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Physician Group Incentive Program (PGIP)
Core clinical process-focused initiatives
Transitions of care
PGIP Ref#: CCP-10-2
BCBSM Administrative Lead:
Susan Burns
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:
- Coordination of care*
- Evidence-based care tracking to reduce gaps in care
- Extended access*
- Individual care management*
- Lean clinical reengineering CQI
- Linkage to community services*
- Patient-provider partnership*
- Performance reporting*
- Preventive services*
- Self-management support*
- Specialist referral process*
- Test tracking and follow-up*
- Transitions of care - Michigan Transition of Care Collaborative (M-TC2)
* These initiatives relate to Patient-Centered Medical Home.
