PI: Hospitalization

Goal: Increase the percentage of hospitalized clients who follow up with medical and/or psychiatry within seven days of discharge

Why are we worried about follow-up visits? When our clients are discharged from a hospital stay, they are often exhausted, disoriented and don’t have a safe, stable environment to return to. That can make taking medications and following other post-discharge instructions extremely difficult to follow. We want to make sure our clients are making the appropriate follow-up appointments to ensure that they continue on paths toward stability and wellness.

What are we doing to reach this goal? We are using CRISP (Chesapeake Regional Information System for our Patients), a regional health information exchange to track our clients who have recently been discharged from an inpatient hospital stay. Our scheduling department receives a daily list and attempts to call to schedule follow-up appointments. They have had greater success in getting patients scheduled for follow-up when they call prior to discharge.

What's next? We have been running a pilot with Mercy Medical Center, and are working on building better relationship with area hospitals so that we might be able to get discharge information uploaded directly into our electronic health records (EHR) system. Staff can support this effort by updating client demographic and contact information in the EHR.