February 15, 2024

As a requirement of the DHS Patient-Centered Medical Home (PCMH) program, patients admitted with an ambulatory sensitive condition must be seen by the primary care PCMH provider or specialist provider within seven days of discharge from the hospital. If the follow-up appointment takes place with a specialist, the specialist provider must share the patient’s follow-up visit notes with the primary care PCMH provider to meet this requirement.