Definition
Post-discharge follow-up is structured contact with a patient in the days after leaving a hospital or emergency department, covering medications, warning signs, and follow-up appointments, to catch problems before they become readmissions.
The evidence base is long: the Care Transitions Intervention (Coleman et al., 2006) and Project RED (Jack et al., 2009) both lowered readmissions with structured follow-up as a core component, and a 2026 single-site quality-improvement study (Wright et al., Worldviews on Evidence-Based Nursing) found 30-day readmissions of 3.5% among patients who received a nurse call within three days, against 17% among those who did not. The strongest results come from full transitional-care programs, so a call alone should be expected to capture part of the effect.
The economics are direct. AHRQ puts the average 30-day all-cause adult readmission at $16,300; CMS's Hospital Readmissions Reduction Program cuts payments by up to 3% for excess readmissions; and Medicare's Transitional Care Management codes (CPT 99495 and 99496) require interactive contact within two business days of discharge. Post-discharge calls intended to prevent readmission are also among the call types the FCC's healthcare exemption covers, subject to its limits.
The usual failure is reach, not protocol. In one cluster-randomized trial, a research team making at least five attempts per patient reached 69% of the intervention group, and many programs never measure whether patients were reached at all.
How Consig handles it
Post-discharge follow-up is one of Consig's core use cases, with a live demo call on the Solutions page. The automation dials, verifies identity, walks the structured protocol, and documents the call; red-flag answers go to a person live within seconds or into the care team's queue with full context.