See topics forPatient Experience
Who We Are
The Post-Discharge Call Management (PCM) team consists of registered nurses who reach out to patients who meet our call criteria, generally within 72 hours of discharge from the inpatient units or Emergency Department at UConn John Dempsey Hospital. We use defined inclusion and exclusion guidelines, so only select patients receive follow-up calls. Our goal is to support a smooth, safe, and positive transition from hospital to home.
Our Purpose
Our nurses provide follow-up calls that:
- Help patients understand and follow discharge instructions to promote better clinical outcomes.
- Ensure patients have the necessary follow-up appointments with primary care providers or specialists to monitor recovery and prevent complications.
- Review medications for accuracy, understanding, and adherence.
- Offer education on managing health conditions at home, including lifestyle and self-care guidance.
- Identify new or worsening symptoms early, allowing for timely intervention and prevention of readmission.
- Connect patients with community resources and supports based on their individual needs.
- Demonstrate care, compassion, and empathy—fostering trust and enhancing the overall patient experience.
Who We Call
Patients discharged from inpatient units or the Emergency Department may receive a follow-up call from the PCM team generally within 72 hours. Because we follow a defined set of exclusions, only select patients are contacted.
Emergency Department Exclusions
- Psychiatric or behavioral health cases (e.g., involuntary holds, suicidal, homicidal, bipolar, depression, substance use)
- Alleged abuse or assault cases (child, domestic, or sexual abuse)
- Discharges to any facility
- Sickle cell visits
- Triage level 5 (green border)
- Patients who left without being seen (LWBS) or against medical advice (AMA)
Exclusions from PCM Outreach
Certain patient groups receive follow-up calls from specialized nursing teams or other departments:
- Labor & Delivery and Same-Day Surgery: Calls completed by nurses from those respective areas.
- Population Health: Contacts patients who have an established UConn Health primary care provider or a LACE score greater than 80.
- Heart Failure and Pulmonary Programs: Manage follow-up for some patients discharged with those specific conditions.
Other Inpatient Exclusions
- Psychiatric patients (e.g., suicidal ideation, major depressive disorder)
- Patients discharged to group homes, skilled nursing, or assisted living facilities
- Patients with a follow-up physician visit scheduled within 24 to 48 hours related to their recent hospital stay
How We Document
PCM nurses document all patient outreach in Patient Call Manager, a secure tool provided through Huron Consulting Group.
Note: The team does not document in Epic.
Questions We Ask
During follow-up calls, our nurses use a consistent, patient-centered approach and ask the following questions if applicable during the call:
- How have you been feeling since your discharge home?
- Were you able to fill your prescriptions?
- Do you have any questions about your medications or discharge instructions?
- Have you received all the recommended equipment?
- Has the home health agency reached out to start services?
- Have you scheduled your follow-up appointments?
- Is there anyone on your care team who provided excellent service you would like to recognize?
- Do you have suggestions for how we could have made your hospital experience better?
How We Intervene
Our goal is to promote continuity of care and ensure every patient’s transition from hospital to home is as smooth, safe, and supportive as possible.
Our nurses may contact staff or care teams by phone, email, or Voalte to clarify care instructions, address post-discharge concerns, or coordinate next steps in a patient’s care. Because the PCM team does not document in Epic, we are unable to send messages or in-basket communications through the Epic system.
Contact Us
Our post-discharge call nurses are in the office calling patients Monday to Friday, 8 a.m. to 4:30 p.m. If you have questions about a post-discharge call, please contact the post-discharge call management team by email at postdischargephonecall@uchc.edu or phone at 860-679-2084.