Patient Readmission Prevention

Comprehensive Call Center Solutions for Post-Discharge Care

Readmission Prevention

Even the best acute management practices and discharge plan executions do not offset the factors that most often lead to readmission and the resulting impact on patient satisfaction. The three main reasons for readmission are:

  • Patients do not follow up with the physician visit
  • Patients do not follow the right medication regimen
  • Patients and/or caregivers don’t understand the treatment plan

AccessNurse focuses on the full range of outbound transitional care calls. As a physician founded and led company with the experience of more than 1 million outbound transitional care calls, we understand that readmission reduction and patient satisfaction are inseparable metrics. Our experience also tells us that calls made within 48 hours of discharge or a change in plan of treatment is the most effective in correcting patient misunderstandings, promoting risk management, reducing readmissions and increasing patient satisfaction.

Clinical Programs

Our clinical programs can be implemented for all discharges or high-risk only on a per-program basis.

48-Hour RN Calls – RN calls the discharged patient within 24 to 48 hours in order to review discharge care plan and assess patient satisfaction. Program can include:

  • All discharged patients with special scripting for high-risk based on diagnosis or high risk only patients using diagnostic-specific scripting
  • EMR view options
  • Escalation directives to notify of immediate problems

Full 30 Day Program –

  • RN calls at appropriate intervals for health coaching and assessment for a full 30 days
  • Patient is given a number to call for a nurse 24/7, if symptoms occur

Non-Clinical Programs

Our non-clinical programs can be implemented for all patients or just low risk discharge patients.

48-Hour PCR Calls:

A Patient Care Representative calls the post-discharge patient 24 to 48 hours post-hospital discharge to assess satisfaction. Program can include:

  • Escalation directives and general information if a referral needs to be made to another department
  • Option for patient to speak with a nurse if they express a clinical concern or symptoms

Automated Calls:

  • Calls are made electronically with customized scripting
  • Calls may screen for those patients who wish to speak with a live agent or a nurse

Clinical and Non-Clinical Programs Features

  • Dedicated RN Program Director
  • Medication review, flexible system allows for complete service customization
  • Real-time information transfers and escalation
  • EMR integration, data transfers, stratification
  • Appointment scheduling
  • Robust reporting to meet any service or ROI objective and provide meaningful clinical data
  • Ability to include patient satisfaction survey
  • Medical Director oversight
  • Care Management initiatives allow follow-up based on diagnosis or compliance

Post-Hospital Nurse Advice Line

Our Post-Hospital Nurse Advice Line allows patients to reach out in the immediate post-discharge period if they have a question regarding the care plan or develop an untoward symptom.

  • Patients are given a card with a toll-free number to call a nurse branded to your organization 24/7 for questions or problems
  • Clinical information can be client or diagnosis specific
  • Symptoms triaged using our triage guidelines / ability to add customized directives
  • Appointment scheduling
  • Standing medication orders
  • Physician notifications protocol
  • Real-time reporting of call data
  • Reporting of clinical indicators of post-discharge population
  • Patient Satisfaction / Post-Discharge Calls


“After partnering with AccessNurse, we noticed how much the nurse documentation improved. We’ve also noticed how professional AccessNurse's Patient Care Coordinators are when working with our patients.”

RN Manager

Privia Health

“I can rest easy at night knowing that the AccessNurse is taking great care of my patients. I have used telephone triage services since 1997, and AccessNurse is the best I have ever used.”


Texas-Based Children's Practice

"Utilizing AccessNurse to cover our daytime overflow volume has been a game changer for our staff and patients. The staff are much happier being able to focus on direct patient care, and the patients really appreciate getting their undivided attention. It's a win-win for all of us."

Clinic Manager

Midwest Family Care Clinic

Case Study: AccessNurse's Post Discharge Readmission Reduction Program Saves Texas Hospital $1.2 Million

FInd out more about how AccessNurse was able to assist a 168-be hospital with a Texas Healthcare system to reduce readmission rates and cut costs.

Download Case Study
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