CC 15 - PSH Care Coordination

Activity Weighting: Medium
Subcategory Name: Care Coordination
Description: Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:

• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;
• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or
• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.

Supporting Documentation

1. Coordinate with care managers/navigators in preoperative clinic to plan and implement comprehensive post discharge plan of care; and 
2. Deploy perioperative clinic and care processes to reduce post - operative visits to emergency rooms; and 
3. Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; and 
4. Implement processes to ensure effective communications and education of patients’ post-discharge instructions. 

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