Connecticut



AMR Integrated HealthcarePatient Navigation Draft MeasuresEstablish Comprehensive Patient Navigation System for Low Acuity 9-1-1 Callers and Frequent ER UsersProject Goal: Navigate and redirect patients who access emergency services to the most appropriate care settings to enhance the use of medical homes and reduce the inappropriate use of emergency services.Project Options:9-1-1 Nurse Triage ProgramWarm hand-off of low-acuity 9-1-1 callers from local 911 EMD service to AMR Nurse Triage and Integrated Navigation system, to facilitate appropriate care dispositions, such as primary care, specialty care, dental care or in-home/self-care, in-home follow-up by MIHP.CAD to CAD interface to support warm handoffLink or provide access to local community resources scheduling software.Admission/Re-admission/Frequent User ProgramIdentify frequent users of emergency services suffering from CHF, COPD, recurrent falls, diabetes and chronic pain.Provide proactive in-home visits by AMR Community Health ParamedicsEducate patients on disease managementAssist with medication reconciliation and complianceAssess home environment to reduce riskConnect patients to social service networks to provide holistic careCoordinate care and communication with patient’s PCP or Medical Home.Observation Admission Avoidance ProgramRefer patients from the emergency department to AMR’s Community Health Program (CHP) for in-home follow-up and care coordination with the patient’s primary care provider (PCP), or Medical Home, as opposed to admitting the patient to 23-hour observation admission.Link Healthcare system EHR program with AMR Logis CAD and reporting programs to provide seamless care coordination and information sharing.Key Measures:Process Measures – Observation Admission Avoidance:Measure - Establish baseline metrics:Number observation admissions and cost of admissionsNumber of potential observation admissions than may be avoided through this program and cost savingsMeasure - Educate physicians and case managers on programNumber of physicians educated on programNumber of case managers educated on programMeasure – Link Healthcare System EHR and AMR Logis programEstablish interfaceTest access and upload for patient data between AMR and partnering systemsAMR and partnering systems are able to view discharge instructions and AMR assessments/interventions conducted at patient’s homeProcess measure – 9-1-1 Nurse Triage ProgramMeasure – Establish baseline metricsNumber of ALPHA and OMEGA calls received by AMR 9-1-1 CenterNumber of potential referrals for alternate disposition other than ambulance to emergency departmentMeasure – Establish link between partnering healthcare systems and appointment scheduling system and AMR Nurse Triage systemInterface establishedInformation able to be accessed, viewed and scheduledMeasure – Expand call triage hours to 24/7Hire and train 4 additional nurses for triage programMeasure – Patient ReferredNumber of patients referred to alternate dispositionCosts avoided from patient referralMeasure – Patient SatisfactionPatient survey questions and Likert scale establishedPhone survey conducted at 1 week from encounterProcess measure – Admission/Re-admission/Frequent User ProgramMeasure – Establish baseline metricsDefine frequency of patient encounters used classified as frequent users of 9-1-1 or emergency roomIdentify patients who meet frequent user definitionCalculate use of 9-1-1 and hospital emergency rooms in defined time parameterCalculate the costs of these servicesMeasure – Enroll PatientsEnroll identified patients into AMR CHPEstablish care plans with patient and PCPConduct in-home visits, patient education and care coordination/referrals for ancillary servicesMeasure – 9-1-1 and ER use reductionMeasure 9-1-1 and ER use post enrollmentMeasure cost savings from reduction of this useMeasure – Patient SatisfactionPatient survey questions and Likert scale establishedPhone survey conducted at 3 and 6 months from referralImprovement Measures – Observation Admission Avoidance:Measure – Patients ReferredNumber of patients referred to the programMetric: Patient CountNumber of observation admissions avoidedPatient CountMetric: Number of patients who did not revisit the emergency department prior to PCP follow-up appointmentMetric: Number of patients who re-visited the emergency department prior to PCP follow-up appointmentCost savings of admissions avoidedPatient CountMetric: Average cost of observation admission per admissionMetric: Number of observational admissions avoidedMeasure – Patient SatisfactionPatient Telephone InterviewsMetric: Number of patient satisfaction surveys completedMetric: Number of patients who rate satisfaction as above averageImprovement measures – 9-1-1 Nurse Triage ProgramMeasure – Patient ReferredPatient Count Metric: Number of patients referred to alternate dispositionMeasure - Costs avoided from patient referralEncounter AnalysisMetric: Average cost of ER visit for Primary Care complaintMetric: Average cost of PCP visit for Primary Care complaintMetric: Cost avoidance of patient navigationMeasure – Patient SatisfactionPatient Telephone InterviewsMetric: Number of patient satisfaction surveys completedMetric: Number of patients who rate satisfaction as above averageImprovement measure – Admission/Re-admission/Frequent User ProgramMeasure – 9-1-1 and ER use reductionPatient CountMetric: 9-1-1 and ER use pre-enrollmentMetric: 9-1-1 and ER use post enrollmentMeasure - cost savings from reduction of this useUtilization DataMetric: Average cost of ER visit for primary care complaintMetric: Average cost of in-home visit by AMR CHPMetric: Average cost of PCP visitMetric: Cost savings of patients enrolled in CHPMeasure – Patient SatisfactionPatient Telephone InterviewsMetric: Number of patient satisfaction surveys completedMetric: Number of patients who rate satisfaction as above average ................
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