Tracking patients who visit the emergency room or need hospitalization represents an important challenge for medical practices. Because you want to ensure that your patients receive all necessary care, you want to offer follow-up services for emergent episodes. In addition, you want to learn whether ER or hospital visits could have been prevented by your intervention, patients’ self-care or patients’ awareness of appropriate ER use.
Family Care Southwest, a five-provider practice in Littleton, Colo., has developed a tracking system to identify and follow patients seen at emergent facilities outside the group’s affiliated hospital system. The two physicians and three physician assistants use a spreadsheet to record such visits and follow up with patients. The spreadsheet’s columns list the reason for the hospital visit; facility; emergency department date; admission date; discharge date; first, second and third follow-up calls; when a letter was mailed; appointment date, etc.
Helen Story, MD, one of Family Care Southwest’s physicians, says, “Open communication with hospitals, hospitalists and specialists we refer to is essential for high-quality patient care. The hospital has our patient data in their system, and we know whom to call for patients’ records. We try to have good working relationships with the information technology folks at all our referral facilities, and with insurance plans, so we receive notification when our patients go to the hospital or urgent care.” She notes that patients appreciate follow-up calls from her office when they are in the hospital and after they return home from the hospital or emergency room — “They like the connection with their primary care provider, and they feel cared about.
”The tracking system helps the practice stay on top of emergent episodes. “A tickler system lets us know to follow up with hospitals and specialists if we have not received a report from them within a week,” Story says. “We also use the system as a reminder for the provider or care coordinator to make follow-up calls to patients.”The practice asks nearly all patients to come in after hospitalization. “We want to let the patient know we provide quality care, review discharge medications and instructions with them and answer any questions they may have,” Story says. In addition, providers want to encourage patients not to use the emergency room to receive primary care.
“Like so many of our PCMH protocols, this effort relies heavily on the staff to maintain the tracking sheet, make the calls, gather the records, arrange the appointments, and have everything ready for the provider,” Story notes. “We encourage patients to bring a support person with them. Patients and families really appreciate the chance to sit down and understand the care they received during their stressful emergent encounter. We make it a point to discuss how to avoid future problems.
“All of us are happy that hospitals and insurance carriers are recognizing that primary-care follow-up is crucial to better outcomes. Systems are evolving: Some hospitals now notify us when one of our patients has been admitted, and most of the time the hospitalists call us when the patient is being discharged. The insurance carriers’ notifications have been a welcome addition, but many still incur some lag time. We look forward to the implementation of a statewide database for more thorough records access.”