redesign coordinator. Care plans are also uploaded to CRISP. We will report this on the quarterly CRP report template. Maintenance of the Care manager/member of Completion is tracked by care plan (track and care management team care manager. Updated report updates). Other care are uploaded to CRISP. Performance of a Care manager/member of Tracked by care minimum of 20 care management team manager and reported minutes of care Other to the care redesign management coordinator. We will activities per month. report this on the quarterly CRP report template. Completion of Care manager/member of Tracked by care medication care management team manager and reported management and (with PDP assist as needed) to the care redesign reconciliation. PDP coordinator. We will Other report this on the quarterly CRP report template. Completion of Care manager/care Tracked by care transitional care management team will manager. Supervisors planning after an review the discharge plan will review a sample of inpatient discharge. and ensure all plan cases during routine elements are followed and staff review. necessary equipment, medication and supplies are in place. Care management team will follow the Coleman Model. Other Securing of Care manager/member of Care management physician care management team software identifies appointments Other discharges and follow within 7 days of an up appointments. The inpatient discharge care redesign coordinator will download this the
redesign coordinator. Care plans are also uploaded to CRISP. We will report this on the quarterly CRP report template. Maintenance of the care plan (track and report updates). Care manager/member of care management team Other Completion is tracked by care manager. Updated care are uploaded to CRISP. Performance of a minimum of 20 minutes of care management activities per month. Care manager/member of care management team Other Tracked by care manager and reported to the care redesign coordinator. We will report this on the quarterly CRP report template. Completion of medication management and reconciliation. Care manager/member of care management team (with PDP assist as needed) PDP Other Tracked by care manager and reported to the care redesign coordinator. We will report this on the quarterly CRP report template. Completion of transitional care planning after an inpatient discharge. Care manager/care management team will review the discharge plan and ensure all plan elements are followed and necessary equipment, medication and supplies are in place. Care management team will follow the Coleman Model. Other Tracked by care manager. Supervisors will review a sample of cases during routine staff review. Securing of physician appointments within 7 days of an inpatient discharge Care manager/member of care management team Other Care management software identifies discharges and follow up appointments. The care redesign coordinator will download this the
CCIP%20IP%20Template%20-%202018%20Draft%20Completed%20Sample.docx