Exploratory Indicator – 7 Day follow-up

7-Day Follow-Up Follow-up in primary care after hospitalization is an important goal of primary care.  However, the current definition of the indicator, as presented in the Health Data Branch (HDB) report, is not useful to AFHTO members.  A few of the issues with the definition are:

• Excludes follow-up by anyone other than the physician; therefore it violates a principle of team-based care
• Excludes follow-up by any method other than office visit; therefore it is not consistent with best practice re: patient centeredness and access via email, phone and/or house calls
• A persistent lack of real-time hospital data prevents health teams from measuring & improving follow-up
• Fails to exclude patients managed in hospital by their primary care physician (and therefore may not need seven-day follow-up once discharged)

AFHTO members remain committed to measuring and improving follow-up, and have, in fact, made considerable progress on this at the team level.  7-day follow-up is presented here as an exploratory indicator to facilitate knowledge transfer and exchange, with the goal of informing a more appropriate definition of this indicator for subsequent iterations of D2D. This indicator was populated only by teams who are already tracking 7-day follow-up in a formal way, at the time of data submission to D2D 2.0.  Teams submitted the most recent data available for this indicator based on the definition or process in place in their team.  Each team also included a brief commentary about the definition, the range of patients included, and the process used for tracking follow-up.  Many teams also provided the rate of follow-up, as defined by HDB, to illustrate the gap between the existing definition and current team-level processes. The range of values is quite wide, as is the variety of approaches to doing, and documenting follow-up.  The quantitative and qualitative data are intended to be interpreted together to develop a more relevant and meaningful version of this indicator for use in subsequent iterations of D2D. Click here to download the PDF version of the Exploratory Indicator for 7-Day Follow-Up graph. This will allow you to hover over the graph and see the stories that each team provided. If you have any problems with the PDF please contact improve@afhto.ca. Click here to download a PDF of all stories submitted by teams.