Post-Discharge Services. Reduce Readmissions and Improve Outcomes

Few patients fully understand their diagnosis and post-discharge instructions after a visit to the emergency department. To prevent avoidable situations where patients are readmitted, it’s crucial to implement proactive, early intervention.

Our post-discharge follow-up service helps hospitals and care centers manage patient care immediately following discharge, serving as an early intervention solution that can help reduce readmission and prevent CMS penalties.

Manage patient post-discharge follow-ups

Using personalized clinical outreach services and customized escalation protocols, we can help you reduce hospital readmissions, increase attendance at follow-up appointments, and improve HCAHPS scores and health outcomes.

Powerful Engagement Solutions for Providers

Customized Communication Plans

Drive patient action and adherence by creating hospital discharge plans by department, floor, provider, or patient population type

Send automated messaging via email, text, and pre-recorded messages based on patient profile
Reduce the workload of your staff, freeing them for higher-value activities
Proactively schedule follow-up appointments and class and event attendance by sending patients real-time scheduling links and using self-service or live voice scheduling

Triggered & Continuous Communication Outreach

Connect with patients or their caregivers within 24 to 48 hours of discharge and after a scheduled follow-up appointment.

Establish an understanding of the patient’s recovery within 24 to 48 hours of discharge
Gauge compliance and identify patients who need additional attention

Customized Post-Discharge Surveys

Get the range of qualitative and quantitative feedback you need, including open-ended questions, and evaluate and track results with documentation to help improve HCAHPS scores.

Route calls to clinical or non-clinical teams based on patient responses to customized survey prompts matched to your facility’s objectives
Customize post-discharge survey questions to garner the range of qualitative and quantitative feedback you need to report
Pose open-ended questions to evaluate and track qualitative feedback

Escalation Protocols

Provide real-time escalation by connecting patients to our clinical agents who can quickly access emergency medical services whenever a critical question or matter arises.

Registered Nurse Consultation

Clarify post-discharge instructions, medication administration, and care plan questions with our clinical experts.

Fill in gaps or patient misunderstandings
Provide advice from our clinical agents and your healthcare staff, or a referral to an outpatient physician instead of choosing to return to the emergency department
Track a patient’s medications, including drug name, dosage, and frequency, and route to help your pharmacists evaluate patient medications for adverse effects

Secure Portal

Capture trend information by category, measure care initiatives, share patient feedback, and escalate patient needs in real time from a secure online portal. Access real-time reporting and call data to evaluate service performance and identify areas of improvement.

Patient Discharge Use Cases

Patient Escalations

Assess whether an escalation is needed to avoid post-discharge complications

Trends Analysis

Track patient adherence and escalations to reduce readmissions

Patient Feedback

Improve HCAHPS scores by quickly responding to survey findings

40% reduction in readmission rates

In the first year of introducing Carenet Post-Discharge Services, a large Texas health system saw a 40% reduction in care center and hospital readmission rates when comparing patients who completed the post-discharge process compared to those who didn’t.