The practice:

5.C.1 Proactively identifies patients with unplanned hospital admissions and emergency department visits.

NCQA will review your documented process for identifying patients who have been hospitalized or have had an ER visit. They'll also want to review a log of patients receiving care from different types of facilities or a report listing patients seen in the ER or hospital. You'll want to coordinate with your local hospital to make sure you are informed when your patients are seen at the hospital.

5.C.2 Shares clinical information with admitting hospitals and emergency departments.

NCQA will review your documented process for providing hospitals and ERs with clinical information, and will review at least three de-identified examples of patient information sent to the hospital or ER. A good example for this would be if you are seeing patients in the office for pre-op visits and providing a visit summary to the hospital.

5.C.3 Consistently obtains patient discharge summaries from the hospital and other facilities.

NCQA will review your documented process for obtaining hospital discharge summaries, and will review at least three examples of a discharge summary received from the hospital.

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

According to NCQA, you'll want to contact patients to evaluate their status after discharge from an ER or hospital and to make a follow-up appointment, if appropriate. Proactive contact includes offering patients appropriate care to prevent worsening of their condition and encouraging follow-up care. In addition to scheduling an appointment, follow-up care includes, but is not limited to, physician counseling; referrals to community resources; and disease or case management or self-management support programs. The practice’s policies define the appropriate contact period. NCQA will review your documented process and at least three de-identified examples of documented patient follow-up.

5.C.5 Exchanges patient information with the hospital during a patient’s hospitalization.

According to NCQA, you'll want to have a two-way communication plan with hospitals to exchange information about hospitalized patients, enabling well-coordinated care during and after hospitalization. NCQA will review your documented process and at least one de-identified example of bi-directional information sharing with the hospital.

5.C.6 Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.

According to NCQA, you'll want a process for working with community partners, such as detention centers, halfway houses, juvenile justice facilities, foster care, child or adult protective services or others, to obtain appropriate consent for release of information to treat and coordinate care with those partners who have legal responsibility for certain patients. NCQA will review your documented process.

5.C.7 Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.

NCQA has stated that in alignment with the Meaningful Use Modified Stage 2 Final Rule, NCQA will accept a report demonstrating provision of electronic care summaries for more than 10 percent of care transitions.

Refer to the "Summary of Care (Transmitted Only)" measure results in the "Stage 2" or "Modified Stage 2" version of the Meaningful Use report in PCC EHR. In order to meet this measure, your practice needs to use PCC's Direct Secure Messaging functionality to transmit a summary of care record electronically to a facility.

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

2014 - PCMH5C

Contents

5.C.1 Proactively identifies patients with unplanned hospital admissions and emergency department visits.

5.C.2 Shares clinical information with admitting hospitals and emergency departments.

5.C.3 Consistently obtains patient discharge summaries from the hospital and other facilities.

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

5.C.5 Exchanges patient information with the hospital during a patient’s hospitalization.

5.C.6 Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.

5.C.7 Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.

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2014 - PCMH5C

5.C.1 Proactively identifies patients with unplanned hospital admissions and emergency department visits.

5.C.2 Shares clinical information with admitting hospitals and emergency departments.

5.C.3 Consistently obtains patient discharge summaries from the hospital and other facilities.

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

5.C.5 Exchanges patient information with the hospital during a patient’s hospitalization.

5.C.6 Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.

5.C.7 Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care.

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