VA Policy on Post-Hospital Follow Up

Step 1: Determine if the patient needs post-hospital follow up, and how soon. Most patients should have a post-hospital follow up, generally within five to 10 days of discharge.

• This needs to be discussed with, and determined by, the attending at the time of discharge.
  
  

Step 2:  If patient needs a post-hospital follow up, who should it be with?

• PMD  — Only when ALL the three criteria listed below are met:
  • There is an identified PMD in CPRS who has written a primary care note for the patient in the last 6 months.
  • PMD has an opening in his/her schedule within a reasonable time frame.
  • There is a verbal discussion with PMD of patient’s hospitalization course. If you cannot reach the PMD via pager or phone, notify the chief resident & schedule the patient’s post-hospital follow up with yourself in Foxtrot (see below).
• Subspecialty clinic — When BOTH criteria listed below are met:
  • The reason for follow up is related to subspecialty issues (example: dialysis patient to f/u with renal, COPD pt to f/u with pulm, etc.).
  • There is a verbal discussion with fellow on service, who agrees that it is appropriate for patient to be seen in their clinic.
• Resident’s VA continuity clinic
  • Only if you have someone on your team who has continuity clinic at the VA.
  • It is encouraged that you then maintain a continuity relationship with that patient, unless they clearly already have a PMD.
• Post-hospital Follow Up Clinic (Foxtrot)
  • For any patient who cannot be followed up by any of the above options.
  • For any patient whose PMD you could not reach to discuss the details of the patient’s hospitalization.
  • Set this up through GUI mail:
    
    • In CPRS, click on “Tools” -> GUI Mail –> “Create”
      
      • To -> Recipient = G.Post.  -> “Post-Hospital F/U PC”.  Remove your name.
      • Subject = PHFU or Post-Hospital Follow Up
      • Text = List patient’s FULL NAME, FULL SSN, FULL DOB.  Then write:  Please schedule (patient/SSN/DOB) in PHFU in FOXTROT clinic on (date/time desired).  Appts usually start at 1:30 pm, every 30 minutes.
  • Needs to be staffed by administrative attending in Foxtrot clinic.
  • If the patient does not have a PMD, place a “Primary Care Consult”
    
    

Reminder:  Do not schedule post-hospital follow up for a patient with a physician who does not know the patient.