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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Provider Toolkit

PW_E192423

Milestone 9: Improved Clinical & Utilization Outcomes

Achieve improved clinical and utilization outcomes 
 

Delivering the best possible care is at the heart of your work every day as a health care provider along with your team. Your participation in the patient-centered primary care program is a reflection of this commitment. We will carefully identify and provide you the best information we have about your attributed patients’ and their utilization and opportunities.

We will offer the best resources available for designing your quality improvement processes and outcomes measurement for your patients. These resources are focused on prevention as well as addressing the needs of patients chronic diseases. These patients present both care management challenges and opportunities for dramatic improvement in outcomes to achieve optimal health.

When looking at chronic illness care and preventative care clinical outcomes, it is often helpful to be able to access evidence-based guidelines and measurement algorithms. Regular use of a population health registry (or an EHR’s registry reporting functionality) will help to provide necessary clinical outcomes data that your practice will be able to use in driving practice-level changes that will favorably impact being able to achieve improved clinical outcomes.

In an effort to begin to achieve improved utilization outcomes, we will be providing you with several different reports, via the Availity® multi-payer portal. Examples of these reports include the ER Utilization report, Inpatient Admissions report, and the Generic Drug report. In addition to these concrete, patient-specific reports, we will also help you with interpreting your “Scorecard” data where overall utilization dollars spent will be reflected. The patient-centered primary care program is designed to provide you with a number of mechanisms and resources for favorably impacting the cost of care for your patient.

Clinical Measures Resources:

BCBSGA Clinical Quality Scorecard Measure Specifications

An expanded listing of the selected quality measures for the patient-centered primary care program detailing measure numerator and denominators, additional technical descriptors, and the citation source for the measures.

BCBSGA Clinical Quality Performance Measures

A list of the clinical quality performance measures that are being used to measure participating provider performance in the patient-centered primary care program.

Clinical Outcome Practice Resources

Practice resources sorted by outcome focused areas.

Utilization Resources

BCBSGA Quick Care Options Brochure

Patient facing brochure detailing options for how to decide on ER alternatives for urgent care or when the primary care doctor is not available.

BCBSGA Saving Your Patients Money With In-Network Lab Referrals

This short fact sheet explains the out-of-pocket cost differences between in-network independent labs and out-of network and hospital-based labs.

Choosing Wisely®

A national campaign coordinated by the American Board of Internal Medicine (ABIM) to address our country's health care spending crisis, aims to promote conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative of other interventions already ordered and received by the patient, free from harm, and really, truly necessary. The Choosing Wisely® one page program description

Five Things Physicians and Patients Lists

Choosing Wisely® campaign’s access to lists developed by several major medical specialty societies addressing "Five Things Physicians and Patients" should question.

A new American College of Physicians (ACP) site created to nurture value based care. 
The principles offer a broad view of how physicians -along with patients, hospitals, health systems, the medical education and training system, medical groups and health policy organizations can engage in the effort to provide higher-quality care that acknowledges that the resources our society can devote to health care are finite. They were developed through a series of workgroups and meetings convened by the ABIM Foundation. 
The Hospital to Home (H2H) initiative, led by the American College of Cardiology and the Institute for Healthcare Improvement (IHI), is a national quality improvement campaign to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease. This website offers access to the tools and strategies to help in improving readmissions and transitions of care. 
A 2013 AMGA hypertension toolkit which includes useful tools, tips, and resources to help jump start a hypertension quality improvement initiative. 
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