What We Tried

We implemented a plan for physician education (see “Educating physicians to reduce readmissions in a rural setting” story) but understood that this was not enough; we knew that we needed to follow our patients once they left the hospital to help them along and to try to ward off any complications that might cause a readmission. Beginning July 1, 2015, we began having our nurses make a follow-up appointment with each patient’s primary physician before they leave the hospital. That appointment is printed on the patient’s written discharge instructions and is also recorded in the EHR. Then, we have a Registered Nurse call the patient 24-72 hours after discharge to see how they are doing, go over their discharge medications with them, address any questions or concerns, and reinforce the importance of keeping their follow-up appointment. The nurse then calls the patient again the day after their scheduled follow-up appointment to make sure they went and to address any new questions or concerns. We found when looking at the data that the diagnoses with the highest readmission rates were congestive heart failure and chronic obstructive pulmonary disease, so the nurse also calls patients with those diagnoses at 14 and 21 days post-discharge to try to make sure that any pending complications are addressed at the clinic before they worsen and cause a readmission.