Practice improvements that engage community resources to support patient health goals

Activity ID

IA_CC_14

Activity Weighting

Medium

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/or

Provide a guide to available community resources.

Validation

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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