Follow-Up Referral Navigator

At a glance

	TCC	SPMF Primary Care	Pacific Primary Care
What it is	Short-term, hospitalist-led medical follow-up after discharge	Connects patients to an ongoing PCP through SPMF / SWBMG	Ongoing residency-based primary care with attending oversight
Inpatient	Epic Chat to Brenda Hooker (TCC)	Epic Secure Chat: MBC PCP Secure Group Chat	Call 415-600-2402
ED	Not confirmed	In Basket pool MIST SPMF SF MA (30316122), SF residents	No dedicated ED workflow confirmed
Insurance	All insurance	Scheduling team checks; not accepted per ED workflow: straight Medi-Cal, Brown & Toland, Partnership	FFS Medicare, NEMS, Blue Cross Medi-Cal, many commercial. Not: Brown & Toland, Hill, straight Medi-Cal, Partnership
Can combine	Yes, with either PCP route	Yes, with TCC	Yes, with TCC

TCC · Transitional Care Clinic

Bridges hospital to home and ongoing primary or specialty care. Supplements discharge planning; does not replace it.

Who qualifies

Adult medicine patients discharged from CPMC
Supports: complex conditions, no PCP, frequent ED visits or admissions, extra coordination needs, hard to reach
These are examples, not required criteria

Excluded

Transplant patients
General assignment cases with established follow-up

Insurance

All insurance accepted. TCC helps with authorizations and may absorb costs.

After discharge

RN check-in within 2 business days; urgent needs expedited
MD visit within 7 days for most patients
Mostly phone or video; in-person available but rare
No video access is not an exclusion

Services

Post-discharge medical assessment
Medication and diagnosis management
Coordination with PCPs and specialists
Home health and DME help
Establishing primary care
Help with follow-up appointments
Outstanding discharge needs
Care coordination to reduce preventable readmissions

How to refer · Mission Bernal, Davies

Identify the patient and their transitional care needs.
Epic Chat Brenda Hooker (TCC).
Include identifiers, contact info, anticipated discharge date, and the help requested.
Coordinate open discharge needs with the primary team and document the referral.

Division of work

Hospital team: specialty referrals, post-acute services, discharge arrangements.

TCC: follow-through, outstanding needs, continuity after discharge.

Manual Epic Chat workflow until referrals are automated through Epic discharge reports.

SPMF Primary Care

Connects patients without a PCP to outpatient care through Sutter Pacific Medical Foundation / SWBMG, to improve continuity and reduce ED use and readmissions.

Who to refer

Inpatient: hospitalized patients who need a PCP before discharge
ED: patients without a PCP who live in San Francisco

Insurance

The scheduling team or PSRs determine eligibility and options, including a medical-group change. The ED workflow lists straight Medi-Cal, Brown & Toland, and Partnership as not accepted.

Inpatient · Mission Bernal

SW/CM identifies a patient who needs a PCP.
Message the MBC PCP Secure Group Chat in Epic.
PSRs verify insurance eligibility.
If eligible, PSRs call the patient to schedule. If a group change may help, they discuss options.
If not accepted, PSRs notify the group.
Once scheduled, PSRs update the group; the appointment shows on the AVS.

Can't reach the patient? PSRs ask SW/CM for help in the group chat.

ED · Epic In Basket

In Basket → New Message.
Open recipient search (hourglass).
Under Pools, search MIST SPMF SF MA.
Select pool 30316122, Add To → Accept.
Associate the patient with the message.
Add what you know: provider gender preference, SF neighborhood, residency-clinic fit, urgency.
Send.

MIST calls the patient and checks eligibility. Monday–Friday business hours; messages accepted 24/7. Urgent requests may get a response within a few hours.

Pacific Primary Care

Residency-based primary care clinic: resident physicians supervised by attendings, with team support and continuity when residents graduate.

Good fit

Adults who need a new PCP
Complex medical or psychosocial needs
Close follow-up after hospitalization
Coordination with specialty services
Benefit from multidisciplinary support

Insurance

Accepted: FFS Medicare, NEMS, Blue Cross Medi-Cal, many commercial plans

Not accepted: Brown & Toland, Hill Physicians, straight Medi-Cal, Partnership

Verify current acceptance before scheduling.

How to refer

Confirm the plan is on the accepted list.
Call 415-600-2402 to request an appointment.
Share discharge and follow-up needs.
Document the referral and appointment.

A dedicated referral process and CM direct line are planned.

Services

Nursing, social work, case management, PA support
Same-day help for urgent needs
Embedded rheumatology, allergy, GI, women's health, addiction medicine

Languages

Mandarin, Cantonese, Spanish, Korean, Vietnamese

Location

2100 Webster St, Suite 516
San Francisco, CA 94115

Still to confirm

Whether automated Epic referrals have replaced the TCC Epic Chat, and whether Brenda is still the contact
Whether TCC or PPC accept ED-only patients
Where patients with no PCP go when neither SPMF nor PPC accepts their plan
PPC's current payer list and its planned case manager direct line
TCC and SPMF workflows at Davies and Van Ness
TCC's current eligibility and exclusion criteria, and whether a separate Epic order is needed
TCC follow-up timelines and the patient line number

Program	Use for	Contact
TCC	Inpatient referrals	Epic Chat: Brenda Hooker
TCC	Patient line	415-600-0821
SPMF	Inpatient (Mission Bernal)	Epic Secure Chat: MBC PCP Secure Group Chat
SPMF	ED	In Basket pool MIST SPMF SF MA 30316122
PPC	Appointments	415-600-2402
PPC	Address	2100 Webster St, Suite 516, San Francisco, CA 94115

Referral plan

At a glance

TCC · Transitional Care Clinic

Who qualifies

Excluded

Insurance

After discharge

Services

How to refer · Mission Bernal, Davies

Division of work

SPMF Primary Care

Who to refer

Insurance

Inpatient · Mission Bernal

ED · Epic In Basket

Pacific Primary Care

Good fit

Insurance

How to refer

Services

Languages

Location

Still to confirm