Post-discharge follow-up

How do we follow up every discharged patient with the symptom and medication questions for their condition, route flagged answers to a nurse for a callback, and write the results to the chart?

Ask the questions the discharge diagnosis needs and route the answers by rule. After discharge, Callvu classifies the patient (the discharge diagnosis, the procedure, the risk of readmission, the medications started or changed, the home services ordered, the language and channel) to the follow-up protocol, sends the questions on the protocol's schedule to the patient or the designated caregiver (symptoms with thresholds, the medications taken as prescribed, the follow-up appointment kept, the home service started, pain, wound, mobility), classifies each answer against the thresholds, routes a flagged answer to a nurse in the Decision Desk for a callback the same day with the answers in front of them, escalates an urgent answer to the emergency instructions at once, and writes the answers, the flags and the nurse's actions to the chart against the discharge encounter.

In scopeComplex: multi-party handoffsCallvu moves: classify, decide, write back

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Last updated November 7, 2026.

The problem today

The readmission on day six came from a weight gain the patient had noticed on day three and told nobody.

Today, without Callvu

The days after discharge are when the plan either works or fails. Programs call patients within two days, if the nurse reaches them; the call covers whatever the nurse remembers to ask; the answers go into a note; a worrying answer depends on the nurse's judgment and time. Patients who were not reached are not called again, and the ones who are getting worse are the ones who do not call.

The questions depend on the condition: heart failure asks about weight and breathing, a joint replacement about pain and the wound, a pneumonia about fever and breathing, a behavioral health discharge about safety; each has thresholds that a nurse should see the same day. The readmission reduction program measures the result; the care transitions codes pay for the contact when it is done within the windows; the privacy rule governs who is asked and how. The questions are a protocol, the answers are classified, and the flags are routed.

A patient asked the right question on day three, with a nurse who calls back that afternoon, does not come back on day six.

How it runs

From the requestto the system of record.

A patient is discharged from the hospital or the emergency department with a follow-up protocol assigned by the discharge diagnosis. Callvu opens the follow-up on the discharge encounter.

Patient or caregiver: Answers the questions on their phone on the protocol's schedule and takes the nurse's callback.
Transitional care nurse: Calls back on flagged answers in the Decision Desk and documents the actions.
Care team and primary care: Receive the results and the escalations through the chart.
Callvu: Classifies the patient to the protocol, sends the questions, classifies the answers, routes the flags, escalates and writes.

Classify to the protocol
The discharge diagnosis and procedure, the readmission risk score, the medications started or changed, the home services and the equipment ordered, the follow-up appointments, the patient's language, channel and the designated caregiver classify the patient to a follow-up protocol with its questions, thresholds and schedule (for example days two, seven and fourteen, or the condition's own).
Ask on schedule
The questions are sent on the protocol's schedule to the patient or the caregiver in their language and channel (a text link, the portal, an automated call that texts a link), in plain terms with the condition's symptoms and thresholds, the medications by name with whether they are being taken as prescribed, the appointment kept or not, the home service started or not; an unanswered check-in is chased on the protocol and then handed to the nurse for a call.
Classify the answers and decide
Each answer is classified against the thresholds: normal, a flag for a nurse callback (a symptom at the threshold, a medication not taken, an appointment missed, a service not started), or urgent (a symptom above the emergency threshold, a safety answer); a flag goes to the transitional care nurse in the Decision Desk with every answer in front of them and only the allowed outcomes (a callback with the actions documented, a same-day appointment, a medication question to the prescriber, a social work referral, or an emergency instruction); an urgent answer shows the patient the emergency instructions at once and alerts the nurse in parallel.
Write back
The answers, the classifications, the nurse's callback and actions and any escalation are written to the chart against the discharge encounter, the primary care provider receives the results with the referral or the appointment, the care transitions contact and its timing are recorded for the billing code where applicable, and the protocol closes at its end with the summary in the chart.

Where it ends: Every discharged patient was asked the questions their condition needs on schedule, every flagged answer reached a nurse the same day with the answers in hand, urgent answers triggered the emergency instructions at once, and the chart holds the follow-up against the encounter. The Decision Trace shows the protocol, each answer's classification and the nurse's decision; the Audit Trace shows each question, answer, callback and escalation with time.

Runtime enforcement

What is enforcedwhile the work runs.

The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.

Regulations

HIPAA Privacy Rule (45 CFR 164.506, 164.510(b) and 164.522(b)) and the TCPA for automated outreach: The follow-up contact is treatment communication with the patient or the caregiver the patient designated or who is involved in their care under the Privacy Rule, in the channel the patient agreed to (confidential communications requests honored); automated texts and calls for care purposes follow the TCPA healthcare treatment exemption and the patient's consent on file.
Hospital Readmissions Reduction Program (42 CFR 412.150 to 412.154) and the transitional care management codes: Medicare penalizes excess readmissions for the measured conditions, and the transitional care management services require an interactive contact with the patient or caregiver within two business days of discharge and a face-to-face visit within the window (seven or fourteen days by complexity), with the medication reconciliation; the follow-up records the contact and its timing for the code.
Nursing scope of practice and the organization's clinical protocols: The protocol's questions, thresholds and nurse actions are approved by the medical staff, the nurse acts within the state's scope of practice, and the escalation to the prescriber or the emergency instructions follows the protocol; the chart documents the nurse's actions.

Company policies

The questions and the thresholds come from the condition's protocol, approved by the medical staff; no nurse improvises the call.
A flagged answer reaches a nurse the same day with every answer in view; an urgent answer shows the emergency instructions at once.
An unanswered check-in is chased and then handed to a nurse; nobody is dropped for not answering.
The chart in the EHR is the system of record for the follow-up against the discharge encounter.

Controls

Protocol classification by diagnosis, risk and medications.
Scheduled questions in the patient's language and channel.
Answer classification against thresholds.
Decision Desk routing to the nurse with required outcomes.
Urgent escalation with emergency instructions.
Chart write with the care transitions contact record.

Clocks and deadlines

First contact: Within two business days of discharge for the transitional care contact, and the protocol's schedule after.
Nurse callback: The same day for a flagged answer; at once for an urgent one.
Protocol end: The protocol's last day, with the summary written to the chart.

Documents and checks

The protocol classification
Each question and answer with time
Each flag and the nurse's callback and actions
Any escalation
The chart record and the care transitions contact

In the Decision Trace

The protocol and why.
Each answer's classification.
The nurse's decision and actions.

In the Audit Trace

Each question sent and answered with time.
Each callback and escalation with time.
The write.

The handoff

Between the front doorand the back office.

The front door

The patient's or the caregiver's phone, the portal, or an automated call that texts the link.

The back office

The transitional care nurse works flags in the Decision Desk with the answers in hand; primary care reads the chart.

The Decision Desk

A flagged answer goes to the transitional care nurse in the Decision Desk with every answer and only a callback with actions, a same-day appointment, a prescriber question, a social work referral, or an emergency instruction.

Proof

In scope.Proof at scale, not one process at a time.

The kind of process Callvu runs in production for customers in this industry. Ask for a reference on this exact process. The results below are the industry's published proof; each claim code links to its record on agents.callvu.com.

23 hospitals in the Ministry of Health network run on Callvu.

Across Callvu customers

More than 1,000 processes are live across Callvu customers.

Across Callvu customers

Questions

What buyers ask next,answered plainly.

What questions are asked?

The ones the discharge diagnosis's protocol sets, with thresholds: symptoms, medications taken as prescribed, the follow-up appointment, the home service, pain and wound, on the protocol's schedule in the patient's language.

What happens to a worrying answer?

It is classified against the thresholds and routed to the transitional care nurse the same day with every answer in view; an answer above the emergency threshold shows the emergency instructions at once.

Does this count for transitional care management?

The interactive contact within two business days and its timing are recorded in the chart for the code, alongside the medication reconciliation.

Related processes

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