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2020 MIPS IA_CC_10: Care transition documentation practice improvements

Activity ID

IA_CC_10

Activity Weighting

Medium

Subcategory 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.

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