Implementation of a follow-up telephone call process for patients at high risk for readmission.

This project included the development and implementation of a follow-up telephone call within 72 hours of discharge, targeting patients at high risk for readmission. The goal was to improve understanding of aftercare instructions and decrease readmissions. Clinical nurse leaders provided an intervention in 66% of patient contacts. Readmission rate within 7 days of discharge was significantly lower (P < .05), and the rate within 30 days of discharge trended lower (P = .053), in the clinical nurse leader contact group than in patients who were not contacted.