The Evolution of Discharge Phone Call Programs

Since the introduction of the Hospital Readmissions Prevention Program (HRPP) much effort has been mustered by both acute and post-acute providers to decrease the number of patients that return to the hospital within the first 30 days after discharge.

One of the more effective interventions for reducing readmissions have been discharge phone calls. Many popular readmissions reduction models such as Project Red, Bridge Model or the Coleman Model couple strong discharge planning initiatives with follow up phone calls once the patient is home. While each model differs slightly there are commonalities to the objectives of the discharge calls.

An effective 24-48-hour discharge phone call is likely to include questions such as:

  • Are you feeling better, worse or the same?
  • Have you received your medications and are you taking them as prescribed?
  • Have you scheduled a visit with your primary care physician?
  • Have you received all of your medical equipment?
  • Did you understand your discharge instructions?

Follow up phone calls at weeks 1, 2 and 3 can include additional objectives such as testing and measuring health literacy, confirming medication adherence and/or confirming primary care physician visit.

Providers have used multiple methods for reaching or attempting to reach patients post discharge. The options for discharge phone calls include:

  • Unit nurses and/or social workers making live calls
  • Centralized call center with clinical professionals making live calls
  • Centralized call center with non-clinical personnel making live calls
  • Automated calls with call backs from provider staff
  • Automated calls with live call center backup

Many discharge calling programs began with a single 24 to 48-hour call to the patient by a unit nurse, which is often not the most effective caller. With multiple years of experience with readmissions prevention and discharge phone calls, providers are now evolving their discharge phone calling programs to increase effectiveness and decrease costs.

Studies have shown that a centralized call center can be twice as effective as unit nurses alone. Centralized call centers allow for dedicated resources, consolidation of best practices and immediate response to patient needs. When paired with an automated transitional care software platform like NexusConnexions, centralized call centers can also be a more cost-effective solution by engaging non-licensed care coordinators to execute the calls.

Automated calls have also increased in popularity with providers as a low-cost solution for completing discharge phone calls. However, automated calls do pose some challenges to overall effectiveness. A recent study on discharge phone calling showed that 30% of all calls were answered by family care givers and that when patients are reached 70-80% of them need some sort of live assistance. This dynamic makes it difficult to rely on automated calls solely.


Family caregivers may or may not accurately convey patient responses and/or concerns and with such a large percentage of patients needing assistance, providers can face an unexpected workflow bottleneck when trying to respond to those patients. Dedicating clinical resources to make return calls to patients who indicated on an automated call that they have an issue or need to talk can erase the cost savings intended from the use of automated calls. This dynamic also increases the likelihood that a patient with a need slips through the cracks and has a rehospitalization event.

Finding the right mix of investment, value and effectiveness at reducing rehospitalizations necessitates the further evolution of discharge phone calling programs.

Some providers are consolidating know best practices into a next-generation hybrid approach to discharge phone calls by mixing automated and live calling initiatives. The key components of this hybrid approach include:

  • A mix of live and automated calls that can be automatically assigned based on risk stratification, diagnosis or calling interval (i.e. 24-48-hour call vs week 3 call)
  • The ability for patients receiving an automated call to opt into a live call supported by a live call center
  • A call program supported by transitional care software to automate assignment of calls to proper resources (i.e. live call center vs automated), deliver call scripts for live calls to empower lower cost non-clinical care coordinators
  • Committing to multiple calls and touches with the patient beyond the initial 48-hour call

As providers continue to look at ways to move the needle on readmissions reductions, further refining discharge calling programs can provide both cost reductions and increased effectiveness. Engaging a centralized call center supported by a strategic mix of automated calls and transitional care software gives providers multiple options and the flexibility to design call programs that are cost-effective but specialized to patient types by diagnosis and risk.

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