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Table 2 Example operational codes

From: Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation

CPC program component Definition and coding rules
Risk-stratified care management A primary care practice’s management of care for patients with complex care needs (e.g., chronic illness or multiple comorbidities). Under this component, practices are expected to deliver care management services for patients with high needs or complex needs (i.e., high-risk patients).
Code discussion of:
• Assigning a risk status to patients on the panel and documenting each patient’s risk status in the electronic health record
• Tracking the percentage of patients assigned a risk status and the proportion of the panel in each risk category
• Generating lists of patients by risk category
• Reporting on which high-risk patients have received care management services
• Forming care teams
• Providing care management services
• Identifying and recruiting high-risk patients to receive care management services
• Developing or using a personalized plan of care for each patient
• Managing or reconciling medications
• Delineating roles of staff who provide care management (e.g., a care coordinator or care manager)
Care coordination (across the medical neighborhood) A primary care practice’s coordination of patient care with other health care providers. This includes ensuring that patient information necessary for providing care is available across the medical neighborhood (i.e., to other providers who care for the patient). This also includes following up with patients who have been discharged from a tertiary care facility.
Code discussion of:
• Selecting a priority area/care interface/transition (e.g., hospital or emergency department (ED)) for care coordination
• Following up with patients after hospital or ED discharge
• Establishing referral compacts and information-sharing arrangements with other providers, including specialists and diagnostic testing facilities