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On its own or in conjunction with an external organization, the practice systematically:

5.C.1 Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visit

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.2 Demonstrates its process for sharing clinical information with admitting hospitals and emergency departments

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.3 Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.4 Demonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.5 Demonstrates its process for exchanging patient information with the hospital during a patient’s hospitalization

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.6 Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only practices)

Description	Example/Screenshot/Documentation	Source	Date Added
Using PCC EHR Care Plan functionality for organizing materials and information in preparation for transitioning a patient from pediatric care to adult care.	Using PCC EHR Care Plans for transitions of care	PCC	07/07/14
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.7 Demonstrates the ability for electronic exchange of key clinical information with facilities

Description	Example/Screenshot/Documentation	Source	Date Added
PCC EHR ability for electronic exchange of key clinical information with facilities	PCC EHR electronic exchange of key clinical info	PCC	07/07/14
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

5.C.8 Provides an electronic summary-of-care record to another care facility for more than 50 percent of transitions of care

Description	Example/Screenshot/Documentation	Source	Date Added
External Organization Policies and Procedures Example	Examples	TPC	03/25/13

PCMH5C

Contents

5.C.1 Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visit

5.C.2 Demonstrates its process for sharing clinical information with admitting hospitals and emergency departments

5.C.3 Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities

5.C.4 Demonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit

5.C.5 Demonstrates its process for exchanging patient information with the hospital during a patient’s hospitalization

5.C.6 Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only practices)

5.C.7 Demonstrates the ability for electronic exchange of key clinical information with facilities

5.C.8 Provides an electronic summary-of-care record to another care facility for more than 50 percent of transitions of care

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PCMH5C

5.C.1 Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visit

5.C.2 Demonstrates its process for sharing clinical information with admitting hospitals and emergency departments

5.C.3 Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities

5.C.4 Demonstrates its process for contacting patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit

5.C.5 Demonstrates its process for exchanging patient information with the hospital during a patient’s hospitalization

5.C.6 Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only practices)

5.C.7 Demonstrates the ability for electronic exchange of key clinical information with facilities

5.C.8 Provides an electronic summary-of-care record to another care facility for more than 50 percent of transitions of care

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