GOALS(SCORE)
VBC's
Compass Rose
Readmission Prevention
Clinical
100


DIAGNOSES INCURRING FINANCIAL PENALTIES FOR READMISSION WITHIN 30 DAYS INCLUDING HEART FAILURE, MI, PNEMONIA, AND COPD

WHAT ARE THE MEDICARE FFS PENALTY DIAGNOSES? 

100

ACO REACH

AETNA MA 

BLUE CROSS/ANTHEM MA

What is our Medicare Priority Contracts?

100

A CARE COORDINATION OVERLAY IN EPIC  THAT WENT LIVE IN 2024

COMPASS ROSE
100

AN URGENT CLINICAL SERVICE PROVIDING MULTIDISCIPLINARY CARE AND DIAGNOSTIC TESTING IN THE HOME.

WHAT IS CARE2U

100

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?

200

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?

200

HEALTHFIRST

FIDELIS

WHAT ARE OUR OUR MEDICAID PRIORITY CONTRACTS?

200

AN Epic OVERLAY TO PROVIDE MORE COMPREHENSIVE DATA TO HELP SUPPORT OUR CARE COORDINATION EFFORTS

WHAT IS COMPASS ROSE?

200

THE MOST IMPORTANT INTERVENTION WHEN A TOC PATIENT IS CONTACTED FOR THE FIRST ?

WHAT IS MEDICATION RECONCILIATION?

200

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?

300

 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?

300

Someone who has an increased chance of developing a severe illness or injury. This can be due to a number of factors, including age, medical conditions, pregnancy, or social determinants of health.

What is a HI Risk patient?

300

A closure reason indicating that a patient was enrolled but then unable to reach after further attempts.

What is"Unable to Reach after Enrollment" ?

300

1. Disengagement and non-adherence

2. Condition complications

3.  Inadequate Transition of Care

4. Misinterpretation of Discharge Instructions5. Demographic Factors

What are the top 5 reasons patients are readmitted to the hospital?

300
  • Don’t chart a symptom such as “c/o pain,” without also charting how it was treated 
  • Never alter a patient’s record - that is a criminal offense 
  • Don't use shorthand or abbreviations that aren't widely accepted
  • Never chart what someone else said, heard, felt, or experienced unless the information is critical. If absolutely needed, use quotations and properly attribute the remarks 
  • Never chart care ahead of time, as situations often change and charting care that has not been performed is considered fraud 

What are the "don'ts" for documenting in a patients record? 

400

Removing barriers that prevent our patients from reaching their optimal level of health and avoiding unnecessary utilization of services.  

What is the GOAL of Care Coordination?

400

The potential financial penalty a healthcare provider may face if they fail to meet established quality and cost benchmarks, meaning they could lose revenue if their patient care falls below expected standards, essentially putting a portion of their income at risk if they don't deliver high-quality care at a controlled cost.

What is Down- Side Risk in Value Based Contracts?

400

A selection in Compass Rose that is completed ONLY if the patient has been Enrolled in Care coordination.

What is the Enrollment Reason tab used for? 

400

Diagnoses seen frequently in the ED that could have potentially been prevented through better coordination with primary care including  Abdominal pain ,  Nonspecific chest pain ,Skin and subcutaneous tissue infections ,Other lower , respiratory disease , Spondylosis; intervertebral disc disorders; other back problems , Urinary tract infections, Other connective tissue disease , Other non-traumatic joint disorders , Other upper respiratory infections , Headache; including migraine , Nausea and vomiting , Conditions associated with dizziness or vertigo , Malaise and fatigue , Chronic obstructive pulmonary disease and bronchiectasis , Other skin disorders

What are main diagnoses considered as potentially avoidable ED admits?

400

A Care coordination note that does not contain the receiver of the call's full name and position or the full name of the provider whom the Care Coordinator is calling.  

" TC to Dr. spoke with Nancy. MD not available.  Left message for CB". 

What is an example of unacceptable documentation in a medical record? 

500

1.  Patient-centered approach: Emphasizes the patient's understanding and involvement in their care plan. 

2. Care coordination: Facilitates smooth transitions between healthcare providers and settings. 

3. Medication management: Ensuring patients understand their medications and potential side effects. 

4. Patient education: Providing clear information about their health conditions and how to manage them. 

5. Red flag awareness: Educating patients on critical signs that could indicate a worsening health situation.

What are Colemans Five Pillars of Transitional Care?

500

A healthcare delivery model where providers are paid based on the quality of care they deliver to patients, focusing on positive health outcomes rather than the quantity of services provided, meaning they are incentivized to improve patient health and manage costs effectively, often through coordinated care and preventative measures; essentially, "value" is measured by the quality of care delivered relative to its cos

What is Value Based Care?

500

A place in EPIC to find information regarding a physician's participation in our IPA. (voluntary vs employed)

What is the Provider Finder tab?

500

$26 Billion Dollars for 2 million patients. 

How much money does it cost Medicare each year for readmissions?

500
  • Smoking
  • Exposure to air pollution
  • Breathing secondhand smoke
  • Working with chemicals, dust, and fumes
  • A genetic condition called alpha-1 antitrypsin deficiency
  • A history of childhood respiratory infections

What are the causes and risk factors for COPD?