1. Schedule and perform Medicare Annual Wellness exam, G code ______ on EVERY Medicare primary care or specialty principal care patient annually.
2. Schedule and perform Medicare Annual Wellness exam, G code ______ on any Medicare beneficiary in the ACO who has not been to the office in 9 or more months.
3. Discuss and document Advanced Directives such as The 5 Wishes or LAPOST. Evaluate recurrent hospital admission patients for hospice when appropriate.
4. Schedule every hospital, rehab, or SNF discharged patient for a TCM office visit within 14 days to meet TCM requirements or 30 days maximum (won't qualify for TCM but meets MSSP quality goal).
5a. Re evaluate home health re-certifications for medical necessity and cost-benefit; utilize home health agencies with high quality scores, lower LOS and low hospital re-admit rate. Consider alternative outpatient programs such as senior senior day centers or partial hospitalization behavioral health programs.
5b. Re evaluate home health for dual eligible patients who concurrently are enrolled in Medicaid Home based care waiver program; most should not need.
6a. For SNF discharges, direct referrals to high performing SNFs under the care of a collaborating physician for improved oversight and length of stay. Schedule specialist outpatient visits during the skilled stay.
6b. For complex discharges,closely evaluate admission criteria to determine the most cost effective location for care: LTAC, SNF with outpatient services, home with home health, home with outpatient services.
7. When appropriate evaluate observation hospital patients for early discharge and close office follow-up within several days.
8. Reduce emergency room visits by making same day or next day office appointments with any available provider (including other LPACO clinics) or one of the patients specialists where appropriate.
9. For non adherent patients, probe for unmet psychiatric needs, social needs, history of mental or physical abuse and counsel / refer appropriately.
10. Focus on fall prevention, incontinence, poor vision, home safety, medication adherence, DVT prophylaxis, aggressive screening and treatment of osteoporosis.
2. Schedule and perform Medicare Annual Wellness exam, G code ______ on any Medicare beneficiary in the ACO who has not been to the office in 9 or more months.
3. Discuss and document Advanced Directives such as The 5 Wishes or LAPOST. Evaluate recurrent hospital admission patients for hospice when appropriate.
4. Schedule every hospital, rehab, or SNF discharged patient for a TCM office visit within 14 days to meet TCM requirements or 30 days maximum (won't qualify for TCM but meets MSSP quality goal).
5a. Re evaluate home health re-certifications for medical necessity and cost-benefit; utilize home health agencies with high quality scores, lower LOS and low hospital re-admit rate. Consider alternative outpatient programs such as senior senior day centers or partial hospitalization behavioral health programs.
5b. Re evaluate home health for dual eligible patients who concurrently are enrolled in Medicaid Home based care waiver program; most should not need.
6a. For SNF discharges, direct referrals to high performing SNFs under the care of a collaborating physician for improved oversight and length of stay. Schedule specialist outpatient visits during the skilled stay.
6b. For complex discharges,closely evaluate admission criteria to determine the most cost effective location for care: LTAC, SNF with outpatient services, home with home health, home with outpatient services.
7. When appropriate evaluate observation hospital patients for early discharge and close office follow-up within several days.
8. Reduce emergency room visits by making same day or next day office appointments with any available provider (including other LPACO clinics) or one of the patients specialists where appropriate.
9. For non adherent patients, probe for unmet psychiatric needs, social needs, history of mental or physical abuse and counsel / refer appropriately.
10. Focus on fall prevention, incontinence, poor vision, home safety, medication adherence, DVT prophylaxis, aggressive screening and treatment of osteoporosis.