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Proactive Post-Discharge Follow-Up at Intermountain Healthcare

Intermountain Pdf Blog

At our recent panel webinar, Jenny Simmonds, MSN, BSN, Clinical Communications Center Director at Intermountain Healthcare, shared insights into their post-discharge follow-up strategies and partnership with CipherHealth. 

Intermountain Healthcare, serving the Salt Lake City area and beyond with 33 hospitals and over 400 clinics, operates with the guiding principle of helping people live the healthiest lives possible. Their expansive network includes an insurance branch, Select Health, which recently surpassed a million members.

A centralized approach to patient communication

Intermountain Healthcare benefits from a centralized team dedicated to patient communications. This setup not only allows for real-time monitoring and feedback on calls but also standardizes the information disseminated to patients. 

Their operations run continuously, 24/7, and 365 days a year. Simmonds noted that patients have the ability to call back or send messages through the health app provided. 

A key objective at Intermountain Health focuses on measuring individual productivity among clinicians and nurses. The centralized model gives an overview of each nurse’s workload, the ability to assess capacity for growth, determine when to increase staff, and evaluate the feasibility of adopting new programs. 

Simmonds highlighted the use of the “Unite Us” program to provide patients with access to essential resources like food and housing, ensuring all team members are consistently updated and equipped to assist with social determinants of health (SDOH).

Systematic post-discharge outreach

Intermountain’s post-discharge process begins with educating patients about the follow-up calls they will receive, which are a critical part of their care continuation. The outreach typically starts within 24-48 hours after discharge, ensuring a seamless transition from hospital to home care. Simmonds noted plans to systematize this process further by including a flyer in the discharge packets across all locations, detailing the upcoming communication.

Personalized follow-up for comprehensive care

The focus of the post-discharge calls extends beyond simple check-ins. Simmonds emphasized the depth of their follow-up, which includes addressing issues like medication affordability, access, and transportation. 

By leveraging technology like CipherHealth, Intermountain’s team can delve deeper into the root causes of patient concerns, allowing for more targeted and effective interventions. This proactive approach is designed to prevent problems before they escalate, potentially reducing readmission rates.

Efficient call-back times and data documentation 

Intermountain’s commitment to swift communication is demonstrated by their callback time of 20 minutes or less. All interactions are meticulously documented within CipherHealth’s system and seamlessly integrated into the electronic medical records (EMR), ensuring no patient feedback is lost and future care strategies are informed by accurate data.

Simmonds also shared how Intermountain audits their phone calls, playing them back for clinical staff to refine and improve communication strategies. This practice not only helps enhance the quality of interactions but also holds the team accountable for maintaining high standards in patient care.

For more information, watch the webinar on demand.


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