In this session, St. Luke's will walk attendees through how they identified this system-wide breakdown and built a centralized, technology‑enabled outreach model without adding large numbers of staff. By partnering across patient experience, care management, physician leadership, and hospital operations, they created a coordinated process led by a small team of specialized nurses one that has already produced incredible six‑month results in reducing readmissions and improving follow‑up appointment adherence. This impact is underpinned by St. Luke's broader commitment to excellence, recently recognized by Premier as the #1 health system in the country for quality and safety based on patient outcomes data. 

• The Problem : how fragmented outreach, duplicative calls, and lack of shared documentation created risk and patient frustration. 
• The Model : the blend of people + technology that now ensures every patient receives coordinated, meaningful follow‑up. 
• The Impact : early data showing improvements in readmissions, appointment completion, and patient perception ("St. Luke's actually does care about me"). 
• The Playbook : practical steps any organization can take to replicate this approach, including governance, workflow design, and cross‑department alignment.