SFHN Primary Care Post-Discharge Phone Call Protocol

Script of procedures to follow for Post-Discharge phone interview with patient

The presentation walks through the steps to get to 2 lists:

  1. a daily ZSFG admissions (census list) list, and
  2. a separate list of discharges from previous 45 days. Both can be sorted by PCC 

(Note that the same LCR screens  are part of the Post-Discharge Phone Call Protocol pdf slide set Appendix A1  

These LCR lists have only admissions and discharge information, not ED and UCC information.  They do let proactive care coordinators go into LCR each day, sort the lists by PCC,  and "pull" the data about any of their clinic's patients.  We don't know which, if any, of the SFCCC clinics are routinely doing this. Our future DTR will be a "push" tool that brings inpatient admit/ discharges to care coordinators' notice more easily, and also integrates ED and UCC visit data. )

The presentation also steps through protocols for entering notes in eCW. However, SFCCC Clinicians do not normally have this level of access and will not be able to follow this procedure.

PRDOC update function in LCR to keep PCP/PCC assignment and contact information
Note: PRDOC contact email can be a either the PCP’s own email, or a dedicated clinic email that can be checked by any team member assigned to care coordination functions as well as by the PCP (if so desired). HR360 sites have adopted this method and could be a resource for learning more about this approach. Examples of their contact emails are PCC558@healthright360.org, PCC1735@healthright360.org.

  • Note: At this time, PRDOC allows for only one contact email to be entered. The new Care Transitions Orderset (see Number 1 below in “Upcoming Tools and Training” section) is designed to allow multiple contact emails for notification of inpatient admissions.

eReferral Training 1: Referring Provider

eReferral Training 2: Scheduler

eReferral Training 3: Specialist Reviewer