- Activity ID
- IA_CC_11
- Subcategory
- Care Coordination
- Category
- Improvement Activities
Objective
Enhance communication during care transitions to improve patient outcomes by establishing standard operations, or preferred practice patterns, for transition communications.
Activity description
Establish standard operations to manage transitions of care that could include one or more of the following:
- Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or
- Partner with community or hospital-based transitional care services.
Suggested documentation
Evidence of information flow during transitions of care. Include at least one of the following elements:
1) Communication lines with local settings – Documentation of standardized lines of communication to manage transitions of care between settings. Communication can occur in whatever format is most useful based on the circumstances of the eligible clinicians; OR
2) Partnership with community or hospital-based transitional care services – Documentation showing partnership with community or hospital-based transitional care services (e.g., written agreement, workflow documentation).