ABSMC Follow-Up Appointment and Post Discharge Call Program

Posted on Oct 10, 2017 in Announcements | 0 comments

Alta Bates Summit Follow-Up Appointment and Post Discharge Call Program

We are pleased to announce that on September 20th (Summit) and 27th (Alta Bates) we implemented our follow-up appointment and post discharge call program. We have partnered with Sutter Physician Services (SPS) to provide the following to our inpatient discharges to home that are 18 years and older:

  • Schedule follow-up appointment(s) with PCP and other treating physicians prior to the patient’s discharge.
  • A phone call by an SPS nurse within the first 24-48 hours post discharge to address patients’ needs and care activities.
  • If an issue is identified, the nurse will follow-up with the physician and/or escalate the issue back to the Medical Center.
  • Physicians will receive documentation of the outreach encounter in their Sutter EHR in basket or via fax.

Physicians can help make this program a success!

  • Document the Anticipated Date of Discharge in your notes.
  • Communicate to Case Management if you identify an error in the PCP so they can correct it.
  • Recognize that “Follow-Up Provider” is where SPS looks for the Provider to make the appointment with and reads notes under instructions for that Provider.
  • Recognize that the Demographics section is where the patient phone number is identified.

You are a valued partner and we welcome your participation and feedback.  Please contact Dr. Ursi Boynton (BoyntoU@sutterhealth.org) or Leslie Costa (costal@sutterhealth.org) for any questions or issues.

Leslie Costa, RN, PhD, CWON
Director Clinical Program Support
Alta Bates Summit Medical Center
Phone: 510-869-6144
Fax: 510-869-6956

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