VCSQI - 9

Milestone 9: Practice works with the primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/ return to primary care, processes for care transition, including communication with patients and family.

Goal: Practice has collaborated with the primary care practices in its medical neighborhood and has jointly developed and implemented criteria for referrals for episodic care, co-management, and transfer of care/ return to primary care, processes for care transition, including communication with patients and family.

Strategies

Define the medical neighborhood with which the practice works most closely
Develop both personal and electronic relationships among medical neighborhood providers to ensure information sharing
Develop formal written agreements or compacts that define information needs of all parties
Formalize lines of communication with local care settings in which impaneled patients receive care to ensure documented flow of information and clear transitions in care.
Ensure that useful information is shared with patients and families at every care transition; partner with patients and families in developing processes and tools to make that happen
Engage payer disease management and complex care management staff to help avoid patient/family confusion

Resources

Google Sites

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