CC 14 - Practice Improvements that Engage Community Resources to Support Patient Health Goals

Activity Weighting: Medium
Subcategory Name: Care Coordination
Description: Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:

• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and 
• Provide a guide to available community resources. including through the use of tools that facilitate electronic communication between settings;
• Screen patients for health-harming legal needs;
• Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
• Provide a guide to available community resources.

Supporting Documentation

1. Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or 
2. Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources.

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