Close this search box.



Intermountain Health: Improving Clinical Outcomes and Reducing Readmissions

Intermountain Healthcare – the largest nonprofit health system in the Intermountain West

  • Mission: Helping people live the healthiest lives possible
  • Vision: Be a model health system by providing extraordinary care and superior service at an affordable cost

Post-Discharge Calls: 2014, before the implementation of CipherOutreach

  • Decentralized model, dependent on each unit managing their own follow up 
  • Little or no coordination between those calls and outreach at the clinic level 
  • No tracking or documentation of calls
  • No resources to help the patient in case of a need for service recovery 
  • No dedicated time to help nurses focus on making meaningful calls 

Post-Discharge Calls: 2015, during the implementation of CipherOutreach 

  • Shift to making centralized calls using CipherOutreach, leading to improved efficiency
  • Shift to a centralized approach also allowed focus time to make these calls and take next steps to address concerns 
  • Free up bedside staff for patient care
  • The primary goal: reduce readmission rates and ED bounce back rates across the system 
    • Secondary goal: increase patient satisfaction 
  • Creation of the Health Answers team
  • Aim:

    • A service aimed at providing timely, free, and accurate health information and follow up to ensure seamless transitions
  • Staff:

    • Staff members are nurses with more than 5 years of experience from varied cultural backgrounds. Training includes phone skills, boundaries, and available resources

Goals of the CipherOutreach implementation and Centralized Post-Discharge Calls

  • Seamless transitions for patients, leading to reduced readmissions 
  • Standardization of calls for all Intermountain Healthcare patients, regardless of how busy their unit of discharge might be 
  • Post-discharge clinical insight, which helps to highlight problems at the unit or hospital level 
  • Standardized documentation and issue resolution 

Patient Education is Key

  • Patient education prior to discharge
  • Automated call
  • 24-48 hours
  • Nurse will call back based on responses

Post-Discharge Follow-Up Focus

  • Clinical vs. Patient Satisfaction
  • Post-discharge follow-up call focused on clinical issues
    • Understanding of discharge instructions
    • Obtaining prescriptions
    • Questions about medications
    • Follow up appointments
    • Barriers to follow up
    • Clinical specific questions
  • Not a patient satisfaction call


CipherHealth Voice (now CipherOutreach) Automated Calls/Texts

  • 4 attempts to reach patients over 1-2 days
  • Voicemail messages left it patient does not answer
  • Return calls trigger human follow up automatically
  • Negative responses trigger a live call from an Intermountain Health Answers nurse
  • Documentation is kept in the EMR (bidirectional interface)

Health Answers Staff

  • Experienced nurses > 5 years experience
  • Varied clinical backgrounds
  • Orientation and training include:
    • Phone skills
    • Boundaries
    • Resources
    • Clinical resources

Health Answers Nurse Follow-up

  • Timely follow up on issues (goal of less than 30 minutes per issue)
  • Ensures patients make seamless transition to primary care provider, reducing leakage 
  • Help find solutions to any barriers
  • Escalate care as needed
  • Documentation in the EMR, enabling identification of common issues or trends

Readmission Rates Improvements

  • 4.9% of patients who received a phone call we readmitted within 30 days. We can see that patients who engage with outreach programs have lower readmission rates than patients who do not engage with the programs.
  • The average difference in readmission rates between engaged and unengaged patients is 2.6 percentage points

Key Takeaways

  • Voice, now CipherOutreach, helps identify patients requiring intervention to efficiently focus nursing time
  • Identification and resolution of patient concerns/issues reduces readmissions
  • Patient engagement post-discharge calls impacted by upstream education