Fig. 2

Overview of qualitative results. Full names of the themes: Facilitator 1 (F1): Patients are grateful for or willing to receive follow-up from providers. F2: Nurses have experiences and skills for assessing symptoms including pain symptoms. F3: Good coordination within clinical teams for post-discharge patient care including symptom assessment. F4: EHR system and templates for follow-up call. F5: Follow-up calls are supported by the CMS or institutional policies. Barrier 1 (B1): Symptom assessment has been part of current provider-initiated follow-up phone calls but the impact has been limited by factors such as competing priorities, coverage, and timing. B2: Providers and patients have difficulty reaching each other. B3: Concerns about pain medication misuse (pain specific). B4: Sub-optimal coordination across clinical teams for post-discharge patient care. B5: No standardized pain assessment and triage protocol for follow-up calls (pain specific). B6: Lack of emphasis on follow-up call reimbursement among cardiology clinics. Patients’ pain burden: Patients’ disease burden related to post-discharge pain symptoms