Post-Discharge Follow-up

Stay in touch after the hospital stay.

For weeks after a hospital stay or the end of a package, Hettie rings to ask how things are going, hears when they start to slip and brings clients back into your service when they need care again.

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What the research says

The honest case for follow-up calls.

Telephone follow-up has a modest evidence base, and we describe it as it is.

Satisfaction and information needs.

A 2019 systematic review of nurse-led post-discharge calls covered 10 studies, of which only two were methodologically strong. It found satisfaction was the most consistent benefit and that calls may help meet information needs. Source: Woods et al., Journal of Clinical Nursing, 2019.

No clear effect on readmission.

The same review found no support for effects on readmission or mortality. An earlier BMC review of telephone follow-up for chronic disease found the evidence inconclusive for reducing 30-day readmission. Source: Jayakody et al., BMC Health Services Research, 2016.

Joined-up services.

HIQA's draft standard 4.3 asks that when someone needs support from more than one service, it is planned so they know who is in charge and experience no gaps. Source: HIQA draft National Standards for Home Support Services. The standards are still in draft.

Given that evidence, we make no claim that calls reduce readmissions. What a follow-up call gives an agency is a documented contact, a chance to hear that daily life has become harder and a route into your intake team when a new need appears.

Administrative questions and clinical questions are different. Hettie asks about support at home, such as shopping, washing and who is helping. Anything that sounds clinical goes to a nurse on your team, in line with the human in the loop principle in the HSE AI strategy for healthcare.

How it works

Three steps, no integration.

  1. You add the client when care ends or they leave hospital.

    Name, number, discharge date and the person on your team who owns the follow-up.

  2. Hettie rings on the dates you set.

    In your agency's name, as an automated assistant, it asks how the client is managing, who is helping and whether anything in daily life has become harder.

  3. New needs reach your intake team.

    A new need, such as help getting in and out of the shower, appears with the client's own words and goes to the named owner. A worry that sounds clinical goes to your nurse.

What your agency sees

An after care list, with an owner for every need.

After care list

The list shows who is in follow-up, who was reached, what new need was found and who owns it, with the client's last answer beside each name. Your intake team sees the clients who may need care again, and everyone else stays on the schedule you set.

Families know who to ring when needs change.

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Pricing

What it costs.

Post-Discharge Follow-up is priced separately from the During care package. You pay per active patient per month, with no setup fee.

Post-Discharge Follow-up

€3
per active patient per month
  • Calls after a hospital stay, so the first days at home are covered
  • New needs passed to your intake team
  • Transcript and write-up for every call
  • No integration needed
Request a demo

Minimum €300 per month per agencyNo setup fee

EARLY ACCESSPilot providers in Ireland join through the early-access programme. Ask us when you request a demo.

See every module and price

Keep exploring

Works well with.

Patient Satisfaction

Check in with every client on a schedule you set.

Welcome Calls

Settle the details before the first visit.

Care Centre

Every call to your office answered, in hours and after.

Frequently Asked Questions.

Want to see who needs you after the hospital stay?

A short chat about how you follow up today, and a walk through the list Hettie would build from last month's discharges.

Request a demo

For home care providers and hospices in Ireland. Early access is open.