The 24-Hour Post-Discharge Call That Prevents the 72-Hour Return

TL;DR: A short, structured phone call within 24 hours catches the failures that most often send people back—missing meds, no ride to follow-up, DME not delivered, and “I’m not sure what to do.” Programs like Project RED and TCM (CPT 99495/99496) formalize the practice; multiple studies show early calls can reduce near-term returns, though results vary by population and execution. The safest read is: do the call, follow a script, and measure it. 1

Why this matters for patients (not just metrics)

People leave the hospital tired, anxious, and juggling new meds. A check-in within 24–48 hours surfaces the real-world problems that didn’t show up on rounds—no oxygen at home, the pharmacy didn’t fill the diuretic, the daughter can’t get Tuesday off to drive. That is exactly what the Project RED follow-up call is designed to find: meds, appointments, services, and “what to do if…”. 1

What is Project RED?

Project RED ("Re‑Engineered Discharge") was developed and tested by the Boston University Medical Center team and disseminated nationally by AHRQ as a toolkit of discharge best practices (including the follow‑up call). The AHRQ materials remain the canonical reference and scripts. It is a practical checklist to make going home safer. It standardizes what patients should leave with—and what teams should verify after discharge: medicines in hand and understood, follow‑up appointments scheduled (and a way to get there), any home services arranged, and clear "what to do if…" instructions. A short follow‑up call 2–3 days later confirms those pieces and fixes gaps on the spot. This article adapts that idea to a 24‑hour check so problems surface even sooner. 1

The evidence base is mixed but meaningful. Older trials and implementation studies report significant drops in early readmissions with timely post-discharge calls; newer studies in specific cohorts show neutral effects when calls aren’t targeted or scripted. The signal: the call can work when it’s structured and connected to action. 2

CMS’s Transitional Care Management policy backs this clinically: it requires interactive contact within two business days of discharge (call, video, or secure message) and pairs it with med reconciliation and an early clinician visit. That is strong institutional cover to make these calls standard. 3

What the evidence actually says (plain numbers)

• Project RED: standardized discharge + a follow-up call at 2–3 days; trials showed lower 30-day readmissions and better patient experience when the call followed a checklist (meds, appointments, warning signs, services). 1
• Telephone follow-up meta/implementation: studies report reductions in near-term returns when calls are timely and scripted; others show no reduction when calls are generic or poorly linked to services. Translation: content and timing matter. 2
• ED cohorts: a callback ~48 hours after ED discharge was associated with fewer ED revisits at 7 days in one large system, suggesting early contact can change short-term behavior. 4

For older adults and ED flow, see the clinical tax of ED boarding for context on risks and early follow-up.

The 7-minute call (use this script tomorrow)

• Goal: confirm tonight is safe and the first week is set up.
• Tone: human, unhurried, one caring voice.
• Who calls: nurse, CM, SW, or trained navigator.
• When: within 24 hours (or next business day) after discharge; if weekend discharge, call Saturday and Monday.

1) Meds in hand tonight

“Do you have all your medicines with you today? Which one are you taking tonight?" → If no or confused: call pharmacy while patient is on the line; arrange meds-to-beds or courier if needed. Medication reconciliation is a core TCM/RED element. 3

2) One teach-back

“Just to be sure we explained it well—how will you take your [name med] today?” → If teach-back fails: offer a simple dosing plan; send a photo instruction via secure text/portal. Teach-back is embedded in RED. 1

3) Follow-up is booked—and ride

“What day and time is your next appointment? Who’s getting you there?” → If not scheduled or no ride: book now; connect to paratransit or voucher. Early visits within 7–14 days are part of TCM codes. 3

4) Two red-flags

“If you notice [flag 1] or [flag 2], call us or go to urgent care.” → Give diagnosis-specific cues (e.g., CHF: rapid weight gain, worse swelling). RED scripts use this exact pattern. 1

5) DME & home setup check (when ordered)

“Is your [oxygen/walker/commode] there and working? Try it now with me.” → If missing or not working: call vendor; consider a same-day fix or short bridge plan. These “last-mile” gaps drive early returns. 1

Protect the first 48–72 hours at home; for HH starts, see getting the first 48 hours right.

6) One number to call

Give a single callback number (or direct line) and confirm the best time to reach them tomorrow if needed.

If anything is unsafe or unclear, escalate immediately to the covering clinician or service (pharmacy, DME, transport). A phone call is only as good as the action it triggers.

Make it stick: small process that wins trust

• Standardize timing: log a “Reached within 24h? yes/no” field. TCM allows two business days; aim for 24 hours because problems cluster early. 3
• Standardize content: use the 5-item checklist above (it mirrors the AHRQ Project RED call domains). 1
• Route fixes while you’re on the line: warm-transfer to pharmacy, book a ride, ping DME. Calls without action don’t move outcomes. This difference explains mixed trial results. 5

For system-level throughput effects of early post-acute action, see the economics overview in the hidden costs of bed delays, and how capacity-first referrals work in building a preferred SNF network.

What to measure (keep it humble and real)

• Reach rate: % of discharges reached within 24h (and within two business days).
• Near-term returns: 72-hour ED revisits for reached vs not reached. Look for a gap at 72 hours even if 30-day reads are noisy. 4
• Fix rate: among reached patients, % with a resolved issue (med obtained, ride booked, DME fixed) during the call.
• Equity check: reach rate by preferred language; pair calls with interpreter as needed.

How to talk about this with your teams

“This isn’t about calling more. It’s about calling smarter, once, with purpose. We will check meds for tonight, one teach-back, the next appointment and ride, two red-flags, and that the equipment works. If something’s missing, we fix it while they’re on the phone.”

How to talk about this with executives

• Policy-aligned: CMS TCM explicitly requires contact within two business days; we’re meeting the spirit by doing 24 hours for safety. 3
• Evidence-aware: Structured calls show meaningful reductions in early returns in several trials, and neutral results when content/timing are weak. We’ll implement the strong version and measure our own effect. 2