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.

Monitors the timeliness and quality of the referral response.

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Documents co-management arrangements in the patient’s medical record.

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Engages with patients regarding cost implications of treatment options.

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Systematically identifies patients with unplanned hospital admissions and emergency department visits.

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Shares clinical information with admitting hospitals and emergency departments.

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Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit.

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Systematic ability to coordinate with acute care settings after office hours through access to current patient information.

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Exchanges patient information with the hospital during a patient’s hospitalization.

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Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities.

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Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care).

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