Care Management

A goal of Primary Care Specialists is to minimize delays and gaps in care during the transition between hospital inpatient (hospital) and outpatient (emergency room, observation) and PCMH care settings.  Our ability to adequately support patients during a transition of care (TOC) period should result in a reduction in hospital re-admissions and improve patient outcomes.

Patient care teams will facilitate safe, planned transitions in care for patients moving between hospital inpatient, emergency room, and the clinic.  PCS shall maintain a process for care coordination that will ensure timely and appropriate post hospitalization follow-up care.  Patient care team members will be required to use care coordination strategies to prevent gaps in care, errors in care, minimize readmissions, and engage the patient in self-care and self-management.

Patients Requiring Post Discharge Follow-up after hospitalization or ER Visit:  Patients will be identified from hospital site specific discharge lists daily.  The provider or care team designee shall contact identified patients by phone within 2 days post inpatient discharge or ER visit.  A follow-up appointment will be scheduled within 7-14 days of same. 

Medication Reconciliation:  The provider or care team designee will reconcile the patient’s most recent medication list to post-hospital discharge medication list.  It is the responsibility of the provider to ensure that medication discrepancies are communicated to the patient, utilize clinical judgement to determine which medications will be continued after hospitalization, and sufficiently document this information into the patient’s electronic medical record. 

Phone Messaging Procedure after Hospitalization or ER Visit:  All patients shall be contacted by phone within 2 days post inpatient discharge or ER visit.  Those patients who cannot be reached by phone will be sent a letter or email with follow-up recommendations.   The provider or care team designee will document in the medical record the date the letter was sent to the patient.

Patient Engagement and Self-Care Education Support:  Patients with chronic conditions shall receive focused instruction on recognizing signs and symptoms or worsening conditions with clear decision points and action plan on how to respond.

Patient Satisfaction Survey:  A patient satisfaction survey will be conducted on a quarterly basis.  The survey shall be made accessible to the patient at the clinic or via the clinic’s website at  The data will be gathered to determine how patients perceive the clinic’s operations.  Results will be used to drive improvements to better serve patient needs and expectations.

Referral:  When the needs of the patient are outside the scope of services provided by Primary Care Specialists, the provider or appropriate care team member shall be responsible for referring the patient to an appropriate healthcare facility/provider.  All referrals should be made during the patient’s visit at the clinic, but no later than 2 days post visit.  For referrals not made during patient date of service, a member of the care team or designee will make 3 attempts by phone to contact the patient regarding the time and date of the appointment with the referral source.  If unable to contact the patient via phone after 3 failed attempts, the care team member or designee will notify the referring provider and send a letter to the patient.

The provider or appropriate care team member must discuss and complete the referral process with the patient – gather pertinent information about the patient’s medical condition, reason for referral, the provider’s assessment and the request for treatment/services.   Each patient shall receive a copy of the referral form, which contains the contact information of the referral provider, facility or community resource.  Referral tracking regarding status thru completion is required for appointments made with both internal and external providers. 

The clinic shall establish and document agreements with providers, facilities, or community resources for any services rendered to PCS patients.  A copy of the consultation report, notes, or other documentation about the status or outcome of the referred service shall be recorded in each patient’s electronic medical record upon receipt.

Diagnostic Tests:  It shall be the policy of PCS that all diagnostic testing related to laboratory tests and diagnostic radiology be communicated to patients within specific timeframes by the provider, care team member, or other designee.  Results that come via mail will be date stamped and placed into the provider’s folder for review within 24 hours after receipt.  Patients will be able to access any test results via the patient portal. Patients will receive a phone call for clinically significant abnormal test results within 2 business days after provider review.  Three (3) attempts will be made over a 3 day period for abnormal test results.  If the patient does not respond to telephone calls, a certified return receipt letter will be sent to the patient.  Patients may access test results via the patient portal at