Readmissions within 30 days decreased 26% at the Cleveland Clinic with a post-hospitalization nurse callback system. Similarly, when Medicare Advantage members received a discharge call, readmissions dropped 23%. This is the result of a nurse coaching patients on medication and follow-up compliance, checking for adverse reactions, assuring access to specialists, and addressing ADL needs.
Risk indicators for patients with stroke, AMI, CHF, COPD, and pneumonia are essential. Actions for at risk patient include notification of PCP or specialist, pharmacist or dietitian consultation, home health visitation, case management, appointment reminders, and facilitation of in-network testing and follow-up.