Connect and check-in with patients after discharge

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Connect and check-in with patients after discharge

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One integral component of reducing our readmission rate from 9 percent to 5 percent was conducting 72-hour callbacks.

The Issue

Our data indicated that from 2014 until June 2015, our readmission rate was 9 percent with no plan in place for improvement.


Location- South Sunflower County Hospital, Indianola, Mississippi.

Setting Type- Acute-care hospital.


Setting- Rural.

Payer mix-42 percent Medicare, 27 percent Medicaid, 10 percent uninsured and 21 percent private/commercial insurance.

Population served- Underserved.

South Sunflower County Hospital provides an emergency room, OB care and delivery, lab and radiology services, outpatient surgery services and a swing bed unit offering physical therapy, occupational therapy and speech therapy. In addition, there are three clinics associated with the hospital, two of which offer extended hours on week days and weekend accessibility.

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.


Our percentage of readmissions for July 1 – December 31, 2015 is down to 5 percent.

Additional Benefits

In addition to our in-house efforts, we were very fortunate to be contacted by our local health alliance about participating in a 3-year grant program that will provide a health coach to educate patients in the hospital and to follow them for 45 days after discharge at no cost to our facility. We are very excited to see how much our rates will decrease with our health coach on board!


To be successful, you must have support from your staff, your physicians and your administration. Education is key and numbers ALWAYS speak louder than words!

Organizational Background

Organization Name: South Sunflower County Hospital

Location: 121 E Baker St, Indianola, MS, United States

Organization Type: Hospital

Organization Model: Not Set