1. Access to care management services 24-hours-a-day, 7-days-a-week, which means providing patients with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.
2. Continuity of care with a designated provider or member of the care team with whom the patient is able to get successive routine appointments.
3. Care management for chronic conditions including: • Systematic assessment of patient’s medical, functional, and psychosocial needs • System-based approaches to ensure timely receipt of all recommended preventive care services • Medication reconciliation with review of adherence and potential interactions • Oversight of patient self-management of medications.
4. Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.
5. Management of care transitions between and among health care providers and settings, including the following: • Referrals to other clinicians • Follow-up after a patient visit to an emergency department • Follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.
6. Coordination with home and community-based clinical service providers as appropriate to support a patient’s psychosocial needs and functional deficits.
7. Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the patient’s care through not only telephone access but also the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.
8. Use of certified electronic health record (EHR) or other health information technology or health information exchange platform that includes an electronic care plan accessible to all providers within the practice, including those who are furnishing care outside of normal business