The purpose of this policy is to provide standardized follow-up time frames and management guidelines for a wide range of medical conditions. This policy is intended to ensure consistency in quality and process throughout clinical practice, promote timely interventions, and optimize long-term patient outcomes across metabolic, vascular, cardiac, pulmonary, neuropsychiatric, musculoskeletal, hematology/oncology, and gastroenterology domains.

2. Scope

This policy applies to all clinicians and all staff involved in the diagnosis, treatment, and follow-up of patients with the conditions outlined herein. It covers both acute presentations and ongoing management across various clinical domains.

3. Policy Statement

All patients presenting with conditions covered under this policy will receive care guided by standardized follow-up intervals:

· Immediate Follow-Up: 1–2 days

· Short-Term Follow-Up: 1–2 weeks

· Regular Follow-Up: 1–2 months

These time frames are used to guide decision-making in patient monitoring, intervention adjustments, and escalation of care as necessary. The recommendations below should be tailored to the individual patient’s clinical situation, severity of presentation, and risk factors.

4. Procedures and Recommendations Following 1-2 FU

A. Metabolic Conditions

Weight/Obesity Conditions

Underweight Patients:

1–2 Days:

· Recheck for electrolyte imbalances if present

· Dietician referral

· Risk of Refeeding Syndrome

1–2 Weeks:

· Evaluate weight trends, assess dietary adherence, and screen for red flags (e.g., gastrointestinal issues, mental health barriers).

· Adjust nutritional plans or supplements as necessary.

· Confirm Care Management enrollment

1–2 Months:

· Reassess weight, BMI, and relevant labs (e.g., albumin, prealbumin if indicated).

· Update nutritional goals and develop a long-term management strategy.

· Reorder/Run Metabolic Test

Overweight/Obese Patients:

1–2 Days:

· Recheck for acute cardiopulmonary complications (e.g., uncontrolled hypertension, new onset edema).

· Address any adverse reaction to new meds

1–2 Weeks:

· Recheck weight if on an intensified plan; identify barriers to dietary and exercise compliance.

· Adjust interventions (medication, meal plan) if early weight changes are not as desired.

· Confirm Care Management enrollment

1–2 Months:

· Obtain updated anthropometrics (BMI, waist circumference) and possibly repeat labs (lipid panel, glucose).

· Consider escalation of therapy (e.g., pharmacotherapy, referral to a nutritionist or behavioral therapy) based on progress.

· Reorder/Run Metabolic Test

Hyperglycemia:

1–2 Days:

· If hyperglycemia is acute (e.g., due to infection, steroids, or stress), recheck levels.

· Address any adverse reaction to new meds

1–2 Weeks:

· Reassess glucose logs, Blood Glucose, and Fructosamine and evaluate whether the precipitating stressor or medication change has resolved.

· Confirm Care Management enrollment

1–2 Months:

· Repeat A1c if indicated (3 Months); ensure stabilization or resolution of hyperglycemia and determine if long-term monitoring is necessary.

Pre-Diabetes:

1–2 Days:

· Confirm initiation of lifestyle changes and address immediate barriers or questions.

· Address any adverse reaction to new meds

1–2 Weeks:

· Reassess weight, fasting glucose, and possibly repeat Fructosamine

· Confirm Care Management enrollment

1–2 Months:

· Decide on the need for further intervention or adjustments to medications based on current trends.

· Repeat Fructosamine and Blood Glucose

· Repeat A1c (3 Months)

Diabetes:

1–2 Days:

· For newly diagnosed or recently uncontrolled diabetes, confirm safe blood glucose ranges and correct usage of insulin/oral agents while watching for acute complications (e.g., hypoglycemia, ketoacidosis, hyperosmolar state).

· Address any adverse reaction to new meds

1–2 Weeks:

· Review glucose logs or continuous glucose monitoring (CGM) data; adjust medications (insulin doses, oral agents) as necessary. Reinforce dietary and exercise regimens and monitor for early signs of complications.

· Repeat Fructosamine and Blood Glucose

· Confirm Care Management enrollment

1–2 Months:

· Repeat A1c (3 Months) and review overall glycemic trends.

· Evaluate for diabetic complications

o Reorder/Run:

§ ABI Test

§ Retinal Eye Exam

§ CGM (if still uncontrolled)

§ Microalbumin, Urinalysis Test

§ Lipid, TSH, CMP, Fructosamine

Cholesterol Management

Hyperlipidemia:

1–2 Days:

· Recheck if the patient has a high cardiovascular risk and confirm patient understanding of dietary modifications.

1–2 Weeks:

· Check for medication tolerance (e.g., myalgias, gastrointestinal issues), ensure dietary compliance, and reinforce lifestyle goals.

· Confirm Care Management enrollment

1–2 Months:

· Repeat lipid panel. Adjust therapy or add additional agents (e.g., ezetimibe, PCSK9 inhibitors) based on the response.

Low HDL:

1–2 Days:

· Reevaluate of Acute Influences

· Address any adverse reaction to new meds

1–2 Weeks:

· Reinforce the exercise plan (both aerobic and resistance training) and assess dietary patterns (quality of fats, overall caloric intake).

· Confirm Care Management enrollment

1–2 Months:

· Recheck the full lipid profile, evaluate HDL improvements with lifestyle changes, and consider medication adjustments if necessary.

Apolipoproteins:

1–2 Days:

· Reevaluate of Acute Influences

· Address any adverse reaction to new meds

1–2 Weeks:

· Confirm lab reliability and consider repeating the test if clinically necessary. Check for medication adherence and side effects.

· Confirm Care Management enrollment

1–2 Months:

· Reassess apolipoprotein levels in the context of therapy and lifestyle changes. Decide on further lipid-lowering strategies based on global cardiovascular risk.

· Discuss referral to Cardiology

Thyroid Disorders

Hyperthyroidism:

1–2 Days:

· If symptomatic (e.g., palpitations, anxiety, tachycardia), recheck to ensure that there is no risk for a thyroid storm.

1–2 Weeks:

· Reassess symptoms and repeat labs if there have been recent medication changes (e.g., methimazole, PTU).

· Monitor for medication side effects such as agranulocytosis or hepatic issues.

· Confirm Care Management enrollment

1–2 Months:

· Repeat thyroid function tests (TSH, T4 ± T3) and adjust antithyroid medications or plan for definitive treatment (radioactive iodine or surgery) as needed.

Hypothyroidism:

1–2 Days:

· Confirm the patient’s levothyroxine regimen if they are severely symptomatic or have an extremely elevated TSH.

1–2 Weeks:

· Assess improvement in symptoms (e.g., fatigue, weight changes), verify medication compliance, and check for potential drug interactions.

· Confirm Care Management enrollment

1–2 Months:

· Recheck TSH to titrate levothyroxine dosage. Evaluate for persistent symptoms or complications such as hyperlipidemia or bradycardia.

B. Vascular Conditions

Blood Pressure Management

Hypertension:

1–2 Days:

· If blood pressure is severely elevated (e.g., hypertensive urgency), ensure safe control with immediate interventions.

1–2 Weeks:

· Recheck blood pressure readings (home or office), assess medication tolerability, and reinforce a low-sodium diet and activity modifications.

· Confirm Care Management enrollment

1–2 Months:

· Confirm blood pressure control with repeated measurements. Evaluate the need for combination therapy or additional lifestyle modifications.

· Collect EKG again

o If Abnormal, follow SOC pathway

Hypotension:

1–2 Days:

· Stabilize the patient with fluids or medication adjustments if symptomatic; recheck blood pressure.

· If blood pressure is severely low (e.g., hypotensive urgency), ensure safe control with immediate interventions.

1–2 Weeks:

· Monitor vital signs closely, ensure that the underlying cause is being addressed, and observe for orthostatic changes.

· Confirm Care Management enrollment

1–2 Months:

· Reassess the medication regimen, evaluate improvements in the underlying causes, and check for recurrence or ongoing symptoms

· Collect EKG again

o If abnormal, follow SOC pathway

Elevated Blood Pressure (Borderline):

1–2 Days:

· Evaluate home readings, reinforce dietary and activity compliance, and determine if pharmacotherapy is warranted.

1–2 Weeks:

· Reassess blood pressure and consider further interventions if readings remain above normal

· Confirm Care Management enrollment

1–2 Months:

· Continue tracking weight, laboratory markers, and cardiovascular risk factors.

· Collect EKG again

o If abnormal, follow SOC pathway

Vascular Disorders (Arterial and Venous)

For disorders involving various arterial territories (e.g., coronary, peripheral, renal, carotid/cerebral) as well as vascular dissections and aneurysms:

1–2 Days:

· In cases of acute presentations (e.g., chest pain, claudication, transient ischemic attack symptoms, suspected aneurysm or dissection), initiate urgent testing or imaging.

· Therapy Initiation: If an acute vascular event is suspected or confirmed, early follow-up supports the rapid initiation or adjustment of treatment protocols—such as antiplatelet therapy, anticoagulation, or other interventions—to stabilize the patient.

1–2 Weeks:

· Review imaging or test results and ensure appropriate specialist follow-up (e.g., cardiology or vascular surgery). Reinforce medication adherence (such as antiplatelets or statins).

· Confirm Care Management enrollment

1–2 Months:

· Monitor for symptom progression or improvement. Repeat imaging (for example, US) and adjust the long-term management plan as needed.

C. Cardiac Conditions

Heart Failure

Heart Failure with Preserved Ejection Fraction (HFpEF):

1–2 Days:

· In the event of new decompensation, assess volume status (monitoring for edema, weight change) and ensure an appropriate diuretic regimen with follow-up by cardiology.

· Review Medication: Diuretic Efficacy and Tolerability or Initiation of Other Heart Failure Medications

1–2 Weeks:

· Check electrolytes and renal function following any medication adjustments. Evaluate clinical improvement in symptoms such as dyspnea and fatigue.

· Confirm Care Management enrollment

1–2 Months:

· Consider an echocardiogram (Echo) to assess ejection fraction if clinically indicated. Titrate or optimize guideline-directed medical therapy (ACE inhibitors/ARBs/ARNI, beta-blockers, mineralocorticoid receptor antagonists, etc.).

Heart Failure with Mixed or Reduced Ejection Fraction:

· Follow similar follow-up intervals as above, with adjustments tailored to the severity and patient response.

Rhythm Disorders

Rapid Arrhythmias (e.g., Atrial Fibrillation, Tachycardia, Bradycardia):

1–2 Days:

· Early Detection of Instability (Acute Symptom Monitoring and ECG Verification)

· Assessment of Therapeutic Efficacy

1–2 Weeks:

· Evaluate the effectiveness of medications (e.g., beta-blockers, antiarrhythmics) and monitor for any side effects. Ensure follow-up ECG or telemetry as needed.

· Confirm Care Management enrollment

1–2 Months:

· Reassess arrhythmia control with repeat ECGs or Holter/event monitoring. Consider referrals for advanced therapies (e.g., ablation or device therapy) if indicated.

Slow Arrhythmias:

Follow similar protocols with adjustments based on the patient’s symptoms and clinical status.

D. Pulmonary Conditions

Pulmonary

Obstructive Lung Disease (Asthma, COPD)

1–2 Days:

· Response to Acute Therapy

· Ensure proper medication adjustments and address any medication adverse reactions

1–2 Weeks:

· Evaluate the response to controller medications or any therapy changes. Adjust inhaled medications and ensure proper inhaler technique.

· Confirm Care Management enrollment

1–2 Months:

· Consider repeating pulmonary function testing if there has been a significant change in therapy. Reinforce lifestyle measures such as smoking cessation and regular exercise.

Restrictive Lung Disease

1–2 Days:

· Response to Acute Therapy

· Ensure proper medication adjustments and address any medication adverse reactions

1–2 Weeks:

· Review imaging to confirm the diagnosis and assess the therapy plan (such as steroid use in interstitial lung disease). Determine if a specialist referral is needed.

· Confirm Care Management enrollment

1–2 Months:

· Re-check lung function or imaging studies, monitor progression, and adjust long-term management plans (e.g., immunosuppressive therapy, pulmonary rehabilitation).

· Repeat Spirometry to check for improvement

Infections (Pulmonary)

1–2 Days:

i. Assess for urgent complications such as pneumonia or severe allergic reactions.

ii. Ensure proper medication adjustments and address any medication adverse reactions

1–2 Weeks:

iii. Confirm resolution or improvement of the infection. If the patient is stable, consider de-escalating antibiotics or other therapies.

iv. Confirm Care Management enrollment

1–2 Months:

v. Order Allergy Testing

vi. Evaluate for recurrent episodes or underlying chronic triggers (e.g., allergen exposure, sinus issues). Consider imaging or specialist referral if recurrent or unresolved.

E. Mind/Mental/Neurological Conditions

Psych

DSM-Based Disorders

1–2 Days:

i. In cases of acute risk (e.g., suicidal ideation, severe psychosis, withdrawal), ensure the development and initiation of a safety plan or consider hospitalization if necessary.

1–2 Weeks:

ii. Check for medication tolerance and side effects (e.g., sedation, mood changes) while monitoring adherence and acute risk factors.

iii. Confirm Care Management enrollment

iv. Confirm Behavioral Health appt.

1–2 Months:

v. Reassess overall symptom changes. Consider medication titration, new therapy options, or referrals for psychotherapy, support groups, or rehabilitation as needed.

vi. Recheck PHQ-9

Seizure Disorders

1–2 Days:

vii. After a recent seizure, ensure the patient’s safety, update medications if indicated, and provide acute care.

1–2 Weeks:

viii. Evaluate seizure frequency, identify possible triggers, and monitor for medication side effects. Reinforce avoidance of known precipitants.

ix. Confirm Care Management enrollment

1–2 Months:

x. Re-check medication levels and consider obtaining an EEG or imaging study if clinically relevant. Adjust the treatment regimen based on seizure control and tolerability.

Memory, Cognitive, and Motor Disorders

1–2 Days:

xi. For an acute decline (for example, after stroke, infection, or trauma), ensure urgent imaging or treatment.

1–2 Weeks:

xii. Reassess the patient’s neurologic status and therapy progress (including physical, occupational, or cognitive rehabilitation). Confirm that follow-up imaging or specialist consultations have been scheduled.

xiii. Confirm Care Management enrollment

1–2 Months:

xiv. Evaluate functional improvements and adjust therapies (medications, rehabilitation plans) accordingly. Monitor for secondary complications such as deconditioning or depression.

xv. Reorder Cognivue test

Other Neuropsychiatric Disorders (Attention/Focus, Sensory, Gait/Balance, etc.)

a. Apply similar follow-up intervals as above, tailored to the severity and impact on daily function.

F. Musculoskeletal Conditions

MSK

Joint Conditions (Arthritis, Arthralgia, Acute Joint Injury)

1–2 Days:

i. In the presence of an acute swollen or red joint, rule out infection or crystal arthropathy with rushed lab results

1–2 Weeks:

ii. Re-evaluate pain, joint function, and the response to any initiated therapy. Consider imaging studies (X-ray, MRI) if the etiology remains unclear or if symptoms persist.

iii. Confirm Care Management enrollment

iv. Confirm Physical Therapy enrollment

1–2 Months:

v. Adjust long-term management strategies (for example, initiation or titration of DMARDs in chronic arthritis or referral for physical therapy) and monitor progression.

Muscle Disorders (Myalgia, Myositis, Atrophy/Sarcopenia, Injury/Rupture)

1–2 Days:

vi. If found for underlying metabolic or autoimmune causes (e.g., checking CK levels), connect with patient.

1–2 Weeks:

vii. Adjust physical therapy plans and consider advanced imaging if improvement is not observed.

viii. Confirm Care Management enrollment

ix. Confirm Physical Therapy enrollment

1–2 Months:

x. Monitor strength gains, symptom resolution, and adjust management accordingly.

Bone Health (Fractures, Osteopenia/Osteoporosis, Osteomalacia)

1–2 Days:

xi. Address pain management and, if indicated, initiate DVT prophylaxis.

1–2 Weeks:

xii. Reassess fracture sites (if in a cast or splint) to ensure proper healing, and review bone density management strategies (calcium/vitamin D supplementation, bisphosphonates).

xiii. Confirm Care Management enrollment

xiv. Confirm Physical Therapy enrollment

1–2 Months:

xv. Repeat imaging studies to confirm healing. Assess and optimize long-term bone health, including appropriate intervals for DEXA scanning and fall prevention measures.

Autoimmune Musculoskeletal Disorders

1–2 Days:

xvi. Arrange for urgent laboratory evaluation (e.g., ESR, CRP, and specific autoantibodies) when indicated and review with patient

1–2 Weeks:

xvii. Reassess symptom control and monitor for medication side effects. Modify therapy or consider bridging treatments if a flare persists.

xviii. Confirm Care Management enrollment

1–2 Months:

xix. Monitor disease activity through joint counts and laboratory markers. Titrate DMARDs or biologics based on patient response and consider rheumatology referral when necessary.

G. Hematology/Oncology Conditions

Hem

Underproduction Disorders (e.g., Neutropenia, Anemia)

1–2 Days:

i. If severe cytopenia is present (for example, neutropenic fever), initiate urgent intervention.

1–2 Weeks:

ii. Monitor complete blood counts (CBC) following any interventions (transfusions, medication changes) and evaluate for underlying causes such as nutritional deficiencies or marrow infiltration.

iii. Confirm Care Management enrollment

1–2 Months:

iv. Track CBC trends and adjust therapy accordingly. Consider hematology referral for persistent or unexplained cytopenia.

Loss Disorders (e.g., Acute Bleeding)

1–2 Days:

v. Discuss hemoglobin/hematocrit in cases of severe anemia or acute bleeding episodes.

1–2 Weeks:

vi. Ensure resolution of bleeding, begin supportive measures such as iron supplementation, and confirm stabilization.

vii. Confirm Care Management enrollment

1–2 Months:

viii. Confirm normalization of RBC levels and iron stores, and evaluate for recurrence or underlying pathology (e.g., gastrointestinal ulcers, fibroids).

Overproduction Disorders

1–2 Days:

ix. If laboratory values identify acute triggers, discuss and treat patient

1–2 Weeks:

x. Repeat CBC or other relevant labs to confirm persistent overproduction; discuss possible hematology referral (including testing such as JAK2 mutation analysis if indicated).

xi. Confirm Care Management enrollment

1–2 Months:

xii. Track trends and consider therapeutic interventions (such as phlebotomy for polycythemia), and evaluate for secondary causes (e.g., smoking, high altitude, EPO-secreting tumors).

Oncologic Lesions (By Body Part/Organ or Histologic Type)

1–2 Days:

xiii. For a newly discovered suspicious lesion, ensure urgent scheduling for imaging and biopsy.

1–2 Weeks:

xiv. Review pathology results, finalize the diagnosis, and initiate or plan appropriate treatment. Manage any acute symptoms such as pain or weight loss.

xv. Confirm Care Management enrollment

1–2 Months:

xvi. Follow up on treatment responses (whether chemotherapy, radiation, or surgery), adjust therapy based on updated imaging/lab results, and monitor for side effects.

H. Gastroenterology Conditions

GI

Inflammatory Conditions (e.g., Crohn’s Disease, Ulcerative Colitis, Severe IBS-D, Acute Infections)

1–2 Days:

i. In cases of a severe flare, ensure appropriate hydration and initiate urgent interventions.

1–2 Weeks:

ii. Reassess symptoms and the response to treatment (antibiotics, steroids, or immunosuppressants). Optimize dietary strategies (e.g., low FODMAP for IBS as appropriate).

iii. Confirm Care Management enrollment

1–2 Months:

iv. Evaluate overall disease control. Consider repeating colonoscopy or other imaging studies, and adjust therapy (escalation or step-down) as clinically indicated.

v. Reorder FOBT

Irritable Bowel Syndrome and Acute Gastrointestinal Conditions

1–2 Days:

vi. For acute episodes (e.g., pancreatitis, cholangitis, gastrointestinal bleeding), stabilize the patient and confirm the diagnosis with lab tests results and discuss with patient

1–2 Weeks:

vii. Review imaging studies (endoscopy, ultrasound, CT), check laboratory trends (liver function tests, lipase, etc.), and assess the response to any interventions (for example, post-ERCP for bile duct issues).

viii. Confirm Care Management enrollment

1–2 Months:

ix. Confirm resolution or significant improvement of the acute episode and plan for long-term management (such as cholecystectomy in gallbladder disease or lifestyle modifications for GERD).

x. Reorder FOBT

Other Gastrointestinal Conditions (Esophageal, Gastric, Intestinal, Colon, Pancreatic, Liver, Gallbladder)

Follow-Up:

xi. Apply similar follow-up intervals based on the clinical presentation. Urgent intervention is required for acute presentations, with reassessment at 1–2 weeks and a comprehensive review at 1–2 months.

5. Documentation and Communication

Documentation:

All follow-up plans and interventions must be documented in the patient’s electronic health record (EHR) including the specific time frames, clinical rationale, and any changes to therapy.

Communication:

Clinicians are responsible for ensuring that the patient and relevant care team members are informed of the follow-up plan. Any significant changes in the patient’s condition should prompt an immediate review of this policy and adjustment of the care plan.

ACT MODEL

PDMC

1-2 Follow Up

SOC Pathways

1-2 Follow Up

1. Purpose

2. Scope

3. Policy Statement

4. Procedures and Recommendations Following 1-2 FU

A. Metabolic Conditions

Weight/Obesity Conditions

Underweight Patients:

1–2 Days:

1–2 Weeks:

Overweight/Obese Patients:

1–2 Days:

1–2 Weeks:

1–2 Months:

Hyperglycemia:

1–2 Days:

1–2 Weeks:

1–2 Months:

Pre-Diabetes:

1–2 Days:

1–2 Weeks:

1–2 Months:

Diabetes:

1–2 Days:

1–2 Weeks:

1–2 Months:

Cholesterol Management

Hyperlipidemia:

1–2 Days:

1–2 Weeks:

1–2 Months:

Low HDL:

1–2 Days:

1–2 Weeks:

1–2 Months:

Apolipoproteins:

1–2 Days:

1–2 Weeks:

1–2 Months:

Thyroid Disorders

Hyperthyroidism:

1–2 Days:

1–2 Weeks:

1–2 Months:

Hypothyroidism:

1–2 Days:

1–2 Weeks:

1–2 Months:

B. Vascular Conditions

Blood Pressure Management

Hypertension:

1–2 Days:

1–2 Weeks:

1–2 Months:

Hypotension:

1–2 Days:

1–2 Weeks:

1–2 Months:

Elevated Blood Pressure (Borderline):

1–2 Days:

1–2 Weeks:

1–2 Months:

Vascular Disorders (Arterial and Venous)

1–2 Days:

1–2 Weeks:

1–2 Months:

C. Cardiac Conditions

Heart Failure

Heart Failure with Preserved Ejection Fraction (HFpEF):

1–2 Weeks:

1–2 Months:

Heart Failure with Mixed or Reduced Ejection Fraction:

Rhythm Disorders

Rapid Arrhythmias (e.g., Atrial Fibrillation, Tachycardia, Bradycardia):

1–2 Days:

1–2 Weeks: