payments, including quality measures care managers will be responsible for gathering pertinent data if information sits within the PDP EHR. Define the information systems to support care redesign and information sharing Our Health Information Technology team will provide and make available reports via Healthy Planet that assess health care and medication utilization trends. The 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. Identify care management staff and their respective patient to staff ratios. Will the ratios be evaluated during the program? Care management will hire a combination of RNs, Social Workers and Community Health Workers. They will be trained in advance of recruiting patients. The ratios are the following: RNs or Social Worker (Care Managers) to patients 1/110 Community Health workers to patients 1/149 Staffing ratios will be examined quarter to ensure that quality care management is being provided. Describe the supervision and monitoring of the care management staff. How will you ensure that the care The Care Management Supervisor with each staff member weekly to review cases and monitor work. The supervisor has access to reports generated by Epic’s Healthy Planet, our Care Management platform to monitor activities of
How often will performance assessments be completed for care management staff? bi-annually, annually) Annually Data Develop approaches for sharing clinical and key information (e.g., Comprehensive Medicare data) with PDPs Monthly performance reports including data related to the PDP’s patient panel will be provided. If the PDP office has the ability to receive reports electronically that is preferred. Relay of data will follow Brent Hospital Privacy Policies, HIPPA and HITECH regulations. Analyze monthly CMS claims data files The analytics team will develop reports and data for examination by leadership monthly. Reports may include total medical spend per patient, number of service providers, and readmissions etc. Use data to support incentive payments and processes Care managers will work with PDP staff to collect this information from the PDP’s EHR bi-annually unless it can be collected via CRISP. We will also make use of the registries available within Healthy Planet to track this information. In terms of the care management resources we provide to PDPs, we will track those on our CCIP budget that we’ll create, which will include the costs associated of all resources provided. Do you plan to share the comprehensive Medicare data you will receive from CMS with PDPs? (check if yes)
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