Follow-Up After ED Visit for People with Multiple High-Risk Chronic Conditions | May 2023 | Clinical Corners

May 1, 2023

Follow-Up After Emergency Department Visit for People with

Multiple High-Risk Chronic Conditions (FMC)


Patients are at a higher risk of complications following emergency department visits because of their functional limitations and multiple chronic conditions. Older adults have increased mortality rates and readmissions rates within the first three months after the emergency department visit.



The percentage of emergency department (ED) visits for members 18 years of age and older who have 2 or more high-risk chronic conditions who had a follow-up service within 7 days of the ED visit.


Eligible Population:


  • An ED visit on or between January 1 and December 24 of the measurement year where the member was 18 years or older on the date of the visit.
  • Patients with the following Chronic Conditions:
    • COPD and Asthma
    • Alzheimer’s disease and related disorders
    • Chronic Kidney Disease
    • Depression
    • Heart Failure
    • Acute Myocardial Infarction
    • Atrial Fibrillation
    • Stroke and Transient Ischemic Attack
  • Patients that had any of the above Chronic Conditions during the measurement year or the year prior to the measurement year, but prior to the ED visit.


What constitutes a follow up visit:

  • Outpatient visit
  • Observation visit
  • Virtual care visit
  • Behavioral health visit
  • Case management visit
  • Electroconvulsive therapy
  • Substance use disorder service
  • Community mental health center visit
  • Complex Care Management Services
  • Intensive outpatient or partial hospitalization
  • Transitional care management services
  • Domiciliary or rest home visit (e.g., boarding home, assisted living visit, custodial care services

Exclusions from measure:

  • Admitted to an acute or nonacute inpatient facility on or within 7 days after the ED visit, regardless of the principal diagnosis for admission.
  • Received hospice services anytime during the measurement year.
  • Deceased during the measurement year.


  • Contact patient as soon as ED discharge notification is received, and schedule follow-up visit within 3-5 days after discharge.
    • Discuss the discharge summary; verify understanding of instructions and that all new prescriptions were filled.
    • Complete a thorough medication reconciliation with the patient and/or caregiver.
  • Virtual care visits are acceptable for follow-up.
  • Keep open appointments so patients with an ED visit can be seen within 7 days of their discharge.
  • Instruct patients to call health care practitioner with any concerns or worsening of symptoms.
  • Submit claims promptly and include the appropriate codes for diagnosis, health conditions and the services provided.



  1. National Institutes of Health (NIH). October 2020. “Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge.”
  2. National Institutes of Health (NIH). 2019. “Emergency Department Interventions for Older Adults: A Systemic Review.”
  3. Department of Health and Human Services (HHS). 2010. “Multiple Chronic Conditions: A Strategic Framework.”


If you have any questions, please contact Dr. Preston Thomas MD, Associate Medical Director at or (248) 484-4980