Measurement and Quality Improvement

A better way to track follow-up after hospitalization

Primary care providers know the importance of following up with their patients after hospitalization. They also know the importance of tracking how well they are doing with that. Read on for a description of a better measure of how the entire team provides follow-up after hospitalization.

Definition of the new indicator for follow-up after hospitalization:

The new indicator is defined as % of those discharges (any condition) where timely (within 48 hours) notification was received, for which follow-up was done (by any mode, any clinician) within 7 days of discharge.

Note that this is a different definition from the Ministry of Health and Long-Term Care (MOHLTC) indicator available on the Health Data Branch (HDB) portal. Based on the input from AFHTO members, this new definition includes follow up by ANY member of the team by ANY method (e.g., phone or in-person visit).

Why is a new definition needed?

The definition above is a better reflection of how follow-up actually happens in primary care teams.  In-person visits with physicians are not required for many patients after they are discharged from hospital, especially if it was their own physician who just discharged them. However, many patients DO receive follow-up by a pharmacist to make sure all of their medications are in order or by a social worker to make sure they are adjusting to being home. Teams do this because it is what their patients want and need. It is also more efficient, freeing up physician appointment time. Unfortunately, as teams get increasingly good at this patient-centered, efficient approach to follow-up, their performance on the current MOHLTC indicator (which is based only on physician billing data) will paradoxically look worse. This is why a new definition is needed.

We already track follow-up in a way that works for our team. Why should we change?

Just as follow-up is important to primary care providers, it is important to MOHLTC as a measure of the quality of transitions in the healthcare system. Transitions are such an important focus that MOHLTC will continue to use whatever measures are available. The current measure has the advantage of being readily available for all primary care providers (i.e., not just AFHTO members). This is a non-negotiable characteristic for any system-level measure. MOHLTC does, however, recognize that the current measure may paradoxically indicate that transitions are getting worse as primary care providers become increasingly efficient at team-based care, with less physicians and more Interprofessional Health Providers (IHPs) providing follow-up care.

Data to Decisions (D2D) 2.0 illustrated that AFHTO members have developed many creative solutions for tracking follow-up in a meaningful way. These solutions undoubtedly are useful in ensuring good quality transitions within the team. However, it is not possible to make a strong argument for system change on the basis of a collection of different strategies in use at small numbers of teams. When AFHTO members can propose a consistent, unified approach, it is easier for system-level decision-makers to respond to our needs. AFHTO members can help themselves and the system by adopting the following consistent approach to measuring follow-up. This would help in the efforts to reframe, expand or even retire the current measure in favour of one that better reflects what does, could and should happen in team-based primary care.

Why track follow-up if teams don’t get hospitalization data?

Tracking follow-up after hospitalization requires 2 bits of data: date of discharge from hospital, and date of follow-up by primary care provider. It is necessary for primary care providers to become proficient at tracking patient encounters with all members of the team in all modes (e.g., phone, in person), no matter what the state of hospital data-sharing is. In fact, better data about how much your team interacts with your patients in all ways is important data beyond follow up after hospitalization. For example, it is a good way to demonstrate the amount of care your team provides. It can also support arguments to reconsider the historic requirement that physicians can only bill in-person visits.  Both of these also require consistent approaches to measurement.

What is the evidence that follow-up even really makes a difference?

Recent analysis is showing that follow-up by a primary care physician within 7 days of discharge from hospital is associated with 68 fewer readmissions per 1000 patients. Follow links for more details:

Who came up with the new definition? Were members and clinicians involved?

Learnings from D2D 2.0 Exploratory indicator: 7-Day Follow up, along with feedback received from Clinical consultations for Strategic D2D indicators, were used to create a proposed indicator definition.

This definition was subsequently recommended by the Indicator Working Group (IWG) to be included in the membership wide vote on D2D 4.0. The indicator definition was endorsed by a membership-wide vote, in which more than 240 members from at least 75 teams participated.

Why just phone encounters?

Actually, it is important to track all encounters with patients. However, most EMRs are good at tracking in-person encounters, at least through the scheduling system. The gap remains in tracking discussions with patients that are not scheduled, in-person visits. Hence, our focus on improving our collective ability to consistently track phone encounters. Eventually, email encounters may also be considered; for now, the focus is on phone encounters as an easier place to start.

But what about the hospitalization data?

AFHTO continues to work with external partners including OntarioMD, local hospitals as well as the Ontario Hospital Association, eHealth Ontario, and LHINs to improve the flow of data from hospitals to primary care.

In the meantime, teams are continuing their local efforts to get as much information as quickly as possible from their local hospitals. Teams can make progress in tracking all patient encounters with any provider (including phone) in a consistent way. This is important not only because the information is useful in itself but also to demonstrate to our external partners our commitment to a better solution and thus help expedite changes in their systems.