Medical Home requirement for follow-up calls

For the three clinically important conditions, the physician and non-physician staff use the following components of care management support:

1. Conducting pre-visit planning with clinician reminders.
2. Writing individualized care plans
3. Writing individualized treatment goals.
4. Assessing patient progress toward goals.
5. Reviewing medication lists with patients.
6. Reviewing self-monitoring results and incorporating them into the medical record at each visit.
7. Assessing barriers when patients have not met treatment goals.
8. Assessing barriers when patients have not filled, refilled or taken prescribed medications.
9. Following up when patient have not kept important appointments
10. Reviewing longitudinal representation of patient’s historical or targeted clinical measurements.
11. Completing after-visit follow-up.

    Scoring – 100% -- 74% or more of patients seen in the past 3 months have at least
    4 items documented.

    (SETMA judges that calling all or even 75% of the patients seen in the clinic on a daily basis would provide no significant benefit to the quality or continuity of care which our patients receive.  However, calling all patients who are discharged from the hospital does have great potential value. And, calling selected patients, identified by the provider who saw them, for a follow-up call at an interval determined by the provider, will have great value.)

PPC-3 D 11 is one of the most difficult data points in the total of NCQA’s 183 total data points. Elsewhere, we have or will discuss PPC-3 D data points 1-3, and 7-9 identified above.

We have just completed the design of a method for fulfilling PPC-3 D data point 11 – “Completing after-visit follow-up.” SETMA has expanded PPC-D Data Point 11 to include ALL

In June, 2009,the Physician Consortium for Performance Improvement, which in part includes the ABIM Foundation, American College of Physicians, Society of Hospital Medicine and the AMA Physician Consortium, published “Care Transitions:  Performance Measurement Set entitled Phase I:  Inpatient Discharges and Emergency Department Discharges.” SETMA is presently deploying the elements of the Care Transitions data set in our hospital plan of care. While a follow-up call from SETMA to the hospital discharges is not a part of the Care Transitions data sets, it soon should be.

Selecting Clinic Patients for receiving follow-up calls from a nurse

Go to the GP Master Plan Template.

In column three, you will find seven buttons:

1. Superbill – this is no longer used, but allows you to review your association of ICD-9 Codes and CPT Codes submitted for this patient encounter.  Unless you simply want to review what your billing looks like, it is unnecessary to ever use this function.
2. Plan Summary – this aggregates all of your plan for this visit and allows you to quickly review your plan of care for this visit at a future visit.
3. Rx Sheet – this allows you to create and to print a copy of the patients active medications.
4. Help Desk – This explains Preventive Visits for commercial insurance carriers and how to use a 25 modifier with Medicare patients.
5. Clinic Follow-up Call – this is the new function which is explained below
6. Hospital Follow-up Call – this is the new function which will be used when a patient is seen in the ER or when they are discharged from an in-patient hospital stay.
7. Chart note – this allows you to create a note of the current encounter.

When you click on the “Clinic Follow-up Call” button, you will launch the following template.

Across the top, you will find the following functions:

1. Telephone Numbers to call – these will be auto-posted to this template from the patient’s demographic information.
2. Send Delayed-E-mail to Follow-up Nurse – the following details how to do this successfully

Details for using the “Delayed-E-mail to Follow-up Nurse”

• Launch the function by clicking on this button
• Select “this template” from the options given and check the box next to “this template.”
• Click OK
• Click on the “To” button on the e-mail which was launched
• Select the Follow-up Nurse

Before this e-mail is sent, you must decide when you want the patient to be called, you do this by:

• Clicking on “Options” in the tool bar across the top of the screen which is displaying the e-mail
  
• Click on the “Do Not Deliver before” box (which is six boxes from the top)
  
• When you click on “do not deliver before,” today’s date will appear in the first box.
  
• To the right of the box with today’s date, there is an arrow, clink on that arrow.
  
• A monthly calendar will appear
  
• Click on the date corresponding to the number of days you wish to delay the call from the date of the present visit, i.e., if today is the 14th and you wish to have the patient called in 10 days, you will click on the 24th. (Be sure to note that calls will not be made on Saturday or Sunday so adjust your call recommendations accordingly.) Also, remember, the default time is 5:00 PM, so if you want the e-mail delivered at 6:00 AM, you will need to change the time as well as the date.
  
• Once you have selected a date, click the “close” button.  You can now send the e-mail.  It will be delivered on the date you have selected.

The Clinic Follow-up Call template is divided into three columns each of which has six functions.  Column I gives the nurse performing the follow-up call a quick review of six elements of the patient’s previous clinic encounter without going from template to template. Column I displays:

1. The date of the visit for which this call is being made
2. The date of the next visit to SETMA
3. The Chief Complaints documented during the visit for which this call is being made.
4. The Acute Assessments for the visit for which this call is being made.
5. The patient’s diet
6. The patient’s exercise

Across the bottom of the three columns, the following are displayed:

1. The date and time of three attempts to call the patient. If after the third attempt, the call is not completed, a letter will be sent to the patient, asking them to call us.

   A letter will be fashioned from the data and questions on the Follow-up call template. This letter will be automatically created; it will become a part of the patient’s record and a copy will be mailed to the patient.

2. New referrals created during the visit for which the call is being made
3. New medications and/or medication changes or renewals made during the visit for which the call is being made.

Column 2 contains 6 functions which allow the provider to select options for which the patient is to be called.

1. General – these questions address the current condition of the patient and how that compares with how the patient felt during their recent visit.

   One of the questions relates to changes in the patient’s condition.  If the answer is that a change has taken place and option appears which allows the follow-up nurse to document the change which has taken place. The nurse can then include this in a follow-up note to the provider.

2. Medications – these questions address the medications prescribed for the patient
   
3. Appointments – this will pull from your referrals all appointments made during your last visit with the patient.
   
4. Click to document completion – this button for use by the nurse making the follow-up call to denote completion of the call.
   
5. Click to send response – this button is for use by the nurse making the follow-up call to notify the provider of the completion of the call and to note any issues which require attention by the provider.  This will go to the provider’s work flow.
   
6. To whom the follow-up nurse spoke.

Column 3 contains opportunities for the follow-up caller to document the patient’s responses to the follow-up call.  The 6 functions in this column will be blank unless or until the provider checks the box in column 2 which gives the follow-up caller instructions for the content of the call.

1. Patient responses for General Questions
   
2. Patient Responses for Medication Questions
   
3. Patient Responses for Referral and appointment questions
   
4. Box for typed in questions or information
   
5. Several Options for documenting actions taken particularly for giving the patient a “stat” appointment if they are not doing well.
6. New Medications, reviewed medication or changed medications from previous visit.

Discharges From the Hospital (In-patient or ER)

It is our intent to place a call to all patients discharged from the hospital whether discharged from inpatient status or from the ER.  In fact, as we begin utilizing the Care Transition data set of the Physician Consortium,  we will document all ER visits in the EMR, and complete a Hospital- Follow-up-Call template for each of the patients seen in the ER.  This will be discussed with our hospital service team.

The Hospital-Follow-up-Call template can be launched from the Hospital Discharge Master Template.

• You will find the button entitled “Hospital Follow-up Call” in the third column at the bottom of the Master Discharge Summary screen.
  
• You will also find the Hospital Follow-up Call Template on the Master GP Plan Template under the Clinic Follow-up Call button in the third column.  This will allow the Hospital Follow-up Call template to be used for those patients seen in the ER.

The Hospital Follow-up Call template works exactly like the Clinic Follow-up Call except that the first column has different information.  It displays:

• Admission Date
  
• Discharge Date
  
• When Patient is instructed to be followed up in the clinic
  
• Provider with whom the patient is to follow-up
  
• Hospice
  
• Home Health
  
• Discharge Diagnoses
  
• Diet
  
• Exercise

All other functions work the same, except in the second column there is a heading entitled Appointments.  This information is pulled from the follow-up instructions given in the Discharge Summary. It allows the follow-up nurse to remind the patient by whom and when they are to be seen.