Milestones

PTN-wide goal: Reducing non-urgent Emergency Department visits

Primary Care

Numbers in each of the five Transformation Phases are PAT Scores necessary to complete the associated Phase.

Click on the Milestone Description below for a Milestone Summary

Milestone # Milestone Description Phase 1 Phase 2 Phase 3 Phase 4 Phase 5
AIMS
1 Practice has met its targets and has sustained improvements in practice-identified metrics for at least one year. 1 2 3
2 Practice has reduced unnecessary tests, as defined by the practice. 3
3 Practice has reduced unnecessary hospitalizations. 3
PERSON & FAMILY ENGAGEMENT (PFE)
4 Practice can demonstrate that it encourages patients and families to collaborate in goal setting, decision making, and self-management. 1 3
5 Practice has a formal approach to obtaining patient and family feedback and incorporating this into the QI system, as well as the strategic and operational decisions made by the practice. 2 3
TEAM BASED RELATIONSHIP
6 Practice sets clear expectations for each team member’s functions and responsibilities to optimize efficiency, outcomes, and accountability. 3
7 Practice has a process in place to measure and promote continuity so that patients and care teams recognize each other as partners in care. 3
POPULATION MANAGEMENT
8 Practice uses a data-driven approach to assign patients to a provider panel and confirms assignments with providers and patients. Practice reviews and updates panel assignments on a regular basis. 3
9 Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk. 1 3
10 The practice provides care management for patients at highest risk of hospitalizations and/or complications and has a standard approach to documentation. 2 3
COMMUNITY PARTNER
11 Practice links patients with appropriate community resources to facilitate referrals. 2 3
COORDINATED CARE
12 Practice has defined its medical neighborhood and has formal agreements in place with these partners to define roles and expectations. 2 3
13 Practice follows up via phone, visit, or electronic means with patients within a designated time interval (24 hours/ 48 hours/ 72 hours/ 7 days) after an emergency room visit or hospital discharge. 2 3
14 Practice clearly defines care coordination roles and responsibilities and these have been fully implemented within the practice. 2 3
ORGANIZED EVIDENCED-BASED CARE
15 Practice ensures that care addresses the whole person, including mental and physical health. 2 3
16 Practice uses population reports or registries to identify care gaps and acts to reduce them. 2 3
ENHANCED ACCESS
17 Practice has mechanisms in place for patient to speak with their care team 24/7. 3
ENGAGED AND COMMITTED LEADERSHIP
18 Practice has developed a vision and plan for transformation that includes specific clinical outcomes and utilization aims that are aligned with national TCPI aims and that are shared broadly within the practice. 3
QUALITY IMPROVEMENT STRATEGY SUPPORTING CULTURE OF QUALITY
19 Practice uses an organized approach (e.g. use of PDSAs, Model for Improvement, Lean, Six Sigma) to identify and act on improvement opportunities. 2 3
20 Practice builds QI capability in the practice and empowers staff to innovate and improve. 2 3
TRANSPARENT MEASUREMENT AND MONITORING
21 Practice regularly produces and shares reports on performance at both the organization and provider/care team level, including progress over time and how performance compares to goals. Practice has a system in place to assure follow up action where appropriate. 3
OPTIMIZE HEALTH INFORMATION TECHNOLOGY
22 Practice uses technology to offer scheduling and communication options that improve patient access by including alternative visit types and electronic communication approaches. 3
STRATEGIC USE OF REVENUE
23 Practice uses sound business practices, including budget management and return on investment calculations. 3
WORKFORCE VITALITY AND JOY IN WORK
24 Practice has effective strategies in place to cultivate joy in work and can document results. 2 3
CAPABILITY TO ANALYZE AND DOCUMENT VALUE
25 Practice shares financial data in a transparent manner within the practice and has developed the business capabilities to use business practices and tools to analyze and document the value the organization brings to various types of alternative payment models. 3
26 Practice considers itself ready for migrating into an alternative based payment arrangement. 2 3
OPERATIONAL EFFICIENCY
27 Practice uses a formal approach to understanding its work processes and increasing the value of all processing steps. 2 3