Is ‘follow up in 1 week’ costing health systems capacity?

A common acute care discharge order, “follow up in one week with primary care,” is a virtually impossible task amid ever-growing waitlists at primary care clinics across the U.S. So what if healthcare facilities stopped defaulting to this order? 

That is a question Craig Cheifetz, MD, president of Inova Health System’s primary care service line, is working through alongside a clinical council at the Fairfax, Va.-based system. 

Inova is approaching the patient access issue from several angles, including shared medical visits, e-consults, primary care walk-in clinics and plans for an after-hours virtual clinic.

Improving access to care could also be done through hiring more people and building more care facilities, but there is another, less expensive approach, according to Dr. Cheifetz, who has worked at Inova for about 29 years. 

For months, Dr. Cheifetz and the clinical council have discussed the idea of changing follow-up discharge orders based on each patient’s needs. The usual “follow up in one week” discharge order is more of a reflex than a national or organizational guideline, he said. 

As president of the system’s primary care service line, he oversees approximately 330 primary care physicians and advanced practice providers at 30 primary care clinics in Northern Virginia. A constant frustration that reaches his ears is around the routine “follow up in one week” order.

“If a very busy emergency room for the majority of time says, ‘Follow up with primary care in one week,’ those who really need it are going to be struggling against those who may not need it,” Dr. Cheifetz said. 

Similar to triage in emergency medicine, it could be beneficial to examine a patient’s readmission risk, condition and other factors to determine the appropriate timeline for a follow-up. If everyone receives the same time frame of one week, it clogs the system and sets an impossible goal.

“If the patient’s medical situation stipulates they need that [one week] follow up, that makes complete sense,” he said. “But we’re talking specifically about chronic, stable follow up, not somebody who has a changing situation.”

Shifting the cadence of follow-up discharge orders can create capacity for new patients and higher acuity cases by breaking the routine of writing “follow up in three months” orders for chronic, stable cases, Dr. Cheifetz said.

For example, if there are Type 2 diabetes patients who are seen every three months but can be safely moved to a four-month follow-up cadence, capacity opens up. 

“As I go out there and talk to folks, all I’m saying to them is, ‘I’m not getting on a soapbox and saying anybody’s wrong,’” he said. “I’m saying, ‘Look at your data to determine if you have capacity that won’t impact your patients or your clinical outcomes.’ So you can say it’s a hypothesis, but it’s a hypothesis that we can watch carefully in healthcare.”

Inova is in the education and technology phase of the idea, Dr. Cheifetz said. The system is working to build algorithms to educate and prompt providers to ask themselves, What is the appropriate follow-up timing for this patient? Does this patient need to be seen in seven days, or can they be seen in 14 days? 

“We’re naturally increasing capacity, without hiring more people and without building more sites and potentially [being] able to get people in sooner,” Dr. Cheifetz said. “This is just a piece to our strategy playbook to try to enhance access.”

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