GOALS(SCORE)
DIAGNOSES INCURRING FINANCIAL PENALTIES FOR READMISSION WITHIN 30 DAYS INCLUDING HEART FAILURE, MI, PNEMONIA, AND COPD.
WHAT ARE THE MEDICARE FFS PENALTY DIAGNOSES?
ACO REACH
AETNA MA
BLUE CROSS/ANTHEM MA
What is our Medicare Priority Contracts?
A CARE COORDINATION OVERLAY IN EPIC THAT WENT LIVE IN 2024
COMPASS ROSE
AN URGENT CLINICAL SERVICE PROVIDING MULTIDISCIPLINARY CARE AND DIAGNOSTIC TESTING IN THE HOME.
WHAT IS CARE2U
COMPLAINTS OF 2-3 POUND WEIGHT GAIN IN A WEEK PERIOD, EXTREME FATIGUE AND LOWER EXTREMITY EDEMA, ABDOMINAL PAIN, SHORTNESS OF BREATH.
WHAT SYMPTOMS SHOULD OUR PATIENTS WITH HEART FAILURE REPORT TO US OR THEIR PHYSICIAN?
6 HOURS PER DAY= 30 MINUTES PER DAY FOR CARE COORDINATION, INITIAL ENROLLMENTS EQUALING 45 MINUTES AND FOLLOW UP CALLS EQUALING 20 MINUTES.
HOW MUCH PRODUCTIVE TIME SHOUD I HAVE IN A DAY?
HEALTHFIRST
FIDELIS
WHAT ARE OUR OUR MEDICAID PRIORITY CONTRACTS?
In Wrap up, this field is ONLY marked completed upon initial call if we actually spoke with the patient.
WHAT is the workflow for completing an initial phone contact in Compass Rose?
ONE OF THE MOST IMPORTANT INTERVENTIONS WHEN A TOC PATIENT IS CONTACTED FOR THE FIRST TIME .
WHAT IS MEDICATION RECONCILIATION?
A LUNCH BOX WITH AN ORAL STEROID, ANTIBIOTICS INSIDE WITH INSTRUCTIONS FOR WHEN THE PATIENT SHOULD USE IT AND TO CALL THE PHYSICIAN TO INFORM THEM OF THE NEED TO USE.
WHAT IS IN A RESCUE COPD KIT?
A TCM/TOC MEASURE ENSURING THE PATIENT HAS A SUITABLE PLAN AND SUPPORT WITHIN 7 DAYS OF HOSPITAL DISCHARGE.
WHAT IS THE 7 DAY FOLLOW UP AFTER HOSPITALIZATION?
Someone who has an increased chance of developing a severe illness or injury. This can be due to a number of factors, including age, medical conditions, pregnancy, or social determinants of health.
What is a HI Risk patient?
A closure reason indicating that a patient was enrolled but then unable to reach after further attempts.
What is"Unable to Reach after Enrollment" ?
1. Disengagement and non-adherence
2. Condition complications
3. Inadequate Transition of Care
4. Misinterpretation of Discharge Instructions
5. SDOH
What are the top 5 reasons patients are readmitted to the hospital?
What are the "don'ts" for documenting in a patients record?
Removing barriers that prevent our patients from reaching their optimal level of health and avoiding unnecessary utilization of services.
What is the GOAL of Care Coordination?
The potential financial penalty a healthcare provider may face if they fail to meet established quality and cost benchmarks, meaning they could lose revenue if their patient care falls below expected standards, essentially putting a portion of their income at risk if they don't deliver high-quality care at a controlled cost.
What is Down- Side Risk in Value Based Contracts?
A selection in Compass Rose that is completed ONLY if the patient has been Enrolled in Care coordination.
What is the Enrollment Reason tab used for?
Diagnoses seen frequently in the ED that could have potentially been prevented through better coordination with primary care including Abdominal pain , Nonspecific chest pain ,Skin and subcutaneous tissue infections ,Other lower , respiratory disease , Spondylosis; intervertebral disc disorders; other back problems , Urinary tract infections, Other connective tissue disease , Other non-traumatic joint disorders , Other upper respiratory infections , Headache; including migraine , Nausea and vomiting , Conditions associated with dizziness or vertigo , Malaise and fatigue , Chronic obstructive pulmonary disease and bronchiectasis , Other skin disorders
What are main diagnoses considered as potentially avoidable ED admits?
A Care coordination note that does not contain the receiver of the call's full name and position or the full name of the provider whom the Care Coordinator is calling.
" TC to Dr. spoke with Nancy. MD not available. Left message for CB".
What is an example of unacceptable documentation in a medical record?
1. Patient-centered approach: identifying what is most important to the patient and emphasizing their involvement in their care plan.
2. Care coordination: Facilitates smooth transitions between healthcare providers and settings.
3. Medication management: Ensuring patients understand their medications and potential side effects.
4. Patient education: Providing clear information about their health conditions and how to manage them and using teachback to validate understanding.
5. Red flag awareness: Educating patients on critical signs that could indicate a worsening health situation.
Evidence-based TOC Model that demonstrates a 20-40% reduction in preventable readmissions.
What are Colemans Five Pillars of Transitional Care?
A healthcare delivery model where providers are paid based on the quality of care they deliver to patients, focusing on positive health outcomes rather than the quantity of services provided, meaning they are incentivized to improve patient health and manage costs effectively, often through coordinated care and preventative measures; essentially, "value" is measured by the quality of care delivered relative to its cos
What is Value Based Care?
A place in EPIC to find information regarding a physician's participation in our IPA. (voluntary vs employed)
What is the Provider Finder tab?
AN EVIDENCED BASED STRATEGY TO REDUCE ED UTILIZATION AND READMISSIONS BY ADRESSING ADVANCED/CHRONIC SYPTOM MANAGEMENT.
What IS PALLIATIVE CARE?
What are the causes and risk factors for COPD?