A6 · Post-acute transitional care
Post-ED follow-up visits, coordinated from the hospital
Coordinate 48-hour home follow-up after an ED discharge: instructions understood, medications in hand, and a primary care appointment that actually exists.
Mission template A6 · Post-ED follow-up (48 hours)
On scene- Received09:12
Referral raised by hospital cm, ED discharge for a frequent user, an elderly patient or a patient with no PCP.
- Scheduled10:04
A program covering the address accepts inside the window: 24–48 hours.
- En route13:06
Crew departs; the patient receives an arrival window by SMS.
- On scene14:11
Vitals; Confirm understanding of discharge instructions; Medication access.
- Completed14:40
Outcome fields recorded (Understood instructions Y/N; Medications obtained Y/N); referrer notified.
Why this program
An ED discharge assumes the patient understood the instructions, filled the prescription and has somewhere to follow up. For a rural patient without a primary care relationship, all three assumptions often fail.
A visit inside 48 hours turns a discharge sheet into a plan, and catches the deterioration that would otherwise bring the patient back through the same doors.
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 A6
Post-ED follow-up (48 hours) · sponsor persona: Hospital CM · window: 24–48 hours · single mission · tele-MD optional
Trigger and window
ED discharge for a frequent user, an elderly patient or a patient with no PCP
Window: 24–48 hours
Skills required: CP
Steps
- Vitals
- Confirm understanding of discharge instructions
- Medication access
- PCP linkage
Outcome fields
- Understood instructions Y/N
- Medications obtained Y/N
- PCP appointment booked Y/N
Escalation and child orders
Symptoms worsening → tele-MD
Child orders: Pharmacy, Mobility to PCP. Logistics requests are raised on VectorCare and tracked against the same mission.
What the sponsor sees
ED case management sees contact, whether medications were obtained, and whether a primary care appointment was booked.
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 contacts and visits inside 48 hours, and records the three linkage fields.
Programs choose which templates they accept, and set their own coverage area and capacity. Nothing is auto-assigned.
What you can measure
- Contact rate inside 48 hours
- Prescriptions obtained after the visit
- Primary care appointments booked and kept
- 72-hour and 30-day ED returns for the cohort
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
ED discharge for a frequent user, an elderly patient or a patient with no PCP. DispatchCare does not receive 911 calls; emergency requests stay in the dispatch system.
Related mission templates
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