Meaningful follow-up for patients who have been hospitalized is an essential element of high-quality, comprehensive care. Not only does it reduce the likelihood of readmission, it saves lives. It has also been identified as a priority by AFHTO’s members and board. Transitions in care, including follow-up, are also a priority area for the 2019-20 QIPs. And it’s not as hard as you think!
Primary care teams can help patients get the right follow-up from the right provider at the right time. There are many different approaches to improving follow-up, but the following elements are essential:
The resources on this page will help you through these steps. Many of them are tools and strategies developed and used by your fellow AFHTO member teams. Some of them (like HRM) are works in progress. Some might not be a good match for your team. Hopefully, some of them will be just what you need to get started or make small but meaningful improvements. Every step gets us closer to the goal of better care after hospital discharge for everyone.
The tools listed below can help you get data from your hospital into your EMR. More information about all of them is available here to help you compare these tools.
Health Report Manager (HRM) lets primary care providers receive patient reports from participating hospitals and specialty clinics (such as cardiology and radiology services) electronically, right into your EMR. There are two kinds of information from HRM:
If your team has not signed up for HRM, contact email@example.com or your OntarioMD practice advisor to get connected. Not sure? OntarioMD has published a FAQ about HRM that provides a lot more detailed information.
We know (because you have told us) that HRM data is not always complete or timely. Not all hospitals use the same codes. You can use this list to see what reports your hospitals are sending. This will help you start conversations with them about what reports you’d like to see. This issue note contains conversation tips to get you started, depending on where your hospital is at.
Some providers in the South West LHIN use ClinicalConnect to download hospital discharge records and other health information into the EMR over the web. The difference is that HRM pushes information to your EMR automatically, but with ClinicalConnect, you have to pull the information by logging in to their portal. HRM will eventually replace ClinicalConnect’s EMR Download tool, although ClinicalConnect will remain available for other reports. If you’re currently using ClinicalConnect, you may want to consider enrolling in HRM to start automatically receiving HRM records and eNotifications now. Contact firstname.lastname@example.org or your OntarioMD practice advisor.
Most providers in the North East LHIN use Physician Office Integration (POI) to get hospital discharge and lab data. Hospitals in the North East are switching from POI to HRM in 2019, so teams will need to enroll in HRM to continue receiving discharge reports. Contact email@example.com or your OntarioMD practice advisor to enroll in HRM. You will need to remain with POI in the near term to continue receiving lab data.
Hospitals in the North West LHIN fax a 7-to-8-page document called a BATON to the primary care provider for each patient they discharge. The BATON – which stands for Better Admissions and Transitions in Ontario’s Northwest – is a discharge plan which includes information on the patient’s need for medication reconciliation, follow-up, CCAC/home support, or physiotherapy.
Hospitals use EHRs (Electronic Health Records) to chart patients electronically. Some primary care teams have been able to negotiate access to their hospital’s EHR in order to review their patients’ progress in hospital. Medical Information Technology, or Meditech, is one such EHR system that members have told us they’re able to use.
Patient-oriented discharge summaries (PODS) are a tool that helps make it easier for patients to understand, remember, and follow discharge instructions and to share this information with their primary care providers. They’re bright, colourful, and written in plain language. PODS were co-developed with patients and family caregivers by researchers at OpenLabs. Patients who receive a PODS on discharge will know to expect follow-up with their primary care provider or team, what questions they should ask, and what information they should share. Consider connecting with your local hospital to find out if they are using PODS. If so, ask them to send you some copies of their PODS for patient education. You can post them in your waiting room or hand them out to patients you know are going to hospital.
Some teams identify and flag patients in hospital. This is easiest when the primary care team is embedded with the hospital and/or clinicians from the team also work in the hospital. Teams who use HRM receive e-notifications when their patients are admitted. In some cases, a member of the primary care team attends discharge rounds, visits patients in hospital, or works with the hospital discharge planner to develop a follow-up plan.
You may not have the resources to follow up with every patient who is discharged from hospital. Doing some follow-up is better than doing none. There are validated tools out there that can help you identify which of your patients are most at risk for readmission to hospital or poor health outcomes, so you can direct your limited resources where they will be most effective.
Different teams use different approaches to triaging their patients. Some teams call every patient and triage them over the phone, then refer them to the appropriate provider for follow-up. Some of these teams combine this process with medication reconciliation or other follow-up processes. Other teams use their hospital discharge data to decide which patients will get a phone call and from whom. The hospital may have done a LACE or HOSPITAL triage at discharge and may send this information to the primary care team along with the discharge summary, or the primary care team may do this themselves.
This resource calculator can help you figure out how many staff and clinician hours your team will need to commit to follow-up. By tweaking your targets, you can find a level of commitment that’s a good starting place for your team. For example, you might target doing follow-up with a certain percentage of your patients who are discharged, or with those with certain conditions, such as COPD or CHF.
The right provider for follow-up is not always a physician or nurse practitioner.
Patients’ ongoing care needs may extend beyond the boundaries of your team. Consider working with other primary care providers, HealthLinks, home care, and hospitals to develop regional and system-level solutions to improve transitions in care. This slide deck outlines the process by which this is happening in the North East LHIN region.
We’re currently in the process of collecting stories from your peers about how they are doing follow-up. Watch this space for more information. In the meantime, check out these past conference and workshop presentations and stories from D2D:
In order to understand the impact of follow-up on patient outcomes and team workflow, and to demonstrate the value of primary care teams, it is important to track all follow-up activity by any provider via any modality. The MOHLTC uses billing data to count follow-up visits, but this includes only in-office appointments with a physician. This means that phone calls, emails, home visits, and visits with other providers are not counted.
This slide deck provides an overview of some of the tools you can use to track follow-up. There are many different options to choose from, depending on where your team is at with EMR use, which EMR you’re using, and how you do your follow-up. These include free text, special types, task lists, shadow billing, and custom forms. More details about these options can be found here. Atikokan FHT has developed a custom post-discharge form (TELUS) for IHPs. Some teams prefer to track outside of the EMR, using spreadsheets.