responsible resources at each stage of the workflow; Periodic self-audit reports and recommendations ------------------------------------------------------------------ Metric 14.3: PPS provides periodic training to staff on warm referral and follow-up process. Minimum Documentation: List of training dates along with number of staff trained; Written training m Milestone # 15: M. D’Urso/ S. Choudhury Project Deliverable DY2 Q4 Milestone #15: Generate lists of patients with hypertension who have not had a recent visit and schedule a follow up visit. Metric 15.1: PPS has implemented an automated scheduling system to facilitate scheduling of targeted hypertension patients. Minimum Documentation: Vendor System Documentation; Other Sources demonstrating implementation of the system; Roster of identified patients Pull roster of identified patient and redact the PHI and send a screenshot to the PMO. Milestone # 16 : M. D’Urso, RN/ S.Choudhury Project Deliverable DY2 Q4 Milestone #16 Facilitate referrals to NYS Smoker's Quitline. Metric 16.1: PPS has developed referral and follow-up process and adheres to process. Minimum Documentation: Policies and procedures of referral process including warm transfer protocols Submit Policy and procedure for referrals to NYS Smoker’s Quit line and training sheets to PMO. Please review the Policies and procedures and vote vie once the PMO has sent out the policies. Milestone # 18: M. D’Urso, RN/ S.Choudhury Project Deliverable DY2 Q4 Milestone# 18: Adopt Strategies from the Million Hearts Campaign Metric# 18.1, 18.2, 18.3: Provider can demonstrate implementation of policies and procedures which reflect principles and initiatives of Million Hearts Campaign. (includes PCP, Specialists, BH) Minimum Documentation: Policies and Procedures; Baseline home blood pressure monitoring and periodic updates exhibiting an increase of monitoring; Documentation of process and workflow including responsible resources at each stage of the workflow; Written training materials Submit Policy and procedure for Million Hearts Campaign and training sheets to PMO. PMO will laminate policy and procedures for partners.
Future Deliverables: Future Deliverables: Milestone# 2: Ensure that all PPS safety net providers are actively connected to EHR systems with local health information exchange/RHIO/SHIN-NY and share health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of DY 3. Metric# 2.1: EHR meets connectivity to RHIO’s HIE and SHIN-NY requirements. Minimum Documentation: QE agreements Milestone# 8: Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment. Metric 8.1: All primary care practices in the PPS provide follow-up blood pressure checks without copayment or advanced appointments. Minimum Documentation: Policies and procedures related to blood pressure checks; Roster of patients, by PCP practice, who have received follow-up blood pressure checks. Milestone# 10: Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit. Metric # 10.1: PPS uses a patient stratification system to identify patients who have repeated elevated blood pressure but no diagnosis of hypertension. Minimum Documentation: Risk assessment tool documentation; risk assessment screenshots, Patient stratification output; Documented protocols for patient follow-up Partners can work with Cory to be connected to the RHIO, Committee will discuss how to incorporate no copayment into policy and procedure. PMO will send out an email to vote on the policies and procedures to be standardized committee wide. The Webinar trainings will be held approximately March 22nd , PMO will send out further information via email.