Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.

CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits

CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments

CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit

CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information

CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization

CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities

CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)

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

CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)

A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)

B. Immunization registries or immunization information systems. (1 Credit)

C. Summary of care record to another provider or care facility for care transitions. (1 Credit)

2017 - Competency CC-C

Contents

CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits

CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments

CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit

CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information

CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization

CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities

CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)

CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)

A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)

B. Immunization registries or immunization information systems. (1 Credit)

C. Summary of care record to another provider or care facility for care transitions. (1 Credit)

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2017 - Competency CC-C

CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits

CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments

CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit

CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information

CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization

CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities

CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)

CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)

A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)

B. Immunization registries or immunization information systems. (1 Credit)

C. Summary of care record to another provider or care facility for care transitions. (1 Credit)

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