Healthcare · Care Coordination

Post-Discharge Follow-up Call

Catch post-discharge problems early and reduce avoidable readmissions.

Apps this needs

EHR / Practice System Read availability and write appointments back to your clinic system. Connect during setup
SIP Trunk Route inbound & outbound calls through your phone system. Connect during setup

How it works

  1. Agent calls within 48-72 hours of discharge, pulling the discharge summary to follow the practice's standard script.
  2. Escalates any red-flag symptom or confusion about instructions immediately to a nurse — never offering clinical guidance.
  3. Confirms the follow-up appointment as scheduled, or books it on the spot if not.
  4. Logs the call outcome to the patient's record for the care team.

Data sources

EHR discharge summary Follow-up appointment schedule Escalation protocol

What it targets

  • Discharged patients reached within 72 hours Target 85%
  • 30-day readmission rate for contacted patients vs baseline Target -15%