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Learn morePhysician Group Incentive Program (PGIP)
Core clinical process-focused initiatives
Transitions of care
PGIP Ref#: CCP-09-12
BCBSM Administrative Lead:
Della Rees, PhD
Description: The Transitions of care initiative is a hospitalist driven initiative that aims to implement and examine the impact of new approaches to systematizing patient care processes at discharge from inpatient to outpatient settings. Physician Organizations will enroll in the Society of Hospital Medicine's BOOST (Better Outcome for Older adults through Safe Transitions) program and work with a BCBSM-contracted coordinating center.
Other core clinical process-focused initiatives:
- Evidence-based care tracking to reduce gaps in care
- Performance reporting*
- Patient-provider partnership*
- Extended access*
- Individual care management*
- Test tracking and follow-up*
- Lean clinical reengineering for PCMH CQI
- Coordination of care*
- Preventive services*
- Specialist referral process*
- Linkage to community services*
- Self-management support
* These initiatives relate to Patient-Centered Medical Home.
