Quality Initiatives - American Medical Group Association质量计划-美国医学协会.ppt

* * * * Value Care Systems Micro-delivery referral systems High volume specialties Ancillary services – Radiology, Lab 360 degree care systems Hospital care Home Health SNF’s ER coverage Community resources Driving Innovation to Nursing Homes “SNFist” model in targeted nursing homes Midlevel with daily presence in SNF Close connectivity to PHN case manager Focus on transitions of care and length of stay Hospital to SNF SNF to home * * Quality Outcomes Program Patient experience/satisfaction Chronic disease metrics Diabetes CHF Coronary Artery Disease Hypertension Preventive services metrics HEDIS, influenza and pneumococcal * ProvenHealth Navigator Quality Criteria - 2009 Quality Indicator Goal Patient Encounters Annual increase patient encounters Diabetes Annual Improvement site Diabetes Bundle Coronary Artery Disease Annual Improvement site CAD bundle Preventive Care Annual Improvement site Preventive bundle Heart Failure 90% patients w/documented action plan Follow-up with Provider 75% within 1 week of Inpt/SNF discharge Follow-up with CM 75% telephone contact w/in 24 - 48 hrs discharge Patient satisfaction PHN patient satisfaction survey implemented on Phase 1 and Phase 2 sites Nursing Home Management Nursing Home Medical Management Model operational and serving at least 2 MH sites per region NCQA PPC-PCMH Certification Certification obtained Value Reimbursement Program Fee For Service P4P payments for quality outcomes Practice transformation stipends PCP Practice Value based incentive payments Opportunity based on efficiency results Payments based on quality metrics Effective redesign care coordination delivers rapid impact * Activity Expected Impact Time to Impact Short term effects Transitions of Care Management Reduce Readmissions 3 months Case management for high risk patients with targeted conditions: DM, HF, COPD Reduce primary admissions ED 3 – 6 months Case Management for other high risk patients Reduce primary admissions ED