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It details how care coordinators identify high-acuity patients, exchange and review clinical information with hospitals, skilled nursing homes, specialists, and other services, and support safe follow-up after discharge or ED visits. The protocol also covers internal care management coordination, quality improvement activities, care planning for high-risk patients, and appendices for transition records and patient tracking.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/coordination-and-continuity-of-care-policy-and-protocol-westminster-medical-clinic-wmc/383378/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/coordination-and-continuity-of-care-policy-and-protocol-westminster-medical-clinic-wmc/383378.png","ImageObject",442,249,{"name":88,"@type":89},"Valentina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-18","2026-09-24",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of WMC’s Coordination and Continuity of Care policy and protocol?","Question",{"text":108,"@type":109},"It provides external care coordination and internal care coordination to ensure continuity of care for patients between WMC and outside facilities, including safe follow-up after discharge.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does WMC handle external care coordination with hospitals and skilled nursing homes?",{"text":113,"@type":109},"The care coordinator reviews and tracks admissions and discharges daily, cross-checks WMC patients with outside facility new admissions and clinical information, and uses a defined workflow to obtain inpatient and ED visit lists.",{"name":115,"@type":106,"acceptedAnswer":116},"What steps are included for internal care coordination and follow-up?",{"text":117,"@type":109},"WMC contacts patients after hospital or ED discharge, reviews specialist information to ensure appropriate follow-up, facilitates communication between the care team, and engages patients by informing them about PCMH benefits.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},383378,1791279481,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},13056703020460,"https://ap-avatar.wpscdn.com/avatar/be000253dac470eee5d?_k=1778207105932848923","Last Updated: February 6, 2011  \nCoordination and Continuity of Care Policy and Protocol  \nWestminster Medical Clinic (WMC) provides external care coordination and ensures continuity of care in collaboration with outside facilities and organizations. Continuity of care protocols outline comprehensive and safe care for patients who receive inpatient and/or outpatient care between WMC and facilities such as hospitals, nursing homes, specialty care, disease management services and others.  \nWMC provides internal care coordination by identifying high acuity patients, as well as those treated in outpatient and inpatient settings and contacting these patients after discharge to provide and/or coordinate follow up care.  \nWMC maintains processes for evaluating, prioritizing and coordinating care for patients who receive in-house care management and provides coordination for patients who receive care from other physicians.  \nCoordination and Continuity of Care Table of Contents  \nExternal Care Protocol   3  \n1. Hospital and Skilled Nursing Home  \na. Identifies patients in facilities  \nb. Sends clinical information to facilities  \nc. Reviews information from facilities  \n2. Specialists  \na. Facilitates appointments and transfer of information  \nb. Communication with patients who fail to keep appointments  \nInternal Care Protocol   10  \n1. Contacts patients after hospital or ED discharge  \n2. Reviews information from specialists to ensure appropriate follow-up  \n3. Facilitates communication between care team  \n4. Engages and informs patients on PCMH benefits  \nQuality Improvement   13  \n1. Engages in Continuous Quality Improvement  \na. Care coordination  \nb. Population Management  \nc. Performance measures  \nCare Planning   18  \n1. Identifies high-risk patients and coordinates care team  \n2. Facilitates healthy behaviors and lifestyle changes  \n3. Coordinates care with Disease Management Organizations  \n4. Facilitates transfer of care  \nAppendices   Electronic  \nA. PCP Transition of Care Record  \nB. Personal Care Assessment and Plan  \nC. ER Visits Tracker  \nD. Specialist Transition of Care Record  \nE. Patient Referral RX  \nF. PCMH ID Card  \nG. RX: Healthier Living CO  \nH. Medical Neighborhood Invitation  \nI. Medical Neighborhood Guide  \nJ. Medical Neighborhood Tracker  \nK. Medical Neighborhood Specialist Toolkit  \nL. Medical Neighborhood Specialist Practice Profile  \nM. PCP Transition of Care Record Checklist  \nN. PCP Transition of Care Record Tracker  \nO. Medical Neighborhood Phone Survey Tracker  \nP. Specialist Transition of Care Record Checklist  \nQ. Score Card Spreadsheet  \nR. Score Card Template  \nReferences   20  \nExternal Care Protocol  \nHospitals and Skilled Nursing Home Facilities  \nIdentifies patients who receive care in hospital, ED and/or skilled nursing home facilities:  \nA. The Care Coordinator at WMC reviews and tracks admissions and discharges, transfers, inpatient lists via fax, email, telephone, and hospital electronic portals for external care facilities each day to identify established patients who have already accessed care in the outside medical facility.  \n1. The Care Coordinator reviews communication documents daily to cross-check WMC patients with health information technology or outside medical facility new admissions, discharges, transfers, patient medications, laboratory results, and patient summaries. To crosscheck with external medical facilities, follow the process below:  \na. Access the current inpatient list at Centura Health Systems.  \n1. Open Internet Explorer  \n2. Log [into](into www.myvirtualworkplace.org)[ ](into www.myvirtualworkplace.org)[www.myvirtualworkplace.org](into www.myvirtualworkplace.org)  \n3. Enter user name and password (user name and passwords are assigned by Centura Hospital systems, contact physician liaison for forms)  \ni. The Centura Hospital portal opens.  \n4. Click on “Work Tools”, Clinical Tools, Meditech  \n5. Citrix Client loads and opens  \n6. Press “enter” when the HCIS CEU. L","cbCaiuL30U1lqcR4","https://ap.wps.com/l/cbCaiuL30U1lqcR4","pdf",1126690,20,"English","# External Care Protocol\n## Hospitals and Skilled Nursing Home\n## Specialists\n# Internal Care Protocol\n## Contacts after hospital or ED discharge\n# Quality Improvement\n## Continuous Quality Improvement\n# Care Planning\n## High-risk patient identification and coordination\n# Appendices (Electronic)\n## PCP Transition of Care Record\n## Patient Referral RX\n## Medical Neighborhood Tracker","[{\"question\":\"What is the purpose of WMC’s Coordination and Continuity of Care policy and protocol?\",\"answer\":\"It provides external care coordination and internal care coordination to ensure continuity of care for patients between WMC and outside facilities, including safe follow-up after discharge.\"},{\"question\":\"How does WMC handle external care coordination with hospitals and skilled nursing homes?\",\"answer\":\"The care coordinator reviews and tracks admissions and discharges daily, cross-checks WMC patients with outside facility new admissions and clinical information, and uses a defined workflow to obtain inpatient and ED visit lists.\"},{\"question\":\"What steps are included for internal care coordination and follow-up?\",\"answer\":\"WMC contacts patients after hospital or ED discharge, reviews specialist information to ensure appropriate follow-up, facilitates communication between the care team, and engages patients by informing them about PCMH benefits.\"}]","Coordination and Continuity of Care Policy and Protocol - Westminster Medical Clinic (WMC) | PDF",1790256444,7]