Care transition standard operational improvements

Activity ID

Activity Weighting

Subcategory Name

Care Coordination

Activity Description

Establish standard operations to manage transitions of care that could include one or more of the following:

• Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or
• Partner with community or hospital-based transitional care services.

Validation

Functionality of information flow during transitions of care to ensure seamless transitions

Suggested Documentation

1) Communication Lines with Local Settings - Documentation of formal lines of communication to manage transitions of care with local settings (e.g. community or hospital-based transitional care services) in which empaneled patients receive care to ensure documented flow of information and seamless transitions; or
2) Partnership with Community or Hospital-Based Transitional Care Services - Documentation showing partnership with community or hospital-based transitional care services