Dr. Amy Kind and Dr. Sharon Weber Collaborate on Phone-Based Transitional Care Program for Surgical Patients

Dr. Sharon Weber

Dr. Amy Kind

A press release about a study led by Sharon Weber, MD (pictured at upper right), professor, Department of Surgery, described how the implementation of a telephone-based transitional care program was used to improve outcomes of  patients undergoing complex abdominal operations. 

The program was a surgery-specific variant of a previous program, Coordinated-Transitional Care (C-TraC), that was developed and led by Amy Kind, MD, PhD (pictured at lower right), associate professor, Geriatrics and Gerontology. 

Dr. Kind and colleagues collaborated with Dr. Weber’s team to create and assess the new surgical program, named sC-TraC. In the program, two nurses underwent a five-week intensive training designed to prepare them to counsel patients on postoperative recovery prior to patients' discharge from the hospital.

After discharge, nurses contacted patients by phone within 24 to 72 hours to review medication reconciliation, symptoms that would warrant direct contact with a nurse, scheduling a follow-up appointment, and confirming that the patient had the nurse's contact information. The program ended once the patient and/or caregiver and the sC-TraC nurse mutually agreed that no further follow-up was needed, or the patient had been discharged for six weeks, or the patient was re-admitted within 30 days after discharge. 

The program reached 95 percent of 212 patients enrolled after complex abdominal procedures, defined as colorectal, hepatobiliary, or other gastric or small bowel resections. “Patients were so unbelievably happy to have someone that they could reach directly on the phone and they didn’t have to go through a phone tree,” said Dr. Weber.

Notably, sC-TraC nurses found in intial phone calls that 46 percent of patients were not taking medications correctly, indicating the need for further study and interventions that target medication reconciliation.