124 STAT. 515 PUBLIC LAW 111–148—MAR. 23, 2010 access to individuals that implement the care plans of patients and coordinate care, such as integrative health care practitioners; (I) collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes, including collection of data on patient experience of care, and identification of areas for improvement; and (J) establish a coordinated system of early identifica- tion and referral for children at risk for developmental or behavioral problems such as through the use of infolines, health information technology, or other means as deter- mined by the Secretary; (7) provide 24-hour care management and support during transitions in care settings including— (A) a transitional care program that provides onsite visits from the care coordinator, assists with the develop- ment of discharge plans and medication reconciliation upon admission to and discharge from the hospitals, nursing home, or other institution setting; (B) discharge planning and counseling support to pro- viders, patients, caregivers, and authorized representatives; (C) assuring that post-discharge care plans include medication management, as appropriate; (D) referrals for mental and behavioral health services, which may include the use of infolines; and (E) transitional health care needs from adolescence to adulthood; (8) serve as a liaison to community prevention and treat- ment programs; (9) demonstrate a capacity to implement and maintain health information technology that meets the requirements of certified EHR technology (as defined in section 3000 of the Public Health Service Act (42 U.S.C. 300jj)) to facilitate coordination among members of the applicable care team and affiliated primary care practices; and (10) where applicable, report to the Secretary information on quality measures used under section 399JJ of the Public Health Service Act. (d) REQUIREMENT FOR PRIMARY CARE PROVIDERS.—A provider who contracts with a care team shall— (1) provide a care plan to the care team for each patient participant; (2) provide access to participant health records; and (3) meet regularly with the care team to ensure integration of care. (e) REPORTING TO SECRETARY.—An entity that receives a grant or contract under subsection (a) shall submit to the Secretary a report that describes and evaluates, as requested by the Secretary, the activities carried out by the entity under subsection (c). (f) DEFINITION OF PRIMARY CARE.—In this section, the term ‘‘primary care’’ means the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Records. Plans. Reports.
