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Veterans Health Administration


A Phone Call a Day Keeps the Doctor Away

A nurse shows a Veteran an information card

Transitional Care nurses like Laury Jensen establish a close relationship with patients while they’re still in the hospital and then call them every week once they’re discharged to make sure they’re OK.

by Tom Cramer, Staff Writer
Thursday, December 26, 2013

After you’re discharged from the hospital, wouldn’t it be nice if your favorite nurse called you every week to see how you were doing?

The Department of Veterans Affairs thinks that’s a pretty good idea, too. In fact, the ‘weekly call’ program is already common practice at the William S. Middleton VA Hospital in Madison, Wis., and is set to expand to VA hospitals in Tomah and Iron Mountain, Mich., in the spring of 2014.

Take Your Medicine

“Studies have shown that within a few days after discharge, many patients are already taking their medications incorrectly,” said Dr. Amy Kind, a geriatrics researcher at the Madison VA who developed the weekly call program, officially known as Coordinated-Transitional Care, (C-TraC).

“Patients or their caregivers may also have difficulty understanding or remembering the care plan,” she continued.

“Transitional care is doing an outstanding job of helping these patients take better care of themselves once they leave the hospital.

“If things are going wrong we want to catch that early,” she added.

According to a December 2012 study published in Health Affairs and authored by Kind, transitional care patients had one-third fewer readmissions after 30 days out of the hospital compared to similar patients not in the program. It also saved $1,225 per patient over 18 months for a total savings of more than $700,000.

 Studies have shown that within a few days after discharge, many patients are already taking their medications incorrectly. 
— Dr. Amy Kind, Madison VA

Far From Home

“We have other transitional care programs in the U.S.,” Kind said, “but they usually involve home visits.

“But for us here at Madison, home visits usually aren’t an option. Three quarters of our Veterans live too far away from our hospital to make home visits practical. So we needed to do something else.”

A weekly ‘check-up’ call from a caring nurse seemed to fit the bill.

“This care model requires a relatively small amount of resources to operate,” Kind noted. “It provides an option to hospitals — especially hospitals with constrained resources, or those in rural areas or other areas challenged by a wide geographic distribution of patients.”

The researcher said you and your transitional care nurse establish a relationship while you’re still in the hospital. Two or three days after you’re discharged, she’ll call you to see how you’re feeling, review your medications with you and generally make sure you’re doing OK. After that, she’ll call you once a week for about a month; more often if necessary.

If she senses that something is wrong, she’ll initiate appropriate follow-up care immediately.

A Friendly Voice

“Our weekly phone calls are very thorough,” Kind said. “They last an average of 36 minutes. And because it’s by phone, a nurse can reach many more patients than she could with home visits. It’s incredibly simple. It’s incredibly efficient. And it seems to be incredibly cost effective.”

And if you’re suddenly not feeling well or simply need to ask a question or hear a friendly voice, you don’t have to wait for your nurse to call you.

“We give you the direct cell phone number of your transitional care nurse so you can reach her right away during business hours,” Kind said. “That’s a nice feature. You don’t have to call the main VA number, unless it’s after hours.”

But not everyone is a candidate for the Coordinated Transitional Care Program.

“Some patients just need more support after they leave the hospital than others,” Kind explained. “We have patients who are older or high risk, like those with previous hospitalizations or those with dementia. These are the patients we’re focused on.”

The researcher described her transitional care program as just one extra step VA is taking to make sure discharged patients have proper control of their own health care.

“The traditional health care culture over the last 25 years has been to discharge the patient and just assume everything will be followed up appropriately,” Kind said. “Yet, that assumption is often false. Our patients still need us once they leave the hospital. It’s our job to help them succeed once they go home.”

To learn more about VA’s Coordinated Transitional Care Program, visit and