Script for Follow-up Phone Call (booking an appointment)
Below is a sample of a script that could be used by a clinic team member to offer an appointment to a patient who has recently been discharged from the hospital. Each clinic team is encouraged to adapt the script so that it works for your team and patients.
Example Script
CALLER: Hello Mr./Ms. [name]. I am [caller's name], a [role at clinic] from [primary care clinic]. We were notified that you were recently discharged from [hospital]. I’d like to schedule an appointment for you to talk with [Doctor] and some team members. Do you have time in the next [X] days?
Will you have any challenges coming to an appointment at the clinic such as arranging transportation, difficulty moving around or another reason?
Sometimes having another person at your appointment like a family member or friend can be helpful so that both of you can hear the discussion with the doctor and team. After you have been in the hospital, there is often a lot to talk about. We encourage you to consider bringing another person to your appointment but it’s ok if you come alone too.
Please make a list of any questions you have about your health. The team will be happy to talk about those with you at the appointment.
If you already have a ‘green sleeve’ and care plan, please bring it to your appointment but don’t worry if you don’t have one completed yet.
If a nurse from the clinic can follow-up with a patient there is an opportunity to collect some key information from the patient which can be documented in the chart to help prepare the team for the appointment. Reviewing the patient’s discharge summary is helpful. Consider talking to the patient about the following items:
Health Status
- Assess if the patient understands the reason for the hospital admission
- Clarify understanding and misconceptions
- Review symptoms to watch out for, and what to do if a problem arises
- Address patient questions
- Assess change in health status since discharge
Medication
- Ask if the patient has a regular community pharmacy that they use
- Review current medications
- Does the patient understand why they take each medication, how much and how often
- Ask if they are experiencing any side effects
- Ask if they have enough medication to last them until their appointment
- Review any concerns patient has with medications
- Do they have any concerns paying for their medication?
Coordination with other health services (if applicable)
- Ask the patient if they feel well supported by family and friends?
- What is their current living situation? Do they feel safe in their home?
- Assess daily living abilities (e.g., cooking, bathing, dressing, taking medications, transportation, housekeeping, etc.)
- Ask about any special equipment needs
- Ask if the patient is connected with home care services
- Ask if they are aware of any referrals that were made to specialists or community programs from the hospital
Tips
- Consider using teach-back whenever explaining important concepts to patients regarding their health care. The goal of teach-back is to ensure that you have explained medical information clearly so that patients and their families understand what you communicated to them. In teach-back, you ask patients or family members to explain in their own words what they need to know or do. The Agency for Healthcare Resources and Quality (AHRQ) website has materials to support implementation of teach-back including:
- Common conditions from discharged patients include heart failure and COPD. Consider asking condition-specific questions:
- Heart Failure -> consider diet (sodium intake), fluid intake and monitoring weight
- COPD -> consider recommendation of flu vaccine, smoking and oxygen use
- Consider asking if there are supports for the caregiver.
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