stage of the workflow; Other sources demonstrating implementation of the system Collect documents and workflows from Action Steps: each PCMH site; the ones who received certification should already have workflow for care coordination Follow up: EHR Workflows from PCMH partners: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) Care coordinators to provider data and Task Step 6: feedback on PCMH as required by PMO to be M. D’Urso, RN/ incorporated for tracking and improvement mechanisms. Collect care coordination tracker from each Action Steps: site and monitor on quarterly basis Care coordinator trackers from PCMH Follow up: partners: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) Project Deliverables DY2 Q4 Perform population health management by Milestone #6 actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers. Utilize existing Population Health Task Step 1# 4. M.Hay Management IT tool, Allscripts Care Director, to identify and attributed lives by creating registries for all participating safety net providers. EHR screenshots from PCMH partners: Follow up: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) Project Deliverables DY2 Q4 Implement preventive care screening Milestone #8: protocols including behavioral health screenings (PHQ-2 5. M. D’Urso, RN/ or 9 for those screening positive, SBIRT) for all patients to identify unmet needs. A process is developed for assuring referral to appropriate care in a timely manner.
stage of the workflow; Other sources demonstrating implementation of the system Action Steps: Collect documents and workflows from each PCMH site; the ones who received certification should already have workflow for care coordination Follow up: EHR Workflows from PCMH partners: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) Task Step 6: Care coordinators to provider data and feedback on PCMH as required by PMO to be incorporated for tracking and improvement mechanisms. Action Steps: Collect care coordination tracker from each site and monitor on quarterly basis Follow up: Care coordinator trackers from PCMH partners: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) M. D’Urso, RN/ 4. Project Deliverables DY2 Q4 Milestone #6 Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers. Task Step 1# Utilize existing Population Health Management IT tool, Allscripts Care Director, to identify and attributed lives by creating registries for all participating safety net providers. Follow up: EHR screenshots from PCMH partners: (CHN, Brightpoint, Rite Care, Jose Quiwa, Advanced Pediatrics, Caring Hands , NYPQ Clinics) M.Hay 5. Project Deliverables DY2 Q4 Milestone #8: Implement preventive care screening protocols including behavioral health screenings (PHQ-2 or 9 for those screening positive, SBIRT) for all patients to identify unmet needs. A process is developed for assuring referral to appropriate care in a timely manner. M. D’Urso, RN/
NYPQ%20PPS%20PCMH%20Meeting%20Agenda%203.7.17.docx