Telephonic Post-Discharge Follow-Up Workflow for High‑Risk Patients

Overview

This workflow helps teams reliably reach high‑risk patients after hospital discharge to catch avoidable problems early, reconcile medications, reinforce education, and escalate timely care when needed. Use it as a standardized starting point and adapt thresholds, scoring, and escalation pathways to local clinical standards and EMR capabilities.

Purpose

Reduce complications and avoidable readmissions by performing a structured telephonic outreach 48–72 hours after discharge for patients identified as high risk.

Scope

Applies to patients flagged as high‑risk at discharge (examples below) from inpatient units, observation, or ED discharges where a post‑discharge check is clinically indicated.

Key Outcomes

• Timely medication reconciliation and problem identification
• Resolved unmet needs or arranged same‑day care when necessary
• Documented outreach and measurable follow‑up activity

Who and When

Timing: Initial call 48–72 hours after discharge. Plan a second attempt within 24–48 hours if unreachable. Schedule additional calls based on risk score or care plan.

Callers: Nurse, care coordinator, or other trained clinician designated by the discharging service. Back‑up persons should be named in the team roster.

High‑Risk Patient Indicators (examples)

Use local criteria to flag patients. Examples to consider:

• Multiple chronic conditions or complex medication regimens (polypharmacy)
• Recent prior readmission within 30 days
• Discharge with new or changed high‑risk medications (anticoagulants, insulin, opioids)
• Limited social supports, transportation barriers, or unstable housing
• Discharge after major surgery, heart failure exacerbation, COPD exacerbation, stroke, or sepsis
• Home oxygen or wound/IV care required

Pre‑call Preparation

1. Confirm patient identity and preferred phone number(s), interpreter needs, and best call times from discharge record.
2. Review discharge summary, medication list, pending test results, scheduled follow‑ups, and care plan.
3. Have patient’s current medication list, wound instructions, and clinic contact numbers ready.

Structured Call Script (use conversational language)

Use this as a template. Record each section in the documentation fields listed below.

Introduction

"Hello, this is [name] calling from [hospital/clinic]. I’m calling to check on how you’re doing after your recent hospital stay on [date]. Is now a good time to talk?"

Confirm identity and supports

Confirm patient name, date of birth, and whether anyone else is with them. Ask about interpreter need.

Medication Reconciliation

Go through key medicines (name, dose, frequency). Ask:

• Are you taking your medicines as prescribed?
• Do you have any questions about how or when to take them?
• Have you missed any doses or had any side effects?

Symptom and Red Flag Check

Ask about common red flags appropriate to the discharge diagnosis. Examples:

• Worsening shortness of breath, new chest pain, fainting, severe dizziness
• High fever, worsening wound drainage, increasing redness/swelling
• New confusion or inability to perform usual self‑care
• Uncontrolled vomiting or inability to tolerate oral medications

Wound/IV/Home Care

Confirm whether home health has visited (if arranged), ask about wound appearance, IV line issues, pain control, and dressing supplies.

Follow‑up Appointments and Tests

Confirm next appointments and whether transportation or scheduling needs are resolved. Check for pending labs/imaging and whether patient knows how they will receive results.

Education Reinforcement

Briefly reinforce the top 2–3 self‑care points (medications, wound care, activity limits, when to seek help). Offer written instruction or teach‑back when possible.

Closing

Summarize the plan, confirm contact info, and give clear instructions for urgent contact (clinic hours and ED guidance). "If you notice X, call us right away or go to the ER."

Pragmatic Risk Checklist & Scoring (adapt locally)

The following simple checklist helps prioritize escalation. Treat it as a local triage aid, not a validated clinical score.

• New or worsening shortness of breath (2 points)
• Chest pain (2 points)
• Signs of infection at wound site or fever >38°C/100.4°F (2 points)
• Unable to take or manage medications (1 point)
• Uncontrolled pain or vomiting (1 point)
• Concern about home supports/unsafe discharge environment (1 point)

Suggested thresholds (local teams must validate): 0–1 = routine follow‑up; 2–3 = expedited clinic appointment same day or next day; ≥4 = clinician‑to‑clinician call for possible same‑day clinic/home visit or ED referral.

Escalation Rules & Actions

• If red flags present (severe chest pain, acute severe dyspnea, confusion, uncontrolled bleeding): advise immediate ED evaluation and notify supervising clinician.
• If risk score meets expedited criteria: arrange same‑day clinic visit or home health assessment. Notify PCP or discharging service via secure message and document action.
• If medication issues or gaps in supplies: coordinate pharmacy delivery, medication reconciliation with prescriber, or home health support same day when feasible.

Documentation Fields (minimum)

1. Call date/time and caller name
2. Patient reached? (yes/no); if no, attempts and next scheduled attempt
3. Medication reconciliation completed? (yes/no) + key changes or issues
4. Symptom review and red flags noted
5. Risk checklist score
6. Escalation action taken (same‑day clinic, home visit ordered, ED advised, prescriber notified)
7. Follow‑up appointment confirmed (date/time/provider)
8. Education topics reinforced and patient understanding (teach‑back yes/no)
9. Disposition and recommended next contact

Reporting Template & Suggested Metrics

Collectable fields for a simple weekly report (spreadsheet or dashboard):

• Number of high‑risk discharges
• Call attempts and successful contacts (% reached)
• Risk scores distribution
• Number and type of escalations (same‑day clinic, home visit, ED)
• Readmissions within 7 and 30 days for contacted vs. not contacted
• Common issues identified (medications, wound care, transportation)

Assignments and Workflow Rules

• Owner: designate an owner role (e.g., Transitional Care Nurse) responsible for initial call list generation and reporting.
• Back‑up: name alternates and times when phone coverage is expected.
• Escalation contacts: list supervising clinician phone numbers and clinic triage lines.

Implementation & Quality Assurance

Train callers on the script, documentation expectations, and escalation rules. Start with a short pilot, review outcomes weekly, and refine the risk checklist and thresholds based on local results. Audit a sample of calls for completeness and accuracy.

Adaptation Notes

This workflow is intentionally adaptable. Teams should map the documentation fields into the EMR or an interactive form, define local risk thresholds, and ensure secure messaging to PCPs/discharging teams. Validate any numeric thresholds or decision rules with clinical governance before use.

Quick Tools to Consider

• Interactive call checklist form that saves each call record
• Automated daily call list from discharge registry for 48–72h cohort
• Simple dashboard showing reach rate, escalations, and readmission comparisons

Use this workflow as a living template: preserve what works, measure outcomes, and iterate to better protect patients during vulnerable transitions.