Patient Care Coordinator Information

• Hospital Medicine Faculty Inpatient Service ([FIS] Red, Blue, Purple, Green)
• Internal Medicine Resident Inpatient Service ([RIS] 5 teams)
• Cardiology Inpatient Service
• MICU Service

• FIS (Red, Blue, Purple), RIS, Cardiology Inpatient Service – the PCCs attend daily MDR meetings where requests are communicated.
• FIS Green Consult and MICU patients – the PCCs receive appointment requests via Epic Secure Chat or email.
• For in-the-moment requests or communication – the PCCs use Epic Secure Chat and prefer all after hours and weekend requests via email.
  1. Epic Secure Chat group: ZSFG IP Patient Care Coordinators (PCC) for Med/Cards
  2. Email address: [email protected]

• Requesting primary care appointments for new or established patients
  • In some cases, the only option is to provide drop-in information for clinics either in SF or in the area where the patient lives.
• Requesting specialty care appointments for established patients only. All other specialty care appointments need to be requested through PCP referral or e-referral for DPH clinics by the primary team.
• Rescheduling and cancelling existing primary care and specialty clinic appointments for admitted patients.
• Contacting discharged patients to provide their appointment details, if not completed prior to discharge.
  • If unable to reach the patient by phone, PCCs send the patient their appointment info via email or mail through USPS, or reach out to patient’s approved contact/s, outpatient social worker, or outpatient case manager
• Fax discharge summaries to various providers/clinics
• Request of Information (ROI) for records from other facilities not accessible in Care Everywhere, including requests for films to be couriered or sent via FedEx to ZSFG.
• Confidential Morbidity Report (CMR) reporting to DPH
  • COVID, occasionally STI and other communicable diseases
• Census data tracking for FIS, RIS, Cardiology and MICU services
• Appointment volume tracking for the appointments the PCCs request

• Requesting new patient appointments for PPO patients who are not established with a PCP
• Requesting new specialty care appointments for patients who are not established in a specialty care clinic.
• Requesting appointments for patients whose primary team is not FIS (Red, Blue, Purple, Green), RIS (5 teams), Cardiology Inpatient Service, or the MICU Service.
• Requesting follow up appointments for patients discharging to:
  • Jail
  • SNF
  • Residential treatment
  • Hospice
  • Transferring to another service or hospital
• Requesting follow up appointments for Street Medicine patients
• Requesting follow up appointments for Heart Plus patients (Cardiology care for patients with substance use disorders; appointments coordinated by ACT)
• Changing a patient’s insurance, primary care clinic, or primary care provider

Core Responsibilities – completed daily

• PCP and Cardiology appointment requests - notifying discharged patients about scheduled appointments and urgent specialty care appointments (if established patient in specialty care clinic)
• Census tracking
• Request of information for outside hospital medical records

Time-Permitting

• Non-urgent specialty care appointment scheduling
• Sending DC summaries to providers/clinics
• CMR reporting
• Appointment volume tracking
• Non-urgent email responses for scheduling requests for discharged patients