GOALS(SCORE)
DIAGNOSES INCURRING FINANCIAL PENALTIES FOR READMISSION WITHIN 30 DAYS IN.CLUDING HEART FAILURE, MI, PNEMONIA, AND COPD
WHAT ARE THE MEDICARE FFS PENALTY DIAGNOSES.
ACO REACH
AETNA MA
BLUE CROSS/ANTHEM MA
What is our Medicare Priority Contracts
A CARE COORDINATION OVERLAY IN EPIC THAT WENT LIVE IN 2024
AN URGENT CLINICAL SERVICE PROVIDING MULTIDISCIPLINARY CARE AND DIAGNOSTIC TESTING IN THE HOME.
WHAT IS CARE2U
COMPLAINTS OF 2-3 POUND WEIGHT GAIN IN A WEEK PERIOD, EXTREME FATIGUE AND LOWER EXTREMITY EDEMA, ABDOMINAL PAIN, SHORTNESS OF BREATH.
WHAT SYMPTOMS SHOULD OUR PATIENTS WITH HEART FAILURE REPORT TO US OR THEIR PHYSICIAN?
6 HOURS PER DAY WITH INITIAL ENROLLMENTS EQUALING 45 MINUTES AND FOLLOW UP CALLS EQUALING 20 MINUTES.
HOW MUCH PRODUCTIVE TIME SHOUD I HAVE IN A DAY?
HEALTHFIRST
FIDELIS
WHAT ARE OUR OUR MEDICAID PRIORITY CONTRACTS?
TO PROVIDE MORE COMPREHENSIVE DATA TO HELP SUPPORT OUR CARE COORDINATION EFFORTS
WHAT IS COMPASS ROSE?
THE MOST IMPORTANT INTERVENTION WHEN A TOC PATIENT IS CONTACTED FOR THE FIRST ?
WHAT IS MEDICATION RECONCILIATION?
A LUNCH BOX WITH AN ORAL STEROID, ANTIBIOTICS INSIDE WITH INSTRUCTIONS FOR WHEN THE PATIENT SHOULD USE IT AND TO CALL THE PHYSICIAN TO INFORM THEM OF THE NEED TO USE.
WHAT IS IN A RESCUE COPD KIT?
A TCM MEASURE ENSURING THE PATIENT HAS A SUITABLE PLAN AND SUPPORT WITHIN 7 DAYS OF HOSPITAL DISCHARGE.
WHAT IS THE 7 DAY FOLLOW UP AFTER HOSPITALIZATION?