Criteria #12 Potentially Preventable Events – Respondent will describe its organizational commitment to quality improvement as it relates to reducing potentially preventable events. More specifically, the Respondent will describe its overall approach and specific strategies that will be used to ensure a reduction in potentially preventable hospital admissions and readmissions, a reduction in the use of the emergency department for non-emergent/urgent visits, and a reduction in the use of unnecessary ancillary services during hospitalization and outpatient visits. Respondent’s approach will also include: A description of the Respondent’s assessment (using available data sources) of hospital utilization rates and the potential for improvement; A description of performance benchmarks for each area of focus; A description of incentives that will be implemented for providers and enrollees aimed at diverting care to more appropriate and cost-effective settings; and A description of interventions and strategies that will be used to target super-utilizers, particularly related to pain management and behavioral health conditions. Evaluation Criteria: The extent to which the Respondent identified specific localized opportunities for improvement in achieving a reduction in potentially preventable events and subsequent steps the Respondent will implement to overcome any barriers across and within different systems of care (i.e., medical, behavioral health). The extent to which the Respondent describes specific care coordination protocols, including a description of the risk stratification algorithm used to identify The extent to the Respondent describes strategies to improve data exchanges and communications between practitioners to improve care coordination efforts for high-risk enrollees, using specific local examples. The extent to which the Respondent plans to include the use of AHCA’s Event Notification System as a means to extract relevant data from hospitals. The adequacy of the Respondent’s description of specific indicators or measures that will be used to evaluate the effectiveness of evidenced-based programs and interventions that target super-utilizers. The extent to which the Respondent describes financial and non-financial provider and enrollee incentives that are aimed at diverting care to more appropriate and cost-effective settings (e.g., incentives for primary care providers that agree to extended or after-hours clinic care for their Medicaid and CHIP patients).
Criteria #12 – Potentially Preventable Events Respondent will describe its organizational commitment to quality improvement as it relates to reducing potentially preventable events. More specifically, the Respondent will describe its overall approach and specific strategies that will be used to ensure a reduction in potentially preventable hospital admissions and readmissions, a reduction in the use of the emergency department for non-emergent/urgent visits, and a reduction in the use of unnecessary ancillary services during hospitalization and outpatient visits. Respondent’s approach will also include: A description of the Respondent’s assessment (using available data sources) of hospital utilization rates and the potential for improvement; A description of performance benchmarks for each area of focus; A description of incentives that will be implemented for providers and enrollees aimed at diverting care to more appropriate and cost-effective settings; and A description of interventions and strategies that will be used to target super-utilizers, particularly related to pain management and behavioral health conditions. Evaluation Criteria: The extent to which the Respondent identified specific localized opportunities for improvement in achieving a reduction in potentially preventable events and subsequent steps the Respondent will implement to overcome any barriers across and within different systems of care (i.e., medical, behavioral health). The extent to which the Respondent describes specific care coordination protocols, including a description of the risk stratification algorithm used to identify The extent to the Respondent describes strategies to improve data exchanges and communications between practitioners to improve care coordination efforts for high-risk enrollees, using specific local examples. The extent to which the Respondent plans to include the use of AHCA’s Event Notification System as a means to extract relevant data from hospitals. The adequacy of the Respondent’s description of specific indicators or measures that will be used to evaluate the effectiveness of evidenced-based programs and interventions that target super-utilizers. The extent to which the Respondent describes financial and non-financial provider and enrollee incentives that are aimed at diverting care to more appropriate and cost-effective settings (e.g., incentives for primary care providers that agree to extended or after-hours clinic care for their Medicaid and CHIP patients).
attachment-a-1-evaluation-criteria.docx