Page 19 - Delaware Medical Journal - May/June 2018
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TRANSFORMATION IN HEALTH CARE
Community Partner Use Community Resources a. The practice shares clinical information with admitting
hospitals and EDs (NCQA PCMH)
b. The practice proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or ED visit (NCQA PCMH)
c. The practice offers or refers patients to structured health education programs, such as group classes and peer support (NCQA PCMH)
4. Supply voice-to-voice coverage to panel members 24/7 (e.g., patient can speak with a licensed health professional at any time)
• PERFORMANCE: Person-Centered Care Enhanced Access Provide 24/7 Access
Optimal Use of HIT Innovate for Access
providing access to clinical advice and continuity of medical record information at all times (NCQA PCMH)
b. The on-call provider has continuous computer access to patient records through remote log-on to the practice’s EMR (NCQA PCMH)
c. The practice regularly assesses its performance on NCQA PCMH:
i. Providing continuity of medical record information for care
ii. Providing timely clinical advice by telephone
iii. Providing timely clinical advice using a secure, interactive electronic system
5. Document sourcing and implementation plan for launching a multi-disciplinary team working with highest-risk patients to develop a care plan
• PERFORMANCE: Person-Centered Care Team-Based Relationships Enhance Teams
• SUCCESS: Sustainable Business Operations of Operation Streamline Work Flows
structure and staff leading and sustaining team-based care (NCQA PCMH)
coordination (e.g., through vendor support or hiring a care coordinator)
c. Practice has documented its approach to implementing team- based care and developing care plans for high-risk patients
6. Document plan to reduce emergency room overutilization • PERFORMANCE: Person-Centered Care Organized,
Evidence-Based Care Reduce Unnecessary Tests Transparent
Measurement and Monitoring Use Data Transparently
a. The practice provides patients with materials for obtaining
is closed (NCQA PCMH)
admissions and ER visits (NCQA PCMH)
c. The practice proactively contacts patients/families for follow- up care after discharge from hospital/ER within an appropriate period (NCQA PCMH)
7. Implement the process of contacting patients who did not receive appropriate preventive care
• PERFORMANCE: Person-Centered Care Population Management Identify Care Gaps/Decrease Care Gaps
a. The practice uses panel support tools (registry functionality) to identify services due (CMS)
b. At least annually, the practice proactively reminds patients or their families/caregivers of needed care (using evidence-based guidelines) for preventive care services, immunizations, and patients not recently seen by the practice (NCQA PCMH)
c. The practice uses reminders and outreach (e.g., phone calls, emails, postcards, patient portals, template letters, etc.) to alert and educate patients about services due (CMS)
8. Implement a multi-disciplinary team working with highest-risk patients to develop care plans
• PERFORMANCE: Person-Centered Care Population
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