Template:Harbor follow up

Follow-up

Follow up in CCC

• The CCC is for patients who do not have insurance and are not assigned to a provider in the County system (unempaneled), and needed a Primary Care Provider to manage uncontrolled chronic disease (Asthma, CHF, Cancer, CVA, ESRD, CF, DM, HIV/AIDS, IBD, Heart Dz, HL, Neuromuscular dz, Psych d/o, CKD, RA, Sz d/o, Substance abuse d/o, Specified debilitating conditions),
• Or need a non-urgent >2 week e-consult referral to a subspecialist. For specialist follow-up within two weeks, call the subspecialty service directly. CCC does not provide long term follow-up for patients, except by helping them get empaneled if they are eligible.
• Only for patients being discharged home (Cannot use for patients sent to Obs/CORE/Psych ED/Admitted).
• Lab / Symptom / Wound follow up: Be specific re: f/u time frame or clinical judgement will be used.
• CCC hours: Mon-Fri 8a-430p, no abnormal lab result review after hours or on weekends
• If you have any questions, you can contact Lidia Asato through Message Center, ext 8117, she is here during business hours Mon-Fri.

Please note:

1. Be very careful about your messaging to the patient. They are going to receive a phone call in a few business days. Do not write that they will be contacted or seen within 1-2 days, as CCC needs a little more flexibility than that. Lidia Asato from the PED is the main RN on this. Trust me, she is very diligent and thorough, your patients will not fall through the cracks. Some patients become angry when the CCC ends up just being a phone call symptom check vs face to face. If you think the patient really needs a face to face, tell them to go to Urgent Care.
2. Just like when we filled out the MLK referral form, patients who are being referred for elective cholecystectomy or hernia repair need a BMI in the chart. This determines which service will perform the surgery. I know we don't always weigh our patients, but you can ask and manually put in the weight. Ideally for these patients, the CCC staff can just put in the eConsult without having to bring the patient back for an in-person appointment and having all the relevant information easily at hand in the chart.
3. Please don't use CCC to obtain stress testing. Keep in mind that the CCC needs at least 2 business days to complete an action. If you want a stress test, please order it and have the clerk book an appointment.
4. For the patients being sent to CCC for e-consult, Lidia Asato (former Ped ED nurse) and Dr. Chiquita Flowers submit the e-consult within 72-96 hours. The responses from specialty clinics are also usually quick (for the most part). The biggest rate limiting factor is the Appointment Service Center (ASC) contacting the patient and scheduling the appointment. If you look in ‘Notes’ and then sort by ‘performed by’ and look under Lidia Asato or Dr. Chiquita Flowers, you can quickly see their notes of the status of the e-consult. If you find that the e-consult was already approved, feel free to give the patient the e-consult ID number, and the number to the ASC (855 521 1718) so that they can call for scheduling. CCC does not schedule the actual appointment, ASC does.
5. Please finish your provider note in a timely fashion so that the CCC staff know how to direct the patient's follow up care. If you don’t, yours and my Message Centers will have requests from CCC to do so, and I’ll contact you directly.
6. If the patient is already removed from the tracking list, and you want them on the follow up track, you have to go through a couple extra steps to put them on the follow up track.
   1. Highlight your patient on the “HAR Look Up” track
   2. Click ‘Modify Event’ on the toolbar.
   3. Then, manually request the BOTH:
   4. ‘Post Visit PVCC’ for adult patients or ‘Post Visit Peds’ for peds patients,
   5. AND ALSO manually request ‘Post Visit Follow Up’ event to put the patient on the follow up track.

Jen Chen, Dir AAED, Mar 29, 2015 / M. Peterson, Dir of OPs, Jun 1, 2015 / A. Wu, Dir AAED Oct 27, 2016