# people identified with high/low levels related to anemia, coronary disease, kidney disease, diabetes, liver disease, thyroid disease % of participating completing physician office within 3 months after report Offer annual blood screening for Laurie Klingensmith Q1 2016 Q2 $1,000.00 # physicians participating physician outreach program physicians K Milliron 2017 Participate in the annual Continue to offer blood pressure Lori Klingensmith June of each $1,000.00 # people participating Groundhog Festival through a screenings, glucose screenings and year # people referred for follow up with cholesterol testing as well as other Health Fair physician educational opportunities throughout the week of the fair. ACTION STEPS ACCOUNTABILITY TIMEFRAME BUDGET IMPACT WILL BE MEASURED AND OBJECTIVE EVALUATED THROUGH INDICATORS Decrease readmissions Discharge planning risk factor score Moran 2016/ 2017 Overall Readmission Rate less than – – through better chronic care of 10 and above the patient is Discharge Planning 14% readmission rate management scheduled for an appointment within 7 Department COPD Readmission Rates less than – days with their primary care provider; Punxsutawney Home 12% readmission rate they get a discharge phone call within Health, VNA and Resta 72 hours they look at med – management, meeting with their physician; any home equipment. If they didn’t go home with home health would they benefit for home health.
# people identified with high/low levels related to anemia, coronary disease, kidney disease, diabetes, liver disease, thyroid disease % of participating completing physician office within 3 months after report physician outreach program Offer annual blood screening for physicians Laurie Klingensmith K Milliron Q1 2016 Q2 2017 $1,000.00 # physicians participating Participate in the annual Groundhog Festival through a Health Fair Continue to offer blood pressure screenings, glucose screenings and cholesterol testing as well as other educational opportunities throughout the week of the fair. Lori Klingensmith June of each year $1,000.00 # people participating # people referred for follow up with physician OBJECTIVE ACTION STEPS ACCOUNTABILITY TIMEFRAME BUDGET IMPACT WILL BE MEASURED AND EVALUATED THROUGH INDICATORS Decrease readmissions through better chronic care management Discharge planning – risk factor score of 10 and above the patient is scheduled for an appointment within 7 days with their primary care provider; they get a discharge phone call within 72 hours – they look at med management, meeting with their physician; any home equipment. If they didn’t go home with home health would they benefit for home health. Moran Discharge Planning Department Punxsutawney Home Health, VNA and Resta 2016/ 2017 Overall Readmission Rate – less than 14% readmission rate COPD Readmission Rates – less than 12% readmission rate
PAH%20Implementation%20Strategy%20Plan%20D04%2010-22-15.docx