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For Health Care Professionals

Call Center

Fidelity Health Care’s Readmission Reduction Call Center serves any physician who admits a patient to a Premier Health facility in several ways.

Appointment Scheduling

Patients with high LACE* scores benefit from a visit to their primary care physician (PCP) shortly after hospital discharge. Doing so is a best-practice protocol established by the Institute for Healthcare Improvement. For some patients, an appointment with their admitting physician instead of their PCP is more appropriate.

These patients may be more likely to keep a follow-up appointment with you if it is indicated on their after visit summary (AVS) that they receive before leaving the hospital. That’s why, prior to their discharge, we:

  1. Call the patient to determine a time that is most convenient for them to attend a follow-up visit at your office.
  2. Phone your office to coordinate the patient’s availability with your open appointment schedule.
  3. Schedule the follow-up appointment with you, notify the patient, and add the appointment to the patient’s AVS.

Day Two Post-Discharge Call

Two days after a high risk patient (based on LACE* score) is discharged, they receive a phone call from a Premier Health care nurse. The nurse:

  1. Verifies that the patient understands each of the instructions that appears on their Discharge Summary.
  2. Instructs disease management education teach-backs on COPD, CHF, CVA, PNA, among others.
  3. Assesses patient’s knowledge of their disease by patient teach-back demonstration, which will indicate red flags to increased risk of readmission.
  4. Queries the patient about medication, side effects and if they have any questions.
  5. Reminds the patient of their upcoming appointment (as outlined above for those with high LACE scores)

Day 14 Post-Discharge Call

Fourteen days after discharge, patients with high LACE* scores receive another call for these reasons:

  1. To verify the patient went to their follow-up appointment (as outlined above). If the patient missed the appointment, they are encouraged to make another one.
  2. To review the information and feedback that occurred during the Day Two phone call.

These calls have shown to be helpful in clearing up information that the patient didn’t fully understand.

*The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge. It incorporates four parameters.

  • “L” stands for the length of stay of the index admission.
  • “A” stands for the acuity of the admission. Specifically, if the patient is admitted through the Emergency Department vs. an elective admission.
  • “C” stands for co-morbidities, incorporating the Charlson Co-Morbidity Index.
  • “E” stands for the number of Emergency Department visits within the last 6 months.

For More Information

Call (937) 208-6400(937) 208-6400 for more details about this service. Or email Yonathan Kebede.