Researchers reviewed the literature on post-discharge follow-up calls and identified nine important tasks to complete during a call. Developing a standardized assessment sheet can also help callers document patient responses during the call, according to the study.
1. Review discharge summary.
2. Instruct patient in self-management and warning signs.
3. Reconcile all medication lists.
4. Provide instructions for seeking emergency and nonemergency after-hours care.
5. Address medical and social issues (housing, transportation, insurance, etc.).
6. Use health literacy techniques to ensure patient understands instructions.
7. Reinforce pre-discharge education.
8. Use “teach-back.”
9. Develop process to share information from the follow-up call with the primary care provider and care team.
More Articles on Hospital Readmissions:
Medication Reconciliation Program Cuts Hospital Readmissions 50%
3 Questions to Ask When Developing Post-Discharge Follow-Up Call Program
4 Ways ED Care Managers Can Facilitate Care Transitions
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