Post-Discharge Follow Up
Preventive outreach helps remind and educate patients about upcoming or overdue routine screenings, such as mammograms or colonoscopies; immunizations, including flu and pneumonia; and annual wellness visits.
Post-discharge follow up can be used to ensure that all patients understand their care instructions and necessary follow up during care transitions as well as educate and manage chronically-ill patients longitudinally.
Care recordings enable clinicians to easily record personalized care plan instructions that patients can access at any time, helping to improve transitions of care and reduce the likelihood of readmission.
Patients who are readmitted to the hospital are visited by their care manager, who completes a readmission round to obtain codifiable information on what brought them back to the hospital. At the end of the inpatient stay, care managers visit again to conduct a transitional care round to review the care plan.
Post-discharge, all patients are enrolled in a call outreach program to ensure they understand their care instructions and necessary follow up to remain healthy in their communities. For chronically-ill patients who may require more in-depth follow up, outreach can be used to enhance care teams’ ability to check in, educate, and guide patients to ensure they are appropriately managing their chronic condition(s).
After the patient completes the post-discharge outreach program, they receive reminders via call or text for routine preventive care, such as cancer screenings, immunizations, and PCP wellness visits.
Effective care management and proactive engagement ensure that patients stay healthy and out of the hospital.
Timely outreach helps narrow gaps in care, improve key quality metrics, and maximize shared savings.
Engage complex populations at scale to reach all patients and access actionable data for care redesign and quality improvement programs.
Gina Intinarelli, RN PhDExecutive Director of Population Health and Accountable Care UCSF Health