Transitions of Care – Hospital and ED Follow Up Toolkit

Toolkit Sections

• Transitions of Care in Azara
• Policy Recommendations
• Documentation and Follow-Up Recommendations
• Sample Script
• Regulatory and Compliance References

Data in Azara

The Great Plains Health Data Network collaborates with statewide health information exchanges (HIE), including South Dakota Health Link and the North Dakota Health Information Network (ND HIN) to bring admission, transfer, and discharge (ADT) data into Azara.  

This integration allows health centers to: 

• Have real-time access to ADT data on your patients  

• Improve care coordination by following up on inpatient and ER discharges 

• Increase hospital follow-up visits and ensure patients are brought back into the primary care setting  

• Measure the number of follow-up visits scheduled and completed after hospitalizations 

• Track the hospital readmission rate for health center patients 

Which patients are included? 

Patients seen during the last 3 years are included in the roster file that is sent to the HIE. This includes patients with visits for medical services and those who receive dental, behavioral health, or other ancillary services. 

If a patient included in the roster file has an ADT from an inpatient facility or emergency department, the information is sent to Azara. 

Data in Azara can be filtered to only include primary care patients or patients seen in the last 12 months, 18 months, or two years.  

Where can I find this information in Azara? 

• PVP: Inpatient and ED discharges are displayed on the PVP. This information includes inpatient and ED discharges with alert details (date, facility, and discharge type). Alerts help front-desk and clinical teams identify recently discharged patients at the point of care. 

• Dashboards: Transitions of Care (ED) and Transitions of Care (I/P) dashboards display key transitions of care metrics, including total number of episodes, trends, readmission rates, follow-up appointments scheduled and completed. 

• Measures: The transitions of care measure set allows you to see the percentage of patients discharged from inpatient and ED settings who have received phone call follow-up, scheduled an appointment, and completed an appointment.  

• Reports: Transitions of Care (TOC) – ED/IP report is processed nightly using HIE data to flag patients with recent ED discharges or IP admissions. It supports timely action such as follow-up calls after ED visits, care planning, and proactive outreach before hospital discharge. The report includes key details such as diagnosis, admit/discharge dates, facility, discharge codes, recent visit history, 30-day readmission indicators, and patient demographics, along with EHR data like provider and next appointment, helping care teams coordinate medication reconciliation, follow-up, and support to reduce readmissions and improve outcomes. 

What ADT information is included in Azara? 

• Patient identifiers – name, date of birth, and MRN to match the ADT record with the EHR patient roster. 

• Facility information – hospital or ED name, location, and facility type (inpatient vs. emergency). 

• Event details – admission date/time, discharge date/time, discharge disposition, and encounter type (e.g., inpatient, ED, observation). 

• Diagnosis data – primary and secondary discharge diagnoses (ICD-10 codes) to help identify follow-up priorities. 

• Readmission flags – indicate if a patient has been readmitted within 30 days of a prior discharge. 

• Follow-up metrics – shows whether a follow-up call, appointment scheduling, or completed visit occurred, allowing health centers to track adherence to transitions-of-care standards. 

• Provider and care team assignment – links the event to the attributed PCP or care manager in Azara for outreach responsibility. 

Azara Training – Transitions of Care  

DRVS TOC Lunch and Learn 

TOC Combined Report: ED and Inpatient

Policy Recommendations

Health centers are encouraged to establish consistent workflows for identifying, documenting, and following up with patients discharged from hospital or ED settings. 

The Clinical Advisory Committee recommends that health centers follow up with primary care patients who have been seen in the last 18 months as a starting point. This can be expanded to 2-3 years based on the health center’s capacity. 

Health center hospital and ER follow-up policies and procedures should include, at a minimum: 

• Notification: Describe how the health center will be notified of patients who are admitted and discharged from the hospital or ER. 

• • Example: The health center utilizes the Transitions of Care report in Azara to identify patient admissions, discharges and transfers.  

• Roles and Responsibilities: The health center has identified staff members, by title, who are responsible for receiving and monitoring ED and hospital admission information. 

• Records: The health center has established a consistent process to obtain patient discharge summaries, document them in the patient chart, and ensure they are reviewed by the primary care team to close the loop and ensure continuity of care.  

• Patient Contact and Follow -Up: The health center identifies a process to contact patients after discharge and documents follow up in the chart, including timeliness of follow up. Health centers should define internal expectations for the timeliness of follow-up based on clinical risk and capacity and should routinely monitor follow-up success and barriers as part of ongoing quality efforts.  

Sample Policy 

Purpose: To ensure timely and coordinated follow-up care for patients discharged from hospitals or emergency departments. This policy supports safe transitions of care, reduces preventable readmissions, ensures compliance with applicable payer and program requirements and aligns with expectations for risk management, continuity of care, and quality improvement.  

Policy Statement: [Health Center] monitors and follows up on hospital and emergency department discharges to ensure patients receive timely, high-quality, and coordinated care.  

[Health Center] utilizes [HIE / Azara DRVS / EHR] to monitor primary care patient admissions, discharges, and transfers (ADT). [Health Center] maintains a tracking system that includes, at minimum includes but not limited to:  

• Patient name and identifier 

• Date of admission or ED visit 

• Date of notification 

• Reason for visit (if known) 

• Documentation received or requested (with request and receipt dates) 

• Date follow-up was initiated and by whom 

 

 [Health Center] obtains discharge summaries and other relevant records and follows up with patients via portal message, text, or phone call to assess recovery, review medications, and determine the need for a follow-up appointment or additional services. 

[Health Center Job Title(s)] are responsible for reviewing the list of emergency department and inpatient discharges, initiating outreach, documenting all contact and follow-up efforts and monitoring the tracking system for completeness.  

Patients will be contacted within two to five business days after discharge, unless a follow-up visit is already scheduled. Follow-up appointments are typically scheduled within seven (7) to fourteen (14) days or sooner as clinically appropriate. 

All contact attempts, communications, and receipt of discharge information are documented in the patient’s health record with follow up activities monitored through the [Health Center]  QI/QA program.

Documentation and Follow-Up

Relevant Records and Documentation: 

Documentation of hospital and emergency department follow-up should include: 

• Discharge Information: Hospital or ED discharge summaries and transition of care reports (TOC ED/IP Report, TOC Scorecard). 

• Medication Reconciliation: Verification of discharge medications and updates to the patient’s medication list. 

• Assessment of Needs: Review of support service needs, care barriers, and need for community or home health referrals. 

• Red-Flag Symptoms: Education provided to the patient on warning signs or symptoms that indicate their condition may be worsening, with clear instructions on when and where to seek care. 

• Follow-Up Actions: Documentation of outreach, contact method, summary of discussion, and scheduled or completed follow-up appointments in the EHR. 

Staff Responsible: 

• Care Coordinators / RN Care Managers review reports daily and initiate patient outreach. 

• Providers and Nursing Teams review discharge summaries, reconcile medications, and ensure follow-up care is scheduled. 

• Quality/Data Staff monitor timeliness and completeness of documentation. 

Definition of Timely Follow-Up:
Timely follow-up is defined as patient contact completed within two (2) to five (5) business days after discharge, based on payer and program requirements. Follow-up appointments are typically scheduled within seven (7) to fourteen (14) days or sooner as clinically appropriate. 

Criteria for Follow-Up: 

• All primary care patients seen within the last 18 months  

• Prioritize those with elevated risk scores, multiple ED visits, or complex conditions (CHF, COPD, diabetes, behavioral health crises). 

• Align your follow-up intensity with payer requirements or value-based contracts (e.g., Medicaid Health Home or Blue Alliance programs). 

Risk Stratification: 

• Not every discharged patient requires the same level of follow-up. Health centers should use risk stratification, a structured way to identify which patients are at highest risk for complications, readmissions, or gaps in care, and tailor outreach accordingly. 

• Use Azara’s Patient Risk and Discharge Status filters to prioritize outreach. 

Risk Stratified Follow Up: 

• High-risk patients: Phone call or face-to-face care coordination with provider, RN, LPN (within scope) within 48 hours. 

• Patients with multiple chronic conditions (e.g., diabetes, COPD, CHF). 

• Recent readmissions (within the last 30 days.) 

• Elderly or frail adults (age 65+ or with functional limitations). 

• Patients with high Azara risk scores or flagged as “high risk” in the TOC dashboards. 

• Patients with behavioral health comorbidities (e.g., depression, substance use disorder). 

• Discharges with complex medication changes or polypharmacy (≥5 active meds). 

• Individuals with unmet social needs (SDOH) such as lack of transportation, housing instability, or limited health literacy. 

• Patients without a designated PCP or those not seen in primary care within the past year. 

• Moderate-risk patients: Scheduled PCP or telehealth visit within 7–14 days. These patients may benefit from a nurse or MA outreach call and a primary care visit within a week of discharge. Examples include: 

• Stable chronic disease patients with one hospitalization or ED visit. 

• Patients with manageable SDOH barriers (e.g., transportation or insurance lapses). 

• Patients discharged for short-term, non-complex conditions (e.g., infections, dehydration). 

• Low-risk patients: These patients can be contacted via text message, patient portal, or automated reminder to ensure they understand discharge instructions. Examples include:  

• Patients with single, resolved acute episodes (e.g., minor injury, uncomplicated UTI). 

• Patients with a recently completed visit and no chronic conditions or medication changes. 

Sample Workflows: 

Transitions of Care Azara Playbook 

Billing and Documentation Resource: 

See page 26 in the NACHC Medicare Reimbursement Resources for FQHCs for the Transition Care Management Billing Guide. 

 

Sample Telephone Scripts 

The following scripts are intended to provide a starting point for outreach to patients who have been discharged from the emergency room or hospital. Three script examples are available – for medical assistants, nurses and front desk staff.  

Medical Assistant (MA) Script – Initial Outreach  

• Purpose: Verify discharge, schedule follow-up visit, identify basic barriers.  

• Scope: May assess logistics and basic social needs but does not perform clinical triage or medication reconciliation.  

Script:  

“Hello, this is [Your Name] calling from [Health Center Name]. I’m following up because we noticed you were recently seen at [Hospital/ER name]. I just wanted to check in and make sure you’re feeling okay and help schedule your follow-up visit with your primary care provider.”  

Ask the following:  

“Were you admitted overnight or seen in the emergency room?”  

“Do you have your discharge paperwork or summary available?”  

“Have you been able to pick up and start any new medications?”  

“Do you have any concerns about getting to your follow-up appointment — such as transportation, cost, or needing someone to help you?”  

“Let’s find a time that works for you to see your provider. We like to see patients within a week after discharge.”  

Close the call:  

“Thank you for your time today. If you notice any new or worsening symptoms before your appointment, please contact our clinic right away or go to the emergency department if needed.”  

Notify RN or Provider If:  

Patient reports worsening symptoms, uncontrolled pain, or confusion about discharge instructions.  

Patient reports not having or not taking medications.  

Patient appears confused, short of breath, or unstable on the phone.  

Patient reports readmission risk factors (e.g., can’t afford meds, no transportation, no support at home). 
Create or update the TOC task in the EHR and forward to RN or provider for clinical follow-up.  

Registered Nurse (RN) Script – Clinical Follow-Up  

• Purpose: Assess post-discharge status, perform medication reconciliation, and identify red flags. 

• Scope: Clinical triage and coordination within nursing practice. RN may escalate to provider for medical decision-making.  

Script:  

“Hi [Patient Name], this is [Your Name], a nurse from [Health Center Name]. I’m calling to check in since I see you were discharged from [Hospital/ER name] on [Date]. How are you feeling today?”  

Key questions:  

“What symptoms are you still having, if any?”  

“Were you given new medications or instructions at the hospital?”  

“Can we review your medication list together?” (verify against EHR)  

“Have you been able to get your prescriptions filled and started them?”  

“Do you understand how and when to take them?”  

“Do you have support at home — someone to help if needed?”  

“Are you able to get to your follow-up appointment?”  

“Is there anything new or concerning since you got home?”  

Schedule or confirm follow-up appointment:  

“I’d like to schedule (or confirm) a follow-up visit with your provider, ideally within 7 days. We can also connect you with our pharmacy or care team if you have medication or equipment questions.”  

Closing:  

“Thank you for taking the time to talk with me. If you experience any worsening symptoms, such as chest pain, trouble breathing, high fever, or severe weakness—please seek immediate care or call 911. Otherwise, we’ll see you at your upcoming appointment.”  

Notify Provider If:  

• Patient reports new or worsening symptoms (fever, chest pain, breathing difficulty, confusion).  

• Medication discrepancies: duplicates, unclear instructions, adverse effects, or missing prescriptions.  

• Hospital readmission risk factors: unstable vitals, multiple admissions, unsafe home situation.  

• Document findings in TOC note, update medication list, and route note to provider for review.  

Front Desk / Patient Access Staff Script – Scheduling Support  

• Purpose: Confirm patient contact, schedule follow-up, and identify logistical barriers.  

• Scope: Administrative only, does not assess symptoms or medications.  

Script:  

“Hello, this is [Your Name] from [Health Center Name]. I’m calling to schedule your follow-up visit after your recent hospital or ER visit. We like to make sure you see your provider within 7 days of being discharged.”  

Ask:  

“How are you doing since you got home?” (pause briefly, then redirect if patient begins to describe symptoms)  

“I’m sorry to hear that, I’ll make sure one of our nurses gives you a call about that. Let’s get your appointment scheduled first.”  

“Do you have transportation to get to your appointment?”   

“Let’s find a time that works best for you.”  

Closing:  

“You’re all set for [Date/Time] with [Provider]. If anything changes or you feel worse before then, please contact us or seek care right away. Thank you for choosing [Health Center Name].”  

Notify RN or Provider If:  

• Patient reports not feeling well or worsening symptoms.  

• Patient reports no access to medications or uncertainty about discharge instructions.  

• Route message or task to RN for clinical follow-up. 

Regulatory and Compliance References

HRSA Program Requirements – Chapter 8: Continuity of Care and Hospital Admitting 

• The health center has internal operating procedures and, if applicable, related provisions in its formal arrangements with non-health center provider(s) or entity(ies) that address the following areas for patients who are hospitalized as inpatients or who visit a hospital’s emergency department (ED):2 

• Receipt and recording of medical information related to the hospital or ED visit, such as discharge follow-up instructions and laboratory, radiology, or other results; and 

• Follow-up actions by health center staff, when appropriate. 

 

PCMH Standards and Guidelines – Competency C: Coordinating Care with Health Care Facilities 

• CC 14 (Core): Identifying Unplanned Hospital and ED Visits 

• The practice has a process for monitoring unplanned admissions and ED visits, including their frequency.  

• CC 16 (Core): Post-Hospital/ED Visit Follow-Up 

• The practice contacts patients to evaluate their status after discharge from an ED or hospital, and to make a follow-up appointment, if appropriate. The practice’s policies define the appropriate contact period and systematic documentation of follow-up.  

• Note: All discharged patients should be contacted, although not every patient may require a follow-up in the primary care practice. 

• Evidence: evidence of contacting patients following a hospital admission or ED visit 

Regulatory and Compliance Resource
See the PCMH Standards and Guidelines from the National Committee for Quality Assurance (NCQA)

 

FTCA Deeming Application Tracking Policies 

• The health center has a tracking and monitoring system for receiving information regarding hospital or ED admissions. At a minimum, the tracking system must include: 

• Patient information 

• Date of admission or visit 

• Date of notification 

• Reason for visit, if known 

• Documentation received 

• Documentation requested, including date requested 

• Follow-up initiated with hospital or patient (includes date initiated). 

• The health center has identified staff members, by title, who are responsible for receiving ED and hospital admission information and monitoring the mechanism that is utilized for receiving hospital and ED admission information. 

• The health center has implemented a mechanism for following up with the patient, provider or outside facility to request pertinent medical information (e.g. diagnostic studies, discharge summary) related to a hospital or ED visit. 

• The policy has been signed and approved by the Governing Board, the individual or the committee that the Governing Board has delegated review and approval authority. If delegation of authority has occurred, there should be a clear delegation of authority statement within the policy. 

Regulatory and Compliance Resource
Read the Federal Tort Claims Act Health Center Policy Manual provided by HRSA.

 

Blue Alliance 

Blue Alliance tracks several quality measures related to Hospital/ED follow up, including: 

• Post-Discharge Follow Up Visits 

• The percentage of attributed members with a visit to a qualified place of service with any qualified provider where qualified services was rendered within 30 days after an acute care hospitalization discharge, excluding deliveries and surgeries which tend to have follow up visits covered under global billing arrangements. 

• Potentially Preventable Admissions (PPA) 

• Potentially preventable admissions are facility admissions that may have resulted from lack of adequate access to care or care coordination. They are ambulatory sensitive conditions for which adequate patient monitoring and follow-up can often avoid the need for admission. 

• Potentially Preventable ER Visits (PPV) such as upper respiratory infections, abdominal pain, ear pain, migraines, or minor injuries.  

• Nationally the reliance on hospital emergency rooms continues to soar even though many of these visits can be prevented with timely access to primary care. 

• Potentially Preventable Readmissions (PPR) 

• Reducing hospital readmissions represents an opportunity to lower health care costs, improve quality, and increase patient satisfaction all at once. Primary Care providers can partner to create the ideal care transition through improved care coordination. 

SD Medicaid Health Home 

The Medicaid Health Home program has established quality care requirements that include “coordinate and provide access to comprehensive care management, care coordination and transitional care across settings.” 

Health centers are paid a per member per month payment to deliver core services – including care management, care coordination, health promotion, comprehensive transition care, individual and family support and referrals to community and social support services.  

The SD Health Home Program Policy Manual indicates that health home providers should: 

• Contact the patient within 5 business days from discharge from the hospital or emergency department; 
• Providing post-discharge contact with recipient/caregiver to ensure discharge orders are understood and action taken;
• Coordinating with the recipient/caregivers and providers to ensure smooth transitions to new settings; and
• Ensuring a follow-up visit with the primary care provider. 

Contact Us

Becky Wahl
Director of Innovation & Health Informatics
becky@communityhealthcare.net

Lindsey Karlson
Director of Programs & Training
lindsey@communityhealthcare.net

Jennifer Saueressig, RN
Clinical Quality Manager
jennifer@communityhealthcare.net

The Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) provided financial support for this publication. The award provided 100% of total costs and totaled $705,000. The contents are those of the author. They may not reflect the policies of HRSA, HHS, or the U.S. Government.