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Care transition standard operational improvements

Activity ID

IA_CC_11

Activity Weighting

Medium

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

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