Activity Description

In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.

Objective & Validation Documentation

Objective: Define and implement a standardized process for transitions of care that are relevant to the eligible clinician’s patient population.

Validation Documentation: Evidence of processes for preparing and implementing patient-centered care transition plans for the first 30 days following a discharge. Include at least two of the following elements:
1) Patient-centered care transition action plans – Documented plans to include out-patient follow-up, medication reconciliation, and post-discharge support. May include: a) patient communications and language preferences; b) available supports and services (medication availability and travel capability); c) patient’s discharge environment, or d) out-patient follow-up plan; OR
2) Implementation of action plan within first 30 days of discharge – May include: a) documentation of staff involved in the care transition; b) records of real-time communication between eligible primary care clinicians and consulting eligible clinicians; or c) records of eligible primary care clinicians included on specialist follow-up transition communication, etc.; OR
3) Patient communication and delivery of support services according to patient preferences within first 30 days of discharge – Examples from patient records that demonstrate conformity with patient preferences. May include: a) patient-preferred communication activities such as phone calls conducted in support of transition; b) accompaniments of patient to appointments or other navigation actions; c) home visits; patients’ access to their medical records; or d) translated discharge materials, etc.; OR
4) Processes for care transition planning – Documentation that defines the steps the eligible clinician will take to prepare and implement the patient-centered care transition plan with every patient.

Information: Guide to reducing disparities in readmissions: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/OMH_Readmissions_Guide.pdf