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Streamlining Patient Outreach and Care Management at Indiana University Health

Iu Health Blog 1

During our recent panel webinar, Successful Patient Follow-Up Strategies, Adria Grillo-Peck, MS, RN, CMC, Vice President Integrated Care Management, Indiana University Health, shared insights on how the health system enhances patient management with CipherOutreach.

IU Health is the largest network of physicians across 16 hospitals in Indiana, as well as an academic medical center, which works in partnership with their School of Medicine.

Timely patient follow-up

IU Health automates post discharge follow-up to patients within 24 to 48 hours of discharge. The system allows case managers to triage calls, ensuring patients who need further intervention or have specific concerns, such as medication management or education, receive timely attention. 

Patient care management at IU Health is centralized, which allows for consistent communication and follow-up. With three dedicated transitional case managers, IU Health ensures that even during weekends or staff absences, patient care continues. This system has proven particularly effective in managing diverse patient needs, including those requiring interpreter services. 

“For us, the centralized model has worked very well, because we have the infrastructure to cover if [staff] is on PTO, or during  late hours, or on Sundays, which is great for our cadence calls, and then we’re able to catch those patients on the weekend,” Grillo-Peck shared. 

Innovating post-discharge outreach

Since its inception in 2016, the IU Health post-discharge program has evolved to optimize patient engagement and reduce readmissions. Initially starting with two hospitals, the program has expanded, standardizing patient interactions to improve outreach efficacy. 

Grillo-Peck highlighted the introduction of a simplified script during follow-up calls, which has significantly improved their reach rates from 60-70% to approximately 94%.

Special focus on pediatric care

Unique to their pediatric hospital, Riley, IU Health has developed child-friendly outreach materials, such as coloring pages, to remind young patients and their families about upcoming post-discharge calls. The idea is that families will post it on their refrigerator as a reminder that they will be receiving a call from the health system. This, in conjunction with a text message letting patients know they will receive a call, helps ensure that families are well-informed and receptive to follow-up.

“I think that has really helped with our reach rates,” Grillo-Peck said. 

Utilizing data and scaling success

Grillo-Peck highlighted that the success of IU Health’s post-discharge outreach program is backed by data, not just anecdotes. In collaboration with CipherHealth, the analysis showed that patients who participated in follow-up calls were less likely to be readmitted, demonstrating the program’s return on investment. 

These positive outcomes have led to discussions about expanding the program system-wide, aiming to standardize and enhance patient care across all facilities.

For more information, watch the webinar on demand.


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