Activity ID
IA_CC_11Activity Weighting
MediumSubcategory 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.
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: Implement Warm Handoff Plus strategy