Use a Customized Follow-Up Plan to Reduce Hospital Readmissions


By Dr. Ravi Raheja

When patients get discharged after a hospital visit, it can be difficult for them to follow or remember discharge instructions. This can lead to higher readmission rates, longer recovery times, and overall lower quality of patient satisfaction.

Did you know?

  • Up to 20 percent of patients are readmitted within thirty days.
  • There is the potential to save 12 billion dollars on readmissions.
  • Hospitals could lose as much as 528 million dollars from Medicare cuts.

Why Hospital Readmissions Occur: A common cause for readmissions is poor follow-up by patients after the procedure. The stress and difficulty faced by patients during their hospital stay makes it common for them to forget or misunderstand the instructions given by providers during the patients’ hospital discharge. Often, patients go home confused about their medication orders, fail to follow the treatment plan, or neglect to follow up with a doctor visit in a reasonable time.

Family members may be able to help patients follow discharge instructions, but they are often distracted because of the hospitalization or not able to help with the patient discharge plan once they go home.

Offer patients customized continued care after patient discharge to:

  • Decrease ER readmission rates.
  • Ensure continuity of care.
  • Increase patient satisfaction.
  • Help patients avoid unnecessary ER visits.
  • Increase patient compliance with instructions.

Nurses trained specifically for post-op care can help a hospital reduce readmissions by creating a customized follow-up plan to keep patients on the correct path to recovery. A hospital staff member will fax the post discharge nurse the instructions from the hospital EMR for patients who have been discharged and are at risk for readmission.

The nurses will make follow-up calls to confirm compliance with medications and screen for necessary follow up visits. If needed, nurses can also be available 24/7 for patients to call if a symptom arises. These calls can be customized to what doctors think will work best and can be adjusted at any time.

The ideal program allows each specialty in the hospital to have its own custom profile, so that each specialty can include custom instructions for the nurses to follow related to the care for specific procedures and specialties. Advanced follow-up systems can even create custom protocols to allow nurses to ask specific and related screening questions. Some examples of these screening questions include:

Medication Compliance

  • Did you get medicines?
  • Do you know how to take them?
  • Are you taking them?
  • Do you have any concerns about taking the medicine?


  • When do you have an appointment scheduled?
  • Are you able to keep that appointment?

Symptom Review

  • Do you know what signs or symptoms to look out for?
  • Do you know what number to call if you have a medical concern?
  • Do you have any questions you would like me to pass on to your doctor?
  • Do you have any symptoms you are concerned about right now?

Following a holistic post-discharge protocol can reduce readmission rates, shorten recovery times, and improve patient satisfaction.


Dr. Ravi Raheja, is the medical director at TriageLogic, which uses innovative technology to offer a comprehensive and customizable post-discharge system. In addition to the customizable post discharge plan above, TriageLogic nurses also remain available for patients 24/7 should any symptoms or questions arise. If your hospital is looking to reduce patient readmission rates, contact TriageLogic to get a quote on post discharge follow-up service.