Evaluating a Telemedical Follow-Up Program for Continuity of Care After Hospital Discharge: Prospective Clinical Intervention Study

Background: The transition from hospital to primary care is a vulnerable period for patients. Telemedicine may enhance continuity of care; however, evidence on its role in supporting hospital-to-primary-care transitions remains limited. Objective: We implemented and evaluated a telephone-based follow-up program to support the transition from hospital to home and primary care, focusing on patient health as well as patient and health care provider satisfaction. Methods: In this prospective, single-center intervention study (University Hospital Basel, September 2022-December 2024), 234 patients discharged from the emergency unit or internal medicine wards received structured telemedical follow-up for up to 10 days until their first primary care appointment. Primary outcomes were patient health and satisfaction; secondary outcomes were health care provider satisfaction. Data were collected using patient-reported outcome measures, patient-reported experience measures, and provider assessments and analyzed descriptively and analytically (P=.05). Results: Patient-reported outcome measure and patient-reported experience measure scores changed during follow-up, while no deterioration was observed. Health care provider satisfaction varied, with telemedical physicians reporting the highest ratings, hospital physicians intermediate ratings, and general practitioners the lowest, citing challenges in information transfer and perceived added value. Conclusions: This study outlines both the potential benefits and the practical challenges of implementing a telephone follow-up program after hospital discharge. Variations in physician satisfaction highlight the need for more user-friendly technical infrastructure and clearer role definitions. Future multicenter studies with broader patient samples, usual care controls, and simplified recruitment processes are required to strengthen the feasibility and generalizability of this approach.