Care transitions occur when a patient transitions between different levels or locations of health care (Kessler, Williams, Moustoukas, & Pappas, 2013). Transitional care is a set of actions designed to ensure the coordination and continuity of health care for patients during a care transition (Coleman, Boult, & American Geriatrics Society Health Care Systems Committee, 2003) and often includes actions such as early assessment of needs for follow-up resources, medication reconciliation, discharge planning, providing education and support to the patient and caregivers, and coordination among health care professionals (Hansen, Young, Hinami, Leung, & Williams, 2011).
Older adults with dementia experience more care transitions than older adults without dementia (Callahan et al., 2012). Providers note distinct challenges to providing transitional care to older adults with dementia, such as a demand for aftercare services that exceeds supply (Kable, Chenoweth, Pond, & Hullick, 2015), poor comprehension of discharge instructions (Ray, Ingram, & Cohen-Mansfield, 2015), discharge instructions and aftercare services that only address the acute reason for hospitalization and not the cognitive impairment (Naylor et al., 2007), and under-utilized and under-prepared caregivers (Naylor, Stephens, Bowles, & Bixby, 2005).
Numerous transitional care interventions improve care transitions for older adult patients (Coleman, Parry, Chalmers, & Min, 2006; Jack et al., 2009; Naylor et al., 2004). However, the majority of intervention studies excluded patients with dementia; therefore, little evidence exists regarding strategies to improve care transitions for this important and vulnerable population (Chenoweth, Kable, & Pond, 2015). A 2013 report by the Agency for Healthcare Research and Quality found that one of the most common reasons for exclusion from transitional care intervention studies was the presence of cognitive impairment or dementia (Rennke et al., 2013). The current study aimed to characterize and compare the transitional care provided to older adults with and without dementia transitioning to and from the hospital.
A more detailed description of the authors' methodology, including sampling and analytic procedures, has been previously published (Prusaczyk, Fabbre, Carpenter, & Proctor, 2018). The current study is a qualitative content analysis of medical charts of patients at Barnes-Jewish Hospital, an urban tertiary care teaching hospital. The Institutional Review Board for Washington University in St. Louis approved the study with a waiver of informed consent. The medical charts of patients age 70 and older at the time of hospitalization discharged between January 1, 2015 and December 31, 2015 were reviewed. Patients were excluded if they were discharged directly from the emergency department, did not have at least one overnight stay in the hospital, or died during hospitalization. The sample was stratified based on documented dementia and whether the patient was hospitalized for a surgical procedure. Dementia was identified using International Classification of Diseases (ICD-9) diagnosis codes previously used in the literature (Bharmal et al., 2007). All records were reviewed by a single investigator (B.P.).
Patients' dementia severity was determined using accepted cutoff scores on tests found in the record (e.g., Montreal Cognitive Assessment [Freitas, Simões, Alves, & Santana, 2013], Short Blessed Test [Katzman et al., 1983; Morris et al., 1989]). For patients without assessments, severity was assigned based on any mention of dementia severity (e.g., “severe Alzheimer's,” “mild dementia”) in the free text of the record. For remaining patients (n = 16, 7.9%), severity was imputed from similar patients based on age, sex, and race using matching methodology for small sample sizes (Gelman & Hill, 2006).
After a thorough literature review, the ideal transition in care framework was chosen to operationalize transitional care variables (Burke, Kripalani, Vasilevskis, & Schnipper, 2013). This framework conceptualizes the ideal care transition by identifying 10 domains that are the “structural supports” for the “bridge” that patients must cross from one care environment to another (Burke et al., 2013, p. 102). The 10 domains include: discharge planning; complete communication of information; availability, timeliness, clarity, and organization of information; medication safety; patient education and promotion of self-management; social and community supports; advance care planning; coordinating care among team members; monitoring and managing symptoms after discharge; and outpatient follow up.
Because this framework was not created for the purpose of guiding medical chart data abstraction, the definitions of these domains had to be adapted for the current study purposes. For example, the medication safety domain was defined in the framework as “taking an accurate medication history, reconciling changes throughout hospitalization, and communicating the reconciled medication regimen to patients and providers across transitions of care.” For the purposes of chart review, the domain was operationalized by categorizing it into three sub-actions:
- An accurate medication history was taken.
- Medication changes were reconciled at least once during hospitalization.
- Medication changes were communicated to the patient, caregivers, or outside-the-hospital providers.
For each of these sub-actions, the chart was reviewed for evidence, which was indicated either by a completed form (e.g., discharge medication report) or by mention in the free-text notes (e.g., “unable to obtain medication history”). In the case of this domain, further operationalization was needed. To determine if an accurate medication history was taken for patients with dementia, history had to be taken from a family member or other provider (e.g., pharmacist, primary care physician). If the patient with dementia him/herself provided the history, documentation was required with a note stating that the hospital provider believed the patient was able to provide an accurate history. If the history came from the patient with dementia with no indication that the hospital provider had assessed the accuracy of the patient's report, then that medication history was not considered accurate. Determining an accurate medication history is difficult. Although guidance from the literature was followed (Pippins et al., 2008; Sullivan, Gleason, Rooney, Groszek, & Barnard, 2005; Tam et al., 2005) and other sources of information were used (e.g., caregivers, pharmacy records, primary care records) to triangulate patient report, the accuracy of the medication history is not guaranteed. However, accuracy for the current study was operationalized in this way and the word accuracy in the title of this domain was used to remain consistent with the framework's original domain names. A full description of all framework domains and their operationalization can be found in Table A (available in the online version of this article).
Operationalization of Ideal Transitions in Care Framework Domains
It is important to point out that it was not always possible in the medical record to determine whether the patient or caregiver was the recipient of an action. Therefore, an action was considered to have been provided if it was noted in the medical record to have been provided to either the patient or caregiver. If there was no evidence an action was provided to either individual, then that action was coded as not having been completed.
Similarly, for the education domain, the medical record did not provide separate details on the methods of education delivery (e.g., teach-back, printed educational materials) and for each specific topic of education (e.g., symptoms, medication changes, follow-up appointments). For each section in the medical record, the provider could select each topic that was covered during the education session and all methods of education delivery used during the session, but the specific topics were not linked to specific delivery methods. For example, in the chart documentation for one education session, providers may select symptom management and medication adherence as the topics covered in that session. They would also select the delivery methods, such as printed materials and teach-back, used during that session. However, this information was not documented in a way that indicated if the printed materials were used for symptom management or medication adherence. Therefore, specific education topics could not be linked with specific delivery methods within an education session.
Bivariate analyses with the Bonferroni correction were conducted for each of the transitional care variables with the primary exposure dementia as well as demographic and other clinical variables to understand how groups differed with respect to receipt of the various transitional care domains.
All quantitative statistical analyses were conducted in R 3.3.2.
The final population for analysis included 210 older adult patients hospitalized in 2015. One hundred twenty-six patients with dementia (42 [33.3%] surgical, 84 [66.7%] non-surgical) and 84 patients without dementia (28 [33.3%] surgical, 56 [66.7%] non-surgical) were included. Table 1 presents the demographic and clinical characteristics of the sample for patients with and without dementia.
Demographic and Clinical Characteristics of Hospitalized Patients with and Without Dementia
Patients with dementia were more likely to be African American compared to patients without dementia (45.2% vs. 25%, p = 0.005), more likely to require use of a wheel-chair (16.7% vs. 6%, p = 0.022), and more likely to live in a facility (30.2% vs. 3.6%, p < 0.0001). Patients with dementia were also more likely to be discharged to a facility (e.g., skilled nursing, rehabilitation facility, short-term hospital) than patients without dementia (52.4% vs. 13.1%, p < 0.0001) (Table 1).
More than one half (58.9%, n = 73) of patients with dementia were taking a cognition-enhancing medication (e.g., galantamine, donepezil, memantine). Twenty-four (19%) patients with dementia were screened with the Montreal Cognitive Assessment tool during their stay and an additional 28 (22%) were screened with the Short Blessed Test. Approximately three fourths of patients with dementia had moderate to severe dementia (71.4%, n = 90).
Transitional Care Differences
Many differences in transitional care processes were noted between patients with and without dementia (Table 2). Providers were significantly less likely to obtain accurate medication histories from patients with dementia (60.3% vs. 85.7%; p = 0.0001) compared to patients without dementia. Patients with dementia were significantly less likely to receive education related to their in-hospital medications (77% vs. 100%, p < 0.0001), diagnoses (45.2% vs. 83.3%, p < 0.0001), follow-up needs (42.1% vs. 81%, p < 0.0001), whom to contact after discharge (40.5% vs. 79.8%, p < 0.0001), medication regimens after discharge (46.8% vs. 79.8%, p < 0.0001), and symptoms after discharge (41.3% vs. 80% p < 0.0001) than patients without dementia (Table 2). Among patients who received education about their medications, patients with dementia were significantly less likely to understand the education (per provider assessment) (43.7% vs. 79.8%, p < 0.0001) compared to patients without dementia.
Transitional Care Provided to Patients with and Without Dementia
Despite receipt of numerous transitional care actions in most patients, key differences in provision of some transitional care actions were found between patients with and without dementia. Patients with dementia were less likely to have accurate medication histories taken and receive education about follow-up needs, whom to contact after discharge, post-discharge medication regimen, and post-discharge symptoms.
The difference in transitional care provided to patients with and without dementia could be due to the finding that patients with dementia were significantly more likely to be admitted to the hospital from a facility and discharged to a facility compared to patients without dementia. To note, specific information on the facilities was not collected; therefore, it is unknown if patients who were admitted from and discharged to facilities were returning to their same pre-hospital facilities. Hospital providers may feel less responsible for educating patients and their caregivers about post-discharge care when the patient is going to a facility because providers at the facility will be responsible for that care. In comparison, patients discharged home (alone or with a caregiver) may feel more responsible for post-discharge care, and thus providers may feel more responsible for providing education. However, even if patients and their caregivers will not be routinely or primarily involved in aftercare, caregivers still report a desire to understand patients' post-discharge needs so they can ask the appropriate questions of providers and know if patients are receiving appropriate care (Naylor et al., 2005). Furthermore, educating caregivers of patients with dementia has been shown to ease caregiver burden (Etters, Goodall, & Harrison, 2008).
Providers may argue that patients with dementia cannot understand or remember the education and therefore it does not need to be provided. Indeed, the current results showed that patients with dementia were significantly less likely to understand the education they received. One could also argue that patients who did not understand their education (per provider assessment) did not receive any education at all. If providers are not prioritizing the education of patients with dementia, perhaps an increased effort to tailor materials to cognition level would improve understanding among this population, which could motivate providers to educate these patients.
However, although nurses were primarily the ones providing education to patients in the current sample, most cognitive assessments were completed by occupational therapy. Therefore, it may not be feasible for nurses to tailor their education methods to patients' cognitive status because nurses may not be aware of that level. Although the cognitive assessment by occupational therapy was recorded in the chart, it may not be recorded in time for nursing to review before providing education. Furthermore, the timing of the assessment would also impact nurses' ability to tailor their education because the patient's cognitive status often fluctuates over the course of hospitalization. This challenge may represent an opportunity for bioinformatics or health information technology to determine ways in which the cognitive assessment can be integrated more quickly and seamlessly into the medical record (or another mode of delivery all together) so that it can be used by nursing more effectively and easily.
A last point of concern relates to patients' discharge summaries. Although not significantly different between patients with and without dementia, it is concerning that <30% of patients had documentation in their charts that stated their discharge summaries were sent to their primary care physicians. When information about a hospitalization is not shared with primary care physicians, it represents a patient safety concern, and indeed those patients are more likely to report problems after discharge (Arora et al., 2010; Kripalani, LeFevre, et al., 2007).
Although the current findings suggest room for improvement, there are areas in which providers are succeeding. For patients with or without dementia, approximately all patients' medications were reconciled during their hospitalization and any changes were communicated to the patient or his/her family. This finding is impressive given that it has previously been reported that of a sample of approximately 300 hospitals, only one half (48%) had fully implemented medication reconciliation procedures (Clay, Halasyamani, Stucky, Greenwald, & Williams, 2008). A sub-group analysis of that sample revealed academic medical centers had the lowest number of fully implementing hospitals (35%). Because the current study was conducted in an academic medical center, the approximate 100% rate is even more striking. Approximately every patient was assessed for cognitive impairment (dementia or delirium). Although there is speculation as to the usefulness of this screening (Shenkin, Russ, Ryan, & Maclullich, 2014), screening for cognitive impairment has been considered by some to be beneficial for hospitalized older adults (Burke et al., 2013; Chow & MacLean, 2001; Jackson et al., 2017).
Given these findings, there are numerous recommendations that can be made for nurses and other providers working with older adults with dementia in the hospital. First, education for patients even if they are discharging to another location of care and are to be assumed under the care of another health care provider is an important component to providing patient-centered care. Second, tailoring this education may increase uptake among patients with dementia; therefore, using a conversational style, repeating information, minimizing the amount of information that has to be remembered, providing similar cues when patients are learning a task and when they are performing the task, avoiding confrontation, integrating reality and reminiscence into the education, and using non-verbal reinforcements, such as smiling and pointing when providing education, are recommended (Davis, 2005; Farran & Keane-Hagerty, 1989; Jootun & McGhee, 2011; Perry, Galloway, Bottorff, & Nixon, 2005). Third, patients' discharge summaries should be sent to their primary care providers and providers should follow existing guidelines on what information should be sent to the primary care physician, how, and when (Kripalani, Jackson, Schnipper, & Coleman, 2007).
The current authors are unaware of any unrelated quality improvement or other hospital-wide initiatives aimed at medication reconciliation or cognitive impairment screening during the study period that may explain these high levels of implementation. In relation, they have no reason to believe the results of this study would not be generalizable to other large, urban academic medical centers. Different results would be expected in smaller, rural hospitals for multiple reasons. There are fewer occupational therapists in rural areas (Peterson, Ramm, & Ruzicka, 2003) and because occupational therapists were the primary providers screening patients for cognitive impairment in the current study, the high number of patients being screened may be expected to decrease in a rural setting. Usually, there are documented rural health workforce issues (MacDowell, Glasser, Fitts, Nielsen, & Hunsaker, 2010), which may make offering many of the transitional actions included in the current study impossible due to limited time and resources.
There are several limitations to the current study. Notably, as with all studies using medical record review, the presence or absence of predictor variables and outcomes are only as accurate as the data recorded. There is the potential that some actions were provided to patients but not recorded in the electronic medical record. Furthermore, the timing of when the transitional care actions were performed was not abstracted from the charts, which is a limitation to the data. In addition, these results came from only one tertiary care academic hospital and may not be generalizable to other hospitals.
To address these limitations, prospective research is needed on transitional care that collects data from a larger number of patients and multiple hospitals. As discussed below, this research would directly contribute to the knowledge base from which effective transitional care interventions for patients with dementia could be based. With the development and implementation of these interventions, the care transition process for older adults and their caregivers could be improved.
There is a critical need to add to the limited evidence base related to transitional care for patients with dementia. The results of the current study suggest that patients with dementia receive many of the same transitional care actions as patients without dementia, yet key differences were found. The transitional care evidence base often excludes patients with dementia, leaving clinicians and providers with little evidence to draw from. In the future, investigators must include patients with dementia in new transitional care studies and test the effectiveness of existing interventions within this community, as well as to better understand the relationship between disposition and transitional care needs.
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Demographic and Clinical Characteristics of Hospitalized Patients with and Without Dementia
|Variable||Mean (SD) Range||p Valuea|
|Dementia (n =126)||No Dementia (n = 84)|
|Age (years)||83.98 (6.43) 70 to 101||79.07 (6.02) 70 to 93||<0.0001|
|Length of stay (days)||5.40 (4.66) 1 to 30||5.49 (5.39) 1 to 33||0.908|
|No. hospitalizations in past 12 months||0.81 (1.19) 0 to 5||0.63 (1.02) 0 to 5||0.225|
|No. emergency department visits in past 12 months||0.70 (1.38) 0 to 10||0.46 (0.96) 0 to 5||0.148|
|Male||53 (42.1)||43 (51.2)||0.246|
|African American (vs. White)||57 (45.2)||21 (25)||0.005|
|Married (vs. not married)||77 (61.1)||40 (47.6)||0.074|
|Living arrangement before hospitalization||<0.0001|
| Alone||15 (11.9)||22 (26.2)|
| With a caregiver||73 (57.9)||59 (70.2)|
| In a facilityb||38 (30.2)||3 (3.6)|
|Cognitive impairment severity|
| Mild||36 (28.6)|
| Moderate/severe||90 (71.4)|
| Unassisted||25 (19.8)||31 (36.9)|
| Cane/walker||66 (52.4)||39 (46.4)|
| Wheelchairb||21 (16.7)||5 (6)|
| Unknown||14 (11.1)||9 (10.7)|
|Admitted for surgery||42 (33.3)||28 (33.3)||1|
| Skilled nursing facilityb||66 (52.4)||11 (13.1)|
| With a caregiver||27 (21.4)||31 (36.9)|
| Home with home health||21 (16.7)||23 (27.4)|
| Rehabilitation facility||8 (6.3)||9 (10.7)|
| Home alone||2 (1.6)||8 (9.5)|
| Short-term hospital||2 (1.6)||2 (2.4)|
|Discharged to higher level of care than pre-admission||62 (49.2)||43 (51.2)||0.888|
Transitional Care Provided to Patients with and Without Dementia
|Variable||n (%)||p Valuea|
|Patients With Dementia (n = 126)||Patients Without Dementia (n = 84)|
|Discharge planning||125 (99.2)||84 (100)||1|
|Discharge summary included|
| Diagnoses||125 (99.2)||84 (100)||1|
| Discharge medications||126 (100)||84 (100)||1|
| Procedure results||124 (98.4)||84 (100)||0.518|
| Follow-up needs||122 (96.8)||84 (100)||0.152|
| Pending test results||7 (5.6)||0||0.071|
|Discharge summary was available to primary care physician||26 (20.6)||23 (27.4)||0.35|
|Accurate medication history taken||76 (60.3)||72 (85.7)||0.0001|
|Medications were reconciled throughout hospitalization||121 (96)||82 (97.6)||0.705|
|Medication changes were discussed with patient or caregiver||124 (98.4)||83 (98.8)||1|
| Number who understood education||55 (43.7)||67 (79.8)||<0.0001|
|Patient or caregiver educated about|
| In-hospital medications||97 (77)||84 (100)||<0.0001|
| Diagnoses||57 (45.2)||70 (83.3)||<0.0001|
| Follow-up needs||53 (42.1)||68 (81)||<0.0001|
| Whom to contact after discharge||51 (40.5)||67 (79.8)||<0.0001|
| Post-discharge medication regimen||59 (46.8)||67 (79.8)||<0.0001|
| Post-discharge medication side effects||3 (2.4)||3 (3.6)||0.684|
| Post-discharge symptoms||52 (41.3)||67 (80)||<0.0001|
| Post-discharge adverse events||9 (7.1)||2 (2.4)||0.206|
|Patient or caregiver asked about any post-discharge management challenges||7 (5.6)||3 (3.6)||0.743|
|Teach-back used during education||122 (96.8)||83 (98.8)||0.650|
|Printed educational materials used||66 (52.4)||54 (64.3)||0.118|
|Patient assessed for delirium or dementia||126 (100)||83 (98.8)||0.4|
|Arranged social or community support post-discharge||3 (2.4)||3 (3.6)||1|
|Advanced care planning||35 (27.8)||18 (21.4)||0.381|
|Coordinated with providers outside of the hospital||113 (89.7)||69 (82.1)||0.172|
|Outpatient follow up scheduled with specialty provider||44 (34.9)||36 (42.9)||0.695|
|Outpatient follow up scheduled with primary care physician||30 (23.8)||38 (45.2)||0.056|
Operationalization of Ideal Transitions in Care Framework Domains
|Ideal Transition in Care Framework Definition||Operationalization||Action and Sub-actions|
|Discharge Planning: Planning ahead for hospital discharge while the patient is still being treated in the hospital. Includes collaborating with the outpatient provider and taking the patient and caregiver's preferences for appointment scheduling into account.||This will be any indication of discharge planning either by completed Discharge Summary form or any mention of “discharge plan/planning” in the free-text documentation.||Action:
1. Discharge Planning
|Complete Communication of Information: The content that should be included in the discharge summaries and other means of information transfer from hospital to post-discharge care.||At a minimum, the following information (coded as sub-actions) should be included in the discharge summary or documentation: (1) Primary and secondary diagnoses, (2) discharge medications, (3) results of procedures, (4) follow-up needs, and (5) Pending test results.||Action:
2. Complete Communication of Information
Sub-actions are items found in discharge summary:
2.2 Discharge medications
2.3 Results of procedures
2.4 Follow-up needs
2.5 Pending test results
|Availability, Timeliness, Clarity, and Organization of Information: The availability, timeliness, clarity, and organization of the information above ensure post-discharge providers can access and quickly understand the information before assuming care of the patient.||All information will be considered available since it was by nature available in the medical record. The information will be considered timely if there is any indication the Discharge Summary form was provided to the PCP prior to discharge or first scheduled follow-up appointment. The clarity and organization of the information will be coded if the Discharge Summary or note contains sub-headings or bullet-points.||Action:
3. Availability, Timeliness, Clarity, and Organization of Information
3.1 Discharge summary existed
3.2 Discharge summary sent to PCP
3.3 Discharge summary contained sub-headings or bullet points
|Medication Safety: (1) Taking an accurate medication history, (2) reconciling changes throughout hospitalization, and (3) communicating the reconciled medication regimen to patients and providers across transitions of care.||One of the three sub-actions indicated either by completed Discharge Medication Report or mention of “medication history” or “medication reconciliation” or mention of discussing medications with patient or PCP in free-text documentation.
For an accurate medication history to be taken, the medication history had to be taken from a family member, primary care physician, pharmacy, or from the patient themselves with (dementia patients only) documentation in the chart that the hospital provider felt confident in the patient's cognitive and recall abilities. If the medication history came from the dementia patient with no indication that the hospital provider had assessed the patient's cognitive function and deemed them to be intact, then that medication history was not considered accurate.||Action:
4. Medication Safety
4.1 Accurate medication history taken
4.2 Medications reconciled during hospitalization
4.3 Changes in medications communicated to patient
|Patient Education & Promotion of Self-Management: Teaching patients and their caregivers about (1) the main hospital diagnoses and instructions for self-care, including (2) medication changes, (3) appointments, and (4) whom to contact if issues arise. Confirming comprehension of instructions through (5) assessment of delirium and dementia and (6) teach-back, and (7) providing educational materials that are appropriate to the patient and caregiver's level of health literacy and preferred language are important.||One of these seven sub-actions indicated by either completed form or mention in the free-text documentation.||Action:
5. Patient Education
5.1 Patient/Caregiver educated about diagnoses
5.2 Patient/Caregiver educated about medication changes
5.3 Patient/Caregiver educated about follow-up appointments
5.4 Patient/Caregiver educated about whom to contact after discharge
5.5 Patient assessed for delirium or dementia
5.6 Provider assessed patient's understanding with teach-back
5.7 Provider used educational materials with patient or gave materials to patient
|Social and Community Supports: Enlisting the help of these supports is crucial for assisting patients with household activities, meals, and other necessities during recovery.||Any indication - by either completed form or mention in documentation – of contacting, enlisting, or utilizing community and social supports.||Action:
6. Social and Community Supports
|Advance Care Planning: May begin in hospital or outpatient setting and involves (1) establishing goals of care and (2) health care proxies, as well as (3) engaging with palliative or hospice care if appropriate.||Any of these sub-actions indicated by either completed form or mention in the free-text documentation.||Action:
7. Advance Care Planning
Establishing goals of care
Establishing health care proxies
Engage with palliative or hospice care if appropriate
|Coordinating Care Among Team Members: Synchronizing efforts across settings and providers is vital as they coordinate information, assessments, and plans as a team.||This will be any indication of communication between the hospital and any outside providers either by completed form or mention in the free-text documentation.||Action:
8. Coordinating Care Among Team Members
|Monitoring and Managing Symptoms after Discharge: Monitoring for new or worsening symptoms, medication side effects, discrepancies, or non-adherence, and other self-management challenges.||Any indication the patient/caregiver was educated on any one of these sub-actions: (1) Post-discharge symptoms, (2) Post- discharge medication side effects, (3) Medication regimen, (4) Inquired about other self-management challenges.||Action:
9. Monitoring and Managing Symptoms after Discharge
9.1 Patient/Caregiver educated about post-discharge symptoms
9.2 Patient/Caregiver educated about post-discharge medication side effects
9.3 Patient/Caregiver educated about post-discharge medication regimen
9.4 Provider inquired about self-management challenges with Patient/Caregiver
|Outpatient Follow-up: Appropriate and prompt post-discharge appointments with providers who have a longitudinal relationship with the patient.||This will be any indication of scheduled follow-up appointments with either the patient's PCP or a specialty provider by completed form or mention in free-text documentation.||Action:
10. Outpatient Follow-up
10.1 Follow-up made with PCP
10.2 Follow-up made with Specialty Provider