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A key to preventing readmissions? Follow-up appointments

Teams are collaborating throughout Asante to standardize the process for follow-up scheduling.


A 77-year-old woman was hospitalized with acute heart failure and atrial fibrillation. She was treated and discharged home. With her chronic conditions, what were the chances she would have been readmitted to the hospital?

Without a follow-up appointment, the chances were nearly 100%. Instead, this real patient was seen by an outpatient cardiac care team within days. Doctors were able to evaluate her condition and schedule a cardioversion to stabilize her a-fib, preventing another hospital stay.

The importance of follow-up appointments can’t be overstated, and that begins with clear communication at discharge and timely outpatient scheduling. A recent assessment of Asante readmission data revealed that not all patients have a follow-up appointment scheduled, and that the processes to schedule follow-up appointments varied between facilities.

As part of a system-level collaboration, Epic, inpatient and ambulatory teams have been developing a standardized process for scheduling follow-up appointments with a focus on discharges to our APP primary care and cardiovascular teams.

The goals are to:

  • Improve efficiency by reducing the number of calls, clicks, Halo messaging and faxes.
  • Ensure patients have a clear understanding of their scheduled follow-up appointment.
  • Identify roles and responsibilities in the follow-up appointment scheduling process.
  • Standardize the follow-up appointment process throughout Asante.
 How the process works

On discharge, Asante clinicians and support staff will schedule a follow-up visit to the patient’s primary care or specialty provider per provider order. Appointments where the patient is to be seen within seven days post-discharge are scheduled by hospital staff. If no timeframe is specified, the visit should take place within five to seven days of discharge.

Nursing staff are responsible to review and ensure follow-up provider appointments are scheduled or communicate with the patient and family (using the teach-back method) that an appointment must be scheduled. Follow-up appointments should be accurately included on the after-visit summary.

The unit clerk, technician or CNA is responsible to schedule follow-up appointments as directed by the nurse, or according to job role or unit workflow. In the absence of support staff, the nurse is responsible to schedule the follow-up appointment or confirm that a plan is in place and noted on the AVS.

Introducing Epic features

New to the follow-up appointment scheduling procedure is the use of Epic One Click. One Click appointments allow the user to identify the provider and schedule the follow-up appointment without calling the office. One Click scheduling is used for follow-up appointments with APP primary care clinics and transitional care units. Hospital staff enters appointment details and ensures the details show up on the AVS.

If One Click is not available or there are no available appointments:

  • Staff calls clinic using telephone messaging.
  • At ARRMC, Halo may be used with some clinics to communicate the need for an appointment to be scheduled per department workflows. This is only a notification for the clinic to schedule. APP clinics commit to a 30-minute response time in the event a scheduling related Halo is sent. Halo should not be used during non-business hours or holidays and this method is not available at ATRMC. The appointment will show up on the AVS if scheduled before AVS is printed.

For non-APP follow-up appointments, staff should call the outside clinic to make an appointment. Appointment information is entered in the follow-up navigator section before the AVS is printed. On weekends and holidays, staff should call the provider’s office the next day or clearly communicate the need for the patient to set up their own follow-up appointment.

Use of One Click and the follow-up appointment procedure is under continuous review to help optimize workflow for hospital staff, APP clinics and patients.

Thank you to our pilot units: ATRMC Ortho Neuro (the original!), ARRMC Heart Center, AACH Medical Surgical Unit and APP clinics. One Click training for additional patient units will take place in December. Your feedback will be helpful to optimize any workflows, so please reach out with questions!

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