Post Discharge Follow Up Services

Remove barriers to recovery, find dissatisfiers, and coordinate care

Supporting your patients after discharge is a critical part of any successful transitional care program.

Timely, personalized patient support improves outcomes and uncovers experience issues.

SironaHealth will reach out to your patients via the telephone, within a predetermined amount of time after discharge, to:

  • Rapidly assess their health status 
  • Escalate them to clinical resources as needed 
  • Review and clarify discharge instructions
  • Facilitate and schedule necessary follow-up care 
  • Gather feedback on their hospital experience

Registered Nurses and Transition Specialists

The right team to manage post hospital care and capture patient feedback

SironaHealth Nurses and Transition Specialists are some of the most experienced in the industry. They ensure your patients receive appropriate and compassionate care, every time. We become a seamless extension of your organization, helping you provide excellent care beyond your facility.

  • Independent, non-biased Transition Specialists ensure reliable experience feedback is collected during follow up. 
  • Physician authored clinical guidelines allow RNs to immediately triage patients experiencing acute symptoms.
  • Teach Back, Motivational Interviewing, and Checklist methodologies are used by all team members.

Patient Specific Post Discharge Campaigns

Proven programs that reduce readmissions and increase satisfaction

SironaHealth's Patient Interaction Manager enables our post discharge follow up team to provide consistent, personally relevant interactions and guidance to your patients. This unique system utilizes personalized scripts for each patient, making sure the appropriate care plan is followed.

  • Identify and remove barriers to health literacy by clarifying follow up care and medication instructions.
  • Implement specific readmission prevention programs focused on patients' with CHF, AMI, and Pneumonia.
  • Customize questions, messaging, escalation rules, and notification triggers to ensure appropriate outcomes.

Dynamic Follow Up Call Scheduling

Segment and queue follow up call schedules based on patient needs

Timely follow up is critical. But when, exactly, should you be making your calls? Rather than sporadically calling patients after discharge in the hope you'll connect at the right time, we schedule outreach based on each patient's unique situation and follow up care needs.  

  • Set timing of your follow up calls based on patient disposition, program parameters, or any other relevant criteria.
  • Conduct multiple outreach campaigns for patients with complex health conditions, such as CHF, AMI, or Pneumonia. 
  • Trigger custom follow up schedules based on what's learned about the patient during the initial outreach call.

Real-Time Notifications

Alert relevant care providers to gaps in care and experience issues

Multi-channel notifications increase the effectiveness of your follow up program by alerting relevant parties that intervention is required. Real-time notifications ensure action is taken to prevent negative patient outcomes or address patient dissatisfiers discovered during follow up.

  • Trigger notifications off of specific patient answers, demographics, or in-home monitoring equipment.
  • Send alerts via live agent calls, automated calls, secure email, text messages, or alpha-text pages.
  • Customize alert rules to match the preferences of each recipient, ensuring successful delivery and follow up.  

Reporting and Analytics

Measure program impact on patient outcomes and satisfaction

SironaHealth provides actionable reporting on the effectiveness of your post discharge follow up program and the positive impact it's having on your readmission prevention and patient experience improvement programs. With SironaHealth's reporting, you'll know: 

  • When patients received follow up, their health status, disposition, and what follow up activities where encorporated.
  • How hospitals—and units—are trending by category/data point, allowing you to prioritize/monitor quality improvement.
  • What's causing poor patient outcomes—resulting in preventable readmissions for CHF, AMI, and Pneumonia.