one behavioral health practice, to testing; Well Child grant access to their respective EHRs Care; Depression and their patients' respective medical Screening; SUD records and care plans. Screening ED Visits for Health Care compact: Practices will enact care compacts with Ambulatory Care Neighborhood CPC, CPC+, Level I medical 1-3 relevant partner providers to track Sensitive 4C; 5B Care SIM providers and coordinate care. Conditions; Total Coordination Cost of Care ED Visits for Health Practices will monitor the status of Ambulatory Care Neighborhood Level II Referral tracking patient referrals between the practice Sensitive SIM, ACC 1.0 5B2 Care and its respective partners. Conditions; Total Coordination Cost of Care ED Visits for Health Practices will follow up with 75% of Ambulatory Care Neighborhood CPC, CPC+, Level III Hospital F/U hospitalized patients within 72 hours of Sensitive 5C Care SIM discharge. Conditions; Total Coordination Cost of Care ED Visits for Health Practices will follow up with 75% of Ambulatory Care Neighborhood CPC, CPC+, Level III ER F/U emergency room patients within one Sensitive 5C Care SIM week of discharge. Conditions; Total Coordination Cost of Care ED Visits for Health Care compact: Practices will enact care compacts with Ambulatory Care Neighborhood Level III community 1-3 relevant community partners to Sensitive ACC 1.0? 4E Care partners refer and coordinate care. Conditions; Total Coordination Cost of Care Well Child Care; Behavioral Practices will regular screen patients BH preventive Depression Level I Health for behavioral health issues using a SIM 3C health screening Screening; SUD Integration nationally recognized screening tool. Screening
one behavioral health practice, to grant access to their respective EHRs and their patients' respective medical records and care plans. testing; Well Child Care; Depression Screening; SUD Screening Health Neighborhood Care Coordination Care compact: medical providers Practices will enact care compacts with 1-3 relevant partner providers to track and coordinate care. Level I ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 4C; 5B Health Neighborhood Care Coordination Referral tracking Practices will monitor the status of patient referrals between the practice and its respective partners. Level II ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care SIM, ACC 1.0 5B2 Health Neighborhood Care Coordination Hospital F/U Practices will follow up with 75% of hospitalized patients within 72 hours of discharge. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 5C Health Neighborhood Care Coordination ER F/U Practices will follow up with 75% of emergency room patients within one week of discharge. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 5C Health Neighborhood Care Coordination Care compact: community partners Practices will enact care compacts with 1-3 relevant community partners to refer and coordinate care. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ACC 1.0? 4E Behavioral Health Integration BH preventive health screening Practices will regular screen patients for behavioral health issues using a nationally recognized screening tool. Level I Well Child Care; Depression Screening; SUD Screening SIM 3C
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