ER
According to CMS guidelines, how many days do we have to schedule the patient for a follow-up after an ER visit?
7 days.
According to CMS guidelines, how many days do we have to schedule a patient for a follow-up after an IP stay?
30 days after discharge.
A "holding tank" in Co-Op that is used to capture ALL ADT events per patient.
What is a TOC Blob?
How many days post-discharge do we have to obtain and upload the discharge summary?
2 days.
What are the two ways we aim to engage with patients after an inpatient stay?
1. You OR a person in your clinic calls the patient to check-in, the call is documented in the EMR and Co-Op.
2. The patient comes in for a visit- this is the best practice but isn't required
What do you do if a patient is still hospitalized?
Snooze the task for a later date.
How would you disposition an ER task created for a patient for whom an ER visit did not occur?
Cancel the task with "created in error."
What happens if the patient already has an appointment in the next 30 days?
Only a discharge summary task will populate in Co-op.
A patient is discharged to an SNF (skilled nursing facility). What option would you choose for this blob?
What is "snooze."
What should happen after an ER visit if the patient is not scheduled for a follow-up appointment (bare minimum)?
A phone call with the patient from either the navigator or clinical staff is documented in the EMR to follow up for the ER visit.
What are the four steps to outreach for a patient discharged to LTC (not SNF or Hospice)?
1. Try to call the patient at the facility.
2. If you can't reach the patient, try a nurse.
3. Ask the nurse if the patient has been seen by a provider since the discharge and if so, when.
4. Disposition task accordingly. Example: if seen by a provider, disposition with "yes, visit already occurred" with the date given by the LTC nurse.
When a patient expires in the facility or is in hospice.
This is rare- occasionally a blob will incorrectly or prematurely close as an ER Chronis Task when it should be an Inpatient Follow-Up. If while working the ER Chronis Patient Engagement task, you discover this is the case what do you do?
2. Submit a Help Desk ticket and CC: your MM
What would you select if a patient is in a long term care facility that isn't SNF or IPR?
Create the hospital visit and select "Home/Permanent Residence" as the Discharge Location
What happens to a blob for a patient who is readmitted to IP within 30 days of discharge?
Co-Op will auto-close that blob and all related tasks, and once obtained, a new blob will populate based on the new ADT information.