In the community | Communicating for Safety resource portal

Follow-up communication

Follow-up communication involves taking further action after a patient has undergone hospitalisation or treatment. This can be making contact with a patient, or caregiver, to check on their progress after they have been discharged from hospital, or providing results of tests or information about a patient to healthcare providers in the community.

Follow-up can involve a home visit, telephone call, email or letter. This can be done by medical, nursing or administrative staff depending on the complexity or sensitivity of the follow-up. For example, a follow-up phone call to provide a patient with information on community resources or a service evaluation survey could be performed by a clerk, whilst a registered nurse may be more appropriate to attend to a postoperative follow-up call. Follow-up conducted by pharmacists can reduce the incidence of post-discharge medication errors by helping patients understanding of their medication regimen.

Key messages

Some groups of patients are at greater risk during the transition from hospital to home
Ending of treatment and transition from one service to another can provoke strong feelings and increase risk of self-harm in patients with mental health conditions
Follow-up communication can improve patient satisfaction by alleviating anxiety
Follow-up communication between healthcare providers promotes continuity of care and reduces the risks to patient safety.

Communication strategies

It is essential that plans are in place to support people who have self-harmed or reported suicidal thoughts. Follow-up services should be arranged for everyone who has presented to the acute care setting having made a suicide attempt or had thoughts of suicide.

A discharge care plan should be developed with the person before they leave the health service organisation, detailing agreed strategies that are accessible, available and valued by the person. Effective communication between the person, their support people and key service providers is crucial to reduce the risks of further suicide attempts.

Guides and tools

NSQHS Standard Action 5.32 requires that a health service organisation ensures that follow-up arrangements are developed, communicated and implemented for people who have harmed themselves or reported suicidal thoughts

Guidelines for integrated suicide-related crisis and follow-up care in Emergency Departments and acute settings (26 pages) – Black Dog Institute
Suicide – discharge and follow up of a person at risk webpage with resources - Victorian Health Department

For patients and families

How to help when someone is suicidal – SANE Australia factsheet and resources
Suicide recovery and support strategies - BeyondBlue
Head to Health - Australian digital mental health resources - Department of Health

Before the call, obtain the patient’s discharge summary and familiarise yourself with their health history, medication regimen and discharge plan
If the medical record reflects that patient does not have a good command of English, a conference call with an interpreter will need to be set up
After introducing yourself, ask if it is a good time to talk. If it is not, get a precise time when you can call back
Ask the patient about their perception of their condition since discharge and their understanding of discharge instructions
If the patient’s condition has deteriorated, intervention may be required. This may include patient education, checking whether medication is being taken as directed, or recommending patient action (such as limit activity, take medication, see their GP or return to hospital)
Check what medication the patient is taking and their understanding of how and why they are taking it
Provide an opportunity for the patient to ask questions
Clarify any follow-up appointments
Discuss what to do if any problems arise
Document your call in the patient’s medical record.

Guides and tools

Postdischarge Followup Phone Call Script – example script that can be tailored – AHRQ (US Agency for Healthcare Research and Quality)

Why is it important?

The transition from hospital to home is a critical time when risk to patient safety can increase due to lack of support or poor understanding of medication and discharge care plans. Studies show that patients appreciate and respond well to follow-up contact as it is reassuring, increases their feeling of being cared for, and provides an opportunity for them ask questions or clarify issues about their care. Follow-up also helps prevent hospital readmission by identifying complications and mitigating risks in a timely manner.

Follow-up can provide an opportunity for the results of pathology tests or imaging to be fed back to the patient. A 2012 study of tests ordered in a Sydney hospital revealed that 47% of missed test results emanated from tests ordered on the day of patient discharge but whose results are never reviewed. Health service organisations need to establish mechanisms to relay outstanding test results of discharged patients to the patient and their GP via follow-up communication.

Follow-up may involve working with external services to identify referral processes to support ongoing comprehensive care. These might include processes for:

Safe return to rural or remote health services
Transfer to sub-acute facilities
Referral for ongoing care in the community
Referral for follow-up of specific clinical or other issues
Referral to services provided by credentialed clinicians in the private sector (e.g. physiotherapists, occupational therapists, dietitians, counsellors).

Specific considerations for mental health

A suicide attempt is the strongest risk factor for subsequent suicide. The risk of a further suicide attempt is greatest immediately following discharge from an emergency department or psychiatric ward and remains high for up to 12 months following a suicide attempt. Dedicated and coordinated aftercare services are essential for people who have attempted suicide. Evidence clearly demonstrates that high quality follow-up communication and aftercare can prevent suicidal behaviour and is critical to keeping people safe.

Taking action: What is my role?

As a leader in your organisation, you have a responsibility to ensure that the systems and processes in your organisation support effective follow-up communication, where appropriate. These processes should describe the patient groups or circumstances in which follow-up contact is required, the method of follow-up communication, who should perform follow-up communication, how it is documented in the medical record and the timeframe in which it needs to occur.

Clinical communications policies also need to include the workforce training requirements for structured processes that result in the transfer of responsibility and accountability for care, and the input of clinical information into My Health Record. Implementation of My Health Record will increase efficiencies of information sharing, improve coordination of care and enhance patient satisfaction.

Effective communication is a key requirement of the NSQHS Standards (second edition). The following table describes actions in the NSQHS Standard that are relevant to follow-up communication.

Action	Description
1.17, 1.18	Processes for entering clinical information into My Health Record
2.8, 2.9, 2.10	Communication that supports effective partnerships
5.32	Follow-up arrangements developed, communicated and implemented for people who have harmed themselves or reported suicidal thoughts
6.1, 6.2, 6.3, 6.4	Clinical governance and quality improvement to support effective communication
6.8(f)	Ensure transfer of responsibility and accountability for care
6.9	Effective and timely communication of critical information, alerts and risks when they emerge or change to clinicians and patients
6.11	Documentation of information

For more information see NSQHS Standards (2nd ed.)

It is important that you are familiar with your health service organisation’s communication policies which may require routine follow-up for certain groups of patients. These may include:

Elderly patients
People who have had day-surgery
Postpartum patients
Patients who have left hospital against medical advice
Patients cared for by specialty outpatient clinics (e.g. oncology, dialysis, diabetes, Hospital in the Home).

Some people may require assertive follow-up when discharged into the community. This includes people:

With a suspected or diagnosed mental illness
At risk of becoming homeless
In situations of domestic violence
Who cannot be sure they can keep themselves safe
Presenting for suicide risk for the first time
With a reported history of poor treatment adherence.

Assertive follow-up should involve more frequent contact with the person, home-visits, intensive case management and support from community services. First follow-up contact should occur within 24 hours of discharge for people requiring assertive follow-up.

Your health service organisation should have documented processes for follow-up communication of the results of pathology and diagnostic tests. It is vital that test results for a patient who has been discharged, are reviewed and passed on to the patient, their GP or relevant healthcare provider.

All follow-up communication should be documented in the patient’s medical record.

Follow-up communication with your healthcare provider is an opportunity for you to: