Follow-up calls help avoid readmissions.

Abstract

Nurse care coordinators, who follow up with patients after discharge, are assigned by service line and follow the patient throughout the hospital stay. Patients who are discharged home with post-acute services, those who will be home alone after a hospital discharge, first-time mothers discharged to home with their babies, families of babies who are discharged from the NICU, and any patient the care coordinator is concerned about after discharge are called. Coordinators use a template to gather specified info from discharge patients.