Tips for Preventing Readmissions through Patient Follow-up Calls

February 13th, 2020 | Published Under Practice Transformation by Jennifer Mensch


Cortex provided this blog post to help CORHIO post-acute care stakeholders improve patient follow-up. 

Providers are looking to patient follow-up phone calls as a way to keep discharged patients from readmitting to the hospital. At first glance, a follow-up call system may seem easy to implement. And many agree: in a 2016 Cortex survey, we found that 87 percent of SNF/HHA admins reported creating and maintaining programs for follow-up calls. However, after only three months, 80 percent had given up.

Why do so many proactive admins ultimately give up on these programs? And how can you enact a program that will endure and satisfy your patients’ needs?

Answer: Facilities need structure to conduct follow-up calls

Talk with any administrator or clinician who has attempted to run a follow-up call program, and you’ll quickly learn about various challenges, including the following questions:

  • Which patients should be called?
  • When should they be called?
  • At what frequency should they be called?
  • What should be asked?
  • How should we follow up if they don’t answer?
  • How do we gather the information in an actionable format?

Through our experience completing more than 200,000 successful follow-up phone calls, we’ve identified three questions that are the most effective in preventing readmissions:

  1. Are you taking your medications as prescribed?

  2. Have you had any of the following symptoms: fever, nausea, vomiting, chills, weakness, or shortness of breath?

  3. Have you had any falls recently?

At first glance, these questions may seem too simple and obvious, but there are nuances in phone surveys that should be considered.

First, post-acute patients are typically older and struggling with multiple comorbidities. This can lead to difficulty in understanding complex questions, questions using number scales for answers, or questions that use jargon with which patients are not familiar.

Secondly, the real work is done in the follow-up to each answer given by the patient. For example, if a patient responds that she has had a fall recently, the caller should then ask a series of clarifying questions:

  • Where did the fall occur?
  • Are you injured because of your fall?
  • What part of your body was injured in the fall?
  • Are you considering seeking medical treatment?

Of course, knowing what to ask and know when, how often, and of whom they should be asked are not the same. How can you decipher when to call and how often? What’s the best method to contact the patient on the first call?

Answer: Keep to a schedule and automate a queue.

There are multiple scenarios that might increase or decrease the number of calls per patient. Some use a 2, 7, 15, 30-day call schedule which boils down to one satisfaction call, two wellness calls, and one reacquisition call. In our experience, this is the best-case scenario for a facility or home health agency. If you don’t have resources for four calls, then we recommend a day 2 satisfaction call and at least one wellness call as a minimum.

The next challenge is automating a queue or, in other words, having patients trickle through a workflow so you know exactly who and when to contact. Without a queue platform, most providers only reach about 10-25% of their patients as it often takes two or three attempts which can be difficult to manage manually.

Preventing readmission isn’t an impossible dream. With the right people asking the right questions at the right time, you can ensure that your patients get the help they need when they need it.

About Cortex

Cortex provides patient satisfaction and wellness calls in real-time to evaluate patient status and health. When an at-risk patient is detected, we immediately route the notice to the most recent care provider. Cortex follows all HIPAA regulations and considers whether the patient is within or outside of the penalizing window the CMS and other payers have identified for readmissions. CORHIO Notifications can be delivered to the Cortex system on behalf of customers, so all patient data is in one place.