Cross-Continuum of Care Pilot Program Initiated

Is coordinating care for your patients with complex, diverse needs who interact with multiple community organizations and services a challenge?  Providers frequently note the negative impact on efficiency and staff resources in the struggle to communicate with the multitude of community based services and resources interacting with, and supporting, their patients. This challenge has been recognized and a pilot program, utilizing the care coordination platform, Crimson Care Management (CCM), has been initiated in Mesa County to support centralized communication between and among the cross-continuum care team.


Quality Health Network, in collaboration with Rocky Mountain Health Plans (RMHP), and other community partners including, long-term care, home health, Mesa County Health Department and Department of Health and Human Services and family medicine providers are participating in the pilot to evaluate CCM. This web-based tool, at full functionality, unites the multiplex of care team members in supporting active patient management across the continuum of care.


The scope of this evaluation pilot is to assess, 1) the capabilities of CCM to enhance the identification of the "community care team" involved with an individual and, 2) the ability of CCM to support timely, efficient and effective communication of the individual's key status changes to all pertinent care team members.


The community partners involved in the pilot will test the tool utilizing a small cohort of high risk RMHP patients. The evaluation period is expected to be completed in the early part of July, 2015. Review of the evaluation results and outcomes will determine the possible next steps, which may include expansion of the evaluation, engagement of others in the community or discontinuation of the utilization of CCM.


If you would like further information regarding this unique pilot project please contact Laura Head, QHN Interface Analyst (970-248-0033) or Lori Stephenson, RN, RMHP Director of Clinical Program Development and Evaluation (970-248-5124). 

Retiring Glenwood Medical Associates, Tim Burns, Leaves 25-Year Legacy 

Managing a medical practice today is far more complex than almost any other small business, and the pace of change is staggering. The standards that were predominating a generation ago no longer drive the rapidly evolving relationship between physicians, patients and healthcare organizations. Other entities, most notably payers and regulators, have imposed themselves into the relationship making for complex and intense internal and external pressures.


The mark of a good Practice Manager is the ability to help their practice navigate the business related changes, so the practitioners can focus on practicing medicine. Tim Burns, Chief Administrative Officer at Glenwood Medical Associates (GMA), a large multi-specialty practice, is just such an individual. He started his tenure at GMA in 1989; it was an 8 physician practice. Today GMA has grown to 24 providers, more than 90 staff members, multiple site locations and they are a Patient Centered Medical Home (PCMH), participate in the Comprehensive Primary Care (CPC) initiative and are part of the region 1 Regional Care Collaborative Organization (RCCO). 


QHN's Senior Account Manager, Sherri Corey, asked Tim if he would share his thoughts and reflections on his 25 years in the industry, how health information technology has changed the practice of medicine and what the healthcare future holds. Below are some excerpts from the conversation.


SC: How has implementing an EHR helped, changed GMA?


TB: Over the years it has absolutely helped.  GMA invested in 1995 in a state of the art EHR, back then that was really only a data repository.  Although it saved money and provided greater efficiency over the time of managing a medical record for a medium sized clinic, it did not have much "minable data" like we have today to report quality measures.  Nevertheless, it allowed the flexibility for providers to access EHR data remotely and helped us address HIPAA, in a much more efficient manner.  For a medium to large practice I do not believe that a paper chart system could work.  It would take an army of people to meet certain industry standards or pay for performance requirements.  

Patient Documents Tab in the QHN System
An Invaluable Resource for Additional Clinical Information

The Patient Documents tab in the new QHN system is located in the Patient Summary (formerly VHR). This area of the system is unique in its functionality, as it allows Users to manually upload clinical documents, such as Advanced Directives, patient visit notes, pain contracts (Rx Management), office memos and case management notes for other care providers to access. Click here for the Quick Tip Sheet on uploading and editing patient documents. 


The documents available in this area of the system frequently add critical information to the patient's clinical history and in the case of Advanced Directive documents invaluable information in emergent and Hospice treatment settings. This is also one of the areas in the system where transcription may be found.


To assure the documents loaded in this area display correctly in all web browsers do not include any special characters such as: ~,/?<>-_!@#$%^&*( ){ }[ ]:;"<>?\ in the original document file name.


The practices/organizations listed below have notified us that they are manually placing their patient care notes under the Patient Documents tab; however there may be others that we are unaware of also utilizing this system functionality.

  • Orthopedic Associates of Aspen & Glenwood Springs
  • Valley View Hospital Heart & Vascular
  • Aspen Valley Hospital (newborn screenings)
  • Vincent Vein Center
  • Western Slope Cardiology
  • Internal Medicine Associates
  • HopeWest
  • Rottman Eye Care
Hot Topics Conference Call
Date: March 18, 2015

Topic: PQRS 2015 and the Value Based Modifier

Presenter: Devin Detwiler-Cunningham, Quality Improvement Manager, Telligen

New Stage 2 Summary of Care FAQ Provides Guidance on Measure #3 


CMS has recently added one new FAQ about the Stage 2 Summary of Care objective. This FAQ provides a response to the below question. 
Question: When reporting on the Summary of Care objective in the EHR Incentive Programs, how can eligible professionals, eligible hospitals, and critical access hospitals (CAHs) meet measure 3 if they are unable to complete a test with the CMS Designated Test EHR (NIST EHR-Randomizer Application)?


See the response: CMS FAQs 


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