Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Medical Home - Follow-up Calls
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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)