PPC-3 Care Management

Element E Continuity of Care

The practice on its own or in conjunction with an external organization engages in the following activities for patients who receive car in inpatient or outpatient facilities or patients who or transitioning to other care.

Data Point 1 Identifies patients who receive care in facilities

Though an electronic function entitled, Inpatient Medical Record Census, which is launched from SETMA’s intranet, all patients admitted to the hospital are identified as to the hospital, provider, when the patient was admitted and when H&P was completed, and when the patient was discharged and when the discharge summary was completed. 

SETMA performs at a 97% efficiency of the H&P being completed on the date of admission and 98% on the discharge summary being completed on the date of discharge. Both are completed in our EMR and are thus available simultaneously at all points of care, including clinic, home health, physical therapy, hospice, nursing home or other points of service.

In a similar way all patients admitted to LTAC, Rehabilitation, Nursing Home or other inpatient facility are tracked. Our referral system tracks patients  being seen in outpatient settings.