By proactively reaching out to patients, I play a key role in efforts to reduce readmissions.

Once they leave the hospital, patients are focused on returning to "normal"

Discharge instruction may be a distant memory

Proactive nurse outreach can confirm patients understand their medication regimen

Connected nurses make sure prescriptions are filled and communicate any changes to the PCP

Appropriate and timely education can divert patients from avoidable ER visits

Remote nurses team up with in-office care teams to focus on the most acute patients and provide transition of care services