If yes, how frequently will data be shared? (Monthly, two Monthly months, quarterly) PDPs without a CEHRT will be required to utilize the Brent Hospital CEHRT. Remote access will be offered and training provided to practices not currently using an EHR. PDPs will be How will the PDP access the able to access the patient health Care Plan through the Brent Care Plan and be notified Hospital EHR or through CRISP. Care Managers will be when an update has been responsible for ensuring PDPs are aware of significant activity made by the care manager? in between outpatient visits through electronic alerts. PDPs will be required to ensure their staff are reviewing alerts and bringing alerts or pertinent information to the PDPs attention. Our Health Information Technology team will provide and make available reports via Healthy Planet that assess health care and medication utilization trends. The tools within Healthy Planet will allow our team to identify trends that exceed norms for patients with like demographics and DRGs. Describe how you will use the Care managers will work with these identified patients and the data to enhance care PDP to develop Care Plans specific to each patient in an effort coordination to better manage utilization and outcomes. Specific factors will be assessed including: multiple primary care providers, use of specialists, extended inpatient stays, co-occurring diagnostic morbidities and medications prescribed and medications filled. Define your process and The Care Management Supervisor will be responsible for frequency for monitoring your providing a monthly report of activities. Reports will be pulled Care Redesign Interventions form Healthy Planet and adapted to reflect the requirements
If yes, how frequently will data be shared? (Monthly, two months, quarterly) Monthly How will the PDP access the Care Plan and be notified when an update has been made by the care manager? PDPs without a CEHRT will be required to utilize the Brent Hospital CEHRT. Remote access will be offered and training provided to practices not currently using an EHR. PDPs will be able to access the patient health Care Plan through the Brent Hospital EHR or through CRISP. Care Managers will be responsible for ensuring PDPs are aware of significant activity in between outpatient visits through electronic alerts. PDPs will be required to ensure their staff are reviewing alerts and bringing alerts or pertinent information to the PDPs attention. Describe how you will use the data to enhance care coordination Our Health Information Technology team will provide and make available reports via Healthy Planet that assess health care and medication utilization trends. The tools within Healthy Planet will allow our team to identify trends that exceed norms for patients with like demographics and DRGs. Care managers will work with these identified patients and the PDP to develop Care Plans specific to each patient in an effort to better manage utilization and outcomes. Specific factors will be assessed including: multiple primary care providers, use of specialists, extended inpatient stays, co-occurring diagnostic morbidities and medications prescribed and medications filled. Define your process and frequency for monitoring your Care Redesign Interventions The Care Management Supervisor will be responsible for providing a monthly report of activities. Reports will be pulled form Healthy Planet and adapted to reflect the requirements
CCIP-IP-Sample-20170110.docx