One health system. Four lessons.

What calling every patient discharged home taught a multi-hospital system about capacity, patient experience, escalation design, and whether its own discharge processes were reaching patients. Everyone in the system agreed post-discharge calls were best practice. The obstacle was capacity. For four years, in partnership with PRC, the system has reached every inpatient discharged home, in multiple languages, with no new hiring. Before partnering with PRC, calls happened at the unit level only when staffing permitted, during a period when staffing rarely permitted. Nurses were out sick, teams were turning over, and coverage differed from one unit to the next. Leadership knew the approach was not working and that something had to change.