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  • 1.  Pediatric post-hospital follow-up TCM

    Posted 12-09-2025 08:31

    Hello,

    I am wondering if anyone is conducting post-hospital follow-up calls for pediatric patients following a TCM model of care and if so, are you using a risk score to identify at-risk conditions or populations? 

    Thank you,

    Marsha Pike, DNP, APRN, CNS



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    Marsha Pike DNP, APRN, CNS
    Pediatric Clinical Nurse Specialist
    Mayo Clinic
    Rochester MN
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  • 2.  RE: Pediatric post-hospital follow-up TCM

    Posted 12-09-2025 14:35

    Dear Marsha,

    Our population health team for pediatric patients, utilize Compass Rose reports for hospital discharge notifications, then outreach to the family to identify if a hospital f/u appt is needed (per discharge plan), will route the chart to the clinical pharmacist for medication reconciliation (if >3 changes to meds were made), and then a message is sent to the provider's team. Unfortunately, our Compass Rose does not assign risk scores for our pediatric patient population, only the adults.



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    Toni Kempner RN, MSN, ACRN
    Director of Nursing
    Multnomah County HD, ICS
    Portland, OR
    503-969-6989
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  • 3.  RE: Pediatric post-hospital follow-up TCM

    Posted 12-10-2025 07:36

    Hello,

     

    Our TOC team calls pediatric patients. We do have a peds risk score but try to call all peds patients unless they have another care provider following them closely (navigator or care manager). If you have additional questions, feel free to reach out. Thank you.

     

    Ashley Rosa, MSN, BSN, RN

    Manager Ambulatory Care Management

    Bronson Healthcare Group, Michigan

     

     



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