If the hospital has an electronic medical record (EMR) and the next level of care provider has access to the complete hospital EMR, select allowable value 1. The EMR must contain documentation that the next level of care provider has access to the EMR.

A continuing care plan may consist of one document or several documents which could be considered a continuing care “packet”. The hospital must be able to identify which document(s) make up the continuing care plan and the hospital must identify what specific documents are transmitted to the next level of care provider.

The first post-discharge day is defined as the day after discharge.

Methods for transmitting the post-discharge continuing care plan include, but are not limited to: U.S. mail, email, fax, EMR access. Giving a copy of the continuing care plan to the patient does not comprise transmission.

Next level of care recommendations may include, but are not limited to: Axis III follow-up, social work and benefits follow-up, pending legal issues and peer support, i.e., Alcoholics Anonymous, Narcotics Anonymous.

• Aftercare discharge plan
• Continuing care plan
• Discharge plan
• Final discharge summary
• Interim discharge summary
• Medication reconciliation form
• Physician discharge orders
• Physician progress notes
• Referral form

• The follow-up prescribing inpatient or outpatient clinician or entity is the clinician, hospital or clinic that is responsible for managing the patient’s medication regime after hospital discharge.
• The treating inpatient or outpatient clinician or entity is the clinician, hospital or clinic that is responsible for the primary treatment of the patient in the absence of medications.
• Some examples of inpatient or outpatient clinicians include, but are not limited to: primary care physician, psychiatrist, advanced practice nurse (APN), physician assistant (PA) Master of Social Work (MSW) and psychologist. Titles of qualified psychiatric practitioners vary from state to state.