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
Providers- What are the 3 steps to Success in Risk Capture?
1- Review Diagnosis Insights Tool
2- Look at reminders for Prospective Queries
3- Manage your Problem List
What does AIDET stand for?
A- Acknowledge
I- Introduce
D- Duration
E- Explanation
T- Thank You
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)
Where do OA and MA staff find the monthy outreach lists?
Teams>Population Health Worklist>Practice
Can HCCs be captured during a telephonic visit?
NO, only face to face office visits; in office and video visits.
What does ACSC stand for?
Ambulatory Care Sensitive Conditions
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.
Let's pull up a calendar view of October 2023. If a patient is discharged on Sunday 10-1-23 what date do they need to be seen by to meet our 14 day follow up?
Friday October 13th
The day of discharge (10/1/23) counts as day 1 and day 14 is a Saturday- therefore the patient must be seen on or before 10/13/23.
True OR False
Repeat BPs should be documented in the "Blood Pressure 2" within the vital signs form in PowerChart?
FALSE
How does risk adjustment benefit the patient or ChristianaCare?
Risk is used to predict the cost of care and identify the resources necessary to provide that care and ultimately helps support population health.
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.