Intervention Measures 2016 Quantity/Volume Outcome Goals Shared Care Alerts AAMC: >350 Care Alerts >30% reduction in a) % of high-utilizer target UM BWMC: 340 Care inpatient visits for population with Care Alerts target population Alerts Pre- and Post- Care Alert creation: who have Care b) ED utilization Alerts at either c) Inpatient admissions hospital d) Per patient charges Shared Care Plans/ AAMC: >250 Care Plans Decreased PAU by a) % of high-utilizer target Care Management those patients who UM BWMC: most Care population with Care Plans and % have care Plan information is that are shared via CRISP managers and included in Care Alerts b) % of high utilizers with associated Care (above) completed health risk assessments Plans Pre- and Post- Care Manager assignment measurements of: c) ED utilization d) Inpatient admissions e) Per patient charges Also, f) % of high-utilizers with assigned care managers g) % of high-utilizers who have been offered and have declined care management services One-Call Care AAMC: Approximately Increase the # of a) # and of calls received and Management 2,100 calls Care Management from what zip codes Service assignments and b) # of referrals provided for Care decrease PAU. Management assignment c) # of referrals to DoAD Community Care See measures in Shared Care Plans AAMC: 275 10% reduction in Management above patients/month capacity bedded care (IP/Obs > 24 hours) UM BWMC: 140 for those patients patients/month capacity being seen by The Coordinating Center Physician House # of patients referred and AAMC and UM BWMC: Decreased PAU due Calls receiving services 500 homebound to better chronic patients receiving condition physician call visits management
Intervention Measures 2016 Quantity/Volume Goals Outcome Shared Care Alerts a) % of high-utilizer target population with Care Alerts Pre- and Post- Care Alert creation: b) ED utilization c) Inpatient admissions d) Per patient charges AAMC: >350 Care Alerts UM BWMC: 340 Care Alerts >30% reduction in inpatient visits for target population who have Care Alerts at either hospital Shared Care Plans/ Care Management a) % of high-utilizer target population with Care Plans and % that are shared via CRISP b) % of high utilizers with completed health risk assessments Pre- and Post- Care Manager assignment measurements of: c) ED utilization d) Inpatient admissions e) Per patient charges Also, f) % of high-utilizers with assigned care managers g) % of high-utilizers who have been offered and have declined care management services AAMC: >250 Care Plans UM BWMC: most Care Plan information is included in Care Alerts (above) Decreased PAU by those patients who have care managers and associated Care Plans One-Call Care Management Service a) # and of calls received and from what zip codes b) # of referrals provided for Care Management assignment c) # of referrals to DoAD AAMC: Approximately 2,100 calls Increase the # of Care Management assignments and decrease PAU. Community Care Management See measures in Shared Care Plans above AAMC: 275 patients/month capacity UM BWMC: 140 patients/month capacity 10% reduction in bedded care (IP/Obs > 24 hours) for those patients being seen by The Coordinating Center Physician House Calls # of patients referred and receiving services AAMC and UM BWMC: 500 homebound patients receiving physician call visits Decreased PAU due to better chronic condition management