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Concept: 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.

• 3 Competencies• 21 Criteria:

• 5 Core• 16 Elective (24 credits)

• 5 New to 2017 criteria

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

Care Coordination and Care Transitions

Criteria Core Elective # Credits

CC01: The practices systematically manages lab and imaging by: A. tracking lab tests until results are available, flagging and following up on overdue results, B. Tracking imaging tests until results are available, flagging and following up on overdue results, C. Flagging abnormal lab results, bringing them to the attention of the clinician, D. Flagging abnormal imaging results, bringing them to the attention of the clinician, E. Notifying patients/families/caregivers of normal lab/imaging results, F. Notifying patients/families/caregivers of abnormal lab and imaging results

X

CC02: Follows up with the inpatient facility about newborn hearing and blood-spot cleaning X 1

CC03: Uses clinical protocols to determine when imaging and lab tests are necessary X 2

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CC 01 (Core)

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CC01-A,B: (2014 equivalent = 5A 1 & 2)• Define timeliness based on history• Use the data to allocate resources to address barriers• HIT Optimization

• Who is the right person to do this work?

• This will be a virtual check in! Consistency, consistency, consistency• Begin with lab order, end with completion/cancelation

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CC01-A,B: Tracking lab, Imaging results

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CC01-A,B: Tracking lab, imaging results

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CC 01 (Core)

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CC01 C,D: (2014 equivalent = 5A 3,4)

• Manual v. electronic

• Begin with lab order, end with completion/cancelation

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CC 01 (Core)

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CC01 E,F: (2014 equivalent = 5A4)• Risk Management: Unsigned encounters

• HIT Creates efficiency• Clinical roles create efficiency

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CC 02 (1 Credit)

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CC02: (2014 equivalent = 5A6) • No newborns = NA• Effort of follow up; not completions

• Consistency

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CC 03 (2 Credits)

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CC03: • What did you use for 3E5 in 2014?

• This is the role of QI in Value Based Care

• Standing orders with EBG

• Decision Trees• Pharyngitis (MU) Templates• URI Templates

• Peer Review

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

Care Coordination and Care Transitions

Criteria Core Elective # Credits

CC04: The practice systematically manages referrals by: A. giving the consultant or specialist the clinical question, the required timing and the type of referral, B. Giving the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan, C. Tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue results

X

CC05: Use clinical protocols to determine when a referral to a specialist is necessary X 2

CC06: Identifies the specialists/specialty types frequently used by the practice X 1

CC07: Considers available performance information on consultants/specialists when making referrals

X 2

CC08: Works with non-behavioral healthcare specialists to whom the practice frequently refers to set expectations for information sharing and patient care

X 1

CC09: Works with behavioral healthcare providers to whom the practice frequently refers to set expectations for information sharing and patient care

X 2

CC10: Integrates behavioral healthcare providers into the care delivery of the practice sites X 2

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

Care Coordination and Care Transitions

Criteria Core Elective # Credits

CC11: Monitors the timeliness and quality of the referral response X 1

CC12: Documents co-management arrangements in the patient’s medical record X 1

CC13: Engages with patients regarding cost implications of treatment options X 2

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CC 04 (Core)

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CC04 A,B: (2014 equivalent = 5B 5,6)

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CC04 C: (2014 equivalent = 5B8)

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CC04,C: (2014 equivalent = 5B8)• Timeliness by specialty• Risk Management: Unsigned documents• How can you make this information useful?• FTCA!!!

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CC 05 (2 Credits)

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CC05

http://www.sandiegocounty.gov/hhsa/programs/ssp/county_medical_services/CMS_Specialty_Ref_Guide_April_2014.pdf

• Prioritize your specialties• Collaborate with specialists• Put standing orders in place• Can you use your EMR?

(KM20)

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CC 06 (1 Credit)

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CC06• Now, why on Earth would we want a list of specialists/specialties?

Bring on CC07….

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CC 07 (2 Credits)

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CC07: (2014 equivalent = 5B1)

Timely Pt. Sat Access

Dr. Endo X 45% 3.6 24 days

Dr. Endo Y 78% 4.6 14 days

Dr. Endo Z 80% 3.0 8 days

• Patient Centered• Start small but important• Justifies collaboration

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CC 08 (1 Credit)

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CC08: (2014 equivalent = 5B2)• CHCs: Use your MOU/MOA• Timeliness, frequency, content

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CC 09 (2 Credits)

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CC09: (2014 equivalent = 5B3)• CHCs: Use your MOU/MOA• Timeliness, frequency, content

• Communication• Sharing of information• Expectations

• CC09 OR CC10

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CC 10 (2 Credits)

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CC10: (2014 equivalent = 5B4)

• Collaboration is NOT Integration!• Who is the integrated population?• What are they communicating?• Who is communicating?• When are they communicating?• Do they have access to documentation?

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CC 11 (1 Credit)

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CC11• Remember 2014 5B8?---this was the intent!• If you did what I said in CC07 then you got it!• If you didn’t…..

• All Referrals ordered by “timely” group:Receipt of referral date – referral order date = time to receiptRate of “time to receipt” within policy = TIMELY

Overheard: “But we don’t have control over this!”

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CC 12 (1 Credit)

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CC12: (2014 equivalent = 5B9)• Is it documented?• Are there shared expectations?• How are these patients determined?• If you co-manage then you have what you need for CC09

• A referral does not mean co-management

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CC 13 (2 Credits)

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CC13• Shared Decision Making Aids!• CM07- Barriers to medication adherence

• “Is cost a concern to you when considering whether you can go to the doctor, take medicine or do what the doctor tells you?”

• Have your resources ready to go (Resource Directory KM)

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• 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 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. .

Care Coordination and Care Transitions

Criteria Core Elective # Credits

CC14: Systematically identifies patient with unplanned hospital admissions and emergency department visits

X

CC15:: Shares clinical information with admitting hospitals and emergency departments X

CC16: Contacts patients/families/caregivers for follow up care, if needed within an appropriate period following a hospital admission or emergency department visit

X

CC17: Systematic ability to coordinate with acute care settings after office hours through access to current patient information

X 1

CC18: Exchanges patient information with the hospital during hospitalizations X 1

CC19: Implements a process to consistently obtain discharge summaries from the hospital and other facilities

X 1

CC20: 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)

X 1

CC21: Demonstrates electronic exchange of information with external entities, agencies and registries (may select one or more)

X 1-3

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CC 14 (Core)

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• Hospital collaboration• Access to hospital portals• HIE• Structured ED Utilization

data!!• Cost, Access, Experience

CC14: (2014 equivalent = 5C1)

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CC 15 (Core)

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• Relevant clinical information

• “If its not documented……”

• Makes 5C1 relevant

CC15: (2014 equivalent = 5C2)

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CC 16 (Core)

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CC16: (2014 equivalent = 5C4)• Supply vs. Demand• Clinical responsibility• 3NA

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CC 17 (1 Credit)

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CC17• Urgent Care/Walk in clinics• Triage nurse• Answering service• Remember AC04?

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CC 18 (1 Credit)

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CC18: (2014 equivalent = 5C5)• Transitions in care require

informed parties on both sides

• Care plan awareness• Medication reconciliation

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CC 19 (1 Credit)

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CC19: (2014 equivalent = 5C3)

• HIT optimization• Hospital collaboration

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CC 20 (1 Credit)

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CC20: (2014 equivalent = 2A4)

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(Maximum 3 Credits)

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CC21: (2014 equivalent = 5B7 and 5C7)

• HIE (1 credit)• IZ registry (1 credit)• Summary of care record (1

credit)

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CC: Your Transformational Application

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