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Practice Improvements that Engage Community Resources to Support Patient Health Goals

Activity ID


Activity Weighting


Subcategory Name

Care Coordination

Activity Description

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:

  • Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.
  • Including through the use of tools that facilitate electronic communication between settings;
  • Screen patients for health-harming legal needs;
  • Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
  • Provide a guide to available community resources.


Availability of formal links to community-based health and wellness programs potentially including availability of resource guides

Suggested Documentation

1) Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or
2) Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources

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