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This proposed timely follow-up standard is similar to several requirements tested in CMS Innovation Center models (such as the CPC+ model's requirement that participating practices ensure patients with ED visits received a follow-up interaction within one week of discharge [64] and the MCP model's requirement that participating practices implement episodic care management to provide timely follow-ups for high-risk patients post ED visit and hospitalization [65] ), and we patterned the timely follow-up element after our policy for TCM services which requires, for example, communication (direct contact, telephone, electronic) with the patient and/or caregiver with 2 business days of discharge and a face-to-face visit within 7 calendar days of discharge. Providing timely follow-ups for patients is an essential element of the delivery of care under an advanced primary care model of care, and we believe this will help achieve timely, seamless care across settings especially after discharge from a facility

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