Implementation of episodic care management practice improvements

Activity ID

Activity Weighting

Subcategory Name

Population Management

Activity Description

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.

Validation

Provision of episodic care management practice improvements (could use medical records or claims)

Suggested Documentation

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)