Resource Library

2019 Best Practice Awards Submission for HIE/ADT Implementation

The goal was to automate data flow containing valuable quality and Admission Discharge Transfer data for all patients. In order to accomplish this goal, the identified need was to develop a process by using a reliable Health Information Exchange system that could send data from the ambulatory Electronic Medical Record, Athena. The HIE/ADT Implementation took place in 2016 to 2017. Goals have been met to capture all the data elements needed and transmit the data through an automated process. The ADT information has also greatly improved identification of patients utilizing ED and IP services in real time.

2019 Best Practice Awards Submission for HIE/ADT Implementation

Through the use of Carespective, the MAG secure provider portal, practice embedded care managers accessed and used the ADT notices to follow patients who have been discharged from an inpatient, emergency department, or other encounter at a hospital facility. The practice care managers' access to real time ADT notices and follow-up with patients after a facility encounter has resulted in an overall decrease in ER visits, a decrease in inpatient readmissions, and a decrease in frequent ER utilization.

2019 Best Practice Awards Submission for Care Management Workflow

Care Management Team within the Primary Care Office is embedded within the Quality Department which allows for patient identification to help close gaps in care. The Certified Medical Assistant role is embraced where they are expected to work to the top of their licensure and assist with mildly complex patients who have needs related to Care Coordination. Certified MA's follow patients who qualify for Care Management based on risk score and/or disease stage whose insurance does not cover Care Management Services. Systematic approach for identifying patients based on lab values, gaps in care, ED/Inpatient stays, blood pressure values, and SDoH needs. Providers are engaged and understand the benefits and importance of the program. Open and frequent communication with the Care Team is expected.

2019 Best Practice Awards Submission for Care Management Workflow

A process was implemented to identify eligible and current care management patients as a part of pre-visit planning/huddle process. The workflow was designed for reconciling, tracking, and reporting current care management patient panels. A workflow was created to guide care managers through the process for completing documentation in progress notes for billable care management phone call encounters. Care management panels were utilized to monitor billing frequency and measure improved clinical quality outcomes on care management patients.

2019 Best Practice Awards Submission for Care Management Workflow

Patient referral and engagement rates were targeted for improvement to increase delivery of care management services and ultimately improve member health outcomes. Assessment revealed barriers at both the practice and program administrative level that impaired successful patient engagement and visit volumes. Using lean principles, workflows were standardized to achieve improvements in rates of successful patient engagement and care management service delivery.

2019 Best Practice Awards Submission for Care Management Workflow

A quarterly report was sent to the pilot practices that identifies patients that would benefit from care management interventions based on their level of risk. The report was used as an aid to the care managers to identify patients who would benefit from care management interventions. Care Management workflow includes address gaps in care, improve care coordination, address SDoH needs, establish self-management goals to improve patient outcomes and reduce health care costs, and address appropriate use of ED.

2019 Best Practice Awards Submission for Care Management Workflow

The goal of the program was to provide specialized and supportive care management to PO-specific members free of charge, serving the managed Medicaid, BCBSM commercial/MA, and other commercial populations. Centralized specialists (pharmacist, behavioral health counselor, dietitian) were available for unlimited referrals to 21 primary care practices. Supportive personnel reduced administrative burden on individual care managers of report generation, program-related troubleshooting and oversight, and data entry. Centralized support was provided for the transition of care process, initiating the phone call requirement.

2019 Best Practice Awards Submission for Care Management Workflow

PHCN has made numerous improvements to its Care Management program over the last year that has enabled the department to grow and reach a larger number of patients. This has included improved workflows, appointment availability at all primary care locations, medication management, and care coordination with the PCP. There are written workflows for major illnesses and planned visits; nutritional education following ADA standards, self-management goal education, and access to community resources.

2019 Best Practice Awards Submission for Care Management Workflow

OSP's information technology team developed an all-program inclusive care management patient roster by practice unit. The All Program Care Management Patient Roster assists practices and care managers identify eligible patients for care management. The IT team also built a care management Population Practice Engagement Dashboard, which publishes current rates of patient engagement in active care management programs for individual practices. The patient roster and engagement dashboard are unique in that they provide comprehensive patient eligibility for care management payer programs and real-time care management program engagement at a practice level.

2019 Best Practice Awards Submission for Care Management Workflow

As part of a pilot, OPNS had previously embedded an RN care manager in two primary care physician practices. The pilot was successful in that the care manager, physicians, and other care team members were able to create processes to identify appropriate patients for care management interventions, create patient panels, utilize the EMR to accurately document care management interventions, and bill PDCM services for eligible members.