TOC
I am a task that is sent when the OTH team is following up with a stable member who was recently discharged from the hospital and is low risk for re-admission.
What is the stable discharge notification task?
This team member is added to the care team after 3 unsuccessful call attempts.
Who is the community health worker?
This is included in every subject of a Pathway communication note.
What is Care Coordination?
This is where I find the name of the clinician who I schedule initial visit in SOL.
What is the care team?
i am completed once a calendar year and show in the Pathway banner when due.
What is the RSA?
These are the days that we do additional post hospital outreach.
What are days 10, 18, and 25?
This is the risk level that we update the member to when you complete 3 unsuccessful call attempts for scheduling.
What is stable?
This is the referrals made drop down that we include in Pathway communication note when reviewing open star gaps, but did not schedule any appointments to close them.
What is Stars Education-No Appt?
This is the type of initial visit do we schedule with our APCs.
What is the APC initial visit?
I am completed every 6 months for all risk levels.
What is the SDOH?
This is the type of PHV we schedule with APCs who have never completed an initial visit with a member.
What is a Post Hospital Comp Visit?
This is the sub-status we update the member to after 3 unsuccessful initial call attempts.
What is UTR-CHW?
These are the drop downs we use when we complete additional calls during member outreach.
What is communication update?
This is the section that we include the clinician's name for the visit.
What is the Service Resource Preference ?
I am completed quarterly for stable members only.
What is the DSNP Care Coordination Assessment>
This is the number of days that we have to call a member to get a PHV scheduled.
What is 3?
This is the sub-status that you update a member to if they decline clinician visits, but agrees to CN outreach.
What is Unable to Engage?
This is what we use to create the template for our Pathway communication note.
What is the CN Doc tool?
This is the button that we use to help us identify best available days for scheduling.
What is the Candidates button?
I am completed once a year if the member hasn't seen a HouseCalls clinician or has COAPS/COAFSA star gaps open.
What is the Clinical Indicator?