Readmission Prevention

Even the best acute management practices and discharge plan executions do not offset the factors that most often lead to readmission and the resulting impact on patient satisfaction. The three main reasons for readmission are:

  • Patients do not follow up with the physician visitnurse on phone sm
  • Patients do not follow the right medication regimen
  • Patients and/or caregivers do not understand the treatment plan

TeamHealth Medical Call Center has over 10 years of clinical experience in administering readmission prevention and post discharge call programs. Our experience has shown us that a post discharge call made within 48 hours of discharge is the most effective in correcting patient misunderstandings, promoting risk management, reducing readmissions and increasing patient satisfaction.

Our outbound staff is dedicated to this service line and has the telephonic assessment skills to make these calls a positive patient experience, reduce readmissions and promote post discharge care plan compliance, service recovery and patient satisfaction.

We offer both Clinical and Non-Clinical Readmission Prevention Programs

Clinical Programs

Our clinical programs can be implemented for all discharges or high risk only on a per program basis.

48 Hour RN Calls – RN calls the discharged patient within 24 to 48 hours in order to review discharge care plan and assess patient satisfaction. Program can include:

  • All discharged patients with special scripting for high risk based on diagnosis or high risk only patients using diagnostic specific scripting
  • EMR view options
  • Escalation directives to notify of immediate problems

Full 30 Day Program –

  • RN calls at appropriate intervals for health coaching and assessment for a full 30 days
  • Patient is given a number to call for a nurse 24/7, if symptoms occur

Non-Clinical Programs

Our Non-Clinical Programs can be implemented for all patients or just low risk discharge patients.

48 Hour PCR Calls – A Patient Care Representative calls post discharge patient 24 to 48 post hospital to assess satisfaction. Program can include:

  • Escalation directives and general information if a referral needs to be made to another department
  • Option to offer for patient to speak with a nurse if they express a clinical concern or symptoms

Automated Calls –

  • Calls are made electronically with customized scripting
  • Calls may screen for those patients who wish to speak with a live agent or a nurse

Both clinical and non-clinical programs feature:

  • Dedicated RN Program Director
  • Medication review, flexible system allows for complete service customization
  • Real time information transfers and escalation
  • EMR integration, data transfers, stratification
  • Appointment scheduling
  • Robust reporting to meet any service or ROI objective and provide meaningful clinical data
  • Ability to include patient satisfaction survey
  • Medical Director oversight
  • Care Management initiatives allow follow-up based on diagnosis or compliance

Post Hospital Nurse Advice Line

Prevent readmissions by giving a post–discharge patient the option to reach out in the immediate post discharge period if they have a question regarding the care plan or develop an untoward symptom.

  • Patients are given a card with a toll free number to call a nurse branded to your organization 24/7 for questions or problems
  • Clinical information can be client or diagnosis specific
  • Symptoms triaged using our triage guidelines / ability to add customized directives
  • Appointment scheduling
  • Standing medication orders
  • Physician notifications protocol
  • Real time reporting of call data
  • Reporting of clinical indicators of post discharge population
  • Patient Satisfaction / Post-Discharge Calls

Experience You Can Depend On

Our experience with post-discharge calls and our Studer Group partnership gives us the knowledge and expertise to enable us to be successful in helping you engage and empower your patients.  Our flexible system allows us to customize your service to meet the needs of your patients and provide robust and actionable reports. Our flexible system allows us to customize your service to meet the needs of your patients and provide robust and actionable reports. Below are some of the customizations that can be made to ensure that your patients receive calls that meet your practice’s goals and guidelines.

  • Practice specific scripting designed to gather the information you need for your clinical services and patient satisfaction focus
  • Secure interfaces for patient specific clinical information views and transfer of data
  • Customized escalation as required by your practice
  • Customized practice specific clinical directives
  • Clinical call schedule customizations based on your service lines
  • Appointment scheduling
  • Patient experience surveys can be added to clinical calls
  • Robust practice specific clinical and return on investment reporting
  • Practice specific satisfaction survey reporting that allows you to quickly pinpoint areas of concentration

Contact us today at 888-203-1118 and let us help you reduce readmissions and empower your patient population.


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Readmission Reduction Program – Texas
Readmission Reduction Program – California
FQHC Outbound Campaign – Texas