PPC-3 Care Management

Element D Care Management for Important Conditions

• Data Point 11 Completing after-visit follow-up

Clinic Visit Follow-up Call Tutorial

This tutorial addresses one of the most complex issues of NCQA’s Patient-Centered Medical Home requirements, which is follow-up calls being made to patients who have been seen in the clinic and in the hospital.  This follow-up call template will allow our healthcare providers to determine that a patient needs to be contacted by telephone following a visit to the clinic.  When we begin this process ALL patients discharged from the hospital will be contacted.  A different template will be in place for use in the hospital setting.  The “Follow-up Call” template will allow our providers to:

• determine that a patient they are seeing needs a follow-up call
• designate why the patient needs a follow-up call
• designate the timing of that call, i.e., one day, three days, ten days, or any other time which would be appropriate.
• receive a response from the nurse who will do the follow-up call as to how the patient is doing and/or any unresolved issues which need attention.
• give a patient a stat appointment if the patient is worsening.

Furthermore, all of our hospitalized patients will receive a follow-up call the day after their discharge with inquires being made about:

• Do you have your follow-up appointments?  With primary care? With Specialist
• Did you get your medications filled?
• Do you know what to take?
• Are you feeling better?  The Same?  Worse?
• If you have any new or worsening problems please call (primary care physician)

As you can see the template displays all of the information which is needed in order for the follow-up-call nurse to make an informed call. This includes:

• Date of last visit
• Date of next visit
• Acute Assessment of last visit
• New Medications prescribed or old medications renewed at the most recent visit
• Referrals made at the most recent visit
• Diet the patient is to be following
• Exercise program recommended to patient

The template allows for the provider to designate when the patient should be called and to denote why the call should be made.  The template allows for the follow-up-call nurse to document the patient or care-giver’s responses to the questions asked.  The nurse can then send a note to the provider detailing the patient’s responses.   The nurse can also schedule a stat visit if the patient’s condition has deteriorated.

In our clinic, it would take 8 new full-time nurses to call ALL patients who are seen each day.  That would add a cost of over $450,000+ to our annual payroll and the benefit would be marginal.  However, with two or three follow-up nurses patients whose healthcare would benefit from a call can be contacted thus fulfilling the intent of the NCQA requirement and we believe improving the quality of care which we are providing our patients.