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Post-discharge communication tips to help patients avoid readmission

Fonda Narke, West Healthcare
Fonda Narke, Director of Product Integration, West Corporation Healthcare Practice

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.

The purpose of this initial call is to:

1. Reconcile medications.

2. Assess the patient’s status post-discharge.

3. Determine whether a referral or labs are needed.

4. Verify patient has obtained their medications and is taking them as prescribed.

Also take this opportunity to confirm the upcoming appointment and any travel arrangements so that issues may be addressed well ahead of time. 

Best practice #2: Capture patient preferences

Be sure to communicate to patients using their channel of choice, which fortunately, most EHRs today can capture. However, it is important to remember to verify and update this preference as part of the pre-discharge process, based upon the patient’s current capabilities. For example, can a patient that prefers email get to and operate a computer? It’s also smart to collect expressed consent and HIPAA waivers from patients and care proxies in order to protect the provider and the organization. This step safeguards the healthcare organization against any concern of violating TPCA or HIPAA when making an outreach.

Best practice #3: Be persistent

CMS expects two attempts be made to connect with a patient within 48 hours of discharge, but what happens when providers have made these attempts without making contact with the patient or patient’s proxy? Don’t give up! Remember that if the patient keeps his or her TCM follow-up appointment, providers can still claim the higher reimbursement, but most importantly, better outcomes and recovery depend on unbroken care. Providers should continue outreach to both the patient and the care provider, and after 48 hours, the notification messaging can change in purpose to become a more focused appointment reminder.

Occasionally, providers may really push for human contact with their patients. In these cases, the organization should consider outsourcing their TCM follow up calls rather than add bodies or build out infrastructure. Companies in the business of supporting manual outreach often have advanced dialing software, which maximizes the connect rate with patients and lowers cost of manual intervention. Use of these services saves staff from the inefficiencies of manual outreach, allowing them to focus on patient care.

Best practice #4: Automate the outreach

The initial call out to a patient or their proxy can take the form of a voice call, text or email. Any of these channels can be used to have the patient call back into the organization, effectively freeing care coordinators to practice at “top of license” by handling inbound calls only. Messages can be customized to change in the event the outreach staff reaches an answering machine or voice mail. The important thing is that an inexpensive technology is being applied to do time-consuming phone tag. Once the patient has been reached, the team can step in to speak with the patient.

Additionally, automation simplifies documentation of the outreach. Notification tools log results of calls, such as no answer, voice mail, or transferred into hospital. This greatly simplifies record keeping and can be integrated into the organization’s TCM workflows.


Post-discharge is an uncertain, often intimidating time for patients with complicated instructions to follow. But with new strategies and tools available to stay in near-constant touch with these patients, providers have a new opportunity to help them stick to their care plans and the path to recovery.  For more best practices, download a white paper on “Six Communication Best Practices for Transitional Care Management.”



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


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