AWV/PCP Utilization
What is our AWV target goal to reach by December 31st?
70%
What does TOC stand for?
Transitions of Care
Where can you find care gap details within the medical record (PowerChart)?
Health Maintenance
How often do HCCs need to be redocumented?
HCCs need to be redocumented at least once every calendar year.
What does the acronym ACO stand for?
Accountable Care Organization
Does the deductible, coinsurance, or copayment apply for the AWV?
No, Medicare waives the coinsurance, copayment and Part B deductible for the AWV.
Does a telephonic visit satisfy the 14 day hospital follow up?
Yes, but does NOT qualify for TCM billing.
Where can staff access the various dashboards?
Ambulatory Dashboard Link
These codes are based on ICD-10 and primarily capture chronic and serious health conditions.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act.
Can an AWV be combined with a routine visit?
Yes- having a combined routine visit and an AWV most likely will create the patient to be repsonsible for any coinsurance, copayment, or deductible as they would normally for a routine or sick visit.
What is one reason patients are readmitted to the hospital?
Lack of timely follow up care in Primary Care.
Poor care coordiantion.
Medication Errors, noncomplaince due to lack of patient understanding at time of discharge.
SDOH barriers (nutrition, transportation, housing)
What is the Hemoglobin A1c test?
This quality metric tracks the percentage of diabetic patients who have had this test performed at least once in the past year.
Can HCCs be captured during a telephonic visit?
NO, only face to face office visits; in office and video visits.
What is the normal range for adult blood pressure?
less than 120/80 mmHg.
What are two additonal ways a patient can send their Advanced Care Planning documents to us other than bringing it in to us or mailing it to us?
1- Email- advancecareplanning@christinacare.org
2- Patient Portal
How many days do the TOC nurses have to reach out to a patient?
It is 2 BUSINESS days.
True OR False
Ordering a test i.e. A1c closes the care gap.
FALSE
What does HCC stand for?
Hierarchial Condition Categories
When should a MED REC be done?
Every encounter with every patient.
How often should a patient between the ages of 18-64 who has one chronic condition be seen by their PCP?
They need to be seen annually.
What is a TOC follow-up visit with the primary care provider?
This type of appointment should be scheduled within 7–14 days after hospital discharge to reduce readmission risk.
True OR False
Repeat BPs should be documented in the "Blood Pressure 2" within the vital signs form in PowerChart?
FALSE
What is MEAT?
What is MEAT (Monitored, Evaluated, Assessed, Treated)?
If the TOC nurse is unable to reach a patient to schedule a follow up visit or the patient declines to schedule, what is the next step?
The practice is responsible to reach out to get the patient scheduled and document attempts within PowerChart.