How will the clinic proactively identify previous patients with unplanned hospital admissions and emergency department visits? Does the clinic care team collaborate with the patient to: Yes/No If yes, explain: Develop patient preferences and functional/lifestyle goals Identify treatment goals Assess and address potential barriers to meeting goals Include a self-management plan Outline how the clinic provides instructions to members for obtaining care and clinical advice when the office is closed? Is clinical information available to on-call staff when the office is closed? If so, how is it accessed? Will you assign members of The State of Indiana clinic care team to coordinate care for individual patients? If so, explain. Are patients provided with a clinical summary of their office visit? Does the clinic generate lists of patients and proactively remind patients of needed preventive/follow-up care? What is your method for contacting patients and how frequently is this done? Do you annually identify populations of prior patients and proactively remind them of needed care based on patient information, clinical data, health assessments and evidence-based guidelines? Collaboration with Community Providers Do you utilize specialist referral services? How is a list of eligible community providers developed for referral? How frequently is the list reviewed and updated? Please describe how you will coordinate care and collaborate with community primary care providers. Will the clinic document inbound and outbound referrals and care coordination in the patient’s medical record? Will the clinic track referrals until the referral is available, flagging and provider/specialist’s report following up on overdue reports? Will the clinic share clinical information with admitting hospitals and emergency departments? What is your standard process for doing so? What follow-up process does your clinic have in place if a patient is referred to an ER or an urgent care from your clinic? Does your model have follow up processes in place if a patient is referred to specialist or community resource from your clinic? If so, outline. Integration with the State of Indiana Health Management Outline your experience integrating your services with an other third party vendors (e.g., employer’s medical plan, population health/disease management, wellness) to provide a seamless, efficient, and effective patient management experience? Do you refer patients to external structured health education programs, such as group classes, peer support, and lifestyle management coaching? What incentives/disincentives do you recommend to optimize clinic utilization? Lifestyle & Condition Management
How will the clinic proactively identify previous patients with unplanned hospital admissions and emergency department visits? Does the clinic care team collaborate with the patient to: Yes/No If yes, explain: Develop patient preferences and functional/lifestyle goals Identify treatment goals Assess and address potential barriers to meeting goals Include a self-management plan Outline how the clinic provides instructions to members for obtaining care and clinical advice when the office is closed? Is clinical information available to on-call staff when the office is closed? If so, how is it accessed? Will you assign members of The State of Indiana clinic care team to coordinate care for individual patients? If so, explain. Are patients provided with a clinical summary of their office visit? Does the clinic generate lists of patients and proactively remind patients of needed preventive/follow-up care? What is your method for contacting patients and how frequently is this done? Do you annually identify populations of prior patients and proactively remind them of needed care based on patient information, clinical data, health assessments and evidence-based guidelines? Collaboration with Community Providers Do you utilize specialist referral services? How is a list of eligible community providers developed for referral? How frequently is the list reviewed and updated? Please describe how you will coordinate care and collaborate with community primary care providers. Will the clinic document inbound and outbound referrals and care coordination in the patient’s medical record? Will the clinic track referrals until the referral provider/specialist’s report is available, flagging and following up on overdue reports? Will the clinic share clinical information with admitting hospitals and emergency departments? What is your standard process for doing so? What follow-up process does your clinic have in place if a patient is referred to an ER or an urgent care from your clinic? Does your model have follow up processes in place if a patient is referred to specialist or community resource from your clinic? If so, outline. Integration with the State of Indiana Health Management Outline your experience integrating your services with an employer’s other third party vendors (e.g., medical plan, population health/disease management, wellness) to provide a seamless, efficient, and effective patient management experience? Do you refer patients to external structured health education programs, such as group classes, peer support, and lifestyle management coaching? What incentives/disincentives do you recommend to optimize clinic utilization? Lifestyle & Condition Management
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