- Activity ID
- IA_PM_15
- Subcategory
- Population Management
- Category
- Improvement Activities
Objective
Use episodic care management to improve quality of care and communication across referrals and transitions of care.
Activity description
Provide episodic care management, including management across transitions and referrals that could include one or more of the following:
• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or
• Managing care intensively through new diagnoses, injuries and exacerbations of illness.
Suggested documentation
Evidence of episodic care management practice improvements. Include at least one of the following elements:
1) Follow-up on hospitalizations, emergency department (ED), or other visits, and medication management – Routine and timely follow-up to hospitalizations, ED, or other institutional visits, and medication reconciliation and management (e.g., documented in medical record or electronic health record [EHR]); OR
2) New diagnoses, injuries and exacerbations – Intensive care management at time of new diagnoses, injuries, and exacerbations of illness documented in medical record or EHR.