In 2014, the Office of Primary Care Services sponsored an IQ initiative at 5 demonstration sites to develop PACT Intensive Management (PIM) interventions targeting patients at high risk of hospitalization and acute care within VA. The design of the PIM program is based on work described above, with patients identified based on a 90-day hospitalization risk ≥ 90th percentile, based on a va risk modeling tool and an episode of acute care in the past six months.19 The set of PIM programs is the provision of intensive care management and cc by an interdisciplinary team working in collaboration with PACT. The CC model was designed to document and deeply understand the implementation of CC by the PIM team. The effectiveness of the description of cc activities was collected using cc Template data. The cc-template documentation of the PIM team showed that 79.4% of CC matches took place 61 minutes. Telephone communications participated in 50.4% of CC meetings and 24% required several modes of communication such as face-to-face, instant messaging and diagram-based communication. Coordination of care during hospitalization and discharge accounted for 5.9% of model use. Of the CC meetings that document hospital transitions, 94.4% documented communication with the hospital team, 58.3% documented coordination with social support, and only 11.1% documented communication with core care teams. Improved communication with PACT teams after discharge from hospital was identified based on this data as the future QI project.

The PIM team initiated 83.2% of CC meetings. vacctraining.adobeconnect.com/tribalconsultationihsthpreimbursementcarecoordinationplan/ For audio, please select 1-800-767-1750, number 85286. Participants interact by submitting written comments or questions about the chat feature during the presentation. Written comments may also be sent by September 25, 2020 to tribalgovernmentconsultation@va.gov or by mail to Department of Veterans Affairs, Suite 915L, 810 Vermont Avenue NW, Washington, DC 20420. Some follow-ups and follow-ups are necessary for care transitions and must be documented. One of the cornerstones of effective coordination of care is the timely exchange of patient information, which helps multiple providers access information services and document the progress of the care plan. This includes demographic and care information contained in the CCBHCs` electronic medical record, as well as medical and performance records of other providers involved in coordinated care. . .

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