In my organization one program being incorporated into the Medicaid population is making automated post discharge calls to members that were seen in the emergency room or had an inpatient stay. Patients receive a post discharge call to remedy any self-identified gaps in care (Harrison et al., 2014). The program focuses on preventing readmissions to the emergency room (Harrison et al., 2014). The team addresses the following areas with the patient to bridge gaps in care:

  • primary care follow-up appointments
  • transportation
  • medication
  • discharge instructions
  • social determinants of health

The program has been live for eleven months. By focusing on the areas above the patient receives a higher quality of care. The preliminary data for 2020 demonstrated that members that interact with the survey had a reduction in utilizing emergency services by 6% and a 5% reduction in inpatient services. Incorporating the program into practice within the organization demonstrates DNP competencies III and IV.



Harrison, J. D., Auerbach, A. D., Quinn, K., Kynoch, E., & Mourad, M. (2014). Assessing the Impact of Nurse Post-Discharge Telephone Calls on 30-Day Hospital Readmission Rates. Journal of General Internal Medicine, 29(11), 1519–1525.