Issue: Follow-up of patients by primary care providers after hospital or ER department visits is a valuable way to improve patient outcomes. However, lack of access to data in primary care settings about hospital events makes it difficult to both measure and improve follow-up care. The available data is currently too old and excludes too many important concepts (ie follow-up by non-physicians, follow-up by phone etc) to be useful to support measurement and improvement by local primary care providers. Clinicians will receive a summary of emerging local solutions to measure follow-up as well as published evidence of the impact of follow-up on patient outcomes for the purposes of developing a consistent approach across the members of AFHTO and possibly beyond. Questions for clinical input 1) What do you think constitutes clinically helpful “follow-up” after hospitalization: appointment is set up? Phone consultation done by nurse? Other? 2) Which patients should be included in follow-up measure: discharged from a medical ward only? Patients NOT attended by family physician in hospital? Others?
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