Discharge:  (3 appointments need to be made: bone health, orthopedics, primary care)

a. BONE HEALTH:  Primary team schedules bone health appointment for 1-2 months after discharge: Place UCSF Skeletal Health Referral or contact initiated with patient’s PMD for bone health care if patient not local

b. ORTHOPEDICS FOLLOW UP:  Orthopedics team schedules Orthopedic Surgery Follow up (based on surgical type):

i.ORIF:  follow-up in Trauma Clinic with Advanced Health Provider for first visit

1. Referral and Orthopedic Intern emails Orthopedic Institute Scheduling Desk for Trauma Clinic follow-up in 2 weeks with radiographs

ii.Hemiarthroplasty or total hip arthroplasty: follow-up with Arthroplasty Fellow for first visit

1. Referral and Orthopedic Intern emails Orthopedic Institute Scheduling Desk for Arthroplasty Fellow Clinic follow-up in 2 weeks with radiographs

iii.Non-Local patient: follow-up with a local orthopedic surgeon in 2 weeks with radiographs

c. PRIMARY CARE: Primary team makes appointment with PCP within 2-4 weeks

d. Ortho Bundled Payment (OBP) program:  If patient meets criteria for the OBP, a Care Support Program Nurse Practitioner will connect with patient before discharge to ensure continuity 

i. Inpatient Case Manager & OBP Program Coordinator will be in communication to ensure collaboration with the UCSF complex care management team

ii. NP from Care Support will often meet patient in house before discharge

e. Primary service ensures detailed instructions for patient and family in the AVS:

iv.UCSF follow-up visits scheduled & listed with clinic addresses and phone numbers

1. Orthopedic Surgery
2. Skeletal Health
3. PCP

v.Post-op instructions

1. Wound care/dressing
2. PT/Activity

       vi. Follow up anticipatory guidance

1.  Specific instructions on when to call the doctor (PCP vs Orthopedic Surgeon)

vi.Updated medication list