Post discharge follow-up involves calling patients after they've been released from the hospital to discuss their recovery, medications, upcoming appointments, and any additional care they may require. Effective follow-up can catch gaps in care before they lead to complications or an unnecessary hospital readmission.

HIPAA compliant email enables providers to reinforce discharge instructions, ask patients structured questions, and provide patients an easy avenue to request assistance. Email should be one facet of a comprehensive transition-of-care program, not a stand-alone solution to readmission prevention.

 

What post-discharge follow-up needs to accomplish

Patients and caregivers face a lot of information on the day of discharge. They need to understand new medications, self-care instructions, what warning signs to look for, and when to seek follow-up care. One systematic review and meta-analysis found “communication interventions at discharge were significantly associated with fewer hospital readmissions.”

The meta-analysis included 19 randomized clinical trials and 3,953 unique patients discussing readmissions. Overall, 9.1% of patients receiving communication interventions were readmitted compared with 13.5% of patients who received usual care. Adherence to treatment recommendations and patient satisfaction were also improved among patients receiving communication interventions.

 

When to send a post-discharge follow-up

How soon providers follow-up with patients after discharge should depend on the patient’s needs, risk of readmission, discharge destination, and the requirements of any relevant care transition programs. The CMS’s transitional care management billing guidelines require providers to communicate with patients or caregivers within two business days for those who qualify. However, this timeframe is specific to billing for certain services and should not be considered a deadline that applies to every hospital discharge.

Emerging clinical evidence also supports reaching out to patients soon after discharge to connect them with outpatient care. One cohort study noted that “receipt of primary care follow-up within 7 days of hospital discharge… was associated with fewer Medicaid readmissions.” Researchers found that 30-day readmissions occurred after 12.7% of discharges with follow-up within seven days, compared with 17.5% of matched patients who had later follow-up appointments or no follow-up.

A CDC review observed a 21% lower adjusted risk of 30-day readmission among the included studies that did find an association between outpatient follow-up and readmissions. However, there was significant heterogeneity between the results of the included studies, and subgroup analyses based on medical diagnosis did not find this benefit was present for every condition.

 

How to craft the follow-up email

  • Use a simple subject line that respects privacy. An opening line can read something like “Checking in after your hospital stay.” Try not to include a diagnosis, procedure, or other health information that is not needed for care in the subject line.
  • State who is reaching out, when the patient was discharged, and why. In the opening lines of the email, patients should know who is contacting them, that they recently received care, and that this message is about their recovery and follow-up care.
  • Ask patients about medication reconciliation. According to an NCBI Bookshelf chapter, “medication reconciliation errors can cause patients to duplicate medications or take incorrect dosages or frequencies of medications.” HIPAA compliant email can include questions about obtaining new prescriptions, discontinuing old medications, and identifying potential side effects.
  • Inquire about symptoms and include clear clinical guidelines. Healthcare providers can attach a concise list of condition-specific symptoms extracted from the discharge plan. Each symptom should be accompanied by clear guidance such as contact numbers for the care team, after-hours nursing, or emergency resources. HIPAA compliant email should never be positioned as an emergency resource.
  • Confirm next steps and address practical concerns. In addition to confirming the date, time, location, and purpose of the next visit, providers can ask whether the patient has transportation, cost concerns related to medications or medical equipment, language access needs, food insecurity, or needs at home.
  • Encourage patients to reply with current health status. Email reminders can encourage patients to reply with their current medications, which symptoms to watch for, or respond yes-or-no.

 

Build a workflow around the email

In one scoping review, researchers found the main facilitators of asynchronous post-discharge communication were “easy access, convenience, less disturbance.” Lack of response time expectations and anxiety over delayed responses were considered barriers.

More granularly, providers can establish guidelines for medication discrepancies, declining symptoms, missed appointments, and no response from high-risk patients. The email being delivered or data being opened shouldn’t be considered confirmation that a patient understood their care plan or intends to follow it. A reply, completed call, attended appointment, or clinical review documented in their chart is much more tangible.

Facilities can track their workflow by response rates, follow up attendances, resolved medication discrepancies, time to escalate, emergency department visits, and condition-specific readmissions.

 

In the news

Tech Target covered a recent Cleveland Clinic and GE HealthCare pilot that tested continuous monitoring on postsurgical patients. In their report, GE HealthCare shared that alerts from monitoring drove clinical interventions that reduced vital-sign abnormalities by about 25%.

The positive impact was notable, but keep in mind that this manufacturer-funded pilot did not test post-discharge email nor did it attempt to prove a reduction in readmissions. What this pilot does demonstrate is how communication tools should correspond to a patient’s level of risk. HIPAA compliant email is great for answering routine questions and sending instructions, but if a patient needs continuous observation, they will benefit from remote monitoring or direct clinical care.

 

FAQs

Can timely patient communication reduce hospital readmissions?

Timely communication can help connect patients with appropriate follow-up care. The CDC review noted that outpatient follow-up was associated with a 21% lower adjusted risk of 30-day readmission across the pooled studies.

 

Why is two-way communication more useful than sending reminders alone?

Two-way communication allows patients to report new symptoms, explain medication problems, ask questions, and identify barriers such as transportation or treatment costs. One of the abovementioned reviews identified easy access and convenience as facilitators of asynchronous post-discharge communication.

 

What is teach-back?

Teach-back asks patients or caregivers to explain instructions in their own words so providers can identify misunderstandings.