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	James L. Holly, M.D.

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Medical Home - Follow-up Calls

This tutorial addresses one of the most complex issues of NCQA's Patient-Centered Medical Home requirements, which is follow-up calls being made to patients who have been seen in the clinic and in the hospital. This follow-up call template will allow our healthcare providers to determine that a patient needs to be contacted by telephone following a visit to the clinic. When we begin this process ALL patients discharged from the hospital will be contacted. A different template will be in place for use in the hospital setting.

The "Follow-up Call" template will allow our providers to:

determine that a patient they are seeing needs a follow-up call
designate why the patient needs a follow-up call
designate the timing of that call, i.e., one day, three days, ten days, or any other time which would be appropriate.
receive a response from the nurse who will do the follow-up call as to how the patient is doing and/or any unresolved issues which need attention.
give a patient a stat appointment if the patient is worsening.

Furthermore, all of our hospitalized patients will receive a follow-up call the day after their discharge with inquires being made about:

Do you have your follow-up appointments? With primary care? With Specialist
Did you get your medications filled?
Do you know what to take?
Are you feeling better? The Same? Worse?
If you have any new or worsening problems please call (primary care physician)

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