Fast Facts
The location of the Ambulatory Fast Facts.
What is the Holzer Intranet.
Frequency of reporting for measures.
What is monthly.
This visit it routinely prepped and completed by the care manager.
What is Medicare Annual Wellness Visit.
AI used to help clinical insight and HCC suggestions.
What is Navina.
Only inverse Measure
What is Glycemic Status Assessment >9 or not collected. (A1c)
Secondary diagnosis needed when ordering.
What is osteoporosis screening.
Edit settings on measure to change frequency.
What is colorectal cancer screening.
You can find the care plan documented here.
What is the care tab in Athena (under the quality tab).
Who can refer to Care Managers?
Who is anyone/everyone. Providers, clinical staff, receptionist, secretaries or self referral.
Teaching sheets/guides that include screenshots from Athena of workflows.
What are Ambulatory Fast Facts.
Satisfied by documenting in the physical exam.
What is Diabetic foot exam.
Employee of the quality department that runs reports and helps answer questions regarding measures.
Who is Beth Buck.
Have been contacted or have attempted contact within 2 business days of discharge, and seen by a provider in the office within 14 calendar days of discharge.
What is Transitional Care Management (TCM).
These patients are often prioritized for care management because they have multiple chronic conditions, frequent hospitalizations, or significant social needs.
Who are high-risk patients?
This must be included in the patients history for exclusion from the Mammography measure.
What is Bilateral Mastectomy or two Unilateral Mastectomies (must have date entered in surgical & procedure history).
Manually asserting the result (positive or negative) and the date in the quality tab.
What is diabetic eye exam.
Equal to or greater than 140/90
What is failure to meet (not satisfying) the controlling high blood pressure measure.
Resources for SDOH
What is Holzer Connect, formerly known as find help.
These are preventive or chronic care opportunities that have not been completed and are often targeted for outreach.
What are care gaps?
Document and score MMSE.
What is workflow to satisfy Dementia Cognitive Assessment
This measure will only be satisfied by billing CPTII code 1123F, 1124F or 1157F.
What is Advance Care Plan.
Intentionally maintaining two measures for this quality metric (MIPS and Adult Preventive)
What is colorectal cancer screening.
Upcoming new service line for care management services.
What is Chronic Care Management (CCM).
The score used to predict healthcare costs based on patient risk.
What is RAF (Risk Adjustment Factor)
This population health goal is achieved when patients receive the right care, at the right time, in the right setting, leading to improved outcomes and lower costs.
What is value-based care.