This activity aims to strengthen communication, transparency, and patient‑centered care across all transitions—outpatient, inpatient, specialty, and community settings. It seeks to promote clinicians' proactively coordinating care, tracking patient progress, documenting actions taken, and maintaining clear, structured processes that reduce fragmentation and improve clinical outcomes. This activity may include: • Documentation of care coordination encounters that track all clinical staff involved, communication steps, and handoffs from the time a patient is scheduled for an outpatient procedure or referral through completion of the episode of care • Systematic tracking of patients referred to consultants or specialists, including confirmation that the referral was received, appointments were completed, and recommendations were integrated into the plan of care • Documentation of care transition practices reflecting a patient‑centered action plan aligned with the patient’s values, preferences, and social context • Implementation of care coordination agreements with frequently used consultants or facilities that set expectations for timely, bidirectional information sharing and clearly define responsibilities across settings.