🏥 Hospital & Emergency Department Follow-Up

To establish a standardized process for following up with patients after hospitalization or an Emergency Department visit to promote continuity of care, reduce readmissions, improve patient outcomes, and ensure timely provider follow-up.

Purpose

Transitions of care are high-risk periods for patients. Timely follow-up after a hospital discharge or Emergency Department visit helps identify medication concerns, reinforce discharge instructions, coordinate additional care, and ensure patients receive appropriate follow-up with their primary care provider.

Policy

The Neighborhood Clinic will make reasonable efforts to contact patients following notification of a hospitalization or Emergency Department visit, review discharge information, identify outstanding care needs, and coordinate timely follow-up with the patient's provider.

Transition of Care Workflow

1️⃣ Receive Notification
2️⃣ Review Hospital Records
3️⃣ Contact Patient
4️⃣ Schedule Follow-Up Visit
5️⃣ Notify Provider
6️⃣ Complete Documentation

Situations Requiring Follow-Up

Hospital Admissions

  • Inpatient hospitalization.
  • Observation stays.
  • Behavioral health admissions.
  • Surgical admissions.
  • Skilled nursing discharge when applicable.

Emergency Department Visits

  • Emergency Department discharge.
  • Urgent care visits requiring PCP follow-up.
  • Trauma evaluations.
  • Chest pain evaluations.
  • High-risk acute illnesses.

High-Risk Patients

  • Multiple chronic conditions.
  • Recent medication changes.
  • Frequent hospital utilization.
  • Behavioral health concerns.
  • Provider-identified high-risk patients.

Medical Assistant Responsibilities

  • Review available discharge documentation.
  • Attempt timely patient outreach.
  • Verify medications and allergies when appropriate.
  • Schedule follow-up appointments according to provider recommendations.
  • Notify the provider of significant concerns.
  • Document all patient communication.
  • Coordinate referrals, imaging, or laboratory testing as directed.

Best Practice

Whenever possible, contact patients within two business days of receiving notification of discharge and schedule follow-up appointments according to provider recommendations and clinical urgency.

Immediate Provider Notification

  • Patient reports worsening symptoms.
  • Medication discrepancies are identified.
  • Patient did not obtain prescribed medications.
  • Patient cannot follow discharge instructions safely.
  • New urgent symptoms develop.
  • The patient declines recommended follow-up care.

Patient Outreach Process

Following notification of a hospital discharge or Emergency Department visit, clinic staff should make timely outreach to assess the patient's condition, reinforce discharge instructions, and coordinate follow-up care.

1️⃣ Verify Patient Identity
2️⃣ Review Discharge Summary
3️⃣ Assess Patient Status
4️⃣ Review Medications
5️⃣ Schedule Follow-Up
6️⃣ Document Completion
Communication Standard

Whenever possible, patients should be contacted within two business days after notification of discharge. If the patient cannot be reached, all communication attempts should be documented and continued according to clinic policy.

Follow-Up Assessment

During the follow-up conversation, staff should assess the patient's understanding of the discharge plan and identify any barriers to recovery.

  • Confirm the patient understands why they were hospitalized or treated.
  • Review current symptoms and overall condition.
  • Verify prescriptions have been obtained.
  • Confirm medications are being taken as directed.
  • Determine whether follow-up testing or referrals have been scheduled.
  • Identify transportation, financial, or social barriers affecting care.
  • Answer administrative questions within your scope of practice.

Best Practice

Encourage patients to bring all discharge paperwork, medication bottles, and any questions to their follow-up appointment to help ensure an accurate medication reconciliation and care plan review.

Unable to Reach the Patient

If the patient cannot be contacted after discharge, staff should continue outreach efforts while documenting every attempt.

  • Call all available phone numbers listed in the medical record.
  • Leave a voicemail only if permitted by the patient's communication preferences.
  • Send a secure RXNT Patient Portal message when appropriate.
  • Document each contact attempt with the date, time, and method used.
  • Notify the provider if outreach is unsuccessful.
  • Follow provider instructions regarding additional outreach efforts.

Escalate Immediately If:

  • The patient reports worsening symptoms.
  • The patient develops new concerning symptoms.
  • The patient cannot obtain prescribed medications.
  • The patient reports confusion about discharge instructions.
  • The patient refuses recommended follow-up care.
  • The provider determines emergency evaluation is necessary.

Documentation Requirements

  • Date notification of discharge was received.
  • Date and time of each outreach attempt.
  • Method of communication (phone, portal, etc.).
  • Summary of the patient's current condition.
  • Medication reconciliation completed or pending.
  • Discharge instructions reviewed.
  • Follow-up appointment scheduled.
  • Provider notified of significant findings.
  • Additional referrals or services arranged.
  • Final disposition documented in RXNT.
Documentation should clearly demonstrate continuity of care from hospital discharge through completion of the patient's primary care follow-up.

Quality Assurance

Medical Assistant

  • Initiate timely patient outreach.
  • Review discharge information.
  • Document all communication.
  • Coordinate follow-up appointments.
  • Escalate clinical concerns promptly.

Provider

  • Review hospital records.
  • Complete medication reconciliation.
  • Address outstanding medical concerns.
  • Update the care plan.
  • Coordinate additional specialty care as needed.

Leadership

  • Monitor timely completion of transition-of-care outreach.
  • Audit documentation for compliance.
  • Review readmission trends.
  • Provide staff education regarding continuity of care.

Hospital & Emergency Department Follow-Up Checklist

✅ Receive notification of hospitalization or Emergency Department visit
✅ Review discharge documentation
✅ Verify patient identity
✅ Contact the patient within two business days when possible
✅ Assess current condition and review discharge instructions
✅ Verify medications and identify barriers to care
✅ Schedule provider follow-up appointment
✅ Notify the provider of any concerns
✅ Document all outreach attempts and patient communication in RXNT
✅ Complete all transition-of-care documentation

Sawubona Standard

The patient's care does not end when they leave the hospital or Emergency Department. Every transition represents an opportunity to reinforce trust, identify potential complications, and support recovery. Through timely outreach, compassionate communication, and coordinated follow-up, The Neighborhood Clinic ensures that every patient experiences a seamless transition back to primary care while receiving the personalized attention that defines the Sawubona philosophy.