Hospital discharge follow-up
A focused outpatient visit to review the discharge plan, medications, available records, and recovery needs after an inpatient stay.
For hospitals & referring clinicians
A bridge between hospital discharge and primary care.
A discharge plan needs an outpatient pathway patients can access.
Follow Up Dr. is a transitional care clinic for patients leaving the hospital or emergency department who need follow-up before they can see their regular clinician.
Illustrative partnership model; hospital workflows are agreed before implementation.
Support after discharge
Focused follow-up.
Continuity with primary care.
Our focus is the gap after discharge: medication questions, unresolved follow-up needs, changes in recovery, and the transition back to primary care.
ER follow-up
An outpatient pathway for clinically appropriate patients discharged from the emergency department who need follow-up before their usual clinician is available.
Return to primary care
Bridge care that supports the patient’s ongoing relationship with their primary care clinician and specialists. Records and handoff processes are agreed with referring teams.
Readmission-reduction priorities
Support your readmission-reduction efforts.
Our goal is to help prevent avoidable hospital readmissions through focused follow-up and continuity of care.
We welcome discussions with hospitalists, emergency physicians, case managers, and discharge planners about a referral pathway that fits their patients’ needs and their organization’s quality priorities.
Align around your patient population
Discuss the discharge populations where follow-up access is a concern, including conditions and procedures tracked under CMS’s Hospital Readmissions Reduction Program.
Eligibility, clinical scope, specialist follow-up, and escalation responsibilities should be agreed before a pathway begins.
Measure what happens after discharge
Choose pilot measures such as successful contact, completed visits, time to follow-up, and handoff completion. Evaluate any effect on readmissions with hospital data and an appropriate comparison.
Readmission reduction is a program goal. Follow Up Dr. does not claim a demonstrated reduction in readmissions or a guaranteed financial result.
Build a referral pathway
Start with a defined pilot.
Proposed for discussion with your hospital, emergency department, case-management, and quality teams.
01 / AGREE
Define the fit
Agree on eligible patients, exclusions, payer access, appointment capacity, staff ownership, and the follow-up timing needed.
02 / CONNECT
Make the handoff clear
Establish an approved referral and records process, scheduling contact, and communication back to the patient’s usual care team.
03 / EVALUATE
Track the result
Review follow-up completion, patient experience, staff effort, and agreed quality measures before expanding the pathway.
Hospital partnership and reporting workflows are proposed; no existing hospital affiliation is implied.
CMS quality alignment
Understand the measure.
Build the right pathway.
CMS’s Hospital Readmissions Reduction Program assesses unplanned readmissions within 30 days after qualifying inpatient discharges for specified conditions and procedures. An ER-only discharge does not itself establish the qualifying inpatient stay for these measures.
ER follow-up and hospital discharge follow-up address different transitions of care. The pilot population and outcome measures should reflect that distinction.
Let’s discuss your follow-up gap
A practical next step
for your discharge team.
Call to discuss a referral pathway with Dr. Robert Milanes.
Please do not send patient records through general text messages. Patients with emergencies should seek emergency care rather than wait for a clinic visit.