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Interactive Voice Response (IVR)
Patient Case Study

 

PROBLEM:
Gloria is a 65-year old patient admitted to Great Lakes Caring Home Health status post-hospital
discharge with CHF, COPD, DM, chronic pancreatitis and multiple other co-morbidities.
She presented on 4L of O2 per NC and 27 medications with six of the medications presenting as
new to her medication profile and plan of care. Her history was frequent use of the emergency room
for her care due to her anxiety brought about by her inability to get to her doctor timely. She had no
transportation readily available for routine care and lived alone with no assistance for emergency needs.


INTERVENTION:
Gloria was identified using Great Lakes Caring Predictive Modeling as a high-risk patient for
readmission within 30 days to the hospital and a risk for continued use of the ER for routine medical
care. Since Gloria was identified as a high-risk patient the following Evidence-Based Practices (EBP)
were applied to her plan of care by the Great Lakes Caring Hospital Readmission Reduction Team.
High-risk alerts were added to her plan of care for all staff to be made aware of her risk status. She
was scheduled daily automated Interactive Voice Response (IVR) calls to her home. If, during those
calls, Gloria indicated she was considering going to the hospital, Great Lakes Caring’s team would be
alerted and would then place a live call to her, immediately. During the first two weeks post-hospital
discharge, Gloria indicated twice she was thinking of going to the ER. On the first occasion, the Great
Lakes Caring Hospital Readmission Reduction Team called Gloria right away. She was transferred
to the on-duty registered nurse and an intervention was made within 18 minutes of the initial call and
resulted in no unnecessary hospital readmission or unnecessary use of the ER. On the second occasion
of being alerted, the Great Lakes Caring Hospital Readmission Reduction Team contacted Gloria,
again transferred her to the on-duty registered nurse and an intervention was made within only five
minutes of the initial call, again resulting in no use of the ER or hospital readmission.


RESULT:
Gloria’s safety, anxiety and medical needs were met in the home, preventing the need for ER visits
on both occasions, due to timely interventions. Gloria remained in her home throughout her 60-day
episode without requiring ER visits or unnecessary hospitalization.

 

Presented by Deb Polkowski, RN CHC
Great Lakes Caring Hospital Readmission Reduction Director