Activity ID
IA_CC_17Activity Weighting
HighSubcategory Name
Care Coordination
Activity Description
Implement a Patient Navigator Program that offers evidencebased resources and tools to reduce avoidable hospital readmissions, utilizing a patientcentered and team-based approach, leveraging evidencebased best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.
Objective
Reduce avoidable hospital readmissions and make hospital stays less stressful and recovery periods more supportive for patients.
Suggested Documentation
Evidence of participation in a Patient Navigator Program (PNP) designed to meet this activity’s objective. Include all of the following elements:
1) PNP participation – Confirmation of participation in PNP. PNP should take into account patients' language and communication preferences, literacy level, and cognitive and physical disabilities; AND
2) Documentation of tools to reduce avoidable hospital readmissions – Tools should be evidencebased whenever possible; AND
3) Quality improvement strategies – Implementation of systems, tools, and strategies as part of the PNP that aim to achieve the objective of this activity. May include workflows and approaches that assist patients with communicating with eligible healthcare clinicians regarding their questions, obtaining information about their procedures/treatments, and arranging for test or appointments.