Population Stratification: Care Protocol Registries 1. Care team roles 1. Care team 1. Care team 1. HbA1c testing 2. Care team empanelment empanelment 2. Well child structure (75%) (95%) care 3. Standing orders 2. Patient 2. QI trainings 3. Depression engagement 3. Shared care screening trainings plans: provider 4. SUD 3. Population health screening Team Based management 5. ED Visits for Care trainings ambulatory 4. Care team care-sensitive huddling conditions 6. CAHPS survey 7. ECHO survey 8. National Core Indicators survey 1. Care compact: 1. Referral tracking 1. Hospital F/U 1. ED Visits for Health medical providers 2. eConsult 2. ER F/U ambulatory Neighborhood 3. Care compact: care-sensitive Care community conditions Coordination partners 2. Total cost of care 1. BH preventive 1. BH registry 1. BH co-location 1. Well child health screening 2. BH share care 2. BH providers care 2. BH referrals plan: patient 2. Depression 3. BH shared screening decision making 3. SUD Behavioral tool screening Health 4. Care compact: Integration behavioral health providers 5. BH agency strategic measures 6. BH referral tracking 1. Process for 1. Shared decision 3. Patient advisory 1. CAHPS survey Patient soliciting patient making tools group 2. ECHO survey Engagement feedback 2. Patient 3. National Core and Experience satisfaction survey Indicators Survey 1. Performs practice 1. Agency strategic 1. Agency QI improvement measures projects Quality activities 2. Agency QI plan 2. Family and Improvement patient engagement in QI projects
Population Stratification: Care Protocol Registries Team Based Care 1. Care team roles 2. Care team structure 3. Standing orders 1. Care team empanelment (75%) 2. Patient engagement trainings 3. Population health management trainings 4. Care team huddling 1. Care team empanelment (95%) 2. QI trainings 3. Shared care plans: provider 1. HbA1c testing 2. Well child care 3. Depression screening 4. SUD screening 5. ED Visits for ambulatory care-sensitive conditions 6. CAHPS survey 7. ECHO survey 8. National Core Indicators survey Health Neighborhood Care Coordination 1. Care compact: medical providers 1. Referral tracking 2. eConsult 1. Hospital F/U 2. ER F/U 3. Care compact: community partners 1. ED Visits for ambulatory care-sensitive conditions 2. Total cost of care Behavioral Health Integration 1. BH preventive health screening 2. BH referrals 1. BH registry 2. BH share care plan: patient 3. BH shared decision making tool 4. Care compact: behavioral health providers 5. BH agency strategic measures 6. BH referral tracking 1. BH co-location 2. BH providers 1. Well child care 2. Depression screening 3. SUD screening Patient Engagement and Experience 1. Process for soliciting patient feedback 1. Shared decision making tools 2. Patient satisfaction survey 3. Patient advisory group 1. CAHPS survey 2. ECHO survey 3. National Core Indicators Survey Quality Improvement 1. Performs practice improvement activities 1. Agency strategic measures 2. Agency QI plan 1. Agency QI projects 2. Family and patient engagement in QI projects
Primary%20Care%20Alternative%20Payment%20Memo%20v3%20for%2012.1%20meeting.docx