Background:
Implementation of telephone follow-up after discharge from inpatient rehabilitation was prioritized from the INESSS-ONF Clinical Practice Guideline. Telephone follow-up was first implemented in 2008 but by 2017, most clinicians in the Acquired Brain Injury (ABI) Inpatient Services had discontinued this practice with no replacement.  A working group consisting of an interprofessional team from the ABI Inpatient Services as well as patient and caregiver partners was formed to improve the sustainability of this practice.  

Purpose:
To refine and implement a sustainable telephone follow-up process in the ABI Inpatient Services with objectives to: 
•	Support use of self-management approach in telephone follow-up.
•	Foster sustainability through built-in processes and structure.
•	Provide accessible resources for ongoing staff orientation and education.
•	Ease transitions to home and independent community living.
•	Support optimal rehab outcomes and allow for future program development and personal learning.
•	Align with Best Practice Guidelines.

Methods:
An Implementation Science framework was used.  Staff surveys and 1:1 interviews were completed with both inpatient and outpatient ABI teams to understand current practices and to identify facilitators and barriers to the completion and sustainability of telephone follow-up.  Clinician feedback, best practice guidelines, and patient and caregiver partners’ inputs were used to refine the purpose, process, and tools.  The revised process and tool were piloted and further refined. Education was provided regarding the new process.  Outcomes were monitored and Plan-Do-Study-Act cycles continued to further refine the process and tool as needed.  
Findings/Results:
The revised telephone follow-up process and tool were found to be feasible to implement by staff (93% completion rate) and majority reported the added time to complete follow-up calls was manageable. New processes were embedded in current interprofessional rounds to enhance collaboration and accountability with the goal of fostering sustainability. Patient/caregiver survey outcomes were positive with all finding value in the phone calls.  Patients/caregivers found the calls helped answer their questions and empowered them to better self-manage and utilize written resources they had received prior to discharge.
Conclusion: 
Feelings of being overwhelmed and anxious are common among patients with ABI and caregivers during discharge transitions.  Speaking with familiar clinicians from their inpatient stay may provide comfort and reassurance, as well as an opportunity for them to ask and clarify questions or issues that may arise after discharge. 
Key principles, learnings, and tools developed can be useful and generalizable to aid development and implementation of telephone follow-up in other services and organizations to enhance discharge transitions of patients with ABI.  Better post-discharge management may also have a wider health system impact, such as readmission rate.  Sustainability of outcome will be re-measured in 6 months’ time (February 2019) to evaluate if telephone follow-up remains an active part of daily practice and to explore opportunities for further learning.

Telephone follow-up: Supporting community transition post Acquired Brain Injury rehab