Provide episodic care management, including management across transitions and referrals that could include one or more of the following:
Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or
Managing care intensively through new diagnoses, injuries and exacerbations of illness.
Provision of episodic care management practice improvements (could use medical records or claims)
1) Follow-Up on Hospitalizations, ED or Other Visits and Medication Management - Routine and timely follow-up to hospitalizations, ED or other institutional visits, and medication reconciliation and management (e.g. documented in medical record or EHR); or
2) New diagnoses, Injuries and Exacerbations - Care management through new diagnoses, injuries and exacerbations of illness (medical record)