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.

Supporting Documentation

1. 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 
2. Tracking of Patient Referrals to Specialists - Medical record or EHR documentation demonstrating tracking of patients referred to specialists through the entire process; or 
3. Referral Information Integrated into the Plan of Care - Samples of specialist referral information systematically integrated into the plan of care.

Resources
2018 Improvement Activities Requirements
2019 Improvement Activities Requirements
2018 MIPS Improvement Activities Fact Sheet
Scores for Improvement Activities for MIPS APMs in the 2018 Performance Period Fact Sheet