PC.6
1. Patients with co-occurring conditions are managed. Note: If the patient’s co-occurring condition(s) is managed by practitioner(s) or setting(s) outside of the program, the information necessary for its management is communicated to practitioner(s) and setting(s) across the continuum of care.
2. The program conducts regular patient care conferences with members of the interdisciplinary team to discuss goals of care, disease prognosis, and advance care planning, and to offer support.
3. The program assists the patient in collecting, organizing, and communicating important health information. (see also Standard IM.1 EP 3)
4. A process addresses the needs for continuing services after discharge, transfer, or service completion.
5. At the time a patient is transferred to a different care setting, information about the patient’s goals, preferences, and values and the patient’s clinical condition are communicated to the providers in the new setting.

Refers to Standard:	StandardId10018
Applicable Programs:
Status:

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