Quality Coordinator % of patients chronic AAMC: Panel Reduced PAU due Panel Management conditions are being successfully management for 60 to better chronic (4 resources) managed (i.e. diabetes A1C under physicians each care management (AAMC) control) managing several hundred patients with at least 2 chronic conditions Behavioral Health / # of new visits for expansion in AAMC: 300 new patient Increased access to Physical Health behavioral health resources therapist visits psychiatric Integration counseling UM BWMC: 133 resulting in Psychiatric new patients, 150 Therapist decreased PAU. new patients Behavioral Health # of behavioral health referrals for AAMC: 990 behavioral Decreased ED visits Navigators (AAMC unique patients health referrals in 2016, adding BWMC in 2017) Readmissions # of readmissions analyzed per AAMC: Assess 150 Reduced Clinical Analysis and cumulative readmissions/month Readmissions UM BWMC: Assess 100 readmissions/month Skilled Nursing AAMC: 2,160 SNF Reduced PAU a) # of additional Ambulatory and Facility (SNF) patients (Readmissions), SNF facilities utilizing CRISP ENS Collaborative UM BWMC: 2,240 SNF Reduced ED visits, and/or Clinical Query Portal. patients Reduced b) 30-day readmission rates, LOS, potentially complications of high utilizers preventable going to/from SNFs who are conditions, participating in the SNF reduced LOS at Collaborative c) # of patients with completed SNF, Reduced TCOC MOLST forms DoAD Senior Triage AAMC: 117 Decreased EMS a) # of super-utilizers (>=5 visits) Team patients utilization being managed by Senior Triage UM BWMC: 117 super Decreased ED Visits Team utilizer patients Decreased Length Pre- and Post- Senior Triage Team of Stay assignment: Decreased TCOC b) EMS Utilization c) ED Visits d) Length of Stay e) # of guardianships established
Quality Coordinator Panel Management (4 resources) (AAMC) % of patients chronic conditions are being successfully managed (i.e. diabetes A1C under control) AAMC: Panel management for 60 physicians each managing several hundred patients with at least 2 chronic conditions Reduced PAU due to better chronic care management Behavioral Health / Physical Health Integration # of new visits for expansion in behavioral health resources AAMC: 300 new patient therapist visits UM BWMC: 133 Psychiatric new patients, 150 Therapist new patients Increased access to psychiatric counseling resulting in decreased PAU. Behavioral Health Navigators (AAMC in 2016, adding BWMC in 2017) # of behavioral health referrals for unique patients AAMC: 990 behavioral health referrals Decreased ED visits Readmissions Clinical Analysis # of readmissions analyzed per and cumulative AAMC: Assess 150 readmissions/month UM BWMC: Assess 100 readmissions/month Reduced Readmissions Skilled Nursing Facility (SNF) Collaborative a) # of additional Ambulatory and SNF facilities utilizing CRISP ENS and/or Clinical Query Portal. b) 30-day readmission rates, LOS, complications of high utilizers going to/from SNFs who are participating in the SNF Collaborative c) # of patients with completed MOLST forms AAMC: 2,160 SNF patients UM BWMC: 2,240 SNF patients Reduced PAU (Readmissions), Reduced ED visits, Reduced potentially preventable conditions, reduced LOS at SNF, Reduced TCOC DoAD Senior Triage Team a) # of super-utilizers (>=5 visits) being managed by Senior Triage Team Pre- and Post- Senior Triage Team assignment: b) EMS Utilization c) ED Visits d) Length of Stay e) # of guardianships established AAMC: 117 patients UM BWMC: 117 super utilizer patients Decreased EMS utilization Decreased ED Visits Decreased Length of Stay Decreased TCOC
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