🚀 PowerBI Pathfinders
Navigate here within PowerBI to evaluate a staff member’s productivity, efficiency, and performance metrics, including touches, scheduling, and care management activity.
Where is Staff View?
This coordinated group of providers shares responsibility for the quality and total cost of care for a defined Medicare population, often earning shared savings for improved outcomes.
What is an Accountable Care Organization (ACO)?
This website enhances optimization of the scheduling tool by providing a real-time view of scheduling needs, including open slots, visit frequency gaps, patients due for follow-up, and care team capacity—allowing teams to proactively close gaps and maximize patient access.
What is "pwa.yourhealth.org "
This score reflects the overall health complexity of a patient population and is used to determine the visit frequency of a patient. This score increases when chronic conditions are accurately documented and recaptured annually, directly impacting both patient care planning and value-based reimbursement.
What is Risk Adjustment Factor (RAF)?
This post-discharge service requires timely follow-up—typically within 7 to 14 days after a hospital or SNF discharge—and includes medication reconciliation, review of discharge instructions, coordination with the care team, and ongoing patient engagement to prevent readmissions.
What is a Transitional Care Management (TCM) visit?
Navigate here within PowerBI to pull a comprehensive care team census for your region, where you can view patient needs and key metrics such as RAF scores, HCC gaps, recent hospitalizations, care management engagement, visit frequency, and overall risk stratification to guide care planning.
What is the “All Patients” view in PowerBI Core 2.0?
This ACO partner collaborates with Your Health Organization to support high-risk patients through coordinated care, advanced illness management, and value-based initiatives.
Who are Advanced Illness Partners (AIP)?
This section of the scheduling tool allows you to quickly search for and locate a specific patient within your assigned population.
What is the "Patient Manager Dashboard?"
This determines the total amount of money allocated to an organization based on a patient’s clinical complexity (RAF score), from which healthcare expenditures are deducted.
What is allotment?
This annual Medicare visit focuses on prevention rather than a hands-on physical exam and includes a comprehensive health risk assessment, review of medical and family history, cognitive and depression screening, fall risk and safety evaluation, updating the patient’s care team, and creation of a personalized prevention plan—all while helping identify and capture chronic conditions for accurate RAF documentation.
What is an Annual Wellness Visit (AWV)?
Navigate here in PowerBI to view a high-level snapshot of scheduling performance, including patients seen, visit volume, scheduling rates, and overall productivity metrics.
Where is "case management overview?"
This type of patient often has multiple chronic conditions, a higher RAF score, recent hospitalizations or ER visits, and social or environmental barriers to care—requiring frequent touches, close monitoring, and support from an interdisciplinary team to prevent decline.
What is a high-risk patient?
This section in the new scheduling tool allows you to filter and identify specific types of appointments, helping teams efficiently target patients due for visits and close scheduling gaps.
What is the "Worklist Overview?"
Carrying a higher weight, these diagnosis codes capture chronic conditions and disease burden, and are used to calculate a patient’s RAF score in value-based care models.
What are HCC (Hierarchical Condition Category) diagnosis codes?
This visit includes a comprehensive, hands-on, head-to-toe evaluation with a full review of systems, complete vital signs, and detailed physical examination. It is used to assess overall health, identify and manage acute and chronic conditions, update medical history, and support accurate diagnosis and documentation.
What is a Comprehensive Physical Exam?
Navigate here in PowerBI to analyze trends in unspecified diagnosis codes and drill through data using keywords or ICD-10 codes to improve documentation specificity.
Where is "Diagnosis Discovery?"
Navigate here to identify the high-needs patient population within each region’s census using data-driven insights and risk stratification.
What is the High Needs Portal in PowerBI (Your Health Insight Portal)?
Every facilitator must complete this actionable step in the scheduling tool to align themselves with patients on their care team and be eligible to schedule and conduct visits.
What is "Claim the patient?"
Integrated withing the EMR (Athena), this tool is used to analyze patient data and surface suspected conditions and care gaps, helping providers improve HCC documentation and RAF accuracy.
What is Navina?
This comprehensive service evaluates memory, cognition, mood, and functional status using standardized tools, often identifying conditions such as dementia. It includes caregiver input, assessment of safety risks (like medication management and fall risk), and results in a detailed, patient-centered care plan with recommendations for treatment, support services, and ongoing coordination with the care team.
What is a Cognitive Assessment Care Plan?
Navigate here within PowerBI to identify recent hospital, ER, and/or SNF discharges across your care group, enabling timely TCM outreach and follow-up.
What is the ADT Patient List?
Often critical for high-risk populations, this billable service includes structured conversations with patients and/or families to define goals of care, document advance directives, identify a healthcare proxy, and align future medical decisions with the patient’s wishes.
What is Advanced Care Planning (ACP)?
This area of the scheduling tool allows you to select patients from your census and view them geographically on a map to optimize routing and visit planning.
What is Census-Based Scheduling (Map View)?
Navigate to this section of a patient’s encounter to document diagnoses at the highest level of specificity and ensure accurate RAF capture.
What is the Assessment & Plan (A/P)?
These two types of care management services provide ongoing, non-face-to-face support—one focusing on social determinants and community resource coordination, and the other on behavioral health conditions—both contributing to comprehensive patient care between visits.
What are Community Health Integration (CHI) and Behavioral Health Integration (BHI)?