A1 · Post-acute transitional care
Post-discharge community paramedicine visits, coordinated from the hospital
Coordinate post-discharge community paramedicine home visits from any SMART on FHIR chart or a web form, track status to completion, and report outcomes for RHT and payer sponsors.
Mission template A1 · Post-discharge follow-up (generic)
On scene- Received09:12
Referral raised by hospital cm, Any inpatient discharge flagged by case management; LACE or HOSPITAL score.
- Scheduled10:04
A program covering the address accepts inside the window: 24–72 hours post-discharge.
- En route13:06
Crew departs; the patient receives an arrival window by SMS.
- On scene14:11
Vitals; Medication reconciliation; Red-flag review.
- Completed14:40
Outcome fields recorded (Visit completed Y/N; Medications reconciled); referrer notified.
Why this program
The days immediately after discharge carry the highest risk of an avoidable return. Medication errors, unfilled prescriptions, missed appointments and unsafe home conditions are common, and none of them are visible from the hospital.
A community paramedic in the home closes that gap. The coordination problem is not clinical; it is knowing the visit was accepted, happened, and produced a finding somebody acted on.
The template is fixed so every referral arrives the same way: a defined trigger, a defined window, a defined skill set, and a defined set of outcome fields. That is what makes the work reportable later without asking crews to write anything twice.
Mission template A1
Post-discharge follow-up (generic) · sponsor persona: Hospital CM · window: 24–72 hours post-discharge · single mission · tele-MD optional
Trigger and window
Any inpatient discharge flagged by case management; LACE or HOSPITAL score
Window: 24–72 hours post-discharge
Skills required: CP
Steps
- Vitals
- Medication reconciliation
- Red-flag review
- Teach-back
- Follow-up appointment confirmed
Outcome fields
- Visit completed Y/N
- Medications reconciled
- Discrepancies found
- PCP appointment within 7 days Y/N
- ED referral Y/N
Escalation and child orders
Any red flag → tele-MD → remain home, clinic or ED
Child orders: DME, Home health, Pharmacy delivery. Logistics requests are raised on VectorCare and tracked against the same mission.
What the sponsor sees
The case manager sees received, scheduled, on scene, and completed or escalated, with the outcome summary on the mission. Aborts push a notification instead of waiting to be discovered.
Status moves through received, scheduled, active, and completed, escalated or aborted. Exception statuses notify the referrer rather than waiting to be discovered at the end of the week.
What the program does
The program accepts in its portal, schedules against its own capacity, documents care in its ePCR as usual, and completes only the sponsor-required outcome fields here.
Programs choose which templates they accept, and set their own coverage area and capacity. Nothing is auto-assigned.
What you can measure
- Median and p90 time from referral to first scheduled visit
- Missions completed without abort
- 30-day readmission for the enrolled cohort versus a comparison cohort
- Escalations to ED or 911 after the visit
Figures shown elsewhere on this site are illustrative unless a source is given. Your reporting reflects your own missions.
Rural Health Transformation
This template maps to CMS strategic goals 1 and 4. Missions, outcome fields and county-level coverage export for state reporting.
DispatchCare is a technology vendor. It does not administer Rural Health Transformation funds.
Questions buyers ask
Any inpatient discharge flagged by case management; LACE or HOSPITAL score. DispatchCare does not receive 911 calls; emergency requests stay in the dispatch system.
Related mission templates
See a mission go from the chart to the home and back.
A 30-minute walkthrough with a coordinator view, a CP program view and the dashboard your sponsor will read.