Suspects
This is what CIS are expected to do for every suspect after every patient visit.
What is "address all suspects?"
This is what the acronym MEAT stands for.
What is Monitor, Evaluate, Assess, Treat?
The morning routine during which the MA would read the quality measures gapping for each patient.
What is huddle?
The name for OSH care model. (Hint: Not fee-for-service)
What is "value-based care?"
What is 7?
This process is used to ensure that the correct actions were taken to address suspects the previous day.
Daily Accountability
Must be included as part of the T2DM coding guidelines
What is the method of control - "Long term (current) use of oral hypoglycemic drugs" and/or "Long term current use of insulin"
These OSH screenings are suspect generating.
What are PHQ-9 and Audit-C?
The goal of Oak Street Health (Hint: Three H statement)
What is "to keep a patient Happy, Healthy, and out of the Hospital?"
Oak Street Health was founded in this year
2012
This is the monthly meeting with CIS and provider to take action on suspects.
What is CDR?
This is used to allow the CIS to return to a note once a positive result is presented in the chart to document a suspect discussed during the original visit.
What is Amendable Language?
These scores for PHQ-9 separates a patient from mild MDD, moderate MDD, and severe MDD.
What is >=5, >=10, and >=20?
These patients will be scheduled every 6 months, 3 months, & 1 month respectively.
What are Good, Fair, Serious/VIP?
This is what Brendan did for work before coming to Oak Street Health
Physical Therapist
This Google Sheet explains all logic of almost every suspect prompted within version 28 of our model.
What is Care Report Data Dictionary Summary?
The rule for billing where "the ICD-10 that is listed in the furthest left position on the E&M row/listed as #1 on a superbill without other CPT codes."
What is "principal position for diagnosis codes?"
These two quality screenings are ideally best to close during the visit as they are quick to close via Canopy and only require a Physical Exam and a few screening questions respectively.
What is LE exam & HF Detection?
This number represents a patient's chronic condition burden, and it important in OSH getting the resources it need to care for them. (Hint: it is usually in decimal form on Canopy)
What is RAF (Risk-Adjusted Factor)?
In June we are switching to Epic, this is the state where Epic is headquartered (100 bonus points for the year it was founded)
What is Wisconsin? (Founded in 1979)
This is a risk adjustment model used by Medicare and insurers to group similar diagnosis codes into categories that predict healthcare costs.
What is HCC (Hierarchical Condition Category (HCC))?
The two CPT codes needed to close the gaps corresponding to a PostDischarge Visit and the two diagnosis codes that must be mapped to them.
What is "long term current drug therapy (Z79.899)/medication reconciliation (1111F) & other specified counseling (Z71.89)/post discharge visit?"
This is what "pre" and "post" refer to in spirometry.
What is bronchodilator?
This is abbreviated SDOH, and includes things beyond direct medical issues that can impact a patient's health.
What is "Social Determinants of Health"?
This is the number of bones in the human body.
What is 206?