Activity Description
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 provide a guide to available community resources including through the use of tools that:
- • Facilitate electronic communication between settings;
- • Screen patients for health-harming legal needs;
- • Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards – based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
- • Provide a guide to available community resources.
| Activity ID | Activity Weighting | Sub-Category Name |
|---|---|---|
| IA_CC_14 | Medium | Care Coordination |