How and when to make follow-up calls

We have been making follow-up calls for sometime now, and want to share with you what we've learned! These are our best practices. You’re welcome to use them; we hope you use them in our platform.

We recommend that every call include these basic questions:

  1. How have you been feeling lately?

  2. Do you have any concerns with your health?

  3. Have you had any of the following symptoms - fever, nausea, vomiting, chills, or shortness of breath recently?

  4. Have you had any falls recently?

  5. Do you have any questions about your medications?

  6. If you ever need medical care, you can call us. Do you have our phone number? (This refers to the number of the facility that the Cortex nurses represent while calling).

A key call occurs within 48 hours returning home from a higher level of care. We recommend asking the basic six questions, along with:

  1. Have you met our care team from {{location name}} who will be taking care of you?

  2. Do you understand how your team will be helping you?

  3. Has someone talked to you about risks for falls in your home?

  4. Has your home health team reviewed your medications with you?

  5. Do you have a 2-week appointment with your primary care physician?

Here are some great questions to evaluate a stay at a skilled nursing facility. Patient experience should be included as one of the “central pillars of quality” in healthcare [1]. We believe the best time to ask these questions is 7 days after discharge. This call includes the basic six questions, plus:

  1. Could {{location_name}} have done anything better to prepare you for home?

  2. How likely would you be to recommend {{location_name}} to a friend? (What could {{location_name}} do better?)

  3. How well did the {{location_name}} team communicate with you?

  4. How was the food at {{location_name}}?

  5. How were the therapy services at {{location_name}}?

  6. How was the nursing care at {{location_name}}?

  7. How were the activities and recreation at {{location_name}}?

  8. How was the overall cleanliness at {{location_name}}?

A key metric you may want to measure is if the patient has visited with their PCP or surgeon. Research shows that having high-risk surgical patients follow up with their PCP or surgeon after discharge decreases their likelihood for readmission to higher levels of care [2]. This is best asked around 14 days after returning home.

  1. Have you seen your Primary Care Physician or surgeon yet?

Another use of follow-up calls is evaluating current home health services. Sadly, a surprising amount of patients are not receiving the care they expect. Two great questions to discover if this is a concern are:

  1. Is there anyone in your care team who is taking extra good care of you?

  2. Are there any care team members who could use some improvement?

Using follow-up calls quickly discovers information that helps you improve your facility, and increases the well-being of the patients you serve. The time we have spent making follow-up calls has taught us a lot, and we are happy to share. We wish you the best in your follow-up call endeavors!


1. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013;3:e001570. doi: 10.1136/bmjopen-2012-001570
2. Brooke, Benjamin S. et al. “Early Primary Care Provider Follow-up and Readmission After High-Risk Surgery.” JAMA surgery 149.8 (2014): 821–828. PMC. Web. 21 June 2017.