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Provide Clinical-Community Linkages

Activity ID

IA_PM_18

Activity Weighting

Medium

Subcategory Name

Population Management

Activity Description

Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.

Validation

Evidence of engagement with community health workers to provide a comprehensive link to community resources and family-based services with an emphasis on improving health, education, and self-sufficiency

Suggested Documentation

1) Documentation of engagement with community health workers;and
2) A demonstrated link to community resources that promote family-based services i.e. paperwork, notes, etc.; and
3) Documentation of coordination with primary care and other clinicians to engage and support patients, use of health information technology, and employ quality measurement and improvement processes, e.g. NCQA Patient-Centered Connected Care(PCCC) Recognition Program or similar programs.

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