Practice improvements that engage community resources to support patient health goals
Description
Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:
Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or
Provide a guide to available community resources.
eMeasure ID
First Performance Year
2017
Last Performance Year
Metric Type
boolean
Weight
medium
Sub-category ID
Care Coordination
CEHRT Eligibility
Bonus under ACI
Varidation
Availability of formal links to community-based health and wellness programs potentially including availability of resource guides
Suggested Documentation
1) Community-Based Chronic Disease Self-Management Programs - Documentation of community-based chronic disease self-management support programs, exercise programs, and other wellness resources (including specific names) with which practices have formal referral links and have potential bidirectional flow of information; or 2) Provision of Community Resource Guides - Medical record demonstrating provision of a guide to community resources