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Care Coordination

Adoption of Health Information Technology

  • Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted and be using a certified/qualified electronic health record (EHR).

    CBE ID
    0488

Biopsy Follow-up

  • Percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care/referring physician and the patient.

    CBE ID
    0645

Medical Home System Survey (MHSS)

  • The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

    Composite 1: Patient-Centered Access
    Composite 2: Team-Based Care
    Composite 3: Population Health Management
    Composite 4: Care Management and Support
    Composite 5: Care Coordination and Care Transitions

    CBE ID
    1909

Medication Information

  • Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that medication information was communicated to the receiving FACILITY within 60 minutes of departure

    CBE ID
    0293

Medication Reconciliation Post-Discharge (MRP)

  • The percentage of discharges during the first 11 months of the measurement year (e.g., January 1–December 1) for patients 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.

    CBE ID
    0554

Nursing Information

  • Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that nursing information was communicated to the receiving FACILITY within 60 minutes of departure

    CBE ID
    0296