Jornal de Ensaios Clínicos
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Effects of Telephone Follow-Ups after Hospital Discharge on Patients’ Home Care: A Randomized Controlled Trial

Tsukasa Domoto*, Yasuyo Matsumura, Midori Fukada

Objective: This study aimed to explore the effects of periodic telephone follow-ups by a hospital nurse to care managers on the problems faced by patients after discharge.

Methods: Participants included eligible patients who were older than 65 years, had a charge care manager, and were discharged from a hospital to their homes or residential care facilities. A director of nursing conducted the telephone follow-ups for care managers one week, one month, and two months after discharge. The control group received the usual follow-up. As the main outcome, patients were asked to respond to 17 items about the problems faced one week and two months after discharge. Care managers completed a self-administered questionnaire survey on nurses’ cooperation telephonically.

Results: The problems faced by patients two months after discharge were not significantly different from those faced after one week. However, comparing the responses from patients one week and two months after discharge, the proportion of patients’ problems in the intervention group decreased for 11 items. The results of the responses from care managers in the survey on cooperation revealed that “psychological support” and “issues related to information sharing before discharge” were common between the intervention and control groups. “Issues related to the method and practice of cooperation” was an original category of the intervention group, and “no memory of the follow-up” was an original category of the control group.

Conclusion: Periodic telephone follow-ups from hospital nurses to care managers did not statistically annoy patients. Furthermore, it was necessary for the patients to have the same nurse continue with regular telephone follow-ups after discharge. Thus, we recommend the reinforcement of information sharing with the patient before discharge, while also highlighting the need for multiple follow-ups after discharge. Additionally, these follow-ups may be effective for providing psychological support to care managers.