Care Setting Transitions and the Primary Care Home

In October 2013, the Institute hosted a webinar featuring Stacy Moritz, Director of Medicare Quality Services at Acumentra Health, on Care Setting Transitions and the Primary Care Home. When participants were asked what their clinics do to get patients into the office within a few days after discharge, responses included the following:

 I run a daily report through our EMR that lists all the hospitalized patients, I watch for their discharge, call patients within two days of discharge, review with patient or caregiver their medications and get them scheduled for follow up within 14 days or 7 days (dependent on acuity).

 We have a care coordination team that receives hospital and ER discharge summaries and contacts patients within two days.

 We schedule same day appointments.

 We have a risk adjusted report of all discharged patients, and our care managers screen and follow up.

 We have designated same day appointments that can be used for transitions of care or other urgent appointment needs.

 Our MA’s call and talk to the patients.

 We encourage patients to communicate with us via MyChart. We have same day appointments to get patients in. If we know a patient is in the hospital, we can access patient records through CareEverywhere to monitor patient status. A nurse on the patient's team will then call the patient within 72 hours of discharge to check on status and answer questions on meds.

 Discharge summaries are directed to our Triage nurse who communicates with the PCP regarding best next steps and timing of phone call to patient with invitation to visit clinic.

 We call the patient within 48 hours if I get the report in time and offer the soonest appointment available with PCP or on call - many times I give them the same day appointment when available. Depending on the acuity of situation I may ask PCP to double book or extend their schedules the same day.

 We have a care coordinator and advice nurses who call the patient within three business days.

 We have an arrangement with the local hospital to call our care manager with any ED or hospital discharge that requires follow up within 3-4 days. She then follows up to connect this patient with the right resource in the time frame needed.