In an administrative office crowded with desks and computers, a select group of nurses is answering questions and allaying the fears of freshly discharged patients.

Nurse Susan Glinsmann reads about “Jane” in the electronic medical record on the screen in front of her. The 84-year-old woman is scheduled for a pacemaker implant at Johns Hopkins in a little over a week. She recently had a bout of shortness of breath and abnormal heart rhythm. Following her cardiologist’s advice, she came to the Emergency Department and ultimately spent two days in the hospital. When she was released, Glinsmann notices, there were changes to her medication regimen.

Jane takes a variety of medications, ranging from fiber supplements to an antibiotic prescribed to treat a urinary tract infection. During their phone call, Glinsmann reviews each one in detail. Then she comes to a new prescription.

“What about the hydralazine?” she asks.

“The what?”

“The hydralazine,” Glinsmann repeats. “Fifty milligrams, three times per day. For your blood pressure.”

“That’s not what I take for blood pressure,” says Jane. “I take Diovan.”

What happens next in the conversation will be crucial to the success of the Patient Access Line (PAL), a telephone follow-up service that helps patients and their families better manage their postdischarge directions.

Twenty-one inpatient units at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center participate in the service, which operates during the workweek, and more are slated to join.

Supported by a three-year federal grant, PAL is part of an effort to avoid readmission for discharged patients. The system works this way: Usually no more than a day passes before a patient gets a phone call from a Johns Hopkins nurse. Using information from Epic electronic medical records and several other databases and systems, the nurse makes sure that each patient understands the care directions and will also answer any questions caregivers might have.

There can be many new challenges—prescriptions to fill, follow-up appointments to schedule, bandages to change, new diets.

“We have to do a little detective work before we make a call,” says Glinsmann, who leads the team of nurses in the call center. “For instance, we know someone was discharged, but where did they go? Home? To rehab? To jail? We comb through a lot of info to find out as much as we can before we call patients.”

PAL nurses help resolve any clinical issues that arise by contacting the patient’s medical team. A priority is making sure that patients follow their medication orders.

Before Jane left the hospital, for instance, she filled a new prescription for hydralazine but didn’t understand that she was to stop taking her old hypertension medicine. 

“The doctor took you off Diovan, Jane,” Glinsmann tells her. “So now your new blood pressure medicine is hydralazine.”

“Oh,” Jane says. “I’m glad you called. I wouldn’t have known that.”

As Jane is scheduled to return for a preoperative appointment, Glinsmann also walks her through those details. Then she answers Jane’s questions about surgery and asks about her diet.

“It looks like they put you on a cardiac diet. Is that new for you?”

“Oh, yeah,” Jane groans. “Low salt and low fat.”

The nurse offers her the option of talking to a nutritionist.

“I think that would help,” Jane says. “I’m not used to this.”

Later Glinsmann notes that the elderly woman might easily have taken two blood pressure medications had she not spoken with her. She says that patients are generally happy to hear from the PAL team, even if they don’t have questions about their discharge instructions.

“Most people are glad to get a chance to talk about their hospital experience,” she says.

Jane, for one, was eager to share. “It was beautiful until they moved me to the old building. I didn’t mind the building, but I got a mattress with a sinkhole in it. Then they got me a nice new mattress but discharged me as soon as I got comfortable!”

The nurse apologizes for the discomfort and makes a note to tell Patient Services about it. Meanwhile, the patient reports that she was pleased with her care overall—and will continue to trust her cardiac health to Johns Hopkins.