Activity ID
IA_CC_10Activity Weighting
MediumSubcategory Name
Care Coordination
Activity Description
In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.
Validation
Patient-centered, care transition action plan with evidence of implementation for the first 30 days following a discharge. Action plan and patient communication that could take into account patient communication and language preferences, available supports and services (as outlined in the CMS suggested documentation), and patients' discharge environment.
Suggested Documentation
Documentation of improved care practices such as staff involved care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications with a patient-centered plan must be demonstrated during the first 30 days following a discharge.
Examples of Additional Activities that Qualify for Attestation
Completing these alternate activities can fulfill the requirements of this Improvement Activity; and Notes
Sub-IA-1: IA may apply to fracture-related care.