CHW
How often the CHW's update the County Community Resource Guides
What is annually or every year
The two diagnoses appropriate for CoCM
Anxiety and Depression
What might an IP TOC nurse schedule for you
What are hospital follow up appointments
A NCM spends the majority of her week here
What are Provider Offices
Who a SNF TOC Nurse sends a referral to upon patient discharge from the facility
Who is the NCM
The number of days that CHW's must outreach ED patients within
What is 7
The three individuals that make up the CoCM Care team
BHCM, Consulting Psychiatrist, and Treating Provider or PCP
The program that IP TOC nurses heavily support
What is CPP or Community Paramedic Program
PCMH Stands for this
What is Patient Centered Medical Home
The frequency of patient encounters while in SNF
The three hospitals patient ED Follow Up calls are made to
What are Henry Ford Genesys, Hurly Medical Center, and McLaren Flint
Two things used to measure CoCM Outcomes
What are PHQ-9 and GAD-7 Scores
Four main diagnoses IP TOC nurses work with
What are CHF, COPD, Sepsis, and Pneumonia
PDCM Stands for
Provider Delivered Care Management
The 4 Facilities that our SNF TOC nurses are embedded at
What are Regency, The Oaks, Wellbridge of Fenton, and Wellbridge of Grand Blanc
The name of the organization our CHW's became certified through
What is MiCHWA also known as the Michigan Community Health Worker Alliance
How often BHCM's are required to provide suicide protocol training to CoCM offices
What is annually or once a year
The floor the IP TOC nurse office is on at Henry Ford Genesys Hospital
What is the 2nd Floor
The insurance company that releases PDCM Reports
What is BCBS
The Hospital that GPHO partnered with for the now retired I-MPACT Program
What is McLaren Flint
The two types of PDCM codes that CHW's are allowed to bill
What are telephonic and care coordination codes
The number of GPHO PCP's CoCM designated (must come within 2)
30
The two systems the IP TOC nurses document in
What is Allscipts EHR (or Epic) and Gems
These must be found to be in place during a PCMH Site Visit
What are PCMH Capabilities
The date that our SNF Waiver Program was retired
What is December 31, 2021