CC 12 - Care Coordination Agreements that Promote Improvements in Patient Tracking Across Settings
Activity Weighting: Medium
Subcategory Name: Care Coordination
Description: Establish effective care coordination and active referral management that could include one or more of the following:
- Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings.
- Provide patients with information that sets their expectations consistently with the care coordination agreements;
- Track patients referred to specialist through the entire process; and/or
- Systematically integrate information from referrals into the plan of care.
- Care Coordination Agreements - Sample of care coordination agreements with frequently used consultant that establish documented flow of information and provides patients with information to set consistent expectations; or
- Tracking of Patient Referrals to Specialists - Medical record or EHR documentation demonstrating tracking of patients referred to specialists through the entire process; or
- Referral Information Integrated into the Plan of Care - Samples of specialist referral information systematically integrated into the plan of care.