Hospital Discharge Medical Follow-Up

Short-term medical follow-up for recently discharged patients to ensure safe transitions from hospital to home and reduce readmission risk.

A doctor examining a male patient with a stethoscope in a medical office, with a lung diagram on the wall and medical supplies on a cart.

Safe Transition Management

Post-discharge care to bridge the gap between hospital and community care, ensuring continuity of medical management and treatment plans.

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Readmission Prevention

Strategic management and coordination across multiple medical specialties to ensure cohesive treatment plans and optimal patient outcomes.

Black and white illustration of a doctor examining a young male patient in a medical office, with a poster of lungs on the wall behind them.

Medication Reconciliation

Review and optimization of discharge medications, ensuring proper dosing, addressing drug interactions, and confirming patient understanding.

Service Overview

Our discharge follow-up clinic focuses on recently discharged patients who need short-term medical follow-up to support safe transitions from hospital to home throughout Calgary and surrounding communities in Alberta. This specialized service addresses the critical post-discharge period when patients are most vulnerable to complications and readmissions.

We provide essential continuity of care through comprehensive medication reconciliation, diagnostic test follow-up, and early identification of complications to reduce readmission risk and improve recovery outcomes. Our Calgary-based post-discharge medical service can be accessed by medical or surgical teams throughout Calgary hospitals, with our focus being on post-discharge management of medical conditions.

Our general internal medicine specialists excel at managing the complex medical needs of recently hospitalized patients, coordinating care between hospital teams and community providers, and identifying potential complications before they require emergency intervention. We ensure seamless communication with both hospital discharge teams and primary care physicians to optimize patient outcomes during this vulnerable transition period.

Our approach includes reviewing discharge summaries, reconciling medications, following up on pending investigations, and addressing any new symptoms or concerns that arise in the immediate post-discharge period. We work collaboratively with referring hospital teams to ensure comprehensive post-discharge medical management.

Referral Forms

Electronic Referral Form

Fill out digitally on your computer or mobile device, then fax the completed form to +1 (825) 540-4071.

Printable Referral Form

Download and print to complete by hand, then fax the completed form to +1 (825) 540-4071.

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Why Refer To Us

Expertise You Can Trust

Board-certified general internal medicine specialists with extensive experience in complex medical conditions and diagnostic challenges.

Collaborative Approach

We work closely with referring physicians and other specialists to ensure coordinated, comprehensive patient care.

Timely Access

Faster access to general internal medicine consultation compared to traditional hospital-based clinics, with flexible appointment scheduling.

Comprehensive Reports

Detailed consultation reports with clear recommendations, ensuring seamless communication with your healthcare team.

Comprehensive Care Through Dual Practice

Our physicians practice both in the hospital and community, bringing broader experience and deeper clinical insight to ensure patient care informed by real-time, hands-on knowledge across the full continuum of care.

Frequently Asked Questions

  • Ideally within 7-14 days of hospital discharge, depending on the complexity of the medical condition and discharge recommendations. Urgent cases can be prioritized for earlier assessment.

  • Discharge summary, updated medication list, any pending lab or imaging results, and a list of questions or concerns that have arisen since leaving the hospital.

  • Yes, we work closely with hospital medical and surgical teams to ensure continuity of care and follow through on all discharge recommendations and pending investigations.

  • Absolutely. While hospital teams can access this service directly, family physicians can also refer patients who may benefit from specialist post-discharge medical management and coordination of care.