PSH Care Coordination

Activity ID

Activity Weighting

Subcategory Name

Care Coordination

Activity Description

Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:

• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;
• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or
• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.

Validation

Evidence of participation in a Perioperative Surgical Home (PSH) model that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care

Suggested Documentation

1) Coordinate with care managers/navigators in preoperative clinic to plan and implement comprehensive post discharge plan of care that could take into account patients' post discharge environment and support system out of the hospital; and
2) Deploy perioperative clinic and care processes to reduce post -operative visits to emergency rooms; and
3) Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; and
4) Implement processes to ensure effective communications and education of patients' post-discharge instructions, taking into account patients' literacy level, language and communication preferences, and cognitive or functional impairments.