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.
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Objective & Validation Documentation
Objective: Use episodic care management to improve quality of care and communication across referrals and transitions of care.
Validation 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.
Example(s): An oncology practice chooses to implement processes to streamline the initial evaluation and care planning of cancer patients. The practice noted previous inefficiencies as related to biomarker testing and therefore, as part of the process development, they identified attributes to biomarker testing that will be beneficial to efficiency improvements:
• Implement and document frequent multidisciplinary meetings that engage medical oncologists early in biomarker testing workflow.
• Set up direct lines of communication between payers and practices to prevent unnecessary back-and-forth clarifications.
• Codify prior authorization requirements for the most common payer organizations to streamline coverage decisions.
• Institute standard reflexive policies of most common tests for first line treatment decisions triggered by diagnosis.
• Implement modern electronic forms for test ordering and communication platforms between medical oncologists and pathology.
• Enact and document specimen logistics best practices that streamline shipping to external labs.