Post-Discharge Follow-Up

Minimize hospital readmissions and improve patient experiences

Readmissions after a hospitalization can pose a risk to all involved—from the patient to the caregiver to the health plan. But partnering with NurseWise can provide a dramatic reduction in readmissions, improved patient satisfaction and improved CMS reimbursement.

Our Post-Discharge Follow-Up program reduces unnecessary, unanticipated and costly post-discharge care and readmissions by ensuring patients have the knowledge, resources and motivation to perform appropriate self-care and follow-up as instructed.

Serving as an extension of your team, we are the front line to your members or patients, not only reminding them of necessary well visits, but scheduling appointments on their behalf as well. Through clinical expertise and demonstrated results, we’ve created a forward-looking program to improve your HEDIS measures and lower your overall medical costs. We focus on providing measurable results through the use of data and analytics, while making it easy for those you serve to access and receive the care they need.

A 2007 MedPAC report found that $15 billion in healthcare spending was attributed to CMS beneficiary readmissions within 30 days of a previous hospital discharge.

During Patient Outreach, Our Nurses:

  • Educate and re-emphasize the post-discharge instructions.
  • Identify potential barriers to after-care and possible contributing factors to risk for readmission.
  • Perform medication review and education.
  • Confirm patient understanding of how and when to take their medications.
  • Confirm ownership of necessary prescriptions.
  • Link to the PCP if immediate needs identified.
  • Triage as appropriate.
  • Escalate needs to a Case Manager for follow up when appropriate.
  • Coordinate appointments and provider follow up.
  • Provide a support system for additional questions.
  • Create better clinical outcomes and an improved and measurable patient-centered experience.

Client Benefits Include:

  • Improved patient adherence with post-discharge instructions (including post-discharge appointment attendance).
  • Clinical care provided by experienced professionals at a fraction of the cost of hospital staff performing follow-up outreach and education.
  • Actionable, timely and easy-to-use reports and results, including red flags, from our outreach allowing for better coordination of care.
  • Live telephonic outreach for improved patient education and satisfaction.
  • A pay-for-performance partnership ensures you see the ROI you are looking for.
  • Improved access to care by addressing and resolving barriers to follow-up exams, including scheduling appointments or conducting reminder calls.
  • Care coordination that is required for patient-centered health home models.
  • Improved CMS reimbursement through a decrease in readmissions.