Researching tools and resources for patients to build out a patient resource library on in Care Navigator Statewide prevalence of chronic Provider referrals to CHT self-management Explore future education and QI initiatives on disease: Diabetes workshops and related resources as part of our overall population health Quality measurement data on BMI screening and management strategy follow-up Support the design of a RiseVT expansion plan to additional communities Medicare ACO chronic disease See above See above composite: Diabetes HbA1c poor control; controlling high blood pressure; and all-cause unplanned admissions for patients with multiple chronic conditions Percentage of VT residents Providers are building protocols into their EMRs Dissemination of best practices and evidence-based receiving appropriate asthma protocols for asthma medication management medication management Multi-Payer ACO tobacco use Provider referrals to CHTs for counseling and Explore focused QI activities through OCV’s newly assessment and cessation support around tobacco cessation forming Primary Care Subcommittee intervention Partner with VDH to support 3-4-50 campaign in local communities with emphasis on Vermont Quits resources and tools
Researching tools and resources for patients to build out a patient resource library on in Care Navigator Statewide prevalence of chronic disease: Diabetes Provider referrals to CHT self-management workshops and related resources Quality measurement data on BMI screening and follow-up Support the design of a RiseVT expansion plan to additional communities Explore future education and QI initiatives on as part of our overall population health management strategy Medicare ACO chronic disease composite: Diabetes HbA1c poor control; controlling high blood pressure; and all-cause unplanned admissions for patients with multiple chronic conditions See above See above Percentage of VT residents receiving appropriate asthma medication management Providers are building protocols into their EMRs Dissemination of best practices and evidence-based protocols for asthma medication management Multi-Payer ACO tobacco use assessment and cessation intervention Provider referrals to CHTs for counseling and support around tobacco cessation Partner with VDH to support 3-4-50 campaign in local communities with emphasis on Vermont Quits resources and tools Explore focused QI activities through OCV’s newly forming Primary Care Subcommittee
B.%20ACO%20Initiative%20to%20Address%20All-Payer%20ACO%20Model%20Quality%20Measures.docx