As a requirement of the DHS Patient-Centered Medical Home (PCMH) program, patients admitted with an ambulatory sensitive condition must be seen by the primary care PCMH provider or specialist provider within seven days of discharge from the hospital. If the follow-up appointment takes place with a specialist, the specialist provider must share the patient’s follow-up visit notes with the primary care PCMH provider to meet this requirement.

This proactive approach contributes to reduced readmission rates, enhanced patient satisfaction with the care team and optimized health outcomes.

What’s Next?

• Review the below list of ambulatory sensitive conditions for which a post-discharge follow-up visit is required.
• Encourage your staff to schedule patients as soon as possible for post-hospitalization care appointments.
• Collaborate whenever possible with the primary care PCMH provider to effectively manage the patient’s ongoing plan of care.

Jefferson Health Plans appreciates your ongoing commitment to the care of your patients and our members. If you have any questions, please contact the Provider Services Helpline at 1-888-991-9023. We are available Monday through Friday from 9 a.m. to 4:30 p.m.