Through this exploratory indicator, teams were asked to report the percentage of patients for whom timely (within 48 hours) discharge notification was received who were subsequently followed up within 7 days of discharge via any mode, by any clinician. Teams shared stories about how they are approaching follow-up after hospitalization and how they track their progress with that. It is clear there is still a wide range of approaches to both providing and tracking follow-up after hospitalization.
Finding out who was hospitalized?
- Teams used a variety of automatic and manual approaches to find out who was hospitalized and who required follow-up, including discharge notifications and using information from sources such as EMRs, hospital databases, HRM and other portals.
- Integration with local hospitals was a significant enabler, either by physicians with hospital privileges rounding on and discharging patients, bringing team members to the bedside to assist with transition from hospital to home, access to hospital databases, or co-location between hospitals and teams.
Who is followed-up?
- The majority of teams reported follow-up after hospitalization for all patients. However, some discussed approaches to follow-up that focused primarily on complex patients, high system users or specific Case Mix Groups (CMGs).
How were patients followed-up?
- Primarily by appointment or telephone. In some instances, depending on the nature of the hospitalization or if being follow-up by a specialist, an appointment was not required.
- Time frame for follow-up was anywhere from 24 hours to 14 days.
- Some teams considered the patient’s needs post-hospitalization, such as reducing unnecessary travel or stress, to determine the best method of follow-up, such as in-person appointment, phone call, or home visit.
Who does follow-up?
- Team-based approaches utilizing physicians, nurses, medical office staff and pharmacists were common, with the latter being particularly focused on medication reconciliation post-discharge.
How is follow-up tracked?
- Follow-up appointments were primarily tracked using EMRs (standardized forms, stamps, Encounter Assistant, fake billing code) and Excel spreadsheets.
| Providing follow-up after hospitalization | |
| What makes it easy? | What makes it difficult? |
| Access to hospital, including hospital privileges, having staff in hospital or access to hospital records | Lack of timely discharge reports |
| Signing up for Hospital Report Manager (automated feed of hospital information to EMR). | Paper-based reporting |
| Proximity to the hospital, such as co-located teams and hospitals. | Lack of human resources available to support follow-up after hospitalization. |
| Participating in pilot projects with their local hospital or Health Links. | |
| Use of EMRs, to identify patients requiring follow-up, prompt a provider to follow-up, or to identify when follow-up has occurred. | |
Click the image below to download an interactive graph of follow-up after hospitalization. This will allow you to hover over the individual bars and see the stories that each team provided about how they tracked follow-up after hospitalization. NOTE: This will not work in all web browsers; if you cannot see the stories, download (save) the PDF and open it in a PDF viewer, such as the Adobe Acrobat Viewer for full functionality. If you have any problems please contact improve@afhto.ca.. 
To access all of these stories in a PDF, click here.
Leave a Reply