Post-discharge communication tips to help patients avoid readmission

Experienced healthcare professionals know that effective communication with patients is key for successful care transitions between the hospital and home or rehab. Time and again, patients stop adhering to meds or abandon therapies altogether if follow up from providers isn’t consistent. As such, a number of communication best practices are recommended for today’s care transition management (TCM) programs, spanning from prior to discharge, to the focus of this article, after the patient leaves the hospital.

Best practice #1: Provide constant contact

Per CMS guidelines, providers must make two attempts to connect with a patient within 48 hours of discharge. These initial attempts at contacting the patient are essential to qualify for a TCM reimbursement. Note that CMS will allow providers to collect for a TCM visit without having made contact within the first 48 hours so long as they can prove the attempts at outreach were made. Definitely reach out the first time within 24 hours, and if the patient cannot be reached, follow up the second day with another outreach.

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care transition management, post-discharge, Six Communication Best Practices for Transitional Care Management, West Corporation


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