Reducing Readmissions by Improving Clinical Communications – Part Six


Research suggests that the best time for a post-discharge call is within the first 2-3 days after a patient arrives home. At this point, the patient has had the opportunity to settle in, fill medications, make follow-up appointments, and it is still early enough for a nurse call to make an impact.

It’s likely many patients won’t answer on the first try, so nurses should plan to call more than once in this timeframe for most patients.

Setting up a Post-Discharge Call Program

The first step in setting up a post-discharge call program is to ensure that call center staff have the best number to reach each patient. Sometimes the number in the patient’s record is not the same as their home or cell phone number. IPC The Hospitalist Company found that by asking patients for the best number to reach them or their caretaker, they were able to increase their successful call rate from 30% to more than 40% of discharged patients.

Customized Care Call Scripts

Providing nurses with diagnosis-specific scripts can help make care calls more efficient and effective, as many conditions have standard red flags nurses should check in on, such as weight gain after discharge for heart failure. Virtually any type of script can be easily created, including some common scripts for post-surgery, diabetic, and pediatric post-discharge calls. Setting up a unique script with detailed questions for each helps ensure patients understand discharge instructions, address any medication questions, and help ensure the patients are not experiencing symptoms that would cause them to be readmitted.

Nurses should also have access to physicians’ discharge notes to review patient-specific follow-ups. Physician discharge notes will need to be completed in a timely manner to give nurses the information they need for the calls.

To supplement the post-discharge nurse phone call, organizations can also use HL7 integration to receive discharge notifications and set up automated appointment reminder calls. This helps increase the likelihood that patients make it to their appointments, and receive the prescribed follow-up care.


Hospital readmissions are costly for both patients and healthcare organizations. In FY 2017, the Centers for Medicare and Medicaid Services withheld more in Medicare payments than ever before in response to hospital readmission rates. More hospitals were penalized than ever, and a higher average percent of Medicare payments was withheld from each penalized hospital.

To avoid the penalties and help patients to stay healthy at home, hospitals can leverage call centers and post-discharge phone calls with customized scripts to check in on symptoms, review medications and treatment plans, and remind patients of follow-up appointments. Studies suggest that such measures reduce the rate of readmissions. For hospitals, implementing a discharge call center program can help avoid or reduce Medicare readmission rate penalties. For patients, the program can improve their post-discharge care management and health.


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