Care Coordination and Care Transitions (CC)

The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result.

Competency B: The practice provides important information in referrals to specialists and tracks referrals until the report is received.

Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.

The practice systematically manages lab and imaging tests

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Follows up with the inpatient facility about newborn hearing and blood-spot screening.

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Uses clinical protocols to determine when imaging and lab tests are necessary.

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The practice systematically manages referrals.

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Uses clinical protocols to determine when a referral to a specialist is necessary.

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Identifies the specialists/specialty types frequently used by the practice.

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Considers available performance information on consultants/specialists when making referrals.

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Works with non-behavioral healthcare specialists to whom the practice frequently refers to set expectations for information sharing and patient care.

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Works with behavioral healthcare providers to whom the practice frequently refers to set expectations for information sharing and patient care.

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Integrates behavioral healthcare providers into the care delivery system of the practice site.

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