2024 MIPS IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings

Activity ID

Activity Weighting

Subcategory Name

Care Coordination

Activity Description

Establish effective care coordination and active referral management that could include one or more of the following:

• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;
• Track patients referred to specialist through the entire process; and/or
• Systematically integrate information from referrals into the plan of care.

Objective

Improve processes for care coordination and active referral management, thus making care more effective and efficient, preventing risky delays and under-treatment, and increasing patient satisfaction and adherence to treatment.

Suggested Documentation

Evidence of care coordination and referral management. Include at least one of the following elements:

1) Care coordination agreements – Documentation of care coordination agreements that establish flow of information and provide patients with information to set consistent expectations; OR

2) Tracking of patient referrals to specialists – Medical record or electronic health record documentation demonstrating tracking of patients referred to specialists through the entire process; OR

3) Referral information integrated into the plan of care – Samples of specialist referral information systematically integrated into the plan of care.

Example/Information

Co-management models for care coordination across treatment settings include establishing collaborative practice agreements/conflict resolution pathways among engaged specialists for all anticipated care episodes; for example:

• Documentation showing a comprehensive written policy such as a service line agreement or Memorandum of Understanding (MOU) that establishes partnerships with community or hospitalbased transitional care services, depicts workflow protocols and flow of information, and defines clear roles for each participating provider or clinical staff member. Written policy should include any foreseen operational and clinical conflicts, with specific escalation and resolution procedures (e.g., concerns around clinical area overstep elevated to hospital leadership, clinical issue presented to hospital review committee).v