RHP Plan Update Provider Template February 28, 2018

Setting Up Your Category A Core Activities and Drivers

CORE ACTIVITY SELECTION Access to Primary Care Services Access to Specialty Care Services Availability of Appropriate Levels of Behavioral Health Care Services Chronic Care Management Expansion of Patient Care Navigation and Transition Services Expansion or Enhancement of Oral Health Services Maternal and Infant Health Care Palliative Care Patient Centered Medical Home Prevention and Wellness Substance Use Disorder

Core Activity Activity implemented by the provider to achieve its Category C Measure Goals. NEW activity Activity from a previous DSRIP Project ALL activities must be tied to at least ONE Measure Bundle Follow “AIM-DRIVER” model Driver Diagram

Driver Diagram depicts the relationship between the aim, the primary drivers that contribute directly to achieving the aim, and the secondary drivers that are necessary to achieve the primary drivers

Driver Diagram - EXAMPLE CATEGORY C METRIC

Driver Diagram - EXAMPLE BRAINSTORM - list all system elements, activities, drivers Focus on Patients with high likelihood of readmission Timely, effective Communications among all Care Team Members (pre and post discharge) Follow-Up Calls Rigorous Medication Review before Discharge Home Tele-Monitoring Schedule PCP Follow-Up Appointment before Discharge Multi-Disciplinary Home Visits Confirm that Patients Understand what they need to know and do Provide Patient with a Transition Coach (RN) ProActive Counseling and Care Planning for End-of-Life Patients

Driver Diagram - EXAMPLE GROUP under high-level headers that summarize the groups 3 to 5 MAX IMPROVE DISCHARGE PROCESS PROVIDE EARLY POST-DISCHARGE SERVICES PATIENT ENGAGEMENT & EDUCATION for SELF-MANAGEMENT Schedule PCP Follow-Up Appointment before Discharge Home Tele-Monitoring Confirm that Patients Understand what they need to know and do Provide Patient with a Transition Coach (RN) Rigorous Medication Review before Discharge ProActive Counseling and Care Planning for End-of-Life Patients Multi-Disciplinary Home Visits Timely, effective Communications among all Care Team Members (pre and post discharge) Follow-Up Calls Focus on Patients with high likelihood of readmission

Driver Diagram - EXAMPLE

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Template All selected Measure Bundles or measures must be associated with a Core Activity otherwise an error message will appear at the bottom of Section 2 to indicate which Measure Bundles or measures are not associated with a Core Activity.

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QUESTIONS