Care coordination agreements that promote improvements in patient tracking across settings

Activity ID


Activity Weighting


Subcategory Name

Care Coordination

Activity Description

Establish effective care coordination and active referral management that could include one or more of the following:

  • Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;
  • Track patients referred to specialist through the entire process; and/or
  • Systematically integrate information from referrals into the plan of care.


Functionality of effective care coordination and referral management

Suggested Documentation

1) Care Coordination Agreements - Sample of care coordination agreements with frequently used consultant that establish documented flow of information and provides patients with information to set consistent expectations; or
2) Tracking of Patient Referrals to Specialists - Medical record or EHR documentation demonstrating tracking of patients referred to specialists through the entire process; or
3) Referral Information Integrated into the Plan of Care - Samples of specialist referral information systematically integrated into the plan of care

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