are you looking at the care plan? Are there any other appointments listed there? Review these appointments.

D. Coordination of Postdischarge Home Services (if applicable):

CALLER: Have you been visited by [name of service, e.g., visiting nurse, respiratory therapist] since you came home?

• If no, CALLER: I will call to make sure they are coming soon.

CALLER: Have you received the [name of equipment] that was supposed to be delivered?

• If no, CALLER: I will call to make sure it is coming soon.

CALLER: I understand that [name of caregiver] was going to help you out at home. Has [name of caregiver] been able to provide the help you need?

• If no, CALLER: Are you going to call [name of caregiver] to see if she [or he] is going to be able to help you?
  • If no, Is there anyone else that could help you out? Can you call [her/him] to see when [she/he] could come?

E. What To Do If a Problem Arises

CALLER: Before we hang up, I want to make sure that if a medical problem arises, you know what to do. If you're having an emergency, for example [give disease-specific examples, e.g., chest pain, trouble breathing], what would you do?

• If patient does not say, "Call 911," explain the need to get an ambulance so he or she can see a doctor right away, and confirm patient understanding.

CALLER: And what about if you [give example of urgent but not emergent problem] in the evening? What would you do then? Check if patient knows how to reach the doctor after hours. If DE help line operates after hours, check that the patient knows that and can find the number on the AHCP. Confirm understanding.

CALLER: And what about if you are having a medical problem that is not an emergency, such as [give disease-specific examples] and want to be seen by your doctor before your next scheduled appointment, what would you do?

• If patient does not know, instruct: You can call your doctor's office directly and ask for an earlier appointment. Sometimes your doctor is very busy, so if you are having difficulty obtaining an appointment, ask if you can be seen by someone else in the office, such as a nurse, nurse practitioner, or physician's assistant. Confirm understanding.

CALLER: Just to make sure we're on the same page, can you tell me what you'd do if [create nonemergent scenario]?

• If patient answers incorrectly, ask: Do you have your doctor's phone number handy? It should be on the care plan on the appointments page. If patient can't tell you the number, say, Let me give you the phone number for your primary care doctor just in case. Do you have a pen and paper to write this down? Do you need me to mail or Email you another copy of your care plan?
  • If yes, confirm address or Email.

CALLER: Do your caregivers have these numbers also?

• If no, ask: Would you like me to Email or mail a copy of your care plan to them?
• If yes, confirm address or Email.

CALLER: That's all I needed to talk to you about. We've covered a lot of information. What questions can I answer for you?

• If none, CALLER: Thank you and have a good day. If you have to follow up with patient on anything, remind him or her that you will be calling back.
• If the patient has questions, answer them.