Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).
ObjectiveDevelop and utilize processes that improve care coordination outcomes.
The eligible clinician identifies an area within their practice in which improved care coordination will improve an outcome. The area(s) for improvement, intervention strategies, and the outcome goals are to be defined by the eligible clinicians involved. Evidence of newly implemented processes and practices to improve care coordination, including both of the following elements:
1) Care coordination process documentation – Documentation of the implementation of practices/processes that document care coordination activities (e.g., record of meeting minutes to discuss changes, swim lane workflow diagram, agenda noting training on new practices/processes for staff, copy of old and new practices/processes on documenting care coordination activities); AND
2) Care coordination outcomes – Documentation of, or ability to demonstrate evidence of, the outcomes from newly implemented practices/processes.
An eligible family practice (FP) clinician frequently sees patients in follow-up after emergency department (ED) visits. The eligible clinician does not have immediate access to the ED records and the process of requesting the records is cumbersome and not practical at the time of follow-up. The eligible clinician works with the ED to create an automatic process within the electronic health record so that a brief summary of the ED visit is forwarded to the eligible clinician doing the follow-up. This would require that the eligible ED clinicians always document a brief summary even when they have not completed the full record and it would require information technology support to generate the email/fax, etc. All eligible clinicians involved (FP and ED) get credit for this activity.