8: Core Process Measures Measure Definition Source Population(s) TEC-C Approach to this measure expected Use of Encounter % of inpatient CRISP All population TEC-C is a home-based care delivery model. Notification Alerts discharges that for covered The TEC-C team is fully registered with CRISP result in an ZIPs, high and receives 100% of the alerts from CRISP. Encounter utilization set, Notification target System alert population if going to a different physician Completion of % High Hospital, High utilization TEC-C screens for eligibility for the MTEC health risk with set, target program using a geriatrics health risk assessments completed population if assessment at intake. As all patients are Health Risk different screened, we expect 100% completion. Assessments Established % of High Hospital, High utilization TEC-C care teams currently develop and longitudinal care set, target document care plans, goals of care, and plan Patients with population if advanced directives within the clinical notes completed different for all patients enrolled in TEC-C. TEC-C will care continue this method and expect 100% completion. Shared Care Profile % of patients CRISP High utilization The TEC-C does not lend itself to this with care set, target measure. The MTEC approach is designed so with data population if that all providers on the MTEC team are shared through different informed and updated from a single EHR. HIE in Care Profile Portion of target % of High Hospital, High utilization The MTEC approach is designed so that each pop. with contact Partners set, target member of the care team together from assigned care Patients with population if serves as a collective group of care manager manager contact with an different for each patient enrolled in TEC-C. By assigned care definition, this measure will be 100% for all manger patients at all time points. Table 9: Program Specific Measures Measure Definition Source TEC-C Approach to this Measure expected F/U visit Follow-up TEC-C All patients TEC-C will use programmatic data to record completed enrolled in and monitor time to follow-up visits. We will visit by care programmatic within 2 days of TEC-C with a monitor this measure annually and team within data hospital hospital anticipate over 50% compliance with this 2 days of discharge or ED discharge or measure. hospital visit ED visit
8: Core Process Measures Measure Definition Source Population(s) expected TEC-C Approach to this measure Use of Encounter Notification Alerts % of inpatient discharges that result in an Encounter Notification System alert going to a physician CRISP All population for covered ZIPs, high utilization set, target population if different TEC-C is a home-based care delivery model. The TEC-C team is fully registered with CRISP and receives 100% of the alerts from CRISP. Completion of health risk assessments % High with completed Health Risk Assessments Hospital, High utilization set, target population if different TEC-C screens for eligibility for the MTEC program using a geriatrics health risk assessment at intake. As all patients are screened, we expect 100% completion. Established longitudinal care plan % of High Patients with completed care Hospital, High utilization set, target population if different TEC-C care teams currently develop and document care plans, goals of care, and advanced directives within the clinical notes for all patients enrolled in TEC-C. TEC-C will continue this method and expect 100% completion. Shared Care Profile % of patients with care with data shared through HIE in Care Profile CRISP High utilization set, target population if different The TEC-C does not lend itself to this measure. The MTEC approach is designed so that all providers on the MTEC team are informed and updated from a single EHR. Portion of target pop. with contact from assigned care manager % of High Patients with contact with an assigned care manger Hospital, High utilization set, target population if different The MTEC approach is designed so that each member of the care team together serves as a collective group of care manager for each patient enrolled in TEC-C. By definition, this measure will be 100% for all patients at all time points. Table 9: Program Specific Measures Measure Definition Source expected TEC-C Approach to this Measure F/U visit completed within 2 days of hospital discharge or ED visit Follow-up visit by care team within 2 days of hospital TEC-C programmatic data All patients enrolled in TEC-C with a hospital discharge or ED visit TEC-C will use programmatic data to record and monitor time to follow-up visits. We will monitor this measure annually and anticipate over 50% compliance with this measure. Partners
1.%20Medstar%20-%20ElderCare%20Proposal.docx