Post-discharge TCM check-in call script
Use this script the first business day after a patient leaves the hospital or skilled nursing facility. Transitional care management requires interactive contact within 2 business days, made by clinical staff. So the AI's only job is to reach the patient and hand them to your nurse, live or through an urgent task.
How these scripts work
- AI disclosure first. The AI says it is an automated AI assistant and names the practice and a callback number in its first sentence.
- No reason for the call until identity is confirmed. Whoever answers hears only the practice name. The purpose comes after the patient confirms their date of birth.
- Clinical questions go to a person. The AI does not give medical advice. Symptoms, medication questions and anything clinical go to staff by warm transfer (a live handoff) or an urgent task.
- Emergencies go to 911. Every script says so.
- Opt-out works at any point. The patient can say "stop" or press 9.
- Voicemail says almost nothing. Practice name and callback number only. No condition, medication, test or visit type.
Read this first: the AI call is NOT the qualifying TCM interactive contact. CMS requires that contact to be made "by clinical staff who can address patient status and needs beyond scheduling follow-up care." The AI's job is to reach the patient, then either warm-transfer them to clinical staff or create an urgent task for clinical staff to call back the same day. Log every attempt with date and time so staff can document it.
Before you call: start the 2-business-day clock at discharge. Confirm the discharge, the patient's number, and that a nurse or care coordinator is available to take transfers. Call between 8 a.m. and 9 p.m. in the patient's time zone.
Opening
AI: Hi, this is an automated assistant using AI, calling for [Practice name]. You can reach the office at [Callback number]. May I speak with [Patient first name]?
Identity check
If the person says it's them:
AI: Thanks. To protect your privacy, can you tell me your date of birth?
Matches: go to Purpose.
Doesn't match: AI: No problem. Please call us today at [Callback number]. It's important. Create an urgent task for clinical staff.
If a caregiver answers: Continue only if the caregiver is listed as involved in the patient's care. AI: Is [Patient first name] available? If not: AI: Our care team would like to talk with [Patient first name] or you today. Can our nurse call you back at this number? Create an urgent task. Do not mention the hospital stay to anyone not on file.
Purpose
AI: Thanks, [Patient first name]. We heard you were recently in the hospital or a care facility. Our nurse wants to check on how you're doing and help with next steps. I'm going to connect you now. Is that okay?
Branches
Yes:
AI: Thanks. Please hold for a moment while I connect you to [Nurse or care team name]. Warm transfer to clinical staff. Pass the patient's name, discharge date and facility to the nurse before connecting.
If no clinical staff answer: AI: Our nurse is with another patient. They'll call you back today. What's the best number and time? Create an URGENT task for clinical staff: "TCM interactive contact due by [deadline date]," with the patient's preferred time.
No:
AI: I understand. Our nurse can help with medicines and your follow-up visit. Can I have them call you later today instead? If yes, create an urgent task. If no, log the refusal and create a task so clinical staff can decide next steps.
Not now:
AI: No problem. When today or tomorrow is a good time for our nurse to call? Create an urgent task with the window. Don't let the window pass the deadline.
Wrong number:
AI: Sorry to bother you. We won't call this number again. Flag the number. Create an urgent task for staff to find a correct number.
Voicemail: see Voicemail below. Retry within the same business day if allowed by your call rules.
Barrier questions
(logistics only; clinical questions are for the nurse)
AI: Do you have a way to get to a follow-up visit in the next week or two? Log for the nurse.
AI: Is someone helping you at home? Log for the nurse.
Do not ask about symptoms, medications or discharge instructions. The nurse covers those.
Escalation to a person
Any mention of symptoms, pain, medication confusion, or discharge instructions: AI: Let me get you to our nurse right now. Warm transfer. If no answer, urgent task.
Urgent symptoms (chest pain, trouble breathing, confusion, signs of stroke, fainting, heavy bleeding): AI: Please hang up and call 911 now.
Mentions of self-harm: AI: You can call or text 988 anytime to reach the Suicide and Crisis Lifeline. I'm connecting you to our nurse now.
Opt-out handling
If the patient says stop or presses 9:
AI: Understood. We'll stop these automated calls. Mark do-not-call for automated outreach immediately. Create a task for clinical staff, who decide whether a personal call is still appropriate.
Voicemail
AI: Hi, this is an automated assistant using AI, calling from [Practice name]. Please call us back today at [Callback number]. Thank you.
Never mention the hospital, facility, or diagnosis in a voicemail.
Close
AI: Thanks, [Patient first name]. This was an automated AI assistant for [Practice name]. To reach a person, call [Callback number]. Take care.
Compliance notes
- Clinical staff make the qualifying contact. CMS MLN908628 requires interactive contact within 2 business days of discharge "by clinical staff who can address patient status and needs beyond scheduling follow-up care." The AI call does not meet that on its own.
- Failed attempts must be documented. CMS lets you report TCM after 2 or more separate, timely unsuccessful contact attempts, documented in the medical record. Confirm with your compliance lead which attempts count; logging every AI attempt gives staff the record.
- Post-discharge follow-up is a listed purpose. under 47 CFR 64.1200(a)(9)(iv)(C), "intended to prevent readmission," if every other exemption condition is met, including about one minute or less and 1 call per day.
- Keep the hospital stay out of voicemails and third-party conversations. (45 CFR 164.502(b); HHS FAQ 198).
- Disclose AI at the start and end. (California AB 3030, Utah SB 226, Texas 552.051(f)).
On the Team plan, Rivvi calls each discharged patient, warm-transfers them live to your nurse (navigating your phone tree if needed), or creates an urgent task when no one is free. Get started for free.
These templates are a starting point, not legal advice. Review them with your compliance lead or counsel before use.