HFA Process
Patients with a risk score of 5 and above followed by an SMG hospitalist get scheduled with what resource?
What is Care Connection?
Patients often follow up with this provider after being discharged.
What is a primary care provider?
This is the main goal of a hospital follow-up appointment.
What is to ensure safety and improve patient outcomes?
Most follow-ups should occur within this timeframe after discharge.
What is within 7 days of discharge.
Patients should be instructed to bring this to follow-up visits.
What is After Visit Summary?
The patients who have a PCP get scheduled with who?
What is their PCP?
Heart failure patients commonly follow up with this specialty.
What is cardiology?
Follow-up appointments help reduce this common hospital quality metric.
What are hospital readmissions?
High-risk patients may need to follow up within these many days.
What is within 3–4 days?
Teach patients to call their PCP if they experience these after discharge.
What are worsening symptoms?
Patients with a risk score of 4 and below who have a smart device and are followed by a SMG hospitalist get scheduled with what resource?
What is the Virtual Access Care team?
Patients with an SMG PCP are scheduled using what Epic tool.
What is One-Click?
Patients discharged without follow-up are at higher risk for this.
What is readmission back to our hospital?
This type of appointment is often scheduled before discharge.
What is a primary care visit?
This method confirms patient understanding of follow-up appointments scheduled.
What is teach-back?
Patients with a risk score of 1-4 who are followed by a Surgeon get scheduled with what resource?
What is the surgery team as a post-op appointment?
If One-Click does not have any appointments, you can schedule with an alternate provider using what Epic tool.
What is Book-it?
Follow-ups allow providers to review this after discharge.
What is the After Visit Summary?
Weekend or holiday discharges require extra attention to this.
What is to schedule in advance before the holidays?
Transportation issues are an example of this type of barrier.
What are social determinants of health?
Patients who have no insurance get scheduled with what resource
What is the ACC?
Virtual follow-ups using technology are called this.
What is telehealth?
This care approach focuses on continuity after discharge.
What is transitional care?
Delayed follow-up can increase the risk of this outcome.
What is readmission or ER return?
Written and verbal instructions help reduce this patient's issue.
What is confusion?