Health center staff should open the Primary care provider directly introduces the patient’s health record and record this patient to the behavioral health, mental health, ET when patient is successfully Warm Hand-off dental health, social worker, or substance use accepted and services are provided as (non-billable) provider at the time of the medical visit defined in the definition section Health center visits the patient’s home for reasons unrelated to assessment, diagnosis, treatment, or Maternity Case Management. home visits include but are not limited to: A community health worker visiting patient’s Health center staff should open the residence to support the family, a parenting class, patient’s health record and record this Home Visit a clinical pharmacist visiting to assist with ET upon completion of the home visit medication management and reconciliation as defined in the definition section Health center staff speaks with patient (including family or representative) or speaks with another health professional regarding the patient’s recent care at an outside health organization (ER, hospital, long-term care facility, etc.) to: Arrange a follow-up at the health Health center staff should open the center or other ET, or patient’s health record and record this Speaks with patient to update care plan ET when they have verified the patient Coordinating Care: and educate on preventive health received or needs to receive health Clinical Follow-up measures, or services from a different provider, and and Transitions in Assists patient with a transition in their care completed 1, 2, or 3 listed in the Care Setting setting definition section. During primary care visit, patient and health center staff identify that patient has dental health Health center staff should open the care needs, and coordinates with dental patient’s health record and record this professionals by assistance with dental ET when they have confirmed that the appointment set-up or speaking directly with the primary care provider set-up a dental dental provider regarding patient’s dental care appointment and/or had spoken with Coordinating Care: Dental needs the dental provider
Warm Hand-off (non-billable) Primary care provider directly introduces the patient to the behavioral health, mental health, dental health, social worker, or substance use provider at the time of the medical visit Health center staff should open the patient’s health record and record this ET when patient is successfully accepted and services are provided as defined in the definition section Home Visit Health center visits the patient’s home for reasons unrelated to assessment, diagnosis, treatment, or Maternity Case Management. home visits include but are not limited to: A community health worker visiting patient’s residence to support the family, a parenting class, a clinical pharmacist visiting to assist with medication management and reconciliation Health center staff should open the patient’s health record and record this ET upon completion of the home visit as defined in the definition section Coordinating Care: Clinical Follow-up and Transitions in Care Setting Health center staff speaks with patient (including family or representative) or speaks with another health professional regarding the patient’s recent care at an outside health organization (ER, hospital, long-term care facility, etc.) to: Arrange a follow-up at the health center or other ET, or Speaks with patient to update care plan and educate on preventive health measures, or Assists patient with a transition in their care setting Health center staff should open the patient’s health record and record this ET when they have verified the patient received or needs to receive health services from a different provider, and completed 1, 2, or 3 listed in the definition section. Coordinating Care: Dental During primary care visit, patient and health center staff identify that patient has dental health care needs, and coordinates with dental professionals by assistance with dental appointment set-up or speaking directly with the dental provider regarding patient’s dental care needs Health center staff should open the patient’s health record and record this ET when they have confirmed that the primary care provider set-up a dental appointment and/or had spoken with the dental provider
APM%20Engagement%20Touches%2020141113_Revision.docx