Often shortened to PCP, this provider should be your first contact for all health-related questions or concerns
What is a Primary Care Physician?
100
Educate all staff on care pathways and INTERACT principles.
What is...2.b.vii
100
This campaign provides clinicians, employers, and public health practitioners with evidence-based strategies for improving cardiovascular health
What is The Million Hearts Campaign?
100
For a Medicaid beneficiary to be included as an engaged patient in 2.d.i, he or she needs to be considered this.
What are Non-Utilizing or Low-Utilizing?
200
RHIO
What is a Regional Health Information Organization
200
Establish protocols and training for care coordinators to assist patients in understanding use of the health system, and to promote self-management and knowledge on appropriate care.
What is... 2.b.ii
200
Multiple studies show that these scores are predictive of most health behaviors, including cancer screenings, healthy diet and regular exercise and medication management
What is The Patient Activation Measure
200
A completed PHQ2 or SBIRT screening makes a patient actively engaged in this project.
What is Project 3.a.i Integration of Behavioral Health and Primary Care?
300
INTERACT
What is Interventions to Reduce Acute Care Transfers?
300
Any member with an active Medicaid CIN can count towards your actively engaged totals, including those with Medicaid and this similar type of insurance.
What is Medicaid Managed Care?
300
Ensure that a 30-day transition of care period is established.
What is ... 2.b.iv
300
Studies show that Medicare beneficiaries who receive care in practices with this recognition spent less per year than beneficiaries in comparison practices.
What is NCQA Patient Centered Medical Home
300
If patients have this documented at some, but not all, visits with their primary care physician, they cannot be included in the Actively Engaged count.
What is... self management goals?
400
MRT
What is the Medicaid Redesign Team?
400
It involves coordinating a patient's needs throughout the 30 day period after a discharge- an Intervention Model is also a requirement for this DSRIP project.
What are Transitions of Care? (or Care Transitions)
400
A 2011 study predicts great promise for this quality improvement program. After 25 nursing homes implemented the program in 2009, they experienced a 17% decrease in hospitalization rates, compared with the same 6-month period the year before.
What is "INTERACT Program"
400
This is the only Domain 2 project that does not have patient engagement targets.
What is... 2.a.i?
500
MAX Series
What is the Medicaid Accelerated Exchange Series?
500
The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women. The most widely used and best-validated instruments in the primary care setting is this tool.
What is PHQ-9
500
Patients that visit this facility in the course of having a crisis stabilized, cannot be counted towards the 3.a.ii actively engaged.