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{"sheet":"Intervention Details","index":0,"n_rows":218,"n_cols":27,"rows_kept":218,"cut":false,"hidden":false,"merged":[[142,2,142,4],[143,2,143,4],[120,2,120,4],[121,2,121,4],[122,2,122,4],[123,2,123,4],[124,2,124,4],[135,2,135,4],[136,2,136,4],[137,2,137,4],[138,2,138,4],[139,2,139,4],[140,2,140,4],[141,2,141,4],[130,2,130,4],[131,2,131,4],[132,2,132,4],[133,2,133,4],[134,2,134,4],[125,2,125,4],[126,2,126,4],[127,2,127,4],[128,2,128,4],[129,2,129,4],[105,3,105,4],[106,3,106,4],[113,3,113,4],[114,3,114,4],[107,3,107,4],[109,3,109,4],[110,3,110,4],[111,3,111,4],[112,3,112,4],[99,3,99,4],[100,3,100,4],[102,3,102,4],[103,3,103,4],[104,3,104,4],[93,3,93,4],[95,3,95,4],[96,3,96,4],[97,3,97,4],[98,3,98,4],[171,2,171,3],[177,2,177,3],[180,2,180,3],[78,1,78,3],[81,3,81,4],[82,3,82,4],[83,3,83,4],[152,3,152,4],[84,3,84,4],[85,3,85,4],[86,3,86,4],[88,3,88,4],[89,3,89,4],[90,3,90,4],[91,3,91,4],[92,3,92,4],[213,3,213,4],[36,1,36,3],[9,0,9,4],[24,0,24,4],[39,1,39,3],[146,0,146,4],[117,1,117,3],[18,0,18,4],[183,2,183,3],[188,0,188,4],[149,2,149,3],[155,3,155,4],[165,2,165,3],[186,3,186,4],[168,2,168,3],[174,2,174,3]]}
[null,"Draft",null,null,null,null,null,null,null,"Hardcoded Trigger for Macro","Rows to Unhide","Macro Event ID","ResetKey",null,null,null,null,null,null,null,null,"Needed for Completion","Complete"]
["Progress Indicator",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AND(SUM(W21:W23)=COUNTIF(V21:V23,\"Y\"),SUM(U21:U23)=COUNTIF(V21:V23,\"Y\") ),TRUE,FALSE)","v":false}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AND(SUM(W26:W146)=COUNTIF(V26:V146,\"Y\"),SUM(U26:U146)=COUNTIF(V26:V146,\"Y\")),TRUE,FALSE)","v":false}]
[null,"Section 1: Provider Selection",null,null,{"$f":"IFERROR(IF(AND(D12<>\"\",D13<>\"\"),\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AND(SUM(W148:W188)=COUNTIF(V148:V188,\"Y\"),SUM(U148:U188)=COUNTIF(V148:V188,\"Y\"),SUM(W159:W163)=COUNTIF(V159:V163,\"Y\"),SUM(X159:X163)<>0),TRUE,FALSE)","v":false}]
[null,"Section 2: Information for Primary Contact",null,null,{"$f":"IFERROR(IF(AND(D21:D23<>\"\"),\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AND(SUM(W190:W213)=COUNTIF(V190:V213,\"Y\"),SUM(U190:U213)=COUNTIF(V190:V213,\"Y\")),TRUE,FALSE)","v":false}]
[null,"Section 3: Core Activity",null,null,{"$f":"IFERROR(IF(AA3,\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[null,"Section 4: Intervention Details",null,null,{"$f":"IFERROR(IF(AA4,\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[null,"Section 5: Analysis Period",null,null,{"$f":"IFERROR(IF(AA5,\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[]
["Provider Selection"]
[]
[null,null,"RHP",null,null,null,null,null,null,"Y",null,18,"Delete-D"]
[null,null,"TPI",null,null,null,null,null,null,"Y",null,19,"Delete-D"]
[]
[null,null,"Project ID",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$L$2:$L$295,MATCH(D13,'Dropdown Box Data'!$K$2:$K$295,0),0),\" \")","v":" "}]
[null,null,"Provider Type",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$M$2:$M$295,MATCH(D13,'Dropdown Box Data'!$K$2:$K$295,0),0),\" \")","v":" "}]
[null,null,"Over $1 M Threshold",{"$f":"IFERROR(VLOOKUP(D13,'Dropdown Box Data'!$D$3:$E$296,2,0),\" \")","v":" "}]
[]
["Information for Primary Contact (regarding information reported in this template)"]
[]
[null,null,"Name:",null,null,null,null,null,null,null,null,null,"Delete-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D21),0,1)","v":0},"Y",0]
[null,null,"Phone:",null,null,null,null,null,null,null,null,null,"Delete-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D22),0,1)","v":0},"Y",0]
[null,null,"Email:",null,null,null,null,null,null,null,null,null,"Delete-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D23),0,1)","v":0},"Y",0]
[]
["Core Activity"]
[]
[null,null,"Pregenerated Unique ID",null,null,null,null,null,null,"Y",{"$f":"IF(D27=\"Other\",1,8)","v":8},1,"Delete-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D27),0,1)","v":0},"Y",0]
[null,"Required if select \"New\" above","User Provided Unique ID from Category A Core Activities",null,null,null,null,null,null,"Y",6]
[]
[null,null,"Core Activity Grouping ",{"$f":"IF(D27=\"New\",\"Type in custom answer here\",IFERROR(INDEX('Dropdown Box Data'!$T$3:$T$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$S$3:$S$722,0),0),\"\"))","v":""}]
[null,null,"Core Activity Title ",{"$f":"IF(D27=\"New\",\"Type in custom answer here\",IFERROR(INDEX('Dropdown Box Data'!$U$3:$U$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$S$3:$S$722,0),0),\"\"))","v":""}]
[]
[null,"Is this intervention associated with a Core Activity newly added in DY10 Round 2?"]
[null,"Y/N",null,{"$f":"IF(B34=\"Y\",\"NOTE: Please confirm the unique ID entered for the Core Activity matches what is entered in the October DY10 Core Activities template.\",\"\")","v":""},null,null,null,null,null,"Y",4,null,"Choose Y/N-B"]
[]
[1,"Describe how the intervention under examination is directly related to the Core Activity selected."]
[null,"Type in answer here",null,null,null,null,null,null,null,"Y",3,21,"TypeAns-B",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(B37),0,1)","v":1},"Y",0]
[]
[2,"Does the intervention under examination include all of the selected Core Activity's Secondary Drivers and Change Ideas?"]
[null,"Please make a selection",null,null,null,null,null,null,null,"Y",39,3,"Y/N-B",{"$f":"INDEX('Dropdown Box Data'!BQ:BQ,MATCH('Intervention Details'!D27,'Dropdown Box Data'!BK:BK,0))","v":{"$error":"#N/A"}},"# of Drivers",null,null,null,null,null,{"$f":"IF(ISBLANK(B40),0,1)","v":1},"Y",0]
[]
["2.a","Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination."]
[null,null,{"$f":"IFERROR(IF(TRIM(D43)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BL$3:$BL$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),\"\")","v":""},null,null,null,null,null,{"$f":"IF(L43<>\"\",\"Y\",\"\")","v":"Y"},{"$f":"IF(OR(D43=\"\",D43=\" \",D43=0),K44+1,0)","v":6},{"$f":"IF(AND(K43=MAX(K43:K48),K43<>K44),13,\"\")","v":13},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BU$3:$BY$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),1),\"\")","v":""},null,null,null,null,null,"",5,{"$f":"IF(AND(K44=MAX(K43:K48),K44<>K45),13,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BU$3:$BY$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),2),\"\")","v":""},null,null,null,null,null,"",4,{"$f":"IF(AND(K45=MAX(K43:K48),K45<>K46),13,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BU$3:$BY$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),3),\"\")","v":""},null,null,null,null,null,"",3,{"$f":"IF(AND(K46=MAX(K43:K48),K46<>K47),13,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BU$3:$BY$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),4),\"\")","v":""},null,null,null,null,null,"",2,{"$f":"IF(AND(K47=MAX(K43:K48),K47<>K48),13,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BU$3:$BY$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),5),\"\")","v":""},null,null,null,null,null,"",1,{"$f":"IF(K48=MAX(K43:K48),13,\"\")","v":""},"Y/N/NA-C"]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(K49=MAX(K45:K49),14,\"\")","v":""}]
[null,null,{"$f":"IFERROR(IF(TRIM(D50)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BM$3:$BM$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),\"\")","v":""},null,null,null,null,null,{"$f":"IF(L50<>\"\",\"Y\",\"\")","v":"Y"},{"$f":"IF(OR(D50=\"\",D50=\" \",D50=0),K51+1,0)","v":6},{"$f":"IF(AND(K50=MAX(K50:K55),K50<>K51),14,\"\")","v":14},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CG$3:$CK$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),1),\"\")","v":""},null,null,null,null,null,"",5,{"$f":"IF(AND(K51=MAX(K50:K55),K51<>K52),14,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CG$3:$CK$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),2),\"\")","v":""},null,null,null,null,null,"",4,{"$f":"IF(AND(K52=MAX(K50:K55),K52<>K53),14,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CG$3:$CK$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),3),\"\")","v":""},null,null,null,null,null,"",3,{"$f":"IF(AND(K53=MAX(K50:K55),K53<>K54),14,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CG$3:$CK$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),4),\"\")","v":""},null,null,null,null,null,"",2,{"$f":"IF(AND(K54=MAX(K50:K55),K54<>K55),14,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CG$3:$CK$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),5),\"\")","v":""},null,null,null,null,null,"",1,{"$f":"IF(K55=MAX(K50:K55),14,\"\")","v":""},"Y/N/NA-C"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D57)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BN$3:$BN$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),\"\")","v":""},null,null,null,null,null,{"$f":"IF(L57<>\"\",\"Y\",\"\")","v":"Y"},{"$f":"IF(OR(D57=\"\",D57=\" \",D57=0),K58+1,0)","v":6},{"$f":"IF(AND(K57=MAX(K57:K62),K57<>K58),15,\"\")","v":15},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CS$3:$CW$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),1),\"\")","v":""},null,null,null,null,null,"",5,{"$f":"IF(AND(K58=MAX(K57:K62),K58<>K59),15,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CS$3:$CW$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),2),\"\")","v":""},null,null,null,null,null,"",4,{"$f":"IF(AND(K59=MAX(K57:K62),K59<>K60),15,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CS$3:$CW$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),3),\"\")","v":""},null,null,null,null,null,"",3,{"$f":"IF(AND(K60=MAX(K57:K62),K60<>K61),15,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CS$3:$CW$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),4),\"\")","v":""},null,null,null,null,null,"",2,{"$f":"IF(AND(K61=MAX(K57:K62),K61<>K62),15,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$CS$3:$CW$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),5),\"\")","v":""},null,null,null,null,null,"",1,{"$f":"IF(K62=MAX(K57:K62),15,\"\")","v":""},"Y/N/NA-C"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D64)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BO$3:$BO$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),\"\")","v":""},null,null,null,null,null,{"$f":"IF(L64<>\"\",\"Y\",\"\")","v":"Y"},{"$f":"IF(OR(D64=\"\",D64=\" \",D64=0),K65+1,0)","v":6},{"$f":"IF(AND(K64=MAX(K64:K69),K64<>K65),16,\"\")","v":16},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DE$3:$DI$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),1),\"\")","v":""},null,null,null,null,null,"",5,{"$f":"IF(AND(K65=MAX(K64:K69),K65<>K66),16,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DE$3:$DI$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),2),\"\")","v":""},null,null,null,null,null,"",4,{"$f":"IF(AND(K66=MAX(K64:K69),K66<>K67),16,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DE$3:$DI$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),3),\"\")","v":""},null,null,null,null,null,"",3,{"$f":"IF(AND(K67=MAX(K64:K69),K67<>K68),16,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DE$3:$DI$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),4),\"\")","v":""},null,null,null,null,null,"",2,{"$f":"IF(AND(K68=MAX(K64:K69),K68<>K69),16,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DE$3:$DI$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),5),\"\")","v":""},null,null,null,null,null,"",1,{"$f":"IF(K69=MAX(K64:K69),16,\"\")","v":""},"Y/N/NA-C"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D71)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(INDEX('Dropdown Box Data'!$BP$3:$BP$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),\"\")","v":""},null,null,null,null,null,{"$f":"IF(L71<>\"\",\"Y\",\"\")","v":"Y"},{"$f":"IF(OR(D71=\"\",D71=\" \",D71=0),K72+1,0)","v":6},{"$f":"IF(AND(K71=MAX(K71:K76),K71<>K72),17,\"\")","v":17},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DQ$3:$DU$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),1),\"\")","v":""},null,null,null,null,null,"",5,{"$f":"IF(AND(K72=MAX(K71:K76),K72<>K73),17,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DQ$3:$DU$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),2),\"\")","v":""},null,null,null,null,null,"",4,{"$f":"IF(AND(K73=MAX(K71:K76),K73<>K74),17,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DQ$3:$DU$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),3),\"\")","v":""},null,null,null,null,null,"",3,{"$f":"IF(AND(K74=MAX(K71:K76),K74<>K75),17,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DQ$3:$DU$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),4),\"\")","v":""},null,null,null,null,null,"",2,{"$f":"IF(AND(K75=MAX(K71:K76),K75<>K76),17,\"\")","v":""},"Y/N/NA-C"]
[null,null,"NA",{"$f":"IFERROR(INDEX('Dropdown Box Data'!$DQ$3:$DU$722,MATCH($D$27,'Dropdown Box Data'!$BK$3:$BK$722,0),5),\"\")","v":""},null,null,null,null,null,"",1,{"$f":"IF(K76=MAX(K71:K76),17,\"\")","v":""},"Y/N/NA-C"]
[]
["2.b","Does the user have any updates or additions to make to the above Secondary Drivers and Change Ideas list?"]
[null,"Please make a selection",null,null,null,null,null,null,null,"Y",39,4,"Y/N-B",{"$f":"INDEX('Dropdown Box Data'!BQ:BQ,MATCH('Intervention Details'!D27,'Dropdown Box Data'!BK:BK,0))","v":{"$error":"#N/A"}},"# of Drivers",null,null,null,null,null,{"$f":"IF(ISBLANK(B79),0,1)","v":1},"Y",0]
[]
[null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas"]
[null,null,{"$f":"IFERROR(IF(TRIM(D82)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(IF(D43=\"\",\"\",D43),\"\")","v":""},null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D89)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(IF(D50=\"\",\"\",D50),\"\")","v":""},null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D96)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(IF(D57=\"\",\"\",D57),\"\")","v":""},null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D103)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(IF(D64=\"\",\"\",D64),\"\")","v":""},null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[]
[null,null,{"$f":"IFERROR(IF(TRIM(D110)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"NA"},{"$f":"IFERROR(IF(D71=\"\",\"\",D71),\"\")","v":""},null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[null,null,"NA","",null,null,null,null,null,null,null,null,"Y/N/NA-C+D"]
[]
[3,"Is the intervention under examination connected to any other Core Activity's Cat C measures?"]
[null,"Please make a selection",null,null,null,null,null,null,null,"Y",32,5,"Y/N-B",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(B118),0,1)","v":1},"Y",0]
[]
["3.a","Select any Cat C measure(s) that are connected to the intervention under examination."]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C",{"$f":"\"'Dropdown Box Data'!EX4:EX\" &4+'Dropdown Box Data'!$EY$2","v":"'Dropdown Box Data'!EX4:EX4"},{"$f":"COUNTIF('Dropdown Box Data'!ET:ET,D13)","v":0}]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C",{"$f":"\"'Dropdown Box Data'!EX4:EX\" &4+'Dropdown Box Data'!$EY$2","v":"'Dropdown Box Data'!EX4:EX4"}]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C",{"$f":"'Dropdown Box Data'!ET2448:ET2460,'Dropdown Box Data'!ET2444","v":{"$error":"#VALUE!"}}]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[null,null,"Please Select a Category C Measure",null,null,null,null,null,null,null,null,null,"Select-Cat-C"]
[]
[]
["Intervention Details"]
[]
[4,"Select the Patient Population Focus Area"]
[null,null,"Please make a selection",null,null,null,null,null,null,"Y",{"$f":"IF(C150<>\"Other\",6,3)","v":6},6,"Select-resp",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(C150),0,1)","v":1},"Y",0]
[]
[null,"4.a","Provide a description of the \"Other\" Patient Population Focus Area"]
[null,null,null,"Type in answer here",null,null,null,null,null,"Y",3]
[]
[null,"4.b","Describe the Patient Population being targeted with the intervention."]
[null,null,null,"Type in answer here",null,null,null,null,null,"Y",10,null,"TypeAns-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D156),0,1)","v":1},"Y",0]
[]
[null,"4.c","Please indicate which payer types are included in the Patient Population described above.  Select all that apply."]
[null,null,{"$f":"IFERROR(IF(TRIM(D159)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"Y / N"},"Medicaid",null,null,null,null,null,null,null,null,"Y/N/NA-C",null,null,null,null,null,null,null,1,"Y",0,{"$f":"IF(C159=\"Y\",1,0)","v":0}]
[null,null,{"$f":"IFERROR(IF(TRIM(D160)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"Y / N"},"LIU",null,null,null,null,null,null,null,null,"Y/N/NA-C",null,null,null,null,null,null,null,1,"Y",0,{"$f":"IF(C160=\"Y\",1,0)","v":0}]
[null,null,{"$f":"IFERROR(IF(TRIM(D161)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"Y / N"},"Medicare",null,null,null,null,null,null,null,null,"Y/N/NA-C",null,null,null,null,null,null,null,1,"Y",0,0]
[null,null,{"$f":"IFERROR(IF(TRIM(D162)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"Y / N"},"Commercial ",null,null,null,null,null,null,null,null,"Y/N/NA-C",null,null,null,null,null,null,null,1,"Y",0,0]
[null,null,{"$f":"IFERROR(IF(TRIM(D163)=\"\",\"NA\",\"Y / N\"),\"NA\")","v":"Y / N"},"Other",null,null,null,null,null,null,null,null,"Y/N/NA-C",null,null,null,null,null,null,null,1,"Y",0,0]
[]
[5,"Provide a general description of the intervention."]
[null,null,"Type in answer here",null,null,null,null,null,null,"Y",3,null,"TypeAns-C",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(C166),0,1)","v":1},"Y",0]
[]
[null,"5.a","Is the intervention described above a different intervention than was analyzed for the Costs and Savings Analysis that was due during DY8 Round 2 reporting?"]
[null,null,"Please make a selection",null,null,null,null,null,null,"Y",{"$f":"IF(C169=\"Y\",3,6)","v":6},7,"Y/N-C",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(C169),0,1)","v":1},"Y",0]
[]
[null,"5.a.i","Provide a general description of the intervention used for the Costs and Savings Analysis that was due during DY8 Round 2 reporting."]
[null,null,"Type in answer here",null,null,null,null,null,null,"Y",3,null,"TypeAns-C"]
[]
[null,"5.b","Is the intervention described above a subset of the prior Costs and Savings Analysis that was due during DY8 Round 2 reporting?"]
[null,null,"Please make a selection",null,null,null,null,null,null,"Y",12,8,"Y/N-C",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(C175),0,1)","v":1},"Y",0]
[]
[null,"5.b.i","Describe the scope of the intervention analyzed for the Costs and Savngs Analysis that was due during DY8 Round 2 reporting?"]
[null,null,"Type in answer here",null,null,null,null,null,null,"Y",null,null,"TypeAns-C"]
[]
[null,"5.b.ii","Describe the scope of the intervention analyzed for the Costs and Savngs Analysis that is due during DY10 Round 2 reporting?"]
[null,null,"Type in answer here",null,null,null,null,null,null,"Y",null,null,"TypeAns-C"]
[]
[null,"5.b.iii","Provide justification explaining the merit of analyzing a subset of the prior Costs and Savings Analysis that was due during DY8 Round 2 reporting."]
[null,null,"Type in answer here",null,null,null,null,null,null,"Y",{"$f":"IF(AND($C$178<>\"\",$C$181<>\"\",$C$184<>\"\"),3,0)","v":3},null,"TypeAns-C"]
[]
[null,"5.c","Explain why the provider selected this intervention for the Costs and Savings Analysis."]
[null,null,null,"Type in answer here",null,null,null,null,null,"Y",16,9,"TypeAns-D",null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(D187),0,1)","v":1},"Y",0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
["Analysis Period",null,null,null,null,null,null,null,null,null,null,null,null,"Check if Overide Code is valid",null,1]
[null,null,null,"Provider Override Code ",null,null,null,null,null,"Y",null,10,null,"Y",null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,6,"Please indicate the day the intervention was initiated.",null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Day Intervention was initiated",null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Example: 5/31/2017",null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,7,"Please indicate the start and end date for the intervention's Startup Period",null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Startup Period Start Date",null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,null,null,null,{"$f":"IF(ISBLANK(D200),0,1)","v":0},"Y",0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Startup Period End Date",null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,"Y",6,11,null,{"$f":"IF(OR(D203<DATE(2011,11,30), D203>DATE(2021,9,29)),\"Fails Test\",\"Passes\")","v":"Fails Test"},null,1,null,null,null,null,{"$f":"IF(ISBLANK(D203),0,1)","v":0},"Y",0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,"7.a","Please explain why the Startup Period is less than a month. ",null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Type in answer here",null,null,null,null,null,"Y",3,null,"TypeAns-D",null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,8,"Would provider like to analyze additional years over the minimum required length of the Operating Period?",null,null,null,null,null,null,null,null,null,null,null,null,1]
[null,null,null,"Please make a selection",null,null,null,null,null,"Y",20,12,"Y/N-D",null,null,1,null,null,null,null,{"$f":"IF(ISBLANK(D209),0,1)","v":1},"Y",0]
[]
[null,"8.a","How many additional years would provider like to analyze?"]
[null,null,null,0,null,null,null,null,null,null,null,null,"Zero-D"]
[]
[null,null,null,"Analysis Period"]
[null,null,null,"Startup Period","Operating Period"]
[null,null,null,{"$f":"TEXT(D200,\"mm/dd/yyyy\")&\" - \"&TEXT(D203,\"mm/dd/yyyy\")","v":"01/00/1900 - 01/00/1900"},{"$f":"TEXT(D203+1,\"mm/dd/yyyy\")&\" - \"&TEXT(EDATE(D203+1,3*12+D212*12),\"mm/dd/yyyy\")","v":"01/01/1900 - 01/01/1903"}]
[]
[null,null,null,"Press this button only after all Progress Indicators at the top of this tab show as \"Complete,\" and provider has reviewed the Analysis Period indicated in the table above. The process to create additional tabs may take a while; please refrain from clicking anything in the template until the process is complete."]

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[]
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[null,null,null,"Total Costs",null,"Total Costs",null,{"$f":"SUMIFS(H$12:H$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(L$12:L$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(P$12:P$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(T$12:T$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(X$12:X$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AB$12:AB$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AF$12:AF$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AJ$12:AJ$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AN$12:AN$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AR$12:AR$236,$B$12:$B$236,1)","v":0},null,"Total Costs",null,{"$f":"SUMIFS(AV$12:AV$236,$B$12:$B$236,1)","v":0}]
[]
[null,null,null,null,null,"Please check the box below to confirm that program costs include costs for existing personnel or resources that might otherwise be allocated for other purposes."]
[]
[]
[null,null,null,"Program Cost Questions"]
[]
[null,null,null,null,null,"Describe any methodologies used and assumptions made to allocate program costs for the Startup Period and the Operating Period."]
[null,null,null,null,null,"Type in answer here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",3,null,"TypeAns-F"]
[]
[null,null,null,null,null,"Describe data sources used for program costs for the Startup Period and the Operating Period."]
[null,null,null,null,null,"Type in answer here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",6,null,"TypeAns-F"]
[]
[null,null,null,null,null,"Describe all activities performed to develop and operate the intervention under examination during the Startup Period and the Operating Period (i.e., activities that make up the intervention such as process changes, E.H.R. changes, hiring additional clinicians to offer more appointments, additional beds, development of classes, development of literature, outreach, etc.).\n\n"]
[]
[]
[null,null,null,null,null,"Type in answer here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",12,null,"TypeAns-F"]

{"sheet":"Category of Service","index":2,"n_rows":43,"n_cols":19,"rows_kept":43,"cut":false,"hidden":true,"merged":[[7,1,9,3]]}
["GH General Modeling Notes","Draft"]
[null,"Progress Indicator"]
[]
[null,"Task 1: Review Category B information.",null,{"$f":"IFERROR(IF(C24=\"Y\",\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[null,"Task 2: Complete Category of Service Questions.",null,{"$f":"IFERROR(IF(COUNTBLANK(C27:D37)+COUNTBLANK(F27:F37)=0,\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[]
[]
[null,"The information below contains your organization's Category B information previously reported for DY9-10. When completing reporting on \"Category of Service\" in this worksheet, please cross-reference responses to your Category B information to align service categories with business components as far as possible."]
[]
[]
[null,"Category B Business Component","Required/Optional","Included in System Definition (Y/N)?","DY9-10 Description of System Component",null,null,null,null,null,null,null,null,null,null,null,null,null,"Row indicator"]
[0,{"$f":"IF(A12<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A12,0),\"\")","v":""},{"$f":"IF(A12<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A12,1),\"\")","v":""},{"$f":"IF(A12<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A12,2),\"\")","v":""},{"$f":"IF(A12<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A12,3),\"\")","v":""},"Sections without response should be hidden.",null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"COUNTIF(Table13[TPI],'Intervention Details'!D$13)","v":0}]
[1,{"$f":"IF(A13<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A13,0),\"\")","v":""},{"$f":"IF(A13<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A13,1),\"\")","v":""},{"$f":"IF(A13<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A13,2),\"\")","v":""},{"$f":"IF(A13<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A13,3),\"\")","v":""},"Sections without response should be hidden."]
[2,{"$f":"IF(A14<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A14,0),\"\")","v":""},{"$f":"IF(A14<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A14,1),\"\")","v":""},{"$f":"IF(A14<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A14,2),\"\")","v":""},{"$f":"IF(A14<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A14,3),\"\")","v":""},"Sections without response should be hidden."]
[3,{"$f":"IF(A15<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A15,0),\"\")","v":""},{"$f":"IF(A15<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A15,1),\"\")","v":""},{"$f":"IF(A15<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A15,2),\"\")","v":""},{"$f":"IF(A15<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A15,3),\"\")","v":""},"Sections without response should be hidden."]
[4,{"$f":"IF(A16<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A16,0),\"\")","v":""},{"$f":"IF(A16<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A16,1),\"\")","v":""},{"$f":"IF(A16<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A16,2),\"\")","v":""},{"$f":"IF(A16<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A16,3),\"\")","v":""},"Sections without response should be hidden."]
[5,{"$f":"IF(A17<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A17,0),\"\")","v":""},{"$f":"IF(A17<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A17,1),\"\")","v":""},{"$f":"IF(A17<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A17,2),\"\")","v":""},{"$f":"IF(A17<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A17,3),\"\")","v":""},"Sections without response should be hidden."]
[6,{"$f":"IF(A18<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A18,0),\"\")","v":""},{"$f":"IF(A18<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A18,1),\"\")","v":""},{"$f":"IF(A18<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A18,2),\"\")","v":""},{"$f":"IF(A18<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A18,3),\"\")","v":""},"Sections without response should be hidden."]
[7,{"$f":"IF(A19<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A19,0),\"\")","v":""},{"$f":"IF(A19<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A19,1),\"\")","v":""},{"$f":"IF(A19<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A19,2),\"\")","v":""},{"$f":"IF(A19<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A19,3),\"\")","v":""},"Sections without response should be hidden."]
[8,{"$f":"IF(A20<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A20,0),\"\")","v":""},{"$f":"IF(A20<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A20,1),\"\")","v":""},{"$f":"IF(A20<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A20,2),\"\")","v":""},{"$f":"IF(A20<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A20,3),\"\")","v":""},"Sections without response should be hidden."]
[9,{"$f":"IF(A21<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A21,0),\"\")","v":""},{"$f":"IF(A21<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A21,1),\"\")","v":""},{"$f":"IF(A21<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A21,2),\"\")","v":""},{"$f":"IF(A21<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A21,3),\"\")","v":""},"Sections without response should be hidden."]
[10,{"$f":"IF(A22<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A22,0),\"\")","v":""},{"$f":"IF(A22<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A22,1),\"\")","v":""},{"$f":"IF(A22<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A22,2),\"\")","v":""},{"$f":"IF(A22<COUNTIF(Table13[TPI],'Intervention Details'!D$13),OFFSET('Cat B System Master'!$G$2,MATCH('Intervention Details'!D$13,Table13[TPI],0)-1+A22,3),\"\")","v":""},"Sections without response should be hidden."]
[]
[null,"I have reviewed the Category B information reported previously."]
[null,null,null,null,null,"--> Macro Takes You Here","This column should be hidden if provider \"Y\" in C8."]
[null,"Category of Service","Does your Organization Provide This Service?","Will this Category of Service be used in the Costs and Savings Analysis?","Explanation for not including Category of Service in the Costs and Savings Analysis.","What % of Target Population's Savings Will Your Organization Realize?"]
[null,"Inpatient Care"]
[null,"Long Term Care, Facility-Based"]
[null,"Outpatient Care"]
[null,"Office-Based Care"]
[null,"Emergency Department Care"]
[null,"Emergency Transportation"]
[null,"Home Health Care"]
[null,"Pharmacy"]
[null,"Other"]
[null,"Other"]
[null,"Other"]
[]
[]
[]
[]
[]
[null,"Press this button only after all Progress Indicators at the top of this tab show as \"Complete.\" The process to create additional tabs may take a while; please refrain from clicking anything in the template until the process is complete."]

{"sheet":"Financial Outcomes","index":3,"n_rows":100,"n_cols":54,"rows_kept":100,"cut":false,"hidden":true,"merged":[[97,2,97,4],[90,2,90,3],[91,2,91,3],[92,2,92,3],[95,2,95,4],[96,2,96,4],[82,3,82,14],[75,3,75,14],[76,3,76,14],[78,3,78,14],[79,3,79,14],[81,3,81,14],[87,3,87,14],[88,3,88,14],[84,3,84,14],[85,3,85,14],[57,3,57,14],[58,3,58,14],[60,3,60,14],[61,3,61,14],[63,3,63,14],[64,3,64,14],[66,3,66,14],[67,3,67,14],[69,3,69,14],[70,3,70,14],[72,3,72,14],[73,3,73,14],[34,5,34,14],[35,5,35,14],[13,5,13,14],[14,5,14,14],[16,5,16,14],[17,5,17,14],[26,5,26,14],[28,5,28,14],[29,5,29,14],[31,5,31,14],[32,5,32,14],[19,5,19,14],[20,5,20,14],[22,5,22,14],[23,5,23,14],[25,5,25,14],[44,5,44,14],[37,5,37,14],[38,5,38,14],[40,5,40,14],[46,2,46,3],[41,2,41,3],[40,2,40,3],[39,2,39,3],[38,2,38,3],[37,2,37,3],[41,5,41,14],[43,5,43,14],[47,2,47,3],[48,2,48,3],[44,2,44,3],[43,2,43,3],[42,2,42,3],[36,2,36,3],[35,2,35,3],[34,2,34,3],[33,2,33,3],[32,2,32,3],[31,2,31,3],[30,2,30,3],[29,2,29,3],[28,2,28,3],[27,2,27,3],[12,2,12,3],[11,2,11,3],[13,2,13,3],[14,2,14,3],[15,2,15,3],[16,2,16,3],[17,2,17,3],[18,2,18,3],[19,2,19,3],[20,2,20,3],[26,2,26,3],[21,2,21,3],[22,2,22,3],[23,2,23,3],[24,2,24,3]]}
[null,null,"Draft",null,null,null,null,{"$f":"COLUMN()","v":8},null,null,null,null,null,null,null,null,{"$f":"COLUMN()","v":17},null,null,null,null,null,null,null,null,{"$f":"COLUMN()","v":26},null,{"$f":"COLUMN()","v":28},null,null,null,null,null,null,null,null,{"$f":"COLUMN()","v":37},null,null,"Hardcoded Trigger for Macro","Rows to Unhide","Macro Event ID","ResetKey","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper","Sumproduct Helper"]
[null,null,"Progress Indicator"]
[]
[null,null,"Task 1: Complete Financial Outcomes Information",null,"Incomplete"]
[]
[null,null,"Guiding Questions","Method of Reporting Financial Outcomes"]
[null,{"$f":"IF(D7=\"Y\",1,0)","v":0},"Enter outcomes directly (yes) or calculate outcomes based on changes in cost (no)?"]
[null,{"$f":"IF(D8=\"N\",0,1)","v":1},"Would you like to enter figures in per eligible receiving person (yes) or in aggregate (no)?"]
[]
[null,null,null,0,0,{"$f":"E10+1","v":1},2,3,4,5,6,7,8,9,10,{"$f":"N10+1","v":10},11,12,13]
[null,null,"Estimated Annual Savings for Target Population"]
[null,null,"Category of Service",null,"Baseline","Operating Year 1","Operating Year 2","Operating Year 3","Operating Year 4","Operating Year 5","Operating Year 6","Operating Year 7","Operating Year 8","Operating Year 9","Operating Year 10",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If possible, can we have only Year columns show up that are indicated as being used for the Analysis Period, and can we have only Categories of Services show up that are indicated as being used in the preceding Helper Information table. Need some way to tell when this tab is \"complete\" for the progress indicator. For example, we need some way to tell when all of the input cells on this tab have been complete."]
[null,null,"Inpatient Care",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Please add two more input columns (qualitative) after each Category of Services row. One column should be for providers to \"Describe the methodologies used and assumptions made to determine data input for this Category of Service\" and the other column should be for providers to \"Descibe the data sources used for this Category of Service.\"",null,"Y",2,null,null,{"$f":"F13","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F16","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F19","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Long Term Care, Facility-Based",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,null,null,{"$f":"F22","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F25","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F28","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Outpatient Care",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,null,null,{"$f":"F31","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F34","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F37","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Office-Based Care",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,null,null,{"$f":"F40","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F43","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,"Emergency Department Care",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,"Emergency Transportation",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,"Home Health Care",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,"Pharmacy",null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,{"$f":"'Category of Service'!B35","v":"Other"},null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,1]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,{"$f":"'Category of Service'!B36","v":"Other"},null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,1]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[null,null,{"$f":"'Category of Service'!B37","v":"Other"},null,null,0,0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",2,1]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service",null,null,"Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.",null,null,"Type in Answer Here"]
[]
[null,null,"Total Number of Individuals Receiving Intervention Annually",null,null,0,0,0,0,0,0,0,0,0,0]
[null,null,"Total Annual Financial Outcomes for the Patient Population",null,null,{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(F13:F43)*F47),SUM(F13:F43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(G13:G43)*G47),SUM(G13:G43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(H13:H43)*H47),SUM(H13:H43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(I13:I43)*I47),SUM(I13:I43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(J13:J43)*J47),SUM(J13:J43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(K13:K43)*K47),SUM(K13:K43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(L13:L43)*L47),SUM(L13:L43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(M13:M43)*M47),SUM(M13:M43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(N13:N43)*N47),SUM(N13:N43))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,(SUM(O13:O43)*O47),SUM(O13:O43))","v":0}]
[null,null,"Total Annual Financial Outcomes Accounted for at your Organization",null,null,{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AS$13:AS$23,'Category of Service'!$F$27:$F$37)*F$47,SUMPRODUCT(AS$13:AS$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AT$13:AT$23,'Category of Service'!$F$27:$F$37)*G$47,SUMPRODUCT(AT$13:AT$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AU$13:AU$23,'Category of Service'!$F$27:$F$37)*H$47,SUMPRODUCT(AU$13:AU$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AV$13:AV$23,'Category of Service'!$F$27:$F$37)*I$47,SUMPRODUCT(AV$13:AV$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AW$13:AW$23,'Category of Service'!$F$27:$F$37)*J$47,SUMPRODUCT(AW$13:AW$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AX$13:AX$23,'Category of Service'!$F$27:$F$37)*K$47,SUMPRODUCT(AX$13:AX$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AY$13:AY$23,'Category of Service'!$F$27:$F$37)*L$47,SUMPRODUCT(AY$13:AY$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(AZ$13:AZ$23,'Category of Service'!$F$27:$F$37)*M$47,SUMPRODUCT(AZ$13:AZ$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(BA$13:BA$23,'Category of Service'!$F$27:$F$37)*N$47,SUMPRODUCT(BA$13:BA$23,'Category of Service'!$F$27:$F$37))","v":0},{"$f":"IF('Financial Outcomes'!$B8=1,SUMPRODUCT(BB$13:BB$23,'Category of Service'!$F$27:$F$37)*O$47,SUMPRODUCT(BB$13:BB$23,'Category of Service'!$F$27:$F$37))","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Hide Column","Hide Column","Hide Column",null,null,null,null,null,null,null,null,"Hide Column","Hide Column","Hide Column"]
[]
[null,null,{"$f":"IF(C55=\"\",#REF!,C55)","v":"Estimated Annual Cost of Care for Target Population"},{"$f":"IF(D55=\"\",C52,D55)","v":"Estimated Annual Cost of Care for Target Population"},"Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population","Estimated Annual Cost of Care for Target Population",null,{"$f":"IF(P55=\"\",N52,P55)","v":"Estimated Annual Cost of Care for Target Population"},"Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Trended Annual Cost of Care for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population","Estimated Annual Savings for Target Population"]
[null,null,null,0,{"$f":"D53+1","v":1},2,3,4,5,6,7,8,9,10,null,null,{"$f":"E53","v":1},2,3,4,5,6,7,8,9,10,null,{"$f":"Q53","v":1},2,3,4,5,6,7,8,9,10]
[]
[null,null,"Estimated Annual Cost of Care for Target Population",null,null,null,null,null,null,null,null,null,null,null,null,null,"Trended Annual Cost of Care for Target Population",null,null,null,null,null,null,null,null,null,null,"Estimated Annual Savings for Target Population"]
[null,null,"Category of Service","Normal Unit Cost Trend (Estimate Only)","Baseline","Operating Year 1","Operating Year 2","Operating Year 3","Operating Year 4","Operating Year 5","Operating Year 6","Operating Year 7","Operating Year 8","Operating Year 9","Operating Year 10",null,"Operating Year 1","Operating Year 2","Operating Year 3","Operating Year 4","Operating Year 5","Operating Year 6","Operating Year 7","Operating Year 8","Operating Year 9","Operating Year 10",null,"Operating Year 1","Operating Year 2","Operating Year 3","Operating Year 4","Operating Year 5","Operating Year 6","Operating Year 7","Operating Year 8","Operating Year 9","Operating Year 10"]
[null,null,"Inpatient Care",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E57*(1+$D57)","v":0},{"$f":"Q57*(1+$D57)","v":0},{"$f":"R57*(1+$D57)","v":0},{"$f":"IF(I57=0,0,S57*(1+$D57))","v":0},{"$f":"IF(J57=0,I57,T57*(1+$D57))","v":0},0,0,0,0,0,null,{"$f":"Q57-F57","v":0},{"$f":"R57-G57","v":0},0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"F57","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F60","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F63","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Long Term Care, Facility-Based",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E60*(1+$D60)","v":0},{"$f":"Q60*(1+$D60)","v":0},{"$f":"R60*(1+$D60)","v":0},{"$f":"IF(I60=0,0,S60*(1+$D60))","v":0},{"$f":"IF(J60=0,I60,T60*(1+$D60))","v":0},{"$f":"IF(K60=0,J60,U60*(1+$D60))","v":0},{"$f":"IF(L60=0,K60,V60*(1+$D60))","v":0},{"$f":"IF(M60=0,L60,W60*(1+$D60))","v":0},{"$f":"IF(N60=0,M60,X60*(1+$D60))","v":0},{"$f":"IF(O60=0,N60,Y60*(1+$D60))","v":0},null,{"$f":"Q60-F60","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"F66","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F69","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F72","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Outpatient Care",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E63*(1+$D63)","v":0},{"$f":"Q63*(1+$D63)","v":0},{"$f":"R63*(1+$D63)","v":0},{"$f":"IF(I63=0,0,S63*(1+$D63))","v":0},{"$f":"IF(J63=0,I63,T63*(1+$D63))","v":0},{"$f":"IF(K63=0,J63,U63*(1+$D63))","v":0},{"$f":"IF(L63=0,K63,V63*(1+$D63))","v":0},{"$f":"IF(M63=0,L63,W63*(1+$D63))","v":0},{"$f":"IF(N63=0,M63,X63*(1+$D63))","v":0},{"$f":"IF(O63=0,N63,Y63*(1+$D63))","v":0},null,{"$f":"Q63-F63","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"F75","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F78","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F81","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Office-Based Care",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E66*(1+$D66)","v":0},{"$f":"Q66*(1+$D66)","v":0},{"$f":"R66*(1+$D66)","v":0},{"$f":"IF(I66=0,0,S66*(1+$D66))","v":0},{"$f":"IF(J66=0,I66,T66*(1+$D66))","v":0},{"$f":"IF(K66=0,J66,U66*(1+$D66))","v":0},{"$f":"IF(L66=0,K66,V66*(1+$D66))","v":0},{"$f":"IF(M66=0,L66,W66*(1+$D66))","v":0},{"$f":"IF(N66=0,M66,X66*(1+$D66))","v":0},{"$f":"IF(O66=0,N66,Y66*(1+$D66))","v":0},null,{"$f":"Q66-F66","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"F84","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"F87","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,null,"Emergency Department Care",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E69*(1+$D69)","v":0},{"$f":"Q69*(1+$D69)","v":0},{"$f":"R69*(1+$D69)","v":0},{"$f":"IF(I69=0,0,S69*(1+$D69))","v":0},{"$f":"IF(J69=0,I69,T69*(1+$D69))","v":0},{"$f":"IF(K69=0,J69,U69*(1+$D69))","v":0},{"$f":"IF(L69=0,K69,V69*(1+$D69))","v":0},{"$f":"IF(M69=0,L69,W69*(1+$D69))","v":0},{"$f":"IF(N69=0,M69,X69*(1+$D69))","v":0},{"$f":"IF(O69=0,N69,Y69*(1+$D69))","v":0},null,{"$f":"Q69-F69","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"AB57","v":0},{"$f":"AC57","v":0},0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB60","v":0},{"$f":"AC60","v":0},0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB63","v":0},{"$f":"AC63","v":0},0,0,0,0,0,0,0,0]
[null,null,"Emergency Transportation",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E72*(1+$D72)","v":0},{"$f":"Q72*(1+$D72)","v":0},{"$f":"R72*(1+$D72)","v":0},{"$f":"IF(I72=0,0,S72*(1+$D72))","v":0},{"$f":"IF(J72=0,I72,T72*(1+$D72))","v":0},{"$f":"IF(K72=0,J72,U72*(1+$D72))","v":0},{"$f":"IF(L72=0,K72,V72*(1+$D72))","v":0},{"$f":"IF(M72=0,L72,W72*(1+$D72))","v":0},{"$f":"IF(N72=0,M72,X72*(1+$D72))","v":0},{"$f":"IF(O72=0,N72,Y72*(1+$D72))","v":0},null,{"$f":"Q72-F72","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"AB66","v":0},{"$f":"AC66","v":0},0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB69","v":0},{"$f":"AC69","v":0},0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB72","v":0},{"$f":"AC72","v":0},0,0,0,0,0,0,0,0]
[null,null,"Home Health Care",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E75*(1+$D75)","v":0},{"$f":"Q75*(1+$D75)","v":0},{"$f":"R75*(1+$D75)","v":0},{"$f":"IF(I75=0,0,S75*(1+$D75))","v":0},{"$f":"IF(J75=0,I75,T75*(1+$D75))","v":0},{"$f":"IF(K75=0,J75,U75*(1+$D75))","v":0},{"$f":"IF(L75=0,K75,V75*(1+$D75))","v":0},{"$f":"IF(M75=0,L75,W75*(1+$D75))","v":0},{"$f":"IF(N75=0,M75,X75*(1+$D75))","v":0},{"$f":"IF(O75=0,N75,Y75*(1+$D75))","v":0},null,{"$f":"Q75-F75","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"AB75","v":0},{"$f":"AC75","v":0},0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB78","v":0},{"$f":"AC78","v":0},0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB81","v":0},{"$f":"AC81","v":0},0,0,0,0,0,0,0,0]
[null,null,"Pharmacy",null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E78*(1+$D78)","v":0},{"$f":"Q78*(1+$D78)","v":0},{"$f":"R78*(1+$D78)","v":0},{"$f":"IF(I78=0,0,S78*(1+$D78))","v":0},{"$f":"IF(J78=0,I78,T78*(1+$D78))","v":0},{"$f":"IF(K78=0,J78,U78*(1+$D78))","v":0},{"$f":"IF(L78=0,K78,V78*(1+$D78))","v":0},{"$f":"IF(M78=0,L78,W78*(1+$D78))","v":0},{"$f":"IF(N78=0,M78,X78*(1+$D78))","v":0},{"$f":"IF(O78=0,N78,Y78*(1+$D78))","v":0},null,{"$f":"Q78-F78","v":0},0,0,0,0,0,0,0,0,0,null,null,null,null,null,null,{"$f":"AB84","v":0},{"$f":"AC84","v":0},0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AB87","v":0},{"$f":"AC87","v":0},0,0,0,0,0,0,0,0]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,null,{"$f":"'Category of Service'!B35","v":"Other"},null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E81*(1+$D81)","v":0},{"$f":"Q81*(1+$D81)","v":0},{"$f":"R81*(1+$D81)","v":0},{"$f":"IF(I81=0,0,S81*(1+$D81))","v":0},{"$f":"IF(J81=0,I81,T81*(1+$D81))","v":0},{"$f":"IF(K81=0,J81,U81*(1+$D81))","v":0},{"$f":"IF(L81=0,K81,V81*(1+$D81))","v":0},{"$f":"IF(M81=0,L81,W81*(1+$D81))","v":0},{"$f":"IF(N81=0,M81,X81*(1+$D81))","v":0},{"$f":"IF(O81=0,N81,Y81*(1+$D81))","v":0},null,{"$f":"Q81-F81","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,null,{"$f":"'Category of Service'!B36","v":"Other"},null,0,0,0,0,0,0,0,0,0,0,0,null,{"$f":"E84*(1+$D84)","v":0},{"$f":"Q84*(1+$D84)","v":0},{"$f":"R84*(1+$D84)","v":0},{"$f":"IF(I84=0,0,S84*(1+$D84))","v":0},{"$f":"IF(J84=0,I84,T84*(1+$D84))","v":0},{"$f":"IF(K84=0,J84,U84*(1+$D84))","v":0},{"$f":"IF(L84=0,K84,V84*(1+$D84))","v":0},{"$f":"IF(M84=0,L84,W84*(1+$D84))","v":0},{"$f":"IF(N84=0,M84,X84*(1+$D84))","v":0},{"$f":"IF(O84=0,N84,Y84*(1+$D84))","v":0},null,{"$f":"Q84-F84","v":0},0,0,0,0,0,0,0,0,0]
[null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
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[null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
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[null,null,"Cumulative ROI",null,{"$f":"IFERROR(SUM(E34:$E34)/SUM($D21:E21),)","v":0},{"$f":"IFERROR(SUM($E34:F34)/SUM($D21:F21),)","v":0},{"$f":"IFERROR(SUM($E34:G34)/SUM($D21:G21),)","v":0},{"$f":"IFERROR(IF(H39=0,0,SUM($E34:H34)/SUM($D21:H21)),)","v":0},{"$f":"IFERROR(IF(I39=0,0,SUM($E34:I34)/SUM($D21:I21)),)","v":0},{"$f":"IFERROR(IF(J39=0,0,SUM($E34:J34)/SUM($D21:J21)),)","v":0},{"$f":"IFERROR(IF(K39=0,0,SUM($E34:K34)/SUM($D21:K21)),)","v":0},{"$f":"IFERROR(IF(L39=0,0,SUM($E34:L34)/SUM($D21:L21)),)","v":0},{"$f":"IFERROR(IF(M39=0,0,SUM($E34:M34)/SUM($D21:M21)),)","v":0},{"$f":"IFERROR(IF(N39=0,0,SUM($E34:N34)/SUM($D21:N21)),)","v":0},{"$f":"SUM(E41:N41)","v":0}]
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[null,null,"Cumulative ROI Recognized by Provider's Organization",null,{"$f":"IFERROR(SUM(E36:$E36)/SUM($D21:E21),)","v":0},{"$f":"IFERROR(SUM($E36:F36)/SUM($D21:F21),)","v":0},{"$f":"IFERROR(SUM($E36:G36)/SUM($D21:G21),)","v":0},{"$f":"IFERROR(IF(H39=0,0,SUM($E36:H36)/SUM($D21:H21)),)","v":0},{"$f":"IFERROR(IF(I39=0,0,SUM($E36:I36)/SUM($D21:I21)),)","v":0},{"$f":"IFERROR(IF(J39=0,0,SUM($E36:J36)/SUM($D21:J21)),)","v":0},{"$f":"IFERROR(IF(K39=0,0,SUM($E36:K36)/SUM($D21:K21)),)","v":0},{"$f":"IFERROR(IF(L39=0,0,SUM($E36:L36)/SUM($D21:L21)),)","v":0},{"$f":"IFERROR(IF(M39=0,0,SUM($E36:M36)/SUM($D21:M21)),)","v":0},{"$f":"IFERROR(IF(N39=0,0,SUM($E36:N36)/SUM($D21:N21)),)","v":0},{"$f":"SUM(E43:N43)","v":0}]
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[null,null,"Cumulative ROI, Net Present Value",null,{"$f":"E34-E21","v":0},0,0,0,0,0,0,0,0,0,{"$f":"SUM(E45:N45)","v":0}]
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[null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",null,{"$f":"E36-E21","v":0},0,0,0,0,0,0,0,0,0,{"$f":"SUM(E47:N47)","v":0}]
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["Progress Indicator",null,null,null,null,null,null,null,null,"These columns will be hidden for providers"]
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[null,"Section 1: General Questions",null,null,{"$f":"IF(B77=\"Type in Answer Here\",\"Incomplete\",\"Complete\")","v":"Incomplete"}]
[null,"Section 2:  COVID-Related Questions",null,null,{"$f":"IF(OR(OR(D92=\"N\",D95<>\"Type in Answer Here\"),D86=\"N\"),\"Complete\",\"Incomplete\")","v":"Incomplete"}]
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["General Questions"]
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[]
[1,"Will the provider continue to operate the intervention post DSRIP?"]
[null,"Y / N",null,null,null,null,null,null,null,"Y",null,3,"Y/N-B"]
[]
[null,null,"1a.","Please explain why provider is not operating the intervention post DSRIP?"]
[null,null,null,"Type in Answer Here",null,null,null,null,null,"Y",3,null,"TypeAns-D"]
[]
[2,"How does the intervention under examination affect the provider’s revenue?"]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",3,null,"TypeAns-B"]
[]
[3,"Please summarize the results of the Costs and Savings Analysis."]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",3,null,"TypeAns-B"]
[]
[4,"On a scale of 1-10, with 10 being very confident, how confident is the provider in the accuracy of their analysis considering the data sources used, the assumptions made, and the methodologies used to complete the analysis?"]
[null,"Please Select from List",null,null,null,null,null,null,null,"Y",9,5,"Select-B"]
[]
[5,"What are the constraints in affecting 100% of the target population with the intervention? (Please select all that apply)"]
[]
[]
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[null,"5.a.","Please explain what 'Other' contraints affected intervention."]
[null,null,"Type in Answer Here",null,null,null,null,null,null,"Y",null,null,"TypeAns-C"]
[]
[null,"5.b.","Please explain why the provider believes all patients that could receive intervention were included."]
[null,null,"Type in Answer Here",null,null,null,null,null,null,"Y",null,null,"TypeAns-C"]
[]
[6,"Please describe how the intervention being examined impacts Medicaid."]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",5,null,"TypeAns-B"]
[]
[7,"Please describe how the intervention being examined impacts at least two different stakeholders as listed below. [Providers will be required to select at least two or more of the options listed below, and, once selected, there will be an Open Field]"]
[]
[]
[null,"How many stakeholders?",null,"# of stakeholders (Min of 2)",null,null,null,null,null,"Y",2,1,"D-# of stakeholders (Min of 2)"]
[]
[null,"Stakeholder One:",null,"Please Select from List",null,null,null,null,null,"Y",2,null,"Select-D"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Stakeholder #"]
[null,"Impact to Stakeholder:",null,"Type in Answer Here",null,null,null,null,null,"Y",null,2,"TypeAns-D",1]
[]
[null,"Stakeholder Two:",null,"Please Select from List",null,null,null,null,null,"Y",{"$f":"IF(5-COUNTIFS($D$49:$E$68,\"Please Select from List\")<=$D$47,2,0)","v":2},null,"Select-D"]
[]
[null,"Impact to Stakeholder:",null,"Type in Answer Here",null,null,null,null,null,"Y",null,2,"TypeAns-D",2]
[]
[null,"Stakeholder Three:",null,"Please Select from List",null,null,null,null,null,"Y",2,null,"Select-D"]
[]
[null,"Impact to Stakeholder:",null,"Type in Answer Here",null,null,null,null,null,"Y",null,2,"TypeAns-D",3]
[]
[null,"Stakeholder Four:",null,"Please Select from List",null,null,null,null,null,"Y",2,null,"Select-D"]
[]
[null,"Impact to Stakeholder:",null,"Type in Answer Here",null,null,null,null,null,"Y",null,2,"TypeAns-D",4]
[]
[null,"Stakeholder Five:",null,"Please Select from List",null,null,null,null,null,"Y",2,null,"Select-D"]
[]
[null,"Impact to Stakeholder:",null,"Type in Answer Here",null,null,null,null,null,"Y",null,2,"TypeAns-D",5]
[]
[]
[8,"Describe the known or anticipated outcomes and/or benefits of the intervention on the Patient Population."]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",3,null,"TypeAns-B"]
[]
[9,"Describe the financial outcomes to the system of care expected or realized as a result of the intervention as reflected in the data input into this template."]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",3,null,"TypeAns-B"]
[]
[10,"Describe any benefits to the provider’s organization due to the intervention that may not be captured elsewhere in this template (e.g., increased recognition for quality; enhanced market share; employee satisfaction/retention; enhanced accreditation; fulfillment of mandated requirements, such as requirements to participate in Medicaid; etc.). "]
[null,"Type in Answer Here",null,null,null,null,null,null,null,"Y",6,5,"TypeAns-B"]
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[null,"COVID-Related Questions"]
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[null,1,"Describe how COVID-19 has impacted the intervention under examination."]
[null,null,null,"Type in Answer Here",null,null,null,null,null,"Y",4,null,"TypeAns-D"]
[]
[null,2,"Did provider have to modify the intervention under examination as a result of COVID-19?"]
[null,null,null,"Y / N",null,null,null,null,null,"Y",null,6,"Y/N-D"]
[]
[null,"2.a.","Please describe the modifications made to the intervention as a result of COVID-19."]
[null,null,null,"Type in Answer Here",null,null,null,null,null,"Y",3,null,"TypeAns-D"]
[]
[null,"2.b.","Did the modifications made to the intervention as a result of COVID-19 affect the outcomes of the intervention?"]
[null,null,null,"Y / N",null,null,null,null,null,"Y",null,6,"Y/N-D"]
[]
[null,"2.c.","Please describe how the modifications made to the intervention as a result of COVID-19 affected the outcomes of the intervention."]
[null,null,null,"Type in Answer Here",null,null,null,null,null,"Y",20,null,"TypeAns-D"]

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[null,"Section 1: Intervention Details",null,null,{"$f":"IFERROR(IF(AND('Intervention Details'!E4=\"Complete\",'Intervention Details'!E5=\"Complete\",'Intervention Details'!E6=\"Complete\",'Intervention Details'!E7=\"Complete\",'Intervention Details'!E8=\"Complete\"),\"Complete\",\"Incomplete\"),\"Incomplete\")","v":"Incomplete"}]
[null,"Section 2: Program Costs",null,null,{"$f":"IF(AND('Program Costs'!J4=\"Complete\",'Program Costs'!J5=\"Complete\"),\"Complete\",\"Incomplete\")","v":"Incomplete"}]
[null,"Section 3: Category of Service",null,null,{"$f":"IF(AND('Category of Service'!D4=\"Complete\",'Category of Service'!D5=\"Complete\"),\"Complete\",\"Incomplete\")","v":"Incomplete"}]
[null,"Section 4: Financial Outcomes",null,null,{"$f":"IF('Financial Outcomes'!E4=\"Complete\",\"Complete\",\"Incomplete\")","v":"Incomplete"}]
[null,"Section 5: ROI Calculations",null,null,{"$f":"IF('ROI Calculation'!I4=\"Complete\",\"Complete\",\"Incomplete\")","v":"Incomplete"}]
[null,"Section 6: Questions",null,null,{"$f":"IF(AND('Qualitative Questions'!E4=\"Complete\",'Qualitative Questions'!E5=\"Complete\"),\"Complete\",\"Incomplete\")","v":"Incomplete"}]
[null,"Section 7: Certification",null,null,{"$f":"IF(AND(A100,B23<>\"\",B24<>\"\",B25<>\"\"),\"Complete\",\"Incomplete\")","v":"Incomplete"}]
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["Index","Cell Address","Section","Subsection","Prompt","Input"]
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[null,{"$f":"CELL(\"address\",'Intervention Details'!D13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$13"},null,null,"TPI",{"$f":"IF(INDIRECT(B4)=\"\",\"\",INDIRECT(B4))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$15"},null,null,"Project ID",{"$f":"IF(INDIRECT(B5)=\"\",\"\",INDIRECT(B5))","v":" "}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$16"},null,null,"Project Type"," "]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$17"},null,null,"Over $1M Threshold"," "]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E5)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$5"},null,"Information for Primary Contact","Section 2: Information for Primary Contact",{"$f":"IF(INDIRECT(B8)=\"\",\"\",INDIRECT(B8))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$21"},null,null,"Name",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$22"},null,null,"Phone",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D23)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$23"},null,null,"Email",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E6)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$6"},null,"Core Activity","Section 3: Core Activity",{"$f":"IF(INDIRECT(B12)=\"\",\"\",INDIRECT(B12))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$27"},null,null,"Pregenerated Unique ID",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$28"},null,null,"User Provided Unique ID from Category A Core Activities",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$30"},null,null,"Core Activity Grouping",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$31"},null,null,"Core Activity Title",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!B37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$B$37"},null,null,"Describe how the intervention under examination is directly related to the Core Activity selected.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!B40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$B$40"},null,null,"Does the intervention under examination include all of the selected Core Activity's Secondary Drivers and Change Ideas?","Please make a selection"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$43"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$43"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C44)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$44"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D44)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$44"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$45"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$45"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C46)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$46"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D46)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$46"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$47"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$47"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$48"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$48"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C50)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$50"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",{"$f":"IF(INDIRECT(B31)=\"\",\"\",INDIRECT(B31))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D50)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$50"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C51)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$51"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D51)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$51"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C52)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$52"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D52)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$52"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C53)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$53"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D53)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$53"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C54)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$54"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D54)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$54"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C55)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$55"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D55)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$55"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$57"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",{"$f":"IF(INDIRECT(B43)=\"\",\"\",INDIRECT(B43))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$57"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C58)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$58"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D58)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$58"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C59)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$59"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D59)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$59"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$60"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$60"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C61)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$61"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D61)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$61"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C62)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$62"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D62)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$62"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C64)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$64"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D64)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$64"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C65)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$65"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D65)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$65"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$66"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$66"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C67)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$67"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D67)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$67"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C68)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$68"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D68)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$68"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$69"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$69"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C71)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$71"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D71)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$71"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$72"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$72"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C73)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$73"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D73)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$73"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C74)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$74"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D74)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$74"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$75"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$75"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C76)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$76"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D76)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$76"},null,null,"Indicate which of the selected Core Activity's Secondary Drivers and Change Ideas are included in the intervention under examination.",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!B79)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$B$79"},null,null,"Does the user have any updates or additions to make to the above Secondary Drivers and Change Ideas list?","Please make a selection"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C82)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$82"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D82)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$82"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C83)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$83"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D83)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$83"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$84"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$84"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C85)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$85"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D85)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$85"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C86)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$86"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D86)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$86"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$87"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$87"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C89)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$89"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D89)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$89"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C90)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$90"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D90)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$90"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$91"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$91"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$92"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$92"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$93"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$93"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C94)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$94"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D94)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$94"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$96"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B104)=\"\",\"\",INDIRECT(B104))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$96"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$97"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$97"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$98"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$98"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C99)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$99"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D99)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$99"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C100)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$100"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D100)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$100"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C101)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$101"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D101)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$101"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C103)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$103"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D103)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$103"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C104)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$104"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D104)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$104"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C105)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$105"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D105)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$105"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C106)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$106"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D106)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$106"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C107)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$107"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D107)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$107"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C108)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$108"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B126)=\"\",\"\",INDIRECT(B126))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D108)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$108"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B127)=\"\",\"\",INDIRECT(B127))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C110)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$110"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B128)=\"\",\"\",INDIRECT(B128))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D110)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$110"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B129)=\"\",\"\",INDIRECT(B129))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C111)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$111"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B130)=\"\",\"\",INDIRECT(B130))","v":"NA"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D111)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$111"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B131)=\"\",\"\",INDIRECT(B131))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C112)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$112"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D112)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$112"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B133)=\"\",\"\",INDIRECT(B133))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C113)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$113"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D113)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$113"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B135)=\"\",\"\",INDIRECT(B135))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C114)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$114"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D114)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$114"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B137)=\"\",\"\",INDIRECT(B137))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C115)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$115"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas","NA"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D115)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$115"},null,null,"If the user has any updates to Drivers or Change Ideas, manually overwrite formulas below or add new Ideas",{"$f":"IF(INDIRECT(B139)=\"\",\"\",INDIRECT(B139))","v":""}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!B118)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$B$118"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?",{"$f":"IF(INDIRECT(B140)=\"\",\"\",INDIRECT(B140))","v":"Please make a selection"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C121)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$121"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?",{"$f":"IF(INDIRECT(B141)=\"\",\"\",INDIRECT(B141))","v":"Please Select a Category C Measure"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C122)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$122"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?",{"$f":"IF(INDIRECT(B142)=\"\",\"\",INDIRECT(B142))","v":"Please Select a Category C Measure"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C123)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$123"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C124)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$124"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C125)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$125"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C126)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$126"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C127)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$127"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C128)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$128"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C129)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$129"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C130)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$130"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C131)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$131"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C132)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$132"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C133)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$133"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C134)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$134"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C135)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$135"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C136)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$136"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C137)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$137"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C138)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$138"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C139)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$139"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C140)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$140"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C141)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$141"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C142)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$142"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C143)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$143"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C144)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$144"},null,null,"Is the intervention under examination connected to any other Core Activity's Cat C measures?","Please Select a Category C Measure"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E7)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$7"},null,"Intervention Details","Section 4: Intervention Details",{"$f":"IF(INDIRECT(B165)=\"\",\"\",INDIRECT(B165))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C150)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$150"},null,null,"Select the Patient Population Focus Area",{"$f":"IF(INDIRECT(B166)=\"\",\"\",INDIRECT(B166))","v":"Please make a selection"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D153)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$153"},null,null,"Provide a description of the \"Other\" Patient Population Focus Area",{"$f":"IF(INDIRECT(B167)=\"\",\"\",INDIRECT(B167))","v":"Type in answer here"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D156)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$156"},null,null,"Describe the Patient Population being targeted with the intervention.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C159)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$159"},null,null,"Medicaid","Y / N"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C160)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$160"},null,null,"LIU","Y / N"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C161)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$161"},null,null,"Medicare","Y / N"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C162)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$162"},null,null,"Commercial ","Y / N"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C163)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$163"},null,null,"Other","Y / N"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C166)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$166"},null,null,"Provide a general description of the intervention.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C169)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$169"},null,null,"Is the intervention described above a different intervention than was analyzed for the Costs and Savings Analysis that was due during DY8 Round 2 reporting?","Please make a selection"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C172)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$172"},null,null,"Provide a general description of the intervention used for the Costs and Savings Analysis that was due during DY8 Round 2 reporting.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C175)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$175"},null,null,"Is the intervention described above a subset of the prior Costs and Savngs Analysis that was due during DY8 Round 2 reporting?","Please make a selection"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C178)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$178"},null,null,"Describe the scope of the intervention analyzed for the Costs and Savngs Analysis that was due during DY8 Round 2 reporting?","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C181)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$181"},null,null,"Describe the scope of the intervention analyzed for the Costs and Savngs Analysis that is due during DY10 Round 2 reporting?","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!C184)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$C$184"},null,null,"Provide justification explaining the merit of analyzing a subset of the prior Costs and Savings Analysis that was due during DY8 Round 2 reporting.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D187)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$187"},null,null,"Explain why the provider selected this intervention for the Costs and Savings Analysis.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E8)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$8"},null,"Analysis Period","Section 5: Analysis Period","Incomplete"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E190)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$190"},null,null,"Provider Override Code ",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D195)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$195"},null,null,"Day Intervention was initiated","Example: 5/31/2017"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D200)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$200"},null,null,"Startup Period Start Date",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D203)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$203"},null,null,"Startup Period End Date",""]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D206)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$206"},null,null,"Please explain why the Startup Period is less than a month. ","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D209)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$209"},null,null,"Would provider like to analyze additional years over the minimum required length of the Operating Period?","Please make a selection"]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D212)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$212"},null,null,"How many additional years would provider like to analyze?",{"$f":"IF(INDIRECT(B189)=\"\",\"\",INDIRECT(B189))","v":0}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!D216)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$D$216"},null,null,"Startup Period",{"$f":"IF(INDIRECT(B190)=\"\",\"\",INDIRECT(B190))","v":"01/00/1900 - 01/00/1900"}]
[null,{"$f":"CELL(\"address\",'Intervention Details'!E216)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Intervention Details'!$E$216"},null,null,"Operating Period",{"$f":"IF(INDIRECT(B191)=\"\",\"\",INDIRECT(B191))","v":"01/01/1900 - 01/01/1903"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!J4)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$J$4"},"Program Costs","Operating Program Costs","Task 1: Enter Operating Program Costs",{"$f":"IF(INDIRECT(B192)=\"\",\"\",INDIRECT(B192))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!D13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$13"},null,null,{"$f":"_xlfn.CONCAT(I193,\" \",J193,\" \",K193,\", \",\"Line \",G193)","v":"Personnel Cost Category, Line 1"},{"$f":"IF(INDIRECT(B193)=\"\",\"\",INDIRECT(B193))","v":""},1,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$14"},null,null,{"$f":"_xlfn.CONCAT(I194,\" \",J194,\" \",K194,\", \",\"Line \",G194)","v":"Personnel Cost Category, Line 2"},{"$f":"IF(INDIRECT(B194)=\"\",\"\",INDIRECT(B194))","v":""},2,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$15"},null,null,"Personnel Cost Category, Line 3","",3,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$16"},null,null,"Personnel Cost Category, Line 4","",4,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$17"},null,null,"Personnel Cost Category, Line 5","",5,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$18"},null,null,"Personnel Cost Category, Line 6","",6,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$19"},null,null,"Personnel Cost Category, Line 7","",7,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$20"},null,null,"Personnel Cost Category, Line 8","",8,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$21"},null,null,"Personnel Cost Category, Line 9","",9,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$22"},null,null,"Personnel Cost Category, Line 10","",10,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D23)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$23"},null,null,"Personnel Cost Category, Line 11","",11,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$24"},null,null,"Personnel Cost Category, Line 12","",12,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$25"},null,null,"Personnel Cost Category, Line 13","",13,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$26"},null,null,"Personnel Cost Category, Line 14","",14,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$27"},null,null,"Personnel Cost Category, Line 15","",15,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$28"},null,null,"Personnel Cost Category, Line 16","",16,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$29"},null,null,"Personnel Cost Category, Line 17","",17,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$30"},null,null,"Personnel Cost Category, Line 18","",18,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$31"},null,null,"Personnel Cost Category, Line 19","",19,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$32"},null,null,"Personnel Cost Category, Line 20","",20,"D","Personnel","Cost","Category"]
[null,{"$f":"CELL(\"address\",'Program Costs'!D33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$D$33"},null,null,"Personnel Cost Category, Line 21","",21,"D","Personnel","Cost","Category"]
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[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 3",{"$error":"#REF!"},3]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 3",{"$error":"#REF!"},3]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$f":"IF(INDIRECT(B7545)=\"\",\"\",INDIRECT(B7545))","v":{"$error":"#REF!"}},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,{"$f":"_xlfn.CONCAT(\"Indirect Cost, Line \",G7550)","v":"Indirect Cost, Line 4"},{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 4",{"$error":"#REF!"},4]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Indirect Cost, Line 5",{"$error":"#REF!"},5]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Startup Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 1 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 2 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 3 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 4 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 5 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 6 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 7 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 8 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 9 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!#REF!)","v":{"$error":"#REF!"}},null,null,"Operating Year 10 Subtotal Indirect Costs",{"$error":"#REF!"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!H243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$H$243"},null,null,"Startup Total Costs",{"$f":"IF(INDIRECT(B7602)=\"\",\"\",INDIRECT(B7602))","v":0}]
[null,{"$f":"CELL(\"address\",'Program Costs'!L243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$L$243"},null,null,"Operating Year 1 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!P243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$P$243"},null,null,"Operating Year 2 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!T243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$T$243"},null,null,"Operating Year 3 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!X243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$X$243"},null,null,"Operating Year 4 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AB243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AB$243"},null,null,"Operating Year 5 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AF243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AF$243"},null,null,"Operating Year 6 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AJ243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AJ$243"},null,null,"Operating Year 7 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AN243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AN$243"},null,null,"Operating Year 8 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AR243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AR$243"},null,null,"Operating Year 9 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!AV243)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$AV$243"},null,null,"Operating Year 10 Total Costs",0]
[null,{"$f":"CELL(\"address\",'Program Costs'!J5)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$J$5"},null,"Questions","Task 2: Complete Questions",{"$f":"IF(INDIRECT(B7613)=\"\",\"\",INDIRECT(B7613))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Program Costs'!F251)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$F$251"},null,null,"Describe any methodologies used and assumptions made to allocate program costs for the Startup Period and the Operating Period.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Program Costs'!F254)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$F$254"},null,null,"Describe data sources used for program costs for the Startup Period and the Operating Period.","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Program Costs'!F259)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Program Costs'!$F$259"},null,null,"Describe all activities performed to develop and operate the intervention under examination during the Startup Period and the Operating Period (i.e., activities that make up the intervention such as process changes, E.H.R. changes, hiring additional clinicians to offer more appointments, additional beds, development of classes, development of literature, outreach, etc.).\n\n","Type in answer here"]
[null,{"$f":"CELL(\"address\",'Category of Service'!D4)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$4"},"Category of Service","Cat B Information","Task 1: Review Category B information.","Incomplete"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D7)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$7"},null,null,"Enter outcomes directly (yes) or calculate outcomes based on changes in cost (no)?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D8)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$8"},null,null,"Would you like to enter figures in per eligible receiving person (yes) or in aggregate (no)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B12)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$12"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C12)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$12"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D12)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$12"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E12)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$12"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$13"},null,null,"Category B Business Component",{"$f":"IF(INDIRECT(B7624)=\"\",\"\",INDIRECT(B7624))","v":""}]
[null,{"$f":"CELL(\"address\",'Category of Service'!C13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$13"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$13"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$13"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$14"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$14"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$14"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$14"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$15"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$15"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$15"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$15"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$16"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$16"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$16"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$16"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$17"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$17"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$17"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$17"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$18"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$18"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$18"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$18"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$19"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$19"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$19"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$19"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$20"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$20"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$20"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$20"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$21"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$21"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$21"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$21"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!B22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$B$22"},null,null,"Category B Business Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$22"},null,null,"Required/Optional",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$22"},null,null,"Included in System Definition (Y/N)?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$22"},null,null,"DY9-10 Description of System Component",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$24"},null,null,"I have reviewed the Category B information reported previously.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D5)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$5"},null,null,"Task 2: Complete Category of Service Questions.",{"$f":"IF(INDIRECT(B7665)=\"\",\"\",INDIRECT(B7665))","v":"Incomplete"}]
[null,{"$f":"CELL(\"address\",'Category of Service'!C27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$27"},null,"Inpatient Care","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$27"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$27"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$27"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$57"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$28"},null,"Long Term Care, Facility-Based","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$28"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$28"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$28"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$60"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$29"},null,"Outpatient Care","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$29"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$29"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$29"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$63"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$30"},null,"Office-Based Care","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$30"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$30"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$30"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$66"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$31"},null,"Emergency Department Care","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$31"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$31"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",{"$f":"IF(INDIRECT(B7688)=\"\",\"\",INDIRECT(B7688))","v":""}]
[null,{"$f":"CELL(\"address\",'Category of Service'!F31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$31"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$69"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$32"},null,"Emergency Transportation","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$32"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$32"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$32"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$72"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$33"},null,"Home Health Care","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$33"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$33"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$33"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$75"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$34"},null,"Pharmacy","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$34"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$34"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$34"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$78"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C35)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$35"},null,"Other 1","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D35)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$35"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E35)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$35"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F35)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$35"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$81"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$36"},null,"Other 2","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$36"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$36"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$36"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$84"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!C37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$C$37"},null,"Other 3","Does your Organization Provide This Service?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!D37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$D$37"},null,null,"Will this Category of Service be used in the Costs and Savings Analysis?",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!E37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$E$37"},null,null,"Explanation for not including Category of Service in the Costs and Savings Analysis.",""]
[null,{"$f":"CELL(\"address\",'Category of Service'!F37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Category of Service'!$F$37"},null,null,"What % of Target Population's Savings Will Your Organization Realize?",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$87"},null,null,"Normal Unit Cost Trend (Estimate Only)",""]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E4)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$4"},"Financial Outcomes",null,"Task 1: Complete Financial Outcomes Information","Incomplete"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$13"},"Financial Outcomes, Estimated Savings","Operating Year 1","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$14"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$15"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$17"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$18"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F20)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$20"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$21"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F23)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$23"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$24"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$26"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F27)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$27"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F29)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$29"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$30"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$32"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F33)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$33"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F35)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$35"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$36"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F38)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$38"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$39"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$41"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F42)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$42"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$43"},null,null,"Other",{"$f":"IF(INDIRECT(B7752)=\"\",\"\",INDIRECT(B7752))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F44)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$44"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$45"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$13"},null,"Operating Year 2","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$13"},null,"Operating Year 3","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$13"},null,"Operating Year 4","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$13"},null,"Operating Year 5","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$13"},null,"Operating Year 6","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$13"},null,"Operating Year 7","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$31"},null,null,"Home Health Care",{"$f":"IF(INDIRECT(B7816)=\"\",\"\",INDIRECT(B7816))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$13"},null,"Operating Year 8","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$13"},null,"Operating Year 9","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$13"},null,"Operating Year 10","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$16"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$19"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$22"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$25"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$28"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O31)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$31"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$34"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O37)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$37"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O40)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$40"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$43"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$47"},null,"Operating Year 1","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$47"},null,"Operating Year 2","Total Number of Individuals Receiving Intervention Annually",{"$f":"IF(INDIRECT(B7857)=\"\",\"\",INDIRECT(B7857))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$47"},null,"Operating Year 3","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$47"},null,"Operating Year 4","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$47"},null,"Operating Year 5","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$47"},null,"Operating Year 6","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$47"},null,"Operating Year 7","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$47"},null,"Operating Year 8","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$47"},null,"Operating Year 9","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$47"},null,"Operating Year 10","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O48)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$48"},null,null,"Total Annual Savings for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$49"},null,null,"Total Annual Savings Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$57"},"Financial Outcomes, Calculated Savings based on Costs","Startup","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D58)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$58"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D59)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$59"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D61)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$61"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D62)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$62"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D64)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$64"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D65)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$65"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D67)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$67"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D68)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$68"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D70)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$70"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D71)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$71"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D73)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$73"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D74)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$74"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D76)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$76"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D77)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$77"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D79)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$79"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D80)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$80"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D82)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$82"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D83)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$83"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D85)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$85"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D86)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$86"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!E87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$E$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D88)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$88"},null,null,"Describe the methodologies used and assumptions made to determine data input for this Category of Service","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!D89)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$D$89"},null,null,"Descibe the data sources used for this Category of Service.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$57"},null,"Operating Year 1","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$57"},null,"Operating Year 2","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$69"},null,null,"Emergency Department Care",{"$f":"IF(INDIRECT(B7932)=\"\",\"\",INDIRECT(B7932))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$57"},null,"Operating Year 3","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$57"},null,"Operating Year 4","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$57"},null,"Operating Year 5","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$57"},null,"Operating Year 6","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$57"},null,"Operating Year 7","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$57"},null,"Operating Year 8","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$63"},null,null,"Outpatient Care",{"$f":"IF(INDIRECT(B7996)=\"\",\"\",INDIRECT(B7996))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$57"},null,"Operating Year 9","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$57"},null,"Operating Year 10","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$57"},"Untrended Annual Cost","Operating Year 1","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Q87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Q$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$57"},null,"Operating Year 2","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!R87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$R$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$57"},null,"Operating Year 3","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!S87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$S$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$57"},null,"Operating Year 4","Inpatient Care",{"$f":"IF(INDIRECT(B8060)=\"\",\"\",INDIRECT(B8060))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!T87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$T$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$57"},null,"Operating Year 5","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!U87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$U$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$57"},null,"Operating Year 6","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!V87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$V$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$57"},null,"Operating Year 7","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!W87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$W$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$57"},null,"Operating Year 8","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!X87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$X$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$57"},null,"Operating Year 9","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$84"},null,null,"Other",{"$f":"IF(INDIRECT(B8124)=\"\",\"\",INDIRECT(B8124))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Y87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Y$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$57"},null,"Operating Year 10","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!Z87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$Z$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$57"},"Estimated Savings from Costs","Operating Year 1","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AB87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AB$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$57"},null,"Operating Year 2","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AC87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AC$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$57"},null,"Operating Year 3","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AD87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AD$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$57"},null,"Operating Year 4","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AE87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AE$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$57"},null,"Operating Year 5","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$78"},null,null,"Pharmacy",{"$f":"IF(INDIRECT(B8188)=\"\",\"\",INDIRECT(B8188))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AF87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AF$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$57"},null,"Operating Year 6","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AG87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AG$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$57"},null,"Operating Year 7","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AH87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AH$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$57"},null,"Operating Year 8","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AI87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AI$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$57"},null,"Operating Year 9","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AJ87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AJ$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$57"},null,"Operating Year 10","Inpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK60)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$60"},null,null,"Long Term Care, Facility-Based",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$63"},null,null,"Outpatient Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK66)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$66"},null,null,"Office-Based Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK69)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$69"},null,null,"Emergency Department Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK72)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$72"},null,null,"Emergency Transportation",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK75)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$75"},null,null,"Home Health Care",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK78)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$78"},null,null,"Pharmacy",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK81)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$81"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK84)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$84"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!AK87)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$AK$87"},null,null,"Other",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$91"},null,"Operating Year 1","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$91"},null,"Operating Year 2","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",{"$f":"IF(INDIRECT(B8252)=\"\",\"\",INDIRECT(B8252))","v":0}]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$91"},null,"Operating Year 3","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$91"},null,"Operating Year 4","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$91"},null,"Operating Year 5","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$91"},null,"Operating Year 6","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$91"},null,"Operating Year 7","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$91"},null,"Operating Year 8","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$91"},null,"Operating Year 9","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O91)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$91"},null,"Operating Year 10","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$92"},null,null,"Total Annual Cost of Care for Target Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O93)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$93"},null,null,"Total Annual Cost of Care Accounted for at your Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$96"},"Outcomes Roundup","Operating Year 1","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!F98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$F$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$96"},null,"Operating Year 2","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!G98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$G$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$96"},null,"Operating Year 3","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!H98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$H$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$96"},null,"Operating Year 4","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!I98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$I$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$96"},null,"Operating Year 5","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!J98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$J$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$96"},null,"Operating Year 6","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!K98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$K$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$96"},null,"Operating Year 7","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!L98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$L$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$96"},null,"Operating Year 8","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!M98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$M$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$96"},null,"Operating Year 9","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!N98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$N$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O96)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$96"},null,"Operating Year 10","Total Number of Individuals Receiving Intervention Annually",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O97)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$97"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'Financial Outcomes'!O98)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Financial Outcomes'!$O$98"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I4)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$4"},"ROI Calculation",null,"Task 1: Review ROI Calculations.","Incomplete"]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D7)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$7"},null,null,"Discount Rate",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$15"},null,"Startup","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$28"},null,null,"Total Annual Savings for Target Population (Increases)",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$32"},null,null,"x Present Value Factor",{"$f":"IF(INDIRECT(B8317)=\"\",\"\",INDIRECT(B8317))","v":1}]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$34"},null,null,"Total Discounted Annual Savings (Increases)",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$36"},null,null,"Total Annual Savings Recognized by your Organization",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$41"},null,null,"Cumulative ROI",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$45"},null,null,"Cumulative ROI, Net Present Value",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!D47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$D$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",""]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$15"},null,"Operating Year 1","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!E47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$E$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$15"},null,"Operating Year 2","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!F47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$F$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$15"},null,"Operating Year 3","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!G47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$G$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$15"},null,"Operating Year 4","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$32"},null,null,"x Present Value Factor",{"$f":"IF(INDIRECT(B8381)=\"\",\"\",INDIRECT(B8381))","v":1}]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!H47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$H$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$15"},null,"Operating Year 5","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!I47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$I$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$15"},null,"Operating Year 6","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!J47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$J$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$15"},null,"Operating Year 7","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!K47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$K$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$15"},null,"Operating Year 8","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$32"},null,null,"x Present Value Factor",{"$f":"IF(INDIRECT(B8445)=\"\",\"\",INDIRECT(B8445))","v":1}]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!L47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$L$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$15"},null,"Operating Year 9","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!M47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$M$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N15)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$15"},null,"Operating Year 10","Operating Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N17)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$17"},null,null,"Total Annual Investment Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$19"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$21"},null,null,"Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$24"},null,null,"Total Annual Financial Outcomes for the Patient Population",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N26)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$26"},null,null,"Total Annual Financial Outcomes Accounted for at Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N28)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$28"},null,null,"Total Annual Savings for Target Population (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N30)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$30"},null,null,"Total Annual Savings Recognized by your Organization (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N32)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$32"},null,null,"x Present Value Factor",1]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!N47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$N$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O21)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$21"},null,"Total","Total Discounted Annual Costs",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O34)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$34"},null,null,"Total Discounted Annual Savings (Increases)",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$36"},null,null,"Total Annual Savings Recognized by your Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$39"},null,null,"Undiscounted Annual Net Cast Flow",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O41)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$41"},null,null,"Cumulative ROI",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O43)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$43"},null,null,"Cumulative ROI Recognized by Provider's Organization",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O45)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$45"},null,null,"Cumulative ROI, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'ROI Calculation'!O47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]ROI Calculation'!$O$47"},null,null,"Cumulative ROI Recognized by Provider's Organization, Net Present Value",0]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!E4)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$E$4"},"Questions",null,"Section 1: General Questions","Incomplete"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!E5)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$E$5"},null,null,"Section 2:  COVID-Related Questions","Incomplete"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$13"},null,"General","Will the provider continue to operate the intervention post DSRIP?","Y / N"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D16)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$16"},null,null,"Please explain why provider is not operating the intervention post DSRIP?","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B19)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$19"},null,null,"How does the intervention under examination affect the provider’s revenue?","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B22)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$22"},null,null,"Please summarize the results of the Costs and Savings Analysis.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$25"},null,null,"On a scale of 1-10, with 10 being very confident, how confident is the provider in the accuracy of their analysis considering the data sources used, the assumptions made, and the methodologies used to complete the analysis.","Please Select from List"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B18)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$18"},null,null,"What are the constraints in affecting 100% of the target population with the intervention. (Check all that apply)","How does the intervention under examination affect the provider’s revenue?"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!C36)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$C$36"},null,null,"Please explain what 'Other' contraints affected intervention.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!C39)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$C$39"},null,null,"Please explain why the provider believes all patients that could receive intervention were included.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B42)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$42"},null,null,"Please describe how the intervention being examined impacts Medicaid.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D47)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$47"},null,null,"How many stakeholders?","# of stakeholders (Min of 2)"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D49)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$49"},null,null,"Stakeholder One:","Please Select from List"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D51)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$51"},null,null,"Impact to Stakeholder:","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D53)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$53"},null,null,"Stakeholder Two:","Please Select from List"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D55)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$55"},null,null,"Impact to Stakeholder:","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D57)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$57"},null,null,"Stakeholder Three:",{"$f":"IF(INDIRECT(B8509)=\"\",\"\",INDIRECT(B8509))","v":"Please Select from List"}]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D59)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$59"},null,null,"Impact to Stakeholder:","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D61)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$61"},null,null,"Stakeholder Four:","Please Select from List"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D63)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$63"},null,null,"Impact to Stakeholder:","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D65)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$65"},null,null,"Stakeholder Five:","Please Select from List"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D67)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$67"},null,null,"Impact to Stakeholder:","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B71)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$71"},null,null,"Describe the known or anticipated outcomes and/or benefits of the intervention on the Patient Population.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B74)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$74"},null,null,"Describe the financial outcomes to the system of care expected or realized as a result of the intervention as reflected in the data input into this template.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!B77)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$B$77"},null,null,"Describe any benefits to the provider’s organization due to the intervention that may not be captured elsewhere in this template (e.g., increased recognition for quality; enhanced market share; employee satisfaction/retention; enhanced accreditation; fulfillment of mandated requirements, such as requirements to participate in Medicaid; etc.). ","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D83)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$83"},null,"COVID-Related","Describe how COVID-19 has impacted the intervention under examination.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D86)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$86"},null,null,"Did provider have to modify the intervention under examination as a result of COVID-19?","Y / N"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D89)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$89"},null,null,"Please describe the modifications made to the intervention as a result of COVID-19.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D92)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$92"},null,null,"Did the modifications made to the intervention as a result of COVID-19 affect the outcomes of the intervention?","Y / N"]
[null,{"$f":"CELL(\"address\",'Qualitative Questions'!D95)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Qualitative Questions'!$D$95"},null,null,"Please describe how the modifications made to the intervention as a result of COVID-19 affected the outcomes of the intervention.","Type in Answer Here"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E8)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$8"},"Certification",null,"Section 1: Intervention Details","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E9)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$9"},null,null,"Section 2: Program Costs","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E10)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$10"},null,null,"Section 3: Category of Service","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E11)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$11"},null,null,"Section 4: Financial Outcomes","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E12)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$12"},null,null,"Section 5: ROI Calculations","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E13)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$13"},null,null,"Section 6: Questions","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!E14)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$E$14"},null,null,"Section &: Certification","Incomplete"]
[null,{"$f":"CELL(\"address\",'Certification Page'!B23)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$B$23"},null,null,"Name:",""]
[null,{"$f":"CELL(\"address\",'Certification Page'!B24)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$B$24"},null,null,"Title:",""]
[null,{"$f":"CELL(\"address\",'Certification Page'!B25)","v":"'[Category A Costs and Savings Template_DRAFT_06_16_2021 (3).xlsm]Certification Page'!$B$25"},null,null,"Date:",""]

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["DYs","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","RHP_TPI","Project ID","RHP","TPI","Performing Provider Name","Performing Provider Type","Ownership","Core Activity ID","Core Activity Grouping","Other Grouping","Continue, Edit, Delete, New Core Activity","Explanation of edits or why discontinuing ","Core Activity Name Short","Other Name","Description of Core Activity","Secondary Driver 1","Secondary Driver 1: Change Idea 1","Secondary Driver 1: Change Idea 2","Secondary Driver 1: Change Idea 3","Secondary Driver 1: Change Idea 4","Secondary Driver 1: Change Idea 5","Secondary Driver 2","Secondary Driver 2: Change Idea 1","Secondary Driver 2: Change Idea 2","Secondary Driver 2: Change Idea 3","Secondary Driver 2: Change Idea 4","Secondary Driver 2: Change Idea 5","Secondary Driver 3","Secondary Driver 3: Change Idea 1","Secondary Driver 3: Change Idea 2","Secondary Driver 3: Change Idea 3","Secondary Driver 3: Change Idea 4","Secondary Driver 3: Change Idea 5","Secondary Driver 4","Secondary Driver 4: Change Idea 1","Secondary Driver 4: Change Idea 2","Secondary Driver 4: Change Idea 3","Secondary Driver 4: Change Idea 4","Secondary Driver 4: Change Idea 5","Secondary Driver 5","Secondary Driver 5: Change Idea 1","Secondary Driver 5: Change Idea 2","Secondary Driver 5: Change Idea 3","Secondary Driver 5: Change Idea 4","Secondary Driver 5: Change Idea 5","Measure Bundles or Meaures Impacted 1","Measure Bundles or Measures Impacted 2","Measure Bundles or Measures Impacted 3","Measure Bundles or Measures Impacted 4","Measure Bundles or Measures Impacted 5","Measure Bundles or Measures Impacted 6","Measure Bundles or Measures Impacted 7","Measure Bundles or Measures Impacted 8","Measure Bundles or Measures Impacted 9","Measure Bundles or Measures Impacted 10","Measure Bundles or Measures Impacted 11","Measure Bundles or Measures Impacted 12","Measure Bundles or Measures Impacted 13","Measure Bundles or Measures Impacted 14","Measure Bundles or Measures Impacted 15","Measure Bundles or Measures Impacted 16","Measure Bundles or Measures Impacted 17","Measure Bundles or Measures Impacted 18","Measure Bundles or Measures Impacted 19","Measure Bundles or Measures Impacted 20","Measure Bundles or Measures Impacted 21","Measure Bundles or Measures Impacted 22","Measure Bundles or Measures Impacted 23","Measure Bundles or Measures Impacted 24","Measure Bundles or Measures Impacted 25","Measure Bundles or Measures Impacted 26","Measure Bundles or Measures Impacted 27","Measure Bundles or Measures Impacted 28","Measure Bundles or Measures Impacted 29","Measure Bundles or Measures Impacted 30","Measure Bundles or Measures Impacted 31","Measure Bundles or Measures Impacted 32","Measure Bundles or Measures Impacted 33","Measure Bundles or Measures Impacted 34","Measure Bundles or Measures Impacted 35","Measure Bundles or Measures Impacted 36","Measure Bundles or Measures Impacted 37","Measure Bundles or Measures Impacted 38","Measure Bundles or Measures Impacted 39","Measure Bundles or Measures Impacted 40","Measure Bundles or Measures Impacted 41","Measure Bundles or Measures Impacted 42","Measure Bundles or Measures Impacted 43","Measure Bundles or Measures Impacted 44","Measure Bundles or Measures Impacted 45","Measure Bundles or Measures Impacted 46","Measure Bundles or Measures Impacted 47","Measure Bundles or Measures Impacted 48","Measure Bundles or Measures Impacted 49","Measure Bundles or Measures Impacted 50","Measure Bundles or Measures Impacted 51","Measure Bundles or Measures Impacted 52","Measure Bundles or Measures Impacted 53","Measure Bundles or Measures Impacted 54","Measure Bundles or Measures Impacted 55","Measure Bundles or Measures Impacted 56","Measure Bundles or Measures Impacted 57","Measure Bundles or Measures Impacted 58","Measure Bundles or Measures Impacted 59","Measure Bundles or Measures Impacted 60","Measure Bundles or Measures Impacted 61","Measure Bundles or Measures Impacted 62","Measure Bundles or Measures Impacted 63","Measure Bundles or Measures Impacted 64","Measure Bundles or Measures Impacted 65","Measure Bundles or Measures Impacted 66","Measure Bundles or Measures Impacted 67","Measure Bundles or Measures Impacted 68","Measure Bundles or Measures Impacted 69","Measure Bundles or Measures Impacted 70","Measure Bundles or Measures Impacted 71","Measure Bundles or Measures Impacted 72","Measure Bundles or Measures Impacted 73","Measure Bundles or Measures Impacted 74","Measure Bundles or Measures Impacted 75","Measure Bundles or Measures Impacted 76","Measure Bundles or Measures Impacted 77","Measure Bundles or Measures Impacted 78","Measure Bundles or Measures Impacted 79","Measure Bundles or Measures Impacted 80","Measure Bundles or Meaures Impacted","Description of Measure Bundle/Measure Impact","Core Activity Provided by a Provider Not Included in the System Definition","Explanation of Provider Not in System Definition","Project ID2","1st Reviewer","1st Reviewer Internal Comments","2nd Review Requested?","2nd Reviewer","2nd Reviewer Internal Comments","HHSC Initial Decision","HHSC Initial Comments to Provider","Provider Response","1st Reviewer3","1st Reviewer Internal Comments4","2nd Review Requested?5","2nd Reviewer6","2nd Reviewer Internal Comments7","HHSC Final Decision","HHSC Final Comments to Provider","Core Activity Name Orig","Core Activity System Group ID","Core Activity System Name ID"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_388701003","017624011.7.1",1,"388701003","Quitman Hospital LLC","Hospital","Private",1,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","017624011.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_388347201","020812601.7.1",1,"388347201","Tyler Regional Hospital LLC","Hospital","Private",2,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","020812601.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_094108002","094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private",4,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","CHRISTUS Trinity Clinic is the primary care provider for the clinics that will be a part of all four bundles.  The providers are required to continue to expand access, effectively manage 3rd next available, monitor phone access by clinical staff, and the patient experience related to timeliness of return phone calls.  In addition, clinic office hours are evaluated, with after-hours availability enhanced.  Referral patterns are closely monitored, to ensure access from patients discharged from the hospital or referred from primary care to specialty.  Our goal will be to maintain a high level of primary care provider access in our locations.  Access to EPIC will be required for all sites of services in order to track patients in a real time process and to be able to facilitate timely appointments for needed services.","Improve utilization of clinical decision support tools by clinicians across the system.","Implementat EPIC across the required system:  All clinics and hospitals reporting must move to EPIC in order to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings","Develop expanded protocols for clinical staff and care management teams to impact patient care."," "," "," ","Improve screening rates to improve potential of outcomes for all payers including MLIU.","Developing dash board to monitor compliance of health maintenance, screenings, immunizations, and bundle performance."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2; A1; C1","All the measure bundles tie back to primary care access. The A1, C1, and C2 are outpatient target populations with both clinical and process measures.  And while B2 is looking at patients who enter our system through the Emergency Department, they all target reductions in visits which requires a place to refer those patient to for service:  a primary care provider.  Thus, continuing to build upon our primary care access measures which now include many of the other measures from DY2 - 6; and having Primary Care as our core activity, we are able to target our populations for improved outcomes.","No","","094108002.7.1","SDH","Approved discontinuation of C2, so removal here is good","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_094108002","094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private",679,"Expansion of Patient Care Navigation and Transition Services","","New","","Implementation of a care transition and/or a discharge planning program","","CHRISTUS Trinity Mother Frances aims to limit return to acute visits and ultimately reduce avoidable readmission rates.  Managing patient care as they transition from inpatient or observation status to the next level of care has proven to result in great outcomes for the patient and avoid unnecessary cost.  Nurse Navigation plays an integral part in the success of the Care Transitions program.  This clinical team member completes an interactive contact with the patient or caregiver within the initial 48 hours of discharge.  Discharge instructions are reviewed, medication reconciliation is completed, continuity of care is delivered with interaction between the patient and their primary care provider, DME, or home health agency.  Education and community resources are arranged and provided as needed.  A face-to-face appointment with the primary care provider is made within 14 days of discharge.  ","Chronic Conditions Management – Heart Failure\nObjective:  Closely monitor those with heart failure diagnosis to decrease disease progression while improving the patient’s quality of life, thus preventing avoidable hospital admissions and lower cost.  \n","Nurse Navigator completes an interactive contact with the patient or caregiver based on a schedule found to represent the highest return to acute: days 4-8, 10-14, and 19-23.  The Navigator follows an established protocol to specifically evaluate patient’s weight, vital signs, breathing capabilities, sleep posture, swelling in extremities, oxygen intake, diet and fluid restrictions, evaluates any chest discomfort, and provides ongoing education as provided and approved by the cardiology team.  Continuity of care is delivered with interaction between the patient and their cardiologist or primary care provider and home health provider if applicable.  The Navigator promotes patient compliance and independence with their own healthcare and becomes a resource for preventing avoidable hospital admissions and reducing cost.  ","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; B2; C1","Patients would need the services of the primary care patient navigators to impact their care decisions and participiation. Included in these services would certainly be an effort to ensure patients are receiving the services as an outpatient under C1 and A1, especially for those diabetic patients who also have  heart disease.  And clearly, if our program goals are successful, utilization of the ED would be reduced.","No","","094108002.7.1","SDH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_387663301","094127002.7.1",1,"387663301","Carthage Hospital LLC","Hospital","Private",5,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","094127002.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_111411803","111411803.7.1",1,"111411803","Anderson Cherokee Community MHMR Center (ACCESS)","Community Mental Health Center (CMHC)","Non‐State Owned Public",7,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Prevalence of the two (2) measures selected to address the Core Activity have been found to be higher in RHP1 than in other parts of the State and initiation of efforts to reduce these chronic conditions to improve the overall health of the region has been identified as a primary imperative and aligns with assessed needs of the region. M1-146, i.e. Screening for Clinical Depression and Follow-Up Plan, was selected to standardize assessment screening procedures to improve the rate of early diagnosis of depression and concomitant rapid initiation of appropriate treatment modalities for positive screenings, as well as screening out individuals not meeting depression criteria to provide additional treatment capacity to the system of care.  The PHQ-9 was selected for use as the standardized screening instrument and will  be administered by licensed clinical staff. Individuals with a positive screening will receive  follow-up. Screening results and follow-up will be entered into the electronic health record to track adherence to required protocols, with regular reports to staff on implementation compliance or lack of compliance and recommendations for performance improvement. The primary system components utilized for implementation of this measure will be through the outpatient clinics in each County, one located in Jacksonville and the other in Palestine. M1-147, i.e. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up, was selected as studies have consistently shown a high correlation between obesity and development of chronic and debilitating health disorders such as diabetes, hypertension and asthma and increases in heart attacks, strokes, and kidney disease. The BMI will be measured at each clinic visit for all individuals 18 and older on date of encounter. Individuals identified to have a BMI outside of normal parameters will receive follow-up, including education. Screening results and follow-up will be entered into the electronic health record to track adherence to required protocols, with regular reports to staff on implementation compliance or lack of compliance and recommendations for performance improvement. The primary system components utilized for implementation of this measure will be through the outpatient clinics in each County, one located in Jacksonville and the other in Palestine.","Standardize screening and follow-up for clinical depression using the PHQ-9.","The evidence-based PHQ-9 was selected for use as the standardized screening instrument and a template will be developed for input of assessment results into the EHR. Individuals aged 12 and above who present for services are given a Client Self-Assessment (CSA) packet to complete which includes an initial 2-question screening for depression from the PHQ-9  - unless excluded for any of the following reasons: active diagnosis of Depression or Bi-polar Disorder within past year, refusal to participate, in an emergent or urgent situation, or functional capacity or motivation to improve may impact accuracy of responses (e.g. court-appointed individual, delirium status). Positive responses to the initial 2 questions will initiate a referral to licensed clinical staff for completion of the full PHQ-9 and referrals for appropriate assessment and clinical interventions. The full PHQ-9 is administered by licensed clinical staff who will receive training prior to using the instrument to ensure standardized implementation. A template will be developed to enter scores into the EHR, make referrals for appropriate follow-up, and also identify exclusions, if any, that precluded completion of the full PHQ-9.","Upon completion of the PHQ-9, licensed clinical staff will complete additional clinical assessments to confirm the initial diagnosis of depression or bi-polar disorder and make referrals. These may include counseling, referrals to psychiatric prescribers for evaluation of the need to initiate medication, education on the nature of the illness, or other cognitive-behavioral skills and interventions. Follow-up will be documented on the PHQ-9 template and entered into the EHR."," "," "," ","Standardize measurement process and follow-up for BMI identified outside of normal parameters.","All individuals 18 and older will have their BMI measured at each clinic visit, with the exception of individuals meeting any of the assessment exclusion criteria. Results will be entered into the EHR through a standardized template to be developed to accurately calculate BMIs outside normal parameters and that also identifies follow-up activities initiated as a result of assessment findings.  Criteria for exclusion from assessment are also included as part of the BMI screening instrument to ensure entry of that information into the EHR. Staff completing the BMI assessments will receive training on completion of the standardized BMI template and on use of the electronically calibrated scales to ensure measurements are accurately recorded.","Individuals identified to have a BMI outside of normal parameters on the BMI screening template will receive follow-up, which will include one or more of the following activities: education, referral to primary care giver, exercise counseling, and/or nutrition counseling. Follow-up activities initiated will be documented on the BMI screening template for entry into the EHR to track adherence to required protocols and for automated data reporting purposes."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-147","RHP1 has some of the highest rates in the State for diabetes, hypertension, and other chronic health conditions, as well as a large uninsured population. As a result, this population frequently waits to seek services until a disease has progressed beyond the point where earlier, and less drastic, interventions could have resulted in a better health outcome for the individual - and less cost to an already over-burdened system of emergency care. The two measures were selected to address these health concerns, as it is believed that earlier identification and follow-up, including education on self-management of these chronic diseases, will lead to better outcomes for individuals served, improve their health and quality of life, and decrease inappropriate utilization of emergency services. Each of the measures align with RHP1s Community Needs Assessment to address and reduce high costs due to potentially preventable hospitalizations, reduce inappropriate emergency room utilization, and improve efficiency in and effectiveness of the health care delivery system.","No","","111411803.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_112667403","112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private",3,"Chronic Care Management","","Continue","","Utilization of evidence‐based care management models for patients with complex needs","","Utilizing one Electronic Medical Record with standardized templates to manage chronic conditions on a more consistent basis. Protocols to consistently review a patient's chronic conditions like diabetes is programmed into the Clinic's Electronic Medical Record to ensure a consistent approach for every applicable patient.","Improve utilization of clinical decision support tools by clinicians across the system.","Manage Diabetes as a Chronic Condition on a more consistent basis","Implement EPIC across the required outpatient system.  All clinics reporting must fully engage in EPIC and have a plan to implement EPIC in the hospital within a reasonable time period.  The goal is to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings to manage chronic Diabetes."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Evidence based protocols in standardized templates will ensure consistent approach to wellness and screening activities in our Clinics which will drive better patient outcomes.","No","","112667403.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",8,"Prevention and Wellness","","Continue","","Use of community health workers to improve prevention efforts","","The primary care clinics will utilize community health workers to perform pre-visit planning activities to determine social determinants of health which might impact the patient's health outcomes and status.  The community health workers collect information such as preventative screening services status, as well as immunization status.  The goal is to prepare and assist the physician/provider in anticipating the preventative needs of the patient in advance of the appointment, so that orders can be submitted, patients screened or labs obtained with results available prior to the appointment.","Screen all eligible patients appropriately based on age, gender and diagnosis.","Conduct pre-visit planning for all patients prior to scheduled appointments at all primary care clinics.","Establish consistent pre-visit planning processes across all primary care clinics.","Establish consistent protocols across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages and labs prior to appointment."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C2; H1; C1","Pre-visit planning is a proactive process that promotes prevention and wellness through assuring appropriate screenings are completed.  The process also allows the provider to have results of the screenings and/or other diagnostic work prior to the appointment, so if an issue or problem arises from the screening or diagnostic procedure, there is no delay in addressing the concern.  Early detection and prevention has been proven to improve outcomes, which is the purpose of the measure bundles in affiliation with this core activity.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use of community health workers to improve prevention efforts","CA-7","CA-7.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",9,"Patient Centered Medical Home",null,"Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Patients who are considered to be high risk or require chronic care management in the Patient Centered Medical Home will be identified by the provider and followed on a consistent basis using care management strategies, pre-visit planning and standing protocols to facilitate improved health outcomes and promote continuity of care and care transitions.","Manage chronically ill and debilitated patients through appropriate, evidenced-based diagnostic testing on a scheduled basis.","Establish templates and protocols to ensure patients are appropriately assessed and re-assessed consistent with evidence based practice associated with specific chronic disease management.","Conduct specific diagnostic testing based on diagnosis prior to appointment.","Identify patients requiring care management in all primary care clinics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1; H1; C2","The management of chronic care patients begins with identifying those patients who have chronic diseases that require consistent monitoring and measurement to maintain compliance and quality of life.  If the patients care is managed well, the quality indicators will show improvement over time and thus increase the bundle measure scores.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",10,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Palliative care is a program that offers an interdisciplinary team approach in caring for those individuals with a chronic debilitating disease.  Typically, the patients are near or at the end of life.  The purpose of the program is to manage symptoms and maintain the quality of life.  The care is delivered primarily in the outpatient setting, with referrals from inpatient and outpatient.","Manage the care needs of the palliative care population in appropriate settings.","Improve the inpatient referral process with the goal of accepting the patient into the palliative care program prior to discharge from the hospital, with follow-up in the already established outpatient palliative care clinic.","Increase the palliative care patient population by continuing to educate colleagues in all primary and specialty care clinics, hospital and departments throughout the organization."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","Palliative care is a program that improves the quality of patient lives.  The impact of the program expands beyond the patient to those who care about the patient.  For those individuals with chronic debilitating or terminal illness, it provides supportive care which primarily focuses on symptom management and controlling the symptoms of the patient in a manner that promotes the highest possible quality of life.  The goals of the program are directly in line with the bundle measure and support achievement of the associated metrics.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",11,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","The integration of behavioral health services in the primary care clinics facilitates access to behavioral health services in our community without the stigma of behavioral health.  The integration of the services also promotes the holistic concept of care.  It is difficult to treat the body separately from the mind and the spirit because each body is a unique system with each of these components.  The goal of behavioral health integration is to address unhealthy behaviors, social determinants of health and behavioral issues that are impacting the physical, emotional and spiritual health of the patient, thus improving the overall health of the patient.","Identifying patients with behavioral health needs in the primary care setting.","Imbed appropriate behavioral health standardized screening tools across all primary care clinics."," "," "," "," ","Create a process to manage those patient who have behavioral health issues within the primary care setting.","Utilize community health workers to focus on the behavioral health population screenings and follow-up in each primary care clinic.","Establish consistent processes and behavioral health algorithms in each primary care clinic."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","The behavioral health integration core activity is critical to the measure bundle by facilitating identification of behavioral health needs that might not otherwise be identified in the traditional primary care setting.  Additionally, behavioral health integration allows access to available behavioral health care services in a destigmatized environment.  Behavioral health care issues impacting the physical health will be addressed in this setting and promote the overall health outcomes of the patients being served.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",12,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Develop interdisciplinary and multi-disciplinary collaboration to make a difference in the quality of care.  This collaboration will be nurse driven with potential to participate in state-wide collaborative/task forces.","Identify areas for improvement that impact maternal mortality rates. Direct causes of maternal mortality include, but may not be limited to hemorrhage, obstructed labor, and premature births; with socio-economic factors being a contributing factor.","Create internal Task Force supported by accurate data and assessments to determine areas of focus an opportunities to improve."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Improved data driven reporting which will be utilized for decision making and ongoing quality improvement associated with maternal care.\n","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",13,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Delivery of pre and postnatal care and behavioral health services to assist in maintaining mother's health during pregnancy and after delivery to prevent complications that can adversely affect health of mother and baby. Includes partnership with FQHC.","Improve delivery of prenatal care. Women receiving no prenatal care are more likely to have a pregnancy-related death than women who receive prenatal care.","Create evidenced-based, standardized protocols for delivering prenatal care."," "," "," "," ","Improve physical and mental health of target population through provision of routine and postpartum care for mothers and newborns.","Create evidenced-based, standardized protocols for delivering prenatal and postpartum physical and mental health services."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Establishes evidence based protocols to improve maternal care and services.  Services will include improvments in EHR to capture data on patient compliance.  The data will  be utilized for decision making, patient follow-up, and ongoing process improvement.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",14,"Expansion or Enhancement of Oral Health Services","","Edit","Due to the change in TJC dental hygiene training curriculum removing sealants as a required learning experience for dental hygiene students, UTHSCT is underway in developing a partnership with St. Paul Children's Foundation Dental Clinic to further expand dental outreach to pediatric patients.","Expansion of school based sealant and/or fluoride varnish initiatives","","UTHSCT will partner with Tyler Junior College Dental Hygiene Clinic and Genesis Primecare Texarkana (FQHC) to offer dental services to low income and uninsured children and adults.  The partnership with TJC will offer school-based \"Sealant Days\" where children will receive oral exams.  Further services including sealants and/or varnish will be provided based off exams.","Lack of access to preventive dental services for children and adults.","Increase \"Sealant Days\" offered at local schools to provide services to children."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"F1; F2","The partnerships with TJC and Genesis Primecare Texarkana (FQHC) will increase access to dental care for adults and children, which will assist with Measure Bundle success.","No","","127278302.7.1","SDH","Flagged for RHP Plan Review to confirm provider made changes in RHP Plan Review. Provider made edits to a Core Activity in DY8 and made additional changes to the same Core Activity in DY9-10 which included omitting a partnership with St. Paul Children's Foundation Dental Clinic. Not sure if this is an issue. Marking for second review.","Y","NB","accepting as is. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of school based sealant and/or fluoride varnish initiatives to otherwise unserved school-aged children by enhancing dental workforce capacity through partnerships with dental and dental hygiene schools, local health departments (LHDs), federally qualified health centers (FQHCs), and/or local dental providers.","CA-3","CA-3.3"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",15,"Access to Primary Care Services","","Delete","Edits have been made to further delineate and include additional performance improvement efforts for this core activity and corresponding measures, specifically addding new processes for increasing the receipt of outside records detailing patient retinal eye exams so that UTHSCT is better able to determine which patients need retinal eye exams.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","UTHSCT will utilize a form of telemedicine by offering retinal eye exams within the primary care clinic.  Patients will have the opportunity to receive their retinal eye exam, based off provider referral, without scheduling another visit.  The scans will be securly stored and a contracted ophthalmologist will read remotely.  A signed report will be scanned into the medical record.","Number of diabetic patients who are not compliant with routine eye exams.","Implement standing order during pre-visit planning for diabetic patients who are not compliant with yearly retinal exams."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Yearly retinal eye exams are recommended for diabetic patients.  Often times, patients do not have access to eye care specialists.  This Core activity will allow patients to receive their retinal exams within their primary care clinic.","No","","127278302.7.1","SDH","Not deleted. Added below with additional edits","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",16,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications",null,"UTHSCT will partner with CHRISTUS St Michael Texarkana to deploy two mobile clinics.  The clinics will travel to local schools to help diagnose and routinely treat children with asthma.  Extensive education on self-management will be provided to the patient and caregiver.  Each patient will receive an individualized asthma care plan to assist with controlling his or her asthma.  In addition, the care teams will communicate with school nurses and primary care providers to provide continuity of care.","Improve access to care to address lack of access to specialized care for children with asthma.","Increase partnerships with local school districts to expand services to more children in RHP1.","Deploy mobile clinics focused on providing asthma self-management education"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4","The Core Activity will increase access to specialized care for children with asthma.  The increased access will hopefully reduce emergency department visits and hospitalizations for asthmatic children.","No","","127278302.7.1","SDH","CA Name is Other. I think this may be fine, but we could also pursue placing this under \"Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co‐morbidities, and/or utilizing acute and emergency care services\", since the focus is on children with asthma. Asking for second review to see if we want to pursue this. I didn't make the change yet, but included a comment stating that we made the change. ","Y","NB","made change","Needs More Information","HHSC has updated the Core Activity Name from \"Other: Deploy mobile clinics focused on providing asthma self-management education\" to \"Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co‐morbidities, and/or utilizing acute and emergency care services\" to better align with the provider’s described Core Activity. HHSC has also added \"Deploy mobile clinics focused on providing asthma self-management education\" as a change idea. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and indicate whether another Core Activity Name is appropriate instead of “Other”.","Agree with changes made by HHSC","LH","Provider accepted HHSC changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_127278302","127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",680,"Access to Primary Care Services","","New","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","UTHSCT will utilize a form of telemedicine by offering retinal eye exams within the primary care clinic.  Patients will have the opportunity to receive their retinal eye exam, based off provider referral, without scheduling another visit.  The scans will be securly stored and a contracted ophthalmologist will read remotely.  A signed report will be scanned into the medical record.","Number of diabetic patients who are not compliant with routine eye exams.","Implement standing order during pre-visit planning for diabetic patients who are not compliant with yearly retinal exams.","Implement a standardized Release of Information (ROI) form that contains local eye doctors to streamline request and receipt of outside records ","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Yearly retinal eye exams are recommended for diabetic patients.  Often times, patients do not have access to eye care specialists.  This Core activity will allow patients to receive their retinal exams within their primary care clinic. at UTHSCT since inception in 2014, retinal screen utilization has tripled going from 101 retinal screens to 303 (year to date) in 2019.","No","","127278302.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_387381201","130612806.7.1",1,"387381201","Jacksonville Hospital LLC","Hospital","Private",17,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","130612806.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_131038504","131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public",19,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Hunt Regional Medical Center (HRMC) is performing multiple actives, in multiple settings focused on improving comprehensive diabetic care. Chronic care management settings include primary care, the Emergency Department, inpatient services, and home health. A total of (11) providers are dedicated to improving chronic care management.  HRMC partnered with the Greenville Community Health Service Agency- Greenville Primary Care Clinic a designated Federal Qualified Health Center (FQHC) to increase primary care capacity for diabetics in Hunt County.  The Community Health Service Agency Greenville Center expanded the clinic hours to add primary care capacity on Tuesday and Thursday evening from 5:00-7:00pm and Saturday from 8:00-1200. We have also added an additional patient centered medical home team including a nurse practitioner, nurse case manager and office staff. Hunt Regional Medical Center (HRMC) is also providing remote patient monitoring and outpatient disease management for heart failure (HF) patients in the home setting. Patients with American Heart Association Stage C and D HF admitted to the hospital for HF exacerbation are offered to participate in the Telehealth HF program. Patients receive intensive case management and education in the home setting including self-management strategies.  Patient weights, vital signs, and medication adherence are remotely transmitted daily to the Telehealth nurse. The telehealth nurse collaborates with the patient and their providers to address adverse findings. Hunt Regional Medical Center is providing navigation services for Emergency Department patients with high medical and social needs. ED patients are screened and their medical record flagged at ED registration for not having a primary care provider and if they have had more than three ED visits in the previous 12 months. Patients identified as lacking a medical home and frequently accessing the ED for non-emergent needs are seen by an ED navigator.  The ED Navigation program utilizes (4) nurse/social worker navigators to perform medical home referrals, intensive case management and disease self-management patient education. HRMC has implemented a Care Transitions program modeled after Project RED (Re-engineered Discharge) to create a smooth, coordinated hospital discharge. All inpatient admissions are assessed for risk of readmission. The care transitions program utilizes (3) Discharge Educators to provide discharge planning, education, medication management, and coordinating outpatient follow-up for moderate to high risk readmission patients.","Establish screening and referral processes. Referral system between the ED and Primary Care Clinic: Patients in the Hunt Regional Medical Center Emergency Department are screened to determine if they have a primary care provider. Patients who do not have a medical home are seen by the ED navigators and provided a referral and appointment to establish primary care at the Community Health Service Agency Greenville Primary Care office.","Screen individuals to determine if they have a primary care provider.  Upon registration in the Emergency Department, patients are asked if they currently have a primary care provider.  Patients without a primary care provider are flagged in the ED electronic health record on the ED status board with a red flag.  The ED Navigators prioritize navigation services to patients without a PCP.","Referral and appointments. Patients without a PCP are given a list of community PCPs to choose from. The ED navigators make the patient a follow-up appointment prior to leaving the ED during business hours and call the patient back with the appointment when after hours."," "," "," ","Medication assistance:  The ED navigators have identified high medical and social need patients often do not have the resources to obtain medication. We have developed and implemented a medication assistance program to connect patients with pharmaceutical assistance programs, refer patients to our primary care FQHC partner to access medications at 340B pricing, and purchase patients medications until long term arrangements are made.","Identification of high risk patients that require medication","Refer high risk patients that require medical assistance to FQHC to obtain the medication"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Primary Care is the cornerstone of preventative, high quality, patient centered care.  Expanded access to primary care will impact chronic disease management of diabetic patients by providing preventative and ongoing diabetic management. Medicaid and uninsured diabetic patients will have expanded access to hemoglobin A1C screening and monitoring, diabetic foot exams, blood pressure control resulting in fewer diabetic complications and ED visits for diabetes.   According to the 2013 ACCF/AHA Guideline for the Management of Heart Failure, uncontrolled chronic conditions including hypertension, diabetes, and cardiovascular disease are the leading cause of heart failure. Further, uncontrolled diabetes contributes to the development and progression of heart failure. Remote patient monitoring will impact chronic disease management of diabetic patients by providing comprehensive and ongoing diabetic management. Medicaid and uninsured diabetic patients who have developed comorbid HF disease will have expanded access to hemoglobin A1C screening and monitoring, diabetic foot exams, blood pressure control resulting in fewer disease exacerbations and progression of disease. The objective of patient navigation is to facilitate and support patients as they navigate through the healthcare system while providing patients with coordinated, timely care.  Providing ED Navigation services will impact chronic disease management of diabetic patients by assisting diabetic high medical and social need patients establish a medical home for preventative and ongoing diabetic management. Medicaid and uninsured diabetic patients will have expanded access to hemoglobin A1C screening and monitoring, diabetic foot exams, blood pressure control resulting in fewer diabetic complications and ED visits for diabetes.  Improved care transitions result in improved health outcomes and reduced hospital readmissions. Providing chronic care management and care transition services will impact chronic disease management of diabetic patients by assisting diabetic patients receive preventative and ongoing diabetic management.  Medicaid and uninsured diabetic patients will have expanded access to hemoglobin A1C screening and monitoring, diabetic foot exams, blood pressure control resulting in fewer diabetic complications and ED visits for diabetes.","No","","131038504.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_131038504","131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public",20,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","Hunt Regional Medical Center has established an outpatient behavioral health clinic to provide prompt mental health stabilization and support for patients with urgent psychiatric needs until they are able to obtain follow-up care with a local mental health provider. The Outpatient Behavioral Health Clinic is staffed by a psychiatrist medical director, psychiatric mental health nurse practitioner, licensed clinical social worker, and registrar. The clinic provides psychiatric medical management and counseling services.","Safety net stabilization:  The Outpatient BH Clinic will provide prompt mental health stabilization and support including medication management and psychosocial counseling for patients with urgent psychiatric needs until they are able to obtain follow-up care with a local mental health provider.","System integration for behavioral health referrals: Patients with serious mental illness may be referred to the Outpatient Behavioral Health Clinic from system primary care practices and the Emergency Department for same-day assessment, stabilization, and medication management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H4","Patients identified with a serious mental illness in the ED will be referred to the Outpatient Behavioral Health Clinic at HRMC to receive behavioral health integrated care. Patients identified with a serious mental illness in the inpatient setting will be referred to the Outpatient Behavioral Health Clinic at HRMC to receive behavioral health integrated care. The Outpatient BH Clinic will provide prompt mental health stabilization and support including medication management and psychosocial counseling for patients with urgent psychiatric needs until they are able to obtain follow-up care with a local mental health provider.","No","","131038504.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_137921608","137921608.7.1",1,"137921608","Sabine Valley Reg MHMR Ctr dba Community Healthcor","Community Mental Health Center (CMHC)","Non‐State Owned Public",21,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Community Healthcore strives to provide whole care services through a variety of methods. Services directly provided by CHC include the following: psychosocial rehabilitation, skills training, counseling, psychiatry medication management, peer lead services, case management, care coordination, screening for key health indicators and mobile crisis outreach services.  Integrated care and health promotions are facilitated through community partnerships.  ","Community Healthcore has developed a robust system of care that includes a full array of community-based behavioral health services that are aligned to CCBHC and Joint Commission Standards. Community Healthcore currently operates clinics and programs in all nine counties in the target area and is licensed as a Texas Local Mental Health Authority. (Note: State licensing regulations align with major components of CCBHC, especially in the areas of staffing, credentialing, cultural competence, and linguistic requirements.) Following is an abbreviated list of services provided by Community Healthcore: \nI. Existing: crisis mental health services, 24-hour mobile crisis teams, ACT Teams, emergency crisis intervention services, crisis stabilization (screening, assessment, diagnosis, including risk assessment). \nII. Existing: patient-centered treatment planning, risk assessment and crisis planning. \nIII. Existing: outpatient mental health and substance use treatment. Established cooperative relationships with judicial officials/court systems and provide Assisted Outpatient Treatment when ordered. \nIV. Existing: targeted case management and care management services. \nV. Existing: outpatient psychiatric rehabilitation services, structured therapeutic activities, counseling, medication management, recovery-oriented services and family therapy.\n","Community Healthcore would like to incorporate best practices associated with risk stratification, and population health methodologies for the purposes of evaluation, identification, and treatment."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,1,1,1,1,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-400; M1-317; M1-261; M1-211; M1-147; M1-105; M1-305; M1-160; M1-319","The utilization of care management and/or chronic care management services, including education in chronic disease self-management are consistent with clinical workflows needed to meet the quality measures identified in Category C.","No","","137921608.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_138360606","138360606.7.1",1,"138360606","Northeast Texas Public Health District","Local Health Department (LHD)","Non‐State Owned Public",22,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","NET Health's Center for Healthy Living utilizes community health worker staff members and educators to facilitate diabetes prevention, diabetes self-management, diabetes support and tobacco cessation classes to the Smith County community. The Center's diabetes program is accredited through the American Association of Diabetes Educators and  utilizes the Diabetes Empowerment Education Program (DEEP) for the diabetes classes. Addtionally, the Center is a pending recognition site through the CDC and uses the National DPP curriculum in the diabetes prevention classes.","Maintain AADE accreditation and CDC pending recognition to demonstrate program quality","Maintain client records according to the National Diabetes and CDC Diabetes Prevention guidelines","Submit yearly reports to AADE and CDC to maintain good standing"," "," "," ","Enrollment, participation and completion of classes offered at the Center","Increase awareness of the services and classes offered at the Center","Training and/or retainment of passionate and skilled educators to facilitate the classes","Analyze participant class surveys, along with pre & post biometric data to evaluate program quality and effectiveness and make improvements, when needed"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-147; L1-IT-10.3.e","By screening, recording and documenting follow up for clients with a BMI outside normal parameters, it provides us an opportunity to enroll these clients into our evidence-based class workshops and provide support for them to improve their health. The PAID survey in the second measure is one of the tools used in our diabetes classes to measure class effectiveness and identify participants who need additional educational interventions.","No","","138360606.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_138360606","138360606.7.1",1,"138360606","Northeast Texas Public Health District","Local Health Department (LHD)","Non‐State Owned Public",23,"Access to Primary Care Services","","Continue","","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff",null,"Our CommUNITY Cares Program is an innovative solution to addressing the need of providing increased access to appropriate and affordable primary care medical homes to the uninsured population in Smith County. The program is focused on reducing the number of unnecessary ED utilization among the uninsured population by using Community Health Worker and health coaches at the Center for Healthy Living to use an electronic multi-directrional referral and navigational tool in order to accomplish appropriate primary medical home placement and referral to social services support.","Patient education on proper usage of ED utilization","Create a guide book for patients to refer to when in doubt of when to use the ED","Ensure clinics provide patients with information on how they can be reached after hours","CHW education to patients in an effort to increase compliance with primary care provider"," "," ","Work with medical providers and social service agencies to adopt program and implement","Selection of clinics and social service aencies who show an interest in participating"," Maintain regular and open communication with clinic and social service partners to ensure patients who are referred receive the care they need"," "," "," ","Cloud-based Navigation Tool that can be shared among multiple medical and social services partners","Integrate the cloud-based system in all parter organizations and provide user training"," "," "," "," ","Partner with a local hospital to integrate program among ED staff when uninsured patients present to the ED with potentially preventable diagnosis.","Work with hospital lead ED staff to implement CommUNITY Cares Program and establish ED workflow to refer uninsured patients into the program",""," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-147; L1-IT-10.3.e","Our Community Cares Core Activity provides our Center staff with increased referrals to our education classes and disease prevention & management services from our program partner agencies. Additionally, it provides our staff with more opportunities to provide class participants with referrals to a primary care physician, mental health services, social services (food pantry, utility & job assistance, transportation) that increases clients' ability to better manage their health.","No","","138360606.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increase in capacity and access to services by utilizing Community Health Workers (CHWs)/promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care","CA-1","CA-1.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_138365512","138365512.7.1",1,"138365512","Andrews Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",33,"Behavioral Health Crisis Stabilization Services","","Continue","","Implement models supporting recovery of individuals with behavioral health needs","","Continue a crisis intervention respite program consisting of a location where individuals in crisis could be brought for a period of up to 14 days in order to allow for stabilization and planning for optimal placement.  Andrews Center also plans to use the additional funding allocation to designate a childrens provider; and with the collaboration from local schools, tele-psychiatry would be an option.","Behavioral health patients in crisis need an alternative to costly acute care","Implement crisis intervention services to capture patients in a conducive environment and conduct assessments, in order to determine an appropriate follow up care plan"," "," "," "," ","Growing need for child and adolescent behavioral health services","Implement a children's telepsych program for children/adolescents to have a designated psychiatric provider"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-305; M1-319","Crisis Intervention provides an avenue to identify and proactively treat depressive conditions that could potentionally lead to suicide risk factors. Early indicators with a rapid response will significantly reduce the risk associated with such idealology and prevent utilization of more costly acute care services.  The core activity of implementing models supporting recovery of individuals with behavioral health needs will impact the M1-305 measure bundle by improving the mental health needs of our youth. This will be accomplished through necessary improvements in greater accessibility to childrens psychiatric treatment by means of mental health diagnostic assessment, appropriate mental health referrals, and psychiatric medications and monitoring. By providing these valuable services, the mental health of our communitys children and teens will vastly improve, their educational skills will increase, and their inclination to self-medicate will lessen thereby decreasing their chances of suicide and other means of self-harm.","No","","138365512.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_138365512","138365512.7.1",1,"138365512","Andrews Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",34,"Access to Primary Care Services","","Continue","","Integrated physical and behavioral health care services","","Improve the integration of behavioral health and primary care services at various potential locations in Region 1, primarily through primary care clinic services in the behavioral health setting.","Prescription medications from multiple providers can create adverse drug reactions and ineffective holistic health maintenance.","Utilize new EMR to implement medication management across locations","Recurring primary care maintenance, in conjunction with behavioral care, ensures compliance with appropriate medication utilization"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-125; M1-287","Successful implementation of primary care services provides a resource for managing multiple medications that could otherwise cause negative interactions. The use of antidepressants must be coupled with a holistic approach that includes documentation and presription of other primary care management medications of other conditions.","No","","138365512.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_388696201","138374715.7.1",1,"388696201","Pittsburg Hospital LLC","Hospital","Private",24,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","138374715.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_138913209","138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public",25,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications","","TRMC will focus on chronic care management specifically targeting heart disease in our community.  We will target patient populations in our Primary Care Clinic and Specialty Care Cardiology clinic.  Our goal is to provide screenings, education and disease managment of high blood pressure in the clinical setting.","Based on the Community Needs Assessment we identified a chronic disease burden in our region with higher rates of high blood pressure in our region than the average state rate.","To work with physicians to establish practice foundations for effective hypertension control and focus on quality improvement efforts as well as proactively monitoring and managing hypertension through population health management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","Measure bundle A2 specifically targets Chronic Disease Management - Heart Disease.  As outlined in the Core Activity and Change Idea above, the focus of controlling hypertension and heart disease directly impacts the metrics for measure bundle A2 by targeting heart disease and hypertension.","No","","138913209.7.1","SDH","Secondary Driver 1: Charge Idea 1 says: [HHSC Note: Provider should edit Secondary Driver 1: Change Idea 1 during the October DY7 reporting period. Change Ideas were not submitted during the RHP Plan Update process for Secondary Driver 1.] Provider appears to have corrected this during DY8R2 reporting. I replaced the language here with language from DY8R2 reporting.","Y","NB","edited the feedback and NMIed","Needs More Information","HHSC has removed language in the Secondary Driver 1: Change Idea 1 that stated, \"[HHSC Note: Provider should edit Secondary Driver 1: Change Idea 1 during the October DY7 reporting period. Change Ideas were not submitted during the RHP Plan Update process for Secondary Driver 1.]\" and edited this language and the Secondary Driver 1 to match what was reported in DY8R2. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column.","Provider agrees with change.","LH","Provider accepted HHSC changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_387515501","139173209.7.1",1,"387515501","Athens Hospital LLC","Hospital","Private",26,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","139173209.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_140425362","140425362.7.1",1,"140425362","Paris Lamar County Health Department","Local Health Department (LHD)","Non‐State Owned Public",27,"Access to Primary Care Services","","Continue","","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","","The Paris-Lamar County Health District has a significant number of patients who have a diagnosis of hypertension.  The Paris-Lamar County Health District plans to utilize Community Health Workers (CHW'S)/ promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care to assist in following BAT recommendations by monitoring the patient's home blood pressure activities and record them in the Electronic Health Record with the clinical outcome resulting in adequately controlled BP. The Community Health Workers (CHW'S)/ promotoras, health coaches, peer specialists and other alternative clinical staff will assist in identifying patients 18-85 years of age who have had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period, order screening supplies, monitor patients blood pressure activities and record them in the Electronic Medical Record. Designated staff with coordinate efforts with primary care physicians to ensure patient blood pressure is adequately controlled. In addition, the Paris-Lamar County Health District plans to utilize Community Health Workers to educate patients 50-75 years of age regarding the importance of Colorectal Screening which addressed Measure L1-107. The Community Health Worker will also be responsible for assisting in schedule appointments and make referrals for additional screening and testing if necessary. Community Health Workers will also assist in ensuring all results are recorded in the Electronic Health Record. ","The Community Health Workers will monitor compliance of patients who recieve the home blood pressure kits to ensure proper use and effectiveness. The Community Health Worker will track patients who receive FOBT stool cards or FIT tests to ensure patient has submitted card/test back to the clinic. Community Health Workers will report the findings quarterly as part of the Quality Assurance Program. Areas of improvement will be identied and addressed with a timeline to implement changes if necessary.","To work with the Medical Director, Physicians, Nurse Practitioners and other clinical staff to implement standing orders for patients with a diagnoses hypertension (HTN) to receive at home BP kits and patients 50-75 years of age receive FOBT/FIT screening for Colorectal Cancer. Patients will be monitored by Community Health Workers who will record activities in the Elecrtonic Health Record. Standing orders will be ammended and/or revised as necessary as part of the QA process."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-IT-1.7; L1-107","Utilizing Community Health Workers and other clinical staff for the purpose of identifying and monitoring hypertensive patients through the use of home blood pressure kits which will assist in increasing the number of patients who blood pressure is adequately controlled. Utilizing Community Health Workers and other clinical staff for the purpose of identifying patients 50-75 years to ensure patients receive appropriate screening for Colorectal Cancer. Related Category C Measure Bundle and Measures L1-IT-1.7 and L1-107 boxes should be checked in above field. Boxes were checked but not able to save.","No","","140425362.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increase in capacity and access to services by utilizing Community Health Workers (CHWs)/promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care","CA-1","CA-1.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_140425362","140425362.7.1",1,"140425362","Paris Lamar County Health Department","Local Health Department (LHD)","Non‐State Owned Public",28,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Continued expansion of the current delivery system, personnel, space, hours, access, and other resources necessary to reach the demand of the underserved population. In our current system, more often than not, patients receive services in urgent and emergent care settings for conditions that could be managed in a more coordinated manner if provided in the primary care setting. The motivation behind the continued expansion of primary care availability at the Paris-Lamar County Health Department is to address CN.1 Insufficient access to primary and specialty health care services. By enhancing access points, available appointment times, patient awareness of available services and overall primary care capacity, patients and their families will align themselves with the primary care setting resulting in better health outcomes, patient statisfaction, appropriate utilization and reduced cost of services. Most individuals find it difficult to schedule appointments during regular working hours; therefore; extending clinic hours, clinic staffing, and space will allow individuals to schedule appointments before and after work and have better access to primary care and reduce emergency department usage.","Continued partnership with Paris Regional Medical Center for the Paris-Lamar County Health District to be a referral source for patients who present at the emergency room for a non-emergent issue. This continued partnership will increase patient awareness of available services offered at the Paris-Lamar County Health Department which will increase overall primary care capacity and reduce emergency department usage for non emergent issues.","The Paris-Lamar County Health District to work with Paris Regional Medical Center to create a combined referal/discharge document for non emergent patients that present at the Emergency Department directing them to the Paris-Lamar County Health District for Primary Care. Referred patients would be documented in the EHR to assist in tracking the number of patients no longer accessing the emergency department for primary care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-IT-1.7","Continuation as Core Activity in DY7 and DY8 to continue to improve BP of patient population.","No","","140425362.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_387377001","208843701.7.1",1,"387377001","Henderson Hospital LLC","Hospital","Private",32,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The primary care clinics will utilize standing orders across all primary care clinics to promote screening and scheduling of age, gender and disease appropriate preventive or appropriate follow-up care. The use of the standing orders will assist in determining if a patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient. Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.\n","Screen all eligible patients appropriately based on age, gender and diagnosis.","Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Our patient population's health should benefit from our core activity. The use of the standing orders will assist in determining if the patient has a problem or a concern allowing the provider the opportunity to detect problems early and facilitate a diagnosis and communicating care needs to the patient.  Early screening and detection allows the primary care provider to facilitate referrals to specialists to provide required or necessary care that will assist the patient in gaining access to specialized care as well with a goal of improving the outcome potential of the patients served.","No","","208843701.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_330811601","330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public",29,"Access to Primary Care Services","","Delete","This core activity is not being discontinued.  This tool does not allow for adequate editing of drivers and change ideas.  As a result, the core activities must be deleted and reentered to account for the edits the provider wants to make.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Increase patient access to healthcare through extended clinic hours on nights and weekends, recruiting a family practice physician and a physician assistant, and adding support staff as needed.","Extended primary care capacity will enable us to identify additional patients at risk for unmanaged diabetes.  The identification of new patients will enable us to provide additional patient education content to more patients.","Develop new print, on-line and in person education formats for patients.","Develop new print, on-line and in person education formats for patients."," "," "," ","Develop additional evidence based clinical interventions for diabetes patients.","Offer frequent and timely blood glucose monitoring during visits/interactions within our healthcare system.","Implement a patient data mining initiative of our EMR to identify patients having a diabetes diagnosis and who have not seen a provider within the last 6-months.  Patient will be either manually called by a Clinical Nurse or receive a letter alerting the patient to contact their provider to schedule an office visit.","Work in conjunction with TMC Bonham Clinic Providers to initiate interventions for identified patients.","Establish structured diabetic clinic encounter to monitor and treat patients who have had a diabetes diagnosis."," ","Extended primary care capacity will also provide increased access for patient care to all diabetes patients.  More specifically, our Certified Diabetes Educator has become a direct member of the patient care team for those identified at risk for unmanaged diabetes.","Development of personalized diabetes management education for patients.","Initiate monthly contact with patients who have been diagnosed with diabetes to address uncontrolled diabetes."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","It is directly applicable to the objective for A1: Improved Chronic Disease Management: Diabetes Care.  The objective for A1 are as follows, \"Develop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.\"","No","","330811601.7.1","SDH","Didn't delete. Added same core activity to allow for additional editing.","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_330811601","330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public",30,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","By partnering with our nearby sister facility (thereby improving the frequency and flow of patient referrals), we have improved patient access by exposing them to an already established specialty physicians network. During the previous DY years, we were able to report a significant increase in the number of specialty visits from patients in TMC Bonham's service area to specialists at our sister facility.","Develop additional evidence based clinical interventions for diabetes patients when patients are seeing our specialist physicians.","Work in conjunction with Specialist Providers to initiate interventions for identified patients.","Offer frequent and timely blood glucose monitoring during visits/interactions within our healthcare system.","Create a mechanism where patients who are diagnosed with diabetes, who see a specialist provider and who have a Bonham Clinic primary care provider are initially identified/flagged for an intervention.  The Bonham Clinic providers will be notified that a clinical intervention needs to occur to assist patients who have uncontrolled diabetes.","Implement a patient data mining initiative of EMR to identify patients having a diabetes diagnosis and who have not seen a provider within the last 6-months.  Patient will be either manually called by a Clinical Nurse or would receive a letter encouraging patient to schedule an appointment."," ","Extended specialty care capacity will enable us to identify additional patients at risk for unmanaged diabetes. The identification of new patients will enable us to provide additional patient education content to more patients.","Develop new print, on-line and in person education formats for patients.","Development of personalized diabetes management education for patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","It is directly applicable to the objective for A1: Improved Chronic Disease Management: Diabetes Care.  The objective for A1 are as follows, \"Develop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.\"","No","","330811601.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_330811601","330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public",31,"Hospital Safety and Quality",null,"Edit","This core activity is not being discontinued.  Provider corrected a typo in the second change idea for the first secondary driver. This is the only change that was made.  The word us was changed to use.","Implementation of evidence-based practices to improve quality of care",null,"Improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.","Patients who utilize our inpatient facility are measured on key measures related to their inpatient stay.","Create a reliable assessment tool that enables us to identify those who are at risk for CLABSI, CLAUTI, Sepsis and patient falls.\n","Create reliable care interventions - for example, outlining clear evidence based indications/guidelines for urinary catheter utilization will decrease use and risk of infection.  Similarly, developing guidelines for utilization of pressure pads and sitters will help to decrease falls.","Create reliable patient and family education materials - especially for patients at increased risk for falls - will reduce the number of falls at home."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity impacts the Hospital Safety measure bundle by establishing a mechanism to measure the following during a patients inpatient stay: CLABSI, CLAUTI, Severe Sepsis and Septic Shock and Patient Fall Rates.","No","","330811601.7.1","SDH","Change to language was only to correct a typo, so ok. The grouping is currently Other: Hospital Safety Process. Changed to Hospital Safety and Quality. Core Activity Name is Other and could possibly be Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls), but it seems what they're doing is broader than that. I'm a little confused by their current name. Asking for second review of Name and action to be taken regarding that.","Y","NB","Made additional change to the title and NMId","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Hospital Safety Process\" to \"Hospital Safety and Quality\" and the Other title from “Patient Experience Improvement Plan” to “Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)” to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and indicate whether another Core Activity Grouping is appropriate instead of “Other”.","Provider agrees with HHSC's action and accepts this change.","LH","Provider accepted HHSC changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_330811601","330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public",681,"Access to Primary Care Services","","New","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Evaluate the potential to add extended hours to the clinic.  Evaluate the need for recruitment of a family practice physician.  Explore the benefit of telemedicine as a support to the clinic.","Possible extended primary care capacity will enable us to identify additional patients at risk for unmanaged diabetes. The identification of new patient will enable us to provide additional patient education content to more individuals.","Develop new print, on-line and in person education formats for patients.","","","","","Develop additional evidence-based clinical interventions for diabetes patients.","Implement a patient data mining initiative in the EMR to identify patients with a diagnosis of diabetes who have not seen a provider within the last six months. Patients will be either manuyally called by a clinical nurse or receive a letter alerting the patient to contact their provider to schedule an office visit.","","","","","Extended primary care capacity will also provide increased access for patient care to all diabetes patients. More specifically, our Certified Diabetes Educator has become a direct member fo the patient care team for those identified at-risk for unmanaged diabetes.","Initiate monthly contact with patients who have been diagnosed with diabetes to address uncontrolled diabetes.","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","It is directly applicable to the objective for A1: Improved Chronic Disease Management: Diabetes Care. The objectives for A1 are as follows, \"Develop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities; improving health outcomes and quality of life; preventing disease complications; and reducing unnecessary acute and emergency care utilization\".","No","","330811601.7.1","SDH","Doesn't match DY8R2, but I think it's ok.","Y","NB","this is new CA","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_366812101","366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private",18,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","CHRISTUS Trinity Clinic is the primary care provider for the clinics that will be a part of this bundle.  The providers are required to continue to expand access, effectively manage 3rd next available, monitor phone access by clinical staff, and the patient experience related to timeliness of return phone calls.  In addition, clinic office hours are evaluated, with after-hours availability enhanced.  Referral patterns are closely monitored, to ensure access from patients discharged from the hospital or referred from primary care to specialty.  Our goal will be to maintain a high level of primary care provider access in our locations.  Access to EPIC will be required for all sites of services in order to track patients in a real time process and to be able to facilitate timely appointments for needed services","Improve utilization of clinical decision support tools by clinicians across the system.","Implementat EPIC across the required system:  All clinics and hospitals reporting must move to EPIC in order to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings","Develop expanded protocols for clinical staff and care management teams."," "," "," ","Improve screening rates.","Developing dash board to monitor compliance of diabetes and bundle performance."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","For our bundle measure access to primary care is the ultimate solution to having patients receive the care they need at the right location, right time, and most effective cost.  Once a patient is within the CHRISTUS Mother Frances Hospital  Sulphur Springs System (outpatient or ED), they are on the EPIC EHR system that allows providers, care navigators, and managers to identify patients who are at risk for needing additional or more frequent care visits in person, group, by phone, or telephonically or virtually. The tracking of the patients status provides a method to identify screenings that are needed, reach out to the patient, and make that appointment and follow-up as necessary.","No","","366812101.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_366812101","366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private",682,"Expansion of Patient Care Navigation and Transition Services","","New","","Implementation of a care transition and/or a discharge planning program","","CHRISTUS Hopkins Health Alliance aims to limit return to acute visits and ultimately reduce avoidable readmission rates.  Managing patient care as they transition from inpatient or observation status to the next level of care has proven to result in great outcomes for the patient and avoid unnecessary cost.  Nurse Navigation plays an integral part in the success of the Care Transitions program.  This clinical team member completes an interactive contact with the patient or caregiver within the initial 48 hours of discharge.  Discharge instructions are reviewed, medication reconciliation is completed, continuity of care is delivered with interaction between the patient and their primary care provider, DME, or home health agency.  Education and community resources are arranged and provided as needed.  A face-to-face appointment with the primary care provider is made within 14 days of discharge.  ","Chronic Conditions Management – Heart Failure\nObjective:  Closely monitor those with heart failure diagnosis to decrease disease progression while improving the patient’s quality of life, thus preventing avoidable hospital admissions and lower cost.  ","Nurse Navigator completes an interactive contact with the patient or caregiver based on a schedule found to represent the highest return to acute: days 4-8, 10-14, and 19-23.  The Navigator follows an established protocol to specifically evaluate patient’s weight, vital signs, breathing capabilities, sleep posture, swelling in extremities, oxygen intake, diet and fluid restrictions, evaluates any chest discomfort, and provides ongoing education as provided and approved by the cardiology team.  Continuity of care is delivered with interaction between the patient and their cardiologist or primary care provider and home health provider if applicable.  The Navigator promotes patient compliance and independence with their own healthcare and becomes a resource for preventing avoidable hospital admissions and reducing cost.  ","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Patients would need the services of the primary care patient navigators to impact their care decisions and participiation. Included in these services would certainly be an effort to ensure patients are receiving the services as an outpatient under A1, especially for those diabetic patients who also have  heart disease.  ","No","","366812101.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 01_DY9-10 Regional Tracker - FINAL Tracker.xlsb","1_376537203","376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public",6,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","The Freestone Emergency Department will monitor current processes related to evaluation and documentation of current medication regimen in the medical record.  The  patient's current meds are to be validated and documented in the medical record, as well as communicating the information back to the primary care provider provided the patient has a primary care provider.  The throughput process in the Emergency Department will be evaluated in an effort to reduce the time from decision to admit to Emergency Department departure time for all admitted patients.  This will include a thorough report to the admitting physician and orders received to promote continuity of care and care coordination.   Finally, any patients being transferred out of the Emergency Department to any location will be sent with relevant documentation from the Emergency Department to promote continuity of care. The processes established in each of these situations will be guided by the underlying goal to increase communication and improve care transitions for every patient that seeks care in the Freestone Emergency Department.","To establish Emergency Room patients with primary care when it is identified that no primary care provider exists for the patient in question to ensure continuity of care. Improve Transition of care processes with receiving facility.","Any E.R. patient that is identified with not having a Primary Care Provider while in the Emergency Room will be scheduled with a provider of their choice or one of FMC Rural Clinic Providers before being discharged from the E.R. and within the recommended time frame for follow up as noted by the Emergency Room Physician's documentation. A checklist will be utilized in an effort to improve continuity of care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","This core activity promotes the transition and continuity of care throughout the healthcare system.","No","","376537203.7.1","SDH","OK","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_019053001","019053001.7.1",2,"019053001","Coastal Health Wellness","Local Health Department (LHD)","Non‐State Owned Public",36,"Access to Primary Care Services","","Edit","The core activity of expanded practice access is not being changed, but is being enhanced by development of color teams within the medical practice area.  Patients will be assigned to a color team, thereby allowing for continuity of care with the same clinical staff for all appointments.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Coastal Health & Wellness will continue to expand primary care access for patients.  This will be achieved by maintaining primary care and support staff, continuing evening and weekend clinic hours, and reducing the wait times for next available appointment for patients.  Patients are also now assigned to a color team which helps with continuity of care, and better management of patient panels for the providers in each color team. Each team consists of a panel of providers with their clinical support staff. Patients will be assigned a primary care provider within their color group. The goal is to have each patient see their primary care provider, and if they are unavailable, to see another provider in the same color group. This will help the continuity of care for the patient as they will be seeing a familiar face each time, and better management of provider panels. New patients can be assigned to provider panels that are not full, and other patients can possibly be moved to other provider panels within the same color group in those instances where a provider panel in a color group may already be full.","Provide patients with advanced scheduling options and increase opportunity for comprehensive primary and specialty care availability.","Assign all patients to a color team to allow for continuity of care and better management of provider panels.","Open provider schedules 6 months out to allow for scheduling of future appointments.","Increase ability for OB and Family Planning services and education thru contracted provider.","Contracting with providers outside our scope to expand specialty care to our patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115; L1-107; L1-186","Assigning patients to color teams will help with continuity of care, and will better allow for management of the provider panels.  Providers will also be more aware of care gaps for their assigned patient populations.","No","","019053001.7.1","LK","Provider describes that they are \"enhancing\" their Core Activity by \"assigning patients to color teams\", but does not describe what color teams are or how they are using them to achieve measure goals. Flagging for additional information.","Y","NB","In agreement.  Added more feedback.","Needs More Information","Provider reported that they are editing their Core Activity to communicate an enhancement to their clinical activity  (\"assigning patients to color teams\"). HHSC requires additional information about this activity and how it relates to the Core Activity described in order to conduct an accurate review of Core Activity Changes. Provider should submit additional information describing color teams and how it helps with continuity of care, and better management of patient panels for the providers in each color team.","Coastal Health & Wellness is seeking accreditation as a Patient Centered Medical Home. As part of this process, all patients will be assigned to a color team – red, blue or green. Each team current consists of a panel of providers with their clinical support staff. Patients will be assigned a primary care provider within their color group. The goal is to have each patient see their primary care provider, and if they are unavailable, to see another provider in the same color group. This will help the continuity of care for the patient as they will be seeing a familiar face each time, and better management of provider panels. New patients can be assigned to provider panels that are not full, and other patients can possibly be moved to other provider panels within the same color group in those instances where a provider panel in a color group may already be full.","LK",null,"N",null,null,"Accepted","HHSC requested additional information explaining the use of \"color teams\" as part of this Core Activity. Provider responded with thorough explanation which HHSC added to provider's \"Description of Core Activity\". The following explanation was added: \"Each team consists of a panel of providers with their clinical support staff. Patients will be assigned a primary care provider within their color group. The goal is to have each patient see their primary care provider, and if they are unavailable, to see another provider in the same color group. This will help the continuity of care for the patient as they will be seeing a familiar face each time, and better management of provider panels. New patients can be assigned to provider panels that are not full, and other patients can possibly be moved to other provider panels within the same color group in those instances where a provider panel in a color group may already be full.\" Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_094092602","094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public",37,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","The Care Management function within UTMB will expand its reach to better support those individuals who are at a higher clinical risk for admissions, readmissions, complications and ED visits.  As each patient is unique, we recognize that they will have custom care plans, but the processes needed to assure that those are developed will be enhanced.  This support of the multidisciplinary care efforts will work to ensure that the patient (or their family) is an active part of their own care management, factoring in discussions about long term goals, realistic expectations and how to identify when to escalate to a higher acuity of care.","Knowledge Gaps Exist for Patients, Providers and Staff regarding appropriate ED utilization.","Develop additional self-management education that describes (at the symptom level) when it is appropriate to go directly to the ED rather than contact their provider in clinic.","Educate providers and staff on where symptom level guidance, to be used to help triage patients who call either the clinic or the Access center, can be located."," "," "," ","Ambulatory Care Management practices are not standardized across all clinics/service lines.","Increase utilization of Epic-based risk scoring tool to identify individuals who would be prioritized for Care Management efforts."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C1; C2; D1","Enhancement of Care Management functionality to meet the needs of the individuals in our system will ensure that chronic conditions are monitored, preventive tests are ordered and that wellness efforts are maintained.  This additional layer of support will, in turn, allow for the components of the Triple Aim (right care, right time, right cost) to be followed.","No","","094092602.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_094092602","094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public",38,"Chronic Care Management","","Edit","Added an additional secondary driver to reflect efforts regarding outreach to patients with known gaps in care.  This proactive outreach plan should positively influence preventable ED and Inpatient usage.","Management of targeted patient populations with high risk for developing complications","","Expanding on the efforts of project 094092602.1.5, the panel management functionality for providers within the EMR will be leveraged to better identify those individuals who are at a higher clinical risk for admissions, readmissions, complications and ED visits.  By providing enhanced data analysis capabilities, our clinical teams can work with individual patients to get the appropriate tests and clinic visits done to ensure that the plan of care meets the needs of the patient.","In the Diabetic population, there are known knowledge gaps regarding self-care and nutrition.","Enhance the patient engagement opportunities to include additional efforts to ensure timely HbA1C testing and follow-up, including a symptom-driven educational strategy to better support these individuals on an ambulatory basis."," "," "," "," ","Closing care gaps in the ambulatory population to keep them (as much as possible) out of higher acuity settings.","Utilize analytic data to develop outreach lists (call, text and/or secured messaging) to reach patients with known health maintenance gaps."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; D1; C1; C2","Enhancement of the ability for providers (and their clinical teams) to more readily identify those patients who are at a higher clinical risk will ensure that outreach efforts for primary and specialty care, especially for the most medically fragile individuals in our system to have the support needed to be actively involved in their own care.","No","","094092602.7.1","LK","Provider added another driver to this core activity of developing an outreach list of patients that have gaps in care. This driver seems aligned and appropriate with the remaining Core Activty; recommend approval. ","Y","NB","in agreement.  Approving","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_094148602","094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private",39,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","BHSET plans to improve navigation referrals and care coordination for patients discharged from the hospital and ED through a revised system-wide discharge process.  Under the new process, care coordinators will send navigation referral requests for patients discharged from the hospital or ED to a patient navigator in BHSETs Smart Health Clinic.   Based on the navigator's intake, a determination is made regarding patient needs for social, navigational and/or medical services, and appropriate services are assigned. In the event that multiple referrals come into the clinic at once, the patient's needs are \"triaged\" and those in the greatest need receive the most immediate care.  BHSET staff members involved in the referrals and/or discharge processes will receive training through the Nursing Education and Informatics departments. In addition, BHSETs Discharge Committee and the Readmissions Taskforce will regularly review, assess, and address areas of improvement for the new discharge process. BHSET believes that our secondary drivers and change ideas  will directly support our core activity assist us in meeting our Readmission measure reduction goals (B1-141 and B1-217), as well as the Post-Discharge appointment measure goals (B1-352).","The 1st secondary driver in support of the core activity is to reduce hospital readmissions (all cause and target conditions such as CHF) for patients served by BHSETs system.","BHSET will provide post discharge patient navigation services targeting hospital and ED patients with chronic diseases who are at high risk of hospital readmissions.","BHSET will design customized navigation services for each patient with goal to maintain patient in the community and avoid hospital readmissions."," "," "," ","The 2nd secondary driver in support of the core activity is to improve and expand patient referrals to patient navigation services for hospital and ED patients at high risk of hospital readmissions.","BHSET will enhance education and training for medical and nursing staff regarding the new patient referral process.","BHSETs Smart Health clinic will triage patient navigation referrals made by hospital and ED staff and emphasize getting needed services and appointments to targeted patients with chronic conditions such as CHF in a timely manner."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The patient navigation core activity impacts the measures of the B1 bundle in several apparent ways. First, it causes BHSET to remain focused on the most critical elements effecting care transitions and reductions in hospital readmissions. The patient navigation and care transition team will be assessing / reassessing patients' knowledge of their chronic disease processes, which will influence readmissions rates - disease specific and all-cuase. The team will also be ensuring that proper hospital follow-up measures are addressed - particularly as they rleate to the post-discharge medication reconcilation and post-discharge appointments. The BHSET system plans to optimize use of this core activity to meet its new DSRP goals.","No","","094148602.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_094164302","094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private",55,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","Woodland Heights Medical Center (\"WHMC\") will implement a navigator program in its Emergency Department to decrease the number of unnecssary ED visits, connect patients with primary care provdiers, and decrease the number of Left Without Being Seen/Treatment occurrences in its ED.","Establish a patient navigator program","WHMC hire up to two full-time equivalent personnel to establish a patient navigator program.","Screen and evaluate ED patients without a primary care provider and assist these individuals to connect to a primary care provider.","Screen and evaluate Medicaid and Low Income and Uninsured patients to assist with follow up care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","A patient navigator program  will reduce emergecy department visits at WHMC for Acute Ambulatory Care Sensitive Conditions (ACSC) and other conditions.","No","","094164302.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_096166602","096166602.7.1",2,"096166602","Spindletop Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",40,"Access to Primary Care Services","","Edit","The changes were made to expand the circle of available primary care service providers rather than directing clients exclusively to the center-owned primary care clinic.  In 1) b) i) the words \"primary care clinic\" were changed to \"primary care services\".  Also a third Change idea was added to include educating BH staff on services available to clients provided by third-party primary care clinics.","Integrated physical and behavioral health care services","","This Core Activity is supported by the DY2-DY6 096166602.2.1 Primary Care Clinic, 096166602.2.7 Peer-to-Peer Support, and 096166602.2.3 Behavioral Health Training projects.  This activity addresses the physical health needs of behavioral health clients to improve key wellness measures and availability to primary care.","Increase referrals to primary care services from the behavioral health outpatient clinics.","Add the primary care clinic to the electronic internal referral form","Educate behavioral health staff on the services available to clients provided by the primary care clinic."," Educate behavioral health staff on the services available to clients provided by third-party primary care providers."," "," ","Utilize internal resources to direct clients to health and wellness programs","Implementation of educational workshops and outreach programs to address key wellness measures"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-115; M1-147; M1-211; M1-259; M1-260","Each of the measures address physical health.  Addressing the physical health needs of clients will result in improved quality of life, as well as, reducing emergency room visits and hospitalizations for more severe illnesses and diseases that occur when physical health is neglected.","No","","096166602.7.1","LK","Provider added another driver to this core activity of developing more robust referral procedures for clients to acess primary care services- not just to providers within their health system but also to other PCPs. Changes seem consistent with what was expected from DY8 Review and aligned with the Core Activity.","Y","NB","Provider updated the Secondary Driver and added a change Idea - acceptable. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_096166602","096166602.7.1",2,"096166602","Spindletop Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",41,"Prevention and Wellness","","Continue","","Self‐management programs and wellness programs using evidence‐based designs","","This Core Activity is supported by the DY2-DY6 096166602.2.7 Peer-to-Peer Support, 096166602.2.3 Behavioral Health Training, and 096166602.2.1 Primary Care Clinic projects.  This activity addresses the supportive services needed for clients to overcome factors that prevent improvement in wellness habits and community interaction.","Utilize internal resources to direct clients to health and wellness programs","Implementation of educational workshops and outreach programs to address key wellness measures"," "," "," "," ","Engage clients to participate in these support services.","Identify potential clients that would benefit from support services."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-105; M1-115; M1-147; M1-260","This Core Activity addresses support services through self-management and wellness programs.  The center offers whole health peer support and Whole Health Action Management (WHAM).  Peer specialists provide whole health interventions, including conducting health risk assessments, setting SMART goals, providing educational and supportive services to targeted individuals with specific disorders, such as, hypertension (M1-103), diabetes (M1-115), or health risks, such as, obesity (M1-147), tobacco use (M1-105), and physical inactivity (M1-147).  Clients are referred to primary care providers for a complete annual physical exam (M1-260).  Also offered is Wellness Recovery Action Plan (WRAP) and Cognitive Adaptation Training (CAT) to promote wellness and adherence to behavioral health treatments and to promote recovery in the community.  Spindletop staff have determined that these evidence-based practices will promote positive health and social outcomes/quality of life.  the primary care clinic partners with these support activities by providing medical and wellness services.","No","","096166602.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_096166602","096166602.7.1",2,"096166602","Spindletop Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",42,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Provision of services to individuals that address social determinants of health","","This Core Activity is supported by 096166602.2.3 behavioral health outpatient services and further supported by the 096166602.2.1 Primary Care Clinic project.  The focus is to identify and address external and social determinants slowing or preventing improvement in overall mental and physical health and wellness.","Assess client's risk of external determinants of health and wellness","Identify and address housing situation and provide alternative options, if needed","Identify and offer treatment for potential risk of harm to self or others in the community","Identify and provide treatment options for substance use disorders"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-261; M1-265; M1-319; M1-340; M1-341","Assessment of external determinants and alternative options, such as treatment, have a significant long-term benefit to both the client and the community.  These interventions remove barriers and support the client in their health and wellness improvement efforts.","No","","096166602.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_112671602","112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private",43,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Research, develop, test, and implement evidence-based protocol to address preventable death and complications for mothers and infants, for specific delivery issues (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","Develop and implement clinical pathways in participation with Texas AIM Plus Program","Develop and implement standing orders and evidence-based protocol","To have staff educated on standard protocol"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","The development and implementation of standard protocols for leading causes of preventable death and complications for mothers and infants will allow us to address the related issues related to Cesarean sections, Antenatal steroid use, and obstetric hemorrhage and have evidence-based plans for reducing the occurrence of these issues.","No","","112671602.7.1","LK","Secondary Drivers seem vague but because we are familiar with the TexasAIM program so HHSC is aware of the specific activities of their Secondary Drivers for this measure","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_112671602","112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private",44,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Research, develop, test, and implement evidence-based protocol to address preventable infections and injury (CLABSI, CAUTI, surgical site infections, Patient Falls, and Post-operative sepsis)","Develop and implement clinical pathways including a nurse-driven catheter and falls protocol, and the establishment of an interdisciplinary infection prevention team","Develop and implement standing orders and evidence-based protocol","To have staff educated on standard protocol"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The development and implementation of standard protocols for leading causes preventable injury and infection will allow us to provide evidence-based solutions for common infection and injury causes that are measured through the Hospital Safety Bundle.","No","","112671602.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_130983309","130983309.7.1",2,"130983309","Angelina County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public",56,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The Angelina County & Cities Health District core activity focus will enhance current primary care service processes to improve preventive health screening timeliness and establish mechanisms for follow-up services that ensure quality health care is provided by the organization.  The Health District has 4.5 mid-level providers who will be committed to this intervention, which will be implemented in one location housing all Health District services. ","Provide breast cancer screening for women and follow-up services after review of test results when medically indicated.","Improved internal processes relative to patient preventive health screening timeliness and follow-up.","Improved patient education relative to the importance of preventive health screenings."," "," "," ","Provide hypertension screening for all patient encounters and follow-up services when hypertension is identified in the clinical setting","Improved internal processes relative to patient preventive health screening timeliness and follow-up.","Improved patient education relative to the importance of blood pressure control.","Connect individuals to lifestyle modification resources."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-186; L1-210","The Core activity and secondary driver objectives will be the framework Angelina County & Cities Health District needs to create a dynamic framework of sustainability and continuity for the progress made relative to preventive care and screening for High Blood Pressure and Breast Cancer Screening as well as follow-up measures.  In addition, Category A elements connect and provide direction for Health District leadership in the development, implementation, and evaluation of quality process improvement activities relative to selected measures under Category C.","No","","130983309.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_131030203","131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public",45,"Prevention and Wellness","","Continue","","Self‐management programs and wellness programs using evidence‐based designs","","Following our one on one self-management sessions with Diabetes patients we are continuing our work as this links to DY1-6 project ID 131030203.2.1. We still notice the lack of diabetes education and poor healthy behaviors. We will focus more heavily on promoting our diabetes educational one-on-one sessions throughout our system.","Provide education sessions to patients with diabetes. We plan on utilizing our licensed clinic personnel who will be in charge of these one-on-one sessions as well as collaborating with local dietary institutions on having them develop a Diabetes cook book with several recipes that we can give away during the sessions.","In pursuit of this, our licensed clinic personnel will conduct the Diabetes health educative sessions as well as doing follow ups with these patients.","Development of a diabetes cook book by local dietary institutions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","This activity will definitely create a platform that will educate diabetic patients on how to manage the disease in terms of avoiding foods and activities that can complicate a patient's health even more and promoting healthy behaviours.","No","","131030203.7.1","LK","Core Activity intervention describes diabetes case management and education; flagging because it seems like a more appropriate \"Core Activity Grouping\" would be \"Chronic Care Management\" rather than \"Prevention and Wellness\".","Y","NB","It is acceptable to have this CA under Prevention and Wellness, as well as Chronic management. Depends on the details and what exactly provider is doing. Leaving it as an NMI but adjusted the note to provider.","Needs More Information","Provider reported that this Core Activity will provide education and care coordination for the diabetic population. Provider has designated this Core Activity Grouping as \"Prevention and Wellness\"'. Depending on all activities that provider is undertaking, provider can also consider Core Activity Grouping of \"Chronic Care Management\". Since HHSC does not have a full description of provider’s undertaking, HHSC is requesting that the provider makes a determination on whether it is appropriate to reflect this activity under Prevention and Wellness or move it to \"Chronic Care Management\" if a more serious management of patients is done.","After consideration and discussions held by the provider, it has been decided to maintain the grouping as “Prevention and Wellness.” The reason for this decision is because the provider is not managing patients or their cases within this Core Activity, and it is of the provider’s opinion that the grouping of “Chronic Care Management” would be misleading. The intention of this Core Activity is to offer patients the education necessary to promote better diabetes self-management, therefore, encouraging improved prevention and overall wellness.","LK",null,"N",null,null,"Accepted","HHSC encouraged provider to review if Core Activity as described was more appropriately \"Prevention and Wellness\" (as provider originally reported) or \"Chronic Care Management\" because the provider's reported activity provided disease education to patients with diabetes. Provider has confirmed that the nature of Core Activity 45 is more accurately represented by the \"Prevention and Wellness\" activity grouping. Provider's selection of the Core Activity for DY9-10 is accepted. ","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_131030203","131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public",46,"Maternal and Infant Health Care","","Edit","","Coordinated prenatal and postpartum care","","We are continuing our work as this links to our DY 1-6 with the project ID 131030203.1.00. We plan on implementing an activity that will be geared towards underserved pregnant women, more priority will be put towards making sure these mothers receive prenatal care and contraception methods.","With the goal to improve and serve our Primary Service area population, we are planning to utilize our EHR system to automate text message communications with our patient population.","We will support our text messaging campaign with personalized clinical and management staff phone follow up.","Creating awareness of the Community Health Education for our target popluation (pregnant women)"," "," "," ","Having noticed that most of our maternal patients go to our clinics and are not aware of the pregnancy classes held at the hospital and the low rate of prenatal visits, lack of education on contraception methods and low rates of postpaturm visits we are considering being more aggressive in creating awareness of these classes.","We are pursuing a focused marketing/education campaign in both English and Spanish within our clinics which will include pre and post natal education information, class schedules and contraception methods."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This will reduce complications of deliveries, increase the use of contraception methods as the clinical staff establishes communication with the patients. Also this will reduce low birth weights as we establish and implement activities that will increase prenatal visits.","No","","131030203.7.1","LK","Provider describes the Core Activity as \"addressing the social determinants of health\" for mothers; however, the secondary drivers seem unrelated to one another and only loosley related to the social determinants of health. Flagging for 2nd review. ","Y","NB","Agree with the concept but the note did not make sence and was not completed. Re-wrote the message","Needs More Information","Provider has designated this Core Activity Title as “Provision of services to individuals that address social determinants of health (SDoH)”. Provider’s description included in Secondary Driver 1 and Change Ideas does not necessarily reflect activities related to SDoH. Provider should review its description of this Core Activity and respond if a different Core Activity title would be more appropriate for provider’s activity (e.g. Implementation of evidence-based strategies to reduce low birth weight and preterm birth or Provision of coordinated prenatal and postpartum care) or provider needs to include additional details describing how SDoH are addressed.","The provider would like to change the Core Activity title to a more appropriate title. The new title is “Delivering Systematic Prenatal and Postpartum Care.”","LK",null,"N",null,null,"Accepted","HHSC encouraged provider to review if Core Activity as described was accurately captured by the Core Activity Title “Provision of services to individuals that address social determinants of health (SDoH)” because it is described as a care assistance program for pregnant women. Provider has confirmed that Core Activity 46 is more appropriately entitled \"“Delivering Systematic Prenatal and Postpartum Care.” However, HHSC updated to a Core Activity Name from the menu: Provision of coordinated prenatal and postpartum care. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_135222109","135222109.7.1",2,135222109,"The Gulf Coast Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",47,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","M1-105 is being added to foster provision of additional services to Gulf Coast Center (GCC) Consumers, 18 years and older, at all Adult Outpatient GCC Clinics within both Brazoria and Galveston Counties. M1-105:  Preventive Care & Screening: Tobacco Use:  Screening & Cessation Intervention is a measure which must be implemented to become a Certified Community Behavioral Health Clinic, a standard to which GCC has proudly committed.  For reporting purposes, GCC will gather information and report utilizing the E.H.R. methodology.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","GCCs Core Activity is inclusive of any activities undertaken in pursuit of GCCs goal to become a CCBHC.  Such endeavors may include, but are not limited to, activities in the areas of licensure requirements; behavioral healthcare integration; facility and service integration; community integration; staffing; availability and accessibility of services; care coordination; scope of services; quality and other reporting; and organizational authority, governance and accreditation.  [Please note:  This template does not accommodate the capacity requisite for listing the full number of Driver/Change Idea Sets associated with GCC'S nine measures, all of which are linked to one core activity.  GCC has generalized and entered the top five secondary drivers from a total of twenty-four.  During the October 2018 reporting, GCC will provide the full driver schematic diagram.]","Identify individuals with specified diagnoses and/or at-risk features.","Identify an age-appropriate, standardized screening/assessment instrument to be implemented for usage.","Build/program the selected screening/assessment tool into the EHR.","Train staff to proficiently administer and score the screening/assessment tool.","Develop reports to track assessment administration and scoring."," ","Increase prescriber schedule fill rates for Revenue Cycle Management.","Select a single scheduling point for appointments at the two largest clinics.","Select a single contact for medical record distribution.","Conduct reminder calls prior to the follow-up appointments.","Modify work flow, or work in appointments through walk-in services.","Increase hours of operation through decentralization of intake services.","Develop/document follow-up plans for individuals identified with specified diagnoses and/or at-risk features.","Identify and select follow-up plan options for implementation.","Build/program the selected follow-up plans into the EHR.","Realign clinic workflow to efficiently accommodate assimilation of the assessemnt and follow-up plan options into the workflow.","Develop reports to track assignment of follow-up plans."," ","Increase COPSD screenings and case management services.","Identify dually diagnosed individuals for COPSD screenings.","Develop/program an EHR report to track progress of screenings."," "," "," ","Increase Substance Abuse referrals for OSAR screenings.","Re-train staff to make referrals, as appropriate.","Develop/program a report in the EHR to track referrals."," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-261; M1-340; M1-160; M1-257; M1-305; M1-317; M1-319; M1-405; M1-105","Five of the ten selected measures are clinic-reported measures for CCBHC's, and have been specified with application of the same source measure used for CCBHC reporting requirements.  Thus, the components being measured, along with the execution of the measurement methodology and the care/treatment approach stipulated within the specifications, align with the Core Activity.  The integration of mental health and substance-use disorder services is one of the principle tenets of CCBHC's; thus, the focus of five of the selected measures is that of behavioral health care integration.  One of the selected measures is an MCO measure.  CCBHC's must demonstrate the ability to collaborate and establish partnerships with MCO's wherein  alternative payment models/value-based purchasing, opposed to fee-for-service payment models, are linked to quality measures.  This partnership, predicated on the linkage between payment for services and value (quality and/or efficiency) of services, is key to catalyzing patient-centric care that will result in improved patient outcomes and enhanced patient experience of care.  In preparation for future negotiations with MCO's, GGC has selected an MCO-required measure.","No","","135222109.7.1","LK","Provider adjusted Measure Bundle to include M1-105: Tobacco Screening and  it was approved. This measure seems to be apporpriately added to this core activity but I am flagging for second review for confirmation.","Y","NB","Accepting 1st reviewer assessment.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_136367307","136367307.7.1",2,"136367307","Burke Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",35,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","As a Texas CCBHC Center, Burke will focus to align provision of care in its mental health clinics to  that of the Certified Community Behavioral Health Clinic (CCBHC) model.  A primary focus of this Core Activity revolves around care coordination.  Care coordination is a critical function of the CCBHC model.  Burke intends to deliberately organize individual's care activities to achieve more productive care.","Burke intends to employ clinicians in a care coordinator capacity, whose role is to focus clinical attention on gaps in care for individuals who are identified as having high needs and/or high risks for mental health and primary care services.  Care coordination activities include going beyond simply making referrals to providers (both within Burke’s spectrum of care and externally) by focusing on barriers that may prevent or pose a challenge to the individual, and ensuring that referrals are completed (i.e. closing the loop on referrals).  High need and/or high risk for mental health and primary care is defined as individuals (both children and adults) who demonstrate moderate to severe scores on the Child and Adolescent Needs and Strengths Assessment (CANS)/Adult Needs and Strengths Assessment (ANSA) domains related to Behavioral Health Needs and the Physical/Medical domain, or who have been identified as recent or frequent utilizers of higher levels of care (i.e. psychiatric hospitalization, medical hospitalization/emergency department utilization).  Coordination of care is an unfunded evidence-based practice that is an integral activity in addressing all the needs of an individual throughout a spectrum of care, and is a critical aspect in the CCBHC model of care.  According to SAMHSA: ‘Care coordination is the cornerstone of many healthcare redesign efforts, including primary and behavioral healthcare integration. It involves bringing together various providers and information systems to coordinate health services, patient needs, and information to help better achieve the goals of treatment and care. Research shows that care coordination increases efficiency and improves clinical outcomes and patient satisfaction with care.’","Burke intends to adopt and implement a care coordination model of care.  Care coordination requires moving beyond a standard approach of case management in which needs are identified and referrals are made.  Clinicians who are providing care coordination activities take a more deliberate approach in organizing the individual’s care needs, both within Burke’s internal care providers and with external providers.  Care coordination activities include follow-up with individuals and providers to identify barriers to receiving identified care needs and ensuring that referrals to care are not just made, but every attempt to assist the individual with keeping/attending referrals is made.  ","Burke plans to hire and train staff in the care coordination model.","Burke intends to identify individuals with high needs for both mental health and primary care services.  This high need and/or high risk target population includes both children and adults who have been assessed using the CANS/ANSA and who demonstrate actionable scores (i.e. scores of 2 or 3) in the Behavioral Health Needs domains as well as the Physical/Medical domain.  This target population can also include individuals for whom recent and/or frequent utilization of higher levels of care (i.e. psychiatric hospitals, medical hospitals, and/or emergency departments) has been identified.  Another factor considered in the identification of individuals who are often at high risk are social drivers of health (i.e. poverty, food insecurity, housing insecurity and other negative conditions that exists in places where people live)."," "," "," Burke intends to expand and enhance its Informatics and Data Analytics capacity in order to focus on social drivers of health.  Burke captures a tremendous volume of data within its Electronic Health Record (EHR) which can be utilized to identify social drivers of health, including potential/actual barriers that prevent or increase the difficulty of an individual receiving care or care equal to those less impacted.  Through expanding and enhancing our Informatics and Data Analytics capacity, Burke could provide care coordinators with enriched data capabilities when coordinating needs, risks, and potential barriers to meeting the individual’s care needs."," Burke intends to hire an additional Data Analytics professional.  This position will be able to mine data pertinent to individuals who have been identified as having high risk and/or high need for mental health and primary care.  Data and reports can be tailored to assist care coordinators in effectively identifying social drivers of health as well as any gaps in care for the targeted population."," Burke plans to identify health information exchanges (HIEs) and other resources that could assist in coordinating referrals for the targeted population of individuals with identified high risks and/or high needs for behavioral health and primary care.  Burke intends to continue to negotiate with managed care organizations (MCOs) to exchange information on shared populations, including hospital admissions and emergency room visits. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,1,1,1,1,1,1,1,1,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-147; M1-160; M1-257; M1-259; M1-260; M1-261; M1-264; M1-265; M1-266; M1-317; M1-286","Many of the measures selected for this Core Activity are CCBHC measures.  Other measures will be impacted by the implementation of care coordination, which is a primary component of the CCBHC model.  It is Burke's intent that with the implementation of care coordination, as well as all other service provision related to the CCBHC model, the selected measures will demonstrate improved outcomes.","No","","136367307.7.1","LK","Core Activity described seems vague- provider describes that they will insititute \"care coordination\" but does not describe the populations that they will target, what entities care is being coordinated with, or what mechanisms they will use to coordinate that care (E.H.R.? any patient outreach or communication? collaboration with partner agencies? etc.) Flagging for 2nd review if HHSC needs additional information.","Y","NB","Agree, but the note was not detailed. Updated feedback to provider","Needs More Information","The provider's listed Core Activity focuses on care integration, however it does not describe details of this care coordination and targeted population.  Provider should include additional details in Secondary Driver 1 and Change Idea 1. Provider can also clarify what is the targeted population (e.g. define high needs) in Change Idea 3. Provider should consider adding new Secondary Drivers and Change Ideas to specify what provider is doing for CCBHC initiative. Provider should include its response in the Provider Response field. Changes to the impacted measures is also dependent on approval of the discontinuation of M1-286.","Secondary Driver 1 – Burke intends to employ clinicians in a care coordinator capacity, whose role is to focus clinical attention on gaps in care for individuals who are identified as having high needs and/or high risks for mental health and primary care services.  Care coordination activities include going beyond simply making referrals to providers (both within Burke’s spectrum of care and externally) by focusing on barriers that may prevent or pose a challenge to the individual, and ensuring that referrals are completed (i.e. closing the loop on referrals).  High need and/or high risk for mental health and primary care is defined as individuals (both children and adults) who demonstrate moderate to severe scores on the Child and Adolescent Needs and Strengths Assessment (CANS)/Adult Needs and Strengths Assessment (ANSA) domains related to Behavioral Health Needs and the Physical/Medical domain, or who have been identified as recent or frequent utilizers of higher levels of care (i.e. psychiatric hospitalization, medical hospitalization/emergency department utilization).  Coordination of care is an unfunded evidence-based practice that is an integral activity in addressing all the needs of an individual throughout a spectrum of care, and is a critical aspect in the CCBHC model of care.  According to SAMHSA: ‘Care coordination is the cornerstone of many healthcare redesign efforts, including primary and behavioral healthcare integration. It involves bringing together various providers and information systems to coordinate health services, patient needs, and information to help better achieve the goals of treatment and care. Research shows that care coordination increases efficiency and improves clinical outcomes and patient satisfaction with care.’\n\tfor Change Idea 1 – Burke intends to adopt and implement a care coordination model of care.  Care coordination requires moving beyond a standard approach of case management in which needs are identified and referrals are made.  Clinicians who are providing care coordination activities take a more deliberate approach in organizing the individual’s care needs, both within Burke’s internal care providers and with external providers.  Care coordination activities include follow-up with individuals and providers to identify barriers to receiving identified care needs and ensuring that referrals to care are not just made, but every attempt to assist the individual with keeping/attending referrals is made.  \n\tfor Change Idea 3 – Burke intends to identify individuals with high needs for both mental health and primary care services.  This high need and/or high risk target population includes both children and adults who have been assessed using the CANS/ANSA and who demonstrate actionable scores (i.e. scores of 2 or 3) in the Behavioral Health Needs domains as well as the Physical/Medical domain.  This target population can also include individuals for whom recent and/or frequent utilization of higher levels of care (i.e. psychiatric hospitals, medical hospitals, and/or emergency departments) has been identified.  Another factor considered in the identification of individuals who are often at high risk are social drivers of health (i.e. poverty, food insecurity, housing insecurity and other negative conditions that exists in places where people live).\n \nADDITIONAL SECONDARY DRIVER (as per HHSC’s advice for consideration)\nSecondary Driver 2 – Burke intends to expand and enhance its Informatics and Data Analytics capacity in order to focus on social drivers of health.  Burke captures a tremendous volume of data within its Electronic Health Record (EHR) which can be utilized to identify social drivers of health, including potential/actual barriers that prevent or increase the difficulty of an individual receiving care or care equal to those less impacted.  Through expanding and enhancing our Informatics and Data Analytics capacity, Burke could provide care coordinators with enriched data capabilities when coordinating needs, risks, and potential barriers to meeting the individual’s care needs.\nChange Idea 1 – Burke intends to hire an additional Data Analytics professional.  This position will be able to mine data pertinent to individuals who have been identified as having high risk and/or high need for mental health and primary care.  Data and reports can be tailored to assist care coordinators in effectively identifying social drivers of health as well as any gaps in care for the targeted population.  \nChange Idea 2 – Burke plans to identify health information exchanges (HIEs) and other resources that could assist in coordinating referrals for the targeted population of individuals with identified high risks and/or high needs for behavioral health and primary care.  Burke intends to continue to negotiate with managed care organizations (MCOs) to exchange information on shared populations, including hospital admissions and emergency room visits. ","LK",null,"N",null,null,"Accepted","HHSC requested additional information explaining Secondary Driver 1 and its Change Ideas. Provider provided additional detail that clarifies the activities of Secondary Driver 1 (Burke intends to employ clinicians in a care coordinator capacity) including Change Idea 1 (Burke intends to adopt and implement a care coordination model of care) and Change Idea 3 (Burke intends to identify individuals with high needs for both mental health and primary care services through CANSA and ANSA assessments). Provider added Secondary Driver 2 (Burke intends to expand and enhance its Informatics and Data Analytics capacity) with Change Idea 1 (Burke intends to hire an additional Data Analytics professional) and Change Idea 2 (Burke plans to identify health information exchanges and other resources that could assist in coordinating referrals). HHSC has updated according to their description. HHSC has also added back in M1-286 as impacted measure as the request to discontinue the measure was withdrawn. Provider's selection of the Core Activity for DY9-10 is accepted.\n","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_136381405","136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public",48,"Prevention and Wellness","","Edit","","Self‐management programs and wellness programs using evidence‐based designs",null,"Patient education targeting tobacco cessation will be developed. This education will include material hand-outs that are reviewed with the patient by the nurse and/or provider. The education will include benefits of cessastion as well as resources to assist the patient in cessation.","Staff development and inservice to ensure understanding of the new education program as well as implementing new practices to maintain continuity within the program","Staff training to include introduction of the new patient education material, required practices in identifying the need for patient education as well as documentation of the need and the steps taken to provide patient education"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This measure bundle seeks to improve patient health through preventive care. Tobacco cessation education supports this objective in that patient success through this activity would lead to improved lung and overall health.","No","","136381405.7.1","LK",null,"N",null,null,"Needs More Information","HHSC has updated the Core Activity Name from \"Other: Patient education on tobacco cessation\" to \"Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)\" to better align with the provider's described Core Activity. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Name is appropriate instead of \"Other\".","Tyler County Hospital accepts HHSC’s change in Core Activity Name","LK",null,"N",null,null,"Accepted","HHSC suggested that the provider change the Core Activity Grouping from \"Other: Patient education on tobacco cessation\" to \"Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)\" to more appropriately capture the tobacco use education campaign being administered by the provider. Provider agreed with HHSC's suggestion. Provider's selection of the Core Activity for DY9-10 is accepted.","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_136381405","136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public",49,"Prevention and Wellness",null,"Edit","","Other","Pneumonia vaccination patient education for those 65 and older ","A patient education hand-out will be created and provided to those patients 65 and older on the benefits of receiving a pneumonia vaccination. This resource will be utilized in a way that will assist the patient in deciding whether getting the vaccination is a benefit to them or not. ","Cost will be relating factor for patients considering the vaccination.","A list of possible resources that are available to assist in the cost as well as a price list of pharmacies where vaccinations can be received."," "," "," "," ","","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","As this bundles objective is preventive care, providing resources that aid those 65 and over in making the decision to receive the vaccination and locating the most affordable option, this activity assist in meeting the objective.","No","","136381405.7.1","LK","Provider lists their first Secondary Driver as \"Cost will be relating factor for patients considering the vaccination.\". This makes me wonder if they understand the concept of a Secondary Driver and what aspect of their transformation activity it's supposed to describe. Also, changing their Cor Activity Grouping to prevention because it's a vaccination education program. ","Y","NB","in agreement. Will think if other options for Other title. ","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other\" (Patient Education on Pneumonia Vaccination) to \"Prevention & Wellness\" to better align with the provider's described Core Activity. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping is appropriate instead of \"Other\".","Tyler County Hospital accepts HHSC’s change in Core Activity Grouping","LK",null,"N",null,null,"Accepted","HHSC suggested that the provider change the Core Activity Grouping from \"Other (Patient Education on Pneumonia Vaccination)\" to \"Prevention and Wellness\" to more appropriately capture the pneumonia vaccination education campaign being administered by the provider. Provider approved HHSC's suggestion.","Other","CA-7","CA-7.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_138296208","138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private",50,"Maternal and Infant Health Care","","Continue","","Coordinated prenatal and postpartum care","","CHRISTUS will expand access to pre and post natal care services to improve the continuum of pregnancy care from prenatal stage through delivery and post partum care, targeting Medicaid, uninsured,  and low income (MLIU) women.   CHRISTUS will engage in outreach and education campaign to increase awareness in the commuity regarding our recently opened OB clinic located near our St. Mary's facility and specifically target MLIU women in need of these services.","Increase access to prenatal and post partum services for MLIU patients who deliver at CHRISTUS hospital","Increase patient volume at CHRISTUS OB clinic through educational campaigns and outreach","Increase staffing at the CHRISTUS OB Clinic to accommodate service expansions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Increasing access to prenatal and post partum care services at our OB clinic directly impacts our selected measure bundle (E1-Maternal Care), which includes prenatal care measures and post partum care measures.","No","","138296208.7.1","LK","Would the Core Activity Name more appropriatedly be  Expanding Access for this activity? Flagging for 2nd review to confirm.","Y","nb","this grouping does not have title/area suggested by 1st reviewer. Leaving it as is.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_139172412","139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private",53,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Provision of navigation services to targeted patients",null,"Tracking and working to improve ED throughput times, as well as tracking Heart Failure follow-up appointments. These activities are reported both internally to the executives and externally. Improving throughput times and increasing the follow-up appointments for HF patients improves the overall patient experience and level of care.","For ED throughput, a sampling of patients are given to report through our Premier reporting system. For HF follow-ups, the first driver is identifying the appropriate patients.","Making the follow-up appointment for the patient and discharging them with education materials.The EMR does not support reminders for staff or best practice alerts to support staff in making follow-up appointments prior to discharge"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Part of our K2 bundle is to show improvement is the Admit Decision to ED Discharge time, as well as proper Transfer Communication within an appropriate time. This is part of the ED throughput times that are currently being tracked and reported.","No","","139172412.7.1","LK",null,"Y","NB","agree with NMI","Needs More Information","HHSC has updated the Core Activity Name from \"Other: Tracking ED throughput times for non-emergent patients, and assisting heart failure patients with education and follow-up appointments.\" to \"Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED\" to better align with the provider's described Core Activity. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Name is appropriate instead of \"Other\". If needed, provider can add additional change ideas to reflect work that is done for care navigation.","CHI Memorial Medical Center Lufkin accept's HHSC's change in Core Activity Name.","LK",null,"N",null,null,"Accepted","HHSC suggested that the provider change the Core Activity name and provider agreed with HHSC's suggestion. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_139172412","139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private",54,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","This core activity is a prevention measure to address hospitalized inpatients 6 months of age or older who were screened for seasonal influenza immunization status and who were vaccinated prior to discharge.","Screening patients for qualifications (age and immunziation status).","Immunizing all qualified patients before discharge.","Scheduling follow-ups for evaluation, therapy or possible admission."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","This measure is also not directly related to the K2 bundle, but is performed in the ED as a preventative care screening. By screening and vaccinating more patients for influenza, the system can possibly decrease unnecessary ED visits for the flu. This is also a service that many patients are not otherwise getting done, so it adds to the level of care they are receiving in our facility.","No","","139172412.7.1","LK","There is a DY8 Flag on this measure suggesting that the porvider identify a measure bundle that has to do with this activity. I think provider is correct in that the Core Actvitiy of coordinating care to vaccinate eligible patients aged 65+ does not tie directly to K2. Additionally, this provider might have misidentified the Core Activity Grouping; should it be \"Prevention and Wellness\" rather than \"Access to Primary Care Services\"? All around this core activity requires some scrutinizing, so I am flagging for 2nd review.","Y","NB","I changed it back to Access to primary Care services. Prevention and Wellness does not have vaccination area. Provider has another CA that ties to their measure bundle.","Accepted",null,null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_200683501","200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private",51,"Chronic Care Management",null,"Edit","","Management of targeted patient populations with high risk for developing complications","","For the core activity the hospital's Trauma Coordinator will work with the RHC's Care Coordinator to mangage the target population of our DSRIP attributed individuals, specifically focused on the MLIU patients and those that receive emergent care. Our selected metrics span preventative and emergency department services.  In early DY7/DY6a, we have already started quarterly system wide hospital/clinic quality improvement virtual meetings to discuss measures and focus and share best practices.  Facilities will be tracking and reporting on metrics at least quarterly, a designated person from each facility (likely the care coordinator) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. In addition, facilities will be utilizing an NQCA worksheet to assist in the organization of quality monitoring activities to include this performance improvement project.","Improve Care Coordination","Develop target population list for patients in need of prevention services from ED visits..","Contact patients and schedule primary care appointments."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2; K1","Coordination of target patient care will help to improve metrics in K1, and coordination between the Trauma Coordinator and RHC Care Coordinator will benefit ED patients served in K2.","No","","200683501.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_284333604","284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private",683,"Hospital Safety and Quality",null,"New",null,"Implementation of standard protocols to address leading cause of hospital infections and injuries",null,"Goal for this Core Activity is to implement practices that will lead to a reduction in health acquired infections throughout the health care facility.","prevent person to person transmission of infections via hand hygiene program and other evidence based procedures","Implementation of a hand hygiene program","Implementation of policies and procedures regarding reduction and prevention of HAI",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Proper hand hygiene impacts hospital safety","No",null,"284333604.7.1","LK",null,null,"NB","this is a newly created CA. Needs a number","Needs More Information","HHSC created a new Core Activity for the provider to reflect activities previously included in Secondary Driver 4 and the related Change Ideas. Provider should include additional information in the Provider Response Area: Description of a Core Activity, and needed changes to the current description for the Secondary Driver and Change Ideas; List of Measure Bundles or Measures Impacted; Description of Measure Bundle/Measure Impact. ","Liberty Dayton Regional Medical Center accepts HHSC's change as written. The only measure bundle tied to this Core Activity is J1. ","LK",null,"N",null,null,"Accepted","HHSC has suggested that the provider create this separate Core Activity. Provider reported that as part of Core Activity 52 (\"Expansion of Patient Care Navigation\"), provider was including the Secondary Driver of \"Reduction in health acquired infections throughout the health care facility\".  HHSC suggests that a new Core Activity of \"Hospital Safety and Quality\" would be more appropriate to capture the clinical activity described. Provider accepted HHSC's suggestion. HHSC has updated the description of how J1 is impacted by this Core Activity; however, provider should include additional details during DY9 reporting. Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 02_DY9-10 Regional Tracker - FINAL Tracker.xlsm.xlsb","2_284333604","284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private",52,"Expansion of Patient Care Navigation and Transition Services",null,"Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments",null,"The goal of this core activity is to enhance care coordination by developing and implementing a standardized communication process for the transitions of care process and utilization of electronic information system to provide communication to clients regarding care and follow up.","Improved communication and continuity of care regarding clients throughout all Liberty Dayton Regional Medical Center locations","Implementation and training of facility wide EMR system"," "," "," "," ","Increase throughput time in the Emergency Department for follow up care in community or for admission","Moving of patients from the ED immediately after admission","Hire staffing for post discharge follow up of certain populations to prevent unnecessary returns or admissions"," "," "," ","Implementation of transfer communication tool for consistant handoff communication of transferred patients","utilization of customized hand off communication tool for all patients transferred to another health care facility"," "," "," "," ",null,null,null," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1; K2","Communication and coordination of care across the continuum is vital for patient safety and reduction in HAI.  Communication results in a reduction of errors, continuity of care, effective patient handoffs and overall patient safety.","No","","284333604.7.1","LK","Secondary Driver 4 does not seem related to overall name and purpose of measure.","Y","NB","agree. Created a new Core Activity","Needs More Information","Provider's selection of Secondary Driver 4, \"Reduction in health acquired infections throughout the health care facility\" does not seem related to the core activity grouping of \"Expansion of Patient Care Navigation and Transition Services\". HHSC created a new Core Activity for the provider under Hospital Safety and Quality and moved Secondary Driver 4 Reduction in health acquired infections throughout the health care facility and related Change Ideas 1 and 2 to the new Core Activity. Provider should inform HHSC if in disagreement with that move.","Liberty Dayton Regional Medical Center accepts HHSC's change.","LK",null,"N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically by removing Secondary Driver 4 (\"Reduction in health acquired infections throughout the health care facility\") from this Core Activity and creating a new \"Hospital Safety and Quality\" Core Activity for this provider. Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020817501","020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private",57,"Expansion of Patient Care Navigation and Transition Services","","Edit","Southeast had to edit the measure in order to change the association to none, the measure is currently associated with the B2 bundle, but Southeast has requested that the measure bundle be dropped for DY9 and DY10.","Provision of navigation services to targeted patients","","Reduce preventable ED Utilization for patients with Chronic and Acute ambulatory care sensitive conconditions through the use of care navigators and community partrnership with primary care providers","Connect Patients to Primary and preventive care services","Care navigators main function will be to provide adults without a PCP educational materials and community resources, as well as assist them in making primary and preventative care appointments, determining the assistance necessary to keep those appointments, and to work with patients and their families to assure that their access to support (financial, transportation, in-home care, etc) is adequate."," "," "," "," ","Identify frequent ED users and use navigators as part of a preventable ED reduction program.","HCA Houston Healthcare South will identify adult patients with high rates of ED utilization The Care Coordinator will target those patients visiting the ED for education and intervention aimed at preventing future ED use for non-emergent ambulatory care sensitive conditions and/or preventing conditions from becoming emergent in the first place."," "," "," "," ","Increase access to care management and/or chronic care management and self-management","Patients will receive self- management education and chronic care management. The Care Coordinator will be dedicated to providing those services. This will increase access to information and resources that adults in Harris County would not otherwise be able to utilize for less emergent healthcare needs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Through our navigation services, we will be able to reduce the number of inappropriate non-emergent presentations to the ED and assist patient in accessing the appropriate services in the appropriate care setting. Ultimately, our efforts should result in reductions for ACSC conditions presenting to ED.","No","","020817501.7.1","BTM","Discontinuation of B2 is pending 2nd review and possibly NMI. The edits are acceptable though, other than association with B2 issue.","Y","NB","Contingent on Cat C resolution","Needs More Information","Provider's request to delete the core activity association to \"none\" is pending the Needs More Information for the discontinuation of bundle B2. ","Per 2/6/20 e-mail, provider is withdrawing request to discontinue B2.","BTM","Per 2/6/20 e-mail, provider is withdrawing request to discontinue B2. Continue core activity.","N",null,null,"Accepted","Provider has withdrawn request to discontinue the core activity. ","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020817501","020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private",58,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Implement standardized evidence based identification and care management protocols for sepsis patients for any patient of BMC that is identified with sepsis or has the potential to develop sepsis.","Increase sepsis bundle compliance for patients that have a case of sepsis or are at risk of developing sepsis.","Increase the number of patients who receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) resuscitation and management bundles after presenting with symptoms of sepsis or septic shock."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The implementation of the sepsis bundle administration on a consistent basis should reduce the instance of sepsis and improve mortality for patients that do have severe sepsis, improving hospital safety.","No","","020817501.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020817501","020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private",684,"Maternal and Infant Health Care","","New","","Implement standard protocols for the leading causes of preventable death and complications","","Improve team response and outcomes of obstetric hemorrhage by updating the Obstetric Hemorrhage - Code Hemorrhage Policy, utilize Code Hemorrhage debriefs to inform quality improvement, and provide ongoing training and education regarding the assessment and treatment of obstetric hemorrhage.  ","Reduce the incedence and effects of post partum hemmorhage (PPH) through education and collaboration to improve the clinical readiness, recognition and response to PPH","Develop a standardized post partum hemmorhage(PPH) protocol/safety bundle identifying the roles/duties of the OB team and rapid response for high risk, critical management for the hemmorhage crisis","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2; E1","This Core activity has positively impacted the bundle in that it has helped Southeast achieve its E2 bundle measure AIM participation goal and in conjunction with the prenatal education that occurs in the outpatient setting Southeast expects to see improvements in both bundle's outcomes for both new moms and infants. Additionally, the processes that have been put in place will directly affect maternal hemorrhage","No","","020817501.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",59,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","24-Hour Nurse Triage Hotline: this program is a phone line available 24 hours a day and 7 days a week that allows a patient to call a specially trained registered nurse that provides guidance and navigation services on the appropriate course of action with current symptoms or concerns. This services has staff and resources to potentially provide over 70,000 encounters a year. This hotline is available to take calls from anywhere in the state of Texas but the core activity focuses advertisement and improvement within the greater Houston area. The 24-Hour Nurse Triage Hotline continously updates staffing models according to demand and  to address quality and includes around 20 staff members that are either nurses or patient navigators.","Educate Memorial Hermann patients and external community about the triage line.","Community promotions at events and other external activities, paid online advertisement, promotion on Memorial Hermann websites."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2; B1","B1: Care Transitions & Hospital Readmission  the objective of this bundle is to implement improvement in care transitions and coordination of care from inpatient to outpatient, post-acute care, and home care settings in order to improve health outcomes and prevent increased health care costs and hospital readmission. This core activity improves care transition and coordination of care for patients in our community by providing navigation and follow up services by phone that could direct patients to the appropriate level of care for their current symptoms and/or concern.B2: Patient Navigation & ED Diversion  the objective of this bundle is to utilize patient navigators (community health workers, case managers, or other types of professionals) and/or develop other strategies to provide enhances social support and culturally competent care to connect high risk patients to primary care or medical home sites, improve patient outcomes, and divert patients needing non-urgent care to appropriate settings. This core activity improves patient outcomes and diverts high risk patients from the ED setting to appropriate care setting by utilizing specially trained CHWs and Registered Nurses (RN) to navigate patients to the appropriate level of care for their current symptoms and concerns.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",60,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Increasing access to services by utilizing qualified staff","","Psych Response Team Case Management: this core activity provides a case management program for behavioral health patients who present to our hospitals and are experiencing a crisis. This program is staffed by specially educated social workers, nurses, and CHWs that continue work with the patient outside of the hospital. Staff assists the patients will prescriptions, follow up appointments, and other navigation services. This core activity has the staff and resources to reach patients in all facilities listed in the system. The staff models for this core activity are continuously updated. Currently the staff consists of 11 Case Managers, 2 Project Managers, 5 Social Workers, and other mental health providers that are available for patient intervention.","The proper identification of patients at our facilities in need of this program.","Education of front line staff at all emergency department and nursing floors on how to identify patients experiencing a behavioral health crisis."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","H2: Behavioral Health and Appropriate Utilization  The objective of this bundle is to provide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions. This core activity provides specialized and coordinated services to patients with serious mental/behavioral health illness by enrolling them in a case management program designed to navigate and coordinate care for the patient outside the hospital or clinic thus reducing unnecessary ED visits, hospital visits, or mental health crises.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increasing access to services by utilizing staff with the following qualifications: Wellness and Health Navigation: Bachelors level professional with experience in mental health and/or wellness initiatives or a peer specialist who has successfully completed the DSHS certification program for peer specialists","CA-9","CA-9.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",61,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Increasing access to services by utilizing qualified staff","","Home Health Psychiatric Program: this core activity provides psychiatric services to patients in the home health setting, including the Medicaid and Uninsured patient population. This core activity is provided to patients as needed and identified by other ongoing core activities. Thie core activity has staff and resources to provide wellness and navigation services including medication adherence and regular behavioral health screenings. This core activity can serve patients that are identified at any Memorial Hermann facility and 2 providers are tied to this activity.","Increasing the education and management of psychiatric medications for this population.","Process improvement on education and follow up for patients prescribed psychiatric medications."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","H2: Behavioral Health and Appropriate Utilization \u0096 The objective of this bundle is to provide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions. This core activity provides specialized and coordinated services to patients with serious mental/behavioral health illness by providing services addressing mental and psychiatric health needs in the patient\u0092s home. These services better coordinate care for the patient and reduce unnecessary ED visits, hospital admission, and hospital readmission.","No","","020834001.7.1","BTM","Removed comment about checkboxes, and H2 is associated with this CA.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has removed  the refence to checkboxes in the Description of Measure Bundle/Measure Impact (Description of Measure Bundle/Measure Impact: The checkboxes will not save but measure bundle H2 should be checked.)",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increasing access to services by utilizing staff with the following qualifications: Wellness and Health Navigation: Bachelors level professional with experience in mental health and/or wellness initiatives or a peer specialist who has successfully completed the DSHS certification program for peer specialists","CA-9","CA-9.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",62,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","Integrated Behavioral Health & Primary Care: this core activity is a new pilot program at Memorial Hermann that provides psychatric services to patients in a primary care setting. This core activity currently consists of a pilot program at four MHMG clinics with plans for improvement and expansion. Staff and resources for this core activity will be able to provide regular behavioral health screenings and interventions for this poulation in the primary care setting. Staffing models for this core activity's pilot have not been finalized and are still undergoing the proof of concept process.","Expand the integrated behavioral health and primary care program to additional primary care clinics","Analyze pilot program performance and identify additional locations where these services are needed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","H1 Integration of Behavioral health in a Primary or Specialty Care Setting - The objective of this bundle is to implement depression, substance abuse disorder, and behavioral health screening and multi-modal treatemetn in a primary care or non-psychatric specialty care setting. This core activity is new pilot program that implements these psychatric services and screenings into our primary care clinics.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",63,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Convenient Care Centers: This core activity increased access to care for Medicaid and uninsured patients by increasing the number of providers accepting this patient population and expanding hours and convenient care center clinics. This core activity impacts four facilities and utilizes anywhere from 30-40 providers.","Expand and/or adjust Convenient Care Center hours as needed based on patient volume and demand to offer after-hours and limited weekend primary care.","Track patient volume and demand at the Convenient Care Centers to determine whether expanding or adjusting clinic hours will effectively increase access to primary care and reduce unnecessary ED visits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","B1: Care Transitions & Hospital Readmission  the objective of this bundle is to implement improvement in care transitions and coordination of care from inpatient to outpatient, post-acute care, and home care settings in order to improve health outcomes and prevent increased health care costs and hospital readmission. This core activity increases access to primary care and improves coordination of care by providing a setting and physicians that provide primary care services to the MLIU population with some appointments available during extended hours.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",64,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Palliative Care Program: This core activity provides palliative care services to Medicaid and uninsured patients by specially trained palliative MDs and mid-level providers. This improves patient and family relations with end of life decisions and quality of life for the patient. This core activity includes services historically not provided for the Medicaid and uninsured patient population. This core activity has the staff and resources to potentially impact all hospital facilities in the system and utilizes a palliative care team of approximately 15 providers.","Increase the number of patients utilizing palliative care.","Continue to educate physicians on palliative care services that are available for their patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","G1: Palliative Care  the objective of this bundle is to provide palliative care services to patients and their families and/or caregivers to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.  This core activity improves patient outcomes and quality of life by providing palliative care services to hospitalized patients, which focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_020834001","020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private",65,"Hospital Safety and Quality","","Continue","","Implementation of evidence-based practices to improve quality of care","","This core activity focuses on creating an environment to improve patient health outcomes and experiecne by reducing hospital related risks and errors. This environment anticipates potential problems, promotes early detection of problems, and always makes responses early. This core activity impacts all hospitals in the system and will impact the large number of staff and providers employed and/or associated with these hospitals.","Continue to monitor risks, errors, and near misses in the hospital.","Utilize systems including EMR reports to track outstanding risks, errors, or potential errors in the hospital."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","J1: Hospital Safety Improve  the objective of this bundle is to improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors. This core activity directly impacts the bundle objective by creating an environment in which potential problems are anticipated, detected early, and virtually always responded to early enough to prevent catastrophic consequences.","No","","020834001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_081522701","081522701.7.1",3,"081522701","Texana Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",66,"Behavioral Health Crisis Stabilization Services","","Continue","","Implementation of community‐based crisis stabilization alternatives","","This core activity is the continuation of the Crisis Center.  The Crisis Center is an 8 bed extended observation unit and a 14 bed crisis residential unit where individuals experiencing a mental health crisis or on the verge a mental health crisis go in lieu of an admission in a psychiatric hospital.  This activity involves over 50 providers (telemedicine psychiatrists, \"warm body\" psychiatrists, LPHA's and QMHP's).  In addition to these providers, the Crisis Center is staffed with RN's, LVN's and rounded by a primary care Nurse Practitioner.","Through crisis screenings, identify patients in need of crisis stabilization services and appropriate for the Crisis Center to reduce hospital recidivism and increase jail diversion.","Utilize a crisis screening tool including medical exclusionary criteria to determine appropriateness for the Crisis Center."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-160; M1-210; M1-257; M1-264; M1-305; M1-317; M1-319","In the Crisis Center, individuals experiencing a mental health crisis are stabilized and assessed for additional medical concerns.  These measures touch on important physical health components as well as managing symptoms of mental illness.  The Crisis Center provides a place for all of these things to be assessed, education provided to the indiviual and plans made for required follow up once discharged from the Crisis Center.","No","","081522701.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.","CA-11","CA-11.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_081522701","081522701.7.1",3,"081522701","Texana Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",67,"Access to Primary Care Services","","Continue","","Integrated physical and behavioral health care services","","This core activity involves establishing a primary care clinic inside of a behavioral healthcare clinic.  A Nurse Practitioner is utilized to diagnose acute and chronic disease conditions.  Individuals are diagnosed, treated and medications provided.   Health education including chronic disease management through medications, nutrition and exercise is provided by a Chronic Care RN.  This clinic is located in the Behavioral Healthcare Clinic at Rosenberg but is open for others being served in behavioral healthcare services in the following clinics:  Behavioral Healthcare Clinic at Wharton, Behavioral Healthcare Clinic at Bay City, Behavioral Healthcare Clinic at Brookshire, Behavioral Healthcare Clinic at Sugar Land.  If these individuals are willing to drive or ride on our van to the Rosenberg Clinic, they can receive these primary care services.  The clinic includes one Nurse Practitioner, one Chronic Care RN and one LVN.","Implement a medication adherence process for chronic conditions (i.e., uncontrolled hypertension or diabetes).","Implement processes in clinic workflow that incorporates patient education delivery."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-210; M1-317; M1-211; M1-257; M1-203; M1-400; M1-182","As individuals are identified in the behavioral healthcare clinic, they are referred to the Nurse Practitioner and Chronic Care RN for treatment and education including medications.  For most individuals, they simply have not had the means to receive these services and pay for the medications.  It is an opportunity for education regarding how substance abuse issues effect not only mental health but physical health as well.  This core activity focuses on educating individuals the regarding tobacco and alcohol use and obsesity and the role these habits play in maintaining good physical health primarily with respect to uncontrolled hypertension and diabetes care.  A large number of those we serve are at risk of Hepatitis C and this core activity focuses on testing and referral for follow up for this disease as well.","No","","081522701.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_082006001","082006001.7.1",3,"082006001","Baylor College of Medicine Grants and Contracts De","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private",68,"Prevention and Wellness","","Continue","","Utilization of whole health peer support","","With the help of BTHC physicians and social workers, the clinic will develop, implement and train providers to use a health behavior intervention protocol based on evidence-based strategies to reduce and prevent obesity in adolescents. Clinical providers, particularly nurse practitioners and licensed medical social workers, are being trained on how to provide quality counseling using motivational interviewing techniques around nutrition and physical activity to all patients, but especially to patients who are overweight or obese. Health behavior intervention will include medically and non-medically related issues. For example, use of electronic devices, evidence-based interventions for obesity management (including utilizing motivational interviewing for assessing readiness for change and increasing motivation for change), provision of lifestyle modification guidance, assistance with generation of SMART goals for weight management, problem solving and addressing barriers to achievement of weight loss goals, frequent follow-up visits, involving peers and family, and targeting the community at large by conducting healthy lifestyle classes during the summer. The objective is to reduce and prevent obesity in adolescents, and to help adolescents with obesity move closer to a healthier BMI and reduce risk for related morbidities. For this activity there are 5 licensed medical social workers available to provide counseling to patients. Two physicians and 8 nurse practitioners are able to provide health behavior counseling interventions. All 11 clinic sites will be implementing core activities mentioned in the drivers below. ","Screening patients for BMI and tobacco use during visits.","Record BMI and tobacco use in EMR system and implement alerts to flag patients out of normal range"," "," "," "," ","Develop and implement a health behavior intervention protocol based on evidence-based strategies to reduce and prevent obesity in adolescents.","Incorporate smart phrases from evidence-based research to best support providers' comfort and quality in providing nutrition, physical activity and tobacco counseling and education."," "," "," "," ","Train social workers and medical staff in obesity counseling","Improve current training materials to meet patient needs"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","These Drivers will help clinicians identify those who smoke and those who are at or above the 95th percentile for BMI. Social workers and medical staff will address smoking cessation and health behavior intervention around childhood obesity. With the social workers' help, the patients will have longer and more detailed interventions beyond the medical visit. With the help of BTHC physicians and social workers, the clinic will develop and implement a health behavior intervention protocol based on evidence-based strategies to reduce and prevent obesity in adolescents--to meet the innovative metric.","No","","082006001.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of whole health peer support, which could include conducting health risk assessments, setting SMART goals, providing educational and supportive services to targeted individuals with specific disorders (e.g., hypertension, diabetes, and health risks such as obesity, tobacco use, and physical inactivity)","CA-7","CA-7.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",69,"Expansion or Enhancement of Oral Health Services","","Edit","City of Houston ran five dental clinics between 10/1/2018 and 9/30/2019, not four clinics as prevsioulsy stated. They are Sunnyside, La Nueva Casa de Amigos Dental Clinic, Northside, Sharpstown, and Magnolia Dental Clinic.","Expanded use of existing dental clinics for underserved population","","For this activity, we will expand the use of our four dental clinics throughout Houston to reach at-risk populations.  This will entail an increase in the client knowledge/education, increase clinical capacity through workforce development, and increase routine dental examinations of at-risk populations. About ten DDS/DMD and one dental hygienist work on this activity.","Increase awareness on the general knowledge of oral health, importance of oral health and self-efficacy","Outreach to vulnerable populations through schools and community events"," "," "," "," ","Increase clinic capacity to meet the expansion needs","Formalize partnership for workforce development with community stakeholders and dental providers"," "," "," "," ","Increase patient recall to ensure clients are meeting suggested dental care guidelines","Ensure clients are scheduled and seen every six months for routine cleanings/examinations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-225; L1-224","For this activity, the use of the city dental clinics will be expanded.  Interventions include oral health education and   treatment. Outreaches in communities and workforce development will increase the at-risk population we engage and serve, respectively. Oral health education will enhance the awareness  around the importance of oral health. The adoption of more aggressive follow up scheduling will increase routine dental examinations of at-risk populations. The combination of these efforts will lead to better oral health and decrease untreated cavities in at risk populations.","No","","093774008.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded use of existing dental clinics for underserved population","CA-3","CA-3.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",70,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Through screening and outreach, we will identify people to offer health education, health promotion, and  interventions which will prevent or help clients manage chronic conditions improve health, and enhance the quality of life.  For home visitation sessions, a registered nurse will provide, prenatal, infant and childhood education for pregnant women and children. A total of 9 nurses work in the home visitation program.  We will also offer educational sessions for clients on oral health, mental health, tobacco cessation, and stress management.","Increase compliance for post-partum care for women seen in home-visitation","Strengthen relationships with providers to get glucose screenings","Establish partnerships with behavioral health providers","Assist clients with securing a payer source for primary care services","Ensure timeliness of follow-up for post-partum mothers"," ","Ensure adequate screening for tobacco use, BMI, and blood pressure of clients who access our services in the clinic setting","Strengthen screening and follow-up protocol a) provider education; b) QA","Connect clients to care coordination group for service linkage","Standardize tobacco cessation counseling in clinic setting"," "," ","Increase awareness on the general knowledge of sexual behaviors and safe-sex, importance of healthy sexual practices and self-efficacy","Outreach to women in family planning, e.g. Healthy Texas Women","Provide education to clients on healthy sexual practices"," "," "," ","Continue standardized STD screening processes for clients accessing services","Increase clinic capacity to screen population accessing services","QA to ensure clients are being appropriately screened"," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-235; L1-105; L1-280; L1-147; L1-210","Through standardized screening for tobacco use, BMI, and blood pressure of clients, high risk populations will be identified and offered counseling and health education on the importance of primary care. The intervention of care navigation can resolve barriers to access to primary care, and thus improve health.  For home visitation sessions, a registered nurse will provide prenatal, infant and childhood education for pregnant women and children, as well as refer the client to primary care and other community resources. The interventions will improve pregnancy outcomes by promoting healthly behaviors.  Women in family planning will be screened for chlamydia and provided with education on healthy sexual practices. The interventions will increase the general health and self-efficacy of those seen. In summary,  the combination of these interventiosn  will hopefully improve  the health and enhance the quality of life of clients.","No","","093774008.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",71,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Use improved screening tests and shortened treatment course to prevent and treat disease.  The use of innovative treatment has reduced traditional treatment visits, thus improving compliance and reduction in administrative costs.  This activity occurs throughout the community and in the homes of patients.  There are around 15 staff members assigned to support this function.","Increase 3HP enrollment of clients targeted for treatment","Identify high risk populations through testing and contact investigations (e.g. congregate settings: homeless shelters, universities, immigrants)","Provide education on 1) importance of treatment; 2) general knowledge of 3HP and DOT"," "," "," ","Increase clincial evaluation of clients targeted for treatment","Provide transportation for clinical appointment for potential clients","Provide translational services to clients trageted for treatment","Provide education on the importance of clinical evaluations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-347","Testing and contact investigation can accurately identify high risk populations with latent tuberculosis infection (LTBI). Education will improve the general knowledge on prescribed treatment regimen, help the clients to understand the benefits of short course therapy. Clinical evaluation will be adopted to ensure   accessing services is not hendered by barriers such as transportation and language. All of these efforts will hopefully lead to higher completion rate of LTBI treatment.","No","","093774008.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",72,"Access to Primary Care Services","","Edit","A second secondary driver was added to focus on the internal referral process from other HHD programs to the HHD Care Coordination program. Care Coordination can offer clients additional resources on health coverage and help link clients to a medical home or primary care physician if needed. ","Establishment of care coordination and active referral management","","Develop and enhance coordination of providers of the individuals, with diabetes, who request services from our agency to help them manage their disease.  Develop and enhance partnerships with key stakeholder who offer programming that help diabetics, pre-diabetics, and their care givers manage their disease. This activity will initiate in the four clinical settings and additional activity will occur throughout the community and in the homes of patients.  There are around eight (8) staff members assigned to support this function.","Increase primary care access for clients without medical homes","Establish new partnerships with primary care providers","Enhance ongoing relationships with referring providers and PCPs","Enhance bi-directional referral protocol with providers","Standardize the referral processes to and from providers"," ","  Establish partnership with local Care Navigation teams (e.g. Links, Connect)","  Enhance bidirectional referral protocols for individuals with pre-diabetes"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115; L1-207","Diabetes and hypertension are both chronic conditions that may require a variety of interventions to manage, including adhering to prescribed medications and education around appropriate eating and physical activity practices.  The establishment and enhancement of relationships with primary care providers and medical homes will strengthen the continuum of care for clients with diabetes. This in turn will hopefully lead to a clients better understanding of and how to manage of their chronic conditions.","No","","093774008.7.1","BTM","Provider reflected changes made in october. Accepting.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Establishment of care coordination and active referral management that integrates information from referrals into the plan of care","CA-1","CA-1.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",73,"Prevention and Wellness","","Edit","Some change ideas under the first secondary driver were not able to be carried out due to decreases in personnel capacity -- specifically, the Conversation Series and in-house tools were not implemented during the measurement period. ","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Provide chronic disease and diabetes self-management education and other behavior-change based services to diabetics, individuals with high blood pressure, individuals with BMIs outside of recommended guidelines, and those at risk of developing any of the aforementioned conditions. Services are centered around, but not limited to, self-management education, active living, healthy eating, community engagement, health coaching, and health connections.  This activity will occur throughout the community and in our 11 mulitservice centers.  There are around six (6) staff members assigned to support this function.","Expansion of educational services offered by the local health department","Develop and update BP, abnormal BMI, tobacco cessation and prevention activities","Host monthly wellness resource seminars, e.g. BP management, DASH diet, alcohol reduction, nutrition, active living, weight management, tobacco cessation","Conduct evidence-based health education series, e.g. Nutrition Ed/DASH, CDSM, Weight Management","Host Pop-up Conversation Series on BP, BMI management topics"," ","Offer tobacco cessation counseling and follow-up to clients","Increase collaborations with local resources, e.g. Quit Line, MD Anderson, etc.","Promotion of internal services offered and link to Health Education"," "," "," ","Increase awareness on the general knowledge of diabetes, importance of diabetes management and self-efficacy","Monitor blood pressure from all diabetic clients we engage","Offer medication adherance education to participants","Implement self-monitoring blood pressure curriculum","Capture HbA1c from all diabetic and pre-diabetic clients","Provide chronic disease self-management educational sessions and trainings"," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115; L1-207; L1-147; L1-210","Development and enhancement of chronic disease and diabetes self-management education will ensure that clients referred for diabetes, weight management, hypertension, and tobacco cessation services will receive appropriate follow-up plans with goals for addressing identified chronic conditions and unhealthy behaviors.","No","","093774008.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_093774008","093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public",74,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","Uses navigators to link clients with acute and chronic conditions and individuals to services that help improve the clients' health and well-being.  Outputs from health department programing indicate that most barriers to care are knowledge based and transportation. This activity will initiate in the four clinical settings and additional activity will occur throughout the community and in the homes of patients.  There are around eight (8) staff members assigned to support this function.","Offer referrals for pre-hypertensive and hypertensive clients","Increase collaborations with local resources for individuals with blood pressure readings outside of the normal parameters","Promotion of internal services offered and link to Health Education"," "," "," ","Offer referrals for BMIs that are outside of normal parameters","Increase collaborations with local resources for individuals with BMIs outside of the normal parameters","Promotion of internal services offered and link to Health Education"," "," "," ","Effectiveness of Care Coordination Services offered to clients","Ensure staff has/completes Community Health Worker Certification","Training in Patient Navigation and specific subject matters","Develop curriculum for continuing education for staff in care coordination"," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-105; L1-147; L1-210","Patient navigators will be used to help develop follow-up plans for clients refeered for weight management, hypertension, diabetes, and tobacco cessation. Navigators will also help clients address any barriers identified to the prevention or managment of the identified condition. These barriers may be social needs, assistance with navigating the health care system, or assistance with accessing appropriate health care setting. To ensure that HHD clients receive the best care possible, its also imperative that the patient navigators are properly trained and can speak to the barriers and identified  for these chronic conditions.","No","","093774008.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_094187402","094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private",75,"Expansion of Patient Care Navigation and Transition Services","","Edit","West had to edit the measure in order to change the association to none, the measure is currently associated with the B2 bundle, but West has requested that the measure bundle be dropped for DY9 and DY10.","Provision of navigation services to targeted patients","","Reduce preventable ED Utilization for patients with Chronic and Acute ambulatory care sensitive conconditions through the use of care navigators and community partrnership with primary care providers","Increase access to care management resources and/or self management education for ED patients.","Patients will receive self- management education and chronic care management. The care coordinator will be dedicated to providing those services. This will increase access to information and resources that adults in Harris County would not otherwise be able to utilize for less emergent healthcare needs."," "," "," "," ","Identify frequent ED users and patients with ACSC and use navigators as part of a preventable ED visit reduction program.","HCA Houston Healthcare West will identify adult patients with high rates of ED utilization. The Care Coordinator will target those patients visiting the ED for education and intervention aimed at preventing future ED use for non-emergent ambulatory care sensitive conditions and/or preventing conditions from becoming emergent in the first place.","Identify patients with specific chronic and acute ACSCs and use navigators to ensure patients with ACSCs are educated regarding their conditions and connect them with a primary care setting for management of their condition."," "," "," ","Connect ED Patients to Primary and preventive care services","The care coordinator's main function will be to provide educational materials and community resourced to adults without a PCP in the ED setting.","The care coordinator will assist identified patients in making primary and preventative care appointments, determining the assistance necessary to keep those appointments.","The care coordinator will work with patients and their families to help ensure that their access to support (financial, transportation, in-home care, etc) is adequate."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Through modification of our current navigation services we will be able to reduce the number of inappropriate non-emergent presentations to the ED and assist patient in accessing the appropriate services in the appropriate care setting. Ultimately, our efforts should result in reductions for ACSC conditions presenting to ED.","No","","094187402.7.1","BTM","Discontinuation of B2 is pending 2nd review and possibly NMI. The edits are acceptable though, other than association with B2 issue.","Y","NB","Contingent on Cat C resolution","Needs More Information","Provider's request to delete the core activity association to \"none\" is pending the Needs More Information for the discontinuation of bundle B2. ","Per 2/6/20 e-mail, provider is withdrawing request to discontinue B2.","BTM","Per 2/6/20 e-mail, provider is withdrawing request to discontinue B2. Continue core activity.","N",null,null,"Accepted","Provider has withdrawn request to discontinue the core activity.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_094187402","094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private",76,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Implement standardized evidence based identification and care management protocols for sepsis patients for any patient of WHMC that is identified with sepsis or has the potential to develop sepsis.","Increase sepsis bundle compliance for patients that have a case of sepsis or are at risk of developing sepsis.","Implement Sepsis Bundle protocol to increase the number of patients who receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) resuscitation and management bundles after presenting with symptoms of sepsis or septic shock."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The implementation of the sepsis bundle administration on a consistent basis should reduce the instance of sepsis and improve mortality for patients that do have severe sepsis, improving hospital safety.","No","","094187402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_094187402","094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private",685,"Maternal and Infant Health Care","","New","","Implement standard protocols for the leading causes of preventable death and complications","","Improve team response and outcomes of obstetric hemorrhage by updating the Obstetric Hemorrhage - Code Hemorrhage Policy, utilize Code Hemorrhage debriefs to inform quality improvement, and provide ongoing training and education regarding the assessment and treatment of obstetric hemorrhage.  ","Reduce the incedence and effects of post partum hemmorhage (PPH) through education and collaboration to improve the clinical readiness, recognition and response to PPH","Develop a standardized post partum hemmorhage(PPH) protocol/safety bundle identifying the roles/duties of the OB team and rapid response for high risk, critical management for the hemmorhage crisis","","","","","","","","","","","","","","","","","","","","","","","","","","","","",1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","This Core activity will help West achieve its E2 bundle measure goals by implementing the processes that have been put in place will directly affect maternal hemorrhage","No","","094187402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_111810101","111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",77,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Preventive services, such as screening tests, for the early detection of disease are associated with dramatic reductions in morbidity and mortality. Our UT Physicians primary care practitioners are the frontline providers who identify patients with potential risks to develop a disease. Screening programs such as cancer screenings (i.e., Pap smear, mammography, colonoscopy or FOBT), cardiovascular and smoking-related disease, obesity, depression or anxiety, have been developed and implemented in the UT Physicians clinics during the first part of the waiver. Our providers will continue to educate patients on the importance of screenings, perform screenings on site when possible, and make referrals as needed. Workflows have been designed and implemented in order to retrieve screening results when performed outside of UT Physicians. Follow-up services will continue to be offered based on screening results. Those who screen positive will receive referrals for appropriate intervention and/or treatment.About 100 primary care providers along with their care team members (e.g., community health worker, referral coordinator, case manager, social worker) across 15 UT Physicians locations will be working on improving the health outcomes in the measure bundles impacted by this core activity.","Identify patients who are eligible for screening and offer eligible patients an appointment","Provide providers and clinic staff with access to preventive care dashboards including gap assessments.  Dashboards provide real time visualizations for health outcomes that highlights individual-, clinic-, and department-level performance.  Additionally, providers can drill down to the patient as the unit of analysis."," "," "," "," ","Improve time to referral and follow up by enlisting support from referral coordinator and/or care teams","Update referral and follow up procedures and workflows to ensure referral status is checked regularly, in addition to at pre- and post- visit planning"," "," "," "," ","Educate patients on importance and benefits of screening","Maximize patient education opportunities during pre- and post- visit planning and provide screening reminders","Provide patients with educational brochures and other visual cues (e.g., posters in waiting rooms, point of care report)"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2; C3; D1; E1; H1","The provision of screening and follow up services is a core tenet of primary care, especially prevention.  The drivers and change ideas identified above serve as a roadmap to improve screening (e.g., cancer, substance use including tobacco, depression, hepatitis, chlamydia) and follow up rates of children and adults seen at UT Physicians.  Physicians will work collaboratively with patients and their care teams to identify who is eligible for screening and to ensure timely referral and follow up post-screening.  Increases in screening may lead to earlier detection and treatment which potentially can contain healthcare costs and the negative and, often, severe consequences of undetected/untreated illness.","No","","111810101.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_111810101","111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",78,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","At UT Physicians, the PCMH model is the gold standard for which comprehensive, coordinated, high quality care is delivered. A central tenet of this model is empanelment which enables physicians and teams to provide continuous care across the medical neighborhood. Care teams will manage patient panels that can be categorized by chronic diseases and preventive care. At least 15 primary care clinics and approximately 100 primary care providers recognize this model to deliver coordinated care.","Assign each patient to a single provider panel with consent from patient to initiate patient centered planning","Employ Murray 4-cut method to those patients without a documented primary care provider (PCP).  This method is evidence-based and systematic for assigning patients to a single provider after a thorough assessment of supply and demand is conducted.  This recognized linkage between the provider and patient promotes continuity of care.","Obtaining consent for provider assignment will be reviewed with clinic staff and patients."," "," "," ","Assess practice supply and demand regularly and re-balance patient load as needed","Determine ideal panel sizes for each practice; reconcile actual versus ideal panel sizes"," "," "," "," ","Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, need, etc.","Manage panels across a comprehensive set of disease and risk levels (population health)"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1; D1","The PCMH model makes the primary care practice the hub for all medical care for children and adults.  Adult and pediatric primary care measure bundles (C1, D1)  will benefit from provider assignment which facilitates continuity of care.  The model is especially important for patients with chronic diseases because there is often the need to coordinate care across specialties. Therefore, the diabetes care (A1) measure bundle will be impacted by primary and specialty care. This core activity describes how teams monitor patient panels using registries to proactively engage patients in needed care.","No","","111810101.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_111810101","111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",79,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","UT Physicians patients often relay a variety of social, economic, and educational barriers to effectively managing their health.  Due to the limited time providers have during the medical appointment, team-based care offers relevant and targeted approaches to addressing patient health needs.  These non-physician staff can provide education, skill building, monitoring and resources outside the medical appointment and help navigate the overwhelming healthcare system.  Tailored care teams will partner with over 100 providers in at least 15 primary care clinics to comprehensively address health barriers.","Establish scope of practice and define roles for care teams that reflect the skills and abilities of team members","Set expectations for care delivered outside of the clinic","Evaluate capacity for internal/external referrals and modify care team duties accordingly"," "," "," ","Provide convenient access points to link patients to provider and care team whenever possible","Expand implementation of same-day appointments to additional clinic location(s)","Utilize the nurse triage line (available 24 hours per day/7 days per week) for urgent clinical advice after hours"," "," "," ","Establish and provide organizational support for care teams that are accountable to patient panels","Assess training needs regularly and provide cross training to ensure care teams are able to meet patient needs consistently"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; H1","UT Physicians adopts the team-based approach to addressing the needs of complex diabetic and hypertensive patients.  Given the comorbidities that often accompany heart disease and diabetes, care teams are poised to support transitions of care, screening, behavioral health integration and management of blood pressure and hemoglobin A1c.  Also, care teams will be accessible to both providers and patients to deliver care via phone, messaging, home visits, and in the clinic. Similarly, since behavioral health is co-located with physical health, teams can seamlessly offer continuous healthcare.","No","","111810101.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_111810101","111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",80,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","Vaccinations are one of the best ways to protect individuals from preventable diseases that could ultimately lead to death. Thus, they are highly recommended for individuals of all age groups including infants, children, adolescents, adults and older adults. Also, some vaccines wear off over time so maintenance and follow-up care for individuals of all ages is critically important. Through this core activity, UT Physicians providers will continue to educate our patients on the importance of vaccinations and will provide the recommended immunizations for eligible children, teens and adults. In addition, our care teams will be used to identify patients who are due for an immunization or a booster. They will reach out to patients and offer an appointment with a provider. About 100 primary care and specialty care providers along with their care team members, including family medicine, internal medicine and pediatrics, will be participating in this core activity, impacting 15 UT Physicians locations.","Educate patients/parents on the importance of immunizations","Train care teams on educating patients on the importance of maintaining vaccinations up-to-date"," "," "," "," ","Use care teams to identify and reach out to patients who are due for immunization/booster","Train clinic leadership (e.g., physicians, case managers, practice managers) on the use of web-based dashboards/smart registries that can identify gaps in care","Train clinical staff (e.g., community health workers, medical assistants) on verifying immunization status at pre visit phone calls"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C3; D1","The provision of vaccinations is a core tenet of primary care services, especially prevention.  Through this core activity, UT Physicians providers and care teams will educate patients on the importance of vaccinations and will provide the recommended immunizations for children, teens and adults. Also, based on age, health condition, and other factors like job or travel, immunizations against pneumonia, influenza, human papillomavirus, hepatitis A and B will be recommended and delivered. This will allow us to successfully achieve immunization measures for children, adolescents and adults included in C1, C3 and D1 measure bundles.Increases in vaccination compliance will lead to better protection of the population against potentially harmful diseases, which will eventually lead to an improved health for the population and a decreased heath costs related to preventable diseases.","No","","111810101.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_111810101","111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",81,"Access to Primary Care Services","","Continue","","Integrated physical and behavioral health care services","","Integrating both physical (PH) and behavioral health (BH) services in one setting allows for more accessible, acceptable, and less costly care to patients. Through integrated care services, patients are able to receive care that is more convenient (located within their community and in a clinic offering extended hours) and coordinated (ability to address PH and BH conditions in a single visit) intervention in a setting that reduces the stigma of receiving BH services. UT Physicians has implemented and will continue to offer an integrated PH and BH care program for both children and adults. At least 15 primary care clinics and approximately 30 behavioral health as well as primary care providers will be participating in this core activity.","Document integrated treatment plans in the electronic health record","Educate providers on how to use and properly document in the integrated treatment plan"," "," "," "," ","Enhance integration meetings among primary care providers and behavioral health providers on a regular basis","Train primary care providers and staff on behavioral health assessment and treatment","Train behavioral health providers in short duration treatment and in physical health diagnosis, especially for common chronic conditions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","UT Physicians established protocols for documenting behavioral health screening, referrals, and developed integrated treatment plans during DY3-6. Moving forward, we continue to standardize pathways across clinics and intensify interdisciplinary collaboration efforts.  We are certain that the best practices we established during DY3-6 will lead to increased screening and better management of depression in the population served by UT Physicians.","No","","111810101.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_112672402","112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public",82,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","This core activity is comprised of screening, diagnostic follow-up and navigation to treatment for cancer as appropriate for breast and colorectal cancers.  This core activity will be conducted at MD Anderson Hospital as well as four locations of Spring Branch Community Health Centers. Providers dedicated to the intervention are two physicians and one radiologist.","Continue screening patients for colorectal cancer using take-home FITs and provide appropriate diagnostic follow-up to patients who test positive and are diagnosed with cancer.","Provide refresher trainings for clinic staff regarding FIT testing guidelines and procedures."," "," "," "," ","Continue offering breast cancer screening and appropriate diagnostic follow-up through Project VALET mobile mammography program.","Use patient reminder calls to decrease the no-show rates for screening services in the mobile mammography van."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","These activities will increase access to cancer screening in the primary care setting.  MD Anderson provides breast and colorectal cancer screening services that might otherwise be unavailable or severely limited at Spring Branch Community Health Center locations and other FQHCs outside our system definition.","Yes","MD Anderson provides mobile mammography and diagnostic follow-up services and colorectal cancer screening and diagnostic follow-up to several other clinics/clinic systems in RHP3 in addition to services provided at MD Anderson Hospital and Spring Branch Community Health Centers which are included in the Category B System Definition. We excluded clinics from our system definition primarily due to data limitations. For example, some clinics do not collect financial class information or accept insurance. One clinic system recently changed its EHR and had not yet entered in legacy data into its new system. Another clinic uses a sliding scale to assess patient fees, but does not retain evidence of or document income status in the patient’s electronic health record once income is verified. One clinic reported being unable to comply with the requirements of data collection according to measure specifications.   \n      \n","112672402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_112672402","112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public",83,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","We will focus on enhancements to after hospital communication.  Two faculty and one project director oversee this initiative. One of the key metrics for this initiative is after hospital communication. The primary driver of this activity is to improve the readmission rate and patient satisfaction by 1) contacting 100% of patients and 2) creating a standardized evaluation process. ","Improve the readmission rate and patient satisfaction","Contacting 100% of patients following disharge","Creating a standardized evaluation process"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The Discharge Management Initiative is expected to positively impact our patients by reducing unplanned readmissions (B1-141 and B1-217)  as well as improving medication reconciliations post-discharge (B1-124).","No","","112672402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_112672402","112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public",84,"Palliative Care","","Continue","","Utilization of services assisting individuals with pain management","","This Core Activity addresses the needs of patients in managing their pain while identifying and mitigating risk of opioid abuse in patients with cancer related pain. A comprehensive checklist for assessing pain in patients taking opioids will be implemented. This includes a targeted intervention to address patient pain and actively engage patients in finding effective treatments for their pain. This core activity will be implemented at MD Anderson Cancer Center's hospital. There are five physicians committed to this intervention.","Implement a system for pain management in patients taking opioids.","Document findings of a comprehensive pain assessment for patients taking opioids","Actively engage patients in decision making  to find effective alternatives for pain management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This Core Activity impacts the measure bundle by enhancing patients utilization of services for pain management by identifying patients at risk for opoid abuse and actively engaging them in finding safe and effective alternatives for pain management.  The core activity will be implemented with patients at MD Anderson Cancer Center. The  core activity also specifically impacts G1-276 Hospice and Palliative Care -Pain Assessment.","No","","112672402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of services assisting individuals with pain management.","CA-12","CA-12.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_112672402","112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public",85,"Hospital Safety and Quality","","Continue","","Implementation of evidence-based practices to improve quality of care","","The aim of this activity is to: 1) maintain inpatient Catheter-associated Urinary Tract Infections (CAUTI) rates and 2) maintain inpatient Central Line Associated Bloodstream Infections without mucosal barrier injury or MBI (CLABSI) rates. Primary drivers are 1) compliance with the institutional inpatient CAUTI insertion checklist for CAUTI or compliance with the institutional inpatient central venous catheter (CVC) insertion checklist for CLABSI and 2) Compliance with the institutional inpatient CAUTI Maintenance Checklist for CAUTI or Compliance with the institutional CVC maintenance checklist for CLABSI.  There are two physicians and one nurse committed to this intervention.","Compliance with Hand Hygiene for CLAUTI and CLABSI without MBI","Feedback on Hand Hygiene rates for both CLAUTI and CLABSI without MBI","Electronic Health Record data capture in OneConnect system"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This core activity positively impacts Hosptial Safety by reducing the number of infections in hospitalized patients.  Specific measures impacted by the intervention include J1-218 Hospital Safety Central line-associated bloodstream infections (CLABSI) and J1-219 Hospital Safety Catheter- Associated Urinary Tract Infections (CAUTI).","No","","112672402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_112672402","112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public",686,"Expansion or Enhancement of Oral Health Services","","New","","Expanded use of existing dental clinics for underserved population","","Dental services are provided in MD Anderson's Dental Oncology clinic and in the dental clinics of Spring Branch Community Health Centers. The program includes routine dental procedures including proophylaxis, fillings and radiographs  at Spring Branch Community Health Centers only and oral cancer screening in the MD Anderson system component.  One dentist and one nurse at MD Anderson and one dentist at Spring Branch Community Health Centers are committed to this intervention.","Assessment and improvement of current documentation practices for dental services within the community clinic E.H.R.","Use relevant dental codes to document procedures previously documented in the patient's notes field.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"F1","This core activity has the potential to positively impact all measures within the F1 dental bundle. Procedures that were documented inconsitently in the notes section will now be documented using appropriate dental codes thereby improving tracking and monitoring of improvement activities related to dental caries, oral cancer screening, smoking cessation and numbers of patients with chronic diseases acessing dental services. ","No","","112672402.7.1","BTM","Although provider stated in October reporting that they lost a dentist and were discontinuing the activity, they also stated that they had hired a new dentist. Accepting core activity as it appears that they have successfully replaced the vacant position. ","N","NB","OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded use of existing dental clinics for underserved population","CA-3","CA-3.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_113180703","113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",86,"Availability of Appropriate Levels of Behavioral Health Care Services","","Delete","The Harris Center for Mental Health and IDD has achieved certification from HHS of Texas as a Certified Community Behavioral Health Clinic on June 11, 2019.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","The Harris Center has selected this quality measure core activity to better align the agency with the Certified Community Behavioral Health Clinic (CCBHC) model for the development of an integrated service delivery framework providing a comprehensive range of mental health and substance use disorder services.  These integrated services are to be provided in a person-centered, trauma-informed and recovery-oriented approach which serves the whole person with an emphasis on quality, access, and a holistic service approach.  The Harris Center will review the standards required to achieve this certification, which expand beyond measures outlined in Waiver 1.0.","Review of CCBHC Measures to identify which measures need to be implemented at the Harris Center for certification.","Post and hire a Director of CCBHC certification to lead our organization through certification preparation and the certification process.","Determine DSRIP measures that have been implemented that meet the CCBHC requirements.","Identify the additional CCBHC measure that will need to be implemented.","Work with program staff and IT to implement the additional measures to track performance."," ","Make changes to clinical workflow and staffing patterns to implement additional screenings, assessments, or documentation to collect data for CCBHC certification.","Determine where in the clinical process data should be collected for each of the new CCBHC measures.","Work with IT to pull the collected data for tracking and reporting."," "," "," ","Submit an application for the CCBHC certification.","Complete a mock certification audit to determine any deficiencies that could impact certification approval.","Make identified changes or modifications as a result of the mock audit for any measures that did not pass the audit."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-160; M1-305; M1-319; M1-342; M1-105; M1-146; M1-287; M1-317; M1-340; M1-341; M1-390; M1-257","This particular measure bundle is essential to this core activity, as CCBHCs are required to increase access to care and ensure an integrated approach to treating substance, mental and primary healthcare needs through care coordination, screenings, referrals and collection of key health indicators.   As well as ensuring a initial evaluation within 10-days and a 7 and 30 day post hospital follow-up by a licensed practitioner.  There were 3 measures identified for this Core Activity that the spreadsheet failed to show for me to select which were M1-340, M1-341, and M1-390.  The following Waiver 1.0 projects will participate in this Core Activity: 113180703.1.1; 113180703.1.4; 113180703.1.5; 113180703.1.6; 113180703.1.7; 113180703.1.12; 113180703.2.1; 113180703.2.2; 113180703.2.3; 113180703.1.8; 113180703.1.11; 113180703.2.4; 113180703.2.5; 113180703.2.7; 113180703.1.100; 113180703.2.101; 113180703.1.3; 113180703.2.8; 113180703.2.9.","No","","113180703.7.1","BTM","Provider has been certified as a CCBHC. Accepting deletion of core activity.\nNB, I'm flagging for second review as I don't know if we have a list or method for \"achieved\" core activities. Also, deleted activities that are accepted have an initial comment stating the selection is accepted. I changed it to \"deletion is accepted\". Letting you know for consistency with other deleted activities across providers/regions.","Y","NB","Agreed since the CA was more about certification.","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_113180703","113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",87,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of telehealth/telemedicine in delivering behavioral services","","Due to the shortage of psychiatrists in Texas and the high number of Medicaid and Low-Income Uninsured individuals seeking mental health treatment, we will be looking at utilizing telemedicine as a resource to utilize.   For many psychiatrists the Medicaid reimbursement rate for psychiatric services is so low and they set a limit of how many individuals on Medicaid that they will treat making The Harris Center the only option for individuals to choose for their psychiatric treatment.  Access to telemedicine in our 24/7 crisis services programs is an optimal use of this type of psychiatry.  The option to utilize telemedicine is a new venture for The Harris Center, but many of our rural community mental health center counterparts have been using this mode of psychiatric treatment with success.","Set-up a system internally to accommodate telemedicine services per the Medicaid guidelines.","Modify our current billing codes to support billing Medicaid and insurances for providing the telemedicine services.","Modify our current staffing workflow to accommodate Medicaid telemedicine requirements.","Identify which clinics and/or crisis services the telemedicine services will be expanded to."," "," ","Secure telemedicine psychiatric services potentially for both our outpatient and some of our crisis service programs.","Response for Proposal (RFP) posted to seek  telemedicine psychiatry providers interested in contracting to provide the identified services."," "," "," "," ","Set-up telemedicine equipment in the clinics and/or crisis services for the telemedicine services.","Identify which site location and offices will be used for telemedicine services.","Purchase and install the necessary telemedicine equipment to activate the service."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-124; M1-147; M1-160; M1-210; M1-256; M1-261; M1-262; M1-263; M1-264; M1-265; M1-305; M1-319; M1-342; M1-405; M1-105; M1-146; M1-266; M1-287; M1-317; M1-340; M1-341; M1-385; M1-386; M1-390","Access to telemedicine psychiatric time will allow us to assure that individuals receive an initial diagnosis within 10 days of contact.  All new patients will receive an initial diagnostic evaluation from a licensed clinician.  This initial evaluation will include assessments for risk of harm; substance and tobacco use; a psychosocial, vocational, housing, and independent living skills assessments.  These assessments will be used to drive treatment. Additional access to psychiatrics via telemedicine will allow for follow-up contact with a prescriber within 7 days of discharge from a psychiatric hospital.  Prior to seeing the doctor an individual will be evaluated by nursing staff for their BMI, high blood pressure, any medications post hospital discharge, as well as any over-the-counter medications they are taking and entered this information in our Electronic Health Record for a physician to access.  In addition the availability of telemedicine psychiatric services can ensure individuals whom otherwise would be on a waiting list for services would receive treatment and receive any services attributed to the measures.   The following Waiver 1.0 projects will participate in this Core Activity: 113180703.1.1; 113180703.1.4; 113180703.1.5; 113180703.1.6; 113180703.1.7; 113180703.2.1; 113180703.1.11; 113180703.2.4; 113180703.2.5; 113180703.2.7; 113180703.1.100; 113180703.2.101; 113180703.1.3; 113180703.2.8; 113180703.2.9.","No","","113180703.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_113180703","113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",88,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Had to add measure M1-257 to this Core Activity after successfully achieving the Texas CCBHC as a Certified Community Behavioral Health Clinic which was our Core Activity #1 selection. ","Utilization of Care Management function that integrates primary and behavioral health","","Substantial research exists to support the benefits of co-locating or the integration of physical and behavioral health care services.  According to the SAMHSA-HRSA Center for Integrated Care, benefits of integration include improving an individuals experience of care, improving the health of the general population, and reducing per capita healthcare costs.  Significant gaps exist for individuals with severe mental illness, which contribute to higher rates of physical health conditions, shorter life expectancies and higher health care costs (SAMHSA).  For these reasons, The Harris Center operates with two FQHCs in two of our Behavioral Health clinics to provide physical health services alongside our psychiatric services for individuals that we serve.  We seek to strengthen this relationship and broaden primary healthcare partnerships at 2 additional clinics.","Expand primary care clinic services within two additional behavioral health clinics.","Facilitate primary care integration in the two additional clinics utilizing either an FQHC or hiring of a Primary Care Physician.","Identify space in two projected clinics to create an office for primary care services."," "," "," ","Promote a culture that values integrated physical and behavioral health care for the treatment of individuals with a mental illness.","Action plan to create and deploy a integrated physical health & behavioral health training to be completed at new employee orientation and annually for mental health providers."," "," "," "," ","Step up to the next SAMHSA Integration Model Level of Integrated Care.","Identify current SAMHSA Integration Model Level of Integrated Care in our current collaborative care project.","Work on the elements needed to move to the next Level of Integrated Care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-124; M1-147; M1-210; M1-259; M1-260; M1-287; M1-257","The integration of primary care and behavioral health services impacts many of the measures we have selected through providing preventative care and screenings and the coordination of needed follow-up care for individuals we serve.  The expansion of this measure beyond previous individuals served in the projects, means more individuals will benefit from this added service.  The following Waiver 1.0 projects will participate in this Core Activity: 113180703.1.1; 113180703.1.4; 113180703.1.5; 113180703.1.6; 113180703.1.7; 113180703.2.1.","No","","113180703.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_127300503","127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private",89,"Expansion of Patient Care Navigation and Transition Services","","Edit","During October 2018, a couple of Change Ideas related to the Secondary Driver - implement care transition pilot interventions for patients needing post-acute care management were deleted. This was not reflected in the original Cat A Core Activities Template. These Change Ideas have subsequently been deleted from the Core Activities Template to reflect this previous change.  BSLMC encountered a challenge in creating high-frequency home care in that this model is quite expensive with no payer system reimbursements at this time. BSLMC has focused these efforts on increasing our Preferred Provider Network (PPN). BSLMC does not have the bandwidth to perform this intervention and has concentrated on the PPN.\nDuring October 2018, one Change Idea related to the Secondary Driver - Maintain and increase partnerships with post-acute care providers to better service various patient needs was deleted. This was not reflected in the original Cat A Core Activities Template. This Change Idea has subsequently been deleted from the Core Activities Template to reflect this previous change.  Expanding the partnership between BSLMC and HealthCare for the Homeless (HCFH) experienced a major challenge – HCFH has identified that BSLMC patients are too sick for Primary Care Providers’ abilities at HCFH. BSLMC has no longer be pursued this relationship. An additional change Idea was added to offset this change during October 2018, which was also not reflected the Cat A Core Activities Template. BSLMC will implement post-acute follow-up appointment electronic scheduling with its partner – Baylor College of Medicine (BCM). These changes were also updated during DY8 October 2019 reporting.","Implementation of a care transition and/or a discharge planning program","","1. BSLMC plans to expand its current Care Transitions team's efforts to include both the CHF patient population as well as increase its focus on transitional care for all at-risk patients within the BSLMC patient population. The team will increase its overall risk-identification of patients with a concentration on mediation of those risks prior to discharge and improvement of post-discharge follow-up planning, including expanding provider partnerships to stratify patients according to risk to different follow-up intervention models.  The team will work closely with Case Management to improve resource utilization within and outside the organization.\n2. Number of providers committed to the intervention include all personnel within the BSLMC system but in particular physicians, nurses, nurse managers, pharmacists, and case managers within the BSLMC system. \na. The CORE Team for this initiative includes:\ni. The Care Transitions team currently consisting of two physician medical directors, a Nurse Practitioner, two nurse navigators, and a clerical assistant. \nb. BSLMC Head of Cardiovascular Quality including a CHF readmissions committee chaired by the Head of CV Quality. \nThe committee consists of BSLMC members from:\ni. Nursing leaders from CV transplant, 14T and ED \nii. Physicians from ED, Cardiology, and Hospitalist service \niii. Case Management\niv. Pharmacy\nv. Transitional Care Team \nvi. Advanced Heart Failure Clinic \nvii. Quality \n3. The number of Locations Impacted totals 20 and are as follows: \na. Hospital inpatient 909 licensed beds servicing \nb. Inpatient 30-bed Rehabilitation Unit \nc. Baylor St. Luke's Medical Center's Emergency Department \nd. Three Community Emergency Departments \ne. Four Ambulatory Surgical Centers \nf. Outpatient Cardiac Rehab \ng. The Cancer Center \nh. Center for Sleep Medicine \ni. Center for Wound Care \nj. THI Outpatient Clinic \nk. Transitional Care Clinic\n l. HLTTC  Heart, Lung Transplant Treatment Center \nm. Kidney Transplant Program \nn. Abdominal Transplant and Liver Disease Clinic. ","Enhance services through further development of a multi-disciplinary care transitions team. The team must include medical director(s), nurse practitioner(s), nurse navigator(s), pharmacy, case management, and clerical assistant(s). Utilize the team to risk stratify patients and improve discharge planning to mitigate readmission risks by implementing a risk stratification model.","Improve selection of interventions for successful and efficient discharge planning through a risk-stratification model that utilizes the BSLMC EMR. Align the model with triggers for early identification and mitigation of patient risk. Improve risk mitigation during patients' inpatient experience based on risk identifiers noted by the risk-stratification model.","Expand the current team to include inpatient management of improved medication reconciliation and post-discharge care coordination."," "," "," ","Implement care transition pilot interventions for patients needing post-acute care management.","Implement a pilot of Home Health Preferred Providers, i. Expand preferred providers, train them in BSLMC processes for patient education, medication reconciliation, post-discharge assessment, and readmission risk mitigation, ii. Provide guidance to the Preferred Providers on BSLMC's Strategic Pathways/Protocols.","Implement a pilot of Hospice/Palliative Care. This program intends to better identify those patients at-risk who would also benefit from earlier inpatient and/or outpatient hospice and palliative care intervention.","",""," ","Maintain and increase partnerships with post-acute care providers to better service various patient needs.","Increase number/types patients referred to San Jose Clinic, the safety-net clinic for the uninsured which BSLMC has long-partnered since the beginning of the DSRIP 1.0 program. In DSRIP 1.0 this partnership focused on the uninsured CHF patients, going into DSRIP 2.0, BSLMC is working to expand services to other at-risk, uninsured patients.","Collaborate with the Clinically Integrated Network (CIN) for post-acute visits. This collaboration already exists for patients who have designated Primary Care and Specialty Care providers within CIN, but BSLMC will attempt to increase the referral base to CIN providers for those patients hospitalized who do not have existing PCP and Specialty Care Providers delegated to ensure more rapid follow-up and connectivity to a medical home.","Implement post-acute follow-up appointment electronic scheduling with BSLMC partner – Baylor College of Medicine (BCM). Work with the CIN to investigate expansion of this model into providers outside of the BSLMC DSRIP system into the greater CHI texas Division system. Work with HHSC and the HIE to investigate the potential for expansion of this model into other providers outside of the BSLMC immediate system. "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","a. The Care Transitions and Hospital Readmissions Bundle is a multi-faceted bundle aiming at reducing 30-day hospital readmissions, improving medication identification and reconciliation, and connecting patients and post-acute caregivers to the hospital experience. b. All of the change ideas and secondary drivers listed above speak to:i. Improving inpatient risk stratification and mitigation, helping identify and mitigate readmission risks.ii. Addressing medication reconciliation needs during the patients hospitalization and post-acute care.iii. Improving patient connectivity to post-acute provider follow-up to avoid unnecessary readmissions.","Yes","Although the majority of the activities will be performed and/or coordinated by providers within the BSLMC System Definition, not ALL of the activities will be performed by providers within the System Definition. Some of the post-acute care services will be coordinated by providers within the BSLMC System but will officially be provided by contracted entities outside of the BSLMC System Definition. As these contracted entities have multiple other patient populations of which BSLMC has no executive leadership, control, or ownership/partial ownership AND has no data sharing nor rationale for data sharing over the patient populations outside of the BSLMC Total PPP, these entities are not included in the BSLMC System Definition.","127300503.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_127300503","127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private",90,"Hospital Safety and Quality","","Edit","Based on internal monitoring of progress towards DSRIP Hospital Safety goals, which are also goals that align with multiple other BSLMC goals, BSLMC has noted progress towards CLABSI and Post-Op Sepsis PY2 goals. Despite progress in CLABSI and Post-Op Sepsis measures, BSLMC has noted a decline in progress towards CAUTI and Patient Fall Rate goals during CY2019. Thus, BSLMC has created additional change ideas to ensure improvement in patient safety, health outcomes, and meeting of DSRIP and other internal measures goals during CY2019. This Core Activity was also updated during DY8 October 2019 reporting. ","Implementation of evidence-based practices to improve quality of care","","1. BSLMC is committed to utilization of a multi-disciplinary approach to improve Hospital Safety, thus improving the patient experience by avoiding unnecessary infection or patient safety occurrences that lengthen hospital stay, increase healthcare costs, and negatively affect patient outcomes. Each hospital safety area has been tasked to various Quality team members and sponsoring physician, is reported on monthly to the Quality Committee, and has various, evidence-based action items to improve outcomes.\n2. Number of providers committed to the intervention include all personnel within the BSLMC system but in particular physicians, nurses, nurse managers, clinical ancillary staff, transportation/dietary personnel and unit secretaries within the BSLMC system.\n3. The CORE Team for this initiative is:\na. BSLMC Quality Team including:\ni. Director of Infection Control\nii. Director of Quality\niii. Quality Program Manager\niv. Quality Nurses for Patient Safety and Quality Review\nb. Nursing executive Leadership, Nursing Management, and Bedside Nurses\nc. Pharmacy team\n4. The number of Locations Impacted totals 6 and are as follows:\na. Hospital inpatient 909 licensed beds\nb. Inpatient 30-bed Rehabilitation Unit \nc. Baylor St. Luke's Medical Center's Emergency Department\nd. Three Community Emergency Departments","Create a multi-disciplinary team to review all hospital safety measures, develop a routine monitoring and reporting mechanism for each, design strategies for improving outcomes, and create an implementation process to include adjustments and changes to action items as needed","Create a multi-disciplinary team that meets monthly to review hospital safety data, including CLABSI, CAUTI, SSI, Patient Fall Rates, and Post-Op Sepsis Rates, review cases, determine fall-out cases and create action plans. \n1. An executive sponsor, a physician champion, nursing leadership, Quality/Safety, Infection Prevention, Environmental Services supervisors, education staff are all included on the team.\n2. Ad hoc members include: pharmacy, lab, materials/supply, IT","Implement routine monitoring to prevent infection (CLABSI, CAUTI, SSI):\n1. Hand hygiene\n2. Contact Precaution compliance to mitigate hospital-based infection\n3. Antibiotic Stewardship","Monitor the completion of Routine Rounds (CLABSI, CAUTI, Fall)\n1. Maintenance/prevention Rounds\n2. Device Rounds","Monitor the routine education of hospital staff to ensure inclusion of:\n1. Annual staff education regarding infection transmission, infection rates, and infection prevention interventions with routine updates monthly","5. Monitor implementation of the CLABSI Prevention Action Items: \na. Prompt removal femoral lines\nb. Roll-out of Swab Caps on high-risk units\nc. Physician team reviewing PI practices for HD tunneled lines\nd. I Save the Line campaign assessing line patency.\ne. New change Ideas:\ni. Standardized CVC insertion and maintenance checklists.\nii.  Implement Days without Harm Dashboard, posts on the Quality website, and Huddle boards.\niii. Increase use of midline and extended dwell peripheral IVs, including staff education on medications that cannot be transfused through midlines. \niv. Monitor Hemodialysis (HD) catheter access by HD and bedside nursing to ensure appropriate utilization.\nv. Implement daily CHG Bathing on all patients with Central lines, including policy updates and staff training.\n6. Monitor implementation of the CAUTI Prevention Action Items: \na. Nurse-driven protocol for indwelling catheter removal to curb CAUTI. \nb. Nurse Manager rounding/daily indwelling catheter audits\nc. Pilot PUREwick external female catheter\nd. New change Ideas:\ni. New process to review hospital acquired infections as they are coded and then present to the CLABSI/CAUTI Steering Committee for trends and initiatives.\nii. Implement nursing and PCA competencies focused on peri-care and catheter care \niii. Implement a standardized insertion/maintenance bundle and a data dashboard.\niv. Implement a two-person Foley insertion\nv. Create improved awareness of the process for Foley removal inpatients with retention/obstruction issues. BSLMC is currently investigating best practices to create staff training. \n7. Monitor implementation of the SSI Prevention and Post-Op Sepsis action Items: \na. Pre-op Blood Glucose testing on all patients\nb. Chlorhexidine Gluconate (CHG) pre-op bathing as nurse-drive protocol. \nc. Using ClipVac for intraoperative hair removal.\n8. For Post-Op Sepsis improvement, the multidisciplinary team has worked on:\na. Chart reviews to identify process failures \nb. Escalation of case issues through medical staff services, as warranted \nc. Implement improvement in clinical documentation & coding of admission types to accurately identify patient risks\nd. Hand hygiene \ne. Implement a multidisciplinary rounding tool for critical care units that includes assessment of mechanical ventilation, glucose, nutrition, antibiotics, skin condition need for central line, need for Foley catheter, need for all other lines all of which are clinical areas that put the patient at risk for Post-Operative Sepsis.  \nf. Pre-op Glucose Testing for all surgical patients. It is being initially rolled out to all elective colorectal patients. \ng. Re-educate through the Staff Nurse Council and Nurse Manager Council on importance and requirement for utilization of the Chlorhexidine Gluconate (CHG) pre-op bathing as a nurse-drive protocol. Create a Huddle Power Minute so this can be discussed at unit daily huddles. \nh. ClipVac for intraoperative hair removal and documentation added to BSLMC EMR \n9. Monitor implementation of the Fall Prevention Action Items: \na. Fall Management policy and procedure revised to incorporate a patient population based approach to falls prevention and fall related injury\ni. Fall Management policy and procedure revised to incorporate a patient population based approach to falls prevention and fall related injury\nb. Bathroom modifications to include raised toilets, grab bars, and more bedside commodes \nc. Universal Fall Precautions for all patients\nd. Reviewing injury risk tools to better identify patients at risk\ne. Hourly nurse rounding to include:\ni. Monitored restroom for fall-risk patients\nii. Bed alarm check\nf. New Change Ideas:\ni. Incorporate Fall Morse Score at bedside shift report and on transfer to any unit/procedure\n1. Utilize high-risk report to identify patients with Morse Score > 45 and validate that high-risk interventions are in place - discuss every shift                                  \n2. Implement weekly reporting of Days Without Harm Dashboard at Tier 2 Huddle          \n3. Post-fall management to include immediate notification to Manager/Director \nii. Implement a positive method to motivate staff to maintain or improve their good work, recognize units that reach 100 days with zero falls"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","In order to successfully improve the patient experience, BSLMC has committed to implement processes to improve patient outcomes, especially related to infection prevention, identification and management. By creating a multi-disciplinary team to collect data, monitor, report, and create action items to improve on each metric that meets and relays findings and changes to processes on a routine basis, BSLMC hopes to improve on all outcomes in the Hospital Safety Bundle. Daily monitoring with real-time interventions in place when action is required has been proven to help improve on all Hospital Safety Bundle items.","No","","127300503.7.1","BTM","Removed two mentions of measures in core activity description and change idea 1. Just left a comment to provider, do we need to give them an opportunity to disagree?","Y","NB","Yes, chagned to to NMI","Needs More Information","HHSC has removed mention of measures in the Core Activity description and Secondary Driver 1: Change Idea 1. If provider disagrees with HHSC changes, provider should respond in \"Provider Response\" field and suggest additional changes, if needed.","Provider is amenable to this change as the Secondary Driver 1. Change Idea 1. is reflected in the Core Activity description itself.","BTM","Provider agreed to changes, which were already entered.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_127303903","127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public",91,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","OakBend will develop and educate staff and physicians on protocols used to decrease primary cesarean sections, increase the utilization of antenatal steroids and decrease hemorrhage. OakBend will engage in the sharing of data with physicians to target individual physician improvement in attaining these benchmarks.  The estimated number of providers committed to the intervention under this core activity consists of twelve physicians in labor and delivery with the goal of reducing the number of C-sections.","OakBend will implement protocols and educate staff and physicians to ensure that they understand the new bundle and strategies involved for providing high-quality care for patients and track data related to individual rates of Cesarean reduction, hemorrhage reduction and percentage of antenatal steroids being administered to maternity patients.","On a regular basis, OakBend will convene and report data results to labor and delivery physicians and staff pertaining to metrics being measured and implement process improvements as necessary to address identified issues."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1; E2","It impacts the the indicated Measure Bundle by focusing on the social and physical factors.  In many instances there are barriers influenced by environmental, social, and physical.  Maternal and infant health specialists will work to improve the health delivery system through advocacy, education and research.","No","","127303903.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_127303903","127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public",92,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","The designated Chronic Care Management clinician (MD, PA, NP) will establish, implement, revise, or monitor and manage care plan that addresses the physical, mental, cognitive, psychosocial, functional and environmental needs of patients discharged from our inpatient facilities.","A specially trained Registered Nurse or Case Worker who will act as a personal healthcare coordinator to navigate patients healthcare needs, resulting in overall health improvement and potential cost savings.","Assign and train RN or Case Worker to perform patient navigation services.","Maintain an inventory of resources and supports that the patient needs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This core activity impacts the indicated Measure Bundle by helping the patient prevent costly hospital re-admissions by ensuring they understand and can follow their care plan.","No","","127303903.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_127303903","127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public",93,"Hospital Safety and Quality","","Continue","","Implementation of evidence-based practices to improve quality of care","","Departments such as Quality, Safety, and Risk to continue working together in accordance with a committee that consists of representatives from both administration and the medical staff to oversee safety and quality, providing opportunities at all medical staff meetings to discuss safety issues.","Develop plan for committee to meet regularly and gain buy-in for the committee to authorize action in response to safety concerns or refer the actions to another group, such as the executive medical staff, that can muster resources and will take action.","Identify and appoint chairpersons to lead committee on patient safety initiatives.","Develop charter to guide committee activities and key focus areas supporting patient safety.","Develop plan to gain buy in from clinicians to participate in safety initiatives."," "," ","Develop committee meeting protocols for structure as a second secondary driver.","Form recurring agenda to discuss specific safety issues.","Determine roles of clinicians as committee members in meeting content development, meeting discussion, and meeting follow up."," "," "," ","Develop committee action protocols as the third secondary driver.","Develop safety protocols as the first change idea for the secondary driver.","Identify actors in safety action plans as the second change idea for the secondary driver.","Develop action timeline and report back on the plan."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","It impacts the the indicated Measure Bundle by managing data, resolve problems, provide feedback and training.  As well as respond to regulatory and other mandates, and encourage individuals to report errors, and does not solely depend on the central safety team for all activity. With these elements in place any hospital setting can make major strides in improving hospital safety.","No","","127303903.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_130959304","130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public",94,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","The hospital will continue to contract with MEHOP, local FQHC, to provide access for all patients during nights and weekends (in addition to the traditional FQHC hours).  The partnership will now expand to include process improvement quality efforts with focus to the diabetic population to ensure coordination, data exchange, ED and Inpatient notifications, and quality based outcome expectations for the population.  One outpatient location will be engaged to include 4+ clinical providers.  We will include additional community providers as we make progress with proceess improvement efforts.","Access to after hours and weekend hours along with transportation to and from clinics","Extend contract with MEHOP (FQHC) to ensure extended hours.  Partner with local agencies to identify transportation option & ensure outreach and communication aligned with access points."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","As identified in the community needs assessment completed for the region as well as the local CHNA performed during the development of the DSRIP Specialty Care Expansion, diabetes is an attributed population that is utilizing the emergency department as a point of primary care and is highly uncontrolled due to access, education, and patient coordination issues.  The hospital's ability to impact this attributed population will be by ensuring connectivity to an ambulatory provider and/or network to implement population health techniques.  The Core activity will continue the MEHOP contract and begin to develop population health strategies to link the hospital district to additional ambulatory resources.","No","","130959304.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_130959304","130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public",95,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Engage the hospital facility, local FQHC (MEHOP) and community based programs to address education and awareness for chronic diseases.  The collaboration among all providers will allow the core activities to engage the patient where they are accessing care & to increase education on how to improve diabetic care which will in turn improve quality indicators for this population.","Access to education and tools for healthy choices of food and activity","Establish educational programs utilizing ambulatory clinics and Community Based Organizations (CBO) to maximize access to fresh foods and understanding the ability to eat healthy on a budget & in a time crunch","Establish relationships with local grocery stores and farmers to build the concept of farmers markets and local sourced foods and provide sources for coupons, etc.","Utilize Diabetic educator in the hospital to expand outreach into the ambulatory setting"," "," ","Implementation of diabetes medication management best practices within community partner practices utilizing provider outreach and ACO network structure.","Identify diabetes medication management best practices that are adaptable to rural settings","Utilize hospital process improvement efforts to communicate & implement diabetes medication management best practices within our community practices utilizing hospital based analytics to drive outreach"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","As identified in the community needs assessment completed for the region as well as the local CHNA performed during the development of the DSRIP Specialty Care Expansion, diabetes is an attributed population that is utilizing the emergency department as a point of primary care and is highly uncontrolled due to access, education, and patient coordination issues.  The hospital's ability to impact this attributed population will be by ensuring connectivity to an ambulatory provider and/or network to implement population health techniques.  The Core activity will continue the MEHOP contract and begin to develop population health strategies to link the hospital district to additional ambulatory resources.","No","","130959304.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",98,"Chronic Care Management","","Edit","Summary of changes includes progress and challenges updated for each driver. Also, the addition of a 2nd change idea to the first secondary driver to incentivize patient participation in health outcomes through the creation of our Wall of Wellness program at each location. Progress update has been provided. Added more detail about the fifth secondary driver change idea that explains what components of our care protocols were addressed. ","Provision of services to individuals that address social determinants of health","","Implement a comprehensive, patient-centered care and support system to address potentially preventable hospitalizations and to prevent uncontrolled diabetes from progressing to a disease state with long term complications. In DY6, we implemented a multidisciplinary approach to diabetes management with the addition of CHWs to our community health center staff to address the Category 3 uncontrolled diabetes HbA1c >9 project by assessing and providing in-home interventions for the social determinants of health. This home visit intervention is undergoing continuous expansion to high-volume ambulatory health centers and potentially specialty clinics (currently at 6 with slated expansion to 2 additional health centers in the next quarter).","Incentivize patient participation in their own health outcomes by creating a \"Wall of Wellness\" at each of our health center locations to showcase patients who have managed and improved their A1c scores.","Reward patients that have managed their diabetes and improved their HbA1c goals by 2 percent with a recognition presentation, small gifts, and displaying their picture on the \"Wall of Wellness\" with success stories meant to inspire other patients to take control of their health."," Partner with Healthy Heart, Healthy You (HHHY) a remote blood pressure monitoring program to highlight patients on the Wall of Wellness who have successfully graduated the program. These patients have successfully lowered and are now maintaining a healthy blood pressure. "," "," "," ","Identification of appropriate documentation practices to capture accurate patient data in order to monitor patient adherance and track outcomes","Update existing methods for capturing specific data elements to facilitate the monitoring of patient outcomes"," "," "," "," ","Further coordination of care for the Diabetes Multidisciplinary Program to bridge clinical practice and self management in order to improve quality of care, patient outcomes, and system capacity.","Utilize case management to assess barriers associated with achieving optimal health outcomes","Integrate point of care pharmacy to assist with medication adherence and adjustments as needed.","Same-day access to patient education and/or nutrition counseling to promote diabetes self-management","Nursing staff to provide patients with a DM program education folder that will serve as a source of information to help guide and organize self-management","PCP initiated intervention (lab orders, referrals, medications, etc.) to improve health outcomes","Expansion of Community Health Worker Home Visit program to increase knowledge, teaching skills, addressing psychosocial needs, and providing social and environmental support to improve self-management among those with Type 2 Diabetes, as well as prevention among those with high-risk indicators.","Community Health Worker home assessment of diabetes knowledge and self-management behaviors to drive educational and clinical interventions.","Screening for social determinants of health to identify barriers and provide resources in order to improve self-management."," "," "," ","Staff development and education to ensure appropriate management and navigation of patients to the right care at the right time","Standardize system-wide protocols for the appropriate management and coordination of services. This is being addressed through the refinement of our initial intake processes that address diagnoses, PCP assignment, initial assessments and treatments. We have also refined our maintenance processes to address appointment scheduling, pre-visit planning, follow-up assessments and f/u treatments. Trouble shooting protocols are also in place to address inactive patients, adherence issues, treatment issues, as well as, ED visits and admissions."," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Provision of a patient-centered care framework in which Community Health Workers bridge clinical practice and self-management in order to improve quality of care, patient outcomes, and system capacity while utilizing evidence-based strategies to improve chronic disease and risk management in alignment with our DSRIP bundle measures.","No","","133355104.7.1","BTM","Edits are on progress and details, no concerns. Accepting.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",99,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Implement interventions that increase the use of appropriate intervals of care and screenings within the primary care setting through an organized, team-based system of care. These interventions will be applied to all 14 ambulatory health centers and 2 specialty locations.  Approximately 200 providers will be committed to the improvement efforts.","Improved tracking systems to identifiy patients needing screening and follow-up","Utilizing Health Information Technology to identify patients in need of screenings and/or follow-up services.","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," ","Intensive outreach and patient education interventions to reach the most marginalized patients.","Provide a team-based approach to identifying patients that require cancer screening and include patient navigators/CHWs for outreach and education","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","The implementation of these interventions will increase the percentage of patients receiving cancer screenings and follow-up services regardless of barriers to access.","No","","133355104.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",100,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","Promote the management of physical health conditions of patients diagnosed with serious mental illness through the integration of primary and behavioral health services.  This will be achieved through effective planning and implementation of protocols for patients in need of care of secondary medical conditions. These interventions will be applied to all 14 ambulatory health centers and will have an impact on Inpatient services at both Ben Taub and LBJ hospitals. Approximately 22 outpatient providers and all admitting inpatient providers will contribute to these improvements.","Reliable planning, communication, and collaboration across operational service areas","Training in effective communications, care transition, and discharge planning"," "," "," "," ","Improved tracking systems for the identification of patients needing screening and follow-up","Utilizing Health Information Technology to identify patients in need of screenings and/or follow-up services.","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H4","Integrating an accurate and effective process that identifies, tracks, and reminds patients will encourage patients to complete any recommended screenings and adoption of these processes allows Harris Health to promote self-management and preventive care in all settings.","No","","133355104.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",101,"Palliative Care","","Continue","","Transitioning of palliative care patients from acute hospital care to other settings","","Align documentation requirements of Inpatient Palliative Care  with Outpatient House Calls and Palliative Clinic to promote palliative care clinical services and to improve care and outcomes for patients with serious illness and their families.","Implement standardized documentation practice that includes comprehensive assessments and screenings that allow for improved patient outcomes and quality of life","Identify standardized screening tools and establish a response protocol for every clinical setting","Educate clinicians on use of the identified screening tools and response protocol","Modify documentation practices to capture specified components related to the continuum of care of the patient"," "," ","Develop integrated workflows that promote effective and collaborative multi-disciplinary functionality","Educate staff on the importance of effective communication, integrated workflows, and how to drive improvement","Reinforce effective communication, planning, and collaboration of the multi-disciplinary teams"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","These activities have had a positive impact in our communication across the inpatient and outpatient settings.  We are still in the beginning stages of reviewing the fall-out data to report on the impact of the documentation changes but we are able to capture the needs of our patients through the use of the standard documentation flow-sheet and ensuring that our care teams are working together when patients transition from inpatient care to home and outpatient care.","No","","133355104.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Transitioning of palliative care patients from acute hospital care into home care, hospice or a skilled nursing facility and management of patients’ needs.","CA-12","CA-12.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",102,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Promote effective population health that shifts the focus of primary care to prevention and lifestyle modification for the prevention and management of disease by effectively navigating patients to the appropriate care based on the individual needs of the patient.  This will be applied in all 14 ambulatory health centers, and 5 school-based clinics with approximately 30 providers committed to these interventions.","Integration and coordination of preventive care services in the primary care setting","Analyze programs and clinical practices to target high cost populations and services to align with metrics","Workforce education and development to improve workflows that align operations with best practices","Identification of barriers to patients' access to care"," "," ","Data driven decision making to determine the best strategies to achieve the triple aim of reducing healthcare costs, advance population health, and improve the experience of care","Utilize health information data that influences and informs policy and operational decision making","Appropriate stakeholder engagement to support efforts and inspire change"," "," "," ","Improved tracking systems to identify patients that meet the criteria for appointments and immunizations","Apply best practice advisories to patients that meet certain requirements for scheduling appointments and ordering medications or immunizations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","Through the use of health information data reports, we will be able to identify patients that meet criteria for preventive care appointments and immunizations based on their medical history. This also addresses the aim of the measure bundle by establishing standards for navigating patients to the appropriate services in order to provide the most comprehensive care available.","No","","133355104.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",103,"Maternal and Infant Health Care","","Edit","","Coordinated prenatal and postpartum care",null,"Reassess existing and evaluate new protocols to align with industry standards of care and prevention to obtain the desired outcomes for mothers and newborns throughout pregnancy, childbirth, and postpartum stages that address associated clinical outcomes","Implement tracking systems to identify patients that meet the criteria for follow-up appointments and screenings","Identify standardized screening tools and establish a response protocol for every clinical setting","Educate clinicians and office staff on use of the identified screening tools and response protocol","Modify documentation practices to capture specified components related to the continuum of care of the patient"," "," ","Effective prevention and management of conditions during pregnancy, childbirth and the early newborn period","Integration and coordination of services with primary and specialty care based on maternal early warning signs (MEWS)","Provide appropriately timed perinatal depression and anxiety awareness education to women and family members"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","By compiling all of the documentation requirements into a standard flow, we can ensure that the appropriate documentation occurs and navigate patients to the appropriate care as needed.","No","","133355104.7.1","BTM","Accepting \"other\" for core activity, as no current CA address behavioral sevices for pregnant women","N","NB","changed  Other","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Implement protocols for behavioral health disorders, including depression, substance abuse and addiction that includes screening, education, consultation with appropriate personnel and referral\" to \"Provision of coordinated prenatal and postpartum care\" to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". ",null,"BTM","Provider did not disagree.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_133355104","133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public",104,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","Enhance programs to facilitate access to health-related programs and services for patients and care providers that promotes continuity of care by identifying and removing barriers and providing effective and efficient use of the health care system for patients, caregivers, and practitioners. The system components that will impact these measures will be primarily inpatient services and the emergency department at Ben Taub and LBJ hospitals.  Additional follow-ups will occur at the 14 ambulatory health centers and in patients' homes. All admitting inpatient and EC providers will be committed to these interventions.","Develop an infrastructure for transitions that promotes quality care and effective communication","Assign responsibilities to appropriate staff to ensure that the patient recieves the proper care","Provision of up-to-date, accessible information about patients and plans of care"," "," "," ","Develop integrated workflows that promote effective and collaborative multi-disciplinary functionality","Educate staff on the importance of effective communication, integrated workflows, and how to drive improvement","Reinforce effective communication, planning, and collaboration of the multi-disciplinary teams"," "," "," ","Provide standardized documentation that encourages patient responsibility and allows for improved access to coordinated and preventive services","Involve patients and family in shared goal setting process","Identify expressed wishes and ensure these are communicated within care teams"," "," "," ","","",""," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1; G1","The aim of the Care Transitions and Coordination bundle is addressed through the effective collaboration of multidisciplinary teams and case management as well as improved documentation of specific health information components in the patient's medical record.","No","","133355104.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_135033210","135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private",105,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services",null,"The core activity is based on community awareness of pneumonia vaccination, tobacco use and advanced care planning.  The program is used to increase patient engagement and improve overall community wellness.  Columbus Community Hospital uses electronic EHR education databases to provide Smoking Cessation, Pneumonia Vaccination and Advanced Directive materials. The content of the materials provided is organized by care setting and comprised of both easy-to-read and standard content, available in several languages.  The number of providers committed to the intervention is 14 providers.   Locations impacted include Columbus Community Hospital, Columbus Medicial Clinic and Four Oaks Medical Clinic.","Educate patients on tobacco use and cessation, pneumonia risk, and benefits of advance care plan.","Train personnel to educate patients for tobacco use and cessation, pneumonia risk, and benefits of advance care plan.","Deploy educational material to patients via EHR on Tobacco Cessation, Pneumonia and Advance Care Planning."," "," "," ","The first Secondary Driver for the Core Activity is screening for tobacco use, pneumonia vaccination, and presence of advance care plan.  Advanced Directives is screened in both the outpatient and inpatient settings giving patient education for their end of life care. The Smoking Cessation screening provides information to patients on the risks of lung cancer, heart disease and respiratory illnesses.  The pneumonia vaccine screening benefits people over 65 years of age and is beneficial to those in danger of pneumococcal disease.","The first Change Idea is to train personnel to do screenings.","Build screener in EHR and in patient forms, so patients health record can be created and managed by authorized providers in a digital format capable of being shared with other providers in the system."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Columbus Community Hospital's Core Activity (Smoking Cessation) impacts the Measure Bundle (Pneumonia) because they are both preventative care.  Smoking Cessation activities are related to your lungs or respiratory care.  An individual that is smoking is more susceptible to getting pneumonia.  Therefore, it is important to educate patients about the dangers of smoking. Tobacco cessation is also important in reducing hospital admissions for pneumonia.  It has been reported, that half of serious invasive pneumococcal diseases occur in people who smoke cigarettes. Advance care planning is essential for people over the age of 65 since it's a process that supports adults at a stage in their life to assist them in understanding and sharing their personal values, life goals, and preferences regarding future medical care.","No","","135033210.7.1","BTM","Targeting lung disease, no other cor activity falls within education and screening for lung disease. Accepting \"other\" designation.","N","NB","changed to NMI ","Needs More Information","HHSC requests that the provider considers other Core Activity Groupings and Areas to see if the Core Activity can be moved to menu. One option to consider is \"Access to Primary Care\" as a Grouping and \"Provision of screening and follow up services\" as a Core Activity. Provider can consider if areas from \"Chronic Care Management\" may be suitable. Please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\".","Access to primary care as a grouping and Provision of Screening and follow up services as a core activity is appropriate.   ","BTM","Provider agreed to change. Made changes to grouping and activity.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically, the Grouping was changed to \"Access to Primary Care\" and the core activity was changed to \"Provision of Screening and follow up services\".","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137805107","137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private",106,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Increasing access to services by utilizing qualified staff","","Mental Health Crisis Clinics: This core activity provides access to crisis stabilization clinics for the Medicaid and Uninsured patient populations. The clinics provide rapid access to initial psychiatric treatment and other outpatient services. The clinics all operate at varying hours to try and provide services outside of normal business hours as allowed. This core activity impacts two locations and is staffed witih psychiatrists, social workers, and other qualified behavioral health navigators. This core activity utilizes 2-4 mental health providers at each shift.","Continue to recruit and onboard qualified staff enabling the clinics to operate at expanded hours.","Utilize Human Resource recruiters to identify qualifed staff","Offer development opportunities to current staff who are able and willing"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","H2: The objective of this core activity is to provide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions. This core activity provides these services by offering an appropriate setting for patients experiencing a mental health crisis. These services assist in coordinating care and providing mental health care in an appropriate setting thus reducing unnecessary ED visits, hospital admission, and future mental health crises.","No","","137805107.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increasing access to services by utilizing staff with the following qualifications: Wellness and Health Navigation: Bachelors level professional with experience in mental health and/or wellness initiatives or a peer specialist who has successfully completed the DSHS certification program for peer specialists","CA-9","CA-9.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137805107","137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private",107,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","ER Navigation Program: This core activity continues the established ER Navigation Program at Memorial Hermann Emergency Departments. This program utilizes navigators to connect uninsured and Medicaid patients to a medical home, thus reducing future visits to the emergency department. This core activity has the staff and resources to impact all hospital facilities in the system. This core activity utilizes 25-30 patient navigators at facilites across the system.","Perform social determinants of health screenings on all patients that are seen","Develop a screening tool for social determinants of health designed for the Medicaid and uninsured populations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","B1: Care Transitions & Hospital Readmissions  the objective of this bundle is to implement improvement in care transitions and coordination of care from inpatient to outpatient, post-acute care, and home care settings in order to improve health outcomes and prevent increased health care costs and hospital readmissions. This core activity improves care transition and coordination of care for patients in our community by providing navigation services that emphasize primary care and establish a medical home. These services assist in reducing unnecessary ED visits.","No","","137805107.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137805107","137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private",108,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","School Based Health Clinics: This core activity provides primary care services at schools in the greater Houston area that allows Medicaid and uninsured students to see a primary care provider during the school day. This allows the student to reduce the time missed from class while seeing a provider and provides a medical home. The program also includes a mobile dental van which provides dental services to the same student population. This core activity has staff and resources to provide over 20,000 encounters a year. This core activity will impact 10 school based clinics across the system. With each clinic and mobile dental van utilizing 4-6 staff members per shift.","Increasing the awareness and utilization of school-based clinics by MLIU students.","Efforts to increase awareness and identification of MLIU students at participating schools.","Tracking utilization of the school based clinics by MLIU students."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1; F2","D1: Pediatric Primary Care  The objective of this measure bundle is to increase access to comprehensive, coordinated primary care & preventive services focused on accountable, child centered care that improves quality of life and health outcomes. This core activity increases access and provides services for MLIU students by offering comprehensive primary care services and specific counseling services to school aged children at multiple School Based Health Clinics throughout the Greater Houston area.F2: Preventive Pediatric Dental  The objective of this measure bundle is to expand access of dental care including screening and preventative dental services to improve long term oral health and quality of life and reduce costs by preventing the need for more intensive treatments. This core activity expands access and provides preventative dental services for MLIU students by offering a mobile dental van available on a rolling schedule to the School Based Health Centers.","No","","137805107.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137805107","137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private",109,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","This core activity focuses on creating an environment to improve patient health outcomes and experience by reducing hospital related risks and errors. This environment anticipates potential problems, promotes early detection of problems, and always makes responses early. This core activity impacts all staff and facilities in the system.","Continue to monitor risks, errors, and near misses in the hospital.","Utilize systems including EMR reports to track outstanding risks, errors, or potential errors in the hospital."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","J1: Hospital Safety Improve  the objective of this bundle is to improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors. This core activity directly impacts the bundle objective by creating an environment in which potential problems are anticipated, detected early, and virtually always responded to early enough to prevent catastrophic consequences.","No","","137805107.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137909111","137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public",110,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","This core activity will expand primary and specialty care services through a hospital-based clinic to a medically underserved area of rural Texas.  The purpose is to provide access to both primary and specialty care services in an area where two-thirds of the population travels outside the service area for health care.   All of our Rural Health Clinic medical providers (physicians (6) and mid-levels (4)) are committed to the intervention.","Provide access to care during non-traditional hours for patients who work, care for children, do not have transportation, or face other challenges that make it difficult for them to seek care during typical business hours.","Our RHC offers extended hours (M-F, 7am - 7pm and Sat., 7am - 5pm).  With the extended hours our patients will have access to care during non-traditional hours for patients who work, care for children, do not have transportation, or face other challenges that make it difficult for them to seek care during typical business hours.","We will monitor utilization patterns during these extended hours to optimize the use of staff and to ensure we are meeting the needs of those we serve."," "," "," ","Since Calhoun County is a designated Primary Care and Mental Health HPSA area, Memorial Medical Center is committed to the recruitment and retention of primary and specialty care providers in the community.","Analyze service gaps to identify recruitment opportunities in primary and specialty care.","Coordinate with third-party recruitment firms to recruit qualified medical providers to our community."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2","Access to care is imperative to an individual's health.  By expanding our services we will improve the health of our patients by providing more timely access to care and coordinating treatment and follow-up care that is not available when patients seek treatment through the emergency department.  We also will improve patient satisfaction as patients will have a regular source for care that is less costly, more efficient, and better meets their health care needs.  Through the creation and operations of a hospital-based clinic and hiring of primary and specialty care providers, this project will enable MMC to better meet the community and Region needs for health care services.   Patients requiring specialty care must often drive long distances to see a provider, and may not receive services until the condition becomes critical.  Patients needing primary care are unable to get appointments, delay care until it is more critical, and use the emergency room department for care that could have been provided in a physician's office.  Through primary and specialty care access patients will receive preventative medicine and interventions for identified chronic diseases.  Appropriate and timely screenings are needed in order to realize the impact of effective preventative medicine.   Bundling of health outcomes will allow for a more formalize review and detection of chronic diseases such as cancer, diabetes, obesity, and others.","No","","137909111.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_137949705","137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private",111,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","Coleman Transition Model: We will continue to risk stratify patients for high risk for readmission; continue utilizing the Coleman transition of care model and offer our patients with complex care needs and family caregivers specific tools to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost and low-intensity evidence-based intervention. While teach back and documentation is a part of our institutional model the following members of the behavioral health/dsrip team will actively use the coleman model: 7 social workers, 1 LCDC, 1 educator, 2 PRN nurses, 2 NP, 1 pharmacist, and 3 bridge aides. These individuals will be working at the following locations: Houston Methodist hospital and San Jacinto hospital. The impact of implementing this model will be throughout the system definition.","Social workers will schedule follow-up appointments with patients in primary care setting","EPIC documentation through social workers in \"discharge summary\" flowsheet"," "," "," "," ","Teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way to confirm that you have explained things in a manner your patients understand. We will use teach back for social workers scheduling appointments to ensure patients are aware of the key information taught.","We will use an EPIC report to measure teach back completion"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","This will help the overall mission to reduce unnecessary hospitalization and improve health of PPP by increasing the services offered and introducing new projects we will be able to reduce the gap in behavioral health.","No","","137949705.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",112,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","The Core Activity selected will be provision of vaccinations to target populations.  All children 2 years of age should have all required vaccines to prevent childhood diseases, as an organization we strive to vaccinate all children according to the CDC schedule.","Human Papillomavirus Vaccine rates are monitored monthly on a Plan-Do-Study-Act (PDSA) document for Patient Centered Medical Home (PCMH) recognition.  Each primary care practice has a process to show improvement for this measure and this process is shared monthly to decide if any changes need to be made.\n\nTexas Children's Pediatrics will be shifting the focus for Fiscal Year 2019 to the Immunizations for Adolescents measure.\nImmunizations Measure for Adolescent rates are monitored monthly on a Plan-Do-Study-Act (PDSA) document for Patient Centered Medical Home (PCMH) recognition.  Each primary care practice has a process to show improvement for this measure and this process is shared monthly to decide if any changes need to be made. ","HPV-patients are called to follow-up for the series vaccines and patients are given the Merck text message reminder to help them remember to follow-up. Staff educate parents on the importance of vaccine."," "," "," "," ","Childhood and adolescent patients receive calls at appropriate well child ages and practice staff call patients to come in for well child visits/immunization to improve immunization rates.","Childhood and adolescent patients-calls are automated to families monthly to remind them of needed appointments. Practice staff will contact patients for upcoming and missed appointments."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","The childhood and HPV activities will improve the number of patients that receive the age appropriate vaccines, throughout the measurement year.  Careful monitoring of the data is helpful in improving rates by increasing awareness of actions that are needed.","No","","139135109.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",113,"Chronic Care Management","","Edit","We are not making a change to the Core Activity, we are only making a modification on the Change Ideas to the first Secondary Driver. We are eliminating the first Change Idea of the first Secondary Driver because the Diabetes Education team is recommending eliminate the insulin pump education as a standalone Change Idea because it is incorporated into the overall Diabetes education Change Idea. The pump education has been ongoing and it is continually updated as pump technology changes.","Management of targeted patient populations with high risk for developing complications","","The core activity consists of a population of established patients with Type 1 and Type 2 diabetes, ages 0-21, who are at risk for developing complications. An Education Care Process Team was developed to support educational metrics regarding nutrition and physical activity for diabetes patients. A High Risk Team was also created in order to focus on patients with poor diabetes control who are at risk for complications/comorbidities. These teams manage targeted patient populations and use data driven methodologies to implement improvement strategies for chronic disease management.","A multidisciplinary education team is developing educational material regarding nutrition and physical activity for certified diabetes educators and Registered Dietitians to deliver to patients. The team meets bi-monthly to develop and implement targeted interventions to support the high risk population.","The Education team will create and/or modify over 100 new education handouts, and make available through an internal intranet, as well as on the internet for patients. The handouts will be developed by evaluating key topics essential to diabetes curriculum and lifelong learning through a multidisciplinary team. ",""," "," "," ","A multidisciplinary High Risk care team working in parallel is developing implementation strategies to improve behavioral health support for patients at high risk for complications leading to hospital admissions.","To increase the identification of high risk individuals, the high risk team is instituting preventative measures with behavioral health support."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D5","Weight assessment continues to be at goal. Annual increases in the delivery of nutrition/physical activity counseling to patients indicate strong continuation of improvement. D5-406 has shown improvement in the current measurement year compared to prior measurement year that we are optimistic will continue through our multicomponent readmission bundle that addresses diabetes education, barriers to diabetes and potential solutions, clinic follow-up and working with community and school support systems. D5-T07 has shown mixed results to-date, however, continued focus by the care process teams on expanding educational material and delivery of interventions toward the high risk population including creation of an acute diabetes clinic for management of ketones are expected to improve results over time.","No","","139135109.7.1","BTM","Changes are in line with October DY8. Accepting.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",114,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Texas Childrens will monitor and manage its asthma patient population across the care delivery system in an effort to improve the care provided and decrease the need for acute and emergency services by this high risk population.","Texas Childrens will utilize its Asthma Care Process Team (CPT) to monitor and manage the asthma population and improve care.  The CPT will develop standardized Aims to guide providers in standardizing and improving care for the chronic asthma population.","The Texas Childrens Asthma Care Process Team leadership will train care teams on the global aims the system is striving to achieve and monitoring for best practice.  Improvement against these aim measures will be regularly tracked and discussed during CPT meetings and shared with physician leadership."," "," "," "," ","The CPT will also develop an Asthma Registry to make this data accessible to care providers at the point of service and drive improved care decisions.  Improved management of the population will be accomplished through visualization tools for tracking of progress towards goals and a registry within the EMR for real-time guidance to physicians and advanced practitioners. The registry will increase the efficiency and timeliness of population management activities such as bulk messaging. Care coordination efforts will also utilize these tools to streamline timely care for avoidance of ED visits and admissions. The registry will provide visibility overall to the persistent asthma patient population to insure prompt and appropriate medication management.","Asthma dashboards will be built out of the Asthma registry to provide real time, actionable data to physician and nurse teams and improve preventive care and proactive management of high risk asthma patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4","With real time access to data on their patients, providers can prevent ED visits and admissions by spotting high-risk behaviors such as missed preventive appointments or frequent refills.  Providers will also have better access to monitor which persistent asthma patients are not currently on controller medications, and intervening to correct.","No","","139135109.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",115,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Palliative care includes the management of pain, dyspnea and other symptoms and addresses the psychological, social and spiritual needs of children living with life-threatening conditions. The goal of palliative care is to achieve the best quality of life for the patient, consistent with their values. This coordinated care is delivered through an interdisciplinary team which follows the patient throughout the care continuum including emergency center, outpatient and inpatient settings.","All new palliative care consults will receive comprehensive palliative care assessments, and evidence based treatment plan interventions (including pharmacologic and non-pharmacologic). Palliative care consults provide a pain assessment based on the appropriate evidence based pain scale for the childs age and development (FACES, FLACC, Numeric, CRIES and PIPP).","Building an electronic consultation document that will identify all the palliative care measures including appropriate screening for dyspnea and pharmacologic and non-pharmacologic interventions for dyspnea based on the evidence available in pediatrics. Palliative Care Measures data will be reviewed by a multidisciplinary Palliative Care team monthly, identify gaps, and conduct rapid cycle PDSAs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","With a standardized approach to the palliative care consults using an electronic medical record with evidence based algorithms, we anticipate that the palliative care measure bundle will demonstrate improved symptom management and treatment preferences for palliative care pediatric patients and their families.","No","","139135109.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",116,"Maternal and Infant Health Care","","Continue","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","","Early antenatal care (1st trimester) with comprehensive evaluation, screening and interventions for high for high-risk behaviors and conditions improves mother and baby outcomes. Postpartum care follow-up within 8 weeks of delivery provides evaluation of maternal physical and emotional well-being, options for birth spacing, and enhanced newborn care.","Promote access to early and comprehensive pre-natal evaluation, screening, & interventions.","Create and implement standardized documentation tools to support behavioral health screenings."," "," "," "," ","Promote access for post-partum evaluation, screening and interventions within 8 weeks of delivery.","Enhance provider and staff awareness of progress through regular communication of metric data, identification of gaps, and development and implementation of rapid cycle PDSAs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","The implementation of evidence-based strategies to reduce low birth weight and preterm birth will have the following impact:  Timeliness of Prenatal Care can help to reduce preterm birth by increasing early access to obstetric care during the first trimester, during which time patients at risk for preterm birth can be identified and appropriate interventions can be implemented.  Behavioral Health Risk Assessment for Pregnant Women allows for assessment, identification, and early intervention by screening for tobacco and drug use among other things, both of which are associated with preterm birth and poor outcomes.  Post-partum follow-up and care coordination improvement provides us the opportunity to impact future pregnancies by screening for behavioral health issues such as tobacco use and promote tobacco cessation prior to becoming pregnant again, as tobacco is linked to preterm birth. Contraceptive Care promotes birth spacing, which has been shown to reduce preterm birth.","No","","139135109.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",117,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Develop and implement standard protocols for the reduction of leading causes of preventable death and complications for mothers and infants (such as Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans).","Promote provider and staff awareness of progress toward goals through regular communication of relevant process and outcome quality improvement data.","Interdisciplinary collaboration at the Texas Childrens Hospital Pavilion for Women to improve and enhance existing processes.","Enhance data transparency through regular communication of continuous quality improvement progress."," "," "," ","Implement evidence-based patient safety bundles such as but not limited to those supported by Alliance for Innovation on Maternal Health (AIM).","Participation in collaboratives focused on reduction of maternal morbidity and mortality, such as but not limited to Texas Department of State Health Services (DSHS), Texas Collaborative for Healthy Mothers and Babies, March of Dimes Healthy Babies are Worth the Wait, Houston Endowment Reducing Maternal Mortality, and Alliance for Innovation on Maternal Health (AIM)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Implementing and reinforcing the utilization of evidence-based bundles, such as those endorsed by AIM, supports the reduction of maternal morbidity and mortality through decreasing the incidence of obstetric hemorrhage and primary cesarean deliveries.  Antenatal steroid administration to mothers at risk for preterm birth has been associated with decreased incidence of potentially preventable pulmonary, cerebral, and gastrointestinal complications in the preterm newborn.","No","","139135109.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",118,"Hospital Safety and Quality",null,"Edit","Texas Children’s Hospital is not changing the Core Activity related to Pediatric Hospital Patient Safety. We are adding a Secondary Driver related to Adverse Drug Event. ","Implementation of standard protocols to address leading cause of hospital infections and injuries",null,"In alignment with the Solutions for Patient Safety national collaborative, Texas Childrens works through 12 hospital acquired conditions (HAC) teams to eliminate preventable harm.  Each HAC team works to implement & measure a standardized harm prevention bundle.  Bundles are developed by identifying best practices of top performing pediatric hospitals in the nation, achieving high reliability with the practice, and then testing their association with improved outcomes.  In addition to the implementation of the prevention bundles, Texas Childrens overlays safety culture work including Error Prevention Methods, Leadership Methods, Cause Analysis, Patient and Family Engagement, and Employee/Staff Safety.Key Driver diagrams are set and followed for CLABSI, CAUTI, Surgical Site Infections, Adverse Drug Events, and Pressure Injuries.  Control Charts displaying both outcomes and bundles compliance rates are followed on a monthly basis to identify trends and take relevant actions.  Examples of Safety culture work include Error Prevention Training for all new employees, faculty, and learners, reporting through to the board level, daily operational safety briefings, unit safety huddles, and regular senior leader walk rounds.","Our PI HAC team will target PDSA cycles aimed at utilizing high reliability leadership methods to continue to reduce pressure injuries.","The PI HAC team will engage with our department of patient and family services to identify a best practice for using patient and family input to guide improvements to the four bundle elements (skin assessment, device rotation, patient positioning, appropriate bed surface, and moisture management)."," "," "," "," ","Our team will continue work on reducing ADEs by targeting improvements related to administration of medications.","The ADE HAC team will use smart pump analysis to eliminate errors during pump programming.  Staff will be required to scan the pump and the medication prompting the pump to automatically set."," "," "," "," "," Our team will continue work on reducing ADEs by targeting the provision of outpatient (discharge) medications through our dedicated pediatric outpatient (retail) pharmacy.","  The Hospital will use a Meds to Beds program to eliminate errors during outpatient prescription filling."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3","The leadership alignment of HAC teams together with the focus on safety culture provides the necessary infrastructure and operational support to continue with effective PDSA cycles targeting each quality measure.","No","","139135109.7.1","BTM",null,"N","NB","NB overrode 1st review and suggested the provider options for Other.","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Evidence Based Interventions\" to \"Hospital Safety and Quality\" to better align with the provider’s described Core Activity.  \n\nHHSC also revised provider’s Core Activity title by moving it from \"Other: Utilization of comprehensive evidence-based interventions to reduce potentially preventable events in high-risk populations\" to \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)\". If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". \n","Provider agrees with changes.","BTM","Provider agreed to changes, which were already entered.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_139135109","139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private",119,"Chronic Care Management","","Continue","","Utilization of evidence‐based care management models for patients with complex needs","","Our goal is to improve management of CP population as these children are at high risk for developing complications and frequently have co-morbidities, such as epilepsy, difficulty swallowing and risk for pulmonary infections as well as failure to thrive, constipation, pain and vision/hearing deficits.  The majority of these children have weakness and hypertonia (spasticity) that interferes with mobility.  They can have preventable complications that can occur such as hip dislocation.  Joint deformities and scoliosis may require treatment to limit pain/loss of function and pulmonary compromise.  Potentially preventable events would decrease with improved management of this patient population including decreased ER and hospital admissions.  Parents and patients require ongoing education about treatment options and community resources including state and local supports.  By coordinating care across the TCH system with multiple points of access  appropriate prevention measures and treatment plans can be initiated.  By providing multi-disciplinary care management to the cerebral palsy population by ensuring access to appropriate specialty care services to improve diagnostic accuracy and timely interventions, improve functional status and overall quality of life as well as improving parental/community education and decreasing parental stress and caregiving burden.  This multi-disciplinary care management will reduce PPEs, decrease complications, and will assist in better assessing and treating co-morbidities.  ED visits and admissions can be reduced as well with improved navigation/access/care coordination.  Children seen in existing clinics have timely surveillance studies to prompt interventions for various conditions such as hip subluxation and scoliosis.  Health optimization/preparatory evaluations are emphasized before undergoing elective surgeries to decrease complications.  An example is that patients undergoing baclofen pump implantation and scoliosis surgeries need adequate nutritional stores.  Dysphagia and poor weight gain may prompt gastrostomy placement to ensure proper healing and avoidance of aspiration pneumonia in the perioperative period.  There is a higher risk for infection and wound breakdown if the child is malnourished.  For maximal success, certain surgeries also have best outcomes if performed in a certain window of time and in a certain order.  For example, a child with severe spasticity should be considered for a tone reducing surgery such as baclofen pump placement or selective dorsal rhizotomy prior to orthopedic surgery.  Gains from orthopedic surgery may be limited if the underlying spasticity is not addressed.  Not all families can attend appointments for baclofen pump maintenance and the childs health may actually be jeopardized if the family is noncompliant or lacks education on how to recognize problems with the pump system.  Education and social work screening are imperative as part of a pre-operative assessment.  This is usually accomplished over several encounters with a physiatrist in spasticity clinic so that a partnership in decision making can be established.  The management of cerebral palsy is a complex process as the causes are varied, and the functional levels and severity of involvement is different from child to child.  Children who are wrongly diagnosed with CP or have a misidentified form of high muscle tone may not respond to certain treatments and surgical treatments could actually introduce risk with little to no benefit.  For example, a child with dystonia will not benefit from a selective dorsal rhizotomy which is a surgery reserved for children with spasticity, and this child may even lose function if undergoing this surgery inappropriately.   Interventions that are skipped in a screening process such as nutritional and pulmonary assessments prior to surgery could result in complications such as poor wound healing, increased peri-operative infections and prolonged hospital stays.  Without proper parental education and supports, establishing a care plan, and post-surgical rehabilitation, optimal outcomes will not be achieved and some children may even lose function. Finally, we are awaiting HHSC approval for inclusion of the Baylor College of Medicine Center for Transition Medicine in this Core Activity. Once we receive this approval, we would like to add information about the Cerebral Palsy transition population.","Care coordination  bringing together specialists in CP both medical and surgical to enhance care to this patient population.  Include PT presence in CP and spasticity clinics.","Care coordinator  RN (individual with clinical knowledge of population a must).  Patients seen in CP clinic/spasticity clinic with only a physiatrist are set up for appropriate multi-disciplinary evaluations at the appropriate times and at the appropriate locations.  The coordinator assists with guiding next steps after diagnostic testing and interventions are performed and prepares the family for specific aspects of that childs care with anticipatory guidance."," "," "," "," ","Appropriate navigation  to assist families in navigating a complex system where some appointments are scheduled on the same day in the same place versus needing to get tests/other visits accomplished outside the main clinics.","Appropriate Navigation  RN (individual with clinical knowledge of population a must).  Seeing the correct specialists to address the issues that the individual child with CP has.  This will vary by patient and severity of involvement.  Some children will already have an established diagnosis of CP and can be assessed initially by a physiatrist for management and treatment options.  At a very young age surgeries would usually not be indicated but surveillance and optimizing health and community participation would be emphasized.  As the children age, their surgical needs increase.  The likelihood of pain and musculoskeletal deformities increases with time."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"I1","Our core activity will ensure access to specialty care services to improve functional status, overall quality of life, and to match patients with cerebral palsy with appropriate care providers at the appropriate time.","Yes","Texas Children's Hospital (TCH) Department of Physical Medicine and Rehabilitation cared for 2,522 patients with cerebral palsy (CP) in 2017. TCH works closely with the Baylor College of Medicine Center for Transition Medicine to transition patients from the pediatric to adult setting which is especially imporatant in this high risk population to reduce urgent and emergency care and improve management of comorbidities.  Key to outcome success for chronic care children is coordinated access and appropriate transition form the pediatric to adult care setting. ","139135109.7.1","BTM","Changes are in line with October DY8. Accepting.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_140713201","140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private",120,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","We will carefully monitor the number of patients in the HMWB CYPRESS ED, HMWB HOSPITAL, and HMWB SPRING ED. The two social workers will create a super utilizer report as well as do a root cause analysis for the readmitted patients. Because of higher volume in the HMWB hospital ED, the social workers will connect ED patients to primary and preventive care through a DSRIP social worker designated to improve care transition by assessing for social determinants and strategize the patient navigation. They will analyze the mobile assessment team report of ED patients.","Social workers will identify super utilizers, assess social determinants, and strategize patient navigation","Social workers will schedule follow-up appointments for patients and include EPIC documentation through social workers in \"discharge summary\" flowsheet"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","This will help the overall mission to reduce unnecessary hospitalization and improve health of PPP by increasing the services offered and introducing new projects we will be able to reduce the gap in health.","No","","140713201.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_158771901","158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public",121,"Expansion or Enhancement of Oral Health Services","","Continue","","Expansion of school based sealant and/or fluoride varnish initiatives","","HCPHES proposes to expand its current oral health outreach and treatment services in a focused effort to provide preventive dental screenings and fluoride varnishes, oral health education, and navigator-assisted referrals to community dental providers, including clinic-based HCPHES dental services. HCPHES staff will cultivate relationships with target schools, school districts, and community organizations to implement a school-based dental assessment and fluoride varnish program to deliver services directly to children where they attend school or congregate. The targeted population for this project is lower income individuals and the project will use the proportion of free and/or reduced lunch students as a proxy measure to identify where project impacts will be most beneficial. The oral health prevention team will be staffed by dental hygienists, dental assistants, community health workers, and program administrators. The proposed project will endeavor to deliver oral health assessments and fluoride treatments twice per school year, reinforced by educational activities and client follow-up. Oral health screenings will consist of inspections for tooth decay, assessment of early periodontal disease (gingivitis), and physical and visual oral cancer screenings. During the summer months, when schools are not in session, project staff will evaluate findings, coordinate future school-based programming, and coordinate community events to larger audiences. HCPHES has seen year over year growth with the expansion and depth of the school based oral health program. It is expected that by the end of 2018, HCPHES will have the program established in 25-30 low income schools through out the HCPHES jursidication, in addition to expanding to low- income after school programs and daycare centers.  As the program enlarges the expectation is to add additional dental clinicians to meet the need. Currently the activities utilizes one supervising licensed dentist, four hygentist, and a host of community health workers and project assistants across 15 school based sites and various low income daycare center sites.","The utilization of Community Health Workers to aid in partnership development and case management.","Community Health Workers (CHW) will be an integral component of the project and will be utilized to strengthen relationships with schools and communities, assist in event planning logistics, and most importantly, provide navigation and referral services to participants to guide them to additional preventive and treatment options. CHW will follow-up with clients following each assessment to evaluate their progress and offer guidance and navigation to the next level of care, as applicable. CHW will have a demonstrated presence in this project and are well suited to interact with community partners and project participants to ensure the project is administered in a way that is culturally and linguistically appropriate to the targeted population."," "," "," "," ","HCPHES will utilize a stage gate approach in applying project management best practices in implementing the youth dental program specifically utilizing a phased release process over the lifecycle of the program.","In each stage gate we will focus on continuous stakeholder feedback from various data collection points including iterative reviews of lessons learned captured from project deliverables in remediating any future challenges and/or risks. In addition, given the majority of the population we serve are Medicaid/low income uninsured individuals, our program will be tailored to overcome the unique challenges/barriers that may exist such as transportation, communication, availability, and location."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-231","Through the expansion and continuation of this core activity HCPHES will be able to provide essential preventative oral health services to MLIU students with in the HCPHES jurisdiction and ensure they are provided with a first line of defense against tooth decay and childhood carries, in addition to navigating the MLIU students to an appropriate dental home.","No","","158771901.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of school based sealant and/or fluoride varnish initiatives to otherwise unserved school-aged children by enhancing dental workforce capacity through partnerships with dental and dental hygiene schools, local health departments (LHDs), federally qualified health centers (FQHCs), and/or local dental providers.","CA-3","CA-3.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_158771901","158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public",122,"Prevention and Wellness",null,"Edit","","Other","Increase in Utilization of Mobile Clinics","HCPHES plans to continue mobile health services to targeted Harris County communities by providing immunizations, health and wellness screenings, health promotion/education activities, while also enrolling individuals and their families into private and public health insurance programs, and guide participants to additional care, as appropriate. The project will capitalize on relationships with community partners, old and new, to plan and implement community events that draw in residents that may not have access to basic health screenings and prevention. HCPHES has expanded the clinical provider base with the addition of one full-time chronic disease physician, and one part time family nurse practitioner, supported by a knowledgeable clinical support staff (RN, LVN, MA, and registration specialist). IN the last demonstration year the mobile health team conducted over 140 unique screening and wellness events through out the HCPHES jurisdiction, in  addition to maintaining immunization and screening activities in three community fixed sites and a refugee health program.  With provisions and incentive payments captured through waiver 1.0 HCPHES has been able to purchase a two opertory medical coach to provide direct service in underserved communities to mitigate access to care issues caused by transportation and resource limitations.","Optimize the use and accessibility of mobile screening and vaccination clinics","A significant proportion of Harris County residents are uninsured and many lack the resources or face geographic and logistical barriers in accessing primary health care and basic health screenings. The project seeks to intervene within the HCPHES jurisdiction by delivering high quality screenings, immunizations for eligible children and adults, and track referral services offered to communities and residents directly. HCPHES plans to continue to collect and capture data related to the number of  unique community/ mobile events conducted each quarter, number of unique individual impacted, and school based immunization compliance rates within targeted MLIU schools."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-269; L1-271; L1-280; L1-343; L1-268; L1-272; L1-345","This core activity impacts the measures seleted by removing the barriers to care identified in the most recent CHNA caused by transportation and resource deficits. This approach makes it easier for the target population to access wellness services, immunizations, STI/D screening services, preventative health education and navigation to essential resources.","No","","158771901.7.1","BTM","NB, do you agree with my change to Access to Primary Care Services for grouping and CA \"Increase in utilization of mobile clinics\"?","Y","NB","in agreement","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Expansion of preventative health screenings and vaccinations to underserved population\" to \"Access to Primary Care Services\". HHSC has also updated the Core Activity Name from \"Other: Expansion of mobile community/school based preventative health screening services and vaccination services to underserved, under insured, low-income, Medicaid eligible populations through partnerships with LHD's, immunization coalitions, and public/private community partnerships\" to \"Increase in utilization of mobile clinics\" to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and indicate whether another Core Activity Grouping and Name is appropriate instead of “Other”.","Provider e-mail on 2/6/20: We would like to select CA-7.9, Other: Mobile Preventive Services, as the Core Activity name.  None of the listed core activities fully encompass the full spectrum of activities that are being performed under this activity.  We are expanding our mobile community and school based prevention and wellness education activities, which include but are not limited to preventative health screenings, vaccination services, tobacco counseling, nutrition counseling, and family planning and reproductive health services/screenings. Additionally, we are establishing partnerships with LHD’s, coalitions, and community partners. Our mobile clinic conducts a variety of prevention and wellness activities, some which are listed as individual core activities and some which are not. Choosing one of the listed core activities would incorrectly limit the breadth we provide for the community. The option of “other” is really the best fit for this activity and the growth of the activity within the department moving forward. ","BTM","Sent a follow up e-mail and did not make the change based on provider's response. Flagging for second review to ensure NB is okay with other.  I think it's fine. ","Y","NB","NB followed up with the provder, and changed it back based on their request - Prevention and Wellness and Other Increase in Moble units.\n\nAfter reviewing your request, unfortunately we still do not think that the naming of the grouping suffices for the activities.  As we do wellness programs/screenings, we do not solely use evidenced based programming, therefore it would be not capturing the range of activities we are providing.  I still believe that the “Other” option originally sent out still fits best due to the large scope of services the mobile initiatives cover. Please let me know your thoughts.\n\n\n","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated Core Activity Grouping to Prevention and Wellness with Core Activity Name remaining as \"Other\" per email agreement from provider.","Other","CA-7","CA-7.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_158771901","158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public",123,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","HCPHES, through the utilization of mobile and fixed clinics, will increase access to the vital services necessary to reduce childhood and adolescent obesity rates in the target communities by providing screenings, health promotion education, and a robust referral program into applicable services such as integrated care programs, primary care providers and treatment programs, as applicable. HCPHES aims to reduce childhood and adolescent obesity, which has been identified by the American Heart Association, Centers for Disease Control and Prevention, American College of Cardiology, and the National Institutes of Health along with many other health and research agencies nationally and internationally, as an elevated risk factor associated with and causing cardiovascular disease and disorders, including but not limited to, coronary heart disease, heart failure, and sudden death. Participants will be recruited through current clinical services, community-based events, and other HCPHES community-based programs. Physical locations for the proposed evidence based program sessions will be identified that best meets the needs of the participants and their families. HCPHES proposes to partner with local agencies that may also offer physical space for this initiative.","Optimize the use and enrollment of \"at-risk\" age appropriate children into the evidence based intervention.","Increase the number of school based intervention sites within MLIU communities to increase enrollment and program completion."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-147; L1-IT-7.11; L1-210; L1-IT-8.23; L1-211","This project is an ever evolving innovative step for HCPHES as an expansion of community-focused intervention aimed at reducing childhood and adolescent obesity. Prior to the launch of this intervention in waiver 1.0, previous outreach efforts consisted of the dissemination of information and program administration from fixed clinical establishments, that did not interface with a large populous of the targeted community. This project has expand services to include mobile clinical operations to meet accessibility needs, and offers  additional services to the targeted population, including community based group programs, individualized exercise programs and individualized follow-up by community health workers and registered dietitians.","No","","158771901.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce and prevent obesity in children and adolescents (e.g., Technology Supported Multi Component Coaching or Counseling Interventions to Reduce Weight and Maintain Weight Loss; Coordinated Approach to Child Health - CATCH; and SPARK among others)","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_158771901","158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public",124,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","HCPHES will adopt and implement a 2As and R (Ask, Advice, and Refer) tobacco intervention and deliver an evidence based group tobacco cessation program. Modified from the evidence based 5As model (Ask, Advice, Assess, Assist, Arrange), the 2As and R is a more practical program approach for clinical settings. The 2As and R is a brief tobacco intervention delivered by providers (designated clinical staff across all clinical programs) that has been shown to significantly increase the likelihood that a client will make an attempt to quit smoking/ tobacco use. The intervention will also be delivered in community settings by community health workers and trained program facilitators (approx. 15 trained resources). HCPHES will continue to  utilize the Freshstart program as a reference framework due to the programs notable outcomes. The Freshstart evidence-based approach is geared to help participants increase their motivation to quit, learn effective approaches for quitting and guide them in making a successful quit attempt.","Enhance the provision of tobacco prevention efforts to current/former/and would be smokers","Monitor the number of individuals receiving the 2A's and R intervention and enrolling into fresh start","Increase the number of trained fresh start facilitators."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-105; L1-400","The selected core activity impacts the selected measures by providing access to evidence based interventions, which have been proven to deter smoking activities and lead to positive quit attempts.","No","","158771901.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_158771901","158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public",125,"Access to Specialty Care Services","","Continue","","Use telemedicine/telehealth to deliver specialty services","","Patients will be given specially adapted cell phones and will record themselves taking each dose of medication.  The video will upload automatically through a secure server and will then be downloaded and viewed at the performing providers office by an outreach worker,nurse, or mid level provider ( approx. 10 dedicated resources) who can confirm the dose was taken.  This process will enhance adherence by allowing the patient to take the medication at a time and in a location convenient to him/her, based on mealtime, commute schedule and work schedule.  This will make it easier for the patient to complete treatment on time, with fewer missed doses, and prevent the development of drug resistance as well as hospitalization for relapse due to inadequate treatment.  Service area will cover HCPH jurisdication.","Provide education to patients on proper utilization of VDOT system and tools.","VDOT program will be evaluated for medication adherance"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-347","The performing provider will improve adherence with treatment in the target population by implementing video-based directly observed therapy (VDOT) for qualified tuberculosis (TB) patients. This project will thereby increase the number of patients who are adequately treated for active TB disease and TB infection and ultimately decrease potentially preventable hospitalizations for tuberculosis as well as costs for treating drug-resistant TB. VDOT will be reserved for patients who have been diagnosed with TB and can spread the bacteria to others.  Factoring in travel and personnel cost, patient cost is estimated at $27K to treat TB, and $130K to treat Multidrug resistant TB.  According to the Verizon Foundation, the VDOT program will reduce cost by 30% to health departments using this program. The use of this program will also increase the number of patients who stick with the proper medication treatment by nearly 50%.","No","","158771901.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use telemedicine/telehealth to deliver specialty services.","CA-2","CA-2.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_181706601","181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private",126,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","Continued utilization of the med/psych unit to address the needs of patients admitted to SJMC with both behavioral and medical health needs.","Utilization of the ED to treat exacerbations of psychiatric conditions and simulataneously address medical co-morbidity needs","The unit will address the needs of both the medical and behavioral health of these patients and will discharge them with care plans for both conditions for follow-up and disease management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","For the core activity to support this bundle, SJMC will continue the med/psych project from DY1-DY6 working on transitions for patients with both medical and behavioral diagnoses in the hospital to ensure all services and needs are met.","No","","181706601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_212060201","212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private",127,"Chronic Care Management","","Edit","Per the October DY8 Reporting Companion, Rice Medical Center (“Rice”) updated Core Activity #1 to describe fully current practices.\n\nCore Activity #1: Rice updated to provide additional information and reflect the closure of Rice’s Wallis clinic.\n\nSecondary Driver #1: Rice revised to ensure both the education and support components of Secondary Driver #1 are included in the description.\n\nChange Idea #1: Rice moved the original Change Idea #1 to Change Idea #2.  Rice added Change Idea #1 to capture the patient education component of Secondary Driver #1.\n\nChange Idea #2: Rice moved the original Change Idea #1 to Change Idea #2.  Rice revised Change Idea #2 to provide detail on current processes in place for providing support services to diabetic patients and increase preventative care visits and improve screening rates. \n\nImpact on Measures: Rice updated this section to describe clearly the impact Core Activity #1 will have on the Improve Diabetes Care Management measures.","Utilization of evidence‐based care management models for patients with complex needs","","Rice provides Diabetes Self-Management Education & Support to patients with a diagnosis of Type 1 or Type 2 diabetes through its Diabetes Education program.  Rice offers diabetic education at its Eagle Lake and East Bernard clinics.  The program consists of one diabetic educator along with a project manager to help coordinate appointments and group classes.  The Diabetes Self-Management Education includes providing education to diabetic patients regarding health and nutrition, and the importance of HbA1c, Blood Pressure, and Foot Care screenings.  The program also offers ongoing support to diabetic patients to improve health outcomes and prevent complications by ensuring timely preventative care exams and screenings for diabetic patients. ","Provide Diabetes Self-Management Education & Support services to patients with a diagnosis of Type 1 or Type 2 diabetes through Rice’s Diabetes Education program.  ","Provide Diabetes Self-Management Education (“DSME”) to diabetic patients regarding health and nutrition, and the importance of HbA1c, Blood Pressure, and Foot Care screenings. DSME is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care.  This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.  The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.  Based on its prior experience with DSME and peer reviewed studies, Rice anticipates Change Idea #1 will improve health outcomes for diabetic patients and reduce utilization rates for preventable complications.  ","Provide ongoing support to diabetic patients to improve health outcomes and prevent complications by ensuring timely preventative care exams and screenings for diabetic patients.  Change Idea #2 includes electronic and manual processes for identifying diabetic patients that are due for a preventative care exam and/or HbA1c, Blood Pressure, and Foot Care screenings.  On a weekly basis, Rice’s Clinical Care Initiatives Coordinator generates electronic reports utilizing the Clinic Financial System to identify diabetic patients that are due for a preventative care exam and/or screening(s).  Rice uses the electronic reports to produce and send notification letters to the patients with contact information to schedule the preventative care exam and/or screening for which the diabetic patient is due.  On a daily basis, Rice’s Clinical Care Initiatives Coordinator reviews patients scheduled for clinic appointments and performs a manual chart review to determine status of preventative care exams and screenings for diabetic patients.  Rice updates each diabetic patient’s chart with an alert that includes a description of the status for preventative care exams and/or screening with a schedule showing the date(s) the preventative care exams and/or screening will be due.  Based on prior experience and peer-reviewed studies, Rice believes the processes for informing patients of preventative care exam and screening schedules will help increase the number of diabetic patients receiving timely services to manage health outcomes, reduce related complications, and ensure prudent healthcare utilization."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Diabetes Self-Management Education & Support (“DSMES”) services provide information and skills to help patients manage their diabetes and related conditions. DSMES services are individually tailored to each patient’s needs, goals, and life experiences and is guided by evidence-based standards. Rice’s DSMES services focus on: (1) helping individuals understand diabetes and treatment, (2) building health eating and physical activity habits, (3) monitoring blood sugar levels, (4) medication adherence, (5) reducing risk for other health conditions, (6) coping with the emotional side of diabetes, and (7) improving overall health outcomes and quality of life.  DSMES services has been shown to be cost-effective by reducing hospital admissions and readmissions, as well as estimated lifetime health care costs related to a lower risk for complications.  Studies also show DSMES services improve HbA1c levels, increase timely screening rates, and reduce the onset and/or advancement of diabetes complications.  Based on these studies and prior experience with providing DSMES services, Rice is confident Core Activity #1 will have a significant impact on its performance rates for each measure in the Improve Diabetes Care Management bundle.","No","","212060201.7.1","BTM","Edits are on additional details and match October reporting. Accepting.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_212060201","212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private",128,"Access to Primary Care Services","","Edit","Per the October DY8 Reporting Companion, Rice Medical Center (“Rice”) updated Core Activity #2 to describe fully current practices.\n\nCore Activity #2: Rice updated to provide additional information related to tracking and notification systems for cancer screenings.\n\nSecondary Driver #1: Rice revised to provide detail on the electronic and manual processes it implemented for cancer screening tracking and notification systems. \n\nChange Idea #1: Rice revised Change Idea #1 to outline the electronic and manual processes it implemented to improve cancer-screening rates.\n\nImpact on Measures: Rice updated this section to describe clearly the impact Core Activity #2 will have on the Cancer Screening measures. ","Provision of screening and follow up services","","Implement tracking and notification systems for cancer screenings.  Tracking and notification systems are key to ensuring providers and patients are aware of cancer screening schedules.  Together, tracking and notification systems help improve timely cancer screening rates.","Implement electronic and manual processes to improve cancer-screening rates by identifying patients that are due for cancer screening and informing patients of cancer screening schedules.","Change Idea #1 includes electronic and manual processes for identifying diabetic patients that are due for a Breast Cancer, Cervical Cancer, and Colorectal screenings.  The tracking system for the electronic and manual processes takes into account unique factors that inform cancer screening schedules (e.g. individual and family medical history and other cancer risk indicators).  On a weekly basis, Rice’s Clinical Care Initiatives Coordinator generates electronic reports utilizing the Clinic Financial System to identify patients that are due for cancer screenings.  Rice uses the electronic reports to produce and send notification letters to the patients with contact information to schedule timely cancer screenings.  On a daily basis, Rice’s Clinical Care Initiatives Coordinator reviews patients scheduled for clinic appointments and performs a manual chart review to determine status of each patient’s cancer screening.  Rice updates each patient’s chart with an alert that includes a description of the status for cancer screenings with a schedule showing the date(s) the next cancer screening is due.  As part of this process, Rice informs patients of the pros and cons of different screening options.  Based on prior experience and peer-reviewed studies, Rice believes the processes for tracking cancer screening and informing patients of cancer screening schedules will help increase the number of patients receiving timely cancer screenings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Core Activity #1 will have a direct impact on Breast Cancer, Cervical Cancer, and Colorectal Cancer screening rates.  Tracking systems are essential to keeping providers and patients aware of the status for cancer screenings and cancer screening schedules.  Studies show advance notification letters increase timely screening rates for Breast Cancer, Cervical Cancer, and Colorectal Cancer.  Additionally, targeting patients during in-person appointments is an effective tool for informing patients of cancer screening schedules and encouraging onsite appointment scheduling when a patient is due for a cancer screening.","No","","212060201.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",129,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","Identification and referral of frequent or inappropriate users of the Emergency Medical Service transport system or Emergency Department care setting for chronic conditions that would be better managed in a medical home with proactive care, coaching and resolution of one or more negative social determinants of health, thus avoiding episodic crisis interventions.Number of providers committed: AccessHealth, FQHC (1 LVN - Care Coordination Manager, Director of Reporting and Analytics, 1 Dietician, 1 LVN, 2 CHWs), Fort Bend County ( 1 Special Projects Coordinator)Locations impacted: AccessHealth, FQHC Adult Clinic at Richmond and Missouri City locations","Establish engagement with referred clients by enrolling them into a navigation team approach to improve health outcomes for the client","Consistent medical home with proactive care provided by a navigation team","Establish connections with specialty care providers, such as urology, optometry, wound care, general surgery, hematology and cardiology"," "," "," ","Improving chronic disease understanding and self-management","Incentivized chronic disease education and self-management courses","Establishing patient specific goals (e.g. weight, exercise, nutrition)","Availability to patients of a registered dietician to better assist them with nutrition and their diets"," "," ","Community Health Worker assessment and referral for mitigation of health impacting social determinants","Collaboration with and referral to social service agencies within the community"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115; L1-207","One of the chronic diseases impacting many of our patients is uncontrolled diabetes. Access to care driven by a proactive team approach improves disease knowledge and self-management, assures access to medical appointments, prescribed medications, dietician counseling, disease education courses and individualized health improvement goals, including exercise. The patients will improve various health markers and specifically will lower their HgbA1c levels and blood pressure.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",130,"Behavioral Health Crisis Stabilization Services","","Continue","","Provision of crisis stabilization services based on the best practices","","Fort Bend County Crisis Intervention Team consists of a specialized team of officers that work closely with Fort Bend County Behavioral Health Services, the local mental health authority, psychiatric hospitals, emergency rooms, emergency medical services (EMS) and community service organizations.  The Fort Bend CIT responds to behavioral health crises in the community, provides stabilization services, directs individuals to the appropriate level of care, reduces unnecessary incarceration and emergency room utilization, provides follow up services and connects individuals with needed clinical and social services.Number of providers committed: Fort Bend County Behavioral Health Services (Director of BHS & Project Specialist) and Crisis Intervention Team (1 Captain, 1 Lieutenent, 10 Deputies, 2 Sergeants)Locations impacted: Zips codes within Fort Bend County (77053, 77406, 77407, 77417, 77420, 77430, 77441, 77444, 77451,77459, 77461, 77464, 77469, 77471, 77476, 77477, 77478, 77479, 77481, 77485, 77487, 77489, 77494,  77496, 77497, 77498,77545,77583)","A network of needed clinical and support services, in the community, for individuals and families.","Establish collaborative partnerships and information sharing to expand clinical resources and social supports","Follow up and continuity of care to connect individuals and families to needed supports and services"," "," "," ","Specialized Crisis Intervention Team (CIT) that is trained and supported to address behavioral health crises, in the community.","Provide ongoing training to CIT to support response and intervention system","Expand crisis intervention training to first responders to enhance cross systems knowledge and coordinated response"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-241","This core activity responds to behavioral health crises and connects individuals with the appropriate level of care reducing the unnecessary incarceration and escalation of dangerous behavior.  The Crisis Intervention Team provides specialized response, stabilization, and follow up services.  The Fort Bend County CIT is a critical component of the countys emergency response system and Ft. Bend Countys Behavioral Health Services. Timely and appropriate response system is critical to preventing unnecessary criminal justice involvement for individuals with behavioral health disorders.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of crisis stabilization services based on the best practices (e.g., Critical Time Intervention, Critical Intervention Team, START model).","CA-11","CA-11.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",131,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","Identify individuals frequently or inappropriately using EMS transport and ED care for episodic crisis care of chronic medical conditions better managed in a medical home.  Paramedics provide assessment and care to identified individuals.  Community Paramedics will connect the patients to the local Federally Qualified Health Center to establish a medical home.  The project will promote the medical home and serve as a community based navigation system.Number of providers committed: Fort Bend County EMS (1 Deputy Chief- Clinical) and Fort Bend County Community Paramedic team (1 Community Paramedic Coordinator, 2 Community Paramedics), Fort Bend County ( 1 Special Projects Coordinator)Locations impacted: Zips codes within Fort Bend County (77053, 77406, 77407, 77417, 77420, 77430, 77441, 77444, 77451,77459, 77461, 77464, 77469, 77471, 77476, 77477, 77478, 77479, 77481, 77485, 77487, 77489, 77494,  77496, 77497, 77498,77545,77583)","Engage clients in chronic illness self- management, healthy lifestyles, preventive care, and positive healthcare decisions","Provide comprehensive chronic disease education course","Establish patient specific goals (e.g. weight, exercise, nutrition)","Empower the client for good medication management:  the right way to administer, when it needs to be administered, proper storage, handling, disposal, etc."," "," ","Identify patients who are at risk for inequalities in social determinants of health that are impacting their health through coordination of care, referrals for service provision","Implement use of a standarized tool to identify at risk clients","Collaboration with and referral to social service agencies within the community"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115; L1-207","Clients who are disconnected from a medical home may present for episodic crisis care for their chronic condition through the EMS pre-hospital care and ED systems.  While care provided in these systems may be excellent, the patient often returns to no ongoing care. The active identification of such patients, proactive linkage to a medical home, provision of navigation services and addressing appropriate social determinants of health can improve health status and health outcomes for these patients.  The measures selected reflect improvement in a common chronic disease of diabetes in the target population.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",132,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","Use of the SBIRT (Screening, Brief Intervention, Referral to Treatment) model integrated in the local FQHC designed to identify, reduce, and prevent problematic substance use disorders. The program is designed to identify individuals with substance use and to effectively help them stop or reduce the current use before they need more extensive or specialized treatment, and to improve their overall health. Number of providers committed: AccessHealth, FQHC (1 SBIRT Counselor & 1 Chief Program Officer), Fort Bend County ( 1 Special Projects Coordinator)Locations impacted: AccessHealth, FQHC Adult Clinic at Richmond and Missouri City locations","Systematically screen all clients to identify those who need further intervention","Monitor the number of CAGE AID screening assessments performed. CAGE-AID (Adapted to Include Drugs) is a version of the CAGE alcohol screening questionnaire, adapted to include drug use.  It assesses likelihood and severity of alcohol and drug abuse. This four item screening tool takes approximately 1 minute to administer and score. The target population for the CAGE-AID is adult patients and can be administered by patient interview or self-report in a primary care setting.","Connect the client with appropriate level of care"," "," "," ","Reduce tobacco, drug and alcohol use in identified patients","Engage patients in motivational interviewing and cessation classes","Provide medication to assist with reduction of tobacco, drug and alcohol use"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-105","This core activity provides infrastructure to integrate substance use recognition and treatment into the FQHC through the SBIRT program. This includes tobacco, alcohol and other drug screening into the standard of care for all family practice adult patients (18 and older). Through the systematic integration of screening into the FQHC, we identify and engage patients in education and intervention.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",133,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Expand the hours of operation of the local Federally Qualified Health Center to increase access to primary care for the Medicaid, uninsured and underinsured population in Fort Bend County. A standard 7 a.m. to 7 p.m. weekday schedule and a Saturday morning schedule from 8 a.m. to 12 p.m.Number of providers committed: AccessHealth, FQHC (1 Family Practice Provider, 1 LVN, 2 Medical Assitants, 3 Front Desk/ Eligibility Staff), Fort Bend County ( 1 Special Projects Coordinator)Locations impacted: AccessHealth, FQHC Adult Clinic at the Richmond location","Same day appointment availability slots to expand access","Monthly reports on availability and usage of same day appointment slots","Develop a contingency plan for days (or parts of the day) when demand far outstrips the availability of physicians"," "," "," ","Maintain a full provider team dedicated to the expanded clinic hours","Develop a contingency plan for days when providers are out of office to ensure there are enough available providers for the capacity need","Dashboard report of staff capacity and usage of same day appointment slots"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-205","Availability and management of early morning, evening and Saturday appointmens as well as additional staff capacity, during the regular hours, are key to improving access to timely care.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",134,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Provision of services to individuals that address social determinants of health","","Assessing the social determinants of health is an integral part of our service delivery system.  Addressing needs such as housing, transportation, food insecurity, and poverty requires collaboration and information sharing with other county departments and community organizations. Number of providers committed: Fort Bend County Behavioral Health Services (Director of BHS, 1 Project Specialist, 1 Recovery & Reintegration Specialist, 1 Case Manager Specialist, 2 Clinical Care Coordinators)Locations impacted:  Fort Bend County Behavioral Health Services located in Richmond, TX","Screen clients (youth and adults) enrolled in Behavioral Health Services for social determinants of health.","Process for integrating social determinants of health data into program management","Expand resources for meeting social determinants of health"," "," "," ","Intensive case management services provided to clients","Connect individuals (youth and adults) and families to needed supports and services, provide follow up and evaluate needs on an ongoing basis to ensure that social determinants of health are met.","Process for information sharing among agencies that provide services that address social determinants of health, in order to facilitate access to those services and supports"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-241","This core activity connects clients to appropriate wraparound services.  Reducing risk factors for recidivism such as the lack of safe and stable housing, employment, and social isolation are essential to improvements in the selected measure.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",135,"Behavioral Health Crisis Stabilization Services","","Continue","","Implement models supporting recovery of individuals with behavioral health needs","","Behavioral Health Services provides intensive case management, strengths-based planning, wraparound supports, wellness curriculum, and individual and family centered services. The focus of our programs for youth and adults are on recovery, reintegration into the community, keeping families together and reduction of incarceration/detention.Number of providers committed: Fort Bend County Behavioral Health Services (Director of BHS, 1 Project Specialist, 1 Recovery & Reintegration Specialist, 1 Case Manager Specialist, 2 Clinical Care Coordinators)Locations impacted:  Fort Bend County Behavioral Health Services located in Richmond, TX","Complete the CANS (Child and Adolescents Needs and Strengths) and ANSA (Adult Needs and Strengths Assessment) to assess needs and strengths. These assessments are multi-purpose tools developed for behavioral health services to support decision making in level of care and individualized service planning, which facilitates quality improvement initiatives and allows for monitoring of the outcomes of services.","Use CANS and ANSA data to assess individual outcomes and modify service plans, accordingly"," "," "," "," ","Patient support/continuity of care of services for clients enrolled in the program","Develop, implement and evaluate the follow up/after care process and use the data to assess client functioning/recovery and identify additional needed services and supports, for clients enrolled in the program"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-241","The comprehensive individual and family services provided are essential to reducing incarceration/detention.  Our programs include follow up and after care supports, also essential to recovery and reducing incarceration.","No","","296760601.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_296760601","296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public",136,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services",null,"Provide a colonoscopy screening to uninsured and underinsured populations who meet the American Cancer Society criteria for this procedure but have no resources to pay for it.  Some patients will receive polypectomies for pre-cancerous polyps, thus preventing a future cancer while others may be diagnosed and treated for cancer at an earlier stage than if it was not diagnosed until symptomatic.  The FQHC, AccessHealth will identify and refer for colonoscopy screening patients meeting the ACS criteria for colorectal cancer routine screening.Number of providers committed: , Fort Bend County ( 1 Special Projects Coordinator), AccessHealth, FQHC (8 Physicians, Director of Reporting and Analytics, 1 Referral Clerk Supervisor, 1 Referral Clerk & COO), 2 Contracted Gastroenterologists, 1 Contracted Hospital (surgical suite, pathology, radiology, anesthesiologist)  & 1 Contracted Outpatient Surgical CenterLocations impacted: AccessHealth, FQHC Adult Clinic at Richmond and Missouri City locations","Assess and reduce patient barriers to completion of screening procedure","Educate patients at the time of referral as to the complete expectations of colonosocpy screening, which included an effective bowl preparation prior to reporting for the procedure. The clinic will ensure brochure availabilty and address patient concerns at the time of the referral.","Connect with community resources for education regarding the need for colonoscopy screening and to counteract fear."," "," "," ","Leverage the Health Information Technology Systems","Implement reports to identify and notify patients due for screening and patients that are hard to reach","Ensure current and reliable data of family history, diagnoses, and symptoms"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-107","Access to colorectal cancer screening is driven by a proactive team approach which improves knowledge of the colorectal cancer screening process and ensures access to a gastroenterologist.   Successful implementation of this activity will improve colorectal cancer screening rates at the FQHC.","No","","296760601.7.1","BTM",null,"N","NB","changed to NMI and changed Other","Needs More Information","HHSC has updated the Core Activity Grouping from \"Prevention and Wellness\" to \"Access to Primary Care Services\" to better align with the provider’s described Core Activity. \n\nHHSC also revised provider’s Core Activity title by moving it from \"Other: Implement Evidence-based Disease Prevention Programs Colonoscopy Screening\" to \"Provision of screening and follow up services\". If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". \n","Fort Bend County agrees with the changes.","BTM","Provider agreed to change, which is already reflected.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_311054601","311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private",97,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services",null,"ECMH will implement strategies to prevent lung diseases, to increase the rate of penumonia vaccination for older adults, and to advocate the use of advance care plan. The system components will include our clinic, ER, and inpatient units. Clinical protocol will be used as guideline and activities will be documented in electronic health record. We project that 21 providers will be committed to participating in this activity, performing intervention and educations to patients. These providers will include hospitalist physicians, ER physicians, and clinic primary care providers.","Screen for tobacco use, pneumonia vaccination for adult 65 or older, and presence of advance care plan.","Train multiple levels of healthcare providers, including physicians, mid-levels, and nurses to perform screening as documented in hospital's clinical protocols.","Utilize EMR to build screener templates, allowing reportable data to be captured."," "," "," ","Educate patients on tobacco use and smoking cessation options and related resources, pneumonia risk for older adult, and the benefits of having advance care plan.","Identify available and appropriate educational material to be use by ECMH as our standards.","Train multiple levels of healthcare providers, including physicians, mid-levels, and nurses to deliver education to patients as documented in hospital's clinical protocols."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","By directly identifying patients that are at risk of smoking-related diseases through smoking screening, we can immediately create necessary treatment plans. We can also begin systematically monitoring progress on the status of pneumonia vaccinations and presence of advance care plans in our health information system. To further population health, we can track this data and develop trending analysis to identify areas for continuous quality improvement in the affiliated measures.","No","","311054601.7.1","BTM",null,"N","NB","changed to NMI ","Needs More Information","HHSC requests that the provider considers other Core Activity Groupings and Areas to see if the Core Activity can be moved to menu. One option to consider is \"Access to Primary Care\" as a Grouping and \"Provision of screening and follow up services as a Core Activity\". Provider can consider if areas from \"Chronic Care Management\" may be suitable. Please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\".","Provider concurs with the revision to select \"Assess to Primary Care\" as the Grouping, and \"Provision of screening and follow up services\" as Core Activity.","BTM","Provider agreed to change. Made changes to grouping and activity.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically, the Grouping was changed to \"Access to Primary Care\" and the Core Activity was changed to \"Provision of screening and follow up services\".","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 03_DY9-10 Regional Tracker - FINAL Tracker.xlsb","3_377705401","377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private",96,"Hospital Safety and Quality",null,"Edit","","Implementation of evidence-based practices to improve quality of care",null,"This core activity is a multi-pronged approach that includes operational planning as well as the standardization of order sets and protocols. The focus is on key operational and quality indicators to include ED Admit to Decision times and improving the consistency of documentation and vital patient information whena  patient is transferred to our facility as well as when a patient is transferred out of our facility to a different facility.","ED surge planning is the first driver of the ED Throughput Intensive. ED surge planning is a program that is designed help Conroe assess their current state, identify gaps, anticipate barriers and mitigate challenges by developing and implementing scenario triggers and controls.","Gain buy-in for the ED surge plans for Tomball Regional Medical Center's emergency department","Assess current emergency department flow and processes within emergency department","Identify optimal emergency department flow, staffing, and proccesses","Identify surge scenarios that incorporate changes in staffing, bolus, ancillary service delays, bed availability for consistent pre-planned responses to issues","Change policies and procedures and work with rest of facility to incorporate ED surge plan into housewide surge plan and track efficacy","Educate and train staff on ED transfer communication criteria","Develop a checklist to assist staff in identifying all required elements when a patient is transferred","Provide training and guidance on utilization of checklist and monitor compliance"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","The ED Intensive Throughput will allow the ED team to identify and anticipate barriers to care, including communication, staffing, bed availability, consistency in response and procedures that are specific and responsive to TRMC's ED needs and aspirational goals. Tomball will focus on the improvement of key ED metrics, which include the selected measures of K2 and we anticipate improvements in each measure of K2 during PY1.","No","","377705401.7.1","BTM","Agree that this is an \"other\". Accepting.","N","NB","changed CA grouping and area and NMIed","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from \"Other: Emergency Department Throughput and Quality\" to \"Hospital Safety and Quality\". \n\nHHSC also revised provider’s Core Activity title by moving it from \"Other: ED Throughput Intensive\" to the area on the menu: \"Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\". If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". \n","HCA Houston Healthcare Tomball does not have any objections to HHSC's reclassification of its Core Activity Grouping to \"Hospital Safety and Quality\" or the Core Activity title change to \"Implementation of evidence based practices to improve quality of care\".","BTM","Provider agreed to change. Made changes to grouping and activity.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically, the Grouping was changed to \"Hospital Safety and Quality\" and the Core Activity changed to \"Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\".","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020811801","020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private",142,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Spohn will screen patients for selected preventive care measures and empower them by providing education and resources for them to maintain a healthy lifestyle","Increase number of patients that are aware of the harmful effects of tobacco use and how to get cessation assistance","Screen all patients for tobacco use and provide counseling and cessation assistance"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Bundle K1 requires Spohn to screen patients for tobacco use and if the patient screens positive Spohn will provide counseling and/or cessation assistance and education.","No","","020811801.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020973601","020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private",143,"Maternal and Infant Health Care","","Edit","CCMC revised the description of Core Activity #1 to include more information according to the October DY8 Reporting Companion.\nSecondary Driver #1:  Revised to broaden the scope.\nChange Idea #1:  Updated to include specific items included in updated policy.\nChange Idea #2: DY7 Change Idea #3 was moved up to #2 with additional context of how change idea would improve Core Activity #1.\nChange Idea #3:  DY7 Change Idea #2 was moved down to #3 with additional context of how change idea would improve Core Activity #1.  CCMC switched Change Ideas #2 and #3 as results from Change Idea #2 drive Change Idea #3.\nSecondary Driver #2:  CCMC changed Eliminate Non-medically indicated cesarean section deliveries to Reduce unnecessary primary cesarean section deliveries.\nChange Idea #1:  Updated to include specific items that will be included in updated policy.\nChange Idea #2:  DY7 Change Idea #2 was included in DY8 Change Idea #1.  DY7 Change Idea #3 is no longer included as a Change Idea.  CCMC is aware patient education is extremely important as a Change Idea and will pursue in the future as more physicians get on board.  Change Idea #2 was the focus for DY8 as a means to increase physician awareness of NTSV cesarean section rates.\nSecondary Driver #3:  DY7 Secondary Driver #3 was eliminated for DY8.  This is no longer a Change Idea, it was successfully integrated into CCMCs processes. \nMeasure Bundles impacted by Core Activity #1.\nCCMC removed B2 as a Measure Bundle impacted by Core Activity #1.  CCMC feels Measure Bundle B2 has more impact from Core Activity #2.","Implement standard protocols for the leading causes of preventable death and complications","","Improve team response and outcomes of obstetric hemorrhage by updating the Obstetric Hemorrhage - Code Hemorrhage Policy, utilize Code Hemorrhage debriefs to inform quality improvement, and provide ongoing training and education regarding the assessment and treatment of obstetric hemorrhage.  Support vaginal birth and reduce unnecessary cesarean births by updating and implementing elective induction of labor scheduling policy and raising physician awareness by publishing provider cesarean birth rates monthly. ","Improve response to and outcomes of obstetric hemorrhage","Update Obstetric Hemorrhage - Code Hemorrhage Policy to include assessment of risk factors for obstetric hemorrhage, utilize quantitative and cumulative blood loss evaluation to identify proper stages of obstetric hemorrhage, and utilize evidence based treatment protocols.  Change idea #1 will help improve outcomes of women with obstetric hemorrhage by ensuring processes and procedures are in place to identify and respond to obstetric hemorrhage events. ","CCMCs Labor and Delivery leadership team will conduct Code Hemorrhage Drills and utilize Code Hemorrhage Event Records to identify successes and opportunities for improvement.  Both successes and opportunities will be applied to ongoing training and educational activities related to obstetric hemorrhage.  Change idea #2 improves obstetric hemorrhage outcomes by utilizing performance assessment to inform continuous quality improvement activities.","Conduct on-going assessment, training and education to an interdisciplinary team of nurses and physicians regarding assessment and management of obstetric hemorrhage.  This includes assessing for hemorrhage risk factors, measuring and documenting quantitative and cumulative blood loss, identifying stages of hemorrhage, and evidenced based treatment goals.  CCMC provides bi-annual obstetric hemorrhage education to all obstetric staff, and provides ongoing education to the interdisciplinary team after each Code Hemorrhage Drill, Code Hemorrhage Event, at staff meetings, in the OB Unit newsletter, and at its annual competency fair.  Change Idea #3 will improve obstetric hemorrhage outcomes by ensuring CCMCs staff have adequate assessment and management competencies to intervene during an obstetric hemorrhage event. "," "," ","Reduce unnecessary primary cesarean section deliveries","Update and implement Elective Induction and Cesarean Section Policy that addresses completion of 39 weeks or more gestation to include favorable cervical criteria requirements to allow scheduling induction of labor if there is no medical indication.  Favorable cervical criteria, defined as a Bishop Score equal to or greater than 6 for multiparas and equal to or greater than 8 for nulliparous, will be required to proceed with scheduling an elective induction of labor.  Elective induction of labor is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable cervix at induction.  CCMC anticipates Change Idea #1 will reduce unnecessary cesarean deliveries by reducing its number of elective inductions in women that do not present with favorable cervical criteria.  ","Post monthly and year-to-date graphs that represent the nulliparous term singleton vertex (NTSV) cesarean delivery rates for each physician and physician group at CCMC in comparison to an attainable goal.  Posting monthly and updated year-to-date graphs will raise physician awareness of NTSV cesarean rates for themselves, their group, and each of their colleagues.  Change Idea #2 should decrease unnecessary cesarean deliveries by creating competition among the physicians to have lower rates.   ",""," "," ","",null,null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2; J1","E2: Maternal Safety - The objective of this measure bundle is to improve maternal safety and reduce maternal morbidity through data driven interventions to prevent and manage obstetric hemorrhage.  Core Activity #1 will reduce cesarean sections and has even greater potential to decrease repeat cesarean sections that have a higher probability of complications such as obstetric hemorrhage.  We anticipate the reduced cesarean sections and improved processes for dealing with complications such as obstetric hemorrhage to improve maternal safety and reduce maternal morbidity.\n\nJ1: Hospital Safety - The objective of this measure bundle is to improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.  Core Activity #1 will reduce cesarean sections and improve obstetric hemorrhage outcomes.  Because cesarean sections and obstetric hemorrhage are both associated with higher risk of health-care associated infections and hospital errors Core Activity #1 will have a positive impact on this measure bundle.","No","","020973601.7.1","NG","Edited per DY8R2 Reporting","N",null,null,"Needs More Information","HHSC has deleted Change Ideas 1-3 under Secondary Driver 3 given that it appears Provider intended to delete Secondary Driver 3. Please indicate in the \"Provider Response\" column if this is incorrect.","CCMC agrees with the edits made by HHSC to this Core Activity.","NG","Provider agrees","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020973601","020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private",144,"Expansion of Patient Care Navigation and Transition Services","","Edit","CCMC revised the description of Core Activity #2 to specify what is being improved according to the October DY8 Reporting Companion.\nSecondary Driver #1:  Not changed.  \nChange Ideas #1 and #2:  Updated to include what is being measured.\nSecondary Driver #2:  Not changed.  \nChange Ideas #1 - #3:  Updated to include what is being measured.\nSecondary Driver #3:  Not changed.  \nChange Idea #1:  Updated to include Change Idea #1 and #2 from DY7 and what is being measured.  \nChange Idea #2 from DY7 was eliminated, added into DY8 Change Idea #1.  \nChange Idea #3 from DY7 was not continued.  CCMC provides resources to patients at discharge and during follow-up contacts but does not have a way to specifically track or measure provision of physician locator number.\nMeasure Bundles Impacted by Core Activity #2.\nCCMC removed E2 as a Measure Bundle Impacted by Core Activity #2.  CCMC feels Measure Bundle E2 has more impact from Core Activity #1.","Identification of frequent ED users and use of care navigators","","Reduce preventable ED visits by utilizing a LACE Readmit Screen Tool (Length of stay, Acuity at admit, Co-morbidities, ED visits past 6 months), a Chronic Disease Registry that is utilized to proactively contact, educate, and track patients by disease status, and a Patient Call Management System that designed to make contact with every patient, inpatient and ED, post discharge.  Utilize Community Health Workers, Case Managers, Nurses, and other staff to communicate with patients and identify potential barriers of disease management including understanding of discharge instructions, prescriptions, follow-up appointments made, and for all ED discharges need for help finding a physician.","Chronic Disease Registry for CHF, COPD, DM, and CAD","Specific questions for each chronic disease that address patient compliance with medications, diet, monitoring, and follow up appointments.  Change Idea #1 provides a guide for staff contacting patients that is specific to their chronic disease, improves chronic disease management, and reduces preventable ED visits related to chronic disease.","Patients entered into the Chronic Disease Registry are proactively contacted based on disease status by CHW to assess their basic knowledge and management of the chronic disease.  Change Idea #2 will reduce preventable ED visits related to chronic disease by increasing knowledge and disease management."," "," "," ","LACE screening tool utilized on every initial RN assessment with score placed on Patient Dashboard in all inpatient care areas","LACE score greater than 11 triggers PCM follow up phone call to be done by CHW within 24 hours post discharge with the intent of making sure our patients have their medications, make their follow up PCP appointments, and see if they have any other questions related to their care.  Change Idea #1 will reduce preventable ED visits by connecting patients to primary care.","Behavioral Health discharges with LACE score greater than 11 receive follow-up phone calls by clinical staff tracked in PCM with the intent of reminding patients of their aftercare appointments, reviewing medications, coping skills, and immediate concerns for the patients safety.  Change Idea #2 will reduce ED visits by assuring behavioral health patients remain safe and are coping well post discharge.","LACE score greater than 11 triggers Case Management to ask additional questions during interview regarding date of last admission, reason for admission in patients own words, name of their PCP, last PCP visit date, taking all medications as prescribed, If not why, name of pharmacy, pharmacy prescription coverage, method of transportation to appointments, contact name and number for transport home on discharge, and caregiver name/number for inclusion in discharge planning process.  Change Idea #3 will decrease preventable ED visits by assuring patients’ needs are assessed and addressed prior to discharge from the hospital."," "," ","Patient Call Manager as tool for follow up contact with both inpatients and ED patients after discharge with the intent of making sure discharge instructions are understood, patients have their medications, have made follow up appoints, and answer any questions relating to their care to drive reduction in ED utilization. ","To assure follow up contact with discharged patients does not get neglected, CCMC will utilize monthly reporting to unit leadership to drive staff engagement in the process.  Monthly reports are by unit and break out attempted and completed calls.  These reports are also discussed at bi-monthly leadership meetings to keep the importance of making patient contacts an ongoing effort.  CCMCs goal is 100% of discharged patients have attempted contact.  Change Idea #1 will decrease ED utilization by making sure patients are contacted after discharge, understood their discharge instructions, and have made their follow up appointments.","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2; H2; J1","B2: Patient Navigation & ED Diversion - The objective of this measure bundle is to utilize patient navigators (community health workers, case managers, or other types of professionals) and/or develop other strategies to provide enhanced social support and culturally competent care to connect high risk patients to primary care or medical home sites, improve patient outcomes, and divert patients needing non-urgent care to appropriate settings.  Core Activity #2 is aimed at reducing preventable ED visits and improving patient outcomes by identifying and addressing potential barriers to disease management. \n\nH2: Behavioral Health and Appropriate Utilization - The objective of this measure bundle is to provide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions.  Core Activity #2 is aimed at reducing ED utilization and will decrease avoidable inpatient admission and readmissions through post discharge assessment of medication and follow up compliance.   \n \nJ1: Hospital Safety - The objective of this measure bundle is to improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.  Core Activity #2 is aimed at reducing ED utilization by encouraging patients to manage their chronic diseases through primary and preventative care.  Providing education regarding medication management and post discharge follow up will improve patient health outcomes and experience therefore CCMC believes Core Activity #2 will have a positive impact on the J1: Hospital Safety measure bundle. \n","No","","020973601.7.1","NG","Edited per DY8R2 Reporting","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020973601","020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private",145,"Behavioral Health Crisis Stabilization Services","","Edit","CCMC revised the description of Core Activity #3 to include substance abuse.\nSecondary Driver #1:  Not changed\nChange Idea #1: Updated to include process to overcome barriers to care and how change idea will improve Core Activity #3.\nChange Idea #2: Updated to include the process for missed treatments and how change idea will improve Core Activity #3.\nCCMC deleted DY7 Secondary Driver #2 from Core Activity #3.  In DY8 Individual case studies of CCMCs patients with SMI whom most often utilize the ED and/or have frequent readmissions revealed many of these patients also suffer from substance abuse, are homeless, have food and medication insecurity, and are non-compliant.  While CCMC continues its mission to seek appropriate resources for its patients upon discharge in an effort to increase overall compliance, which is a major factor for patient success, this is not a driver or change idea for Core Activity #3.  Core Activity #3 focuses on utilization of PHP and IOP programs and few patients from the case studies had the means to comply.","Implementation of community‐based crisis stabilization alternatives",null,"Utilization of PHP's and IOP's will increase access of behavioral health and substance abuse treatment to more individuals in the community with more intensive focus that will increase patient compliance and reduce readmissions and emergency department utilization for behavioral health and substance abuse.\n\n","Monitor attendance of PHP and IOP and contact those who do not participate","Identify barriers for participation in or completion of programs in order to increase patient compliance with ordered treatments for PHP and IOP.  Patients can remain in the programs if reasonable and excusable barriers are identified and can be overcome, if there is not a reasonable or excusable barrier that can be overcome the patient can be discharged from the program to open the slot for another patient.  Change Idea #1 will increase access to care for behavioral health and substance abuse by assisting patients overcome barriers to access.","Define process for clients enrolled into PHP or IOP programs and do not attend.  CCMCs protocol for patients that do not attend scheduled PHP/IOP appointments is: if a patient misses a minimum of 3 appointments staff call multiple times until they speak to the patient, if the patient is unable to be reached the information is passed to the Outpatient Manager, The Director of Intake, and the treatment team before being discharged from the program.  Change Idea #2 aims to increase patients' compliance with ordered treatments so the PHP and IOP programs can be successful at decreasing readmissions and ED utilization."," "," "," ","",null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2; B2; J1","H2: Behavioral Health and Appropriate Utilization - The objective of this measure bundle is to provide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions.  Core Activity #3 will increase access to treatment options for individuals with behavioral health and substance abuse.  CCMC anticipates Core Activity #3 will lead to a decrease in ED utilization and avoidable inpatient readmissions.\n\nB2: Patient Navigation & ED Diversion - The objective of this measure bundle is to utilize (community health workers, case managers, or other types of professionals) and/or develop other strategies to provide enhanced social support and culturally competent care to connect high risk patients to primary care or medical home sites, improve patient outcomes, and divert patients needing non-urgent care to appropriate settings.  Core Activity #3 at the heart is utilizing other community based settings for behavioral health and substance abuse treatment options.  CCMC anticipates utilization of PHP and IOP programs will reduce utilization of inappropriate ED visits and readmissions.\n\nJ1: Hospital Safety - The objective of this measure bundle is to improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.  Core Activity #3 is driven by providing other community based settings for behavioral health services that improve patient health outcomes to a larger audience and reduce the inpatient burden with anticipated impact of improved patient experience.  CCMC believes Core Activity #3 has a positive impact on measure bundle J1: Hospital Safety but currently does not have a way to quantify the impact. ","No","","020973601.7.1","NG","Edited per DY8R2 Reporting. Updated Core activity grouping and title from \"other\" to something more reflective of IOP/PHP","Y","NB","In agreement. Moved the new title to a column from Other title","Needs More Information","HHSC updated the Core Activity grouping and title from \"other\" to the on menu option: \"Behavioral Health Crisis Stabilization Services: Implementation of community‐based crisis stabilization alternatives that meet the behavioral health needs of the patients.\" Provider description of core activity (PHP/IOP) appears to be in line with this core activity title. Provider should confirm their agreement with this change in the \"Provider Response\" column. HHSC has deleted Change Idea 1 under Secondary Driver 2 given that provider intended to delete Secondary Driver 2. ","CCMC agrees with the updates made to the grouping of, title of, and edit to this Core Activity made by HHSC.","NG","Provider agrees","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted","Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.","CA-11","CA-11.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020991801","020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public",146,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","This core activity is designs to give our community better acces to primary care.  We are increasing the hour of operation at our rural health clinics and designing the clinics to improve patient flow to accomidate more patients.","Renovating the rural health clinics will allow for better patient flow and allow for more patients to be seen","Increasing the number of patient rooms and expanding the waiting room to accomidate more patients and family."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core actvity is design to increase the number of patients we see at our rural health clinics.  This increase will lead to more people in our community receiving the tobacco use screening and cessation inervention, more of our elderly population learning about the pneumonia vaccine and hopefully choosing to receive one.  It will also lead to more of our population leaning about the need for advanced care plans and if they already have one we will be able to load it in to our EHR so we will have it if it is needed at any of our facilities in the future","No","","020991801.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_020991801","020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public",147,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","Increase tobacco cessation education","Provide in person counseling on the effects of tobacco use and why tobacco cessation is important for the patients health","Provide counseling while patient is at our facility. We will also provide educational material for the patients to take with them."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Provide in person counseling on the effects of tobacco use and why tobacco cessation is important for the patient's health while patient is at our facility.  We will also provide educational material for the patients to take with them to impact K1-105.","No","","020991801.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_080368601","080368601.7.1",4,"080368601","Coastal Plains Community MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",148,"Access to Primary Care Services","","Edit","Coastal Plains no longer contracts with two (2) primary care providers.  We now contract with a single FQHC to provide primary care services.  Contracting with one (1) primary care provider allows for a more streamline provision of services within our clinic settings.","Integrated physical and behavioral health care services","","Coastal Plains plans to continue to contract with one (1) primary care provider to ensure these services are accessible to all enrolled underinsured/non-insured clients in our nine (9) county area.  Integrating behavioral health and physical health care services has helped reduce the number of emergency room visits since clients are now able to get their basic primary care needs met through local provider.","All Adults enrolled into care with Coastal Plains will be screened for BMI at each behavioral health visit.  This is related to Category C Measure M1-147.","All BMI data will be documented and entered in Coastal Plains electronic medical record to assist provider in identifying individuals with BMI's that are beyond normal parameters."," "," "," "," ","Adults with diabetes will have HbA1c level checked at behavioral health visit.  This is related to Category C Measure M1-115.","Coastal Plains plans to implement assessments in its' electronic medical record to flag and/or assist in monitoring individuals with high HbA1c screenings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-115; M1-147","Integrating behavioral health and primary care will allow enrolled clients to receive both types of services during scheduled clinical visits.  The provision of primary care will lead to improvements in HbA1c levels and an increase in BMI readings falling within normal parameters.   Improvements will result from Coastal Plains direct care, provider services and referrals to outside providers.","No","","080368601.7.1","NG","Edited per DY8R2 Reporting","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_080368601","080368601.7.1",4,"080368601","Coastal Plains Community MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",149,"Substance Use Disorder","","Edit","Coastal Plains no longer contracts with two (2) substance use disorder (SUD) service providers.  We now contract with a single provider for these services.  Contracting with one (1) SUD provider allows for a more streamline provision of services within our clinic settings.","Office-based additional treatment for uninsured individuals","","Coastal Plains plans to continue to contract with one (1) SUD service provider to ensure these services are accessible to all enrolled underinsured/non-insured clients in our nine (9) county area.  Integrating behavioral health and SUD services has helped reduce the number of substance related crisis episodes since clients are now able to receive intensive outpatient SUD services.","All adults screened and identified as unhelathy alcohol users will be referred to SUD provider at each clinic location. This is related to Category C Measure M1-317.","Coastal Plains plans to implement criteria in its' electronic medical record to flag and/or assist in monitoring individuals with SUD issues.  We also plan to ensure a referral process is in place for individuals identified as having a SUD."," "," "," "," ","All adults will be screened for tobacco use and those who are users will be offered tobacco cessation intervention counseling.  This is related to Category C Measure M1-105.","Coastal Plains' electronic medical record will flag tobacco users and referrals will be provided to Navigators who will will offer tobacco cessation classes at each clinic."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-317","Integrating behavioral health and SUD services will allow clients to participate in both services while enrolled with Coastal Plains Community Center.  The provision of SUD services and education will lead to a decrease in alcohol and tobacco use and increase awareness regarding the physical and mental health problems associated with substance use and/or abuse.","No","","080368601.7.1","NG","Edited per DY8R2 Reporting","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Office-based additional treatment for uninsured individuals","CA-10","CA-10.6"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_094118902","094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private",687,"Access to Primary Care Services","","New","","Provision of screening and follow up services","","DeTar selected the core activity of managing patients with chronic disease who are at a high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services.  The community assessment reflects a lack of access to care and a high rate of diabetes. To address this core activity DeTar will 1) continue to expand the Family Residency Program 2) Use the Residency Program to treat, monitor, and screen all patients including indigent and 3) monitor all inpatients for healthcare associated infections, including CLABSI, CAUTI, SSI, and post-operative sepsis.  DeTar established the FM Residency in collaboration with Texas A&M in DY 4  as a way to expand access to primary care services to patients regardless of funding.  At the time it was established, there was only one family medicine group in DeTar’s geographic region accepting MILU patients.  This lack of primary care providers negatively impacted the primary care services MILU patients had access to, and some suffer from chronic conditions such as diabetes.  The lack of primary care physicians’ to provide management of the chronic condition sometimes resulted in an out-of-control episode that forced the patient to seek emergency care. By 2020, DeTar will have 24 residents and 3 faculty members.   Secondly, DeTar plans to utilize the residency clinic to treat patients with chronic conditions who would otherwise not have access to primary care. These residents provide outreach to a Victoria Women's Shelter, Community Mental Health Center, and homeless shelters.  By going to their location and treating these patients who would otherwise not receive primary care, the chronic disease is better managed and unnecessary ED visits are avoided.   Third, DeTar monitors all inpatients for healthcare associated infections, including CLABSI, CAUTI, SSI, and post-operative sepsis.  DeTar has found that it is often its inpatients with chronic conditions who develop these healthcare associated infections. By closely monitoring all inpatients, DeTar can decrease the likelihood that its patients, especially those with chronic conditions, develop these healthcare associated infections.  This, in turn, will decrease the amount of unnecessary care DeTar needs to provide to treat these healthcare associated infections and the negative impact these infections have on the patients’ health.","Increase opportunities for blood pressure and blood sugar monitoring.  Implement measures to prevent diabetes complications","Computer programming to trigger follow-up reminders for foot exams, sugar follow-ups, order lab in OP PCP Clinics.  ","Standing orders for patients with diabetes risk factors and screens will be in chart for blood sugars on every visit.","Implement in-office instrumentation for HbA1c monitoring","","","Assess every hospitalized patient every shift for foley care, central line maintenance, fall risk assessment, and proper surgical site care to prevent hospital acquired conditions.","Bedside shift report in presence of patient where safety factor checklist is reviews and precautions in place.   Chart to reflect fall risk assessment and line care.","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; J1","This core activity has impacted related measure bundles (A1 and J1) positively.    This is evidenced by:\nA1 – Diabetes Chronic Care:  Implemented processes in outpatient clinics to consistently conduct foot exams that include visual inspection, pulse palpation, and monofilament exam on diabetics.   Previously this was done inconsistently.  Current data reveals improvement over prior year.   Blood pressure monitoring has always been done, but processes now include more frequent appointments when normal parameters are exceeded and interventions such as education on lifestyle changes to control blood pressure are carried out and documented.  Blood sugar control is an ongoing measurement and we have added in clinic HbA1c monitoring.\nJ1 – Chronic care patients who need hospitalization are identified upon admission as high risk.    Safety measures are taken to prevent complications such as falls, CAUTI, CLABSI, or surgical site infections.  The patient is educated repeatedly during the hospitalization and, if they leave while still having risks (such as PICC line) they are educated on self-care and given timely follow-up appointments with the PCP.\n","No","","094118902.7.1","NG",null,"N",null,null,"Needs More Information","Approval of replaced Core Activity is pending approval of discontinuation of Measure Bundle A2.","DeTar no longer wishes to discontinue A2 Bundle","NG","Not sure this information is pulling correctly. There's no core activity ID and I'm not sure how to add one. This is the providers only core activity, and it's showing as new. This appears to be their existing core activity. ","Y","NB","thanks to NG note, we discovered that the other CA for this provider was not pulling even though provider did not request to delete. We populated it. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_094118902","094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private",150,"Chronic Care Management",null,"Edit",null,"Management of targeted patient populations with high risk for developing complications",null,"DeTar selected the core activity of managing patients with chronic disease who are at a high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services.  RHP 4s community assessment found a lack of access to care in RHP 4.   Additionally, there is a high rate of diabetes and heart disease in RHP 4.  As such, DeTar wants to provide a way to manage the high rate of diabetes and heart disease and lack of access to care in RHP 4. To engage in this core activity, DeTar plans to implement three activities  expanding its Family Residency Program (the Program); utilizing a nurse practitioner (NP) to treat patients in rural areas and a local FQHC who often have chronic conditions, including heart disease and diabetes; and monitoring all inpatients for healthcare associated infections, including CLABSI, CAUTI, SSI, and post-operative sepsis.  First, DeTar plans to expand its Program. In DY1-6, DeTar partnered with Texas A&M to establish the FM Residency Program as a way to expand access to primary care services to patients who would otherwise not have access to primary care services.  Prior to implementation of the Program, there was only one family medicine group in DeTars geographic region that accepted MILU patients.  This lack of primary care providers negatively impacted the primary care services that MILU patients had access to.  Often times, these MILU patients who cannot access primary care services have chronic conditions such as heart disease and diabetes.  The lack of primary care and management of these chronic conditions results in a manageable chronic condition  turning into a severe condition that the patient seeks emergency care for because they have not properly managed the condition. Since inception DeTar successfully built the infrastructure, recruited and hired faculty and residents, and complied with GMEC requirements for the Program. The first residents were admittedin 2016.  By January 2018, DeTar had 12 residents and 3 faculty members in the Program. DeTar plan to grow the Program in the future so that it will have 24 residents. By expanding number of residents and faculty the number of providers in its region who can manage and treat those patients with chronic conditions will increase.  Second, DeTar plans to utilize a NP in local and remote locations to treat patients with chronic conditions who would otherwise not have access to primary care.  This NP will treat patients at the local FQHC and surrounding counties. By utilizing the NP, DeTar will be able to treat patients who would otherwise not receive primary care.  In turn, this will decrease the likelihood that these patients seek unnecessary emergency treatment to manage chronic conditions, such as diabetes and heart disease.  Making a primary care provider, such as this NP, available enables patients to manage their chronic conditions in a primary care setting. Third, DeTar will monitor all inpatients for healthcare associated infections, including CLABSI, CAUTI, SSI,and post-operative sepsis.  DeTar has found that it is often its inpatients with chronic conditions who develop these healthcare associated infections. By closely monitoring all inpatients, DeTar can decrease the likelihood that its patients, especially those with chronic conditions, develop these healthcare associated infections.  This, in turn, will decrease the amount of unnecessary care that DeTar needs to provide to treat these healthcare associated infections and the negative impact that these infections have on the patients health.","Increased Access to Care by PCP","Apply with GMEC to increase number of residents in program to 8 per year","Faculty recruitment to meet requirements for expanded number of residents","Complete scheduling/expansion plans as needed for additional number of residents","NP scheduled for surrounding county visits with chronic patients each week","Plan for clinic hour extensions beyond 5:00 p.m. if needed with more residents","Increase opportunities for blood pressure/blood sugar monitoring to prevent chronic disease complications","Introduce bedside glucose testing to Residency Clinic; NP to provide BP & Sugar monitoring in remote clinics","B/P monitoring all visits; repeat B/P if out of parameters.   Protocol development for sugar & B/P monitoring all visits","Pts who were hospitalized for chronic conditions to have F-U appt scheduled before leaving hospital within 3-7 days","NP to schedule Follow up visits in community clinics and to work FQHC clinic to monitor patients with chronic disease","Residency case manager to assist obtaining resources for essential supplies (BS monitor, meds, etc.) when indicated","Optimize use of Clinic Computer system for regular monitoring of chronic patients","Use computer triggers and reminders to assure patients complying with ongoing monitoring","Reprogram computer to trigger new reminders with changes in patient assessment/condition","Laboratory testing to be scheduled at prescribed intervals for optimal management of condition","Call back system by staff to patients who fail to meet appointments","Provision of needed resources by case management for patients needing assistance","Prevent/minimize Hospital Acquired Conditions that increase suffering, LOS, Costs if Pt needs hospitalization","Nurse driven protocol use for foley removal; reasons for continuation to be reviewed all change of shift reports","Sterile technique on insertion of all central lines, all PICC lines at bedside and in invasive areas","Clinical Pharmacy review of antibiotic management by patient when hospitalized","Infection Prevention follow-up on any suspected surgical wounds","Adherence to fall prevention program approved by Medical Staff.",null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; J1; A2","DeTar selected the core activity of managing patients with chronic disease who are at a high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services.  For its measure bundles, DeTar selected A1  improved chronic disease management of diabetes; A2  improved chronic disease management of heart disease; and J3  hospital safety.  DeTars core activity impacts the A1 and A2 bundles because the core activity increases the availability of providers who are able to treat MILU patients who would otherwise not have access to care and who have chronic conditions.  RHP 4s community assessment found a lack of access to care.   Additionally, there is a high rate of diabetes and heart disease in RHP 4.  Prior to establishment of DeTars residency program, MILU patients only had one practice in Victoria to seek treatment.  The lack of treatment can cause these MILU patients, especially those with chronic conditions such as heart disease and diabetes, to mismanage their medical conditions.  This mismanagement often causes the patient to seek unnecessary emergency treatment.  DeTars residency program will expand the number of providers who are able to treat MILU patients.  Additionally, DeTars provision of a NP who travels to rural areas as needed enables DeTar to treat MILU patients who may otherwise have limited access to primary care.  Through the expansion of the residency program and providing a NP, MILU patients, especially those with diabetes and heart disease, can access primary care and learn how to manage their chronic conditions.  Regular provider attention, treatment plan adjustments, and assessments contribute toward DeTar meeting each measure in bundles A1 and A2. Additionally, if a pt with a chronic condition requires hospitalization, because of their condition they may develop healthcare associated infections, including CLABSI, CAUTI, SSI, and post-operative sepsis. By closely monitoring all inpatients, DeTar can decrease the likelihood that its patients, especially those with chronic conditions, develop these healthcare associated infections.  This, in turn, will decrease the amount of unnecessary care that DeTar needs to provide to treat these healthcare associated infections and the negative impact that these infections have on the patients health.  As such, the monitoring and protocols that DeTar is implementing will contribute to DeTar meeting each measure in bundle J1.","No",null,"094118902.7.1",null,null,null,"NB","Due to the comments from the 1st reviewer for a 2nd Core Activity that Detar has it was discovered that the provider is missing one of their Core Activities even though it was not deleted. Provider confirmed that they intend to continue with it.",null,null,"This Core A activity is continued and not new. However, when DeTar submitted we edited the verabge because of changes in our program/strategies.  Therefore, we changed the description associated with it. Below we have provided the information we have requested. Please let me know if you have any questions or concerns.\nThanks,\nBritney\n\n\nFor DY8  the specifics she requested are\nCore Activity Grouping           CHRONIC CARE MANAGEMENT \nCore Activity Title   Chronic Disease Management\nIt was continued\nCore Activity Description  (this was quoted in Ms. Boston's attached file)\n\n\n\n\nSecondary Driver 1 -  Increased Access to Care by PCP\nSecondary Driver 1: Change Idea 1–  Apply with GMEC to increase number of residents in program to 8 per year\nSecondary Driver 1: Change Idea 2 Faculty recruitment to meet requirements for expanded number of residents\nSecondary Driver 1: Change Idea 3  Complete scheduling/expansion plans as needed for additional number of residents\nSecondary Driver 1: Change Idea 4 NP scheduled for surrounding county visits with chronic patients each week\nSecondary Driver 1: Change Idea 5  Plan for clinic hour extensions beyond 5:00 p.m. if needed with more residents\n \nSecondary Driver 2  Increase opportunities for blood pressure/blood sugar monitoring to prevent chronic disease complications\nSecondary Driver 2: Change Idea 1– Introduce bedside glucose testing to Residency Clinic; NP to provide BP & Sugar monitoring in remote clinics\nSecondary Driver 2: Change Idea 2 - B/P monitoring all visits; repeat B/P if out of parameters.   Protocol development for sugar & B/P monitoring all visits\nSecondary Driver 2: Change Idea 3  Pts who were hospitalized for chronic conditions to have F-U appt scheduled before leaving hospital within 3-7 days\nSecondary Driver 2: Change Idea 4  NP to schedule Follow up visits in community clinics and to work FQHC clinic to monitor patients with chronic disease\nSecondary Driver 2: Change Idea 5  Residency case manager to assist obtaining resources for essential supplies (BS monitor, meds, etc.) when indicated\n \nSecondary Driver 3   Optimize use of Clinic Computer system for regular monitoring of chronic patients\nSecondary Driver 3: Change Idea 1–  Use computer triggers and reminders to assure patients complying with ongoing monitoring\nSecondary Driver 3: Change Idea 2    Reprogram computer to trigger new reminders with changes in patient assessment/condition\nSecondary Driver 3: Change Idea 3    Laboratory testing to be scheduled at prescribed intervals for optimal management of condition\nSecondary Driver 3: Change Idea 4    Call back system by staff to patients who fail to meet appointments\nSecondary Driver 3: Change Idea 5     Provision of needed resources by case management for patients needing assistance\n \nSecondary Driver 4  Prevent/minimize Hospital Acquired Conditions that increase suffering, LOS, Costs if Pt needs hospitalization\nSecondary Driver 4: Change Idea 1–  Nurse driven protocol use for foley removal; reasons for continuation to be reviewed all change of shift reports\nSecondary Driver 4: Change Idea 2  Sterile technique on insertion of all central lines, all PICC lines at bedside and in invasive areas\nSecondary Driver 4: Change Idea 3   Clinical Pharmacy review of antibiotic management by patient when hospitalized\nSecondary Driver 4: Change Idea 4   Infection Prevention follow-up on any suspected surgical wounds\nSecondary Driver 4: Change Idea 5   Adherence to fall prevention program approved by Medical Staff.\n",null,null,null,"NB","thanks to NG note for the other CA, we discovered that the this CA was not pulling even though provider did not request to delete. We populated it. One note: it seems that Secondary Driver 4 could be a separate CA. the provider did not respond to the follow up question. leaving it as it for now. including a note for DY9","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. During October DY9 reporting, HHSC will work with the provider to determine if the Secondary Driver 4 needs to be reflected as a separate Core Activity.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_094222903","094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private",151,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Utilization of Care Management function that integrates primary and behavioral health","","Spohn is integrating primary and behavioral health care by having the primary care provider screen patients for behavioral health conditions and when necessary refer to a behavioral health provider co-located in the same clinic.","Refer patients that have tested positive for possible alcohol abuse","Implement an alcohol abuse screening tool in order to identify patients with possible alcohol abuse"," ",null," "," ","Patients are screened with a depressed, alcohol, and substance abuse too, and where positive, are referred to a mental health provider that is located on site.  "," The mental health provider will provide alcohol and substance abuse counseling, and refer patients who score positive for depression to outside resources or to counselors within the hospital system.  Licensed counselors will begin providing group therapy sessions in DY9, as well as implementing telemedicine in Q2 of DY9.  "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","Measure H1-317 evaluates the number of patients screened for alcohol abuse and if the patient screens positive how many are counseled.","No","","094222903.7.1","NG","AQ notes from October reporting review for RHP Plan Update: Request that provider adds SD and CI that are representative of what they are doing. Provider did not update anything. ","Y","NB","Agree. Updated the language to include AQ suggestions.","Needs More Information","Core activity appears to be the Category C measure, rather than an intervention to improve the category C measure. Provider should add secondary driver and change idea that are representative of interventions conducted. Provider should consider other Secondary Drivers and/or Change Ideas that will impact the measure bundle besides implementing an alcohol abuse screening tool. This could be other activities that the provider has been working on but may not have documented in their core activity submissions. For example, based on the provider's \"Progress and Challenges\" response to Secondary Driver 1, the provider could include telemedicine counseling as a Change Idea. Provider should identify the secondary driver and change idea in the provider response column. ","Patients are screened with a depressed, alcohol, and substance abuse too, and where positive, are referred to a mental health provider that is located on site.  The mental health provider wil provide alcohol and substance abuse counseling, and refer patients who score positive for depression to outside resources or to counselors within the hospital system.  Licensed counselors will begin providing group therapy sessions in DY9, as well as implementing telemedicine in Q2 of DY9.  ","NG","Updated secondary driver. ","N",null,null,"Accepted","HHSC added secondary driver and change idea as indicated. Provider's selection of the Core Activity for DY9-10 is accepted. ","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_112673204","112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private",152,"Access to Primary Care Services","","Continue","","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","","The core activity related to primary care services has seen significant success since participating in the DSRIP program. We have added two additional providers and continue to see fantastic patient volumes.","The first secondary driver for primary care services is to continue to reach more patients in the rural community.","The first change idea is to add an aditional provider in order to assist in reaching more patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","This core activity assists with the rural emergency care bundle because the goal of the measure bundle is to improve patient health. The core activity has already helped to improve patient health by increasing the number of providers, and with the increased number of providers, patient health from emergency care should improve as well.","No","","112673204.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increase in capacity and access to services by utilizing Community Health Workers (CHWs)/promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care","CA-1","CA-1.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_112673204","112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private",153,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","With regards to the specialty care services core activity, we have added specialists in all of the target specialties and expect continued positive patient impacts as a result. As this core activity grows, a struggle we continue to see is recruiting physicians to our community.","The first secondary driver for the specialty care activity is to focus on improving our outcomes for diabetic patients and reduce obesity in patients.","The hospital could implement a screening of patients for diabetes with availability of standing orders for such screening."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","This core activity focuses specifically on improving our outcomes for diabetic patients, which is unrelated to improving patient health regarding emergency care.","No","","112673204.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_121775403","121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public",154,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","Spohn is integrating primary and behavioral health care by having the primary care provider screen patients for behavioral health conditions and when necessary refer to a behavioral health provider co-located in a primary care clinic.","Refer patients that have tested positive for possible alcohol abuse","Implement an alcohol abuse screening tool in order to identify patients with possible alcohol abuse"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1; H2","Both bundles H1 and H2 have measures that require the implementation of an alcohol screening tool and brief counseling if the patient screens positive.","No","","121775403.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_121775403","121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public",155,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Spohn will increase the number of patients being screened for disease and given/referred to appropriate follow up services in Spohn's primary care clinics.","Increase screenings on high risk patients in Spohn clinics","Increase provider and patient education on importance of screening and follow up"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; H4; C2; C3; E1","Bundles C1, H4, C2, C3, and E1 all revolve around screening patients at risk for disease. This involves increased education by the provider to know who to screen and assistance in making the tools available to them as well as education to the patient to consent to the screening.","No","","121775403.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_121775403","121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public",156,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Spohn will increase communication and collaboration across the care team to identify, learn, and ultimately improve processes that will prevent safety events","Spohn will reduce targeted safety event rates through performance improvement activities","Spohn will record and analyze data to identify trends and conduct interventions accordingly."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Bundle J1 requires Spohn to track and improve upon safety event rates for conditions such as CAUTI, CLABSI, falls, SSI, and post-operative sepsis.","No","","121775403.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_121808305","121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public",157,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","Patients will be educated by patient care representatives and emergency room staff to alternative treatment options such as clinic and their expanded hours for treatement of non-emergent and chronic conditions in order to reduce Emergency Department visits.","Expand clinic hours and days and redirect non-emergent patients","Expand hours in the clinic to be more available for walk-in patients"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Patients with non-emergent needs can be redirected by patient care representatives and emergency room staff from the emergency department to the clinic regardless of payor type, allowing the emergency department to focus on those patients who do require emergency services and allow them speedier access to care.","No","","121808305.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_130958511","130958511.7.1",4,"130958511","Nueces County","Local Health Department (LHD)","Non‐State Owned Public",169,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","We will utilize the data collection from the Mobile Bod Pod, Fit Bit/Mobile activity tracker project, outlying rural area education program, and Healthy South TX expansion projects to collect more specific data on the population of South Texas related to obesity, diabetes, and other chronic diseases. Just since 3/23/16, CMS has approved Medicare payments for pre-diabetes prevention education in ages 60 plus. Therefore, we propose to expand our 1115 waiver system to offer pre-diabetes prevention training as a Medicaid and underfunded population service along with our diabetes self-management education programs. This would tie together community efforts and the need for extensive data collection through Healthy South TX, 1115 Waiver, to prevent and drastically reduce the incidence of type two diabetes and related complications within Nueces county and its surrounding regions.Diabetes mellitus is a very destructive and misunderstood disease with long term implications. The dynamics that go hand in hand with diabetic patient management is challenging and widespread. It is often without discrimination of race, ethnic background, and/ or geographic region. Most patients who have been diagnosed with diabetes were pre-diabetic for an average of 5-10 years prior to meeting the criteria to be diagnosed with diabetes mellitus (usually type 2- onset is in adulthood).  Corpus Christi has a special circumstance where the general population has a significant genetic predisposition compounded with obesity, and poor eating habits. In having identified the factors that create a recipe for increased percentages of diabetic residents, it is important to understand the issues the residents face when diagnosed with diabetes. Most culturally driven food choices in Corpus Christi Coastal Bend Area are high in fat and salt content, and are low in nutritional value. This, combined with lack of educational opportunities to help patients better understand the risks, consequences, and negatively impacted outcomes from poor blood sugar control is a need so great that this program has been created to support the community in helping patients change their lives and generations to come.Patients will receive HgbA1C, Blood Pressure, and BMI test, combined with counseling of results, referrals based on identified needs / health issues, and education to assist the patient in better understanding how to reverse the damage that has been done, or at least prevent further damage from taking place.","The administering of HgbA1c, Blood Pressure and BMI testing in a moilized unit , capturing data that is tracked over a period of 3, 6, 9, 12 months. Consulting and referring patients to primary care when needed and making sure all participants are staying active and eating healthy. Educating the participants of healthy and safe exercises that are within the individual patients physical ability, promoting group activities and incentive driven goals.","CCNCPHD will be rolling out this mobilized concept of testing HgbA1c, Blood Pressure, and BMI as a way to maximizing  outreach efforts in Nueces County and surrounding Coastal Bend rural areas. One very important and essential change idea was that CCNCPHD  changed its methods of capturing data from paper forms to  electronically in real time. The Bod Pod Trailer which will house sensitive electronical testing equipment will also contain the latest WiFi equipment, lap tops, and signiture pads, enabling all data to be  entered electronically via internet and password encrypted secured sites.","CCNCPHD staff will need training on hooking up and unhooking  mobilized Bod Pod  Trailer Unit, as well as towing and parking training, all staff will be trained in the operations of the Bod Pod Trailer , from operable lighting and generator start ups and A/C operations for keeping the trailer temperature at an operable temperature. additional Bod Pod training will take place for staff operating the electronical equipment Bod Pod and Fit-Mate testing componenets.","CCNCPHD will be eliminating the use of paper forms and streamlining the process out in the  field , to provide a more efficient and modernized process for our patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-147; L1-IT-1.10; L1-IT-1.7","Expanding the Patient navigators outreach efforts of administering BMI, HgbA1c and Hypertension  testing to the targeted Low income , uninsured and Medicaid populations in Nueces county and surrounding rural  Coastal Bend area's. all three test will be administered in the Mobilized Bod Pod unit.","No","","130958511.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_130958511","130958511.7.1",4,"130958511","Nueces County","Local Health Department (LHD)","Non‐State Owned Public",170,"Chronic Care Management","","Edit","As our program evolved to meet the needs of the MLIU target population, we found that our clients were unable to attend a prolonged 6 week self-management workshop for various personal reasons to include work obligations, family obligations, available transportation, and other reasons that our program could not mitigate for the clients to participate.  We also perceived a lack of interest and lack of willingness to commit to a 6 week education course.  Often we found a >50% attrition rate in participation at the initial class and subsequent classes despite the client's initial commitment and early planning.  The costs associated with preparing for these 6 week courses was often a loss as clients failed to attend as scheduled. We have now evolved our education classes to a single monthly 2-hour session covering various topics to support chronic disease self-management.  We have found that the number of clients paricipating in these new classes is 6 to 8 times more than our previous 6 week course.  Because of these new efforts, our average class size increased from 5 to over 30 participants per session, and that number continues to grow as word of mouth advertisement from participants has spread.  A 30-35 class size is manageable at this time, however we are considering offering bi-weekly classes now as client interest and participation has grown. ","Utilization of care management and/or chronic care management services","","Participants who attend our monthly diabetes self-management education classes will be able to participate in a variety of wellness activities.  New participants begin a class by receiving free wellness screenings at the initial class which include: Tanita BMI screening, A1c testing and a Blood Pressure screening.  Each participant is provided a follow up plan, which includes nutrition and exercise information to help them manage their health goal and educating participants on what their ideal body weight should be.  Monthly goals are set at every class session and participants are given the opportunity to discuss their successes and challenges amongst their peers.  Setting monthly goals encourages participants to return for the next class session.  In subsequent classes program participants receive education and tips on healthier food choices and label reading. Participants are taught to choose whole wheat grain products instead of enriched white flour and pasta products and learn to choose low fat dairy and milk products over full fat dairy and whole milk.  Our CHW’s also provide tips on choosing the best proteins to intake for a healthier body, including lean meats, egg whites, and nuts.  Staff will also emphasize the importance of eating fruits and vegetables for a well-balanced diet.   Participants are also introduced to menu planning and work in groups to plan a healthy meal for a guest with diabetes in their home. This experience is extremely interactive for the participants and can be tailored towards individual needs.   Cooking demonstrations are also conducted by our CHW’s and our WIC nutritionist.    The purpose of our cooking demonstration is to demonstrate heart healthy cooking and inspire participants to learn new cooking skills to prepare nutritious delicious meals.  Participants are provided copies of the recipe before the demonstration and are encouraged to ask questions while the meal is being prepared.  This is an extremely interactive exercise for participants as they are also encouraged to volunteer and assist with sections of the meal preparations. \nOur CHW’s encourage our class participants to join monthly Fitness challenges in an effort to encourage exercise.  Participants will be able to compete with others in these challenges to get highest number of steps, most workouts logged, most calories burned, and similar additional challenges.  The top 3 winners of these challenges are eligible for a fitness related prize such as a Fitness tracker, exercise bands, and other prizes to encourage fitness activities.  During our diabetes education classes, program participants are invited to join our CHW’s for 15 minutes of physical activity.  This can include a game of chair volleyball, resistance band exercises, step aerobics, or a walk around the LHD parameter. During the walking session participants are educated on the importance of physical activity and are encouraged to form a walking group with their peers to help motivate and encourage one another.  The purpose of these activities are to assist participants with increasing their physical activity.  All activities can be modified as needed to maintain a consistent exercise pattern.  Program participants are encouraged to attend one of our fitness classes offered twice weekly at the LHD.  Patients, LHD employees and our CHW’s will exercise up to 45 minutes under the direction of a fitness instructor.  Participants are given exercise bands and taught proper ways to stretch before and after a workout.  Participants are also taught the proper way to use free weights and other gym equipment available and educated as to what muscle group is targeted.  Exercise Wellness workouts are customized to each participant needs, abilities and physical and health conditions so as not to overexert anyone at any time.  \nOur CHW’s have found that adding Diabetes Bingo as an additional incentive to our classes has significantly increased the attendance and our client’s knowledge retention has increased.  Incorporating Diabetes Bingo has added an additional exciting and interactive activity to our class agenda and has been responsible for an increase in popularity in our community.  Our bingo prizes are specific to our program goals to encourage healthy habits in our winners.\nAfter 3 months, participants will receive follow up wellness screenings:  Tanita BMI, A1c testing, and Blood pressure.   Our CHW’s will compare previous results taken with each participant and help determine if there is an improvement in results or if healthy number ranges were maintained. ","Program Incentives have been a necessary secondary driver that have been added to our monthly classes to increase client participation. Fitness challenges have encouraged participation in our chronic disease management program.  We offer fitness incentives to our 3 top monthly winners which has encouraged many others to join the challenges.   Friendly competition between participants keeps them active and healthy.  Our Health Promotions Coordinator has organized 9 fitness challenges thus far with over 155 participants.  The challenges vary from most walking distance, workouts, calories burned, running distance, strides, and many more. Participation in these fitness challenges has further improved our outreach to our target population and supported our chronic care management services goal.  \nWe have significantly improved attendance by supplementing our classes with Diabetes Bingo.  Incorporating Diabetes Bingo has added an exciting and interactive activity to our class agenda which has been responsible for an increase in popularity in our community.  The Bingo games are knowledge based and participants are learning important diabetes information while also having fun.  All prize incentives are specific to our program goals to encourage healthy habits.","The first change idea to the fitness challenge incentive program is to have multiple challenges occurring at the same time to encourage max participation.  Participants had to wait for the next monthly challenge before they could join one.  We determined that once we had a group of at least 15 willing participants, then we could immediately start a new challenge. Ultimately, the goal is to have as many people actively exercising while learning to manage their chronic diseases.  \nWe found that participants were mastering the diabetes knowledge in the bingo games.  Therefore, we introduced new topics to expand their knowledge about chronic disease management.  The new topics include nutrition, fitness, hypertension, and obesity.   ",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-147; L1-IT-1.10; L1-IT-1.7","This core activity impacts our measures because they are all interconnected.  Participants who attend our classes begin by receiving free initial wellness screenings which include: BMI, A1c and blood pressure.  Each participant is provided a follow up plan which includes nutrition and exercise information to help them manage their health goal.  Participants are also educated on what their ideal body weight should be.  After 3 months, participants will receive follow up wellness screenings.  Our CHW’s will compare previous results with each participant and help determine if there is an improvement in results or more individual intervention is required.  We have received more client referrals to our classes from primary care providers and community health clinics in our region.  In summary, this has increased our total client volume further supporting our measures.","No","","130958511.7.1","NG","Edited per DY8R2 Reporting","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",158,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","Several of the Measure Bundles will required an increase in the number of available staff to increase the likelihood of the measurement outcome goals. Hiring and/or converting of part-time to full-time employee status in the specialty service areas which include High Risk NICU Follow-up Program and Endocrinology and Diabetes program will help to accomplish our goals.","Increasing the staff available to provide services will be key in accomplishing the Core Activity","Hire and/or convert a part-time staff to support the program in satellite locations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,1,0,0,0,0,0,0,0,1,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"I1; A1-112; A1-207; D5; A1-115","A majority of BMI, Nutritional Consulting and Physical Consulting occurs in several outpatient clinical areas however based on shortages in dietation staff we have a low utilization of nutritional and physical consulting. Increasing the availability of these staff will increase the number of children educated on physical and nutritional counseling.","No","","132812205.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",159,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments",null,"Driscoll will be making revisions to the after visit summary (transition record) for inpatient and emergency department services which will include additional patient care information. The nursing staff will review this information with the patient prior to their departure from the facility. This documentation enhancement will allow more information for their follow-up provider and themselves.","Educate clinical staff on changes and implement systematic changes to the Electronic Medical Record","Technical support staff changes the documentation in the transition record and submits for approval to the clinical and medical education staff","Revise the after visit summary (transition record) for inpatient and emergency department services which will include additional patient care information."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The Core Activity creates additional educational tools through the facility's transition records which are given to patients and their families upon discharge from the facility.","No","","132812205.7.1","NG","Updated title from \"other\" to be on menu","Y","NB","in agreement. Updated the message to provider to delete a reference to governance committee, seems from a different place.","Needs More Information","HHSC changed the core activity title from \"Other\" to \"Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients.\" Please confirm you agree with this change in the \"provider response\" column. ","Provider Agrees","NG","Provider agrees","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",160,"Hospital Safety and Quality",null,"Edit","","Implementation of evidence-based practices to improve quality of care",null,"The safety governance committee will be responsible for the oversight and review of the pediatric SPS Saftety Measures. They will create tools for monitoring and ongoing assessments for review.","Continuous staffing training and education on the eletronic medical records","Documentation of Committee formation and membership"," The hospital has individual workgroups for all SPS Measures (D3 measure bundle) that reviews the results and findings with all applicable system areas on a routine basis. Measures are reported through a Dashboard in Qlik and managed by the Quality Department."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3; D1-503","The governance committee will consist of a hospital acquired condition over group, safety event review and event classification team, comprehensive patient safety dashboard and error prevention program training and ongoing assessment of safety culture","No","","132812205.7.1","NG","Updated title from \"Other/Other\" ","Y","NB","Agree. Added another recommendation","Needs More Information","HHSC changed the core activity grouping and core activity title from \"Other/Other\" to Hospital Safety and Quality: Implementation of evidence-based best practices to improve quality of care. Please confirm you agree with this change in the \"provider response\" column. A governance committee is in line with the evidence-based practices examples included in the example. HHSC also  recommends provider adds additional Change Idea to specify what tools will be created for monitoring and to reflect review assessments. Approval of Core Activity is pending approval of changes to Category C measure selections. ","Provider Agrees. The hospital has individual workgroups for all SPS Measures (D3 measure bundle) that reviews the results and findings with all applicable system areas on a routine basis. Measures are reported through a Dashboard in Qlik and managed by the Quality Department.","NG","Added change idea. ","N",null,null,"Accepted","HHSC added change idea as indicated. Provider's selection of the Core Activity for DY9-10 is accepted. ","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",161,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","The Patient's navigation section has been created for providing feedback on the patient's present behavorial  or mental health concerns. The assessment will let medical staff know if that patient is presenting any depressive moods, a suicide risk and other behavorial concerns.  The Safety & Injury Prevention Assessment should be updated regularly to meet current healthcare standards.","Update the existing EMR Safety and Injury Preventation navigation section of a patient's record to  current healthcare standards","Create a policy for Patients at Risk for Self-harm and/or Suicide that will address Patient Safety and Injury Prevention"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,1,1,1,1,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1-300; H2-305; H3-144; H3-287; H1-146","The current Safety & Injury Prevention Assessment tool located in the EMR is based on the standardized tool PHQ-9 however by creating this workgroup or committee we will be making further improvements to follow-up processes and current procedures upon completion of this assessment.","No","","132812205.7.1","NG",null,"N",null,null,"Needs More Information","Approval of Core Activity is pending approval of changes to Category C measure selections. ","Add back the H1-146 Measure to this Core Activity","NG","Added back H1-146.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has added back in H1-146 as an impacted measure.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",162,"Palliative Care","","Delete","Driscoll is requesting that all G1 DSRIP Measures related to Palliative Care Service be removed from the DY9-10 selection. This Core Activity is directly related to Palliative Care Services.","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Driscoll doesn't currently have a palliative care program however we treat many patients with cancer, ESRD, heart disease, neurological diseases and more that would benefit from increased palliative services. Driscoll would like to increase patient life-sustaining treatment preferences during their stay at our facility.","Create a palliative care patient registry in the electronic medical records","Meet with IT frastructure to discuss the creation of a palliative care registry"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"","The activity would increase our patient and parent involvement in life-sustaining activities and treatment preferences.","No","","132812205.7.1","NG","NMIing their discontinuation of palliative care measures, so not approving the deleting on of this core activity at this time. ","Y","NB","OK","Needs More Information","Provider indicated that they are discontinuing this palliative care core activity along with the discontinuation of all palliative care measures. Provider did not provider an adequate justification for deleting the palliative care measures, and has received and NMI. HHSC is similarly asking for additional information on the discontinuation of this core activity. Provider should clarify intent for this core activity, along with the associated measures, in the \"Provider Response\" column. ","Updated Category C information to Loss of Significant System Component. Discontinue Core Activity","NG","The deletion of the palliative care bundle was approved, so core activity can be removed. ","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted. ","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_132812205","132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private",688,"Chronic Care Management","","New","","Utilization of care management and/or chronic care management services",null,"Reduce emergency department visits for patients with an asthma diagnosis through enhancing patient coping skills and education. To create change in this patient population, an asthma coordinator has been created within the organization to address these patient needs. The Asthma Coordinator receives an immediate request to provide services while the patient is in our facility and enables tracking of the patient's encounter.","Through the creation of an orderset, communication of asthma coordination will be sent immediately to Case Management per the Asthma Action Plan. This will help to prevent future emergency department visits and hospitalizations. The Asthma Coordinator will review the patient's visit information and make any appropriate follow-ups with the patient","n Asthma Committee Charter was created to improve the delivery of care to asthma patients specifically in the Emergency Department and Inpatient/Observation setting. The Asthma Action Plan was created by the Committee to improve asthma education through community alliance. The Asthma Action Plan is triggered through the EMR system via Physician Orderset.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,1,1,1,2,0,1,0,0,0,0,0,0,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4; B2-242; B2-392; D1-212; D1-400; D1-503; L1-269; D1-284","This core activity will help to divert patients from the ED. Patients seen in the Pulmonolgy clinic will asthma should receive a flu shot on an annual basis. We also know that individuals who use tobacco can increase their asthma symptoms. Asthma and Broncilitius is one of the high utilizers of our ED and Inpatient services therefore providing preventative measures with help to address these patient specific populations","No","","132812205.7.1","NG","Updated title from other to something on menu, as suggested by AQ during october reporting review. ","Y","NB","Agree. Also added another recommendation to strengthen Change Ideas.","Needs More Information","HHSC changed the core activity grouping and core activity title from to Chronic Care Management: Utilization of care management and/or chronic care management services, including education in chronic disease self‐management. Please confirm you agree with this change in the \"provider response\" column. The core activity title was previously \"other\" and has been updated to reflect an item on the menu in line with the core activity as described by the provider.  HHSC also recommends adding additional Change Idea(s) to reflect upcoming work. Secondary Driver 1: Change Idea 1 reflects an action that has been already completed (the Asthma Action Plan was created by the Committee). Approval of Core Activity is pending approval of changes to Category C measure selections. ","Provider agrees. Continue with B2-242 and D1-284 in Core Activity","NG","Provider agrees","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has added back in B2-242 and D1-284 as impacted measures.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135233809","135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public",163,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","In an effort enhance the quality of care for patients with chronic conditions and managing patients overall health to prevent them from developing chronic conditions. e are using a Manual tool that will capture all tobacco patients, diabetes patients needing foot care, patients who have or have not received the Pneumonia vaccine, and finally patients who do or do not have an Advanced Care Plan.  Upon entering the facility, patients are screened by nursing staff for the items above to ensure the required tests are conducted during the visit.  The nursing staff will enter information into the medical record to ensure the tests are performed and then upon discharge, information is abstracted from the medical Record manually by staff onto an Excel spreadsheet.  The information on the Excel spreadsheet is communicated back to mgmt. and caregivers on any screenings missed and follow-up that needs to be performed.  The information in the spreadsheet is also used for calculation purposes to monitor percentage rates on patients being screened and provided proper follow-up.","Vaccines, Screenings, Exams, Counseling, and Education: The hospital has implemented a tool to ensure that we are capturing the necessary patient population.  If patients meet the criteria, we are abstracting data into our screening tool to ensure they get the appropriate vaccines, screenings, exams, and counseling.","Select and implement a screening tool to aid in the identification of chronic conditions.","Abstract patient data to ensure proper health maintenance."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The core activity will enable our clinic to better screen and treat patients with Diabetes.  The core activity will help us identify older patients needing to be vaccinated for Pneumonia.  The core activity will also assist us in developing advanced care plans for our clinic patients.  By using drivers such as vaccines, screenings, exams, counseling, and education our clinic will stive to improve our patient outcomes directly related to the measures found in K1:  Rural Preventive Care.","No","","135233809.7.1","NG","Core activity description is very weak. Agree with the categorization, but have asked for more clarity of the activity. ","Y","NB","In agreement.","Needs More Information","The description of the core activity is incomplete and unclear. Provider should submit a revised description of the core activity in the \"provider response\" column. The core activity description should include a clear delineation of the providers intent to develop a tool to target screenings, and define the population that will be screened. ","Based on the Core Activity, we are using a Manual tool that will capture all tobacco patients, diabetes patients needing foot care, patients who have or have not received the Pneumonia vaccine, and finally patients who do or do not have an Advanced Care Plan.  Upon entering the facility, patients are screened by nursing staff for the items above to ensure the required tests are conducted during the visit.  The nursing staff will enter information into the medical record to ensure the tests are performed and then upon discharge, information is abstracted from the medical Record manually by staff onto an Excel spreadsheet.  The information on the Excel spreadsheet is communicated back to mgmt. and caregivers on any screenings missed and follow-up that needs to be performed.  The information in the spreadsheet is also used for calculation purposes to monitor percentage rates on patients being screened and provided proper follow-up.","NG","Added additional provider description. ","N",null,null,"Accepted","HHSC updated the Core Activity Description based on the provider's response. Provider's selection of the Core Activity for DY9-10 is accepted. ","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135254407","135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",137,"Chronic Care Management","","Edit","","Implementation of a medication management program","","All primary and psychotic medications will be documented and reviewed in the medical record.  Gulf Bend will use a team approach to include nursing staff and a provider to accomplish this activity.","To achieve better outcomes on medication management and improve continuum of care.","The nurses and/or doctor will verify and document all medications; prescriptions, over the counters, herbals, and vitamin/mineral/dietary supplements and must contain the medications' name, dosage, frequency, and route of administration in the medial record.  This is to include additions, changes, and discontinuation of medications. ",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-287","Review and document all medications at initial psychiatric evaluation and psychiatric appointments.","No","","135254407.7.1","NG","Per AQ review in October, I updated the change idea to reflect what they previously changed. ","Y","NB","Added a statement about provider's confirmation","Needs More Information","HHSC updated the \"Secondary Driver 1: Change Idea 1\" to reflect edits submitted during DY7. Provider should confirm their agreement with this change in the \"Provider Response\" column.","We confirm the secondary driver change. ","NG","Provider agrees","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a medication management program that serves patients across the continuum of care","CA-8","CA-8.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135254407","135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",138,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","Implementation to identify unhealthy alcohol use by utilizing 2-4 LPHA staff members during the intake process or counseling services. Screenings and counseling services are provided at two locations Gulf Bend Center in Victoria and Place4 in Port Lavaca. Gulf Bend Center provides research-based Alcohol screening on every individual who presents for a diagnostic assessment. If unhealthy use is identified, brief counseling is immediately provided to increase consumer awareness of alcohol use and the consequences of excessive consumption. Gulf Bend Center will refer and connect individuals to SUD services available in our seven surrounding counties regardless of ability to pay.  Care Coordinator will then provide follow up contact with client to arrange appointments, confirm that individual went to appointments, and collective relevant data.  Gulf Bend Center will continue to motivate and encourage consumers to participate in SUD treatment.","Conducts screening of patients at intake to identify level of alcohol consumption"," Screen every individual for preventive care and screening;  unhealthy alcohol use; screening and brief counseling using 'the Audit Questionairre'."," "," "," "," ","Provide local resources and counseling for identified individuals with a score of 8 or higher on the Audit Questionaire.","Provide brief intervention and refer to treatment programs.","Provide brief counseling and material to alcohol users considered heavy to excessive drinkers. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-317","Raises awareness to the health risk of alcohol use and offers resources to reduce alcohol consumption.","No","","135254407.7.1","NG","Core activity is a measure. Have asked provider to update or remove the core activity to reflect intervention to improve rate, rather than the Cat c measure itself. ","Y","NB","in agreement.","Needs More Information","The core activity description appears to be the Category C measure, rather than the intervention to improve the Category C measure. Provider should update to the core activity to reflect actions they are taking to increase screening rates. The core activity currently is an outcome, and not an intervention to improve the measure. ","(description of this Core Activity) Gulf Bend Center provides research-based Alcohol screening on every individual who presents for a diagnostic assessment. If unhealthy use is identified, brief counseling is immediately provided to increase consumer awareness of alcohol use and the consequences of excessive consumption. Gulf Bend Center will refer and connect individuals to SUD services available in our seven surrounding counties regardless of ability to pay.  Care Coordinator will then provide follow up contact with client to arrange appointments, confirm that individual went to appointments, and collective relevant data.  Gulf Bend Center will continue to motivate and encourage consumers to participate in SUD treatment.","NG","Added additional provider description. ","N",null,null,"Accepted","HHSC updated the Core Activity Description based on the provider's response. Provider's selection of the Core Activity for DY9-10 is accepted. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135254407","135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",139,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","GBC is committed to creating a zero suicide community by aligning with CCBHC models such as quality improvement plan to include EBP (evidence based practices) protocols such as screening, brief intervention and referral to treatment, person centered recovery planning, motivational interviewing and case management. ","GBC will use the Columbia Suicide Severity Rating Scale (C-SSRS) to identify individuals at risk of suicide.","Upon evaluation of C-SSRS Gulf Bend Center staff will identify whether the consumer is at risk to self or to others. A) All individuals are screened with the C-SSRS at each contact to identify individuals at risk of suicide. B) Individuals who present in crisis have 24-hour access to mobile crisis intervention services to assist in the de-escalation of the behavioral health crisis and refer the customer to outside entities as needed.","GBC will ensure staff have training on administering CSSRS.  This will include nurses, case management, crisis, and health practitioners. ",null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-319","This impacts measure M1-319 Adult MDD; Suicide Risk Assessment","No","","135254407.7.1","NG",null,"N","NB","Requesting that the provider adds additional info on CCBHC activities","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for CCBHC activities since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","(First Change idea for the above Secondary Driver) Upon evaluation of C-SSRS Gulf Bend Center staff will identify whether the consumer is at risk to self or to others. A) All individuals are screened with the C-SSRS at each contact to identify individuals at risk of suicide. B) Individuals who present in crisis have 24-hour access to mobile crisis intervention services to assist in the de-escalation of the behavioral health crisis and refer the customer to outside entities as needed.","NG","Added as a third change idea. ","N",null,null,"Accepted","HHSC updated Change Idea 1 as indicated. Provider's selection of the Core Activity for DY9-10 is accepted. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135254407","135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",140,"Prevention and Wellness","","Edit","","Implementation of interventions focusing on social determinants of health","","Identify individuals who use tobacco and provide access to tobacco cessation program. This aligns with our core measure of preventive care and screening of tobacco use: screening & cessation intervention.","Gulf Bend Center will increase and strengthen consumer awareness of the long-term effects that will contribute to health conditions related to smoking. Gulf Bend Center provides Smoking Cessation counseling with an RN.  (First Change Idea for the above Secondary Driver) Gulf Bend Center will screen all individuals for tobacco use and if positive for use we provide educational material and brief counseling along with recommending Smoking Cessation Counseling. ","Gulf Bend Center will screen all individuals for tobacco use and if positive for use we provide educational material and brief counseling along with recommending Smoking Cessation Counseling."," "," "," "," ","Gulf Bend Center continues to promote positivity by implementing a Tobacco-free environment which creates a safer, healthier facility for consumers and staff. Gulf Bend will continue to have trained staff to provide Smoking Cessation education and counseling. ","Gulf Bend Center will be fully committed to maintaining health and safe environment for staff and clients served by the center. Gulf Bend Center will also, continue to provide resources to obtain NRT assistance with achieving a positive lifestyle change. Care Coordinators and Case Managers will follow up with individuals to ensure they are attending counseling and identify barriers to smoking cessation. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105","Raises attention and awareness to the health risks of tobacco use and offers strategies to reduce the adverse effects of tobacco use.","No","","135254407.7.1","NG",null,"N","NB","Provider does not have a lot of info for social determinants of health.","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","(First Secondary Driver) Gulf Bend Center will increase and strengthen consumer awareness of the long-term effects that will contribute to health conditions related to smoking. Gulf Bend Center provides Smoking Cessation counseling with an RN.  (First Change Idea for the above Secondary Driver) Gulf Bend Center will screen all individuals for tobacco use and if positive for use we provide educational material and brief counseling along with recommending Smoking Cessation Counseling.  (Second secondary Driver) Gulf Bend Center continues to promote positivity by implementing a Tobacco-free environment which creates a safer, healthier facility for consumers and staff. Gulf Bend will continue to have trained staff to provide Smoking Cessation education and counseling.  (First change idea for the above Secondary Driver) Gulf Bend Center will be fully committed to maintaining health and safe environment for staff and clients served by the center. Gulf Bend Center will also, continue to provide resources to obtain NRT assistance with achieving a positive lifestyle change. Care Coordinators and Case Managers will follow up with individuals to ensure they are attending counseling and identify barriers to smoking cessation. ","NG","Modified drivers and change ideas as requested. ","N",null,null,"Accepted","HHSC updated Secondary Drivers and Change Ideas as indicated. Provider's selection of the Core Activity for DY9-10 is accepted. ","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_135254407","135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",141,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Other","Increase access to continuity of care to services by utilizing a mental health practitioner to complete the 7 and 30-day follow-up.","Gulf Bend Center provides follow up to each patient after discharge from any inpatient psychiatric unit for continuity of care that connects the individual to Gulf Bend Center Medication Management services (includes a psyche evaluation), assesses for immediate and continued risk of suicide, provides suicide prevention services (minimum weekly visit to learn coping skills and ways to stay safe and prevent repeated crisis episodes) and assists the individual in determining the best array of services to improve function to include case management, counseling, referral to outside resources for addictions, need for applying for disability, Medicaid or food stamps, and safety plans to maintain safety at the initial 7 day follow up with an LPHA.  If the patient does not show for the 7 day follow up, LPHA will attempt to reschedule, mail a letter to offer services and attempt a face to face home visit if unable to reach the patient to reschedule.  On subsequent follow up within 30 days, patient is scheduled to see an LPHA for psyche evaluation/medication management.  If the patient does not show for this appointment, attempts are further made to reschedule the patient, the patient’s assigned case manager/care coordinator is alerted and further attempts are made to engage the individual by either an LPHA, Case Manager or Care Coordinator, to prevent decline in functioning and to continue needed services.  Care Coordination by an assigned Care Coordinator will further assure the individual connects with outside needs to gain access to medical, substance use and stabilization resources within the initial 30 days. ","Provide follow up appointment and community resources for clients.","Improve communication between treatments teams and hospitals to facilitate aftercare.","Provide clients with access to a mental health provider, resources for case management, counseling, and basic needs. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160","Ensures a licensed practitioner is available to perform all 7-day hospital follow-ups and all 30-day hospital follow-ups. This will consequently improve patient outcomes.","No","","135254407.7.1","NG","Core activity is the Cat C outcome. ","Y","NB","in agreement. Added about Other title.","Needs More Information","Core activity is unclear and appears to be an outcome rather than an intervention. The core activity intervention should not be the same as the associated Category C measure. Provider should update the core activity to better reflect the interventions provider is undertaking to improve the 7 and 30 day follow up rates, for example implementation of community-based crisis stabilization alternatives if that better reflects the intervention. After the revisions, provider should re-evaluation the Core Activity Title to see if one of the areas on the menu (instead of Other) fits provider’s activity.","(description of this Core Activity) Gulf Bend Center provides follow up to each patient after discharge from any inpatient psychiatric unit for continuity of care that connects the individual to Gulf Bend Center Medication Management services (includes a psyche evaluation), assesses for immediate and continued risk of suicide, provides suicide prevention services (minimum weekly visit to learn coping skills and ways to stay safe and prevent repeated crisis episodes) and assists the individual in determining the best array of services to improve function to include case management, counseling, referral to outside resources for addictions, need for applying for disability, Medicaid or food stamps, and safety plans to maintain safety at the initial 7 day follow up with an LPHA.  If the patient does not show for the 7 day follow up, LPHA will attempt to reschedule, mail a letter to offer services and attempt a face to face home visit if unable to reach the patient to reschedule.  On subsequent follow up within 30 days, patient is scheduled to see an LPHA for psyche evaluation/medication management.  If the patient does not show for this appointment, attempts are further made to reschedule the patient, the patient’s assigned case manager/care coordinator is alerted and further attempts are made to engage the individual by either an LPHA, Case Manager or Care Coordinator, to prevent decline in functioning and to continue needed services.  Care Coordination by an assigned Care Coordinator will further assure the individual connects with outside needs to gain access to medical, substance use and stabilization resources within the initial 30 days. ","NG","Modified description as requested. ","N",null,null,"Accepted","HHSC updated the Core Activity Description based on the provider's response. Provider's selection of the Core Activity for DY9-10 is accepted. ","Other","CA-9","CA-9.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_136436606","136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private",164,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Spohn will participate in the OB Hemorrhage Collaborative, implement recommended practices, and report data accordingly in effort to reduce OB Hemorrhage","Spohn will implement recommended practice in association with the OB Hemorrhage Collaborative","Spohn will compare recommended practices to Spohn's current practices to create an implementation plan for the recommended practices"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Improving OB Hemorrhage rates is directly associated with the OB Hemorrhage bundle as part of bundle E2.","No","","136436606.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_137907508","137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public",165,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","We will be requesting the assistance of the Community Health Worker to identify the frequent ED users and provide healthcare resources and community assistance to prevent readmissions. Our goal is to provide the patient with the tools needed to manage their healthcare and take a proactive approach to preventive care thereby decreasing healthcare costs and resources. We will rely on our ED physicians, case managers, and nursing staff to support this core activity.","We will use our Community Health Worker to help drive this core activity","CHW will provide education, follow up, and connection with community resources for frequent ED patients to reduce over all healthcare costs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; B1","This core activity is being developed to alleviate the readmissions, improve patient outcomes, and assist patients to transition out of the hospital and back to home.  This core activity will also facilitate the education regading the importance of preventive care and chronic disease screening.","No","","137907508.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_138305109","138305109.7.1",4,"138305109","Nueces County MHMR Community Ctr dba Behavioral Hl","Community Mental Health Center (CMHC)","Non‐State Owned Public",166,"Prevention and Wellness","","Continue","","Self‐management programs and wellness programs using evidence‐based designs","","Certified Peer Specialists will provide group sessions with a focus on whole health and wellness to target medication compliance, obesity, substance abuse, and depression, diabetes.","Staff will refer individuals to the Peer Run Day Center, lived experience","Individuals will be able to participate in group interventions and experiece the group dynamic to help foster change"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-257; M1-182; M1-147; M1-261","It will help provide interventions, follow up, and prevention associated with diabetes screenings, BMI, Dual Diagnosis and Substance Abuse Assessments.","No","","138305109.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_138305109","138305109.7.1",4,"138305109","Nueces County MHMR Community Ctr dba Behavioral Hl","Community Mental Health Center (CMHC)","Non‐State Owned Public",167,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Utilization of telehealth/telemedicine in delivering behavioral services","","We were just given notice on a telemed contract funded through a local healthplan who is discontinuing the service as one of their DSRIP projects. We are actively exploring entering into a contract with Univerity of Texas Medical Branch (UTMB) to continue to provide telehealth services so that we may continue to address the needs of individuals with ADHD and Major Depressive Disorder. We also currently contract with SOC Telemed in order to expand services for adults and youth crisis.","Psychiatric evaluation including for substance abuse and medication management will be provided via telehealth and our medication clinics","Medication education and rehab and case management for co ocurring substance use disorders will be provided by members of the clients' treatment teams."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-305; M1-257; M1-261; M1-160","Psychicatric servcies will be provided to assesses for substance abuse, diagnose disorders that will be referenced in a treatment plan and provide evaluation and management for such disorders as major depressive disorders and attention deficit hyperactivity disorder.","No","","138305109.7.1","NG","Incomplete sentence. Asking them to clarify. ","Y","NB","In agreement. Added another request to update description","Needs More Information","Description of core activity appears to be cutoff and ends with \" We also currently contract with…\" Provider should complete description of core activity in the provider response column, or indicate if this partial sentence should be removed. Provider should also review the description of its Core Activity to see if updates are needed (e.g. if UTMB contract was established  - it was a while back, not just now, etc.)","We were just given notice on a telemed contract funded through a local healthplan who is discontinuing the service as one of their DSRIP projects. We are actively exploring entering into a contract with Univeristy of Texas Medical Branch (UTMB) to continue to provide telehealth services so that we may continue to address the needs of individuals with ADHD and Major Depressive Disorder. We also currently contract with SOC Telemed in order to expand services for adults and youth crisis.","NG","Updated description as requested. ","N",null,null,"Accepted","HHSC updated the Core Activity Description based on the provider's response. Provider's selection of the Core Activity for DY9-10 is accepted. ","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 04_DY9-10 Regional Tracker - FINAL Tracker.xlsb","4_138305109","138305109.7.1",4,"138305109","Nueces County MHMR Community Ctr dba Behavioral Hl","Community Mental Health Center (CMHC)","Non‐State Owned Public",168,"Prevention and Wellness","","Continue","","Implementation of interventions focusing on social determinants of health","","Assessment of the quality of life domains for our intellectual and developmentally disabled consumers so that specific areas can be targeted for improvement by working with providers and legally authorized representatives.","face to face contacts monthly occurring in the individual's natural environment","monthly contacts with collateral contacts to determine the needs and functioning of individuals"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-385","Assessments for quality of life will occur at least twice a year to focus and improve social determinents of health and/or family support services that can be added to individual's person directed plans.","No","","138305109.7.1","NG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_020947001","020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private",175,"Chronic Care Management","","Edit","There are no changes made to the Core Activity for Valley Regional Medical Center (VRMC).  VRMC is only editing template for the purpose of elaboration to the description, Secondary Driver section and first Change Idea section.  ","Utilization of care management and/or chronic care management services","","Title:  Chronic Disease Management:  Diabetes Care\nDevelop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.  The Core Activity is managed via the Diabetes Management Center (DMC) at Valley Regional Medical Center (VRMC).  The DMC staff which includes a Certified Diabetic Educator/Nurse Practitioner, Nutritionists, and Outreach Specialist are devoted to treat the community by providing quality care through evidence based diabetic self-management education.  The DMC is active in community outreach events to promote the availability of their outpatient services for diabetic patients.  In addition, DMC has established relationships with local primary care physician offices, which increased referrals to the outpatient center.  The DMC abides to the AADE program guidelines.  Overall, DMC is committed to the improvement of quality patient care and assistance in diabetes management.  Our focus on patient education, follow-up, and management will result in better overall health outcomes for the targeted population, including increased quality of life, reduced use of acute care, and slower progression of this chronic disease.","Outpatient clinic services via the Diabetes Management Center (DMC) are the first driver of chronic care management.  The services provided at the DMC are diabetes education, meal planning, glucose screenings, hemoglobin A1C testing, insulin teaching, coping skills and guidance to help patients find a plan that helps them reach healthy goals.  Patients will improve their health by learning how to manage blood glucose levels, monitor their blood pressure readings, and understand their medications, decrease risk of disease complications and overall diabetes self-management.  DMC understands that all of these components are necessary in order for patients to achieve better health outcomes. ","Diabetes Management Center (DMC) monitors patient progress at the end of four visits within a 3 month time frame.  The DMC expects to see a significant reduction in Hemoglobin A1C rates and blood pressure rates for the population being served.  The DMC evaluates clinical data in order to determine which patients did not show progress.  The DMC will then follow up with those patients to share results, identify missed opportunities, and re-educate within a 6-month time frame. These important steps will lead to the improvement that is necessary to achieve better health outcomes for the target population."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Columbia Valley Regional Medical Center via the DMC aims to reduce patients whose A1C levels out of control by providing education, nutrition guidance and ongoing monitoring of their blood pressure via the diabetes management outpatient clinic.  The DMC provides education sessions for patients who enroll in the program over a 3-month period.  Patients are screened for glucose levels, receive nutrition education sessions, blood pressure monitoring and receive a foot exam during one of their visits. Patients who complete the program see significant improvement on their A1C levels and overall health benefits. This is an important step in the diabetes disease management process and evidence that the intervention and education provided by the DMC shows positive results.  These initiatives help the diabetic population increase quality of life, reduce the use of emergent acute care services, slow progression of diabetes, and prevent complications.  ","No","","020947001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",176,"Chronic Care Management","","Delete","This Core Activity has been deleted and then added under a new Category Grouping and Name that better describes the secondary drivers and change ideas.  ","Utilization of care management and/or chronic care management services","","This core activity will focus on both the clinical and lifestyle components to help address chronic care management of diabetes and heart disease. This integrated approach in key in ensuring that patients receive necessary care and support to manager their conditions.","Assist patients to adhere to the clinical advice and directions of their provider.","Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance and assist in addressing the social determinants."," "," "," "," ","Implement group interventions to promote lifestyle changes.","Provide opportunities for community-based Diabetes Self-Management Education and other group interventions","Provide opportunities for chronic disease support groups"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The secondary drivers and change ideas have been selected to address areas that could results in gaps to care.  Both the adherence to clinical advice (e.g. taking medications as prescribed) as well as lifestyle management (e.g. self-monitoring, nutrition, physical activity) are all important in addressing chronic diseases. These activities will result in improved patient outcomes for Bundles A1 and A2.","No","","085144601.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #176 AND Accept the new addition of the CA in row 86, which is essentially just an update of CA #176 (e.g. the new CA in row 86 simply updated CA #176's Core Activity Grouping from \"Chronic Care Management\" to \"Prevention and Wellness\"…and then also added a third Secondary Driver), but provider decided to go about the update by deleting CA #176 and newly adding a CA rather than just editing CA #176... \n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","there is nothing in our guidance that prohibits that so I agree with accepting.","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",177,"Chronic Care Management","","Edit","Elements of this Core Activity have been edited to more clearly group secondary drivers and change ideas under the appropriate Core Activity Name.    ","Provision of services to individuals that address social determinants of health","","This core activity will focus on creating opportunities for lifestyle components to help address chronic care management of diabetes and heart disease.","Provide resources that support patients with accessing services and supplies needed for chronic care management.","Patient navigators and community health workers connect individuals to transportation services to help patients attend group classes, PCP appointments, lab appointments, and other visits.","Identify individuals in need of financial support for medications, copays, lab costs, and other exam costs. SWs provide financial resources through Compassion Funds process to participants identified as needing this type of support.  "," Social Workers conduct assessments to identify barriers that impact individuals with their self-management goals and connect patients to community resources. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","85.93% of individuals in our system are considered MLIU. Patients experience many barriers that impact their ability to prioritize their health. Such barriers include financial challenges and lack of transportation to attend their doctor’s appointments or follow-up appointments regarding their diabetes, hypertension, or cancer screenings. By providing transportation and financial resources to complete visits, exams, labs, and obtain medications related to their diabetes, hypertension, or cancer screenings, we are taking action on addressing two of the most common barriers that participants face.\n\nIn addition, involving Social Workers in addressing other social factors that impact care is also very important as there are many other unique circumstances that patients experience that must be assessed individually. Social Workers facilitate patients’ referrals to community resources and services including opportunities to cover costs of screening and potential follow-up for some types of cancer (C2), help pay for laboratory fees, PCP visits, co-pays, medication or specialty care for patients with uncontrolled Type 2 diabetes or uncontrolled high blood pressure (A1 and A2).  \n\nThe impact that addressing Social Determinants of Health will have on bundles A1, A2, and C2 is that more patients will have access to supportive services needed to comply with medical visits for diabetes (bundle A1), heart disease (bundle A2), cancer screening exams (bundle C2), and patients’ overall health. Transportation and financial support to pay for these exams, medication, and in some cases referrals to specialty care are examples of supportive services. Social Workers provide another form of support by evaluating patients’ needs through screening and assessment, connecting patients to resources outside the clinic, and advocating for patients to receive the care and follow up they need to improve health outcomes.","No","","085144601.7.2","JJ","Edits are good (e.g. added more detail to Secondary Driver 1 and Change Ideas 1-3), but please second review any concerns with their newly adding C2…I think this CA is more only about A1 and A2 but do not feel strongly to NMI them just on the grounds of C2…so have Accepted.\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","chnaged to NMI with additional recommendaiton","Needs More Information","HHSC accepts provider’s updates, but requests additional information regarding impact of this Core Activity on each of the measure bundles. Provide should include additional information in the \"Provider Response\" column.","The impact that addressing Social Determinants of Health will have on bundles A1, A2, and C2 is that more patients will have access to supportive services needed to comply with medical visits for diabetes (bundle A1), heart disease (bundle A2), cancer screening exams (bundle C2), and patients’ overall health. Transportation and financial support to pay for these exams, medication, and in some cases referrals to specialty care are examples of supportive services. Social Workers provide another form of support by evaluating patients’ needs through screening and assessment, connecting patients to resources outside the clinic, and advocating for patients to receive the care and follow up they need to improve health outcomes.\n\nWe have expanded our initial responses below -   \n85.93% of individuals in our system are considered MLIU. Patients experience many barriers that impact their ability to prioritize their health. Such barriers include financial challenges and lack of transportation to attend their doctor’s appointments or follow-up appointments regarding their diabetes, hypertension, or cancer screenings. By providing transportation and financial resources to complete visits, exams, labs, and obtain medications related to their diabetes, hypertension, or cancer screenings, we are taking action on addressing two of the most common barriers that participants face.\nIn addition, involving Social Workers in addressing other social factors that impact care is also very important as there are many other unique circumstances that patients experience that must be assessed individually. Social Workers facilitate patients’ referrals to community resources and services including opportunities to cover costs of screening and potential follow-up for some types of cancer (C2), help pay for laboratory fees, PCP visits, co-pays, medication or specialty care for patients with uncontrolled Type 2 diabetes or uncontrolled high blood pressure (A1 and A2).  ","JJ","Much more detailed response, very sufficient.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the detailed update to Description of Measure Bundle/Measure Impact.","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",178,"Access to Specialty Care Services","","Edit","This Core Activity has been edited to reflect new secondary drivers and change ideas underway that related to the Primary Driver. The last change idea was also edited so that it covers all specialty care service and not only on diabetic eye screening. ","Improvement in access to specialty care services with the concentration on underserved areas","","This core activity will focus on closing the loop on referrals to specialists and expanding services for specialty care within the primary care setting. \n\nSu Clinica clinics and Rio Grande State Center provide behavioral health screening and services within their primary care setting. Patients with diabetes are at increased risk for depression and anxiety, therefore, behavioral health is an important aspect of diabetes management and directly relates to bundle A1. \n\nBoth Su Clinica and Rio Grande State Center provide women’s health services, which include cervical cancer screening (measure C2-106). In addition, patients who are eligible for breast cancer screening are identified, provided with referrals and connected to financial resources to help with screening. Referrals to breast cancer screening, obtaining results, and properly documenting the completed screenings in the EHR are tracked for patients at both SC and RGSC.\n\nIn DY7-8, Su Clinica and Rio Grande State Center patients had improved access to diabetic retinopathy screening through the use of a retinal telemedicine platform that was implemented within these clinics. Patients can receive this exam without needing to visit a specialist. Retinal images are read by an eye specialist through the telemedicine platform and made available to the primary care provider. Additionally, some patients needing referrals to specialist for additional screening received financial assistance to complete the referral. \nSu Clinica also provides podiatry services within the primary care setting. For DY 9-10, the same services will continue for both clinics.\n","1. Increase opportunities for patients to receive needed specialty care services and enhance care coordination for specialist referrals","Enhance or implement a specialist referral tracking process. Close the loop on referrals to specialists including receiving and documenting the report from the specialist and identifying when patients have not completed the referral.","Identify specialists and/or resources for low/no cost specialty care services."," Implement specialty care services in primary care settings to expand the services that patients can receive in their medical home and improve completion of these referrals.  "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","Patients of Rio Grande State Center and Su Clinica are primarily low-income uninsured and have reduced access to specialty care due to high costs or lack of availability of specialists who accept all payment types. Improvement of the tracking of specialist referrals will help the clinics ensure that patients receive the right services at the appropriate intervals. \n\nIt is especially important to continuously seek out specialists who will offer discounts to patients referred by the clinic and/or accept vouchers or alternative payment types. In conjunction, more opportunities are provided by continually identifying programs, grants and community services specifically for specialty care.\n\nCreating opportunities for patients to receive specialist services in their medical home will have the greatest impact in improving access.\nIn house referrals will prevent patients from having to go to another setting for services which we know can often result in low rates of referral completion and/or challenges with closing the loop with other providers. Some of the specialty care services integrated into primary include – \nRio Grande State Center and Su Clinica: behavioral health, women’s health, diabetic eye screening, Medication Therapy Management, lifestyle medicine\nSu Clinica only: endocrinology, podiatry\n","No","","085144601.7.2","JJ","CA 179 was deleted and consolidated into CA 178 which I think is fine","N","NB","changed to NMI and requested additional clarification","Needs More Information","HHSC accepts provider’s updates, but requests additional information if it is available. Provider should include additional details on type of specialists that the provider is improving access to based on previous experience in DY7-8 and goals for DY 9-10. Provider should include additional information in the \"Provider Response\" column.","Su Clinica clinics and Rio Grande State Center provide behavioral health screening and services within their primary care setting. Patients with diabetes are at increased risk for depression and anxiety, therefore, behavioral health is an important aspect of diabetes management and directly relates to bundle A1. \nBoth Su Clinica and Rio Grande State Center provide women’s health services, which include cervical cancer screening (measure C2-106). In addition, patients who are eligible for breast cancer screening are identified, provided with referrals and connected to financial resources to help with screening. Referrals to breast cancer screening, obtaining results, and properly documenting the completed screenings in the EHR are tracked for patients at both SC and RGSC.\nIn DY7-8, Su Clinica and Rio Grande State Center patients had improved access to diabetic retinopathy screening through the use of a retinal telemedicine platform that was implemented within these clinics. Patients can receive this exam without needing to visit a specialist. Retinal images are read by an eye specialist through the telemedicine platform and made available to the primary care provider. Additionally, some patients needing referrals to specialist for additional screening received financial assistance to complete the referral. \nSu Clinica also provides podiatry services within the primary care setting. For DY 9-10, the same services will continue for both clinics.","JJ","Provided detailed response","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the detailed information regarding specialty care services to the Description of Core Activity.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",179,"Access to Specialty Care Services","","Delete","This Core Activity was consolidated under another Core Activity Name. The Secondary drivers and Change Ideas will continue to be implemented but have been grouped under another Core Activity that appropriately reflects the Primary Driver. ","Provision of services to individuals that address social determinants of health","","Identify patients at risk of not completing an eye exam referral and provide education, navigation and support to ensure that diabetic patients routine eye exams.","Promote eye exam visits to patients with diabetes.","Provide transportation to patients with diabetes to attend eye exam appointments","CHWs to provide education to patients with diabetes referred to the CCM program on the importance of receiving an eye exam and re-connect participants to their medical home when patients have not been to their appointments"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","This Core Activity addresses measure A1-111 Comprehensive Diabetes Care: Eye Exam (retinal) performed. The Core Activities described above will ensure that patients have support to attend exams appointments and identify when patients are not attending due to social barriers.","No","","085144601.7.2","JJ","CA 179 was deleted and consolidated into CA 178 which I think is fine","N","NB","agree","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health.","CA-2","CA-2.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",180,"Expansion of Patient Care Navigation and Transition Services","","Delete","This Core Activity was consolidated under another Core Activity Name. The Secondary drivers and Change Ideas will continue to be implemented but have been grouped under another Core Activity that appropriately reflects the Primary Driver. ","Provision of navigation services to targeted patients","","Improve cancer screening and chronic care management for diabetes and heart disease through navigation to services targeting the patients specific needs.","Pro-actively identify patients in need of navigation services","Define target populations to receive navigation services","Create reports from EHR and define report distribution and intervals","Create and/or update workflows for patient outreach"," "," ","Link patients with appropriate community services","Employ patient navigators to assist patients during clinic visits and home visits","Provide training and materials for providers and staff","Provide specific informational materials to patients","Implement tracking methodology for community referrals"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; C2; A1","This Core Activity addresses all selected measure bundles A1, A2, and C2. Most chronic care patients would benefit from navigation to services that will help them manage their health. Due to low health literacy in the clinics population, most would benefit from outreach and education about the importance of cancer screenings.","No","","085144601.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #180 AND Accept the new addition of the CA in row 87; although provider said that in deleting CA #180, the new CA in row 87 would be grouped into a new CA Grouping, it appears that the new CA in row 87 is almost identical to CA #180...so it is unclear if provider meant to make more substantial changes by newly adding the CA in row 87...but there are no blatant issues I see with the newly added CA so I'm accepting\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","OK","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",181,"Prevention and Wellness","","Edit","Elements of this Core Activity have been edited to more clearly group secondary drivers and change ideas under the appropriate Core Activity Name.     ","Use of community health workers to improve prevention efforts","","Deploy Community Health Workers to patient homes and community settings to provide motivation, education and connection to screenings to prevent cancer, diabetes and hypertension. ","Community Health Workers provide healthy lifestyle education in the patient’s home to prevent complications from high blood pressure and uncontrolled diabetes.","Deploy Community Health Workers to patient homes to offer tailored in-home education to patients about healthy lifestyle change, with a focus on physical activity and nutrition.","Community Health Workers connect patients to free exercise classes, healthy cooking classes, weight-loss support groups and online support groups."," "," "," ","Community Health Workers promote cancer screenings (colorectal, breast, cervical) to clinic patients by providing tailored educational modules in their homes and connecting them to clinic screenings and addressing barriers to attendance.","Community Health Workers identify patient barriers to attending clinic cancer screening appointments (transportation, funding, fear) & connect patients with clinic social services and other resources to assure they received their screening tests.","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","This Core Activity addresses bundles A1, A2 and C2. Patients of Rio Grande State Center and Su Clinica are primarily low-income uninsured with lower health literacy. Many patients face barriers to making healthy lifestyle changes like eating well, exercising and obtaining cancer screenings. CHWs are uniquely trained and positioned to effectively reach patients with culturally relevant information and resources to make healthy lifestyle changes and prevent cancer and complications from chronic disease like diabetes and hypertension.  ","No","","085144601.7.2","JJ","Edits seem fine;\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","N",null,"OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use of community health workers to improve prevention efforts","CA-7","CA-7.6"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",689,"Prevention and Wellness","","New","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","This core activity will focus on both the clinical and lifestyle components to help address chronic care management of diabetes and heart disease. This integrated approach is key in ensuring that patients receive necessary care and support to manage their conditions.","Assist patients to adhere to the clinical advice and directions of their provider.","Multidisciplinary Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance.","","","","","Implement group interventions to promote lifestyle changes.","Provide opportunities for community-based self support management of chronic disease and lifestyle changes ","","","","","Provide individual interventions through CHWs to assess, support, and as needed, provide referrals to address barriers to clinical care and self-management.","Utilize Motivational Interviewing (MI) as a technique to engage patients in self-management.","Community Health Workers administer appropriate surveys (e.g. Physical Activity, Healthy Eating, Medication Adherence, Environmental Assessment, PHQ-9) and implement workflows to connect patients to appropriate services.","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The secondary drivers and change ideas have been selected to address areas that could results in gaps to care.  Both the adherence to clinical advice (e.g. taking medications as prescribed) as well as lifestyle management (e.g. self-monitoring, nutrition, physical activity) are all important factors in addressing chronic diseases. These activities will result in improved patient outcomes for Bundles A1 and A2.","No","","085144601.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #176 AND Accept the new addition of the CA in row 86, which is essentially just an update of CA #176 (e.g. the new CA in row 86 simply updated CA #176's Core Activity Grouping from \"Chronic Care Management\" to \"Prevention and Wellness\"…and then also added a third Secondary Driver), but provider decided to go about the update by deleting CA #176 and newly adding a CA rather than just editing CA #176... \n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","there is nothing in our guidance that prohibits that so I agree with accepting.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_085144601","085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",690,"Expansion of Patient Care Navigation and Transition Services","","New","","Provision of navigation services to targeted patients","","This core activity will focus on improving cancer screening and chronic care management by continuously identifying patients in need and linking them to the appropriate services. Identifying patients will occur via meaningful use of the EHR and other community services data.","Pro-actively identify patients in need of navigation services. \n\nThis Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Su Clinica and Rio Grande State Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition. Due to low health literacy in the clinics' population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","Use EHR data along with community services data to define target populations to receive navigation services.","Continue to enhance reports from EHR and other data sources and improve report distribution and intervals to perform frequent gap analysis.","","","","Link patients with appropriate community service(s).","Employ patient navigators and care managers to assist patients during clinic visits and home visits.","Provide training and materials for providers and staff.","Provide specific informational materials to patients.","Implement tracking methodology for community referrals.","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","This Core Activity addresses all selected measure bundles A1, A2, and C2. Most chronic care patients would benefit from navigation to services that will help them manage their health. Due to low health literacy in the clinics population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","No","","085144601.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #180 AND Accept the new addition of the CA in row 87; although provider said that in deleting CA #180, the new CA in row 87 would be grouped into a new CA Grouping, it appears that the new CA in row 87 is almost identical to CA #180...so it is unclear if provider meant to make more substantial changes by newly adding the CA in row 87...but there are no blatant issues I see with the newly added CA so I'm accepting\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","changed to NMI and also added another recommendaion for new Change ideas ","Needs More Information","HHSC accepts provider’s updates, but requests additional information regarding target population for this Core Activity; this information can be added to Secondary Driver 1 - Proactively identify patients in need of navigation services. Provider should include additional information in the \"Provider Response\" column.","This Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Su Clinica and Rio Grande State Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition. Due to low health literacy in the clinics' population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","JJ","Provided detailed response","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the detailed description of the target population for Secondary Driver 1.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",182,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","This core activity seeks to identify the patient population that are at high risk of developing complications, co-morbidities, and/ or utilizing acute and emergency care services for Diabetes and Heart Disease. The goal is to be able to properly manage this target population.","Identify patient population with chronic diseases such as diabetes and heart disease that are at high risk of developing complications, co-mornidities, and/ or utilizing acute and emergency care services.","Effectively navigate patients to the most appropriate health care setting and provide education as needed. Furthermore, provide chronic disease self-management education to patients as applicable."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By properly identifying the Diabetic and Heart Disease patients will allow us to properly manage their care at a primary care level rather than having them come through the ED with advanced complications.","No","","094113001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",183,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","This core activity will enhance the coordination between primary care and emergency departments to have a continuum of care between the two. This will allow patients to be seen by their primary doctor post discharge.","Review discharge report with patient and caregivers and provide education where necessary. Set up appointment with patient's PCP prior to patient discharge.","Prior to discharge, assure patient has follow up appointment with PCP"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Establishing a follow up appointment with primary care providers for discharged patients will allow them to visit their PCP right after being discharged from hospital. This follow up can potentially reduce the amount of re-admissions.","No","","094113001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",184,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","This core activity seeks to implement a program of care transitions and/ or discharge planning so that patients and their caregivers are fully aware of the next steps. Ultimately to close any existing gaps that may exist between acute care and non-acute care entities.","Review discharge report with patient and caregivers and provide education where necessary. Set up appointment with patient's PCP prior to patient discharge.","Prior to discharge, review transition record with patient and caregiver"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Establishing a focused support program to provide transition and discharge planning to patients and caregivers empowers them to perform home treatments and understand potential post-discharge effects, potentially resulting in reduced re-admissions.","No","","094113001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",185,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","This core activity seeks to identify patients that meet the age grouping for patients at risk of developing  Cervical cancer, Colorectal cancer, Breast Cancer, and Chlamydia and provide them with appropriate screening and follow up services. Furthermore, identify those patients with an out of normal parameter BMI and provide a follow up plan. Also, Patients will be surveyed for tobacco usage and cessation counseling will be provided for those that are smokers.","Identify, screen and provide education for patients identified as tobacco users and/ or BMI outside of normal parameters. Provide patients with HbA1c testing and cancer screenings. ","Upon visit, review patients medical record and provide appropriate screenings and follow up services"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Identification  and provision of appropriate tests and screenings will allow us to enhance our preventive care initiatives at the primary care level. This prevention environment will in turn aid in reducing the amount of people developing cancers and other dieases related to obesity.","No","","094113001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",186,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","This core activity seeks to identify individuals that meet the age qualifications and provide them with preventive vaccinations for Influenza, Pneumonia, and Human Papillomavirus.","Identify patients who meet qualifications to have vaccinations for Pneumonia, influenza, and Human Papillomavirus","Upon visit, determine patient's vaccination staus, provide patient education on vaccinations, and provide vaccination if requested."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","By identifying the individuals that meet the qualifications for developing  Influenza, Pneumonia, and Human Papillomavirus, will allow us to provide preventive vaccinations and avoid future diseases while being treated at the primary care level.","No","","094113001.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_094113001","094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private",187,"Hospital Safety and Quality",null,"Edit","","Implementation of evidence-based practices to improve quality of care",null,"This core activity seeks to maintain and improve the high level of quality care that patients deserve to be treated with. The end goal is provide an exceptional experience to patients and their families by reducing the risk of health-care related infections and reducing hospital errors.","Proactively identify rates of concern and implement corrective actions","Provide ongoing prevention education to staff including new hires at time of orientation","Implement initiatives to improve patient fall rates. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Having a constant monitoring program of quality indicators such as CLABSI, CAUTI, SSI, & Fall rates, will enable us to maintain the high quality standards that we abide by. By providing high quality care, patients and families will have an increased satisfaction over their visit.","No","","094113001.7.1","JJ","During DY8R2 Review, AQ suggested that this \"Other\" core activity group could be updated to \"Hospital Safety and Quality\" and the title could be changed to \"Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\"; I agree!\nPlease second review my manual changes made and the Accepted sign off and HHSC drafted Comment about the manual changes - I wasn't sure if it's okay to Accept when making those manual changes","Y","NB","changed to NMI and also added another recommendaion for new Change ideas since it is vague","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Quality care\" to \"Hospital Safety and Quality\" and the Core Activity Title from \"Other: Provide high quality patient care\" to \"Implementation of evidence-based practices to improve quality of care (e.g. Quality Departments, monitoring and evaluation, etc.)\" to better align with the provider's described Core Activity. If the provider disagrees with the changes, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and/or Core Activity Name is more appropriate than \"Other\". HHSC also recommends provider add additional Change Idea(s) to specify identified rates of concern that the provider is working on what corrective actions are implemented.","Provider  agrees with HHSC's update to Core Activity Grouping and Title. Change ideas: (1) Provide ongoing prevention education to staff including new hires at time of orientation.  (2) Implement initiatives to improve patient fall rates. ","JJ","Provider agreed to HHSC's changes and also provided one additional Change Idea #2: Implement initiatives to improve patient fall rates. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the addition of a Secondary Driver 1: Change Idea #2. ","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",171,"Chronic Care Management","","Delete","This Core Activity has been deleted and then added under a new Category Grouping and Name that better describes the secondary drivers and change ideas.  ","Utilization of care management and/or chronic care management services","","This core activity will focus on both the clinical and lifestyle components to help address chronic care management of diabetes and heart disease. This integrated approach in key in ensuring that patients receive necessary care and support to manager their conditions.","Assist patients to adhere to the clinical advice and directions of their provider.","Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance and assist in addressing the social determinants."," "," "," "," ","Implement group interventions to promote lifestyle changes.","Provide opportunities for community-based Diabetes Self-Management Education and other group interventions","Provide opportunities for chronic disease support groups"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1","The secondary drivers and change ideas have been selected to address areas that could results in gaps to care.  Both the adherence to clinical advice (e.g. taking medications as prescribed) as well as lifestyle management (e.g. self-monitoring, nutrition, physical activity) are all important in addressing chronic diseases. These activities will result in improved patient outcomes for Bundles A1 and A2.","No","","111810101.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #171 AND Accept the new addition of the CA in row 59, which is essentially just an update of CA #171 (e.g. the new CA in row 59 simply updated CA #171's Core Activity Grouping from \"Chronic Care Management\" to \"Prevention and Wellness\"…and then also added a third Secondary Driver), but provider decided to go about the update by deleting CA #171 and newly adding a CA rather than just editing CA #171... \n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","there is nothing in our guidance that prohibits that so I agree with accepting.","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",172,"Chronic Care Management","","Edit","Elements of this Core Activity have been edited to more clearly group secondary drivers and change ideas under the appropriate Core Activity Name.         ","Provision of services to individuals that address social determinants of health","","This core activity will focus on creating opportunities for lifestyle components to help address chronic care management of diabetes and heart disease.","1. Provide resources that support patients with accessing services and supplies needed for chronic care management.","Patient navigators and community health workers connect individuals to transportation services to help patients attend group classes, PCP appointments, lab appointments, and other visits.","Identify individuals in need of financial support for medications, copays, lab costs, and other exam costs. SWs provide financial resources through Compassion Funds process to participants identified as needing this type of support.  "," Social Workers conduct assessments to identify barriers that impact individuals with their self-management goals and connect patients to community resources. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","91.44% of individuals in our system are considered MLIU. Patients experience many barriers that impact their ability to prioritize their health. Such barriers include financial challenges and lack of transportation to attend their doctor’s appointments or follow-up appointments regarding their diabetes, hypertension, or cancer screenings. By providing transportation and financial resources to complete visits, exams, labs, and obtain medications related to their diabetes, hypertension, or cancer screenings, we are taking action on addressing two of the most common barriers that participants face.\n\nIn addition, involving Social Workers in addressing other social factors that impact care is also very important as there are many other unique circumstances that patients experience that must be assessed individually. Social Workers facilitate patients’ referrals to community resources and services including opportunities to cover costs of screening and potential follow-up for some types of cancer (C2), help pay for laboratory fees, PCP visits, co-pays, medication or specialty care for patients with uncontrolled Type 2 diabetes or uncontrolled high blood pressure (A1 and A2).\n\nThe impact that addressing Social Determinants of Health will have on bundles A1, A2, and C2 is that more patients will have access to supportive services needed to comply with medical visits for diabetes (bundle A1), heart disease (bundle A2), cancer screening exams (bundle C2), and patients’ overall health. Transportation and financial support to pay for these exams, medication, and in some cases referrals to specialty care are examples of supportive services. Social Workers provide another form of support by evaluating patients’ needs through screening and assessment, connecting patients to resources outside the clinic, and advocating for patients to receive the care and follow up they need to improve health outcomes.","No","","111810101.7.2","JJ","Edits are good (e.g. added more detail to Secondary Driver 1 and Change Ideas 1-3), but please second review any concerns with their newly adding C2…I think this CA is more only about A1 and A2 but do not feel strongly to NMI them just on the grounds of C2…so have Accepted.\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","I see your point, but also maybe follow what they think. If they improvie transportation more patients can have cancer screening, maybe. Anyway we can NMI it and request more detials for the impact.","Needs More Information","HHSC accepts provider’s updates, but requests additional information regarding impact of this Core Activity on each of the measure bundles. Provide should include additional information in the \"Provider Response\" column.","The impact that addressing Social Determinants of Health will have on bundles A1, A2, and C2 is that more patients will have access to supportive services needed to comply with medical visits for diabetes (bundle A1), heart disease (bundle A2), cancer screening exams (bundle C2), and patients’ overall health. Transportation and financial support to pay for these exams, medication, and in some cases referrals to specialty care are examples of supportive services. Social Workers provide another form of support by evaluating patients’ needs through screening and assessment, connecting patients to resources outside the clinic, and advocating for patients to receive the care and follow up they need to improve health outcomes.\n\nWe have expanded our initial responses below -   \n91.44% of individuals in our system are considered MLIU. Patients experience many barriers that impact their ability to prioritize their health. Such barriers include financial challenges and lack of transportation to attend their doctor’s appointments or follow-up appointments regarding their diabetes, hypertension, or cancer screenings. By providing transportation and financial resources to complete visits, exams, labs, and obtain medications related to their diabetes, hypertension, or cancer screenings, we are taking action on addressing two of the most common barriers that participants face.\nIn addition, involving Social Workers in addressing other social factors that impact care is also very important as there are many other unique circumstances that patients experience that must be assessed individually. Social Workers facilitate patients’ referrals to community resources and services including opportunities to cover costs of screening and potential follow-up for some types of cancer (C2), help pay for laboratory fees, PCP visits, co-pays, medication or specialty care for patients with uncontrolled Type 2 diabetes or uncontrolled high blood pressure (A1 and A2).  \n","JJ","Much more detailed response, very sufficient.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the detailed update to Description of Measure Bundle/Measure Impact.","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",173,"Expansion of Patient Care Navigation and Transition Services","","Delete","This Core Activity was consolidated under another Core Activity Name. The Secondary drivers and Change Ideas will continue to be implemented but have been grouped under another Core Activity that appropriately reflects the Primary Driver. ","Provision of navigation services to targeted patients","","Improve cancer screening and chronic care management for diabetes and heart disease through navigation to services targeting the patients specific needs.","Pro-actively identify patients in need of navigation services","Define target populations to receive navigation services","Create reports from EHR and define report distribution and intervals","Create and/or update workflows for patient outreach"," "," ","Link patients with appropriate community service(s)","Employ patient navigators to assist patients during clinic visits and home visits","Provide training and materials for providers and staff","Provide specific informational materials to patients","Implement tracking methodology for community referrals"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","This Core Activity addresses all selected measure bundles A1, A2, and C2. Most chronic care patients would benefit from navigation to services that will help them manage their health. Due to low health literacy in the clinics population, most would benefit from outreach and education about the importance of cancer screenings.","No","","111810101.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #173 AND Accept the new addition of the CA in row 61; although provider said that in deleting CA #173, the new CA in row 61 would be grouped into a new CA Grouping, it appears that the new CA in row 61 is almost identical to CA #173...so it is unclear if provider meant to make more substantial changes by newly adding the CA in row 61...but there are no blatant issues I see with the newly added CA so I'm accepting\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","agree","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",174,"Prevention and Wellness","","Edit","Elements of this Core Activity have been edited to more clearly group secondary drivers and change ideas under the appropriate Core Activity Name.       ","Use of community health workers to improve prevention efforts","","Deploy Community Health Workers to patient homes and community settings to provide motivation, education and connection to screenings to prevent cancer, diabetes and hypertension. ","Community Health Workers provide healthy lifestyle education in the patient’s home to prevent complications from high blood pressure and uncontrolled diabetes.","Deploy Community Health Workers to patient homes to offer tailored in-home education to patients about healthy lifestyle change, with a focus on physical activity and nutrition.","Community Health Workers connect patients to free exercise classes, healthy cooking classes, weight-loss support groups and online support groups.",""," "," ","Community Health Workers promote cancer screenings (colorectal, breast, cervical) to clinic patients by providing tailored educational modules in their homes and connecting them to clinic screenings and addressing barriers to attendance.","Community Health Workers identify patient barriers to attending clinic cancer screening appointments (transportation, funding, fear) & connect patients with clinic social services and other resources to assure they received their screening tests.",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","This Core Activity addresses bundles A1, A2 and C2. Patients of Rio Grande State Center and Su Clinica are primarily low-income uninsured with lower health literacy. Many patients face barriers to making healthy lifestyle changes like eating well, exercising and obtaining cancer screenings. CHWs are uniquely trained and positioned to effectively reach patients with culturally relevant information and resources to make healthy lifestyle changes and prevent cancer and complications from chronic disease like diabetes and hypertension.  ","No","","111810101.7.2","JJ","Edits seem fine;\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","N",null,"OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use of community health workers to improve prevention efforts","CA-7","CA-7.6"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",691,"Prevention and Wellness","","New","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","This core activity will focus on both the clinical and lifestyle components to help address chronic care management of diabetes and heart disease. This integrated approach is key in ensuring that patients receive necessary care and support to manage their conditions.","Assist patients to adhere to the clinical advice and directions of their provider.","Multidisciplinary Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance.","","","","","Implement group interventions to promote lifestyle changes.","Provide opportunities for community-based self support management of chronic disease and lifestyle changes ","","","","","Provide individual interventions through CHWs to assess, support, and as needed, provide referrals to address barriers to clinical care and self-management.","Utilize Motivational Interviewing (MI) as a technique to engage patients in self-management.","Community Health Workers administer appropriate surveys (e.g. Physical Activity, Healthy Eating, Medication Adherence, Environmental Assessment, PHQ-9) and implement workflows to connect patients to appropriate services.","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The secondary drivers and change ideas have been selected to address areas that could results in gaps to care.  Both the adherence to clinical advice (e.g. taking medications as prescribed) as well as lifestyle management (e.g. self-monitoring, nutrition, physical activity) are all important factors in addressing chronic diseases. These activities will result in improved patient outcomes for Bundles A1 and A2.","No","","111810101.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #171 AND Accept the new addition of the CA in row 59, which is essentially just an update of CA #171 (e.g. the new CA in row 59 simply updated CA #171's Core Activity Grouping from \"Chronic Care Management\" to \"Prevention and Wellness\"…and then also added a third Secondary Driver), but provider decided to go about the update by deleting CA #171 and newly adding a CA rather than just editing CA #171... \n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","there is nothing in our guidance that prohibits that so I agree with accepting.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",692,"Access to Specialty Care Services","","New","","Improvement in access to specialty care services with the concentration on underserved areas","","This core activity will focus on closing the loop on referrals to specialists and expanding services for specialty care within the primary care setting","Increase opportunities for patients to receive needed specialty care services and enhance care coordination for specialist referrals","Enhance or implement a specialist referral tracking process. Close the loop on referrals to specialists including receiving and documenting the report from the specialist and identifying when patients have not completed the referral.","Identify specialists and/or resources for low/no cost specialty care services.","Implement specialty care services in primary care settings to expand the services that patients can receive in their medical home and improve completion of these referrals.  ","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","Patients of Hope Family Health Center and Brownsville Community Health Center are primarily low-income uninsured and have reduced access to specialty care due to high costs or lack of availability of specialists who accept all payment types. Improvement of the tracking of specialist referrals will help the clinics ensure that patients receive the right services at the appropriate intervals. \n\nIt is especially important to continuously seek out specialists who will offer discounts to patients referred by the clinic and/or accept vouchers or alternative payment types. In conjunction, more opportunities are provided by continually identifying programs, grants and community services specifically for specialty care.\n\nCreating opportunities for patients to receive specialist services in their medical home will have the greatest impact in improving access.\nIn house referrals will prevent patients from having to go to another setting for services which we know can often result in low rates of referral completion and/or challenges with closing the loop with other providers. Some of the specialty care services integrated into primary include – \nBCHC: Dental, women’s health, behavioral health, Medication Therapy Management, endocrinology\nHFHC: women’s health, behavioral health\n\n\n","No","","111810101.7.2","JJ","Good, new addition;\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","N",null,"OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_111810101","111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",693,"Expansion of Patient Care Navigation and Transition Services","","New","","Provision of navigation services to targeted patients","","This core activity will focus on improving cancer screening and chronic care management by continuously identifying patients in need and linking them to the appropriate services. Identifying patients will occur via meaningful use of the EHR and other community services data.\n","Pro-actively identify patients in need of navigation services. This Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Brownsville Community Health Center and Hope Family Health Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition.  Due to low health literacy in the clinics’ population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","Use EHR data along with community services data to define target populations to receive navigation services.","Continue to enhance reports from EHR and other data sources and improve report distribution and intervals to perform frequent gap analysis.","","","","Link patients with appropriate community service(s).","Employ patient navigators and care managers to assist patients during clinic visits and home visits.","Provide training and materials for providers and staff.","Provide specific informational materials to patients.","Implement tracking methodology for community referrals.","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2","This Core Activity addresses all selected measure bundles A1, A2, and C2. Most chronic care patients would benefit from navigation to services that will help them manage their health. Due to low health literacy in the clinics population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","No","","111810101.7.2","JJ","Second Review my sign-off language to Accept the deletion of CA #173 AND Accept the new addition of the CA in row 61; although provider said that in deleting CA #173, the new CA in row 61 would be grouped into a new CA Grouping, it appears that the new CA in row 61 is almost identical to CA #173...so it is unclear if provider meant to make more substantial changes by newly adding the CA in row 61...but there are no blatant issues I see with the newly added CA so I'm accepting\n\nI don't think it's an issue but just keep in mind to make review sign offs consistent between Providers RHP 05_111810101 (Unv of Tx HSC at Houston-UTHSC Sponsored Projects) and RHP 05_085144601 (University of Texas Health Science Center SA) since they are reporting the exact same same Core Activities and changes to those Core Activities","Y","NB","changed to NMI and also added another recommendaion for new Change ideas since it is vague","Needs More Information","HHSC accepts provider’s updates, but requests additional information regarding target population for this Core Activity; this information can be added to Secondary Driver 1 - Proactively identify patients in need of navigation services. Provider should include additional information in the \"Provider Response\" column.","This Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Brownsville Community Health Center and Hope Family Health Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition.  Due to low health literacy in the clinics’ population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","JJ","Provided detailed response","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the detailed description of the target population for Secondary Driver 1.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_112716902","112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private",188,"Expansion of Patient Care Navigation and Transition Services","","Edit","Adding a secondary driver; Utilize patient navigators to help connect high risk patients to primary care, improve patient outcomes and divert patients needing non-urgent care to appropriate settings with chronic ambulatory care sensitive conditions (ACSC); Diabetes patients.","Identification of frequent ED users and use of care navigators","","Reduce Emergency Department visits for select ambulatory care sensitive conditions by utilizing case workers in the Emergency Department to navigate patients to the appropriate primary care setting.","Case manager workers contact Emergency Department patients with specified ambulatory care sensitive conditions to ensure connection and follow up with a primary care physician.","Contact patients with specified ambulatory care sensitive conditions and attempt to schedule those patients for an appointment in our family medicine clinic or get them connected with their PCP."," "," "," "," ","  ACSC Diabetes as top conditions for Chronic ACSC Emergency Room visits, Rio is looking reduce emergency visits and divert patients to proper follow up care to ACSC conditions patient population.","  Emergency Room case workers & diabetes center educators are working togeter to help ACSC Diabetes patients improve their diabetes self-care skill and create conscientiousness about diabetes risks, importance of following up with PCP and enhance quality of life."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","RGRH will reduce the number of ACSC related emergency department visits by providing patient education and navigation services.","No","","112716902.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_112716902","112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private",189,"Maternal and Infant Health Care","","Continue","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","","Screen maternal patients for high risk behavior and if neccesary refer them to a specialist for follow up treatment. We will also provide patient education that will result in patient compliance and healthy outcomes for mother and baby.  For identified \"high risk\" pregnancies we will provide Maternal Fetal consultation and access to a Dietitian for Diabetes education and monitoring.","Reduce complications from Gestational Diabetes for expecting mothers.","Gestional Diabetes in an expectant mothers will be confirmed via a glucose screening that will be ordered within one hour and after three hours of the first screening."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1; E2","Improve maternal health outcomes by providing early prenatal screening and treatment.","No","","112716902.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_112716902","112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private",190,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Decrease CAUTI/ CLABSI SIR values. Reduce the post- operative sepsis rate for the Total knee replacement (TKA), Total hip replacement (THA) & Bariatric Surgery.","For CLABSI, active surveillance of all central lines in the adult ICU. For CAUTI,active surveillance of all central lines in the adult and pediatric ICUs. Surveillance will rotate.","Infection control practitioner will review all central lines of the ICU's by physically looking at the line  & dressing and speaking with the primary care nurse about medical necessity for the line."," "," "," "," ","Identify patients who develop SSIs after surgery.","Antibiotics given within 1 hr. prior to incision. Pre-operative skin preparation with chlorhexidine  or iodophor."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Significant impact on patient outomes by reducing length of stay, potential for harm, unneccesary complications and mortality for conditions such as sepsis.","No","","112716902.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_135035706","135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private",191,"Chronic Care Management","","Continue","","Utilization of evidence‐based care management models for patients with complex needs","","Our goal is to develop and implement chronic disease management of diabetes in our facility.  Our goal is focused toward improving the management of diabetes and comorbidities, by improving and preventing disease complications.   This would include comprehensive diabetes care foot exam, comprehensive diabetes care of the hemoglobin A1C and control of blood pressure.  The staff will be pro-active in scheduling patients follow up visits and reminding them to go to all their appointments.  The physician is referring and encouraging patients with A1C over 9.0 to attend nutrition classes.Our clinic has been able to service the health care needs and manage chronic conditions in our community.  Previously our patients would seek care at the emergency room or would not get any time of care.  Our facility continues to educate our staff and patients on the importance of monitoring their health conditions and to prevent any further issues with their health.","Increase the number of patients who are scheduled and show up to follow up visits.","Training Staff to schedule patients timely for their follow up appointments. Provide education to our patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Our goal is focused toward improving the management of diabetes and comorbidities, by improving and preventing disease complications.","No","","135035706.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_136332705","136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public",192,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","The measure bundle we have selected is measure bundle B1 which is associated with care transitions and hospital readmissions. This bundle incorporates proper education of staff to accurately document patient medications being taken at home.  It also coordinates care with the patient's care team to develop a proper pathway of care and discharge plan.  This individual pathway of care and discharge plan will help produce more positive outcomes for our patient population especially those patients suffering with chronic diseases.  With the appropriate provider's education and transition of patient care the hospital should begin to see a positive trend of readmission rates.  Implementation of our hospitalist program will help us to integrate a more comprehensive care plan for our patients and help facilitate a more efficient transition of care.  This will also create an environment conducive to better chronic disease management in our facility.  It will also help develop healthier working relationships with other health care organizations that will continue the care of the hospitals patients and create positive outcomes for the patients and help maintain a healthier community. This will help lower the monetary burden placed on the state.","The secondary driver will be coordinating proper patient discharge planning with the providers and the other health care facilities or caregivers upon transition of care.  This will include the availability to print and verbalize discharge education and instructions to the appropriate personnel who will resume the care of the patient once discharged from our facility.","The change idea that would be associated with this core activity would be to have the all the policies reviewed when it comes to discharge planning of the patient. We will change the standard policies to incorporate the transition of the proper documentation and education needed be given to the proper individuals or facility assuming care of the patient upon discharge."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This core activity will impact the selected measure bundle by ensuring that patients and patients care givers post hospital stay have the proper information and education to ensure positive outcomes for the patient. This in turn should allow our facility to see positive trends of readmissions rates and overall health of our patient population.","No","","136332705.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_136332705","136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public",193,"Access to Specialty Care Services","","Continue","","Use telemedicine/telehealth to deliver specialty services","","Starr County Memorial Hospital is in negotiations with a partner in RHP5 to develop and implement a hospitalist program to provide comprehensive care to our inpatient population. The current dynamic for this patient service is that the hospital relies on local primary care providers to look after those patients who require such care. Currently our patient population does not have access to specialty care other than to seek those services at other neighboring facilities which places a financial strain on the patients and family. With the implementation of the hospitalist program we plan to incorporate access to specialty care via telemedicine. The hospitalist will be able to contact specialist via telemedicine and together with the care team develop a pathway of care and a discharge plan that should produce positive patient outcomes. It will also help provide the proper preventative care and education for patients and for those assuming care for the patients once discharged from our facility. This falls in line with our measure bundle B1.","We will be signing a secondary contract to have the specialists available via telemedicine so they can aid in the care plans of the patients and consult with the hospitalist to ensure positive outcomes for the patient. They will have access to live patient data via secure access to our EMR so they can make informed decisions about the patients care.","We will be purchasing new software to facilitate the access to telemedicine to ensure patient care and safety. We will also be reconfiguring 1 to 2 computers on wheels to make available to the medical care group placed in charge of the patients care. This will allow them to securely communicate with the specialist to develop a care plan and discharge plan."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The addition of specialty care via telemedicine will help us achieve our measure bundle b1 by allowing us to provide comprehensive care. The ability to have specialty care will allow the facility to properly provide an effective care plan and a comprehensive discharge plan which will incorporate other facilities that will assume care of our patients upon discharge.","No","","136332705.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use telemedicine/telehealth to deliver specialty services.","CA-2","CA-2.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_138708601","138708601.7.1",5,"138708601","Tropical Texas Behavioral Health","Community Mental Health Center (CMHC)","Non‐State Owned Public",194,"Access to Primary Care Services","","Edit","","Integrated physical and behavioral health care services","","TTBHs primary care clinics will provide primary care services to the behavioral health population served.  Services include promoting education, prevention, recovery and wellness.  This will be accomplished by screening all eligible clients for chronic co-morbid conditions (diabetes, obesity, hypertension, and substance use) and providing integrated care services and self-management tools to adequately control and improve conditions.","Identify clients with chronic illnesses (e.g. screening for HbA1c, BMI, blood pressure) to establish appropriate treatment plans and provide follow up services to monitor treatment effectiveness.","Screen all eligible clients for chronic conditions (diabetes, obesity, hypertension, and substance use) and, if present, provide follow up services to monitor symptoms."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,1,1,0,1,0,1,1,0,0,0,0,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-207; M1-103; M1-115; M1-317; M1-105; M1-211; M1-100","Screening tools help physicians identify clients with co-morbid conditions and establish appropriate treatment plans to improve overall health.  Early screening in high-risk clients, such as diabetes, hypertension, obesity, and substance use allow physicians to develop a comprehensive treatment plan and improve coordination of behavioral and primary health care.","No","","138708601.7.1","JJ","During DY8R2, AQ and NB recommended further review during the RHP Plan update review since CA 194 and CA 196 overlap in their descriptions and secondary drivers, so could be consolidated into one and re-organized into a more appropriate CA Grouping and CA Title; \n\nPlease second review my idea and sign-offs to suggest deleting CA 196, and editing CA 194, keeping CA Grouping \"Access to Primary Care Services\" but updating the CA Title from \"Provision of screening and follow up services\" to \"Integrated physical and behavioral health care services\" and then consolidating the responses between CA 196 and CA 194 for \"Second Driver 1\" and the associated measures","Y","NB","Changed to NMI","Needs More Information","Based on the overlapping descriptions between Core Activity ID 194 and ID 196, HHSC has edited Core Activity 194 by consolidating Core Activity 196 into Core Activity 194. Specifically, HHSC has updated Core Activity 194 from Core Activity Title \"Provision of screening and follow up services\" to \"Integrated physical and behavioral health care services\". Additionally, HHSC has consolidated the responses from CA 196 into CA 194 for \"Second Driver 1\" and the associated measures. If the provider disagrees with the changes to consolidate Core Activities 194 and 196, then please provide an explanation in the \"Provider Response\" column.","TTBH agrees with consolidating the core activities as suggested by HHSC.","JJ","Provider agreed to HHSC's changes.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_138708601","138708601.7.1",5,"138708601","Tropical Texas Behavioral Health","Community Mental Health Center (CMHC)","Non‐State Owned Public",195,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","TTBHs behavioral health clinics will provide improved care and enhanced access to integrated care across the following service arrays:  behavioral health, primary care, substance use disorders, veteran services, and Intellectual & Developmental Disabilities services.  Implementation of the CCBH model will include expansion of person-centered, family centered, trauma informed, and recovery oriented care that integrates physical and behavioral health care to serve the whole-person.  This will be accomplished by comprehensively screening all eligible clients to identify their needs and provide a holistic care approach to treatment.","Identify clients with needs assessed through routine screening; ensuring follow up and supports are provided with a focus on improving overall quality of care and positive health outcomes.","Provide patient education to identify symptoms and conditions associated with their assessed needs: substance use disorder, chronic care conditions, mental illness."," "," "," "," ","Develop a care coordination model and process across all levels of care.","In preparation for state-wide implementation of the CCBHC model as the standard for Texas Community Centers, care coordination guidelines, risk stratification, and other tools will be developed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",2,2,2,2,1,2,1,2,2,1,1,1,1,1,1,1,1,2,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-105; M1-146; M1-165; M1-259; M1-260; M1-261; M1-262; M1-263; M1-266; M1-287; M1-305; M1-319; M1-342; M1-390; M1-317; M1-103; M1-115; M1-147; M1-207; M1-211","Screening tools help physicians identify clients with behavioral health, primary care, and substance use conditions and establish appropriate treatment plans to improve overall health.  Early screening in high-risk clients allow physicians to develop a comprehensive treatment plan and ensure appropriate care and follow-up is provided to treat the whole-person.","No","","138708601.7.1","JJ",null,"N","NB","changing to NMI","Needs More Information","HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for CCBHC activities since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes or clarify that changes are not needed.","TTBH has added an additional secondary driver and change idea to this core activity.  \nSecondary Driver: Develop a care coordination model and process across all levels of care.\nChange Idea: In preparation for state-wide implementation of the CCBHC model as the standard for Texas Community Centers, care coordination guidelines, risk stratification, and other tools will be developed.","JJ","Provider added a Secondary Driver 2 and a Secondary Driver 2: Change Idea 1","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on provider's NMI responses, specifically the addition of a Secondary Driver 2, and a Secondary Driver 2: Change Idea #1. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_138708601","138708601.7.1",5,"138708601","Tropical Texas Behavioral Health","Community Mental Health Center (CMHC)","Non‐State Owned Public",196,"Chronic Care Management","","Delete","","Utilization of care management and/or chronic care management services","","TTBHs primary care clinics will provide primary care services to the behavioral health population served.  Services include promoting education, prevention, recovery and wellness.  This will be accomplished by screening all eligible clients for chronic conditions and providing self-management tools to adequately control and improve chronic conditions.","Identify clients with chronic illnesses for associated screening: HbA1c test, BMI, Blood Pressure.","Screen all eligible clients for chronic conditions and, if present, provide follow up services to monitor symptoms."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-115; M1-147; M1-207; M1-211","Early screening in high-risk clients, such as diabetes, hypertension, and obesity allow physicians to develop a treatment plan to improve health outcomes.  Through assessment and the development of a person-centered self-care plan, primary care will work collaboratively with the person served to help them set goals for improved self-management of their specific condition using community resources, personal support systems, and formal treatment services.","No","","138708601.7.1","JJ","During DY8R2, AQ and NB recommended further review during the RHP Plan update review since CA 194 and CA 196 overlap in their descriptions and secondary drivers, so could be consolidated into one and re-organized into a more appropriate CA Grouping and CA Title; \n\nPlease second review my idea and sign-offs to suggest deleting CA 196, and editing CA 194, keeping CA Grouping \"Access to Primary Care Services\" but updating the CA Title from \"Provision of screening and follow up services\" to \"Integrated physical and behavioral health care services\" and then consolidating the responses between CA 196 and CA 194 for \"Second Driver 1\" and the associated measures","Y","NB","Changed to NMI","Needs More Information","Based on the overlapping descriptions between Core Activity ID 194 and ID 196, HHSC has deleted Core Activity 196 (instead consolidating Core Activity ID 196 into Core Activity 194). If the provider disagrees with the changes to consolidate Core Activities 194 and 196, then please provide an explanation in the \"Provider Response\" column.","TTBH agrees with consolidating the core activities as suggested by HHSC.","JJ","Provider agreed to HHSC's changes.","N",null,null,"Accepted","Provider agreed to HHSC's deletion of the Core Activity and edits to Core Activity 194.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",197,"Chronic Care Management","","Edit","Changes to Core Activity #1 reflect progress updates and additional details explaining efforts related to the Core Activity. The identified grouping and change idea remain the same.","Utilization of evidence‐based care management models for patients with complex needs","","This Core Activity seeks to utilize evidence-based care management models to address patients with high-risk health care or complex needs. Through the 1115 Waiver, DHR Health has enhanced its care management efforts in RHP 5, expanding access to care through facilities including the Diabetes and Endocrinology Institute. The health system continues to recruit specialist physicians and staff to address the demands of RHP 5's complex patient needs.","Care coordination  for patients suffering from diabetes and related complications/comorbidities","Care coordination guidelines will be integrated within the clinic to allow for patients to have opportunities to receive guidance and resourses.  These would enable care coordinators to better manage the patients current conditions that would require education and/or follow-up care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The Diabetes and Endocrinology Institute impacts measure bundles A1 and A2.  Part of the standard of care is ensuring that diabetes eye care is addressed (A1-111), foot exams are provided (A1-112), blood pressure is tracked (A1-207/A2-210) and A1cs are monitored (A1-115).  Furthermore, access to diabetes management/coordination entails monitoring blood pressure, medications, general education, access to behavioral health, and social work.  Access to this breadth of services is intended to empower the patient and support reductions in both short and long-term complications as well as overutilization of intensive care services (A1-500, A1-508, A2-384, A2-501 and A2-509).","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",198,"Prevention and Wellness","","Edit","Changes to Core Activity #2 reflect progress updates and Core Activity description adjustments. The identified grouping and change idea remain the same.","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Primary care related services offered through the school-based health centers will provide necessary preventive care that aligns with the Healthy Texans and Healthy South Texas initiatives. This effort is being hardwired into the management protocols in each of the respective clinics as they continue to both expand care to disenfranchised populations and manage this population to support healthy community efforts.","Follow-up protocols for patients post screenings and assessments.","Follow-up protocols are being improved on to ensure that patients are receiving all necessary screenings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2","As DHR Health continues to improve services in both the inpatient and outpatient settings, it is important to take into consideration all preventative measures.  DHR Health is collaborating with the Edinburg Consolidated Independent  School District (ECISD) School-based Health Center and Pharr San Juan Alamo Consolidated Independent School District (PSJA-ISD) School-based Health Center to address gaps in primary care.   Each of these services address preventative measures including tobacco cessation, A1c readings, and BMI Index to help make sure vaccines are up to date.  Moreover, these services help secure necessary referrals according to the results of the screening to better manage the patients within the health system.","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",199,"Chronic Care Management","","Edit","Changes to Core Activity #3 reflect progress updates and Core Activity description adjustments. The identified grouping, change idea, and related measures remain the same.","Utilization of care management and/or chronic care management services","","The Core Activity is aimed at increasing the impact of the Care Link Clinic.  The Care Link Clinic has served as an inpatient-outpatient collaboration to better manage patients identified as high-risk for a 30-day readmission.  Through this clinic, DHR Health has seen success in managing high-risk patients, such as those diagnosed with Congestive Heart Failure (CHF) and other heart related conditions.  Utilization of evidence based protocols has preempted readmissions through proactively engaging patients to enlist their participation allowing for engagement post-discharge.  ","Increased patient engagement through enhanced services.","Increasing availability to clinicians will provide opportunities to drive patients to the right care settings according to the patients' presented conditions. This will be conducted through telephonic or telemedicine capabilities to provide increased clinician availability to those seeking help."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","DHR Health continues to focus on improving the health of the RHP5 community, especially among the underserved population. The Care Link Clinic’s utilization of evidence-based protocols for care management and chronic care management directly address health issues for patient populations associated with bundle A2, including Congestive Heart Failure (CHF). Service offerings at the Care Link Clinic include provider care coordination, nutritional counseling, RN clinical assessments, and disease specific education all tailored to the individual patient needs.","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",200,"Prevention and Wellness","","Edit","Changes to Core Activity #4 reflect progress updates and Core Activity description adjustments. The identified grouping, change idea, and related measures for the Core Activity remain the same.","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","DHR Health considers cancer prevention a major initiative.  Each collaborating outpatient clinic (Diabetes and Endocrinology Institute, PSJA School Based Health Center and the ECISD School Based Health Center) within the DHR Health System definition provides screenings for various cancers such as cervical, colorectal, and breast.  The system will provide education, referral services, or disease management depending on the results of the screening.  ","Referral and follow-up processes for patients determined to have or in risk of developing cancer","Referral and follow-up protocols are being assessed to determine the effectiveness of patient communication and service turnaround"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","As DHR Health continues to provide important patient care services  in both the inpatient and outpatient settings, it is important to take into consideration preventative measures to identify diseases at an early stage. This Core Activity is directly related to bundle C2, Primary Care Prevention – Cancer Screenings. DHR Health is improving the process for cancer screenings in primary care clinics by standardizing the process through electronic systems and hardwiring the referral process, connecting patients with the appropriate specialty care providers in a timely manner.","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",201,"Maternal and Infant Health Care","","Edit","Changes to Core Activity #5 reflect progress updates and additional details explaining efforts related to the Core Activity. The identified grouping, change idea, and description for Core Activity 5 remain the same.","Implement standard protocols for the leading causes of preventable death and complications","","The Maternal Fetal Medicine (MFM) program aims to increase access to maternal specialty services within the RHP 5 community.  MFM, prior to the waiver, was a rare specialty in the community, forcing the community Obstetrics/Gynecological (OB/GYN) physicians to manage their own high-risk patients, or refer them outside of the region.  This project and Core Activity closely aligns itself with the Women’s Hospital at Renaissance (WHR), ensuring that proper resources are utilized to manage the patient and drive quality outcomes.  \n\nOutcomes in this initiative are driven by evidenced-based protocols that include: \n1. Determining the delivery method (vaginal vs. C-section) according to the patient’s risk factors\n2. Ensuring that antenatal steroids are provided, and \n3. Providing insight on OB hemorrhage improvement metrics\n","A process for ensuring patient receives steroids and determining what method of delivery will be pursued (vaginal vs. C-section).","Constant review of antenatal steroid metrics and C-section rates as it pertains to the MFM patient population to determine if better cross communication can be obtained regarding delivery of management of services."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Women’s Hospital at Renaissance (WHR) is the largest birthing center in RHP 5 and one of the largest in the state of Texas. MFM, in collaboration with WHR and the surrounding OB/GYN community, participate in monthly committees to observe outcomes and determine areas of opportunities.  With the presence of MFM within the committee, an increased level of expertise is leveraged to support high-risk pregnancies.  These factors include ensuring that antenatal steroids are received (E2-151) and that a C-section is utilized only when evidence supporting need is present (E2-150).  Through close collaboration with a panel of specialists including neonatologists, pediatric cardiologists, and MFM physicians, standards and protocols are developed to promote the best possible outcomes.","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_160709501","160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private",202,"Chronic Care Management","","Edit","Changes to Core Activity #6 reflect progress updates and Core Activity description updates. The identified grouping, change idea, and related measures remain the same.","Utilization of evidence‐based care management models for patients with complex needs","","The core activity is centered on the establishment of a pediatric multispecialty clinic utilizing multiple specialists to manage pediatric chronic conditions including Asthma. In doing so, specialists will provide more patient-centric care, reducing travel and time burdens associated with having multiple specialist visits. Lastly, coupling this with coordination of care for primary care physicians and various care settings, this core activity will aim to improve outcomes, reduce ED utilization and unnecessary hospitalizations for Asthma patients.","Improved care coordination with primary and specialist physicians, ancillary services and various care settings  ","Through the establishment of a pediatric multispecialty clinic, patients will see multiple providers within the same setting, promoting care management discussions with primary care physicians and specialists. Additionally, through care coordination, patients will be guided in their condition management and triage episodes of care to the appropriate care settings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4","DHR Health continues to increase the quality and scope of care services for the pediatric patients of the RHP5. This Core Activity is directly related to bundle D4, Pediatric Chronic Disease Management: Asthma. To reduce unnecessary acute and emergency care utilization for asthma and related respiratory illnesses of the pediatric population, DHR Health has brought in a pediatric pulmonologist, delivering care in the outpatient setting. Through the utilization of evidence-based care management, the provider care team will be able to provide preventative care services, such as annual check-ups and individual treatment plans, to address complications brought on by asthma.\n","No","","160709501.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_343698201","343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",203,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","The SOM expects to increase screenings in order to promote early disease detection and to provide guidance regarding follow up treatments and services.","Educate patients regarding benefits of screenings and preventive care","Schedule more mobile clinic outings to make care more accessible"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2; C1","This Core Activity promotes an increase in screenings and the importance of preventive care.  Primary Care screenings such as for tobacco use and Influenza, as well as for cancers, can be promoted while guiding patients towards healthier lifestyle choices.","No","","343698201.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_343698201","343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",204,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","The SOM expects to continue expension of specialty care services as clinical departments build their faculty base and new clinics are opened in the underserved Rio Grande Valley.","Increase the number of specialty providers by hiring more SOM faculty","Develop specialty fellowships to attract and retain more providers"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4; H1","This Core Activity focuses on expanding specialty care services, such as pediatric and mental health specialists, by attracting and retaining more providers in this region.","No","","343698201.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 05_DY9-10 Regional Tracker - FINAL Tracker.xlsb","5_343698201","343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",205,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of mobile clinics that can provide access to BH care","","The SOM expects to increase mental health screenings via mobile clinics in order to promote and provide higher levels of behavioral health services in remote and impoverished areas in the Rio Grande Valley.","Increase use of mobile clinic to provide more access in underserved areas","Schedule more mobile clinic outings to make care more accessable"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","This Core Activity impacts the selected Bundle as the SOM strives to increase access to mental health services by increasing behavioral health screenings and follow up care in both clinical and mobile clinic settings.","No","","343698201.7.1","JJ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JJ",null,null,null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of mobile clinics that can provide access to BH care in very remote, inaccessible, or impoverished areas of Texas","CA-9","CA-9.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_020844901","020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private",218,"Maternal and Infant Health Care","","Edit","CHRISTUS Santa Rosa (CSR) made great progress between DY7 to DY8 and therefore has updated several of the change ideas to reflect the activity that it is currently focused on as part of this Core Activity.  The following is a summary of what was changed: 1) Updated the Change Idea for Driver #1; 2) Updated the Change Idea for Driver #2; 3) Updated the Change Idea for Driver #3; 4) Update all three Change Ideas for Driver #4; and 5) Deleted a Secondary Driver that was removed during DY7 reporting.","Implement standard protocols for the leading causes of preventable death and complications","","CHRISTUS Santa Rosa Health System will develop a standard protocol to be implemented at Santa Rosa Hospital  Westover Hills and CHRISTUS Santa Rosa Hospital  New Braunfels. The protocol will take into account the specific populations served by the Westover Hills and New Braunfels campuses. Santa Rosa will also collaborate with its sister organization, Children's Hospital of San Antonio (CHOSA), to determine best practices to include in the protocol and to incorporate lessons learned at the CHOSA campus as well.","Early recognition of hemorrhage in the pregnant patient          ","Utilize drills and simulation to ensure proficiency in assigning hemorrhage risk and response to maternal hemorrhage. This change idea is designed to supplement the nurses’ annual review, identify opportunities for improvement and ensure there is a clear understanding of role responsibilities during an actual event."," "," "," "," ","Address lack of adequate prenatal care.    ","Educate all Women’s Services Associates and Providers on the Severe Hypertensive bundle to evaluate and respond appropriately to the signs and symptoms of hypertension and pre-eclampsia"," "," "," "," ","Reduce unnecessary elective deliveries prior to 39 weeks","Ensure that providers are educated and following processes to utilize algorithm requiring Physician Department Chair and Women’s Services Director approval prior to scheduling elective deliveries. Infants born at 37 weeks of gestation do not fare as well as infants born at 39 weeks of gestation and have higher rates of short-term complications.  Additionally, women who have had prior cesarean deliveries are at higher risk for uterine rupture. This change idea is designed to reduce elective inductions which will help to reduce the risk and need for additional cesareans.  "," "," "," "," ","Timely intervention of the hemorrahage in the pregnant patient","Implement code for Mass Transfusion Protocol (MPT) at each of Santa Rosa’s campuses. ","Maintain and improve a drill team to ensure regular drilling of the post-partum hemorrhage process. This change idea is designed to ensure that Santa Rosa’s providers are trained to timely intervene when hemorrhage is present.","Educate providers regarding Obstetrical Hemorrhage Protocol and ensure processes are followed to timely intervene in post-partum hemorrhage cases "," "," ","",null,"",""," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","The objective of the selected measure bundle is to improve maternal safety and reduce maternal morbidity through data driven interventions to prevent and manage obstetric hemorrhage. This core activity involves the development and use of a standardized approach for dealing with early elective deliveries, hemorrhages, preeclampsia with a major focus on supporting vaginal births over primary cesareans.  Having a standardized approach will help ensure that Santa Rosa is successful in improving maternal safety and reducing maternal morbidity.","No","","020844901.7.1","KT","I propose (but have not made) the following changes (if the 2nd reviewer agrees with them, they will need to make them): \n\n1) Secondary Driver 2 currently reads as follows: \"Lack of prenatal care is a secondary driver to preeclampsia.\" I propose revising to read as follows: \"Address lack of adequate prenatal care.\"  \n\n2) Secondary Driver 3 currently reads as follows: \"Reducing the risk of uterine rupture will help to reduce unnecessary elective deliveries prior to 39 weeks.\" I propose revising to read as follows: \"Reduce unnecessary elective deliveries prior to 39 weeks.\"\n\nI actually made the following change:\n\n1) Deleted Secondary Driver 5: Change Idea 1, since provider deleted Secondary Driver 5.\n\nAssuming the 2nd Reviewer is OK with these changes, I have indicated in the \"HHSC Initial Comments to Provider\" field that these changes were made.  However, the 2nd Reviewer will need to review the proposed changes and if they agree, make those changes.\n","Y","NB","Agree with the changes. Made  changes that were not previously changed. Changed from Accepted to NMI.","Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. However, HHSC made the following changes:\n\n1) Secondary Driver 2 previously read as follows: \"Lack of prenatal care is a secondary driver to preeclampsia.\" HHSC revised it to read as follows: \"Address lack of adequate prenatal care.\"  \n\n2) Secondary Driver 3 previously read as follows: \"Reducing the risk of uterine rupture will help to reduce unnecessary elective deliveries prior to 39 weeks.\" HHSC revised it to read as follows: \"Reduce unnecessary elective deliveries prior to 39 weeks.\"\n\n3) HHSC deleted Secondary Driver 5: Change Idea 1, since provider deleted Secondary Driver 5.\n\nIf the provider disagrees with any of these changes, please provide an explanation in the \"Provider Response\" column.","Provider agrees with HHSC’s changes","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_020844901","020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private",219,"Prevention and Wellness","Implementation of UP Campaign at each campus.","Delete","The Core Activity was not deleted.  CHRISTUS Santa Rosa was not able to update the Grouping in the template, so it deleted the old one and then created a new core activity.  The Grouping was updated to \"Hospital Safety and Quality\" and the Name was updated to \"Implementation of evidence-based practices to improve quality of care (e.g. Quality Departments, monitoring and evaluation\".  In addition, CHRISTUS Santa Rosa (CSR) made great progress between DY7 to DY8 and therefore has updated several of the change ideas to reflect the activity that it is currently focused on as part of this Core Activity.  The following is a summary of what was changed:  1) Updated the Change Idea for Driver #1; Updated the Change Idea for Driver #2; 3) Updated all three Change Ideas for Driver #3; and 4) Deleted two Secondary Drivers that have been completed and are no longer relevant to this core activity:  Reduction of Length of Stay and Address the Opioid Epidemic by Offering Alternative Pain Management.","Other","","Through its participation in the Hospital Improvement Innovation Network, CHRISTUS Santa Rosa will implement the UP Campaign, which designed to prevent over sedation, mobilize patients, hardwire hand hygiene and optimize inpatient medications.","Reducing adverse drug events","Maintain and improve the multi-disciplinary pain management team to continue providing tools for the healthcare team that aid in reducing adverse drug events, such as over-sedation."," "," "," "," ","Prevent Hospital Acquired Pressure Ulcers                                            ","Encourage patient turning every two hours through turning schedules and getting patients up and moving as often as possible."," "," "," "," ","Prevent Hospital Acquired Infections                                                                 ","Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections.","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance. "," "," ","","",""," "," "," ","",null,"",""," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The objective of this measure bundle is to improve patient health outcomes and experience of care by reducing the risk of health-care associated infections, and reducinig hospital errors. This core activity involves the implementation of a campaign that is designed to \"simplify safe care, streamline interventions, reduce multiple forms of harm with simple easy-to-accomplish activities, and consolidate basic interventions\" that target several areas aimed at decreasing harm.  There are four components to this campaign:  1) WAKE-UP - Prevent over-sedation; 2) GET-UP - Mobilize patients; 3) SOAP-UP - Hardwire hand hygiene; and 5) SCRIPT UP - optimize inpatient medications.","No","","020844901.7.1","KT","Provider was not able to update the Core Activity Grouping for this core activity in the Provider Template, so they \"deleted\" it and created a \"new\" core activity that reflects the appropriate Core Activity Grouping to replace it.","Y","NB","In agreement","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-7","CA-7.9"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_020844901","020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private",694,"Hospital Safety and Quality","","New","","Implementation of evidence-based practices to improve quality of care","","Through its participation in the Hospital Improvement Innovation Network, CHRISTUS Santa Rosa will implement the UP Campaign, which designed to prevent over sedation, mobilize patients, hardwire hand hygiene and optimize inpatient medications.","Reducing adverse drug events                                                                             ","Maintain and improve the multi-disciplinary pain management team to continue providing tools for the healthcare team that aid in reducing adverse drug events, such as over-sedation.","","","","","Prevent Hospital Acquired Pressure Ulcers                                                           ","Encourage patient turning every two hours through turning schedules and getting patients up and moving as often as possible.","","","","","Prevent Hospital Acquired Infections                                                                              ","Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections.","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance. ","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The objective of this measure bundle is to improve patient health outcomes and experience of care by reducing the risk of health-care associated infections, and reducinig hospital errors. This core activity involves the implementation of a campaign that is designed to \"simplify safe care, streamline interventions, reduce multiple forms of harm with simple easy-to-accomplish activities, and consolidate basic interventions\" that target several areas aimed at decreasing harm.  There are four components to this campaign:  1) WAKE-UP - Prevent over-sedation; 2) GET-UP - Mobilize patients; 3) SOAP-UP - Hardwire hand hygiene; and 5) SCRIPT UP - optimize inpatient medications.","No","","020844901.7.1","KT","Secondary Driver 3: Change Idea 1 - Recommend deleting all but the first sentence. Assuming the 2nd Reviewer is OK with this change, I have indicated in the \"HHSC Initial Comments to Provider\" field that the change was made.  However, the 2nd Reviewer will need to review the suggested change to confirm they agree, and if so, make the suggested change.","Y","NB","decided to leave as is. Updated response to provider.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC understands that this Core Activity is a replaced for the Core Activity which previously was under Prevention and Wellness. ",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_020844903","020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private",220,"Maternal and Infant Health Care","","Edit","A great deal of progress was made since DY7 reporting, so CHofSA updated several of the change ideas to reflect the activity that it is currently focused on as part of this Core Activity. The following is a summary of what was changed:  1) Updated the Change Idea for Secondary Driver #1; 2) Updated the Change Idea for Secondary Driver #2; 3) Updated the Change Idea for Secondary Driver #3; 4) Updated all 3 Change Ideas for Secondary Driver #4; and 5) Removed a Secondary Driver that was deleted during DY7.","Implement standard protocols for the leading causes of preventable death and complications","","The Children's Hospital of San Antonio (CHofSA) will develop a standard protocol to be implemented at CHofSA. To incorporate as much knowledge as possible into the protocol, CHofSA will collaborate with its sister organization, CHRISTUS Santa Rosa Health System, to determine the best practices to be included in the protocol.","Address lack of adequate prenatal care","Update and expand educational programs in place for physician offices and health departments of prenatal care through the expansion of Maternal Fetal Medicine Clinics (MFMs), pursuit of Maternal Levels of Care Designation and exploring additional opportunities for growth through the TexasAIM cohort. This change idea is designed to improve provider training and education, which will address lack of adequate prenatal care in CHofSA’s community."," "," "," "," ","Reduce unnecessary elective deliveries prior to 39 weeks","Ensure that providers are educated and following processes to utilize algorithm requiring OB in Chief and Women’s Services Director approval prior to scheduling elective deliveries.  Infants born at 37 weeks of gestation do not fare as well as infants born at 39 weeks of gestation and have higher rates of short-term complications.  Additionally, women who have had prior cesarean deliveries are at higher risk for uterine rupture. This change idea is designed to reduce elective inductions which will help to reduce the risk and need for additional cesareans.  "," "," "," "," ","Early recognition of hemorrhage                                                                                                                    ","Ensure nursing and physicians have access to education on early recognition of hemorrhage.  This change idea is designed to boost the skill sets of physicians and nurses and to improve CHofSA’s OB Hemorrhage Patient Safety Measure."," "," "," "," ","Timely intervention of the hemorrhage                                                                                              ","Maintain and improve the post-partum hemorrhage code (“Mass Transfusion Protocol”) to notify all providers needed in post-partum hemorrhage cases. The MTP is a component of the Hemorrhage code. Early recognition and intervention is key to preventing worsening hemorrhage. The MTP is activated if the patient has dire need of multiple transfusions."," Implement and maintain a drill team to ensure regular drilling of the post-partum hemorrhage process. This change idea is designed to ensure that CHofSA’s providers are trained to timely recognize and  intervene when hemorrhage is present."," Provide ongoing education to providers regarding Obstetrical Hemorrhage Protocol and ensure processes are followed to timely intervene in post-partum hemorrhage cases. "," "," ","",null,"",""," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","The objective of the selected measure bundle is to improve maternal safety and reduce maternal morbidity through data driven interventions to prevent and manage obstetric hemorrhage. This core activity involves the development and use of a standardized approach for dealing with early elective deliveries, hemorrhages, preeclampsia with a major focus on supporting vaginal births over primary cesareans.  Having a standardized approach will help ensure that Children's Hospital of San Antonio is successful in improving maternal safety and reducing maternal morbidity.","No","","020844903.7.1","KT","I propose (but have not made) the following changes (if the 2nd reviewer agrees with them, they will need to make them): \n\n1) Sec ondary Driver 1 currently reads as follows: \"Lack of prenatal care.\"   I propose revising to read as follows: \"Address lack of adequate prenatal care.\"\n\n2) Secondary Driver 2 currently reads as follows: \"Reducing the risk of uterine rupture will help to reduce unnecessary elective deliveries prior to 39 weeks.\"  I propose revising to read as follows: \"Reduce unnecessary elective deliveries prior to 39 weeks.\"\n\nI actually made the following change:\n\n1) Deleted Secondary Driver 5: Change Idea 1, since provider deleted Secondary Driver 5.\n\nAssuming the 2nd Reviewer is OK with these changes, I have indicated in the \"HHSC Initial Comments to Provider\" field that these changes were made.  However, the 2nd Reviewer will need to review the proposed changes and if they agree, make those changes.","Y","NB","Agree with suggestions and made changes","Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. However, HHSC made the following changes:\n\n1) Secondary Driver 1 previously read as follows: \"Lack of prenatal care.\"   HHSC revised to read as follows: \"Address lack of adequate prenatal care.\"\n\n2) Secondary Driver 2 previously read as follows: \"Reducing the risk of uterine rupture will help to reduce unnecessary elective deliveries prior to 39 weeks.\" HHSC revised to read as follows: \"Reduce unnecessary elective deliveries prior to 39 weeks.\"\n\n3) HHSC deleted Secondary Driver 5: Change Idea 1, since provider deleted Secondary Driver 5.\n\nIf the provider disagrees with any of these changes, please provide an explanation in the \"Provider Response\" column.","Provider agrees with HHSC’s changes","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_020844903","020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private",221,"Hospital Safety and Quality","","Edit","A great deal of progress was made since DY7 reporting, so CHofSA updated several of the change ideas to reflect the activity that it is currently focused on as part of this Core Activity. The changes that were made are as follows:  1) Removed the change idea from Driver #1 that was removed during DY7 reporting and updated the remaining change idea; 2) Updated Change Idea #1 and added a new Change Idea to Driver #2; 3) Updated all three Change Ideas for Driver #3; and 4) Deleted two secondary drivers that have been completed and are no longer relevant to this core activity:  Reduction of Length of Stay and Address the Opioid Epidemic by Offering Alternative Pain Management.  Additionally, CHofSA updated the Grouping of this Core Activity to be \"Hospital Safety and Quality\" and selected \"Implementation of evidenced-based practices to improve quality of care (e.g. Quality Departments, monitoring and evaluation, etc.).","Implementation of evidence-based practices to improve quality of care","","Through its participation in the Hospital Improvement Innovation Network, Children's Hospital of San Antonio will implement the UP Campaign, which is designed to prevent over-sedation, mobilize patients, hardwire hand hygiene, and optimize inpatient medications.","Prevent Hospital Acquired Pressure Ulcers","Conduct regular reviews of nursing sensitive indicators and frequent skin assessments to identify high risk patients for Hospital acquired pressure ulcers. ",""," "," "," ","Reduce adverse drug events","Improve processes utilized by the multi-disciplinary team to identify tools to reduce adverse drug events"," "," "," "," ","Prevent Hospital Acquired Infections                                                                                    ","Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections. ","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance"," "," ","",null," "," "," "," ","",null,"",""," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3","The objective of this measure bundle is to improve patient health outcomes and experience of care by reducing risk of health-care associated infections, and reducing hospital errors.  This core activity involves the implementation of a campaign that is designed to \"simplify safe care, streamline interventions, reduce multiple forms of harm with simple easy-to accomplish activities, and consolidate basic interventions\" that target several areas aimed at decreasing harm.  There are four components to this campaign:  1) WAKE-UP - Prevent over-sedation; 2) GET-UP - Mobilize patients; 3) SOAP-UP - Hardwire hand hygiene; and 5) SCRIPT-UP - optimize inpatient medications.","No","","020844903.7.1","KT","The \"Notes for the RHP Plan Update Review Team (optional)\" field of the \"DY8Rd2_Core Activities\" file states the following: \"Please see if Other can be moved on the menu. See the note from the October review: This has same core activity title and activities as the core activities for Christus Santa Rosa Hospital (TPI 020844901) but this one is under the Hospital Safety Core Activity Grouping, and the other is under Prevention and Wellness. Both look like they were approved that way in DY7, so not sure it is a problem but wanted to raise it as an inconsistency.\"  These issues have been resolved.\n\nSecondary Driver 3: Change Idea 1 - Recommend deleting all but the first sentence. \n\nProvider deleted Secondary Driver 4 but did not delete Secondary Driver 4: Change Idea 1, so I deleted it.\n\nProvider deleted Secondary Driver 5 but did not delete Secondary Driver 5: Change Idea 1, so I deleted it.\n\nAssuming the 2nd Reviewer is OK with these changes, I have indicated in the \"HHSC Initial Comments to Provider\" field that these changes were made.  However, the 2nd Reviewer will need to review the suggested change to Secondary Driver 3: Change Idea 1 to confirm they agree, and if so, make the suggested change.\n\n","Y","NB","Secondary Driver 3: Change Idea 1 - Recommend deleting all but the first sentence. NB did not make any changes to this. \nThe rest is OK>, but changed to NMI","Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted.  HHSC  deleted Secondary Driver 4: Change Idea 1 and Secondary Driver 5: Change Idea 1 because the provider deleted Secondary Drivers 4 and 5. If the provider disagrees with the changes, please provide an explanation in the \"Provider Response\" column.","Provider agrees with HHSC’s changes","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",209,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Develop patient advocacy strategies to care for and provide education and information for Diabetes patients, age 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes, Type 1 or 2, during the measurement year or the year prior to the measurment year to determine patients.  Use preventative measure protocols to ensure adherence to prescribed care of diabetes patients for associated screening/testing performed during the measurement year.","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.","Population Health Management Team will conduct pre-visit chart review using the diabetes registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for diabetes care and maintenance.","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review diabetes care gaps."," "," ","Manage a targeted population of diabetes patients that are at high risk for developing complications, co-morbidities, and have a history or potential high utilization of acute and emergency services.","Using a diabetes registry built in the electronic medical health record, identify and contact patients with gaps in care for diabetes screenings and/or follow up care.","Provide diabetes self-management education to engage patients as health care partners in identifying risk factors by self-monitoring of foot health, glucose, and blood pressure.","Use diabetes registry information to identify social determinants that contribute to poorly controlled diabetes","Work collaboratively to develop practice wide standard work protocols for Diabetes Care Management."," ","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for closing diabetes care gaps: eye exam, foot exam, A1C, blood pressure, BMI.","Create standard work processes for diabetes bundle measure that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1","This core activity will engage and provide education to patients about required screening/testing associated with Diabetes control and maintenance, ensure associated exams conducted as necessary and follow up care is ongoing, and that patients self-manage and maintain regular visits with physician to avoid unnecessary emergecy department visits.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",210,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","With a focus on prevention, manage a targeted population of patients >18 to determine and monitor preventative measures and protocols for Tobacco use and Cessation Intevention, BMI Screening and Follow Up, and Comprehensive Diabetes Care.","Using care gap registry built in electronic health medical record, identify and educate patients with a BMI out of range (Normal Parameters:  Age 65 years and older BMI >= 23 and < 30 Age 18  64 years BMI >= 18.5 and < 25), patients identified as tobaco users, and patients who received HbA1c testing during the measurement year.","Provide patient with self-management education to engage patients as health care partners in identifying risk factors for those with out of range BMI, A1C, or tobacco use.","Practices will review use of tobacco (of any type) from patient  social history (via the report) and determine if intervention was performed if positive for tobacco use.","Determine percentage of patients who received intervention if positive for tobacco use","Practices will review to determine if last Hgb A1c measurment was documented within the past year and determine percentage of patients who received an HbA1c."," ","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for identifying, monitoring, and caring for patients with out of range BMI, A1C, or use tobacco.","Create standard work processes for preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," ","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management.","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review preventative measures in the prevention of heart disease, diabetes, and effects of tobacco use."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","This core activity will engage and provide education to patients about preventative screenings and testings that will aid them in self-care and maintance of disease, thus promoting healthy Texans.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",211,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","With a focus on prevention, follow up, and documentation, educate and offer provisions for patients to obtain critical vaccinations and screenings to avoid preventable illness/disease.","Using patient care gap registry built in electronic medical health record and the SAIRS registry, identify patients who may be due for Pneumonia, Influenza HPV vaccinations or Chlamydia screening.","Using patient data, identify, contact, confirm patients who may qualify for immunizations/screening.","Proactively attempt to obtain and record out medical records for immunizations or screenings received outside UT Health."," "," "," ","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide preventative education related to immunizations and screenings.","Population Health Management Team will follow up with post visit activities to ensure patient received immunizations, provided outside records, or completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review immunization and screening status."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","Providing UT Health patients with information and education about the importance of receiving recommended immunizations and screenings promotes Healthy Texans, will improve the overall health of our population, decrease illness and spread of disease, and reduce cost of care.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",212,"Chronic Care Management","","Edit","Removed \"NMI:\" notations in the relevant fields. These were added during a previous reporting cycle.                                                           ","Utilization of care management and/or chronic care management services","","Develop patient advocacy strategies in Chronic Care Management practices and education for cardiovascular disease screening and prevention by reviewing identified patients, age 18-85.  Use preventative measure protocols to ensure adherence to prescribed care of Cardiovascular Disease patients for associated screening/testing performed during the measurement year.","Manage a targeted population of patients with a blood pressure outside of the goal (<140/90), and monitor those on statin therapy that are at high risk for developing complications or co-morbidities, thus reducing heart failure admission rate and reducing the rate of Emergency Department visits for CHF, Angina, and Hypertension.","Using a patient registry built in the electronic medical health record, identify and contact patients that have had a blood pressure that is out of goal range or is on statin therapy\t\t\t\t\t\t","Provide hypertension self-management education to engage patients as health care partners in identifying risk factors of heart disease. \t\t\t\t\t\t","Create the ability for a patient to self monitor and report blood pressrue readings in My Chart, a secured patient portal with results directly forwarded to primary care physician.\t\t\t\t\t"," "," ","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for closing heart disease care gaps \t\t\t\t\t\t\n","Create standard work processes for heart disease bundle measure that will be assigned, worked and validated by a designated primary care clinical practice. \t\t\t\t\t\t\n","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices.  \t\t\t\t\t\t\n"," "," "," ","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.  \t\t\t\t\t\t","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management \t\t\t\t\t\t\n","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.\t\t\t\t\t\t\n","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Practice Team to review patient status for upcoming appointments and review heart disease care gaps   \t\t\t\t\t\t\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","This core activity will engage and provide education to patients about Heart/Cardiovascular Disease to ensuring associated exams and medication regimens are consistent and follow up care is ongoing.  These preventative measures and protocols will assist to reduce heart failure admission rate and Emergency Department visits.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",213,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","This core activity promotes identification and follow up of clinical depression diagnosis.  In addition, it promotes the relationship and integration of Primary Care and Behavioral Health services to our patients.","Utilize PHQ 2 screning tool at every visit and PHQ 9 screening tool when warranted to determine a diagnosis of clinical depression and care plan for diagnosis.","Through our EMR, EPIC, utilize a PHQ-2, which progresses to PHQ-9 if score is greater than 0","PCP provided counseling, will re-assess next visit; PCP provided medication adjustment/consult, will re-assess next visit; referral to BHC; refer to PCC Psychiatry; Refer to external Psychiatry; Refer to external Psychotherapy;","To identify remission at 6 months, track patients with a diagnosis of MDD or dysthymia AND initial PHQ-9 score 10+","Consult with Primary Care Physician to make follow up calls to patients."," ","Determine care plan for patients diagnosed with PHQ9 <9","Create behavioral health professional standard work to follow up 2x per month"," "," "," "," ","Identify patients whose behavioral health is not in remission","Create standard work process for behavioral health professionals to manage and change course for treatment  that is not improving condition of the patient.","Create standard work process and training of all clinical staff for identification and management of suicide risk."," "," "," ","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for identification and management of behavioral health conditions.","Create standard work processes for behaviroal health preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," ","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient or clinic regarding PHQ2 and PHQ9 screenings and follow up actions based on results.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for behavioral health screenings and follow up care plan."," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","This core activity promotes, not only the physical health of our patients, but also identifies emotional and psychological health.  In addition, it promotes the relationship and integration of Primary Care and Behavioral Health services to our patients.","No","","085144601.7.1","KT","The \"Notes for the RHP Plan Update Review Team (optional)\" field of the \"DY8Rd2_Core Activities\" file states the following: \"Please evaluate if tie to Cat C needs to be updated. See note from October review: Provider said core activity affects H3 Measure Bundle, which is Chronic Non-Malignant Pain Management, but I think they meant H4: Integrated Care for People with SMI, as there was no discussion of pain management in their descriptions. It does look like they also put H3 for DY7, so maybe it was already approved?\"  Provider changed the \"Measure Bundles or Measures Impacted\" field to H1: Integration of Behavioral Health in a Primary or Specialty Care Setting, which fits with the core activity description so I believe this concern has been addressed.","N",null,"OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",214,"Access to Primary Care Services","","Edit","Removed \"NMI:\" notations in the relevant fields. These were added during a previous reporting cycle.                                                           ","Provision of screening and follow up services","","With a focus on prevention, follow up, and documentation, educate and offer provisions for patients to obtain critical screenings to avoid preventable disease and promote early detection of cancer and other disease.\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy\t\t\t\t\t\n","Identify patients:  Women 21-64 who have a cervix and have not had cervical cytology in the last 3 years or co-testing in the past 5 year\t\t\n","Identify patients:  50-75 years of age who have not had:                                                                                               -Fecal occult blood test (FOBT) during the measurement year. \n- Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n- Colonoscopy during the measurement year or the nine years prior to the measurement year.\t\t\t\t\t\n","Identify patients: Women 50-74 who have breasts and have not had a mammogram ( no time period is specified\t\t\t\t\n"," "," ","Using care gap registry built in electronic medical health record, identify patients that are in need of critical screenings or have had screening with no follow up documented\t\t\t\t","Create standard work processes for preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.\t\t\t\t\t\t\n"," "," "," "," ","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan to promote critical and prevenative cancer screenin]\t\t\t\t\t\t\n","Population Health Management Team will follow up with post visit activities to ensure follow up appointments scheduled and attended, outside records provided, screenings completed, determine understanding of visit instructions, and next steps for their care plan.\t\t\t\t\t\t\n","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Practice Team to review patient status for the completion of preventative cancer screenin. \t\t\t\t\t\t\n","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management\t\t\t\t\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Identifying and offering provision of critical screenings will assist in the early detection and overall care of cancer, thus improving quality of life for patients and their families as well as reduce overall cost of care for these types of cancers.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",215,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Removed \"NMI:\" notations in the relevant fields. These were added during a previous reporting cycle.                                                           ","Utilization of Care Management function that integrates primary and behavioral health","","Identify and counsel patients, aged 18 years and older, who were determined to be an unhealthy alcohol user at least once within the last 24 months.        ","Screen all patients, aged 18 years and older for unhealthy alcohol use with systematic method, at every visit. \t\t\t\t\t\t\n","If score of 4 or more (men) or 3 or more (women), discuss and gauge readiness to change drinking habits.\t\t\t\t\t\t\n","If readiness is not determined, indicate that's okay and if they change their minds, we have resources to help (provide written info).  If readiness is determined, provide information on available resources to help (provide written info); Alert PCP.\t\t\t\t\t\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","Determining and offering counseling for unhealthy use of alcohol leads to the potential prevention of alcoholism and diseases and cost of care associated with alcoholism.","No","","085144601.7.1","KT","May want to consider combining this core activity with the core activity below related to ADHD. Requesting second review.","Y","NB","We could but they have only 2 CA like this that deal with different populations and different activities so I am OK with keeping them separately.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",216,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Removed \"NMI:\" notations in the relevant fields. These were added during a previous reporting cycle.                                                           ","Utilization of Care Management function that integrates primary and behavioral health","","Identify the presence of ADHD symptoms, followed by physician collaboration and counseling in an effort to assist and determine best care and treatment for child and family as well as recommendation for school.","Work collaboratively with Primary Care and Behavioral Health to determine symptoms, level of impairment, other psychiatric disorders, and child's strengths in coping\t\t\t\t\t\t\n","Conduct diagnostic interviews with patient and parents\t\t\t\t\t\t\n","Conduct physical exam of child along with review of psychological and lab tests\t\t\t\t\t\t\n","Use parent and teacher rating scale to further assess the presence of ADHD\t\t\t\t\t\t\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","By collaborating Primary Care and Behavior Health to identify the presence of ADHD symptoms, care plan, treatment can be implemented to create positive Quality of Life for child, parents, and educational experience. ","No","","085144601.7.1","KT","May want to consider combining this core activity with the core activity above related to alcohol use. Requesting second review.","Y","NB","We could but they have only 2 CA like this that deal with different populations and different activities so I am OK with keeping them separately.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_085144601","085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",217,"Substance Use Disorder","","Delete","Our MPT has decreased and we will now prioritize our efforts on achieving the remaining 5 bundles. We will continue to sustain our efforts to improve mental health care but will no longer report them through DSRIP.","Utilization of Prescription Drug Monitoring program","","Determine patients, aged 12 years and older, screened for clinical depression with a diagnosis of chronic pain as well as assessment and monitoring of pain medications.","Monitoring and follow up of pain medication use, documentation, pain assessment and follow up, and Opioid Therapy evaluation and follow up.","Screen for depression and address positive screens using PHQ2 and 9.","Inquire about pain score and document plan of action for results","Eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"","With an Opioid Epidemic in America, evaluating and documentation of pain medication use by an eligible professional is key in prevention and misuse/abuse of controlled substances and potential illness and death.","No","","085144601.7.1","KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Utilization of Prescription Drug Monitoring program (can include targeted communications campaign)","CA-10","CA-10.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_091308902","091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public",222,"Prevention and Wellness","","Delete","The reason that this Core Activity is being discontinued for DY9 – DY10 is because the measure associated with the Core Activity is being dropped by the provider.","Implementation of interventions focusing on social determinants of health","","Implement community based approaches to reduce the risk of violence and/or recidivism amongst individuals who are considered high risk of offending or re-offending.","Establish effective relationships/communication with program clients.","Establish weekly contact with program clients to document progress towards improved social well-being and address ongoing concerns and challenges."," "," "," "," ","Identify client barriers that accelerate encounters with law enforcement and establish alternatives by connecting the client with community resources.","Develop a standardized list of community resources that can be made available to clients for addressing social determinants of health."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"","By identifying client barriers that accelerate encounters with law enforcement and establishing ongoing connections with clients, staff will be able to connect clients with resources to eliminate such barriers in an effort to reduce the number of preventable admissions and readmissions to criminal justice settings amongst individuals who are considered high risk of offending or re-offending.","No","","091308902.7.1","KT","Provider is requesting to delete L1-241. However, this request is being NMI'ed. If the request is ultimately denied, presumably the provider will need to continue this core activity.","Y","NB","In agreement","Needs More Information","Each measure needs to have a core activity tied to it. Provider has requested to delete L1-241, but is receiving an NMI for this request. If the request is approved, provider may delete this core activity. If the request is not approved, provider will need to maintain this core activity or implement a new core activity that is tied to the measure.","If the request is not approved, Metro Health will continue to maintain this core activity or implement a new core activity that is tied to the measure.","KT","Provider is requesting to delete this core activity as well as the measure associated with it (L1-241). The \"HHSC Final Decision\" and \"HHSC Final Comments to Provider\" depend on the decision on whether the provider's request to discontinue L1-241 is approved.","Y","NB","L1-241 is approved for discontinuation. Accepting the deletion of this Core Activity since this provider has several other ones.","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_091308902","091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public",223,"Prevention and Wellness","","Edit","The reason that this Core Activity is being edited for DY9 – DY10 is because the provider is adding two more sexually transmitted disease measures L1-343 and L1-245.","Implementation of evidence based strategies to reduce sexually transmitted diseases","","Metro Healths STD/HIV program operates a walk in clinic and mobile health unit which fully functions as an extension of the clinic in community settings during non-traditional hours.  It allows the provision of screening and treatment to high risk populations in non-traditional settings such as the local homeless shelter, local bars and other congregate settings.","Increase the utilization of mobile clinics to enhance access to services.","Utilize Metro Health's Mobile Health Unit to provide sexual health screenings, education and on the spot treatment for patients at high risk of contracting and/or spreading sexually transmitted infections.","Develop a routine testing schedule based on incidence rates of STD/HIV in Bexar County and ensure schedule is easily accessible to the public."," "," "," ","Provision of follow up services for individuals at risk of re-infection for Syphilis and un-complicated Gonorrhea.","Establish a standardized clinic protocol for conducting follow up calls to remind individuals who have tested positive for and were treated for Gonorrhea and primary or secondary Syphilis to return for follow up testing at the recommended intervals."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-344; L1-280; L1-346; L1-343; L1-345","Community access to the mobile clinic in established locations at frequent intervals will enable testing and treatment for primary/secondary syphilis and gonorrhea as well as increase screening for chlamydia in women ages 16-24.  The implementation of non-traditional hours will extend services to portions of the population not previously reached. Heat maps will also enable the Mobile Outreach Team to develop and advertise a schedule of services that is accessible to the public by reducing barriers to coming into a traditional clinic facility such as transportation, child care and hours of operation.","No","","091308902.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence based strategies to reduce sexually transmitted diseases.","CA-7","CA-7.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_091308902","091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public",224,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","Metro Health clinic staff within the TB and STD/HIV clinics will screen patients to identify smoker status and provide tobacco cessation education/resources for individuals who identify as tobacco users.","Screen clients for tobacco use and identify individuals who are tobacco users who require tobacco education/resources.","Implement a standardized screening tool for Metro Health clinics."," "," "," "," ","Establish appropriate referral networks for tobacco cessation services for adolescents and adults who identify as tobacco users.","Develop provider materials to be distributed at clinics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-105; L1-400","By establishing a consistent protocol for tobacco screening within Metro Health clinics, clinic staff will be able to determine the smoker status of adolescents and adults and provide education and/or referrals for tobacco cessation services.","No","","091308902.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_091308902","091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public",225,"Expansion or Enhancement of Oral Health Services","","Continue","","Utilization of targeted dental intervention for underserved population in alternate setting","","Metro Health will provide limited oral health evaluations, sealants and fluoride varnish applications to vulnerable and underserved school aged children within school settings.  Services will include limited case management activities in order to assist families in connecting with a main dental home provider.","Improve access to dental services for children with unmet dental needs. ","Provide limited oral health evaluations, sealants and fluoride varnish applications to school aged children. "," "," "," "," ","Incorporate case management services for children identified as having urgent or unmet dental needs beyond the scope of the program.","Partner with Dental Managed Care organizations to help link families to a main dental home. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-225; L1-IT-7.6; L1-224; L1-231","Through these interventions, the department aims to reduce the number of children that have urgent dental needs, reduce the number of children that have untreated decay, identify children that are at elevated risk and apply fluoride and/or sealants and increase the proportion of children that receive sealants to at least one permanent first molar. By providing case management services to children with unmet/urgent dental care needs the program seeks to connect children to a dental home for treatment before decay progresses.","No","","091308902.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of targeted dental intervention for vulnerable and underserved population in alternate setting (e.g., mobile clinics, teledentistry, FQHC, etc.)","CA-3","CA-3.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_091308902","091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public",695,"Access to Primary Care Services","","New","","Provision of vaccinations to target population",null,"Metro Health clinic staff within the Immunizations clinics will screen patients to identify individuals who are in need of the flu vaccine.  A recommendation to be vaccinated will be made to any individual who is found not to be vaccinated for influenza.","Identify individuals who have not been vaccinated for influenza.","All patients who come to the clinic for immunizations services will be screened to determine if they have been immunized against influenza.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-269","This Core Activity will impact the selected measure in that going forward staff will be required to screen patients for having received the influenza vaccination and if found to not be immunized to provide a strong recommendation for all patients ages 6 months and older to be immunized.","No","","091308902.7.1","KT",null,"N",null,null,"Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Prevention and Wellness to Access to Primary Care Services. \n\nHHSC also revised provider’s Core Activity title by moving it from Other (Maximizing influenza vaccine uptake) to the area on the menu: Provision of vaccinations to target population. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". \n","Metro Health Agrees with the change.","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",226,"Access to Specialty Care Services","","Continue","","Use telemedicine/telehealth to deliver specialty services","","One of the goals of this program is to bring the best of acute diagnosis and treatment recommendations for Stroke and other telemedicine services to remote communities which often do not have specialists and the resources to provide the advanced medical treatment.  Approximately 18% of patients in rural community hospitals are transferred to San Antonio for specialty care that could be handled by rural hospitals with availability to specialists.   Methodist's TeleStroke Program.  Methodist is also considering expanding this program to include other specialities.","Timely delivery of tPA to eligible patients (delivery within 60 minutes of arrival).","Provide training programs and resource materials to \"Spoke\" facilities that their administration and medical staff can use to develop treatment protocols."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Although hospital safety is the primary focus of the J1 Bundle, its objectives also include improving patient outcomes and experience of care.   Interventions either through  the Telestroke program will provide patients with medical care as well as education about their condition, and provide information on lifestyle changes that will help to reduce risk.","No","","094154402.7.1","KT","The \"Notes for the RHP Plan Update Review Team (optional)\" field of the \"DY8Rd2_Core Activities\" file states the following: \"Please review if additionl measures selected by the provider can be tied to this CA. See October review ntoe: The only measures the provider said are impacted are Hospital Safety, and they specifically mentioned falls, but did not mention falls anywhere else. Seems like it could also impact B1-141: Risk Adjusted All-Cause 30-Day Readmission for Targeted Conditions and B1-217: Risk Adjusted All Cause Readmission.\" I agree that it seems like this core activity could impact other measure bundles selected by the provider. However, the provider only selected the following 3 measure bundles: J1 - Hospital Safety; H2 - Behavioral Health and Appropriate Utilization; and E2 - Maternal Safety.  And I don't think the core activity impacts the other 2 bundles. So I accepted it, but am requesting a second review to confirm.","Y","NB","thanks for looking into that. No further changes.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Use telemedicine/telehealth to deliver specialty services.","CA-2","CA-2.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",227,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of telehealth/telemedicine in delivering behavioral services","","The other goal is to provide timely consultations, diagnosis and treatment recommendations for Behavioral Health/Substance Abuse patients in Emergency rooms and Medical Acute floors at Methodist Hospital operating sites. There are not enough psychiatrists in the community to evaluate Behavioral Health/Substance Abuse patients in every Methodist Hospital Emergency Department or to consult on Behavioral Health/Substance Abuse patients who are admitted to the Methodist Hospital Acute Care facilities with Medical Conditions too.  Emergency Department physicians and Internal Medicine physicians are limited in their ability and comfort in treating psychiatric disorders.","Improve timeliness of treatment for Behavioral Health patients presenting in the Emergency Department.","Expand the Behavioral Health Assessment Referral Center capability to further improve throughput and timeliness of treatment."," "," "," "," ","Provide outpatient services for those patients who have not yet identified a permanent behavioral health provider.","Establish an outpatient transition clinic to provide post-discharge care for patients within seven days of discharge to bridge needed care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","Behavioral Health and Appropriate utilization is the focus of Measure Bundle H2.  Though the Behavioral Health Telemedicine Program, Methodist will provide more timely assessments to patients presenting to Methodist Emergency Departments, as well as to inpatients hospitalized for other medical conditions who may have Behavioral Health concerns.","No","","094154402.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",228,"Chronic Care Management","","Delete","","","",null,null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Activities undertaken along with the specific interventions and/or screenings included in this Measure Bundle will help Methodist achieve its goals of reducing morbidity rates and reducing readmission rates due to Coronary Heart Failure.  The improved communication processes noted above will also aid in the reduction of hospital errors, and will improve patient health outcomes and experience of care.","No","","094154402.7.1","KT","The Secondary Drivers and Change Ideas don't seem to support the Core Activity Grouping/ Name/ Description.  Provider indicates that the core activity is intended to impact Measure Bundle J1, so may want to consider combining with the Hospital Safety and Quality core activity.","Y","NB","agree but updated the response a little. ","Needs More Information","The Secondary Drivers and Change Ideas don't seem to support the Core Activity Grouping/ Name/ Description.  Provider indicates that the core activity is intended to impact Measure Bundle J1, so provider should indicate if appropriate to move the Secondary Drivers and Change Ideas from this core activity to the Hospital Safety and Quality core activity or provider needs to clarify if the Core Activity Grouping and title need to be updated or if Secondary drivers and/or change ideas need to be updated. Provider should include additional information in the provider response field.","Methodist agrees with HHSC's recommendation.  Please move the secondary drivers and change activities originally submitted under the Chronic Care Management Grouping to the Hospital Quality and Safety Grouping.  Please remove Chronic Care Management as a Core Activity.","KT","I moved Secondary Driver 1, and Secondary Driver 1: Change Idea 1 for this core activity to Secondary Driver 4 and Secondary Driver 4: Change Idea 1 for the core activity under the Hospital Quality and Safety grouping. This  core activity will need to be deleted (I'm not sure of the process for doing that and didn't want to delete anything I wasn't supposed to).","Y","NB","reflected that this Core Activity is deleted.","Accepted","HHSC has deleted this core activity, and moved Secondary Driver 1, and Secondary Driver 1: Change Idea 1 for this core activity to Secondary Driver 4 and Secondary Driver 4: Change Idea 1 for the core activity under the Hospital Quality and Safety grouping.",null,"CA-8","NA"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",229,"Other","Enhance focus to continually promote a culture of patient safety and zero patient harm.","Delete","This Category was previously listed as \"Other\".  Methodist is not discontinuing this Core Activity, but moving this initiative  to a  new Core Activity category added to the Measure Bundle Protocol by HHSC.","Other","Provide an exceptional patient and family care experience.","Improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors. Improve maternal safety and reduce maternal morbidity through data driven interventions to prevent and manage obstetric hemorrhage.","Decrease CLABSI rates through focus on maintenance protocols, insertion criteria, and removal of CLABSI catheters.","Share best practices for central line management and appropriate utilization."," "," "," "," ","Decrease Catheter Associated Urinary Tract Infection (CAUTI) rates through focus on protocols to reduce the number of Foley Catheters.","Develop protocols for catheter removal as well as those for appropriate insertion in the Emergency Department."," "," "," "," ","Improve sepsis metrics through focus on evidence based order sets, appropriate device use to optimize fluid administration, and regular communication to Emergency Department medical leadership.","Monitor sepsis bundle performance and other key metrics such as timely delivery of antibiotics through Sepsis dashboard reports."," "," "," "," ","Improve maternal outcomes through reduction of Cesarean Section Rate.","Develop campus action plans for reduction and communicate expectations to medical staff."," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1; E2","Not only are the activities undertaken in association with these Measure Bundles critical to Methodist's oversll goals to promote a culture of safety and zero patient harm,  they are also identified as Community Needs in the RHP6 Community Needs Assessment--Improve the safety and quality of care delivered in clinical settings; and Improve maternal and child health.","No","","094154402.7.1","KT","Provider is replacing this Core Activity with the Hospital Safety and Quality Core Activity below.","N",null,"OK","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-1","CA-1.10"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",696,"Hospital Safety and Quality","","New","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Improve patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.","Decrease CLABSI rates through focus on maintenance protocols, insertion criteria, and removal of CLABSI catheters.","Share best practices for central line management and appropriate utilization.","","","","","Decrease Catheter Associated Urinary Tract Infection (CAUTI) rates through focus on protocols to reduce the number of Foley Catheters.","Develop protocols for catheter removal as well as those for appropriate insertion in the Emergency Department.","","","","","Improve sepsis metrics through focus on evidence based order sets, appropriate device use to optimize fluid administration, and regular communication to Emergency Department medical leadership.","Monitor sepsis bundle performance and other key metrics such as timely delivery of antibiotics through Sepsis dashboard reports.","","","","","Improve internal and external interdisciplinary communication processes to improve throughput.","Develop facility interdisciplinary teams to include hospitalists, facility chief medical officers, pharmacy, radiology, and respiratory therapy to review processes affecting LOS metrics.","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity directly impacts Methodist's J1 measures to reduce CLABSI, CAUTI and Sepsis rates.  Not only are the activities undertaken in association with this Measure Bundle critical to Methodist's overall goals to promote a culture of safety and zero patient harm,  they are also identified as Community Needs in the RHP6 Community Needs Assessment--Improve the safety and quality of care delivered in clinical settings; and Improve maternal and child health.","No","","094154402.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_094154402","094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private",697,"Maternal and Infant Health Care","","New","","Implement standard protocols for the leading causes of preventable death and complications","","Improve patient health outcomes and experience of care by reducing the Casarean Section Rate; implement evidence based proctocols for Early Elective Delivery and OB Hemorrhage.","Improve maternal outcomes through reductions of the Casarean Section rate.","Develop campus action plans for reduction and communicate expectations to medical staff.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","This Core Activity directly impacts Methodist's E-2 measure to improve its C-Section Rate (E2-150). Not only are the activities undertaken in association with this Measure Bundle critical to Methodist's overall goals to promote a culture of safety and zero patient harm,  they are also identified as Community Needs in the RHP6 Community Needs Assessment--Improve the safety and quality of care delivered in clinical settings; and Improve maternal and child health.","No","","094154402.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_112688004","112688002.7.1",6,"112688004","Frio Regional Hospital","Hospital","Private",232,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","To improve access and the quality of care between our primary care and Emergency Department for better outcomes of our patients and thereby decrease cost and improve health and satisfaction.","Update processes within the ED to improve transfer communication and medication reconciliation.","Include topics in regular staff meeting agendas.","Provide staff training on appropriate EMR documentation.","Provide real-time staff training during patient care visit.","Conduct daily audits of documentation."," ","Educate patients on appropriate use of ED and primary care services.Patients do not know where to seek appropriate care.","Provide educational materials to patients","Provide list of alternatives for urgent care"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Our core activity impacts our selected Measure Bundle by helping to improve the quality or patient health of emergency care in rural and critical access hospital.  It accomplishes this by recognizing the importance of care coordination and care communication thereby improving overall care transitions for patients.","No","","112688002.7.1","KT","The \"Notes for the RHP Plan Update Review Team (optional)\" field of the \"DY8Rd2_Core Activities\" file states the following: \"Please review if additionl measures selected by the provider can be tied to this CA (e.g. B1, B2).\" However, provider only selected measure bundle K2, so I don't see there is an issue.","N",null,"OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_112742503","112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private",234,"Behavioral Health Crisis Stabilization Services","","Edit","","Implement models supporting recovery of individuals with behavioral health needs",null,"Goal: patient engagement to improve follow up care 7 days/30 days from discharge from Clarity CGC\nJust as reflected in the regional community needs assessment, our area is at a deficit of health literacy and even more so, mental health literacy. When a patient is admitted into the hospital, whether it is their first time or they are a new patient, it can be a frightening time for the family to understand patient needs and reconclie those needs with their family lifestyle. Once a patient has been admitted to the hospital, discharge planning begins with our Care Coordination team. They leverage information collected on the patient and their family when they were admitted and will add additional assessments to help recognize barrier to aftercare treatment. In some cases, those barriers can be resolved through mental health education, understanding the importance of follow-up care to the child's stability and why attending appointments is critical. Other times, there are larger wraparound services needed.","Mitigate patient risk factors to increase patient support","The first change idea for improving follow-up care at the 7 day/30 day mark is peforming a focused patient risk assessment","The second change idea for improving follow-up care at the 7 day/30 day mark is contacting the patient within 72-hours after discharge to understand how the patient and family is doing with their coping skills, medication management and compliance with other medical orders and appointments."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160","With a clear understanding of the social determinants and other barriers to compliance with discharge orders, our Care Coordination team can better support a patient and their family to ensure they understand the importance of completeing a 7 day/ 30 day follow up appointment in the safety and stability of their child. If there are additional barriers that are revealed, the Care Coorindation team member can help the family with additional wraparound supports.","No","","112742503.7.1","KT","This provider currently has 4 core activities that they are continuing into DY9-10.  The provider indicates that Core Activities 1 & 2 impact M1-160: Follow-Up After Hospitalization for Mental Illness. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure.  The provider indicates that Core Activities 3 & 4 impact M1-390: Time to Initial Evaluation: Mean Days to Evaluation. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure. \n\nCORE ACTIVITY 1 (this core activity)\nCore Activity Grouping - Behavioral Health Crisis Stabilization Services\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 2\nCore Activity Grouping - Other\nOther Grouping - \"Provider Access to see patients within 7 days/30 days of discharge from Clarity CGC\"\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 3\nCore Activity Grouping - Other\nOther Grouping - \"Decrease the time between first patient contact and initial evaluation for services\"\nCore Activity Name - Other\nOther Name - \"Improve patient access\"\n\nCORE ACTIVITY 4\nCore Activity Grouping - Other\nOther Grouping - \"Increase provider efficiencies: Increase provider access allowing for a shorter time between when a family contacts Clarity CGC and a child receives an assessment\"\nCore Activity Name - Other\nOther Name - \"Increase provider efficiences\"\n\nIt seems like Core Activities 1 & 2 can be combined; however, I'm not sure what Grouping or Name to put them under.  Likewise, it seems like Core Activities 3 & 4 can be combined; however, I'm not sure what Grouping or Name to put them under.  Requesting a second review.\n\n\n","Y","NB","Updated the title to move on the menu, but decided not to combine CA 1 and 2 (234 and 235) beecause one is within provider's system and one is not. ","Needs More Information","HHSC revised provider’s Core Activity title by moving it from Other (patient engagement to improve follow up care 7 days/30 days from discharge from Clarity CGC) to the tile on the menu: Implement models supporting recovery of individuals with behavioral health needs. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping is appropriate instead of \"Other\".","Clarity CGC accepts the proposed ccore activity changes ","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_112742503","112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private",235,"Behavioral Health Crisis Stabilization Services",null,"Edit","","Implement models supporting recovery of individuals with behavioral health needs",null," Goal of this Core  Activity is to Increase provider access for patients who are discharged at 7 and/or 30 days from Clarity CGC..\nIf Clarity CGC is at capacity when it comes to outpatient services, we must rely on community providers to see our patients at the 7 day and 30 day milestone. This also means the provider must share patient data with Clarity in order to report on this milestone. Too many times, we are told by providers that HIPPA prevents them from sharing data-- though we know that is not the case when it comes to continuity of care. Clarity CGC is starting practice-by-practice outreach to engage and inform these community partners with the hope of not only being able to secure appointments for this population but to get appointments with providers who are willing to understand the true implications of HIPPA and share data.","Develop a tool kit of HIPPA documents, Clarity CGC patient needs and other supports to meet with key community providers in strategic areas of our county (as we know close to home is important to our patients and their compliance to appointments) to help engage their support and services.","Engage our community relations team to consistently meet with these providers to help them stay engaged and understand and address concerns."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160","Clarity CGC cannot handle the capcity of patients who need appointments at the 7 and 30 day milestone following discharge. While we are working on internal efforts to help our capacity, it will take additional outside resources in the community with the capacity to see patients, ability to help patients with severe mental illness and be willing to share data. This isn't an easy proposition. However, we feel we can work to persuade enough providers to truly make an impact with this population.","Yes","Based on the current capcity of Clarity Child Guidance Center, the 7 day appointment/30 day might be performed by a partner in the community who provides outpatient therapy. Clarity CGC is doing everything possible to keep those patients in our continuum of care. However, the volume of patients doesn't allow us to do this with a portion of our patients. Please be advised this is a capcity issue and has nothing to do with their payor status. As a disproportionate share hospital, more than half of Clarity CGC's patients live at or below the Federal Poverty Level are on Medicaid or CHIP.","112742503.7.1","KT","This provider currently has 4 core activities that they are continuing into DY9-10.  The provider indicates that Core Activities 1 & 2 impact M1-160: Follow-Up After Hospitalization for Mental Illness. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure.  The provider indicates that Core Activities 3 & 4 impact M1-390: Time to Initial Evaluation: Mean Days to Evaluation. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure. \n\nCORE ACTIVITY 1 \nCore Activity Grouping - Behavioral Health Crisis Stabilization Services\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 2 (this core activity)\nCore Activity Grouping - Other\nOther Grouping - \"Provider Access to see patients within 7 days/30 days of discharge from Clarity CGC\"\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 3\nCore Activity Grouping - Other\nOther Grouping - \"Decrease the time between first patient contact and initial evaluation for services\"\nCore Activity Name - Other\nOther Name - \"Improve patient access\"\n\nCORE ACTIVITY 4\nCore Activity Grouping - Other\nOther Grouping - \"Increase provider efficiencies: Increase provider access allowing for a shorter time between when a family contacts Clarity CGC and a child receives an assessment\"\nCore Activity Name - Other\nOther Name - \"Increase provider efficiences\"\n\nIt seems like Core Activities 1 & 2 can be combined; however, I'm not sure what Grouping or Name to put them under.  Likewise, it seems like Core Activities 3 & 4 can be combined; however, I'm not sure what Grouping or Name to put them under.  Requesting a second review.\n\n\n","Y","NB","Updated the title to move on the menu, but decided not to combine CA 1 and 2 (234 and 235) beecause one is within provider's system and one is not. ","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Other (Provider Access to see patients within 7 days/30 days of discharge from Clarity CGC) to the one on the menu: Behavioral Health Crisis Stabilization Services. \n\nHHSC also revised provider’s Core Activity title by moving it from Other (Increase provider access for patients who are discharged at 7 and/or 30 days from Clarity CGC.) to the tile on the menu: Implement models supporting recovery of individuals with behavioral health needs. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping is appropriate instead of \"Other\". \n","Clarity CGC accepts the proposed ccore activity changes ","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_112742503","112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private",236,"Availability of Appropriate Levels of Behavioral Health Care Services",null,"Edit","","Other","Improve patient access to services","Clarity CGC goal is to improve patient’s access to timely services which can be achieved by increasing provider’s efficiencies and changing existing practices related to the response time. \nChildren's mental health care has become a commodity where provide supply cannot meet demand. As a result, it can take an unrealistic amount of time from a family member contacting Clarity for an assessment until the actual assessment is performed. We are prepared to change the way we do business to shorten that time period.\nClarity CGC is also evaluating various models which would allow us faster access to assessments. This includes psychological assessments of patients, patients who are at risk to hurting themselves and others and need crisis assessment and those who would benefit from a walk-in type of \"clinic\" on our existing campus.","Decrease the time to speak to a person on the admissions team to start the assessment process.","The first change idea is to have every call returned within 24-hours.","The second change idea is to make contact with the family within 72-hours, allowing for a faster assessment and understanding of the child's needs."," "," "," ","Answer more live calls from families as they call Clarity CGC.","Establish a call center allowing Clarity CGC to answer more live calls where families will not have to leave a message for a returned call."," "," "," "," ","Increase provider efficiency through management of internal resources.","Improve utilization management and oversight of patients in outpatient services.","Implement centralized scheduling for all clinicians in outpatient."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-390"," This Core Activity impacts selected measure bundle M1-390.\nOur admissions team is staffed with Master's level clinicians, which is helpful as they can triage calls and start the assessment process by phone. The downside of having this level of care is that each call can last 30-45 minutes, meaning other families trying to call into Clarity at that point will need to leave a message and get a returned call. By changing the way we do business, we plan on adding phone staff, shortening phone assessment time and better serve a volume of customers allowing us to shorten the time between when a family calls to when their child is assessed.","No","","112742503.7.1","KT","This provider currently has 4 core activities that they are continuing into DY9-10.  The provider indicates that Core Activities 1 & 2 impact M1-160: Follow-Up After Hospitalization for Mental Illness. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure.  The provider indicates that Core Activities 3 & 4 impact M1-390: Time to Initial Evaluation: Mean Days to Evaluation. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure. \n\nCORE ACTIVITY 1 \nCore Activity Grouping - Behavioral Health Crisis Stabilization Services\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 2 \nCore Activity Grouping - Other\nOther Grouping - \"Provider Access to see patients within 7 days/30 days of discharge from Clarity CGC\"\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 3 (this core activity)\nCore Activity Grouping - Other\nOther Grouping - \"Decrease the time between first patient contact and initial evaluation for services\"\nCore Activity Name - Other\nOther Name - \"Improve patient access\"\n\nCORE ACTIVITY 4\nCore Activity Grouping - Other\nOther Grouping - \"Increase provider efficiencies: Increase provider access allowing for a shorter time between when a family contacts Clarity CGC and a child receives an assessment\"\nCore Activity Name - Other\nOther Name - \"Increase provider efficiences\"\n\nIt seems like Core Activities 1 & 2 can be combined; however, I'm not sure what Grouping or Name to put them under.  Likewise, it seems like Core Activities 3 & 4 can be combined; however, I'm not sure what Grouping or Name to put them under.  Requesting a second review.\n\n\n","Y","NB","NB combined 236 and 237 by deletign 237.","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Other (Decrease the time between first patient contact and initial evaluation for services) to the one on the menu: Availability of Appropriate Levels of Behavioral Health Care Services. HHSC’s assumption that this Core Activity does not address crisis services. \n\nHHSC did not move the Core Activity title from other to the one on the menu but updated it to “Improve patient access to services” (previous title Improve patient access).\n\nHHSC combined two of the Core Activities (Improve patient access and Increase provider efficiencies) into one - Improve patient access to services. HHSC updated a description of Core Activity to include both. HHSC moved Secondary Driver and related Change Ideas from the deleted Core Activity (Increase provider efficiencies) into the combined one (Improve patient access to services). If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. \n","Clarity CGC accepts the proposed ccore activity changes ","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Other","CA-9","CA-9.7"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_112742503","112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private",237,"Other","Increase provider efficiencies: Increase provider access allowing for a shorter time between when a family contacts Clarity CGC and a child receives an assessment.","Delete","","Other","Increase provider efficiencies","Clarity CGC is evaluating various models which would allow us faster access to assessments. This includes psychological assessments of patients, patients who are at risk to hurting themselves and others and need crisis assessment and those who would benefit from a walk-in type of \"clinic\" on our existing campus.","Increase provider efficiency through management of internal resources.","Improve utilization management and oversight of patients in outpatient services.","Implement centralized scheduling for all clinicians in outpatient."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-390"," This Core Activity does impact selected measure bundle M1-390. Clarity CGC is seeing patient volume like never before. In fact, 68% of our patients in 2017 were new to Clarity. This means changing the way we approach care to allow not only the right level of care at the right place and the right time, but the proper utilization of our resources. Clarity has begun a process to adjust how a patient enters on system of care and how we manage patient care while they are in the system. To do this, we will need to add and adjust resources in admissions to handle the influx of calls and care needed. Second, providing utilization management as resource management, we can ensure patients who are stable and who have responded well to treatment the step down, and possibly step out of the level of care provided. Finally, by centralizing scheduling of outpatient services, the Utilization Management and Care Coordination teams can work with clinicians to manage their appointment loads with greater efficiency. We feel these changes can provide a big opportunity to accommodate the volume of needs in our community.","No","","112742503.7.1","KT","This provider currently has 4 core activities that they are continuing into DY9-10.  The provider indicates that Core Activities 1 & 2 impact M1-160: Follow-Up After Hospitalization for Mental Illness. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure.  The provider indicates that Core Activities 3 & 4 impact M1-390: Time to Initial Evaluation: Mean Days to Evaluation. The Core Activity Grouping and/ or Name for both of these core activities duplicate the language of this measure. \n\nCORE ACTIVITY 1 \nCore Activity Grouping - Behavioral Health Crisis Stabilization Services\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 2\nCore Activity Grouping - Other\nOther Grouping - \"Provider Access to see patients within 7 days/30 days of discharge from Clarity CGC\"\nCore Activity Name - Other\nOther Name - \"patient engagement to improve follow up care 7 days/ 30 days from discharge from Clarity CGC\"\n\nCORE ACTIVITY 3\nCore Activity Grouping - Other\nOther Grouping - \"Decrease the time between first patient contact and initial evaluation for services\"\nCore Activity Name - Other\nOther Name - \"Improve patient access\"\n\nCORE ACTIVITY 4  (this core activity)\nCore Activity Grouping - Other\nOther Grouping - \"Increase provider efficiencies: Increase provider access allowing for a shorter time between when a family contacts Clarity CGC and a child receives an assessment\"\nCore Activity Name - Other\nOther Name - \"Increase provider efficiences\"\n\nIt seems like Core Activities 1 & 2 can be combined; however, I'm not sure what Grouping or Name to put them under.  Likewise, it seems like Core Activities 3 & 4 can be combined; however, I'm not sure what Grouping or Name to put them under.  Requesting a second review.\n\n\n","Y","NB","NB combined 236 and 237 by deletign 237.","Needs More Information","HHSC deleted this Core Activity and combined the information from this one into another Core Activity. HHSC combined two of the Core Activities (Improve patient access and Increase provider efficiencies) into one - Improve patient access to services. HHSC updated a description of Core Activity to include both. HHSC moved Secondary Driver and related Change Ideas from the deleted Core Activity (Increase provider efficiencies) into the combined one (Improve patient access to services). If the provider disagrees with the deletion of this Core Activity, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. ","Clarity CGC accepts the proposed ccore activity changes ","KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-1","CA-1.10"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_119877204","119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public",238,"Prevention and Wellness","","Edit","Val Verde Regional Medical Center restructured and updated the list of team members who will contribute with the DSRIP Core Activity to include our Registered Dietician, Women’s Health Director, Pediatric Director, and our Clinic DSRIP nurse due to the loss of population health coordinator. \nThe Counseling first change idea was updated to include the addition of our Registered Dietician who can offer individual counseling related to nutrition to our patients as this can impact children and adolescents of all ages and with chronic illnesses. Our Licensed Behavioral Therapist was focused on children ages 5 who met certain criteria for services. \nThe Community Outreach first change idea was revised to include an interdisciplinary team approach. Val Verde Regional Medical Center will work closely within departments to take on a stronger approach to making health related events known to the public. VVRMC will also partner with other organizations to increase impact and for sharing and maximizing resources that can benefit our community. VVRMC continues to strive to strengthen its’ foundation by increasing the number of collaborative partners in supporting the community’s needs. Although S.F.D.R.C.I.S.D continues to be our strongest partner, we wish to increase all available benefits and resources to the community. \nThe Community Outreach second change idea was revised to include the initiatives VVRMC has taken to promote community health events. This change was made as VVRMC continues to make every effort to reach, attract, and engage as may members of our local community as much as possible with topics focused on the benefits and available resources such as prevention and wellness. \n","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","The four pediatric providers, Director of Women's Services, Director of Pediatric Unit, Clinic DSRIP nurse, DSRIP project manager, and our Senior Leadership Team will continue to work together to develop evidence-based guidance and support for the promotion of good nutrition, healthy diets and physical activity for prospective and expecting parents to infancy through young adults. The guidance and support developed will be implemented in the Rural Health Clinic, Women's Health Center, inpatient units, and community. The overarching goal of this core activity is to reduce and prevent obesity in children and adolescents.","Counseling: Providers will provide evidence-based guidance and support for the promotion of good nutrition, healthy diets and physical activity for prospective and expecting parents to infancy through young adults.","Patients will be provided nutrition and physical activity counseling during their encounter with pediatricians. Patients may be referred to our Registered Dietician for one to one, individualized nutritional education and counseling if appropriate or as recommended by our physicians. "," "," "," "," ","Screening: Providers will routinely assess children and adolescents and prospective or expecting mother's nutrition, physical activity, sedentary behavior and growth according to established guidelines.","Patients will be screened for time spent watching television, videos, or screens, sleep duration, time spent on physical activity, BMI, gestational diabetes, breastfeeding, birth weight, and consumption of fast food, sugary drinks, and fruit and vegetable intake. Patients will be assessed for Mental illnesses and mood disorders that affect nutritional status and overall well-being (Updated October 2018). Physician EHR training was conducted 1:1 to assist with documentation and increase knowledge of educational tools available for patients. "," "," "," "," ","Community Outreach: VVRMC will participate in community programs that promote physical activity and reduce sedentary behaviors in children and families.","Val Verde Regional Medical Center will continue to promote community events targeted towards prevention and wellness on children and adolescents. VVRMC’s partnership with our local school district, San Felipe Del Rio Consolidated Independent School District and other such as The Community Health Improvement Coalition as strengthened our efforts on Community Outreach. ","VVRMC has developed a Teen Fit Summer program to promote health and wellness in Teens ages 12-18. This programs duration is for 8 weeks, is provided 3 x week for an hour sessions with a certified physical fitness instructor for CrossFit, Zumba, and Yoga. The Teen Fit Program has been a successful part of our community outreach with good participation.   The course also offered 30 minutes of nutrition education and cooking classes by a nutritionist and a Registered Dietician. The use of social media as alternate and more comfortable mode of communication has also played a role in VVRMC’s community outreach with its use to increase awareness in wellness and prevention of illnesses, publicize community health fairs with emphasis on self-management, healthy eating, mental health, and assistance in coping with chronic illnesses. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","According to the Data Resource Center for Child or Adolescent Health, more than one in three children in Texas are overweight or obese. There is limited childhood weight data available specifically for Val Verde Country, however, city-data.com determined Val Verde County's low-income, pre-school obesity rate to be 17.7% compared to the Texas statewide average of 15.7%. Free lunch is provided through our public school district for elementary schools.   Research suggests that early-life poverty is linked to later childhood obesity. More specifically, children who experienced poverty by two years of age were 1.6 times more likely to be obese by 15 years of age than children who did not experience poverty. Childhood obesity is a chief population health concern because it can lead to many other chronic diseases and premature death. Preventative care and providing supportive environments is key to population health. This core activity provides an opportunity to sharpen our focus on assessment, guidance, and community support for preventing and reducing childhood obesity. This is aligned with our D1: Pediatric Primary Care Measure Bundle, specifically the measure D1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents.","No","","119877204.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce and prevent obesity in children and adolescents (e.g., Technology Supported Multi Component Coaching or Counseling Interventions to Reduce Weight and Maintain Weight Loss; Coordinated Approach to Child Health - CATCH; and SPARK among others)","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_121782006","121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public",240,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","This Core Activity has been selected, in part, to document the continuation of a project from the initial round of DSRIP (DY1-5). While all pieces of this project will remain intact, there is no direct correlation connecting this project to the newly selected Measure Bundle A1 Diabetes Care.","Continued proper patient navigation for Palliative Care patients.","Maintain high level performance in the patient navigation process for Palliative Care patients, specifically for percentage of discharges to home care / hospice / SNF."," "," "," "," ","Continued proper proper pain assessment / management for Palliative Care patients.","Maintain high level performance in the percentage of pain assessment / management process within 24 hours for Palliative Care patients."," "," "," "," ","Continued proper follow-up services for Palliative Care patients after an inpatient visit.","Maintain high level performance in the follow-up process for Palliative Care patients after an inpatient visit by increasing follow up calls and home visits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","While this Core Activity does not specifically address the newly selected Measure Bundle A1 Diabetes Care, UMH has choesen this Core Activity to document the continuation of a project from the initial round of DSRIP (DY1-5).","No","","121782006.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_121782006","121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public",241,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","This Core Activity has been selected, in part, to document the continuation of a project from the initial round of DSRIP (DY1-5). However, of all Core Activities selected, this Core Activity has the most direct impact on the newly selected Measure Bundle A1 Diabetes Care. Specifically, the diabetes registry created in DY3 will be utilized and further developed to achieve goals set forth in the Measure Bundle.","The use of the patient registry will help improve clinical care and support diabetes self-management education.","Use the patient registry to help identify social / environmental factors that contribute to a patients poorly-controlled diabetes.","Use the patient registry to help integrate physical and behavioral health to improve health of people with diabetes and behavioral health issues."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","The Core Activity impacts the selected Measure Bundle (A1 Diabetes Care) by being the launching point through which all new initiatives begin for better diabetes management in the community.","No","","121782006.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_121990904","121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",208,"Prevention and Wellness","","Continue","","Implementation of interventions focusing on social determinants of health","","The provider will focus on improving program goals to increase involvement in areas that are outside of traditional behavioral health services.  By enhancing screening processes, and reviewing the social, financial and environmental issues that impact our patient population.","Promote healthy eating/ active lifestyles,  diabetes prevention/management, prevent/control tobacco use","Provide health related videos in the patient waiting areas","After screening for BMI and tobacco use, staff will provide interventions through educational materials and referrals","Refer clients to QUIT Line as a Tobacco cessation resource"," "," ","Address social \"determinants of health\" affecting health by addressing access and availability of healthy food sources in our communities.","Screen patients for health conditions impacted by food access and/or dietary habits.","Collaborate with the area Food Bank to identify opportunities to increase access to food resources for clients.","Determine eligibility for area commodity programs, and link clients to these resources.","Collaborate with Texas A&M Agri-life Extension offices to provide educational opportunities relating to nutrition and healthy living."," ","Implement evidenced-based practices to identify and address social determinants related to alcohol and other drug use.","Train staff in SBIRT (Screening, Brief Intervention, Referral, and Treatment) for substance use","Screen individuals who are seeking mental health services through our agency for risky levels of use of alcohol and other drugs.","Provide brief intervention to individuals with identified problem use, or at risk  for a substance use disorder."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-261; M1-147; M1-182; M1-105; M1-287","The provider delivers services in a rural area that is designated as a HPSA.  The challenges of transportation, seriously impact access to care.  Lack of education, cultural influences, language barriers, and limited family supports all have negative impact on the overall care patients receive.   As one of the only comprehensive providers in our area, we are going to affect change by supporting these activities related to prevention and wellness.","No","","121990904.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_127294003","127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private",242,"Maternal and Infant Health Care","","Edit","Changing from an \"Other\" Core Activity to a HHSC pre-approved Core Activity. Changing to a pre-approved Core Activity should mitigate NMI questions or unclear activities.","Coordinated prenatal and postpartum care",null,"Design a process that covers all the requirements of the maternal care bundle in a way that supports provider education that will reduce variation, provides for consistent and repeatable documentation and supports corrective action as needed to improve outcomes. ","Develop appropriate clinical templates that cover patients receiving the following at a post-partum visit:- Breast feeding evaluation and education, including patient-reported breast feeding- Post-partum depression screening- Post-partum glucose screening for gestational diabetes patients and- Family and contraceptive planning","Gather input from providers and other users on clinical templates needs and implement improved templates. Monitor use of new templates and workflow and adjust as indicated to achieve targeted performance.","Educate providers and other users on requirements within the new template and workflow."," "," "," ","Develop appropriate clinical templates that cover patients receiving the following at a prenatal visit:\n• Behavioral health risk assessment"," Gather input from providers and other users on clinical templates needs and implement improved templates. Monitor use of new templates and workflow and adjust as indicated to achieve targeted performance.",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This core activity will provide a process that ensures all elements of the measure bundle are addressed and properly documented on each prenatal and post-partum visit.","No","","127294003.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133257904","133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public",244,"Prevention and Wellness","","Delete","Deleting this and replacing with essentially the same core activity to avoid using \"other\". See new core activity below under Access to Primary Care Services - Provision of Screening and follow up services. We are clarifying  our original language.  This core activitiy includes screening and testing of populations at high-risk for TB and the offering and provision of TREATMENT for those identified with TB infection or referral for treatment for those with TB disease. Drivers and change ideas were also modified for clarity.","Other","Provide Screening, Testing  and Follow-Up Treatment Services for Populations at High-Risk for TB","The San Antonio Metropolitan Health District's TB Program - our local health department partner - is responsible  for activities associated with our sole CatC measure (the latent TB infection rate).  They conduct screening activities to identify high-risk individuals, test those at high-risk, and treat those with identified TB infection.","Patient Engagement.  The homeless population comprise our largest screening and testing group and experience significant challenges and barriers.","Reduce wait times for clinic appointments","Hire a nurse to communicate results and assess homeless patients on-site."," Focus on encouraging patients with TB infection to accept treatmentk."," "," "," ",null," "," "," "," "," ",null," "," "," "," "," ",null," "," "," "," "," ",null," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-347","MEASURE L1-347 IS NOT DISPLAYING. This activity is significant to our organization which is focused on preventing TB disease.  In order to identify TB disease or infection, systematic screening to identify those at high-risk and then to test and encourage acceptance of treatment is necessary.","No","","133257904.7.1","KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-7","CA-7.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133257904","133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public",245,"Prevention and Wellness","","Edit","We originally selected the \"Other\" core activity name during our original selection of the name of this Prevention and Wellness core activity. In preparing the DYs 9-10 provider templated, we believe that the selected name from the drop-down option within this grouping is more appropriate. Also added a secondary driver related to assessment of functional status/quality of life to impact I1.","Implementation of evidence-based strategies to empower patients to make lifestyle changes",null,"The TCID behavioral care team will take lead on systematically assessing patients with depression or other behavioral health issues, documenting barriers and challenges identified at patient admission and offer and provide appropriate interventions for patients to help support lifestyle changes","Good communication between care teams and patients to support patient engagement in making lifestyle changes.","Consistently review current patient education/counseling practices, processes intervention approaches."," "," "," "," "," No formal process for assessment of patient functioning/quality of lide at admission and discharge","Implement and routinely assess functional status/quality of life through a standardized measurement tool"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-317; L1-105; M1-146; I1","The activities associated with this core activity focus on assesssment of functional status, quality of life, behavioral and mental health  issues identified in patients on admisssion and discharge, as appropriate.  These activities support implementation of appropriate interventions for patients and directly impact TCID performance on each measure.","No","","133257904.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133340307","133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",247,"Availability of Appropriate Levels of Behavioral Health Care Services","","Delete","Per guidance from HHSC when possible aligning Core activities with existing HHSC selections; we have consolidated all activities in a single core activity.  By selecting \"Availability of Appropriate Levels of Behavioral Health Care Services\" grouping and \"Provision of care aligned with Certified Community Behavioral Health Clinics (CCBHC) model,\" we are able to better align the activities in our organization to those related to accomplishing improved processes and outcomes through the new system being created.  As a requirement of CCBHC data collection, improved processes, clinical outcomes, and better care delivery we align the system goals; through a single core activity.    ","Utilization of telehealth/telemedicine in delivering behavioral services","","Expenditures and demand continue to increase and the ability to pay for and to support the current models are stretched to the limit. Utilization of telehealth/telemedicine in delivering Behavioral Health services, has become an extremely attractive option and a necessity in frontier and rural areas.   Televideo services are provided to the following counties in Hill Country's catchment area (Bandera, Comal, Edwards, Gillespie, Kendall, Kerr, Kinney, Medina, Real, Uvalde, Val Verde, Hays, Blanco, Llano, Kimble, Mason, Menard, Schleicher, and Sutton). Currently services are provided by psychiatrists, psychologist, and counselors(LPC). In an effort to provide high-quality and patient-centered care, in the most cost effective way, we are looking to expand televideo service provision to an extended array of provider types.","Increase efforts to provide cost-effective person centered care with high-quality results","Increase cost savings and address reimbursement barriers (Cost can at times prohibit/limit available service)","Educate and encourage individuals in care on the benefits of televideo care (Increase comfort with video services, will allow individuals access to a wider array of services)","Inform and educate staff on alternate service delivery options (Understanding service options to support improved outcomes)"," "," ","Increased access to specialty services in rural and outlying areas","Increased crisis supports and follow-up care across all areas (Via televideo)","Purchase/relocate and install IT equipment in high need provider shortage areas","Increase outreach to high-risk and underserved groups (Peer Support follow-up calls/ engagement)"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-146; M1-160; M1-165; M1-181; M1-241; M1-257; M1-261; M1-262; M1-286; M1-305; M1-317; M1-319; M1-340; M1-341; M1-405","Increase access to services through televideo, will expand access across the system, allowing individuals in the most rural and frontier areas services they might not have access to without considerable hardship.  This type of access also allows specialty service providers to engage more people and spend less time behind the wheel.  All measures are supported by this core activity, though increase access and increasing the quality care through quality care options.  Efforts to increase billing and billing options will allow for sustainability and expanded service access areas.","No","","133340307.7.1","KT","Requesting second review to confirm that the replacement of this core activity and the three other core activities with the core activity  in the Core Activity Grouping \"Availability of Appropriate Levels of Behavioral Health Care Services\" and the Core Activity Name \"Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model\" is acceptable.","Y","NB","In agreement","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133340307","133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",248,"Availability of Appropriate Levels of Behavioral Health Care Services","","Delete","Per guidance from HHSC when possible aligning Core activities with existing HHSC selections; we have consolidated all activities in a single core activity.  By selecting \"Availability of Appropriate Levels of Behavioral Health Care Services\" grouping and \"Provision of care aligned with Certified Community Behavioral Health Clinics (CCBHC) model,\" we are able to better align the activities in our organization to those related to accomplishing improved processes and outcomes through the new system being created.  As a requirement of CCBHC data collection, improved processes, clinical outcomes, and better care delivery we align the system goals; through a single core activity.    ","Increasing access to services by utilizing qualified staff","","Whole Health planning is currently available in the following counties in Hill Country's catchment area (Bandera, Comal, Edwards, Gillespie, Kendall, Kerr, Kinney, Medina, Real, Uvalde, Val Verde, Hays, Blanco, Llano, Kimble, Mason, Menard, Schleicher, and Sutton).  Whole Health planning is provided by Certified Peer Specialist. The goal is to continue to expand these services to increase engagement, and improve outcomes by utilizing a whole health/whole person approach.","Encourage Health-promoting social environments across the system","Provide training on healthy food choices, magazines on healthy living in lobbies, healthy food choices in vending machines"," "," "," "," ","Improve engagement in Whole Health Peer Support Programming","Promote special events to increase participation (Walk pet therapy, Volunteer events, Guest speakers, Leadership and skill building with community businesses)","Marketing materials, celebrate successes, engage the community stakeholders (Increase engagement to improve outcomes)","Technology - myStrength.com, Fitbit challenges, Geo cashing contest, Kept appointment contest, Volunteerism contest (Increase engagement)"," "," ","Increase cost savings across the health care continuum","Decrease use of ER for primary care needs through education and resource linkage (Whole health addresses physical health needs)","Work with managed care to find reimbursement opportunities (Navigation, whole health planning, and increased linkage to resources for improved outcomes)"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-105; M1-147; M1-165; M1-181; M1-241; M1-286","Services such as Peer Support, are structured to be available to any and all individuals in mental health services.  Peer support engagement includes specialty supports such as use of Whole Health planning, WRAP services, and Getting Into the Driver's Seat, these specialty services encourage engagement into all areas of service, encourage independence, self-advocacy, recovery, and improve outcomes across the system of care.","No","","133340307.7.1","KT","Requesting second review to confirm that the replacement of this core activity and the three other core activities with the core activity  in the Core Activity Grouping \"Availability of Appropriate Levels of Behavioral Health Care Services\" and the Core Activity Name \"Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model\" is acceptable.","Y","NB","In agreement","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Increasing access to services by utilizing staff with the following qualifications: Wellness and Health Navigation: Bachelors level professional with experience in mental health and/or wellness initiatives or a peer specialist who has successfully completed the DSHS certification program for peer specialists","CA-9","CA-9.3"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133340307","133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",250,"Other","Provide access to a broad range of Behavioral Health services to ensure timely, effective treatment that minimizes the use of crisis services, reduce emergency department (ED) utilization, inpatient utilization, incarceration and promotes recovery.","Delete","Per guidance from HHSC when possible aligning Core activities with existing HHSC selections; we have consolidated all activities in a single core activity.  By selecting \"Availability of Appropriate Levels of Behavioral Health Care Services\" grouping and \"Provision of care aligned with Certified Community Behavioral Health Clinics (CCBHC) model,\" we are able to better align the activities in our organization to those related to accomplishing improved processes and outcomes through the new system being created.  As a requirement of CCBHC data collection, improved processes, clinical outcomes, and better care delivery we align the system goals; through a single core activity.    ","Other","Provide access to a broad range of Behavioral Health services to ensure timely, effective treatment that minimizes the use of crisis services, reduce emergency department (ED) utilization, inpatient utilization, incarceration and promotes recovery.","Provide access to a broad range of Behavioral Health services to ensure timely, effective treatment that minimizes the use of crisis services, reduce emergency department (ED) utilization, inpatient utilization, incarceration and promotes recovery. Specialty care services are provided to the following counties in Hill Country's catchment area (Bandera, Comal, Edwards, Gillespie, Kendall, Kerr, Kinney, Medina, Real, Uvalde, Val Verde, Hays, Blanco, Llano, Kimble, Mason, Menard, Schleicher, and Sutton). Service providers contribute to the core activity accross the spectrum of services offered within the system of care. All providers are charged with supporting the delivery of care in the least restrictive and most appropriate environment possible.  Addressing the highest need/risk populations will improve outcomes and promote recovery.","Effective communication between care providers both internal and external stakeholders","Hospital engagement and follow-up care coordination (Streamline communication)","Jail matching, mental health courts, jail diversion opportunities, continuity of care (Improve communication and integration of services for target population)","Include specialty services on follow-up planning and all high-risk individuals (Improve team communication)"," "," ","Improved access to early intervention mental health care","Education of all staff on early signs and how to report those early signs of crisis (Include all level of staff in early identification)","Utilization of crisis assessments and monitoring assessments: Columbia Suicide Scale, PHQ-9","Promote alternatives to hospitalization: Crisis Respite Centers (Educate all staff on available options)"," "," ","Person Centered Care with a team approach to recovery","Identify new avenues of patient engagement: Weekly calls to high risk individuals, drop ins, peer to peer volunteers, myStrength.com","Clearly identify resources to contact in the event of an impending crisis (Provide high risk individuals with clear list of options available before a full-blown crisis)","Focused medication management and feedback tracking (Engage in ongoing communication around medication to improve adherence and encourage communication when medication is not working as expected)"," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-146; M1-160; M1-241; M1-261; M1-262; M1-287; M1-286; M1-305; M1-317; M1-319; M1-340; M1-341; M1-405","All activities in the system of care work to support the measures selected, and the listed core activity.  Providing access to a broad range of Behavioral Health services to ensure timely, effective treatment that minimizes the use of crisis services, reduce emergency department (ED) utilization, inpatient utilization, incarceration and promotes recovery.  The focus on independence and recovery, is reflected in each service and activity we provide.  The selected core activity and measures will work to improve quality and identify areas of improvement.","No","","133340307.7.1","KT","Requesting second review to confirm that the replacement of this core activity and the three other core activities with the core activity  in the Core Activity Grouping \"Availability of Appropriate Levels of Behavioral Health Care Services\" and the Core Activity Name \"Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model\" is acceptable.","Y","NB","In agreement","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-1","CA-1.10"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_133340307","133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public",699,"Availability of Appropriate Levels of Behavioral Health Care Services","","New","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","The drive toward becoming a Certified Community Behavioral Health Center is at the root of all activities taking place within the organization.  To change a system of service delivery requires the attention of all aspects of that system from Financial through to Service Delivery and engaging our community stakeholders in the change process.  Providing access to a broad range of Behavioral Health services to ensure timely, effective treatment that minimizes the use of crisis services, reduce emergency department (ED) utilization, inpatient utilization, incarceration and promotes recovery in a model such as CCBHC is goal.   ","Identify and establish Environmental Readiness of the system","Acquire and Implement a New Electronic Health Record (E.H.R.)","Establish and improve collection of stakeholder feedback (Needs Assessment)","Identify and prepare for designation and negotiations with Designated Collaborative Organizations","Marketing and rebranding of organization (Communication Strategy, Website, Mission, Vision, Values, etc.)","Review and align current and create new policies and procedures as needed to align with CCBHC","Strategic Planning Through the Transition and Cost Reporting and Calculation (Project plan, IS/IT Needs Assessment, Strategic Plan, Cost Reporting, etc.)","Communicate new payment model; workforce impact and operational impact throughout the system","Identify and adjust personnel needs (Job Descriptions, New staffing needs, Provider Shortages, etc.)","Identify new services and community partners; leverage current relationships and develop new relationships. ","Develop IT infrastructure that can support collection of data and outcome information as well as link back to cost","Align all planning with a Person Centered and Trauma Informed approach (hours, environmental surroundings, treatment planning, service delivery, etc.)","Create a Clinical Excellence Plan that aligns with CCBHC","Include Population Health and Social Determinates of Health in future Clinical Planning (Primary Care Integration, Peer Support, Telehealth Options, etc.) ","Utilize new technology to provide better care (E.H.R appointment reminders, patient portal, myStrength.com, user friendly assessments, kiosk for benefits enrollment, telehealth services, etc.)","Expanded Service Hours (Nights, Weekends, Expanded Hours, etc.)","Formalized Care Teams (Align Caseloads, Expand Service Options, Design new follow-up systems, etc.)","Create feedback loop for outcomes (through technology or new processes) (System Survey)","Project Management, Education, and Continuous Quality Improvement ","Develop an agile system responsive to Continuous Quality Improvement activities/feedback","Improve data capture, analysis and management (through technology and process improvement).  New E.H.R. ","Participate in learning and collaborative activities (CCBHC, DSRIP, Clinical, VBP, Managed Care, etc.)","Educate and engage system in CCBHC goals (Board of Directors, Community, Individuals Served, Staff, etc.)","Develop a project and implementation plan aligning current contracted requirements as closely to CCBHC as can be","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-105; M1-146; M1-147; M1-160; M1-181; M1-241; M1-257; M1-261; M1-262; M1-265; M1-287; M1-305; M1-317; M1-319; M1-340; M1-341; M1-405; M1-165; M1-286","The measures we have selected where selected to align with CCBHC outcome measures while also working within our current system capacity.  As we continue to improve our systems through alignment with CCBHC; clinical excellence and process improvements support the improved outcomes we seek.  A new system of care and the guidance provided by the CCBHC model has already improved outcome measures tracking and data management.  A new E.H.R. will have a tremendous impact on all services provided, billing, care coordination, data management/collection, assessment tracking and delivery, streamline processes, and unencumber how we deliver care.  Expanding hours and options for care that better align with the care people want such as groups/classes focused on; physical health, substance use, social skill building, nutrition, employment, and financial management are all supported in the new system model.  These new supports will promote continued engagement in services with a clear and distinct end of service plan, or a participation at the lowest possible need. ","No","","133340307.7.1","KT","Requesting second review to confirm that the replacement of the four related activities with this core activity is acceptable.","Y","NB","In agreement. The new one is pretty comprehensive.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_135151206","135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public",252,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","With our portal usage at only 4%, there is significant room for improvement. This will give our community of patients and providers access to tools that will contribute to the efficiency and effectiveness of preventive medicine and chronic disease management, including managing/preventing diseases related to tobacco dependence or lack of vaccinations. This will also help to improve the rate of advance care planning discussions.","Increase the number of patients utilizing our patient portal for meaningful communication about their healthcare.","Educate staff on how to web enable patients to provide them access to the portal.","Execute marketing campaign about the portal to increase awareness within our patient base.","Create patient handout or \"portal survival guide\" to help familiarize and encourage patients to use the portal."," "," ","Increase utilization of patient education on smoking cessation, vaccinations and advance care planning through improved patient communication via portal.","Enable reminders through portal messaging campaigns for vaccinations and advance care planning discussions.","Have providers push the patient education within our EMR directly to the patient portal, creating a more convenient way to access the education."," "," "," ","Provide additional training to the staff","Draft scripting and training documents for staff and providers, training quarterly.","Train quality data analysts on reporting required to identify target populations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","For preventive care to be effective in managing chronic diseases, we feel that the patient's engagement as an active participant in their own healthcare is an important factor. Communication between providers and patients through the portal will engage patients to take a more active role in their healthcare. We feel that this, in turn, will help to keep their health at the forefront of their thoughts and will give us more of a chance to effect it positively.","No","","135151206.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_136141205","136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public",253,"Access to Primary Care Services","","Edit","Minor changes were made to the description of this Core Activity to more accurately convey the activities occurring within the Health System, and minor edits were made to remove references to dates when edits to this Core Activity previously occurred. ","Provision of vaccinations to target population","","The Health System will continue to offer a variety of vaccines in order to prevent the spread of vaccine preventable illnesses and to ensure that all individuals have access to recommended vaccinations.","Improve documentation in the electronic health record.","Potential improvements include data entry standardization, reviewing/updating standard operating procedures as needed, and staff training."," "," "," "," ","Assess immunization education materials and promote education about vaccinations among staff, providers, and patients. ","Ensure appropriate distribution of education materials and implement/continue education activities to inform staff, providers, and patients about the importance of providing/receiving recommended vaccinations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C3; D1","This Core Activity will support the provision of comprehensive primary care services for adults and children, and will contribute to appropriate clinical interventions for patients with Hepatitis C.","No","","136141205.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_136141205","136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public",701,"Expansion of Patient Care Navigation and Transition Services","","New","","Provision of navigation services to targeted patients","","Health System patient navigators support linkage to care, care coordination, and continuity of care for: \n-Patients missing routine primary care services\n-Patients missing services related to diabetes, heart disease, or hepatitis C (i.e. routine labs, follow-up appointments, etc.)\n-Patients at risk of admitting to the hospital or emergency department visits\n-Patients requiring pre/postal natal care\n-Patients receiving palliative care services","Optimize the utilization of data available in the electronic health record.","Develop reports and working lists to identify patients in need of navigation services. ","","","","","Standardize procedures across the Health System to ensure patients receive quality care that adequately addresses their needs.","Develop and implement standard operating procedures (SOPs) to ensure patients receive appropriate services in a timely fashion and to address barriers to care.","","","","","","","","","","","","","","","","","","","","","","",2,3,3,3,2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1; C3; D1; A2","This core activity will support the provision of comprehensive primary care services for adults and children as well as the provision of primary and specialty care services to address chronic disease such as diabetes, heart disease, and hepatitis C. Additionally, this core activity supports the prevention of unnecessary ED visits and hospital admissions.","No","","136141205.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","HHSC has updated the impact to Measure Bundles to include A2 based on  provider's withdrawal to discontinue and removed E1 and G1 as they were no longer added. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_136430906","136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private",255,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","Correctly identify and provide vaccinations to the targeted population based on Metric K1-268 (patients with an encounter during the performance period who are over the age of 65 on the date of their encounter)","Required information is not consistently documented correctly in the Electronic Medical Record (EMR) or in the correct module within the Electronic Medical Record.","Improve the way this information is documented through the Meditech upgrade"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity specifically is aimed at those individuals who need a vaccination, which ties to metric K1-268 (Pneumonia Vaccination Status for Older Adults)","No","","136430906.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_136430906","136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private",257,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","This Core Activity needs to identify patients who have a critical need for screening and in addition to being identified and screened also receive follow up services (education) or referrals as needed","Patients are not correctly identified as needing a screening, or if they are correctly referred to follow up services or other providers","Patients Social History not correctly reviewed and documented by provider or staff, leading to potentially missed referrals for tobacco users. Educate staff on where to best document this in the EMR","Identify patients who are age 65 or older but do not have an advanced care plan or documentation of an ACP on record, based on metric K1-285 requirements"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This Core Activity is tied directly to metrics K1-105 (Tobacco Use: Screening & Cessation Intervention) and K1-285 (Advanced Care Plan) and exists to ensure that those patients who have a need for additional services are correctly referred to those services - inside or outside of the clinic - in a timely manner.","No","","136430906.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_136491104","136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private",258,"Behavioral Health Crisis Stabilization Services","","Continue","","Implement models supporting recovery of individuals with behavioral health needs","","SWGH will strategize with each individual, providers, outpatient programs, clinics and community leaders to create a process by which patients are not only scheduled for 7-day follow up appointments but that assists the individual in removing barriers for non compliance with aftercare (i.e, housing, transportation, lack of social support and education). SWGH is currently working with local first responders on an innovative project to indentify and address the needs of individuals over-utilizing the 911 system and emergency service resources as a vessel to access mental health services.  SWGH will continue to use patient navigation resources (in-house and community) to track over-utilization but will add aftercare as key component. We are participating in a  Bexar County law enforcement navigation project (MEDCOM), SWGH  expects increase in our ER volume.","Patients must be assessed for suicide risk and activities of daily living.","Train staff on assessment tools and screening protocols.","Implement assessment tool and screening protocol."," "," "," ","High-utilizing patients currently receive services from multiple providers which inhibits continuity of care.","Participate in city-wide program with first responders to transport patients to their regular source of care.","Coordinate follow up care to prevent readmissions and promote outpatient services."," "," "," ","Patients need follow-up care by our health care practitioners and community partners.","Schedule follow up visits for patients following ED visits and admissions.","Make follow up calls to remind patients about their appointments.","Provide transportation assistance for patients to get to their follow up appointments."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","SWGH will strategize with each individual, providers, outpatient programs, clinics and community leaders to create a process by which patients are not only scheduled for 7-day follow up appointments but that assists the individual in removing barriers for non compliance with aftercare (i.e, housing, transportation, lack of social support and education).  This project should improve continuity of care while reducing over utilizaton of resources in order to improve the quality of life and living of the behavior health patient.","No","","136491104.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_137251808","137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",261,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Provision of services to individuals that address social determinants of health","","Improving access and ensuring availability to our services for mental health and behavioral health directly aligns with needs identified in our regional community needs assessment. This Core Activity helps CHCS strengthen our coordination efforts with our population within our community.","Quality Assurance Plan, Continuous Quality Improvement Activities","Standardize Clinic Flows to ensure data collection consistently, reliability and integrity","Strengthen monitoring and compliance efforts: establish data dashboards/reports","Report data findings/tracking on metrics monthly at waiver workgroup meeting"," "," ","Standardize Operating Procedures: Developing and Implementing","All eligible staff professionals attest to documented list of current medications","Creating, modifying/updating our Policy and Procedures throughout CHCS to align with new outcome measures and overall patient care and outcomes.","Standardize lab request orders from all providers to ensure all necessary labs at one time","Update and Standardize Clinic workflows at all Outpatient clinics"," ","Promote and Strengthen Integrated Care Model (Behavioral Health and Primary Care Services) across Organization","Include introduction of Integrated Care model and services offered at CHCS through New Employee Orientation.","Hire and train all new and current staff as need on integration/CCBHC model","All direct care staff and supervisors to receive a one-day, in-person Case Management to Care Management training: National Council","All direct care staff trained on trauma-informed care and person centered recovery planning: Care Planning for Dual Diagnosis on Recovery Plan for individuals with a substance use and behavioral health diagnosis","","Engage and strengthen collaborations with Community Partners","Ensure attendance and collaboration with: South Texas Crisis Collaborative(STRAC),  Community Health Improvement Plan (CHIP), Community Medical Directors Round Table (CMDRT)","","",""," ","Staff Training and Education: Developing and Implementing","Train staff on rationale for collecting clinical information and appropriate interventions: New material available through our online training: Relias Learning; and will be added to clinical supervision","Train additional staff on SBIRT: Screening, Brief Intervention and Referral for Treatment","Updating and creating new reference material for staff such as our One Point Lesson sheets (OPL)","All direct care staff trained on trauma-informed care and person centered recovery planning: Care Planning for Dual Diagnosis on Recovery Plan for individuals with a substance use and behavioral health diagnosis","Establish/Maintain: meeting with treatment/clinical team members, executive leadership, case managers",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-256; M1-287; M1-261; M1-257; M1-306; M1-262; M1-405; M1-264; M1-341; M1-265; M1-266; M1-160; M1-400","As a Community Mental Health Center, the metrics listed above were selected through the HHSC menu of options for CMHCs. Provision of services to individuals that address social determinants of health and/or family support services is an important component on impacting overall health outcomes in our community. Improving access and ensuring availability to our services for mental health and behavioral health directly aligns with needs identified in our regional community needs assessment.","No","","137251808.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_137251808","137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",262,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","As a Community Mental Health Center, the integration of primary care and behavioral health services allows us to focus on prevention efforts utilizing the provision of screening and follow-ups on new outcome measures. Conducting screening and follow-ups allows us to identify key health risk factors early and link then to care and treatment needed.","Establish and Implement Preventative Care and Screening for individuals","Implement standardized screening tools and protocols for possible health risk factors: Screen every individual for BMI, blood pressure, tobacco use, depression and have follow up documented","Improve identification process of individuals in need of screenings and follow-ups: Establish client registry to identify individuals in need of an annual physical exam and diabetes screenings; monthly chart reviews conducted off client registry."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-147; M1-207; M1-210","Improving access and ensuring availability to our services for mental health, behavioral health and physical health needs directly aligns with needs identified in our regional community needs assessment. This Core Activity helps CHCS strengthen our coordination efforts with our population by implementing new quality health outcomes to our population.","No","","137251808.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_138411709","138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public",264,"Chronic Care Management","","Edit","The Core Activity will remain the same, but additional change ideas have been added.  These include development of new processes and the addition of resources that will enhance the organization's efforts in managing the diabetic population.","Management of targeted patient populations with high risk for developing complications","","For this core activity, we will improve clinical management of diabetes, improve care-coordination for patients with diabetes, and we will increase healthy behaviors.","Develop and implement care-coordination activities to improve patient follow-up","We will implement a system where patients come in to have their blood pressure checked every 2 weeks so that we can monitor this closely.","We will implement a system where patients with an elevated A1c will come in every two weeks to discuss diet, glucose logs, and overall compliance with treatment plan. "," "," "," ","Improve clinical-community linkages to resources (mental health, Wesley Nurse, Food Bank, Specialists) as well as access to healthy foods","We will work to improve collaborations with partners in the community.  We will reach out to mental health resources, our local Wesley Nurse at the Methodist church, the SA Food Bank, and Specialists both locally and in the neighboring counties.","We will have our Transitional Care Nurse (TCN) make home visits when patients are unable to make their appointment at the Clinic.  Updated October 2018.","We will work to collaborate with the SA Food Bank, HEB, and Agrilife so that our patients may have access to healthier foods.  Food vouchers will be provided to patients and the food bank distrubution will occur on site.","We will provide counseling services at the clinic for those patients who have mental health needs such as anxiety and depression, as treatment of mental health diagnoses have been shown to improve compliance with chronic disease management. ","","Identify social/environmental factors that contribute to poorly controlled diabetes/non-adherence","We will work to decrease the barriers that our patients face.  Some of these include transportation, funding, and cultural issues.  We will work to get our patients transportation to and from visits and classes as well as pay for classes and healthy foods.  We will also work to improve cultural barriers facing our county.","We will work to expand part time staff who will enable us to keep track of our patients\u0092 compliance on a regular basis.  Modified October 2018."," "," "," ","Develop and implement processes to ensure annual foot and eye exams are completed","Reminders for appts (text messages, postcards); patient progress report","The nursing and provider status boards will be updated so that the daily patient list will display the most recent eye and foot exam dates.","Will provide eye exams in the clinic with referrals as needed to local physician partners."," "," ","Increase access to diabetes self-management education (classes and solo instruction)","We have determined that one of the issues we need to address is having diabetes education on site.  We will work to have a diabetes educator on site so that patients can receive education right away during their visit.","Increase access to cooking classes for healthier cultural cuisine","Work with the community on increasing access to classes on nutrition"," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","The Guadalupe Clinic for Chronic Disease Care operates five days/week to provide access to care and disease management for unfunded/low income Guadalupe County residents with chronic disease. Patients are connected with resources to aid in chronic disease management, to include follow-up visits, prescription assistance, laboratory services, and disease-specific education (including Diabetes Self-Management Education). Clinic staff includes a Nurse Practitioner, Registered Nurse, Certified Nurse Assistant, and Office Coordinator.","No","","138411709.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_159156201","159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private",265,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","Increased development and expansion of the Baptist Health System Continuing Care Network based on quality outcomes and results of site visits under the leadership of the BHS Post-Acute Steering Committee (PAC). The PAC will be comprised of case management, hospital administration, hospitalists, Transitional Care Managers/ Nurses, pharmacy, and inpatient/outpatient rehab leadership. The PAC will focus on maintaining a network of skilled nursing facilities with high quality outcomes and expand the network to home health agencies and hospice.","Post-acute placement of patients to facilities that are engaged in collaboration with BHS and maintain low readmission rates and high quality ratings.","Reporting of % of patients that were discharged to a CCN facility at quality meetings to increase focus at the system and facility-level.","Re-education to all Case Managers and physicians on the CCN list and why it's important to use.","Development of a more \"patient-friendly\" handout that lists the SNFs and HHAs in the CCN.","Case management review session every time the CCN list is updated"," ","Review CCN member readmission rates and CMS Star Ratings each quarter and update CCN list biannually.","Schedule quarterly CCN forums to maintain communication and engagement with agencies.","Implement requirement for CCN membership to agree to random site visits by PAC members which will add an additional element of insight to quality of care at the facilities."," "," "," ","Maintain physician engagement on CCN utilization and discharge patterns","Make CCN utilization and post-acute discharge patterns a standing agenda item at quarterly BPCI physician meetings.","Investigate better communication options between surgeon's office and SNF/HHA on patient's progress and discharge plan."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Increasing collaboration with Transitional Care Manager, Case Managers, Administration, physicians, and post-acute settings with high quality outcomes will reduce all-cause 30 day readmissions.","No","","159156201.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_159156201","159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private",267,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","Develop and implement a process for capturing the BISHOP score on all maternal patients prior to the administration of pitocin and use this data for a reduction in primary cesareans.","Add BISHOP score in electronic medical charting system.","Educate physicians and nurses on increased documentation of score.","Share BISHOP score data with OB Medical Staff Committee."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Implementation and utilization of the BISHOP score in labor induction decision-making may help decrease the primary cesarean section rate and improve maternal health outcomes.","No","","159156201.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_159156201","159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private",268,"Prevention and Wellness","","Delete","Change the selection of Core Activity from \"Prevention and Wellness: Other\" to \"Hospital Safety and Quality: Implementation of evidence-based practices to improve quality of care\" because this is a more accurate description of the core activity.","Other","Hand Hygiene campaign to re-invigorate focus on compliance","Hand hygiene compliance campaign system-wide: focusing on re-education of staff, monitoring of hand foam usage on unit, visitor program implementation, provide hand wipes for patients at the bedside.","Increase hand hygiene compliance throughout system.","Increase hand hygiene observations with wide-spread secret shopper program.","Unit directors monitor and report out on hand foam usage each month.","Provide hand wipes for patients at the bedside to encourage patient hand hygiene"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Increasing hand hygiene compliance through the entire system will contribute to reducing CLABSIs, CAUTIs, and SSIs and prevent the spread of infections throughout the community.","No","","159156201.7.1","KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ",null,"KT",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted. ","Other","CA-7","CA-7.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_212140201","212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public",246,"Access to Primary Care Services","","Edit","The provider is deleting the change idea of purchasing a software program associated with the secondary driver.  It was determined that the tracking software initially proposed would be costly, difficult to interface with the EMR, and not patient friendly.  In addition, the software would cost more than the anticipated return.   Therefore, the provider is utilizing other means described below to accomplish the same end result.","Establishment of care coordination and active referral management","","The provider plans to establish a position for a care coordinator / chronic care manager role within the rural health clinics to ensure patients receive the appropriate preventive screenings, wellness visits, referrals, etc.","lack of capacity to provide adequate care coordination and referral services","Hire an additional full-time NP, MA, and call center supervisor for \"connected in care\" program to manage: every 3-6 month visits for patients with chronic illnesses, offer monthly case management by phone and email, and identify coverage needs for referral to specialists","Clinic expansion to include a designated office space for new team members",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Establishing a new care coordination position and expanding the referrals department roles will both impact all preventive measures directly.  Those identified as tobacco users will have  cessation intervention provided and follow up on success.  Those seeking assistance with advanced care planning will have the resource available.  Patients with a positive depression screening or positive behavioral health risk assessment in pregnant women, will be identified, assistance/resources/referrals provided, and follow up plan established.  Target populations requiring their immunizations such as influenza and pneumococcal will be scheduled for their vaccinations.   Lastly the diabetic population will be identified for annual well visits including their foot exam.","No","","212140201.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Establishment of care coordination and active referral management that integrates information from referrals into the plan of care","CA-1","CA-1.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 06_DY9-10 Regional Tracker - FINAL Tracker.xlsb","6_217884004","217884001.7.1",6,"217884004","Dimmit County Memorial Hospital","Hospital","Private",233,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","Utilze education materials to educate the community on their chronic illinesses to improve their quality of life.  At the same time prevent unnecessary ER visits.  It entails calling to make sure patients make it to their appointments, making sure they take their medications.  Utilize community members to help this patients stay in compliance with their care.","Increase hospital engagement with the community to monitor and manage chronic illnesses.","Use Community Health Workers(CHWs)/ promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care.","Expand practice access via the Nurse Advice Line.","Establish care coordination and active referral management systems that integrate information from referrals into the plan of care.","Provide ongoing follow-up services.","Use the nurse advice line to deliver ongoing assessments."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Reduce ER visits for selected condition or conditions:  CHF, diabetes, angina/hypertension, behavioral health & substance abuse, COPD or dental.","No","","217884001.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_133542405","133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",271,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","The description of this core activity was updated to reflect the evolution of CCBHC activities at Integral Care. Change ideas were updated to represent efforts that are ongoing and to remove initatives that have been successfully implemented.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","Certified Community Behavioral Health Clinics (CCBHCs) provide a comprehensive range of community-based mental and substance use disorder services.  Using standardized measures, these integrated services are to be provided in a person-centered, trauma-informed and recovery-oriented approach to screening, assessment, prevention, and treatment.  The National Council reports that pilot site preliminary outcomes show improved access to care, increased community collaborations, and improved staff recruitment and retention. Integral Care is one of eight centers in Texas certified as a CCBHC pilot site and continues to enhance its service delivery with the principles of the CCHBC model. As part of this model, Integral Care seeks to identify interventions to coordinate and amplify existing services including improved coordination and access to substance use and co-occurring disorder treatment services for children and adults, population health management, and increased access to routine whole-person integrated care.","Identify and address high-risk populations that have a demonstrated need for substance use or co-occurring services in order to drive targeted, evidence-based interventions.","Implementation of risk stratification methods and population health management practices to conduct effective care coordination and to meaningfully impact health outcomes.",""," "," "," ","Promote linkages to care post hospital inpatient discharge.","Identification of patients in need of an inpatient visits or follow-up coordination post inpatient encounter.",""," "," "," ","Expand access to routine mental health services within an integrated clinic setting.","Expand access optimization efforts to increase the number of individuals who receive routine services after hours and on the weekends at integrated clinics.",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-160; M1-181; M1-405; M1-261; M1-262; M1-305; M1-317; M1-319; M1-340; M1-341; M1-342; M1-390","These particular measures are essential to this core activity, as CCBHCs are required to increase access to care (M1-342, M1-390), provide interventions and use a standardized approach to treating substance use needs (M1-261, M1-317, M1-340, M1-341, and M1-405), and promote care coordination after discharge (M1-160). Risk assessment approaches will use high risk drivers such as major depression and screenings to identify high-risk patients and provide targeted referrals (M1-262, M1-319, M1-305, M1-181, and M1-146).","No","","133542405.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_133542405","133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",272,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Changes to the core activity reflect new initiatives and goals in the area of physical and mental health integration. The change ideas are reflective of health navigation activities designed to enhance care coordination.","Utilization of Care Management function that integrates primary and behavioral health","","Integral Care is strengthening our integrated primary and behavioral health care practices to care for the whole health of each individual. Integral Care is scaling its implementation of health navigation services to improve continuity of care for individuals with comorbid physical and mental health conditions. This integrated primary and behavioral health care core activity will focus on chronic disease prevention and management using screenings, counseling, and ongoing treatment.","Enhance care continuity and coordination through health navigation for children and adults.","Develop robust care coordination teams to promote linkages to care across the continuum.","Create a referral process to specialty services to support direct care staff when clinically indicated."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-210; M1-211; M1-287; M1-400; M1-255","These particular measures are essential to this core activity, as integrated behavioral and primary care should encompass prevention, screening, and treatment as needed (M1-105, M1-147, M1-210, M1-211) and integrate primary care and medication information and monitoring to advance safe and effective treatment (M1-287, M1-255).","No","","133542405.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_137265806","137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private",274,"Chronic Care Management","","Edit","Provider is removing the second and third Secondary Driver and Change Idea pairs from Core Activity #1 and replacing them with a new Core Activities which better reflect the activity planned for DY 9 & 10.  Provider is also adding Change Ideas to Core Activity #1 to reflect planned DY9 & 10 activities.  ","Management of targeted patient populations with high risk for developing complications","","Management of high risk patient populations by using the expertise of existing committee structures to target clinical practice variation and/or gaps in the continuum of care.","Leverage the GoodHealth Solutions Center and utilize improvement tools to improve management of chronic disease.","Utilize the GoodHealth Solutions Center's resources, including care coordination and virtual care technologies, to optimize patients' self care management.","Develop care coordination protocols and resources within the outpatient clinics to support targeted populations."," "," "," ","Leverage the Network CHF Readmission Project to help improve management of chronic disease.","Utilize the existing CHF Readmissions dashboard, prevention tools, and job aides to find opportunities to improve admission rates and ED visit rates for the heart disease population."," Apply the learnings from the CHF Readmissions Project to the diabetes population to improve admission rates and ED visit rates."," "," "," ","",""," "," "," "," ","","",""," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Performing Provider will introduce recommended workflow changes aimed at improving documentation, screening and follow-up, and decreasing clinical variation which will allow for a more proactive response to the needs of these patient populations.  Provider will also develop and implement care coordination protocols in the outpatient setting to support improved outcomes in targeted populations.","No","","137265806.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_137265806","137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private",275,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Establishing standard workflow and documentation practices related to cancer screenings, immunizations, and high-risk behaviors to guide appropriate patient education and clinical follow-up to the target population.","Leverage the Ascension Medical Group Quality Team to influence outpatient providers to improve screening and follow-up services.","Utilize EHR functionality to prompt providers to routinely screen patients for immunization status and high-risk behaviors then prompt appropriate follow-up services and education."," "," "," "," ","Leverage the Oncology Clinical Service Line to improve screening and follow-up rates.","Utilize GoodHealth Solutions Center to improve patient satisfaction with appointment availability which will improve screening and diagnostic throughput."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2","The implementation workflow changes and standardized documentation practices will improve provision of screening and follow-up services across all primary care prevention measures.","No","","137265806.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_137265806","137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private",704,"Hospital Safety and Quality","","New","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Develop standard work documents and job aids containing evidence-based practices for preventing infections and injuries including monitoring practices to evaluate compliance with evidence-based practices and continuing education campaigns.","Conduct root cause and common cause reviews of all hospital infection and injury events.","Implement standard mechanism for sharing findings of event reviews with all applicable clinical departments and staff.","Implement targeted education campaigns as indicated by identified common causes.","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Performing Provider will implement a comprehensive process including evidence-based practices, systematic event review, communication of relevant findings, and education and training to address leading causes of hospital infections and injuries reflected in the selected Measure Bundle.","No","","137265806.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_186599001","186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private",276,"Chronic Care Management","","Edit","Performing Provider is updating the Core Activity to reflect changes made in DY8 Round 2 reporting.  Provider is also removing the first Secondary Driver and Change Idea pair and replacing them with a new Core Activity which was added to the menu for DY9 & 10 and is a better fit for the associated measure bundle.","Management of targeted patient populations with high risk for developing complications","","Management of high risk patient populations by using the expertise of existing committee structures to target clinical practice variation and/or gaps in the continuum of care.","Leverage the clinical quality team to identify and implement evidene-based protocols and decrease variation in clinical practice.","Utilization of standard protocol guidelines for educating patient and providers on appropriate treatment and management of pediatric asthma.","Develop standard protocol guidelines to improve diabetes self-management in the pediatric population."," "," "," ","Leverage the clinical quality team to improve provider workflow and decrease variation in clinical practice.","Utilization of EHR functionality to standardize workflow and documentation."," "," "," "," ","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4; D5","Performing Provider will introduce workflow changes aimed at prevention of emergency and hospital inpatient services for the chronic diseases targeted by the selected measure bundles as well as improve self-management of pediatric asthma and diabetes.","No","","186599001.7.1","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_307459301","307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",278,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications","","CCCs vision is to create a healthcare delivery system that is a national model for providing high quality, cost-effective, person-centered care and improving health outcomes for its vulnerable population.  Its priority focus areas include building an integrated delivery system, improving value in care and optimizing the health of the population, including through activities that support reducing the incidence of chronic disease and improving the management of chronic disease for MAP patients.","Improve health outcomes by developing value driven contracts with key partners that focus on primary care services, complex primary care services, and cancer screening for MAP patients who typically have one or more chronic diseases.","Conduct immunization and diabetes care promotion activities focusing on vulnerable populations to increase immunization rates and improve comprehensive diabetes care in the primary care setting. \n\n","Provide complex primary care clinic services to vulnerable patients experiencing complications with managing their diabetes.  ","Conduct outreach to vulnerable populations to promote cancer screenings. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C2; C1","By providing high quality, cost-effective, person-centered medical care, the CCC will focus on an integrated delivery system so that providers treating patients, particularly those with chronic conditions, can manage the care effectively, thereby increasing appropriate screenings and potentially decreasing chronic disease complications.","No","","307459301.7.1","KT","The Core Activity Grouping for this core activity is \"Chronic Care Management.\"  \n\nThe Core Activity Name is \"Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services.\"  \n\nThe current Description of Core Activity reads as follows: \"CCCs vision is to create a healthcare delivery system that is a national model for providing high quality, cost-effective, person-centered care and improving health outcomes for its vulnerable population.  Its priority focus areas include building an integrated delivery system, improving value in care and optimizing the health of the population, including through activities that support reducing the incidence of chronic disease and improving the management of chronic disease for MAP patients.\"  I suggest shortening/ revising it to read as follows: \"Improve the management of chronic disease for Medical Access Program (MAP) patients.\" \n\nI also suggest creating two new, separate core activities to better describe some of the activities the provider included under this core activity. One would be under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of vaccinations to target population.\" The other would be under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of screening and follow up services.\"\n\nSecondary Driver 1 currently reads as follows: \"Improve health outcomes by developing value driven contracts with key partners.\" I suggest changing it to \"Improve disease management for MAP patients with diabetes\" or something to that effect.\n\nSecondary Driver 1: Change Idea 1 currently reads as follows: \"Conduct immunization and diabetes care promotion activities focusing on vulnerable populations to increase immunization rates and improve comprehensive diabetes care in the primary care setting.\" I suggest revising it to read as follows: \"Conduct diabetes care promotion activities focusing on vulnerable populations to improve comprehensive diabetes care in the primary care setting.\"  \n\nSecondary Driver 1: Change Idea 3 currently reads as follows: \"Conduct outreach to vulnerable populations to promote cancer screenings.\" I suggest moving this to the new, separate core activity under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of screening and follow up services.\" I also suggest asking the provider : 1) how they will ensure follow up services are provided to those who screen positive for cancer; and 2) to add a Description of Core Activity and at least one Change Idea for each Secondary Driver.\n\nFor the new, separate core activity under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of vaccinations to target population\" I would add the following as Secondary Driver 1: \"Conduct immunization activities focusing on vulnerable populations to increase immunization rates.\" I would then ask the provider to add a Description of Core Activity and a Change Idea for this Secondary Driver. \n","Y","NB","Included feedback for the provider. Mande it an NMI.","Needs More Information","Provider should update its description of the Secondary Driver 1 to specify which specific area provider is impacting (e.g. Improve disease management for MAP patients with diabetes, etc.). \nProvider could also consider deleting this core activity and creating two new ones: \n\nOne would be under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of vaccinations to target population.\" The other would be under the Core Activity Grouping \"Access to Primary Care Services\" and the Core Activity Name \"Provision of screening and follow up services.\"\n\nIf the provider feels that new Core Activities are a better representation of what provider is doing, provider needs to submit a description of Core Activities and corresponding Secondary Drivers and Change Ideas in the \"Provider Response\" column. If the provider feels that the existing Core Activity should remain, provider should include this in the response along with the suggested changes.","Provider requests to change the Secondary Driver 1 for this Core Activity to be more specific, as follows: Improve health outcomes by developing value driven contracts with key partners that focus on primary care services, complex primary care services, and cancer screening for MAP patients who typically have one or more chronic diseases. ","KT","I updated Secondary Driver 1 has requested by provider. Please review to confirm this is acceptable.","Y","NB","Acceptable. Updated to reflect Edit status for this Core Activity.","Accepted","HHSC has updated Secondary Driver 1 based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_307459301","307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",279,"Access to Specialty Care Services","","Edit","","Improvement in access to specialty care services with the concentration on underserved areas","","Expand the specialty care network and services and transform the referral management infrastructure to improve care plan coordination between primary and specialty care providers","Increase access to necessary services through expanded partnerships.","Increase dental services focusing on vulnerable populations.","Increase hospice care services focusing on vulnerable populations.",null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; F1; G1; C2","By providing high quality, cost-effective, person-centered centered medical care, the CCC will focus on an integrated delivery system so that providers treating patients with conditions requiring specialty care can manage the care effectively, thereby increasing appropriate screenings and potentially decreasing adverse disease outcomes and complications.","No","","307459301.7.1","KT","The Core Activity Grouping for this core activity is \"Access to Specialty Care Services.\"\n\nThe Core Activity Name is \"Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.\"\n\nThe previous \"Description of Core Activity\" read as follows: \"CCCs vision is to create a healthcare delivery system that is a national model for providing high quality, cost-effective, person-centered care and improving health outcomes for its vulnerable population.  Its priority focus areas include building an integrated delivery system, improving value in care and optimizing the health of the population, including by expanding the specialty care network and services as well as transforming referral management infrastructure to improve care plan coordination between primary and specialty care providers.\" I revised it to read as follows: \"Expand the specialty care network and services and transform the referral management infrastructure to improve care plan coordination between primary and specialty care providers.\"\n\nI deleted Secondary Driver 1: Change Idea 3 and Secondary Driver 1: Change Idea 4 because both included the following phrase at the end of the description: \"Deleted October 2018.\"","Y","NB","changed it to NMI","Needs More Information","HHSC has updated the Description of Core Activity to simplify it. HHSC has also deleted Secondary Driver 1: Change Idea 3 and Secondary Driver 1: Change Idea 4 because both included the following phrase at the end of the description: \"Deleted October 2018.\" If the provider disagrees with these changes, please provide an explanation in the \"Provider Response\" column.","Provider accepts changes.","KT",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_344398801","344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public",706,"Maternal and Infant Health Care",null,"New",null,"Provision of services to individuals that address social determinants of health",null,"Improve postpartum care","Improve Postpartum Care and Follow-Up Services at Mom's Place and through Health Equity","Hire additional nursing staff to engage clients in postpartum care and follow-up.","Identify a postpartum depression screening tool and develop a procedure for the implementation of the screening tool and staff response to results.","Assist clients with gestational diabetes in being linked to appropriate medical care for glucose testing. ","Engage clients in family and contraceptive planning and increase referrals to medical homes and/or community organizations.","Increase breast feeding evaluation and education.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-235","This core activity impacts L1-235 Post-Partum Follow-Up and Care Coordination","No",null,null,null,null,null,null,null,null,null,null,"KT","I added this new core activity based on the \"HHSC Initial Comments to Provider\" for the core activity in row 55.\n\nI wasn't sure how to update \"Measure Bundles or Meaures Impacted\" so I didn't mess with it so as not to mess up the file. But the measures that this core activity impacts should include the following:\nL1-235","Y","NB","Added  the measure based on Kim's note. Also included a basis description on the impact on measures. Will need to follow up during the reporting. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. During DY9 reporting, provider will need to include additional information on how this Core Activity impacts measures. ","Provision of services to individuals that address social determinants of health.","CA-4","CA-4.4"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 07_DY9-10 Regional Tracker - FINAL Tracker.xlsb","7_344398801","344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public",707,"Access to Primary Care Services",null,"New",null,"Provision of vaccinations to target population",null,"Increase immunizations","Increase coordination and opportunities for the provision of immunizations.","Develop a system-wide policy to support and facilitate an increase in immunization opportunities. ","Increase strategic planning activities and continue immunization outreach in collaboration with NHC and HE that prioritize hard-to-reach and elevated risk populations.  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-268; L1-269; L1-272","This core activity impacts\nL1-268 Pneumonia vaccination status for older adults\nL1-269 Preventive Care and Screening: Influenza Immunization\nL1-272 Adults (18+ years) Immunization status   ","No",null,null,null,null,null,null,null,null,null,null,"KT","I added this new core activity based on the \"HHSC Initial Comments to Provider\" for the core activity in row 55.\n\nI wasn't sure how to update \"Measure Bundles or Meaures Impacted\" so I didn't mess with it so as not to mess up the file. But the measures that this core activity impacts should include the following:\nL1-268\nL1-269\nL1-272","Y","NB","Added  the measure based on Kim's note. Also included a basis description on the impact on measures. Will need to follow up during the reporting. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. During DY9 reporting, provider will need to include additional information on how this Core Activity impacts measures. ","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_020957901","020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private",288,"Access to Primary Care Services","","Edit","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)",null,"Through its collaboration with local clinics, RRMC will increase patient access to primary care for low-income patients so that these patients will have access to more preventive services and be better able to manage their chronic disease (specifically, diabetes).  Increased access to primary care allows these patients to access healthcare before their symptoms become severe and require treatment in the Emergency Department.","RRMC's partner clinics will improve their internal processes to regularly assess risk factors that may not have been consistently monitored before (e.g. performing more thorough foot examinations, regularly measuring blood pressure control) in order to quickly identify issues and implement any necessary interventions to try and improve the patient outcome.","Train clinic staff in appropriate methods for assessing and documenting diabetic risk factors"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Through improving the clinics' staff training, it will standardize their processes so that they increase the consistency in which they assess diabetic risk factors in order to improve patient outcomes, which is the goal of the A1 Measure Bundle.","No","","020957901.7.1","DF","This provider has \"other\" selected for Core Activity Name. I imagine that provider could select one of the other Core Activity Grouping and Names, but there is not enough information in their Core Activity for me to tell what the Core Activity Title should be classified as definately, so I guessed and updated both the grouping and title. Provider said that they were increasing access to care, but they did not say how they were increasing access to care (for example, increasing hours, etc.),then their secondary driver one states that they are improving their process to increase screening for things like Diabetes foot exams (but not necessarily increasing clinic hours in order to do this). I almost wonder if they should not be in the access to primary care services bucket as it does not look like they are actually increasing access to care.","Y","NB","I moved it back to Access to primary Care Serived but changed the title, changed to the NMI","Needs More Information","HHSC has updated the Core Activity Name from \"Other: Collaborate with local providers to improve accessibility to preventive care for low-income patients\" to \"Expanded Practice Access\" to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and indicate whether another Core Activity Grouping and Name is appropriate instead of “Other.”","Provider approves HHSC's change.","DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_081771001","081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",289,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Prevention and wellness for consumers served is identified as a key component and integral to optimizing both treatment benefits and response to treatment for those seeking mental health/behavioral health services.  Primarily there are two components to this Core Activity for each of the four areas of focus: 1.) Screening and 2.) Follow-up and/or Interventions.  The four areas of focus or domains will include but may not be limited to a.) Tobacco Use/Cessation, b.)  Adult BMI, c.) Diabetes d.) Blood Pressure.","Empowering consumers to make educated and supported decisions around the use of tobacco as it relates to their general health and providing support to encourage and promote successful tobacco use cessation.","Utilize Tobacco Use Screen at Intake and throughout various consumer contact points in the consumer flow, i.e. CW visits, medication pick-ups, intake activities, E&M, other assessment appointments.","Provide an array of options to the consumer to support the decision for cessation","Provision of educational materials, pharmacological support, psychoeducational support, referrals","Provision of prescriber/nursing level educational support and subject matter materials"," ","Identifying individuals with Adult Body Mass Index screening outside of normal parameters established by national standards.  Empowering consumers to make educated and supported decisions regarding healthy weight, promoting physical activity, and exploration of healthy nutritional/dietary alternatives","BMI calculations will be incorperated into the collection of vital signs at each prescriber/nursing level encounter.","Height and Weight will be empirically derived with standard scales and statiometer in lieu of consumer self report for height","Provide an array of options to the consumer to support decision to achieve and maintain healthy weight","Provision of educational materials, pharmacological considerations, and referrals"," ","Addressing the proclivity for Diabetes among individuals served with shizophrenia and/or bipolar","Provision of screening and ongoing monitoring of A1C and blood glucose levels for individuals identified","Prescriber/Nursing level referrals as indicated for identified consumers","Provision of educational materials, pharmacological considerations, collaboration with PCP"," "," ","Addressing the potential for chronic hypertension and related medical conditions/risks","Provision of screening and ongoing monitoring for hypertension as indicated for identified consumers","Prescriber/Nursing level referrals as indicated for identified consumers","Provision of educational consultation, resource material, and pharmacological considerations"," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-105; M1-182; M1-210","This Core Activity enhances current service delivery by promoting the opportunity for individuals to be an active partner in their overall health and well being within the scope of these particular measures.  It also provides a framework to further develop and expand efforts for the organization to proceed in the direction of  integrated  health care.  This Core Activity provides the data, analysis and information for benchmarking and evaluation of service delivery improvement opportunities as well as ongoing established services to mitigate barriers to optimal health, provide choices for individuals served, and maximize the overall health and wellbeing of individuals served within the scope the selected measures.","No","","081771001.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_081771001","081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",291,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of services to individuals that address social determinants of health","","Addresses M1-160, M1-390: Minimize the barriers, to include time and resources, in order to enter into behavioral health treatment through call center contracts and follow-up coordination, coordination with outside agencies, and intake structure and decrease the likelihood of re-admission into an inpatient psychiatric facility.","Decrease wait time to access behavioral health services.","Utilize call center services to maintain 24 hours/7 day per week access to intake information.","Implement data sharing with call center to ensure follow-up calls on call center inquiries are maintained during normal business hours.","Transition from an appointment schedule structure for intake assessments to a walk-in service.","Provide transportation to individuals in need of transportation assistance that are referred from local county courts to facility to complete intake assessments.","Provide staff structure to coordinate with jail diversion programs to provide navigation services to individuals into behavioral health services.","Enhance services to individuals discharging from a psychiatric inpatient facility.","Develop collaboration with community inpatient psychiatric hospitals to coordinate discharge of current behavioral health consumers.","Develop system of scheduling clients that have been discharged from an inpatient psychiatric hospital with a licensed clinical staff.","Provide follow-up service with a licensed clinical staff to clients recently discharged from a psychiatric hospital to evaluate cause of hospitalization, provide psychoeducation on any change in diagnosis or medication, and assess current needs of the client."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160; M1-390","Increasing navigation through coordination with other entities, to include call center contracts, local inpatient psychiatric hospitals, and local county jails; providing support with transportation assistance, increasing care to clients recently discharged from inpatient psychiatric facilities, and structuring a walk-in intake policy within the organization will decrease barriers to individuals obtaining behavioral health services resulting in a reduction of psychiatric hospitalization, resulting in completion of M1-390 and M1-160.","No","","081771001.7.1","DF","The Description of Measure Bundle/Measure Impact for this row is weird… it said \"PP Test WBS4 FR2.9 and FR2.10\"...why does that look like an online system thing - this is coming from the template as well. I wrote a note to provider asking them to respond to this question and I removed the text from this cell so that the provider could respond. Anyways, I also removed all references to NMI in the cells, and wrote a note to provider about this. All else looks ok.","Y","NB","this was Punita's text that we did not delete. ","Needs More Information","HHSC removed language referring to NMIs. If the provider disagrees with changes, Provider must provide a response to the Description of Measure Bundle/Measure Impact for this Core Activity. Provider should include its response in the Provider Response field.","Description of Measure Bundle/Measure Impact for this Core Activity: Increasing navigation through coordination with other entities, to include call center contracts, local inpatient psychiatric hospitals, and local county jails; providing support with transportation assistance, increasing care to clients recently discharged from inpatient psychiatric facilities, and structuring a walk-in intake policy within the organization will decrease barriers to individuals obtaining behavioral health services resulting in a reduction of psychiatric hospitalization, resulting in completion of M1-390 and M1-160.","DF","I made updates to the Description of Measure Bundle/Measure Impact for this Core Activity as directed by the provider. Looks good. Other edits to this row were made during initial reviews to remove reference to updating the CA.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically changing the Description of Measure Bundle/Measure Impact.","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_081771001","081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",292,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","This Core activity will incorporate 3 areas of focus which have direct linkages and are congruent with the CCBHC model.  1. Depression Screening and appropriate follow-up for affirmative findings. 2.  Monitoring annual remission rates for individuals diagnosed with Major Depression and/or dysthimia. 3. Monitoring medication compliance for individuals served with a diagnosis of schizophrenia.","Establish baseline and concurrent medication compliance rates for individuals with schizophrenia","Establish corrolation of medication compliance and level of symptomology impacting quality of life."," Nurses monitor medications closely and follow-up with phone calls and/or drop off medications at residence if needed."," "," "," ","Consistant and standardized evaluation/screening for depression","System wide deployment of standarized depression screening by use of the PHQ-9","Establish baseline annual remission rates for individuals with diagnosis of depression"," Created monitoring system to alert provider staff when depression assessment was 11-13 months in arrears."," "," "," Expedite initial services"," Provide trauma screening at intake"," Provide social determinants of health screening at intake"," Take vitals and provide information to clients at intake"," Provide wellness education and create treatment plan incorporating trauma, social determinants of health, and wellness at intake"," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-181; M1-146; M1-180","Core activity creates provisions for standardized screening, treatment, Follow-up, and therapeutic maintenance which is congruent with both evidence based practice and provides care aligned with Certified Community Behavioral Health Clinic model.","No","","081771001.7.1","DF","Looks Ok.","N","NB","requested to revisit","Needs More Information","HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for CCBHC activities in addition to what is already described since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","The provider would like to add the following:\nSecondary Driver 1: Change idea 2\nNurses monitor medications closely and follow-up with phone calls and/or drop off medications at residence if needed.\nSecondary Driver 2: Change idea 3\nCreated monitoring system to alert provider staff when depression assessment was 11-13 months in arrears.\nSecondary Driver 3\nExpedite initial services\nSecondary Driver 3: Change Idea 1\nProvide trauma screening at intake\nSecondary Driver 3: Change Idea 2\nProvide social determinants of health screening at intake\nSecondary Driver 3: Change Idea 3\nTake vitals and provide information to clients at intake\nSecondary Driver 3: Change Idea 4\nProvide wellness education and create treatment plan incorporating trauma, social determinants of health, and wellness at intake\n","DF","I made the updates as requested by the provider.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating Secondary Driver 1, Change Idea 2; Secondary Driver 2, Change Idea 3; and Secondary Driver 3, Change Ideas 1-4.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_088334001","088334001.7.1",8,"088334001","Bell County Public Health District","Local Health Department (LHD)","Non‐State Owned Public",295,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Expanding access to sexually transmitted disease (STD) testing and treatment for all males and females seen at the Temple and Killeen clinics. Previously, walk-in STD testing and treatment was available two (2) full days a week at each clinic. The planned activity is to increase walk-in STD testing to three (3) full days a week for testing and treatment.","Increasing the time allotted for STD testing and treatment in each clinic will provide clients with an increased access to the clinic services","Added appointment times and added walk in times at each clinic","Listing the increased hours on social media platforms already in place"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-280; L1-345","Expanding practice access by increasing time alloted for STD testing and treatment will increase the screening for chlamydia in females 16-24 years old and decrease the percentage of newly diagnosed gonorrhea. Our clinics will accomplish this by providing greater flexibility for clients to choose time to come to clinics. It will also decrease wait times for these clients if a broader range of times is available. Clients can also bring partners in for testing and treatment. This will decrease the overall spread of these infections.","No","","088334001.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_088334001","088334001.7.1",8,"088334001","Bell County Public Health District","Local Health Department (LHD)","Non‐State Owned Public",296,"Prevention and Wellness","","Continue","","Implementation of evidence based strategies to reduce sexually transmitted diseases","","Review the pertinent literature to determine evidence based strategies specific to chlamydia infections and implement selected strategies in our clinics.","Clients with chlamydia infection are largely asymptomatic, so testing just clients who present with symptoms misses a large percentage of infections.","Offer screening to clients, especially in the selected population, who present to the clinics requesting contraception, but do not specifically request STD testing.","Use urine testing on clients who decline genital testing for chlamydia to increase number of clients who accept testing."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-280","Evidence shows that the highest prevalence of chlamydia infections occur in persons less than 24 years of age. By utilizing the evidence based strategies found in the literature, the clinics will increase screening in the targeted population of females 16-24 years old.","No","","088334001.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence based strategies to reduce sexually transmitted diseases.","CA-7","CA-7.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_094119702","094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private",306,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","To Reduce Emergency utilization for Behavioral Health and Substance Abuse conditions with a numerator that will have 2 different rates, the first being the total number of ED visits with a primary or secondary diagnosis of behavioral health conditions and the second being the total number of ED visits with a pimary or secondary diagnosis code of substance abuse with a denominator for both being the total number of ED visits for individuals.","Educate patients of the services we provide in this particular area\n","make resources, signs, and open communications that can educate our community more on what services we offer and how to utilize them\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","We believe that with getting out into our community and educating people on the services we offer in our behavioral health program, it will help reduce the admissions & Readmissions in the ER due to the Outpatient & Inpatient resources we offer that they can take advantage of.","No","","094119702.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_094151004","094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private",297,"Access to Primary Care Services","","Edit","Performing Provider is modifying Secondary Driver and Change Ideas to more accurately reflect the current activities as of the end of DY8 and the planned activities for DY9 and DY10.","Provision of screening and follow up services","","Performing Provider will implement standard processes for screening and follow up services.  This will include screening for tobacco use and following up with cessation interventions as appropriate, screening for pneumonia vaccination status and following up with vaccination as appropriate, and screening for presence of advance directives and following up with education and support as appropriate.  This core activity will impact approximately 5 locations and 15 providers.","Performing Provider will implement standard, role-based workflows in all applicable clinical settings to support consistent provision of all primary and preventive care screening and follow up services.","Clinical and operational leadership will develop education and training for new staff as well as maintenance education for existing staff to support compliance with all established workflows.","Clinical and operational leadership will monitor target population for completion of indicated screenings and utilize EHR functionality to communicate needed interventions."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The core activity directly impacts all measures in the selected Measure Bundle as described above in the description of Core Activity.  Specifically, this will include screening for tobacco use and following up with cessation interventions as appropriate, screening for pneumonia vaccination status and following up with vaccination as appropriate, and screening for presence of advance directives and following up with education and support as appropriate.","No","","094151004.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126844305","126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public",282,"Behavioral Health Crisis Stabilization Services","","Delete","Recognizing that provision of care aligned with the CCBHC model supports all activities under this core activity, BTCS consolidated Core Activity 2 under Core Activity 1.  BTCS ended Secondary Driver 2.1 and associated Change Ideas, as BTCS accomplished the target goal for expansion of acute psychiatric beds at the end of DY7.  Secondary Driver 2.2 was moved to Secondary Driver 1.4 under the CCBHC Core Activity, with no revision to the Driver or Change Ideas.","Implementation of community‐based crisis stabilization alternatives","","Growing evidence supports community-based acute psychiatric care settings, such as Crisis Stabilization Units, Extended Observation Units, Crisis Residential Treatment and Crisis Respite as effective, less restrictive alternatives to inpatient care.  According to a 2014 SAMHSA study, community-based crisis stabilization models demonstrate a return on investment as high as $2.16 per dollar invested and are just as effective as longer inpatient hospitalization.  This core activity is in alignment with the Comprehensive Inpatient Mental Health Plan and specifically supports Texas Statewide Behavioral Health Strategic Plan objectives 1.1, 2.3, 2.5, 2.6 and 4.2.  The continuation of the following projects will contribute to the successful achievement of this core activity:  CCR RHP7_126844305.1.2, ACT IDD RHP7_126844305.2.2, TDCJ RHP7_126844305.2.3, EOU RHP8_126844305.1.2, and TDCJ RHP8_126844305.2.4.","Increase the number of community-based acute psychiatric care beds serving individuals in our service area from 32 beds to 38 beds by the end of DY7.  ","Double the capacity of the Georgetown Extended Observation Unit (EOU) from 6 beds to 12 beds by the end of DY7. "," "," "," "," ","Sustain existing local Children's Crisis Respite (CCR) homes for children experiencing a personal or family crisis.","Obtain licensure for Children's Crisis Respite (CCR) homes to expand opportunities for reimbursement","Contract with at least one entity (insurance plan or agency) to provide respite care to children"," "," "," ","Engage in at least two efforts per year to increase jail diversion activities and continuity of care for persons exiting or diverted from jail which promote utilization of community-based acute care settings as opposed to criminal justice involvement for individuals with a mental illness and/or developmental disability.  ","Educate at least one community partner per year on the SAMHSA GAINS Center Sequential Intercept Model (SIM), and include references to SIM within relevant Memorandums of Understanding.","Complete SIM mapping exercises with community stakeholders, including law enforcement personnel, in at least two counties by the end of DY8.  ","Offer Mental Health First Aid for Law Enforcement trainings at least twice a year"," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-160; M1-181; M1-262; M1-305; M1-319","Increasing access to a broad continuum of community-based options for persons needing acute psychiatric care ensures we are able to coordinate: (1) interventions for moderate to severe depression, along with wrap-around services post-discharge which contribute toward remission (M1-146, M1-181), (2) suicide prevention and crisis stabilization when a person is at risk to self or others (M1-319, M1-262, M1-305), and (3) gradual step-down options for individuals discharging from state psychiatric hospital facilities who may need additional support before returning home (M1-160).","No","","126844305.7.1","DF","Looks OK. Provider is deleting this one. I initially started to remove the \"updated October 2018\" line at the end of some of the drivers and change ideas, but I am guessing that is not necessary as they are deleting this row.","N",null,"OK","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","BTCS accepts the suggested changes.   ","DF","A provider response on this one is unnecessary as the deletion was accepted.","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.","CA-11","CA-11.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126844305","126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public",283,"Access to Primary Care Services","","Delete","BTCS folded all active drivers and change ideas from Core Activity 3 under Core Activity 1.  This includes Secondary Driver 3.1, which became Secondary Driver 1.5.  BTCS modified the driver from engaging in at least one new partnership per year to focusing efforts on implementing Level 5 Integration.  BTCS ended associated Change Ideas 2-3 as both were accomplished at the end of DY8.  BTCS also moved Secondary Driver 3.2 under Core Activity 1, while ending Change Ideas 2 and 3, which have been accomplished.  BTCS ended Secondary Driver 3.3, as the driver and associated Change Ideas were achieved by the end of DY8.","Integrated physical and behavioral health care services","","Substantial research exists to support the benefits of co-locating or integrating physical and behavioral health care services.  According to the SAMHSA-HRSA Center for Integrated Care, benefits of integration include improving an individuals experience of care, improving the health of the general population, and reducing per capita healthcare costs.  Significant gaps exist for individuals with severe mental illness, which contribute to higher rates of physical health conditions, shorter life expectancies and higher health care costs (SAMHSA).  For these reasons, BTCS operates at Level 4 integration with an FQHC partner in Bastrop, Caldwell, Gonzales and Guadalupe counties to serve the holistic needs of individuals in our care.  We seek to strengthen this relationship and broaden primary healthcare partnerships in other areas.  This is in alignment with Texas Statewide Behavioral Health Strategic Plan objectives 1.2, 2.1, 2.3, 2.5, 3.1 and 3.2.  The continuation of Integrated Care RHP7_126844305.2.4 and Expanded Access RHP8_126844305.1.1 support this core activity.","Strengthen existing primary care services and partnerships by engaging in at least one new partnership or service each year.  Updated October 2018.   ","Sustain Behavioral Health Consultant positions through exploring various avenues by the end of DY10.  Updated October 2018.","Achieve a 90% fill rate for existing primary healthcare provider schedules by the end of DY8.  Updated October 2018.","Create an action plan by the end of DY7 to move from Level 4 to Level 5 integration.  Updated October 2018."," "," ","Establish at least one new healthcare partnership per year with organizations committed to holistic care.  Updated October 2018.","Improve and/or develop new referral pathways by collaborating on clear protocols with at least one partner per year.  Updated October 2018.","Implement at least two standardized screenings for the early identification of health conditions by the end of DY7.  Updated October 2018.","Utilize telemedicine and telehealth to increase access to services by the end of DY8.  Updated October 2018."," "," ","Promote the value of integrated services and educate on how to navigate resources by implementing the following change ideas in DY7-8.  Updated October 2018.","Ensure at least three checkpoints exist throughout clinic workflows to obtain relevant medical information (i.e. Name of Primary Care Provider, Physical Exam Records) by the end of DY8.  Updated October 2018.","Share protocols and lessons learned with community partners and stakeholders through at least one presentation or meeting per year.  Updated October 2018.","Include a module in New Employee Orientation about the value of integrated healthcare and how to access available resources by the end of DY7.  Updated October 2018."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-211; M1-210; M1-259","The integration of primary care and behavioral health services impacts this measure bundle through preventative care and screenings (M1-147, M1-211, M1-210) which result in coordination of appropriate care (M1-259).  Updated 2018 as M1-260 has been removed.","No","","126844305.7.1","DF","Provider is deleting this one.","N",null,"OK","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126844305","126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public",285,"Behavioral Health Crisis Stabilization Services","","Delete","Crisis and recovery services are also integral to the CCBHC model.  For this reason, BTCS folded any remaining and continuing Core Activity 5 drivers under Core Activity 1.  BTCS will continue Secondary Driver 5.1 by providing training to schools and community members under Category 5; this driver became Secondary Driver 1.9.  BTCS ended Secondary Drivers 5.2 and 5.3 as these drivers and associated Change Ideas have been achieved.  ","Implement models supporting recovery of individuals with behavioral health needs","","Evidence-based practices exist to support the recovery of individuals with behavioral health needs.  These include, but are not limited to: Wellness Recovery Action Planning (WRAP), Cannabis Youth Treatment (CYT), Individual Placements and Supports (IPS) Supported Employment, Supported Education, Seeking Safety, Cognitive Behavioral Therapy (CBT), Assertive Community Treatment (ACT), and Aggression Replacement Training (ART).  These services can be provided within models of care promoting recovery, such as Peer-Led Transitional Housing, Coordinated Entry, Integrated Care, First Episode Psychosis Coordinated Specialty Care, Extended Observation Units, Medication Assisted Treatment (MAT), Intensive Outpatient Substance Use Services, and the Sequential Intercept Model.  These models and evidence-based practices increase opportunities for recovery at the individual and family-level, group-level and system-level.  This core activity is supported by the continuation of the following projects:  SUD RHP6_126844305.1.2, Youth Counseling RHP7_126844305.1.1, CCR RHP7_126844305.1.2, SUD RHP7_126844305.1.3, Transitional RHP7_126844305.2.1, ACT IDD RHP7_126844305.2.2, TDCJ RHP7_126844305.2.3, Integrated Care RHP7_126844305.2.4, Expanded Access RHP8_126844305.1.1, EOU RHP8_126844305.1.2, and TDCJ RHP8_126844305.2.4.  These efforts align with Texas Statewide Behavioral Health Strategic Plan objectives: 1.1, 1.2, 2.1, 2.3, 2.5, 3.2 and 4.2.","Coordinate training for at least 500 staff, school personnel and community members for the early identification and intervention of behavioral health symptoms.  Updated October 2018.","Provide at least three trainings per year to educate law enforcement, school personnel, emergency departments and emergency responders on BTCS available service array.  Updated October 2018.  ","Provide Mental Health First Aid (MHFA and YMHFA) and Applied Suicide Intervention Skills Training (ASIST) to at least 400 people per year.  Updated October 2018."," "," "," ","Expand access to Certified Peer Specialists, Veteran Peers, Family Partners and Peer Recovery Coaches by hiring at least one new peer support position per year, or by collaborating with a partner to provide this service.  Updated October 2018.","Increase access to peer support and family partner services during crisis stabilization and follow-up by dedicating at least one position for this purpose during DY7.  Updated October 2018.  ","Participate on the Texas HHSC Peer Support Stakeholder Workgroup at least once per month until its conclusion to define the scope of peer support, along with training, certification and supervision requirements.  Updated October 2018."," "," "," ","Explore new and strengthen existing models for supporting recovery by fortifying or adding at least one new recovery-focused, peer-led curriculum, project, or program per year.  Updated October 2018.","Measure progress outcomes for individuals involved in Assertive Community Treatment by the end of Demonstration Year 8.  Updated October 2018.","Expand the availability of substance use services in acute crisis units by adding at least one onsite (in-person or televideo) substance use service per year at an Extended Observation Unit or Respite Center.  Updated October 2018.","Continue to develop financial sustainability for the adult transitional homes through a comprehensive sustainability assessment by the end of Demonstration Year 7, which includes strategies for implementation in DY8.  Updated October 2018."," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-261; M1-100; M1-160; M1-181; M1-257; M1-262; M1-263; M1-264; M1-265; M1-266; M1-305; M1-317; M1-319; M1-400; M1-405","Recovery-focused models promote rapid follow-up upon discharge from crisis service systems, as well as coordinated wrap-around services to reduce symptoms and prevent recidivism (M1-160, M1-181).  Assertive Community Treatment, Transitional Housing, First Episode Psychosis Coordinated Specialty Care, field-based case management and other models support psychosocial and risk assessments, vocational rehabilitation, housing assessments and skills training for individuals, regardless of diagnosis (M1-262, M1-263, M1-264, M1-265, M1-266, M1-305, M1-319, M1-405).  A substance use service continuum supports screenings, interventions and care planning for substance use disorders and co-occurring diagnoses (M1-100, M1-257, M1-261, M1-317, M1-400).  Updated October 2018.","No","","126844305.7.1","DF","Provider is deleting this one.","N",null,"OK","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126844305","126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public",709,"Availability of Appropriate Levels of Behavioral Health Care Services","","New","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","This is the same as the first Core Activity.  We have additional drivers to add and therefore are adding a second core activity to reflect the additional drivers.  The drivers added here are meant to flow with the first Core Activity.  Defined for the first time in the Excellence in Mental Health Act, Certified Community Behavioral Health Clinics (CCBHCs) provide a comprehensive range of mental health, physical health and substance use disorder services.  These integrated services are to be provided in a person-centered, trauma-informed and recovery-oriented way which serves the whole person.  Additionally, services are driven and measured by national quality standards.  The National Council reports that pilot site preliminary outcomes show improved access to care, increased community collaborations, and improved staff recruitment and retention.  Although Texas was not selected as a pilot site, BTCS is certified as a CCBHC and is aligning service delivery with the CCHBC model.  \nThis includes crisis services. Growing evidence supports community-based acute psychiatric care settings, such as Crisis Stabilization Units, Extended Observation Units, Crisis Residential Treatment and Crisis Respite as effective, less restrictive alternatives to inpatient care.  According to a 2014 SAMHSA study, community-based crisis stabilization models demonstrate a return on investment as high as $2.16 per dollar invested and are just as effective as longer inpatient hospitalization.\nSubstantial research also exists to support the benefits of co-locating or integrating physical and behavioral health care services, which is central to the CCBHC model.  According to the SAMHSA-HRSA Center for Integrated Care, benefits of integration include improving an individual’s experience of care, improving the health of the general population, and reducing per capita healthcare costs.  Significant gaps exist for individuals with severe mental illness, which contribute to higher rates of physical health conditions, shorter life expectancies and higher health care costs (SAMHSA).  For these reasons, BTCS is seeking to operate its integrated care settings at Level 4-5 integration to serve the holistic needs of individuals in our care.  \nAs a CCBHC, BTCS also integrates substance use services into its mental and physical health service array.  Medication-Assisted Treatment (MAT) is the combination of behavioral therapy and medications to treat substance use disorders, including Alcohol Use Disorders (AUD), Opioid Use Disorders (OUD) and Tobacco Use Disorders (TUD).  FDA-approved medications are utilized to relieve withdrawal symptoms so that a person may safely discontinue alcohol, tobacco, heroin or pain medications in outpatient settings.  Studies show that MAT decreases opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission.  \nEvidence-based practices exist to support the recovery of individuals with behavioral health needs.  These include, but are not limited to: Wellness Recovery Action Planning (WRAP), Cannabis Youth Treatment (CYT), Individual Placements and Supports (IPS) Supported Employment, Supported Education, Seeking Safety, Cognitive Behavioral Therapy (CBT), Assertive Community Treatment (ACT), and Aggression Replacement Training (ART).  These services can be provided within models of care promoting recovery, such as Peer-Led Transitional Housing, Coordinated Entry, Integrated Care, First Episode Psychosis Coordinated Specialty Care, Extended Observation Units, Medication Assisted Treatment (MAT), Intensive Outpatient Substance Use Services, and the Sequential Intercept Model.  These models and evidence-based practices increase opportunities for recovery at the individual and family-level, group-level and system-level.  \nThe continuation of the following projects will contribute to our success:  SUD RHP6_126844305.1.2, SUD RHP7_126844305.1.3, Integrated Care RHP7_126844305. 2.4, Expanded Access RHP8_126844305.1.2, and Youth Counseling RHP7_126844305.1.1, CCR RHP7_126844305.1.2, ACT IDD RHP7_126844305.2.2, TDCJ RHP7_126844305.2.3, EOU RHP8_126844305.1.2, and TDCJ RHP8_126844305.2.4.  Additionally, these efforts support Texas Statewide Behavioral Health Strategic Plan objectives 1.1, 1.2, 2.1, 2.3, 2.4, 2.5, 2.6, 3.1, 3.2, and 4.2.","Strengthen existing primary care services and partnerships by moving from Level 4 to Level 5 integration in DY9-10. ","Sustain Behavioral Health Consultant positions through exploring various avenues by the end of DY10.  ","Implement level five integration by the end of DY10 for at least two additional locations. ","","","","Establish at least one new healthcare partnership per year with organizations committed to holistic care.  ","Improve and/or develop new referral pathways by collaborating on clear protocols with at least one partner per year. ","","","","","Continue the provision of Medication Assisted Treatment in DY9-10. ","Participate in at least one continuous quality improvement exercise per year to improve programming and collaborations with external partners.  ","","","","","Coordinate training for at least 500 staff, school personnel and community members for the early identification and intervention of behavioral health symptoms. ","Provide at least three trainings per year to educate law enforcement, school personnel, emergency departments and emergency responders on BTCS available service array.","Provide Mental Health First Aid (MHFA and YMHFA) and Applied Suicide Intervention Skills Training (ASIST) to at least 400 people per year. ","","","","","","","","","",2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-100; M1-105; M1-146; M1-147; M1-160; M1-181; M1-210; M1-211; M1-257; M1-259; M1-261; M1-262; M1-263; M1-264; M1-265; M1-266; M1-305; M1-317; M1-319; M1-342; M1-390; M1-400; M1-405","This Core Activity has been added to allow for the connected drivers.  These secondary drivers are meant to be with the first core activity and the connection to the outcome measures is stated above with that core activity.  ","No","","126844305.7.1","DF","The provider added this Core Activity because they had too many secondary drivers than the template allowed. This Core Activity is just a continuation of their only other Core Activity with the additional drivers/change ideas. Not sure if this is how provider is supposed to do things - Maybe it just gets the same CA Unique ID. Please review. I also took out references such as Updated October 2019, and I wrote a provider about this. I also copied doen the Measure Bundles or Measures Impacted from their only other Core Activity as this CA is a continuation of their edited CA. I assumed that this one is Ok and accepted in the response to provider.","Y","NB","Can be OK but if have time update to provider's language, changed to NMI","Needs More Information","HHSC has removed references indicating when the change idea or driver were updated. HHSC also updated the Measure Bundles or Measures Impacted to reflect that this Core Activity is a continuation of provider's other Core Activity. If the provider disagrees with changes, please respond in the \"Provider Response\" column with the suggested changes.","BTCS accepts the suggested changes.   ","DF","Provider accepted previously made changes.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126936702","126936702.7.1",8,"126936702","Williamson County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public",300,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Our clinics will implement an expanded, comprehensive screening for immunization status.","Patient Screening for Immunization Status","Develop Standard Operating Procedure for screening and entering immunization status into EMR.","Test Standing Order for screening"," "," "," ","Increase competency of providers for parental follow-up after screening, to improve immunization schedule adherence.","Create a standardized toolkit to train providers to educate parents on the importance of childhood immunization and briefly counsel them on immunization gaps and how to obtain/document immunizations missing from the patient record."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-271; L1-108","One of the biggest challenges in achieving performance on this three immunization measures is assuring patient compliance - either by completing their immunization series, or evidencing it if complete. This Core Activity will significantly impact the selected measures by giving our providers and their patients better tools for understanding the necessity of vaccination, facilitating more effective counseling (based on best practices and industry successes), and ensuring that our internal record-keeping and follow-up with patients are being conducted consistently.","No","","126936702.7.1","DF","Looks OK.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_126936702","126936702.7.1",8,"126936702","Williamson County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public",301,"Access to Primary Care Services","","Edit","The Core Activity was changed because previous submissions for Secondary Drivers and Change Ideas into the DSRIP Online Reporting System for April DY8 wasn't included. The template had incorrect entries and was changed to reflect previous submission.","Provision of vaccinations to target population","","Our clinics will improve immunization in our population through enhanced outreach, improved inventory management, and advertised programs (\u0093Back to School,\u0094 etc.).","Implement strategies to improve resource capacity, reduce waste and save on cost","Work with MedLine to run use and needs analysis for clinical supply inventory, to standardize supplies and equipment, improve quality for patients, and identify cost savings.",""," "," "," ","Expand outreach activities                                   ","Implement creative marketing strategies to recruit more MLIU clients to our public health clinics to receive low or no-cost immunizations","Capitalize on existing activities, like Back-to-School physicals, to increase immunizations via add-ons to other encounters",""," "," ","","","","","",""," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-347; L1-147; L1-271; L1-108","This Core Activity has significance for all of our measures and is the activity we are using to identify cost savings. Working with MedLine will allow us to identify therapeutically-equivalent, lower-priced supplies, and standardize our inventory and ordering process. In addition to improving quality for patients (by having a consistent and uniform source of supplies with set pricing), this inventory management change will allow us to pass on cost savings to patients indirectly, through reallocation to services.","No","","126936702.7.1","DF","Looks OK.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_192622201","192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private",307,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","Cedar Park Regional Medical Center (\"CPRMC\") will implement am ED patient navigation program with three goals:  (1) identify individuals without a primary care provider and  connect them with such a provider to receive primary and preventive care; (2) identify Medicaid and Low Income and Uninsured (MLIU) individuals who would receive better care other than through the ED and connect them with such care; and (3) help ensure that patients receive the care they need in the right setting, which will in turn ensure that CPRMC will have healthier patients and will avoid unnecessary use of the emergency department.","Hire one or two full time personnel to screen MLIU and other individuals.","Referrals of appropriate patients to Samaritan Health Ministries"," "," "," "," ","Increase patient navigation, coordination, and resource connection services for patients","Implement a 24/7 RN telephone triage line using Good Health"," "," "," "," ","Identify patients who would benefit from navigation services","Create specific care pathways (through Good Health) and use case management personnel to help direct patients using these pathways."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","The provision of navigation services to connect patiients with primary care providers, reduce use of the ED, and improve the quality and efficiency of care provided to MLIU and other patients will reduce emergecy department visits at CPRMC for Acute Ambulatory Care Sensitive Conditions (ACSC) and other conditions.","No","","192622201.7.1","DF","Looks OK.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_220798701","220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private",287,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Patients who establish care at one of the PCMH locations will receive coordinated and integrated primary care services. Through connecting patients to a PCMH, preventive screenings and services will be included as part of the care that patients receive. We are considering ways to make access to screenings more convenient and integrated with other wellness types visits to help increase adherance. Using social workers, navigators and other staff to also help educate patients on the importance of preventive care will help to also increase adherance. We plan to socialize the preventive care measures with the physicians on a regular data dashboard will also help to create reminders and encourage physicians to help remind patients to get their appropriate preventive services.","Prevention not a priority for high risk/complex patients","Combine preventive and chronic disease care in fewer appointments, create reminders for preventive services through patient portal and other outreach strategies. We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. This can include, education through brochures and reminders through text messages and other means"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The core activity of establishing a PCMH for patients encompasses both chronic and preventive care services. The collective focus on prevention and wellness (in addition to chronic illnesses) from our emergency room departments, EMS, the overall hospital and the community will not only ensure that patients are connected to a PCMH, but will also help prevent catastrophic events and facilitate better self care/management strategies. We plan to engage physicians to educate and inform patients about preventive services, the importance of this and completion of preventive services in the PCMH. The PCMH is the main location where this work will occur.","No","","220798701.7.1","DF","Looks OK.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_353712801","353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private",303,"Expansion of Patient Care Navigation and Transition Services","","Delete","During DY8, many of the challenges faced by rural facilities became prevalent for Marble Falls in both the hospital and the limited clinics. Financial and budget constraints, staff downsizing, and leadership changes contributed toward eliminating the RN Care Manager role specifically designed for this Core Activity. Although the specific role was eliminated, we were able to realign certain elements of that role within the Baylor Scott & White Quality Alliance consolidation of services, much in alignment with the sustainability strategy.  ","Implementation of a care transition and/or a discharge planning program","","This program plans to utilize a Care Navigator (either a social worker or RN) to assist with medical and social navigation services to ensure patients are connecting to health related social need agencies and also primary care or other clinical services in the community. Through some education (written and verbal) and reinforcement post disharge, the MLIU patients will be connected to primary care and other local services as appropriate","Compliance and patient follow up post discharge from hospital to primary care","Provide educational pamphlets and reminders via phone/text about importance of preventive services in primary care"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Through catching patients when they come to the ED for preventable conditions/situations, we will use Care Navigators to help drive the dialogue with patients to primary care and establishing care at a PCMH in order to receive preventive and chronic disease management care. At the point when the patient comes to the ED, there is an opportunity for the Care Navigator to educate on the importance of prevention and connection to a PCMH to promote wellness and improvement in health outcomes.","No","","353712801.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 08_DY9-10 Regional Tracker - FINAL Tracker_DF.xlsb","8_353712801","353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private",304,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Patients who establish care at one of the PCMH locations will receive coordinated and integrated primary care services. Through connecting patients to a PCMH, preventive screenings and services will be included as part of the care that patients receive. We are considering ways to make access to screenings more convenient and integrated with other wellness type visits to help increase adherance. Using social workers, navigators and other staff to also help educate patients on the importance of preventive care will help to also increase adherance. We plan to socialize the preventive care measures with the physicians on a regular basis via a data dashboard. This dashboard will create reminders for physicians about 1) their metrics and 2) to remind them to encourage their patients to get their appropriate preventive services.","Prevention not a priority for high risk/complex patients","Combine preventive and chronic disease care in fewer appointments, create reminders for preventive services through patient portal and other outreach strategies. We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. This can include, education through brochures and reminders through text messages and other means"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The core activity of establishing a PCMH for patients encompasses both chronic and preventive care services. The collective focus on prevention and wellness (in addition to chronic illnesses) from our emergency room departments, EMS, the overall hospital and the community will not only ensure that patients are connected to a PCMH, but will also help prevent catastrophic events and facilitate better self care/management strategies. We plan to engage physicians to educate and inform patients about preventive services, the importance of this and completion of preventive services in the PCMH. The PCMH is the main location where this work will occur.","No","","353712801.7.1","DF","Looks Ok.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"DF",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_009784201","009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",310,"Expansion or Enhancement of Oral Health Services","","Edit","","Expanded use of existing dental clinics for underserved population","","To create new dental clinics to enhance access to care. ","We have identified two new locations for two new dental clinics to enhance access to care. ","We have identified two new locations for two new dental clinics. One location is in West Dallas and one location is in South Dallas. We will work with the City of Dallas at the West Dallas Multipurpose Center for the West Dallas location, and we will work with Frazier Revitalization to develop the South Dallas location. This location is at Hatcher Station Village which is adjacent to Parkland Health & Hospital System's newest Community Oriented Primary Care Health Center. We look forward to collaborating with Parkland to enhance access to oral health services for this under-served community. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"F1; F2; L1-225; L1-231","We will implement reporting on these measure bundles at the new South Dallas Dental Clinic. After the clinic opens, we will be able to report patient data related to this core activity.","No","","009784201.7.1","LH","NMI because Measures Impacted Description references that they added it during one of the reporting periods and status rather than how the Measures are Impacted by this CA","Y","NB","NB also changed the grouping and title and informed the provider. ","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from \"Access to Primary Care Services\" to \"Expansion or Enhancement of Oral Health Services\". HHSC also revised Core Activity title from \"Provision of services\" to \"Expanded use of existing dental clinics for underserved population\". If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. \n\nPlease indicate in the \"Provider Response\" column how the Measure Bundles/measures are impacted by this Core Activity. The current description references why the Core Activity was added and provides a status update rather than describing the impact on the measures. ","We accept these changes. We will implement reporting on these measure bundles at the new South Dallas Dental Clinic. After the clinic opens, we will be able to report patient data related to this core activity.  ","LH","Provider submitted response on 2/6 - updated field and noted that they will need to include more during reporting","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically changed the description of Measure Bundles/measures impact. HHSC approved this Core Activity; however, HHSC may require additional details for this Core Activity during DY 9 reporting (e.g.  additional details on how this Core Activity impacts the Measure Bundles).","Expanded use of existing dental clinics for underserved population","CA-3","CA-3.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020908201","020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private",311,"Chronic Care Management","","Edit","","Utilization of care management and/or chronic care management services","","Healing Hands Ministries will refer appropriate diabetic and hypertensive patients to the evidence-based Stanford Chronic Disease Self Management Program.  Healing Hands Ministries is also implementing shared medical appointments that will include a visit with dietician, physician and nurse in the same visit.  Nurse provides 1-1 education regarding insulin and other medications, dietician instructs regarding healthy eating plans.  The shared medical appointments are offered in English and Spanish.  They will also be implementing  individual appointments with the nurse for additional individualized education at the direction of the medical provider.","Implement shared medical appointments and individualized plans of care and nurse driven education.","Identify high risk chronic disease patients appropriate for shared medical appointments and individual appointments with nurse and/or dietician."," "," "," "," ","Locate CDSMP classes in low income, high need zip codes close to where patients live or receive care.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1","CDSMP classes, shared medical appointments and individual appointments with nurses and/or dieticians teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure.","Yes","CDSMP classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.).","020908201.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020908201","020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private",314,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.  Clinic will also be implementing a questionaire based database to identify social determinant and behavioral health needs of patients.","Implement Radiant Interactive Group, Inc.'s Lifespan platform to screen patients for factors related to social determinants of health and up to 15 behavioral health conditions.","Screen all new patients with the Lifespan platform to identify social determinants and behavioral health needs and utlize clinical team to facilitate interventions to address the needs.","Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By identifying and addressing the social determinants of health and behavioral health needs of patients, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","020908201.7.1","LH",null,"N","NB","NMI - asked for details","Needs More Information","HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","LH","Added CI 2 to SD 1","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically adding Change Idea #2 to Secondary Driver #1. ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020943901","020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private",315,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","By implementing and improving compliance with evidence based tactics that are proven to decrease infection and injury rates, we will improve care for patients and achieve our goals to reduce preventable infections and injuries. The tactics include proper insertion techniques, aseptic adherence, good hand hygiene, approriate screenings for infections and goal directed therapies.","Implement CLASBI evidence based care bundle components","Implement standardized checklist for insertion for actions pre-insertions, during and post-insertion","make available a standard CVC kit to ensure optimal products used (foley, dressings, CHG)","Implement daily review of necessity for central line and protocols for removal"," "," ","Improve early identification of sepsis and early directed goal therpay for surgical patients.","Screen patient pre and post surgical procedure to identify sepsis symptoms."," "," "," "," ","Compliance with basic standards of urinary catheter care","implement standardized best practice insertion techniques for urinary catheters","Improve aherence to nurse protocol for shift assessment of catheter need and removal per protocol"," "," "," ","STOP SSI bundle procedures to reduce surgical site infections in cardiac, hip and knee surgical patients","improve pre-surgical screening for Staphylococcus aurea (SA) to idenify patients postive for MSSA or MRSA","improve compliance with decolonization of SA for positive screened patients with nasal mupirocin and CHG bathing prior to surgical procedures"," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Implementing basic standards of care for urinary catheter care and CVC bas proven to decrease infection rates. Hourly nurse rounding is an evidence based process to decrease patient falls. Utilizing a bundle comprised for S. aureus screening, decolonization, and targeted prophylaxis was associated with a statisically significant decrease in complex S. aureus SSIs. Screening for sepsis patients before surgery and after to start goal directed therapy will reduce post sepsis infections and complications. The evidence based strategies have been proven to reduce infections/injuries and improve hospital safety.","No","","020943901.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020943901","020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private",317,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications","","Providers at PediPlace pediatric clinic will target asthma patients with an Asthma Opportunity including severity score, assessing medication needs, lifestyle, barriers and action plan to reduce need for ED visits","Management of pediatric patients with asthma based by using PASS (pediatric  asthma severity score)","Implement PASS (pediatric  asthma severity score) to determine likelihood of ED visits . easy to use and see score will improve provider knowledge of patients risk and improve medical management","Assessment of medication needs for asthma patients","Assessment of lifestyle and barriers to treatment ","Establishment of an action plan for improving patient's health by addressing issues identified in change ideas 1-3"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D4","Providing a systems ot measure severity of pediatric asthma will aide providers in deciding protocols for medical care . Tool availability should be easy to use and understand.","No","","020943901.7.1","LH","Previous DY7-8 reviewer notes were still included in change ideas. Updated text and asking provider if they agree with changes","Y","NB","In agreement","Needs More Information","HHSC has updated Change Ideas 1-3 to remove questions asking what happens with the assessment that appear to be remaining from the previous DY7-8 RHP Plan Update. HHSC has updated Change Idea 4 to indicate that the action plan will be based on the activities under Change Ideas 1-3. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. ","Provider agrees with HHSC updates for Change Ideas.","LH","Provider accepted HHSC changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020943901","020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private",318,"Availability of Appropriate Levels of Behavioral Health Care Services","","Delete","We have decided to no re-select the H2 Behavioral Health measure bundles for DY9 and 10 due to declining volumes and patient transitions to other providers in the area","Utilization of Care Management function that integrates primary and behavioral health","","Educating primary care providers on the risk of substance abuse for those patients with psychiartic disorders and comorbid influence we can advise them options for treatment plans using a mix of therapies and medications","Education of practitioners (behavioral and physical) on treatment options for patients with substance abuse","Implement alcohol screenings for patients with MDD and bipolar to indentify patients high risk of substance abuse"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"","By assessing patients alcohol use, we are better prepared to develop treatment plans for MDD and bipolar. Alcohol use  can compromise the treatment for psychiatric disorders.","No","","020943901.7.1","LH","QA Issue - 1st reviewer approved discontinuation of H2 and deletion of associated CA; however, if it does not get approved by 2nd review, then this CA should be changed to NMI","Y","NB","2nd review approved the discontinuation of H2. ","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020967802","020967801.7.1",9,"020967802","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private",320,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","HELP targets uninsured, high utilizers of emergency and acute services for enrollement into a chronic disease management program.  These uninsured patients generally are at higher risk for complications and co-morbidities.","Provide an APRN to manage chronic diseases (diabetes and heart disease) in low-income, uninsured patients frequently using the ED for chronic disease management as they do not have access to a medical home.  This will be provided through a chronic disease management program that includes clinical care.","Purchase new point-of-care testing equipment in the new HELP program location so the APRN can make timely adjustments to medications during the clinic visit.  These patients face many barriers including lack of transportation and lack of consistent communication service.  By providing point-of-care testing with results completed while the patient is still at their visit, the APRN can discuss the results and make changes to the care plan and medications at the time of the clinical visit providing efficient and effective management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","A mid-level provider using point-of-care lab testing allows for immediate changes to be made to medications helping the patients improve biometrics.","No","","020967801.7.1","LH","CA 320 Secondary Driver 1, Change Idea 1 is identical to CA 321 Secondary Driver 1 - need clarificiation and provider may consider combining.","Y","NB","OK","Needs More Information","For this Core Activity ID 320, Secondary Driver 1, Change Idea 1 is identical to Core Activity ID 321 Secondary Driver 1. Please indicate in the \"Provider Response\" column an updated Change Idea for this Core Activity ID 320 or consider combining the two Core Activities. If combining the Core Activities, indicate in the \"Provider Response\" column what the Core Activity Name, Core Activity Description, Secondary Drivers, and Change Ideas would be used.","Core Activity ID 320 should be:\n\nSecondary Driver:  MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.\n\nWork with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics.","LH","Comments appear to be mixed up and this response is intended for CA 321","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. Note that the provider response appeared to be intended for Core Activity ID 321 rather than 320. HHSC did not make changes to this Core Activity and only made changes to Core Activity ID 321.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_020967802","020967801.7.1",9,"020967802","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private",321,"Chronic Care Management","","Edit","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective. Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","020967801.7.1","LH","CA 320 Secondary Driver 1, Change Idea 1 is identical to CA 321 Secondary Driver 1 - need clarificiation and provider may consider combining.","Y","NB","OK","Needs More Information","For this Core Activity ID 321, Secondary Driver 1 is identical to Core Activity ID 320 Secondary Driver 1, Change Idea 1. Please indicate in the \"Provider Response\" column an updated Secondary Driver for this Core Activity ID 321 or consider combining the two Core Activities. If combining the Core Activities, indicate in the \"Provider Response\" column what the Core Activity Name, Core Activity Description, Secondary Drivers, and Change Ideas would be used.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","LH","Made changes from CA 320 response to CA 321","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updated Secondary Driver 1 to \"MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.\"","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_094140302","094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private",323,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identifying zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure).","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.","094140302.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_094140302","094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private",324,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","HELP targets uninsured, high utilizers of emergency and acute services for enrollement into a chronic disease management program.  These uninsured patients generally are at higher risk for complications and co-morbidities.","Provide an APRN to manage chronic diseases (diabetes and heart disease) in low-income, uninsured patients frequently using the ED for chronic disease management as they do not have access to a medical home.  This will be provided through a chronic disease management program that includes clinical care.","Purchase new point-of-care testing equipment in the new HELP program location so the APRN can make timely adjustments to medications during the clinic visit.  These patients face many barriers including lack of transportation and lack of consistent communication service.  By providing point-of-care testing with results completed while the patient is still at their visit, the APRN can discuss the results and make changes to the care plan and medications at the time of the clinical visit providing efficient and effective management."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","A mid-level provider using point-of-care lab testing allows for immediate changes to be made to medications helping the patients improve biometrics.","No","","094140302.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_094140302","094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private",326,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to addres social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)","Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","094140302.7.1","LH",null,"N","NB","NMI - asked for details","Needs More Information","HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","LH","Added CI 2 to SD 1","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically adding Change Idea #2 to Secondary Driver #1. ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_094192402","094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private",328,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","By implementing and improving compliance with evidence based tactics that are proven to  decrease infection and injury rates , we will improve care for patients and achieve our goals to reduce preventable infections and injuries.  The tactics include proper insertions techniques, aseptic adherence, good hand hygiene, apprproriate screening for infections and goal directed therapies.","Compliance with basic standard of urinary catheter care","implement standardize  best practice insertion techniques for urinary catheter","Enhance adherance to nurse protocol for shift assessment of catheter need and removal per protocol","implement appropriate CAUTI workup with reflex testing protocols"," "," ","Implement CLASBI evidence based care bundle components","implement standardized checklist for insertion  for actions pre-insertation , during and and post insertion","make available a  standard CVC kit to ensure optimnal products used (foley, dressings and CHG)","implement daily review of necessity for central line and protocols for removal"," "," ","Improve compliance with hourly nurse rounding to address 4 P's(potty, position, pain and possession) to reduce patient falls","Post weekly audits in units."," "," "," "," ","STOP SSI bundle procedures to reduce surgical site infections in cardiac , hip and knee surgical patients","implement pre-surgical screening for Staphylococcus aureua(SA) to identify patients postive for MSSA or MRSA","improve compliance with decolonization of SA for positive screened patients with nasal mupirocin and CHG bathing prior to surgical procedures"," "," "," ","Improve early identification of sepsis and early directed goal therpay for surgical patients.","Screen patient pre and post surgical procedure to identify sepsis symptoms."," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Implementing basic standard of care for urinary catheter care  and CVC has been proven to decrease infection rates. Hourly nurse rouding is an evidenc based process to decrease patient falls.  Utilizing a bundle comprised of S aureus screening, decolonization, and targeted prophylaxis was associated with a statistically significant decrease  in complex S aureus SSIs. Use of the full bundle was associated with significantly lower rates of complex S. aureus SSIs. Screenng for sepsis to start early directed goal therapy has decreases sepsis infections and complex sepsis in post surgical cases.  The evidence based strategies have been proven to reduce infections/injuries and inprove hospital safety.","No","","094192402.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_121758005","121758005.7.1",9,"121758005","Dallas County","Local Health Department (LHD)","Non‐State Owned Public",332,"Behavioral Health Crisis Stabilization Services","","Edit","Updated the core activity focus area for DY9 & 10. We will focus on aligning our strategies to support the updated community needs where clients with mental health issues and who are homeless may be diverted from jail to a new triage and/or deflection center where they will receive a variety of community-based services. Our activities will be focused on assessing the needs of the target population prior to them going to the triage and/or deflection center. As well as assessing and connecting clients to community services who are not required to go to the deflection or traiage center.","Implement models supporting recovery of individuals with behavioral health needs","","Dallas Countys behavioral health project involves behavioral health crisis stabilization services. Dallas Countys focus will continue to be on individuals who enter the criminal justice system through the Dallas County Jail. Throughout DY2-6, Dallas County has been able to see that the jail is a system that is utilized at a high rate by individuals with mental health needs. According to the data feeds used, approximately 60% of individuals in the jail have some sort of identifier of a past or current mental health need. This is from past or recent utilization of public systems, or through notification of mental health concerns from jail staff. Through our screening and triage process, we have been able to see that about 25-30% of the individuals in the jail have a current and active behavioral health concern. Through our core activity of behavioral health crisis stabilization services, we will continue to utilize our screening and triage system that allows for real-time identification of individuals booking into the Dallas County Jail with a mental health flag. As part of the Waiver extension, we will continue to utilize our system of identification and face-to-face assessments in order to refer and help link individuals to recovery-oriented treatment services in the community. Dallas County's behavioral health expansion project is actively taking part of the Smart Justice Initiative. This involves increased expansion of behavioral health assessments through judicial court order, and increased involvement in linkage to community-based services for individuals released from jail on a mental health personal recognizance bond. In DY9-10, Dallas County will focus efforts to enhance its face-to-face assessment process to include increased identification and brief interventions to address social determinants of health including housing and other psychosocial needs. Dallas County will continue to address behavioral health needs in the criminal justice system to help reduce recidivism and the rate in which individuals with mental health needs cycle through the system in crisis.","Utilization of mental health screening and triage system","Use increased mental health information and data feeds to aid in identification of those individuals in the Dallas County jail with a recent history or current behavioral health need."," "," "," "," ","Identification of individuals in the Dallas County Jail pending state hospital admission on a misdemeanor forensic competency commitment, in order to connect them to treatment services to allow them to connect to mental health services and a prescriber within 7-30 days after hospital discharge","Use weekly competency court staffings as a means for enhancing systems between the Public Defender's office and the District Attorney's office regarding case dismissals to aid in direct treatment linkage after hospitilization. Use this time as a way to also create quicker access to referrals in order to make strong connections in the jail and in the state hospital to assist with 7-30 community treatment connection and overall treatment fidelity."," "," "," "," ","Utilization of face-to-face mental health assessments in order to connect individuals in the criminal justice system to community treatment resources to aid in preventing system readmissions.","Utilization of the triage system to ensure timely completion of all face-to-face assessments to aid in connection with individuals in the Dallas County jail prior to release."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-160; L1-262; L1-263; L1-265","This Core Activity is directly tied to Measures L1-160, L1-262, L1-263 and L1-265 in that the key focus on our core activity is to aid in preventing access to higher levels of care, specificially the criminal justice system (Dallas County Jail) and inpatient hospital admissions. Through targeting our efforts around these measures and this core activity, we will continue to see increased utilization of lower levels of community-based treatment and resources, and reduce the rate of reentry into these higher level systems. Our measures provide a means to enhance and streamline processes to quicker identification and referral connection.","No","","121758005.7.1","LH","Although provider did not edit CA during DY8 Rd 2, it seems related to the addition of 3 measures and removal of 1 measure. QA Issue - If 2nd reviewer does not approve discontinuation of L1-241, then this needs to change to NMI ","Y","NB","HHSC has approved the addition of the new measure for DY9/10, so OK to adust this CA.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_121758005","121758005.7.1",9,"121758005","Dallas County","Local Health Department (LHD)","Non‐State Owned Public",333,"Prevention and Wellness","","Continue","","Implementation of evidence based strategies to reduce sexually transmitted diseases","","Dallas County is transitioning the DY2-6 project 2.2 into one of its core activities in DY7-8. Accordingly, DCHHS will continue its evidence-based health promotion program for disease prevention in communities with higher risk of preventable conditions such as STDs and TB. This activity will primarily involve dissemination of health information to prevent STD/TB infections and increase immunizations in high-risk populations by fostering protective behaviors.  To this effect, DCHHS will continue utilizing three previously tested strategies for expanding access to health information and enhancing community awareness of disease risks and available preventive services at the DCHHS facilities.  These strategies are:a)   Increase awareness by increasing community access to health information on disease prevention through promotion activities such as health fairs;b)   Utilize media presentations to promote behavior change by impacting knowledge, awareness and/or attitude; and c)   Collaborate with community stakeholders and medical providers through panel discussions, health education programs, printed materials, and social media.Under this activity DCHHS will continue to: (1) participate in community events and health fairs and distribute STD, TB and Immunization awareness packets as well as health promotional items; (2) conduct STD, TB, and Immunization presentations with topics on each disease and application of prevention techniques; (3) provide health information through information web postings, public announcements, social media, etc.; (4) conduct mobile clinic and field testing for STD/HIV; (5) conduct pre- and post-event assessments of event participants; and (6) develop relationships and collaborate with stake holders.","Collaboration with Stakeholders: Collaboration with various stakeholders to facilitate and organize events and address specific information needs.","Collaboration with Community Organizations: Collaboration with community organizations such as schools, colleges, senior homes, etc. to organize educational events and media presentations.","Collaboration with Medical Providers: Collaboration with other medical providers for information sharing and organizing joint events including free screenings."," "," "," ","Health Education and Promotion: Dissemination of information to create awareness and bring about behavioral changes.","Community Events and Presentations: Participation in community events to distribute STD, TB and Immunization awareness packets and health promotion materials. In addition, conducting presentations at various community organizations and agencies.","Web and Social Media: Utilization of DCHHS website and social media to disseminate health information and public announcements as well as notices about upcoming public events."," "," "," ","Increased Utilization of Preventive Services: Creating awareness about available screening and preventive services at the DCHHS.","Free Screening & Mobile Clinic: Conducting free STD screening and mobile clinics at community events and at previously identified locations in the community","Follow-up after initial treatment: Increase outreach and follow-up after initial treatment at the DCHHS clinics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-271; L1-344","L1-271: We believe that increased awareness on the benefits and availability of immunization services created through this core activity would positively affect the vaccination rate in the community including among adolescents.   In addition, our health educators will provide more specific information regarding the benefits of such vaccines as human papillomavirus (HPV) to dispel some misconceptions.L1-344: Through its health education and promotion program, DCHHS continues creating awareness on the transmission, treatment and prevention of STD including syphilis. We believe that this awareness will prompt individuals to practice preventive behaviors, seek proper treatment if diagnosed with infection, and adhere to treatment and follow-up protocols. In addition, as part of this core activity, DCHHS will intensify its outreach effort to elicit individuals for follow-up after initial treatment for Syphilis and other sexually transmitted infections.","No","","121758005.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence based strategies to reduce sexually transmitted diseases.","CA-7","CA-7.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_121776205","121776204.7.1",9,"121776205","Baylor Medical Center At Irving","Hospital","Private",335,"Patient Centered Medical Home","","Edit","","Utilization of care teams that are tailored to the patient’s health care needs","","In DY2-6 we focused on creating the services and infrastructure for a PCMH, now, through its establishment and success, we will focus on prevention as well as the high need populations of Diabetes through providing integrated, coordinated and structured PCMH care model.","Addressing chronic illness management and path to wellness and prevention","Use multipronged approach for education/reinforcement and convenience through incorporating chronic disease (diabetes and cancer screening) visits with regular office visits through reminders and patient messaging through the BSWH MyChart app to patients for follow up visits/screenings or medication and monitoring adherence.","Use multipronged approach for education/reinforcement and convenience through incorporating chronic disease (diabetes and cancer screening) visits with wellness, goal setting, and other techniques to improve overall quality of life."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C2","Patients connected to a PCMH will receive integrated and coordinated care addressing clinical and social needs. Through the utilization of RN Care Managers, CHWs, Pharmacists, there will be a focus on cancer screenings and diabetes education, prevention/maintenance and improvement coordinated with the Physician care and follow up.","No","","121776204.7.1","LH","Seems the Core Activity Name is not well-aligned and should instead be \"Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care\". Secondary Driver is too broad and Change Idea also seems like it could be narrowed","Y","NB","accepting 1st reviw results.","Needs More Information","It appears that the currently selected Core Activity Name of \"Utilization of care teams including non-physician health professionals\" may not be the best fit for the described Core Activity. HHSC recommends updating the Core Activity Name to \"Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care\". Please indicate in the \"Provider Response\" column if provider agrees or disagrees with this change. Provider may also consider updating the Secondary Driver to be more specific of what activities are taking place and narrow the Change Idea based on lessons learned in DY7-8.","Provider agrees with HHSC recommendation to update the Core Activity Name to \"Provision of coordinated services for patients under Patient Centered Medical Home (PCMH) model, which incorporates an empanelment of patients to physicians, and management of chronic conditions and preventive care.\" Provider submitted replacement of Secondary Driver 1 and 2 change ideas","LH","Updated SD1 and CI1, added C12","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updated Secondary Driver 1 and Change Idea 1 and added Change Idea 2. ","Utilization of care teams that are tailored to the patient’s health care needs, including non-physician health professionals, such as pharmacists doing medication management; case managers providing care outside of the clinic setting via phone, email, and home visits; etc.","CA-5","CA-5.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_121988304","121988304.7.1",9,"121988304","Lakes Regional MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",308,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of telehealth/telemedicine in delivering behavioral services","","Utilize telemedicine and telehealth services to provide consultations and increase capacity for behavioral health and other specialty provider services to targeted population in a rural service area.","Adequate access of telemedicine service capacity at major locations within service region.","Increased integration of EHR utilization and availability of patient treatment plan information to internal and external providers."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-105; M1-146; M1-147; M1-160; M1-257; M1-261; M1-262; M1-263; M1-265; M1-266; M1-317; M1-319; M1-385; M1-386","Measures selected will rely on ready access to licensed and medical staff during the diagnostic intake and evaluation process. Medical services will largely occur via telemedicine at all major outpatient sites. This will provide the basis for the interventions in in the individual's treatment plan to achieve improvement in the chosen measures.","No","","121988304.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_126686802","126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",338,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","UT Southwestern Medical Centers (UTSW) goal is to increase the documentation and utilization of preventative screenings in the primary care setting with the aim to provide patient education, increase access to follow up services and clinical interventions as needed. UTSW will employ effective evaluation, screening and diagnosis of patients with hypertension. Staff will appropriately utilize clinical interventions focused on managing patients blood pressure, ensuring blood pressure stays within the recommended control limit while also ensuring that a follow-up plan is documented in the patient EMR. One of the primary in-office evaluations with increased focus includes, but is not limited to, immunization status for patients.  Upon identified need, vaccinations will be provided to the target populations specified in the measure bundle.  UTSW will also emphasize the continued utilization of cancer screenings in the primary care setting. Several of the evaluations could include, but are not limited to, screening for cervical cancer, yearly colorectal exams, and applicable mammogram imaging. All providers billing for services within the defined UTSW system as they pertain to the associated measurement bundle specifications will be covered under this core activity. For a detailed list of clinic locations to be impacted please see Category C Selection tab","Routine in-office evaluation of patients medical history as it pertains to diagnosing preventative chronic health conditions","Implementation of a standardized approach to medical history documentation and review"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; C1; C2","This core activity ensures that an effective preventative health screening infrastructure is in place to ensure that patients may be effectively evaluated, screened, and diagnosed in accordance with the measure bundle metric specifications.","No","","126686802.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_126686802","126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",339,"Expansion of Patient Care Navigation and Transition Services","","Edit",null,"Implementation of a care transition and/or a discharge planning program","","UT Southwestern Medical Centers (UTSW) aim is to reduce readmission rates for select chronic conditions. Research has shown that a large percentage of hospital readmissions are preventable or avoidable. UTSW will expand and/or enhance the use of discharge processes to ensure patients are appropriately transitioned to the next level of care. All providers billing for services within the defined UTSW system as they pertain to the associated measurement bundle specifications will be covered under this core activity. For a detailed list of inpatient and clinic locations to be impacted please see Category C Selection tab.","Enhance the discharge process within the hospital to ensure appropriate transition of care","Collaborate with IR to build a discrete documentation process for documenting within an External Appointment Field in the EMR system, giving the capability to schedule and document appointments that occur outside the system due to patient travel limitations, patient preference, or continuity of care. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This core activity directly impacts measures within the B1 measure bundle, specifically targeting the measures related to reducing readmissions for high risk patient populations.","No","","126686802.7.1","LH","Approval of deletion is pending approval of discontinuing B1","Y","NB","this is an NMI for Cat C. should remain as an NMI here too. ","Needs More Information","Provider indicated that they are discontinuing Measure Bundle B1 Care Transitions and Hospital Readmission along with this Core Activity. Provider did not provide an adequate justification for deleting bundle B1 and has received an NMI. HHSC is not approving deletion of this Core Activity until the discontinuation of bundle B1 has been resolved.","UT Southwestern Medical Center is withdrawing the request to delete the B1 bundle and will continue this core activity. Update Change Idea 1 to: Collaborate with IR to build a discrete documentation process for documenting within an External Appointment Field in the EMR system, giving the capability to schedule and document appointments that occur outside the system due to patient travel limitations, patient preference, or continuity of care. ","LH","Updated Change Idea 1 based on provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating Change Idea 1 and impact to B1.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_126686802","126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",341,"Availability of Appropriate Levels of Behavioral Health Care Services","","Delete","Provider requested replacement during DY9-10 RHP Plan Update NMI response","Utilization of telehealth/telemedicine in delivering behavioral services","","UTSW has a current teletherapy program which could be expanded through collaboration with multi-disciplinary departments (such as primary care, psychiatry, telemedicine, etc.). Over the past several years, UTSW has worked on streamlining the process through which the VitalSign6 program is integrated into a clinic\u0092s typical workflow. All providers billing for services within the defined UTSW system as they pertain to the associated measurement bundle specifications will be covered under this core activity. ","Expand access to Telehealth services to patients who screen positive for depression in the primary care setting.\n","Enhance EMR documentation of PHQ scores and follow up plans"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","This core activity supports measure bundle H1 by establishing screening for depression and/or assisting with follow up and establishing new workflows by expanding telehealth services.","No","","126686802.7.1","LH","Change Idea #1 doesn't seem related to expanding access to telehealth","Y","NB","accepting 1st review results.","Needs More Information","Secondary Driver 1, Change Idea 1 does not appear to be a specific action related to Secondary Driver 1 of expanding access to telehealth services for patients who screen positive for depression. Please indicate in the \"Provider Response\" column an updated Change Idea 1 that connects to the Secondary Driver."," UT Southwestern Medical Center would like to change the core activity associated with the H1 bundle.  If possible, UT Southwestern Medical Center would like to change the name of the Core Activity to: Implement models supporting recovery of individuals with behavioral health needs.  As a part of the DSRIP program, UT Southwestern Medical Center (UTSW) has worked on implementation and utilization of Measurement-Based Care (MBC) model to screen, treat, monitor and assist recovering patients dealing with depression under the VS6 program. The VitalSign6 program is a quality improvement project, which utilizes a point-of-care web-based application, VS6 tool, to screen, monitor depressive symptoms, and support treatment planning and medical decision making. Under the aim of implementing this care model, VS6 team shares and disseminate evidence-based findings to train community providers who treat patients with depression.  The VitalSign6 program has a significant impact to the H1 bundle and, as such, increasing the screening through this program is a logical core activity for this bundle.\n\nShould HHSC approve this change to the core activity, the organization would state the secondary driver as: Identify patients with behavioral health needs through self-reported screening measures & by educating primary care clinic staff.   The associated change idea would be: increase the rate of documented symptom severity measures for patients with depression to support recovery of depressive symptoms and to track changes over time.","LH","Replaced CA with New CA","N",null,null,"Accepted","Based on the provider's response, HHSC has deleted the Core Activity for DY9-10 given the change to the Core Activity Grouping and added a new Core Activity. ","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_126686802","126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",710,"Behavioral Health Crisis Stabilization Services",null,"New",null,"Implement models supporting recovery of individuals with behavioral health needs",null,"UT Southwestern Medical Center (UTSW) has worked on implementation and utilization of Measurement-Based Care (MBC) model to screen, treat, monitor and assist recovering patients dealing with depression under the VS6 program. The VitalSign6 program is a quality improvement project, which utilizes a point-of-care web-based application, VS6 tool, to screen, monitor depressive symptoms, and support treatment planning and medical decision making. Under the aim of implementing this care model, VS6 team shares and disseminate evidence-based findings to train community providers who treat patients with depression. ","Identify patients with behavioral health needs through self-reported screening measures & by educating primary care clinic staff. ","Increase the rate of documented symptom severity measures for patients with depression to support recovery of depressive symptoms and to track changes over time.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","The VitalSign6 program has a significant impact to the H1 bundle and, as such, increasing the screening through this program is a logical core activity for this bundle.","No",null,null,null,null,null,null,null,null,null,null,"LH","Added CA per provider's response","N",null,null,"Accepted","HHSC has added the Core Activity based on the provider's response. ","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_127295703","127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public",342,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Continue to identify and proactively manage patients with chronic disease conditons that are high risk for developing complications and co-morbidities using evidence-based care protocols for specific conditions that will provide point of care, between care and post care interventions to improve the quality of life for patients as well as decrease high cost utilization within the healthcare system.","Maintain NCQA PCMH status in our primary care clinics.","A health care team will continue to tailor services to a patient's unique health care needs and proactively provide preventive, primary, routine and chronic care."," "," "," "," ","Identification of patients with chronic disease by the use of evidence based guidelines.","Continued use of the chronic disease registry to identify and manage patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C3","Management of chronic diseases through a registry and tailored health plans improve effective management of chronic conditions and ultimately improve patient clinical indicators, health outcomes, and quality.","No","","127295703.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_127295703","127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public",343,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Disease management emphasizes prevention of diseaserelated exacerbations and complications using evidencebased guidelines and patient empowerment tools. It can help manage and improve the health status of a defined patient population over the entire course of a disease.","Implement innovative evidencebased strategies to increase appropriate use of technology and testing for targeted populations.","Use patient registry to enhance patient screenings and immunizations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2; D1","Evidence-based strategies in disease prevention increase testing for targeted populations in reducing/preventing obesity, cancer screenings, tobacco cessation, and immunization status.","No","","127295703.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_135032405","135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private",345,"Patient Centered Medical Home","","Delete","Provider continues to support partner charity clinic but given that the clinic management is provided through another health system, the provider has chosen to focus its DSRIP activities within the provider's system.","Provision of services to individuals that address social determinants of health","","Provider will continue developing workflows to route hospital patients residing in Brother Bills Helping Hand clinic's targeted zip code (75212) and in need of a medical home and/or assistance with issues related to social determinants of health to the clinic. Established clinic patients will not only have access to the medical home, but also community services offered through the charitys other community partners. Services include a food bank, GED classes, exercise classes, and job training.In alignment with Methodist Dallas Medical Centers (MDMC) commitment to equitable, culturally competent care, the provider will also ensure that the clinic is staffed with a bilingual provider to meet the needs of the communitys growing Spanish-speaking population. Access to a primary care team and increased coordination between the clinic and MDMC will ensure continuous, comprehensive, and coordinated care for patients served by the medical home.","Increased coordnation of care between provider and medical home","Formalize referral process and establish primary point of contact","Educate providers Case Management and Social Services staff on clinics activities related to social determinants of health"," "," "," ","Increased access to quality, patient-centered care","Increase PCP availability and access by positioning a full time, bilingual provider in the clinic"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Brother Bills Helping Hand clinic's targeted zip code (75212) is an underserved, low income neighborhood within the providers service area. Establishing a medical home in the community will enable patients to manage their chronic illnesses with a primary care provider and avoid preventable ED visits. These potential outcomes directly align with the measures included in the Patient Navigation & ED Diversion bundle.","No","","135032405.7.1","LH","Reasonable that provider wants to delete CA, note that they didn't delete during DY8 Rd 2","N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health.","CA-5","CA-5.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_135032405","135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private",346,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","As in DY 2 - 6, the provider will continue to utilize at least two highly skilled, case management professionals (RNs and/or social workers), to identify frequent ED users and connect them to local primary care providers. Additionally, the navigators will work with the patient to identify the clinical and non-clinical factors driving the patients frequent ED visits and address care barriers (i.e. social determinants of health) with the goal of improving health outcomes and patient self-efficacy.  Interdisciplinary care teams will be leveraged to address high risk patients with complex clinical and social needs, through the development of care plans and care coordination with external care resources.Beginning in DY7, the patient navigators will be able to utilize the robust reporting and data collection capabilities of the providers new EMR to develop targeted interventions based on the patients individual care needs. This enhanced patient navigation intervention will allow navigators to efficiently identify, assess, and address this population of patients frequenting the ED for non-urgent care issues.","Increased care and referral coordination for patients with chronic illnesses and high ED utilization","Creating reports in new EMR to proactively identify patients with previous multiple visits in the last 6 months","Implement care plans for complex, high ED utilization patients","Formalize navigation workflows and communication with hospital, PCP, and MCO case management staff","Educate clinical staff and enable patient navigation referral in EMR"," ","Sufficient access to affordable primary care providers","Develop and maintain PCP resource list for MLIU patient population; ensure list is accessible in EMR. Utilize innovative outreach methods (i.e. volunteers - healthleadsusa.org, education events, texting, etc.) for communicating importance of PCP and appropriate ED usage to MLIU patient population.","","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2; J1","The provider's core activities will directly impact the measures included in the Patient Navigation & ED Diversion bundle by identifying and targeting this population of ED high utilizers and patients with frequent readmissions; providing related education on disease self-management and appropriate ED usage; and referring patients to an appropriate PCP or specialist with post discharge follow up as needed. Proactive coordination between clinical care teams and case management will contribute towards the hospital's patient safety goals as the core activities will develop increased communication channels among staff and proactive identification of patient risk levels.","No","","135032405.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_135234606","135234606.7.1",9,"135234606","Denton County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",349,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Utilization of Care Management function that integrates primary and behavioral health","","Operate an integrated clinic that has primary and behavioral health care together.  Work wholistically to understand client needs and provide care.  Employees both a psych provider and a medical provider to address co existing disorders.","provide an individual behavioral health and medical services in the same system","Run more screenings and labs for our mental health clients to determine the population need for further coordination of physical health needs."," "," "," "," ","upgrade technology to provide better communication between providers","We currently have two EHR systems. Our clients who receive integrated services have their records stored in one system and our non-integrated clients records are stored in another system. We are working to merge these two systems for more efficient care and record sharing. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-180; M1-390; M1-147; M1-317; M1-319","Our integrated clinic is measuring BMI, PHQ-9, suicide risk, tobacco cessation, and medication adhearance.  The clinic works with both psychiatric and medical providers to ensure that individuals that come into the clinic are receiving measurements needed to collect data and follow up with needed public health measures.","No","","135234606.7.1","LH","SD 1, CI 1 is unclear and repetitive of SD 1. SD 2, CI 1 is also unclear ","Y","NB","Accepting 1ster reviewer results","Needs More Information","Change Idea 1 for Secondary Driver 1 seems duplicative of the Secondary Driver language and should be a specific action, e.g. set up appointment system to allow for addressing physical health followed by behavioral health care, train physicians to incorporate behavioral health screenings. Change Idea 1 for Secondary Driver 2 is vague on what is referenced by streamline communication. If there are specific lessons learned from DY7-8, then update the Change Ideas to be specific actions and indicate them in the \"Provider Response\" column.","Under the change idea tab it could read: Run more screenings and labs for our mental health clients to determine the population need for further coordination of physcial health needs. ","LH","Provider submitted response on 2/7 - updated CI 1","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically changing Change Idea 1.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_135234606","135234606.7.1",9,"135234606","Denton County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",350,"Behavioral Health Crisis Stabilization Services","","Edit","","Implementation of community‐based crisis stabilization alternatives","","Continuation of our crisis residential unit which is built on psychosocial rehabilitation and group skills training on a variety of topics to decrease the likelihood of a client experiencing a crisis in the future.","Provide skills training groups daily to clients to increase independence","Provide at least 4 groups per day with a variety of topics"," "," "," "," ","Provide case management services to clients at CRU","Employ a Case Manager to assist clients in securing daily living needs prior to discharge"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-147; M1-319","This core activity was chosen because it has made a significant impact on our community.  It has helped the community by reducing hospital and jail recitivicim in the Denton area by providing individuals with new skills to cope with crises. The skills training does include information about nutrition and the health benefits of a safe BMI. The program also impacts depresion screening and suicide screening because the clients are taught how to seek help when experiencing either condition. Clients also are screened for depresion and suicide risk while in the program. ","No","","135234606.7.1","LH","Reporting flag - Asking if CA impacts measures since they referenced BMI, depression screening, and suicide risk in DY8 Rd 2 reporting ","Y","NB","In agreement","Needs More Information","Provider indicated that this Core Activity does not impact any selected measures. During DY8 Round 2 October reporting, provider noted that this Core Activity impacts the BMI measure, depression screening measure, and suicide risk measure. If this Core Activity does impact M-146, M-147, and M-319 or other measures, please indicate in the \"Provider Response\" column which measures and how they are impacted by this Core Activity. ","This program provides skills training and psychosocial rehab programs that can implact these measures. The skills training does include information about nutrition and the health benefits of a safe BMI. The program also impacts depresion screening and suicide screening because the clients are taught how to seek help when experiencing either condition. Clients also are screened for depresion and suicide risk while in the program. ","LH","Provider agreed to measures impacted","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating the impacted measures to include M1-146, M1-147, and M1-319 and updated the description of impact. ","Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.","CA-11","CA-11.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_136360803","136360803.7.1",9,"136360803","Denton County dba Denton County Health Department","Local Health Department (LHD)","Non‐State Owned Public",352,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","A reduction in the patient HBA1C is the AIM of the DSRIP project. A reduction of only 1% can reduce complication by 40%.  DCPH has established a successful Diabetic Education and Case Management team, of licensed and non-license professionals in both Denton and Lewisville locations. All team member are fluent in the native Spanish language, eliminating one of the largest barriers to care. This team is responsible of appointment follow up, face-to-face interpretation with patient and provider, medication distribution, in house CLIA waived testing, ( HBA1C, Retinal Scan, vitals, BG levels), and self-management education.","Secondary driver would be the education, which reduces the HBA1C, and empowers the patient to take control of their disease. The empowerment comes from the knowledge brought to light during individual and group weekly education classes. The collaboration with Texas AM AgriLife allows the use of a proven education system implemented through the DECM program. Nutrition is the driver for the education provided by the DECM program. Self-management is teaching empowerment for the patient to take control of their disease. Case managers, by participating in the face-to-face office visit now can provide feedback to the provider and precise interpretation of the language.","The DECM team at weekly group education provide a diabetic friendly meal. At each class, the chief provides a small demonstration of how to prepare the meal, leaving recipes for the class.","Standard Delegation of Orders are being up dated to allow more freedom for the licensed personnel to provide testing and assessments to keep the provider more informed on the patients condition"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-207; L1-115","The DECM team in both locations addresses each measure. As the team works with the patient to improve the HBA1c, the team is continuously feeding information to the provider. This information can be in the form of continuous glucose monitoring, blood levels of lipids, ongoing educational improvements and the increase in self-management of the disease. Applied The Wagner Chronic Care Model to each measure creates a team of professionals caring for the patient. Empower the patient and increasing self-management.","No","","136360803.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_137252607","137252607.7.1",9,"137252607","Metrocare Services","Community Mental Health Center (CMHC)","Non‐State Owned Public",353,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Added the two new measures, M1-262 and M1-305, to the Measures Impacted by this Core Activity section as both measures are also utilized as measures for the CCBHC model.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","The organization has chosen to align with the Certified Community Behavioral Health Clinic (CCBHC) model which will consist of activities such as preventative screenings and other clinical quality efforts. The alignment of CCBHC means the agency will increase services that impact utilization, quality, and outcomes thereby reducing emergency room utilization and jail costs while increasing the life expectancy of individuals served.","Implement preventative care screenings and care protocols targeted towards impacting medical and behavioral health.","Test standing order for physical health screenings","Incorporate new processes for behavioral screening & interventations"," "," "," ","Enhance service delivery to individuals with autism to impact quality of life","Incorporate new training curriculum for parent and caregivers."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-211; M1-317; M1-386; M1-261; M1-103; M1-115; M1-125; M1-147; M1-180; M1-207; M1-210; M1-255; M1-259; M1-262; M1-319; M1-385; M1-400; M1-305","The alignment of CCBHC means the agency will increase services that impact utilization, quality, and outcomes thereby reducing emergency room utilization and jail costs while increasing the life expectancy of individuals served.  ","No","","137252607.7.1","LH",null,"N","NB","cleaned up the language","Needs More Information","HHSC deleted the following reference to M1-305 from Description of Measure Bundle/Measure Impact since the measure is added to the list of measures impacted: \"M1-305 is also impacted by this Core Activity. The template would not allow me to select or add it to the table above.\" If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column. ","Metrocare does not disagree with HHSC Initial Comments to Provider.","LH","Provider accepted HHSC changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",354,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","A care transition program, including a discharge planning and post discharge support, will be developed and applied across the continuum of care at Childrens Health.  Clinical and administrative leadership from emergency care, acute care, ambulatory care, primary care, home health, physical medicine and rehabilitation (Our Childrens House), care management (accountable care, case management, care coordination, and patient education will develop the program to facilitate a supportive, consistent approach to transition.","The program will work to build stronger relationships and collaboration with some less utilized resources such as payer case management. The project will also include collaboration with Health Information Management and Information Systems for data collection and standardized documentation to enhance communication between providers and with patients. This would include standardization in utilization of our discharge documents and a creation of a provider to provider handoff tool.  In this program, patients will be stratified utilizing a system-wide risk stratification method based upon complexity of diagnosis, previous health behavior, and the cost of care provided. This determines needs with discharge planning and the level of support offered at the time of discharge.","Patients will be stratified utilizing a system-wide risk stratification method based upon complexity of diagnosis, previous health behavior, and the cost of care provided.  This determines needs with discharge planning and the level of support level of support offered at the time of discharge.  The activity will be based on the Population Health model where the population is divided into three groups; the highest risk, the rising risk, and the generally healthy population.  T"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The patient will receive right level of care at the right place, and at the right time and the family will be confident in following the treatment plan, know what the next point of care is, and who to contact with any concerns.","No","","138910807.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",355,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services",null,"Childrens Health primary care clinic locations will actively implement a patient appointment reminder system. Providers and clinic staff throughout Childrens Health will reach out to patients to notify them of their annual well-child appointments, immunizations, sick visits and any other primary care appointments as appropriate. Childrens Health primary care locations that include Childrens Health Pediatric Group (CHPG) practices, Complex Care, Foster Care, adolescent based clinics such as our Dallas Adolescent and Young Adult (AYA) Program and clinics that serve the At-risk patient population.","The Childrens Health primary care clinic locations will incorporate the Electronic Health Record (EHR) system as an avenue of patient preventive reminder distribution. The EHR system will allow providers and staff to use a bi-directional method of communication which is administered through a patient portal called MYChart.  In addition, a preventive outreach mail-out campaign will be utilized to inform patients of their annual well-child appointment. This campaign is scheduled to run on an ongoing basis. Providers and staff will also implement a telephonic patient reminder system, in which the clinic staff will actively call the patient prior to their scheduled appointment.","Childrens Health will monitor patient no-show rates to determine if method and frequency of the patient reminder system needs to increase with telephonic reminders, patient reminder mail-out cards, or by EHR preventive reminder distribution."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","The impact of this core activity ensures that patients have adequate access to well-child appointments, prevention services, and urgent care appointments on an as needed basis.","No","","138910807.7.1","LH","Use of \"Other\" for Core Activity name seems appropriate here as there is not a CA for Patient Outreach - reminders for well-child visits","Y","NB","Revisit","Needs More Information","HHSC recommends that the provider revisit its Core Activity Title/area to see if this Core Activity can be reflected by the options in the menu. Provider can consider \"Provision of Screening and Follow up Services\" as a Core Activity title. Please respond in the \"Provider Response\" column with the suggested changes.","Provider agrees with the core activity name change","LH","Provider accepted HHSC changes","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating the Core Activity name.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",358,"Hospital Safety and Quality","","Edit","","Implementation of evidence-based practices to improve quality of care",null,"Across Childrens Health, we conceptualize, evaluate, and continually work to improve quality from the perspective of the patient and their family and their expectations of healthcare providers. The Quality Program puts the patient and their family at the center of everything we do with the standard of meeting their expectations: Keep me safe, heal me, and Be Nice to me in this order.  Our teams are dedicated to Patient Safety, Quality, Clinical Quality Improvement, and Infection Prevention and Control.   The Safety and Quality department has developed a Hospital Acquired Pressure Injuries (HAPI) Improvement Team with the goal to provide processes to maintain skin integrity, prevent skin breakdown, and promote healing if skin integrity is compromised.","1. Patient Safety Tool Kit2. Yes, to safety, no exceptions patient safety classes","1. Optimization of Hospital Acquired Condition (HAC) Flowsheet in Epic  Improve staff understanding of the HAPI bundle requirements Ensure all documentation rows are included in the HAC flowsheet Provide reinforcement education on proper use of HAC flowsheet","2. Bundle Reliability Improvement Efforts Goal to reach 90% reliability to the HAPI Bundle Creation of observer education to help clarify compliant versus non-compliant elements Identify opportunities for improvement by analyzing trending non-compliant elements Utilize monthly Skin Safety Flyer for education on identified areas of improvement","3. Implementation of newly revised Braden QD Scale Revised mobility scale that helps predict both immobility-related and device-related pressure injury risk in pediatric patients Creation of computer based testing (CBT) for nursing staff","4. Skin Safety Fair    Provide information on various pressure injury prevention equipment/supplies/devices Provide hands-on sessions for proper processes regarding repositioning/turning Creation of virtual sessions/workshops to accommodate staff schedules"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3","The impact of this core activity supports the development, implementation, and monitoring of initiatives aimed to improving the quality of care for patients through establishing clinical standard work guidelines and associated supporting tools.","No","","138910807.7.1","LH","This CA appears to fit under either of the other Hospital Safety and Quality names and does not need to be distinguished","Y","NB","In agreement","Needs More Information","Provider selected \"Other\" for Core Activity Name; however, it seems this Core Activity could be under \"Implementation of evidence-based practices to improve quality of care\". The Core Activity Name is not intended to target or limit by population. Please indicate in the \"Provider Response\" column if provider agrees with the Core Activity Name change to assist HHSC in standardizing analysis of Core Activities.","Provider agrees with the core activity name change","LH","Provider agreed to CA name change","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating the Core Activity name.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",359,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of Care Management function that integrates primary and behavioral health","","At the center of the program is the behavioral health care manager (BH CM) who is aligned to 3-4 pediatric primary care practices, becoming a member of the treatment team.  The relationship and inter-dependence forged by the BH CM and the medical providers is the key to program success.  The BH team serves to enhance the treatment outcomes for all children and families they serve by surrounding the family with resources, providing brief interventions and keeping communication flowing with all involved in the patient familys care.   The BH CMs are on-site in each practice and are available for consultation and case collaboration, as well as to meet potential referrals and provide in person direct services.  The provider is encouraged to refer all patients where there is any suspicion of a behavioral health concern. Once a referral is received the BH CM contacts the family within two days of receipt of the referral for standard cases and immediately for urgent referrals.  The BH CM conducts a structured, assessment  a comprehensive, clinical interview designed to assess various psychosocial domains and elicit information about the patients broader level of behavioral health functioning.  At the completion of the assessment, the BH CM, in collaboration with the family, develops a care plan which includes the patient and familys behavioral goals, barriers to reaching those goals and strategies to address those barriers.","The BHCM will conduct a structured comprehensive assessment to assess various psychosocial domains and elicit information about the patients broader level of behavioral health functioning.  At the completion of the assessment, the BHCM, in collaboration with the family, will develop a care plan which includes the patient and familys behavioral goals, barriers to reaching these goals and strategies to address these barriers.  The care plan may include:  brief-short term psychotherapy sessions conducted in-person or virtually, to include the patient and the patients family, referrals to community resources if needed, and advocate with providers, school personnel or community resources.","The assessment, the BH CM, in collaboration with the family, develops a care plan which includes the patient and familys behavioral goals, barriers to reaching those goals and strategies to address those barriers. The care plan may include: 1) brief-short term psychotherapy sessions conducted in-person or virtually between the BH CM, the patient and the patients family, focused on behavioral activation, motivational interviewing, psycho-educational counseling, cognitive-behavioral and solution-focused interventions. These interventions have demonstrated efficacy in short-term settings; 2) referrals to community resources (psychiatry, support groups, etc.), including regular telephonic follow-up phone calls to ensure the family has connected with the resources, the resources are meeting the familys needs, and the family is effectively working with on their care plan; 3) advocacy with providers, school personnel or community resources."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","The core component of utilization of the care management function will directly support the fulfillment of the measure bundle by ensuring patients receive a follow-up contact by licensed Behavioral Health clinician through referral linkage and case management follow-up and by providing in-person short-term behavioral health intervention through in-clinic therapy sessions.","No","","138910807.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",361,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","The addition of a social worker to help support the more than 3,000 patients in the diabetes clinic and COACH clinic combined.  A social worker helps parents and patients understand that diabetes is a family disease, helps to develop family milestones, and encourages the adherence to healthy lifestyle behaviors they were introduced to in the clinic.","Develop and implement diabetes management interventions that improve patient health outcomes and quality of life, prevent onset or progression of comorbidities, and reduce unnecessary acute and emergency care utilization.","Utilize social workers to help parents and patients understand that diabetes is a family disease, helps to develop family milestones, and encourages the adherence to healthy lifestyle behaviors they were introduced to in the clinic."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D5","One in seven youth with T1DM meet the clinical cutoff for depression which is double the rate of depression in children without diabetes (Hood et al, 2006); one in four adolescents with T1DM has depressive symptoms. Depression in children and adolescents with T1DM has been associated with poorer glycemic control and recurrent diabetic ketoacidosis admissions.Children and adolescents face many psychosocial barriers that may prevent effective diabetes management. These barriers may come in a roller coaster like pattern and each developmental stage can bring on new and unique challenges.   As a child matures, he/she assumes more responsibility in their disease management.  This additional accountability and burden can lead to a failure to adhere to management strategies or perhaps indulging in self-destructive behaviors.  Social workers play an important role in a healthcare team, and their skills are particularly important in diabetes management. A diabetes diagnosis can be frightening and overwhelming for children and adolescents, as the single most important issue is a feeling of being different from their peers. Social workers help parents and patients understand that diabetes is a family disease.  They provide assistance in developing family milestones and encouragement in the patients  adherence to the healthy lifestyle behaviors introduced to in the clinic.","No","","138910807.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_138910807","138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private",362,"Access to Primary Care Services","","Edit","","Integrated physical and behavioral health care services","","Childrens Health primary clinic locations will continue to integrate behavioral health services in the primary care setting. Behavioral health services to include depression screening for patients ages 11 years through 18 years, autism screening for ages 18 months through 30 months, ADHD management for patients ages 6 years through 18 years, as well as access to psychology services.","Implementation of an Appointment Compliance Initiative. Intervention reports will be reviewed weekly and continue to allow clinic staff to effectively identify patients who may not have received the necessary follow up appointments. Childrens Health staff will call patients who need their 30-day follow-up and patients who are in the continuation phase to assist in appointment compliance. The project team will also continue to try new methods for reminding families and address any transportation issues they may have that would prevent them from keeping appointments.","Follow up calls for patients who need their 30 day follow up appointment. Childrens Health will monitor patient no-show rates to determine if methods for reminding patients on their appointments are appropriate.","Follow up calls for patients who are in the continuation phase to assist in appointment compliance. Childrens Health will monitor patient no-show rates to determine if methods for reminding patients on their appointments are appropriate.","Initiative to add the transporation issues."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","The impact of this core activity ensures that patients have adequate access to behavioral health appointments on an as needed basis.","No","","138910807.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. Note that HHSC has removed extra text from Secondary Driver 1, Change Idea 3 asking how the transportation issues will be addressed. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_139485012","139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private",364,"Chronic Care Management","","Edit","","Utilization of care management and/or chronic care management services","","Utilization of a care management team comprised of RN Care Manager, CHW, Pharmacist and Physician overisght to help with patient education, treatment, medication management and counseling/support for lifestyle change management and wellness. There will be a focus on CHF/Heart Disease, Diabetes, COPD/Asthma by this care team to ensure patients are receiving comprehensive clinical care","Addressing chronic illness management and path to wellness and prevention","Utilization of creative strategies for care management including follow up phone calls","Utilization of creative strategies for care management including wellness care plans","Utilization of creative strategies for care management including techonology through the use of RetinaView portable scanning machines to increase point of service capacity for diabetes eye exams at the clinic locations.","Utilization of creative strategies for care management including  tracking of behavior change goals"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C3; A1; A2; C2; H1","All of the measure bundles are impacted and benefit from the integrated care management approach to chronic disease through a heightened focus on the patient on chronic illness management, other services such as cancer screening, behavioral health and Hep C will also be addressed as part of managing the holistic needs of the patient. Specifically A1 and A2 will be addressed by this team approach","No","","139485012.7.1","LH","Change idea reference technology (TBD) so asking for clarification","Y","NB","broked down Change Idea 1 into several. Inlcuded feedback. Kept 1st review feedback. ","Needs More Information","HHSC created multiple Change Ideas for Secondary Driver 1 by separating all items that were included in Secondary Driver 1: Change Idea 1 “Utilization of creative strategies for care management including follow up phone calls, wellness care plans, technology (TBD) and tracking of behavior change goals\". If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. Secondary Driver 1, Change Idea 3  references \"technology (TBD)\". Based on lessons learned in DY7-8, please enter in the \"Provider Response\" column an updated Change Idea to address the TBD or other needed changes that are specific actions.","Provider agrees with HHSC change creating multiple Change Ideas for Secondary Driver 1 that were originally all-inclusive in the original Secondary Driver 1: Change Idea 1. Provider would also like to update the Secondary Driver 1, Change Idea 3 to read, \"Utilization of creative strategies for care management including techonology through the use of RetinaView portable scanning machines to increase point of service capacity for diabetes eye exams at the clinic locations.\"","LH","Provider agreed to split out of Change Ideas and updated CI 3","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating Change Idea 3.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_209345201","209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private",366,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","As in DY 2 - 6, the provider will continue to utilize at least two highly skilled, case management professionals (RNs and/or social workers), to identify frequent ED utilizers and/or patients with frequent hospital admissions and connect them to local primary care providers. Additionally, the navigators will work with the patient to identify the clinical and non-clinical factors driving the patients frequent hospital visits and address care barriers (i.e. social determinants of health) with the goal of improving health outcomes and patient self-efficacy.  Interdisciplinary care teams will be leveraged to address high risk patients with complex clinical and social needs, through the development of care plans and care coordination with external care resources.Beginning in DY7, the patient navigators will be able to utilize the robust reporting and data collection capabilities of the providers new EMR to develop targeted interventions based on the patients individual care needs. This enhanced patient navigation intervention will allow navigators to efficiently identify, assess, and address this population of patients.","Increased care and referral coordination for patients with chronic illnesses, high ED visits, and frequent hospital readmissions","Creating reports in new EMR to proactively identify patients with previous multiple visits in the last 6 months","Implement care plans for complex, high ED utilization patients","Formalize navigation workflows and communication with hospital, PCP, and MCO case management staff","Educate clinical staff and enable patient navigation referral in EMR"," ","Sufficient access to affordable primary care providers","Develop and maintain PCP resource list for MLIU patient population; ensure list is accessible in EMR.","Utilize innovative outreach methods (i.e. volunteers - healthleadsusa.org, education events, texting, etc.) for communicating importance of PCP and appropriate ED usage to MLIU patient population."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","The provider's core activities will directly impact the measures included in the Patient Navigation & ED Diversion bundle by identifying and targeting this population of ED high utilizers and patients with frequent readmissions; providing related education on disease self-management and appropriate ED usage; and referring patients to an appropriate PCP or specialist with post discharge follow up as needed.","No","","209345201.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_391575301","364710901.7.1",9,"391575301","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private",329,"Patient Centered Medical Home","","Delete","Provider request removal of the Patient Center Medical Home Core Activity.  Although the provider still refers to the Mission East clinic, the clinic relocated from Dallas to Mesquite, TX. The new location is not on the Dallas Area Public transportation line.  Patient’s either refuse to be referred there or they no-show if they are referred due to lack of transportation.  In addition, the status of the ongoing partnership with this clinic is under review.   \n\nThe provider refers patients to other appropriate resources as well, but they may not be a PCMH.  ","Provision of coordinated services for patients under Patent Centered Medical Home model","","White Rock has partnered with Mission East Dallas, a local FQHC that is a certified PCMH to improve access to primary care services available to LIU in the East Dallas, Mesquite and Garland communities.  White Rock identifies LIU individuals utilizing its emergency room for chronic conditions and those without a dedicated primary care are referred to Mission East Dallas for Medical Home treatment of their chronic conditions, services that are not appropriate in an episodic environment like an ER.","Management of patients utilizing the hospital emergency room for non-acute/chronic disease management concerns","Identify patients utilizing the hospital emergency room for non-acute/chronic disease management concerns. Provider will utilize eMR system to identify individuals that fall into two categories; high utilizers of emergency room and those whose chief complaints are identified as chronic disease management in nature such as CHF, COPD exacerbation and symptoms related to uncontrolled diabetes.  Both of these groups will be reviewed concurrently to identify opportunities to provide linkage to resources that will address the chronic disease management needs.","Connect patient with Mission East Dallas or Hospital CHF Clinic based on individualized issues"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","Project, while it does not impact any selected Measure Bundles, but it does tie directly to the RHP 9 Community Needs Assessment, conducted in 2017 which notated the needs to focus on Chronic disease care as well as support the needs fore care coordination and preventative care.","No","","364710901.7.1","LH","Approval of deletion is pending approval of discontinuing B1","Y","NB","OK","Needs More Information","Provider indicated that they are discontinuing Measure Bundle B1 Care Transitions and Hospital Readmission along with this Core Activity. Provider did not provide an adequate justification for deleting bundle B1 and has received an NMI. HHSC is not approving deletion of this Core Activity until the discontinuation of bundle B1 has been resolved.","Provider request removal of the Patient Center Medical Home Core Activity.  Although the provider still refers to the Mission East clinic, the clinic relocated from Dallas to Mesquite, TX. The new location is not on the Dallas Area Public transportation line.  Patient’s either refuse to be referred there or they no-show if they are referred due to lack of transportation.  In addition, the status of the ongoing partnership with this clinic is under review.   \n\nThe provider refers patients to other appropriate resources as well, but they may not be a PCMH.  ","LH","Provider's response of reason for deletion is acceptable and added to explanaiton","N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 09_DY9-10 Regional Tracker - FINAL Tracker.xlsb","9_391575301","364710901.7.1",9,"391575301","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private",330,"Expansion of Patient Care Navigation and Transition Services","","Edit",null,"Identification of frequent ED users and use of care navigators","","White Rock has developed and implemented a standardized care transitions model that addresses the individualize needs of patients being discharged from the hospital and identifies post-acute services that the patient requires.  The patients are matched up with the resources available within the community and follow up calls are performed to ensure compliance.","Open new 501a Clinic - an Integrated Primary and Specialty Care Clinic","In addition to community resources, connect identified patients to City Hospitals White Rock new 501a clinic being implemented in DY9"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","By implementing a standardize methodology for care transitions, hospital staff can ensure that consistant information is received on patients improving its ability  to identify post acute services needed and improving impacts on readmissions due to noncompliance on instructions due to lack of knowledge.","No","","364710901.7.1","LH","Approval of deletion is pending approval of discontinuing B1","Y","NB","OK","Needs More Information","Provider indicated that they are discontinuing Measure Bundle B1 Care Transitions and Hospital Readmission along with this Core Activity. Provider did not provide an adequate justification for deleting bundle B1 and has received an NMI. HHSC is not approving deletion of this Core Activity until the discontinuation of bundle B1 has been resolved.","Our Early identification of post-acute service needs is well established, and we completed the creation of the standing order for Social Service visits early in the stay during DY 7-8 \n\nWe propose a change of Core Activity Name to: \nIdentification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.\n\nSecondary Driver:  Open new 501a Clinic - an Integrated Primary and Specialty Care Clinic\n\nSecondary Drive 1: Change Idea 1: In addition to community resources, connect identified patients to City Hospitals White Rock new 501a clinic being implemented in DY9\n\n\nAligns with Measure Bundle:  B1","LH","Provider will continue with changes to Name, SD and CI","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updating the Core Activity Name, Secondary Driver 1, Change Idea 1. and listing B1 as the impacted Measure Bundle.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_020950401","020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private",369,"Maternal and Infant Health Care","","Edit","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth",null,"A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations.","Assessing risk of preterm delivery when presenting to hospital","admininsting antenatal steriod to delay delivery and imporve preterm baby health"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","The goal is to assure that all infants born before 34 weeksgestation receive appropriate anternatal treatment to avoidserious health problems. The key drivers, which arecategories that will drive change to make this possible","No","","020950401.7.1","JQ",null,"N",null,null,"Needs More Information","HHSC has changed the Core Activity Name from \"Other\" to \"Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)\". Please indicate in the \"Provider Response\" column if you disagree with this change or whether there is another Core Activity Name from the menu that should be used. ","Provider agrees with HHSC change to Other core activity","JQ","Provider agreed so no further changes needed","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_020950401","020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private",370,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","By implementing and improving compliance with evidence based tactics that are proven to decrease infection and injury rates, we will improve care of our patients and achieve our goals to reduce preventable infections/complications. The tactics include proper insertion techiniques, aseptic adherence , good hand hygiene, appropriate screenings and goal directed therapies.","Compliance with basic standards of urinary catheter care","Improve training on standardized best practice techniques for urinary catheters","Enhance adherence to nurse protocol for shift assessment of catheter need and removal per protocol"," "," "," ","Implement CLASBI evidence based care bundle componenets","Improve utilization of standarized checklist for insertion actions from pre-insertion, during and post insertion","Make available standard CVC kits to ensure optimal products are uses (foley, dressings and CHG)","Improve daily review of need for central lines and protocols for removal"," "," ","Screen patients for sepsis before and after surgical procedures","Improve compliance with sepsis screening for schedules patients for earlier idenfitication and early goal directed therapy"," "," "," "," ","Hourly nurse rounding to address the  4 P's (potty, pain, position and possessions) to reduce patient falls","Improve compliance with hourly nurse rounding by sharing and posting weekly audits in units"," "," "," "," ","STOP SSI bundle procedures to reduce surgical site infections in cardiac, hip and knee surgical patients","Improve compliance with pre-surgical screening for Staphylococcus aureua (SA) to identify patients positive for MSSA and MRSA before surgery","Improve compliance with decolonization of SA for positive screened patietns with nasal mupirocin and CHG bathing pior to surgical procedures"," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Implementing basic standards of care for urinary catheter care and CVC bas proven to decreae infection rates. Hourly nurse rounding is an evidence based process to decrease patient falls. Utilizing a bundle comprised for S. aureus screening, decolonization, and targeted prophylaxis was associated with a statisically significant decrease in complex S. aureus SSIs. Screening for sepsis patients before surgery and after to start goal directed therepay will reduce post sepsis infections and complications. The evidence based strategies have been proven to reduce infections/injuries and improve hospital safety.","No","","020950401.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_021184901","021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private",372,"Access to Primary Care Services","","Edit","","Provision of vaccinations to target population","","Access to primary care for wellness and preventative care (including provision of vaccinations) will be enhanced.  Currently, 124 providers are committed to the interventions across 34 primary care locations.","Enhancement will include organization-wide commitment to improve patient access through expansion of patient services to potentially include an increase in numbers of providers and/or staff, after-hours clinic availability and additional site locations.","Expansion will potentially occur across numbers of providers, either through an increase in the number of physicians, mid-level staff and/or clinical staff in primary care clinics (or combination of the aforementioned) to help increase immunization measure performance rates within the D1 primary care bundle: D1-108: Childhood Immunization Status (CIS), D1-271: Immunization for Adolescents, and D1-389: Human Papillomavirus Vaccine (age 15-18). In addition, said expansion may also include the availability of extended clinic hours in the Neighborhood Clinics which service the majority of MLIU clients, as well as clinic times dedicated to the delivery of specific vaccinations (i.e. flu), and the potential addition of new site locations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1","All measures within bundle are factors in 2014 Patient Center Medical Home standards and guidelines, which incorporates empanelment of patients to physicians, and management of chronic conditions, preventive care, utilization of care teams, data exchange between medical homes and hospitals.","No","","021184901.7.1","JQ","Core Activity is providing immunizations, but all other descriptions are very vague and do not reference vaccinations at all, just access to primary care services and expanding staff, so maybe this could just be absorbed under the other core activity for patient centered medical homes. ","Y","NB","In agreement","Needs More Information","Provider needs to make changes to the Description of the Core Activity, Secondary Driver 1, and Secondary Driver 1, Change Idea 1 to clarify how these are related to the Core Activity Name: Provision of vaccinations to the target population. ","Description of the Core Activity: \nAccess to primary care for wellness and preventative care (including provision of vaccinations) will be enhanced.  Currently, 124 providers are committed to the interventions across 34 primary care locations.\nSecondary Driver 1:\nEnhancement will include organization-wide commitment to improve patient access through expansion of patient services.\nSecondary Driver 1, Change Idea 1:\nExpansion will occur across numbers of providers, mid-level and clinical staff in primary care clinics to help increase immunization measure performance rates within the D1 priimary care bundle: D1-108: Childhood Immunization Status (CIS), D1-271: Immunization for Adolescents, and D1-389: Human Papillomavirus Vaccine (age 15-18). ","JQ","2/3: Provider revision is still too vague. Just says organization wide commitment and expansion of patient services, but not which services, or how that will affect immunization rates. Email provider for follow up. 2/5: Provider submitted additional revisions, which I updated the tracker to reflect. No further information needed. ","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC edited the Secondary Driver and Change Idea 1.  ","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_081599501","081599501.7.1",10,"081599501","MHMR of Tarrant County","Community Mental Health Center (CMHC)","Non‐State Owned Public",377,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","MHMR has selected core activities and quality measures to better align the agency with the Certified Community Behavioral Health Clinic (CCBHC) model allowing for the development of an integrated service delivery framework.  With an emphasis on quality, access, and a holistic approach to recovery for individuals served, MHMR will provide additional screenings in clinics  to assess physical and mental health needs, suicide risk, substance use, and social determinants of health and provide timely access to services. MHMR's outpatient behavioral health clinics and providers are committed and will support this core activity.","Provide immediate screening, assessment, and diagnosis, including risk assessment.","Implement new screening and assessments tools to assess physical and mental health needs, suicide risk, and substance use.","Provide counseling intevention and/or education as needed."," "," "," ","Enhance individual outreach, education, and engagement through care coordination.  Based on a person and family-centered plan of care, the Care Coordinators provide continuity of care and navigation across the spectrum of health services including physical and behavioral healthcare, social services, housing, educational systems, and employment opportunities as necessary to facilitate the wellness and recovery of the whole person.  Care Coordinators  remove barriers to accessing health services by providing advocacy and health navigation and by providing outreach and engagement services to those in need of those services.","Assess, provide referrals, and follow-up on all case management needs (e.g. financial, legal, social, educational, and medical).","Coordinate and monitor access to specific programs (skills training, individual, family, and/or group therapy, support Services, trauma Services, psychiatric Services, pharmacological services, SUDS services, crisis prevention, management, and postvention services).","Coordination with outside providers which involves continuity of care and navigation across the spectrum of health services."," "," ","Expand access to integrated care through an enhanced workforce.  To further integrate  services and provide a holistic approach to recovery, MHMR is adding a wellness team, comprised of nurses, to provide care coordination addressing both behavioral and physical health concerns.","Implement best practices in RN care coordination for the wellness team.","Provide core functions of RN care coordination to include nursing rehabilitation (medication reconciliation and education on topics including medications, behavioral health diagnosis, and primary care conditions, including obesity).","Provide care coordination for accessing primary care, including scheduling PCP appointments, attending appointments as needed, and discussing follow through with appointments.","When requested, follow up on all referrals for labs, primary care, specialisty providers, and additional community resources."," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-211; M1-305; M1-342; M1-100; M1-105; M1-147; M1-165; M1-255; M1-262; M1-317; M1-319; M1-390","Alignment with the CCBHC model will further improve our system of care through an integrated service delivery framework, improved individual experience through care coordination, and overall health for Medicaid, low-income and uninsured populations.","No","","081599501.7.1","JQ",null,"N","NB","Seems sufficient details. Leaving it as accepted","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_081599501","081599501.7.1",10,"081599501","MHMR of Tarrant County","Community Mental Health Center (CMHC)","Non‐State Owned Public",379,"Substance Use Disorder","","Continue","","Office-based additional treatment for uninsured individuals","","MHMR has integrated its mental health and substance use disorder treatment services, enabling individuals at any clinic to receive full behavioral healthcare.  To further address substance use disorders, MHMR is enhancing assessment and referral to treatment options for individuals served.  MHMR's outpatient behavioral health clinics and providers are committed and will support this core activity.","Provide immediate screening, assessment, and referral for substance use disorders.","Improve coordination of care for individuals with substance use disorders.","Enhance psychiatric evaluation to better identify needs related to substance use disorders.","Improve documentation process for tracking individuals with a dual diagnosis."," "," ","Provide timely access to substance use treatment options.","Provide brief intervention and counseling for alcohol and opioid dependence.","Improve referral process to substance use counselors for individuals newly diagnosed with substance use disorders."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-257; M1-340; M1-100; M1-261; M1-341; M1-405","This core activity will allow for the ability to provide the right care, at the right time, in the right setting. Individuals with substance use disorders will be better identified through improved screening and assessment and will have access to a variety of outpatient substance use treatment options.","No","","081599501.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Office-based additional treatment for uninsured individuals","CA-10","CA-10.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_083149703","083149703.7.1",10,"083149703","Tarrant County","Local Health Department (LHD)","Non‐State Owned Public",373,"Maternal and Infant Health Care","","Continue","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","","Continue the Steroid intervention program promoting the use of antenatal steroids (17P) to prevent preterm birth in women with a history of spontaneous birth.","Locate physicians familiar with implemention and follow up with clients who receive 17P throughout their pregnancy.","Speak to new JPS residents shortly after they rotate into clinics"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-IT-8.12","Measure is based on the continued Steroid intervention without this core activity the measure could not continue","Yes","TCPH will screen for potential candidates in our clinics and our WIC locations. WIC is a non-clinical service and is not being counted in our Category B System. When a patient is identified she will be referred to her physician for the recommended intervention. Our services are navigational as we will be following the patients throughout pregnancy.","083149703.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_083149703","083149703.7.1",10,"083149703","Tarrant County","Local Health Department (LHD)","Non‐State Owned Public",375,"Access to Primary Care Services","","Edit","Changes made to add additional information to the core activity due to increased efforts by clinical staff and programs to increase the immunizations efforts in the community. ","Provision of vaccinations to target population","","Tarrant County Public Health will provide vaccinations as needed to prevent childhood and adolescent illnesses as well as Flu and Pneumonia to the residents of Tarrant County.","Residents are not always aware of the need for vaccinations and immunizations especially during seasonal outbreaks.","Improve immunization educational materials.","Increase amount of immunization public information through social media."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,1,1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-108; L1-268; L1-269; L1-271","By providing vaccinations at low to no cost Tarrant County Public Health will continue to help stop the spread of illnesses protecting Tarrant County residents from undue medical costs and concerns.","No","","083149703.7.1","JQ",null,"N",null,null,"Needs More Information","Approval of Core Activity changes are pending approval of discontinuation of L1-186.","TCPH has decided to keep previous core activies with no changes requested. Requesting to continue previous reported core activies. ","JQ","The change this provider had originally made was to add L1-205 to list of measures impacted. Since provider has withdrawn request, will update the tracker accordingly to remove that. ","N",null,null,"Accepted","HHSC has updated to remove L1-205. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_083149703","083149703.7.1",10,"083149703","Tarrant County","Local Health Department (LHD)","Non‐State Owned Public",376,"Access to Primary Care Services","","Continue",null,"Provision of screening and follow up services","","Tarrant County Public Health will provide screening services for cancer, tuberculosis and sexually transmitted diseases to clients who would otherwise not receive screening due to income or lack of knowledge.","Provide screening services for at multiple locations for sexually transmitted diseases.","TCPH will promote our screening services through social media and community health worker outreach."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,1,1,1,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-280; L1-344; L1-347; L1-186","Tarrant County Public Health plans to increase the number of clients screened for cancer, tuberculosis and sexually transmitted diseases expecting to decrease the spread of illness and cost of care associated with these diseases","No","","083149703.7.1","JQ",null,"N",null,null,"Needs More Information","Approval of Core Activity changes are pending approval of discontinuation of L1-186.","TCPH has decided to keep previous core activies with no changes requested. Requesting to continue previous reported core activies. ","JQ","Given provider's request to keep core activities with no changes, will update tracker to put L1-186 back into list of measures affected. Provider withdrew request to add L1-343, so took that out of measures impacted. ","N",null,null,"Accepted","HHSC has updated to remove L1-205 and  L1-343 and added back L1-186. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_112677302","112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private",386,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Palliative care nurses and in-house clergy help inpatients referred to palliative care service address end-of-life decisions and care needs through discussions with patients and appropriate family members.","Conduct multi-disciplinary conferences including patient and family members to comprehensively cover all concerns and information for them to make an informed decision.","Complete advanced care plans, advanced directives and treatment preferences including spiritual needs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","Documentation of treatment preferences and end of life choices is necessary to appropriately create a comprehensive palliative care plan.","No","","112677302.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_112677302","112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private",387,"Palliative Care","","Continue","","Transitioning of palliative care patients from acute hospital care to other settings","","Palliative care nurses and care transitions staff work on discharge planning from the initial referral into palliative care service.  This includes the transition plans and finding the appropriate location for transfer or discharge.","Develop a plan for continuity of care and seamless transfer.  This plan will include all care provided by entity and recommended care plan post discharge/transfer.","Work with appropriate receiving entity and/or patient and family to educate regarding the treatment plans and treatment preferences of the patient."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","Continuity of care is important for this patient population.  By creating a comprehensive plan including treatment preferences, care provided and end of life preferences, these patients will transition seamlessly and have no changes to the care plan post discharge.","No","","112677302.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Transitioning of palliative care patients from acute hospital care into home care, hospice or a skilled nursing facility and management of patients’ needs.","CA-12","CA-12.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_112677302","112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private",389,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers all HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure)","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.)","112677302.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_112677302","112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private",390,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","HELP targets uninsured, high utilizers of emergency and acute services for enrollement into a chronic disease management program.  These uninsured patients generally are at higher risk for complications and co-morbidities.","Providing a mid-level provider to manage the chronic diseases (diabetes & heart disease) for these patients that generally have not had access to the appropriate level of care resulting in seeking routine care through the ED.","Providing point of service lab testing which allows provider to adjust medications as needed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","A mid-level provider using point-of-care lab testing allows for immediate changes to be made to medications helping the patients improve biometrics.","No","","112677302.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_112677302","112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private",392,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","112677302.7.1","JQ",null,"N",null,"changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 7: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_120726804","120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private",393,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers HELP patients to the evidence-based Stanford Chronic Disease Self-Mangement Program. HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barrers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherance to dietary restrictioms which allow the patient to lower biometric scores such as HbA1c and blood pressure.","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.","120726804.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_120726804","120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private",396,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","120726804.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_121794503","121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private",397,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure)","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.)","121794503.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_121794503","121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private",399,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","121794503.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_121794503","121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private",400,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","121794503.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",402,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Establish standard screening protocols for use across the health network in order to improve early detection of common health concerns. These processes can address both standard health maintenance and high risk screening activities. For each specific screening, the appropriate follow-up plan and referral process will be defined.","Improve the early detection of common health concerns through the use of standard screening tools/protocols.","Standardize screening and follow-up processes across all care settings"," "," "," "," ","Provide additional screening and follow up services for high risk population","Enhance the use of registries for high risk patients to track compliance with standard screening and follow-up protocols (this change idea is specific to H1 and H2)"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; C2; H1; H2; A1","Each of the bundles identified for this core activity have screening and/or follow-up measures. Establishing standard clinical processes will help us ensure that our patients receive appropriate screenings and follow-ups to identify and manage their health needs.","No","","126675104.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",403,"Chronic Care Management","","Continue","","Implementation of a medication management program","","Patients with varying risk factors often require different statin interventions. Implementing the standardized use of evidence based protocols for statin therapy across the system will improve patient care.","Implement the standardized approach for using statin therapy  to help lower cholesterol levels in the blood.There is currently a lack of standardized use of evidence based statin therapy protocols across the system","Implementing a best practice advisory with an attached clinical decision support template in EMR system that recommends a clinically appropriate statin based on the ASCVD risk score for the patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","Implementing the standardized use of evidence based protocols for statin therapy will help us ensure that our patients receive appropriate interventions based on their individual needs.","No","","126675104.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a medication management program that serves patients across the continuum of care","CA-8","CA-8.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",405,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","As a safety-net hospital much of our patient population use the emergency department as their \"primary care\" provider even when their medical condition is not urgent. Education for both staff and patients will guide the patient to internal and external services and programs that may be available that can lead to better health outcomes.","Educate patients of availiability of services within the community.Patients are unaware of available internal and external services and programs that may be available and may have a lack of understanding of the appropriate care settings for their needs.","Through an ED Transitions of Care task force we will implement a new workflow to schedule follow-up appointments with PCP's before discharge from ED. We will also make follow-up calls to patients after ED discharge to remind the patient of their follow-up appointment and to educate the patient on the appropriate care settings for their needs."," "," "," "," ","Eduate staff on services and programs available within the organization and in the community. Staff are not aware of all of the services and programs that are available both internally and externally.","Schedule internal education sessions to educate staff and physicians about services (embedded acute care providers, extended hours etc) and access within PCMH's."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Implementation of education programs for both staff and patients that can guide the patient to internal and external services and programs that may be available can lead to better health outcomes.","No","","126675104.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",406,"Maternal and Infant Health Care","","Edit","","Implement standard protocols for the leading causes of preventable death and complications","","The implementation and enforcement of standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans) will lead to better health outcomes for both mother and child.","Make changes in the management of inductions: In order to reduce primary c-sections we will review/revise our policies that impact the management of this process.","Revise, educate and implement best practice protocols for oxytocin, cervical ripening, augmentation, management of inductions and stages of labor."," Revise Bishop Score documentation policy to ensure appropriate documentation by both nurses and providers."," "," "," ","Implement and enforce standard protocols for the leading causes of preventable death and complications for mothers and infantsAccurate gestational age is necessary  for determination of eligibility for, and  safe administration of, antenatal steroids.","In order to improve accurate gestation age we will implement a best practice alert in our EMR that will notify an OB provider when a new sonogram report is available to review. This will ensure all sonograms are reviewed and that dating information is changed, if indicated to ensure accurate EDD. Reports that monitor use of the new alert will be created to track compliance."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","The implementation and enforcement of standard protocols for antenatal steroids and scheduled c-sections will lead to better health outcomes for both mother and child.","No","","126675104.7.1","JQ","Provider's description of Core activity is almost identical to the core activity name, so it does not give any more clarity about the activity. Secondary driver 1 and its associated change idea also just say they will change policies, but does not say to what. Since this is a continuation of DY7 and 8 they should have already revised their policies and should be able to give more detail now. ","Y","NB","In agreement","Needs More Information","HHSC requests additional detail on the Description of Core Activity, Secondary Driver 1, and Secondary Driver 1, Change Idea 1 to more clearly explain what policies or protocols have been revised and what the new protocols are. ","The following new policies were created to provide best practice structure around existing workflows – oxytocin, cervical ripening, augmentation, and induction. Additionally, we revised the Bishop Score documentation policy to ensure appropriate documentation by both nurses and providers. ","JQ","2/3:Provider description is still inadequate. Will email for follow up. 2/5: Provider agreed to my proposed revisions, so I have updated the tracker accordingly. No further information needed. ","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically HHSC modified Secondary Driver 1, Change Idea 1 and added Change Idea 2. ","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",409,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Utilization of telehealth/telemedicine in delivering behavioral services","","Primary care providers are not always comfortable with making behavioral health diagnosis and care decisions without consultation from a behavioral health specialist. Telehelath consults can extend the reach of limited behavioral health provider services.","Improve primary care provider's access to resources for managing BH needs of patients. Primary care providers need access to additional resources to manage the behavioral health needs of their patients.","Increase awareness of available behavioral health support  from behavioral health providers to primary care providers through the EMR via referral or  through a dedicated virtual consultation phone line."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H1","Primary care providers are not always comfortable with making behavioral health diagnosis and/or care decisions without consultation from a behavioral health specialist. With the expansion of telehealth behavioral health services, primary care providers will be able to provide the appropriate care within the primary care setting.","No","","126675104.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_126675104","126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public",410,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","We are deleting the first Secondary Driver listed for this Core Activity – “coordination of communication across care settings” – due to the fact that the work around this Core Activity has been mainly focused on the second Secondary Driver listed. At this time, we do not have any plans to move forward with initiatives around the Change Idea associated with the first Secondary Driver listed. The minimum requirement of one Secondary Driver per each Core Activity and one Change idea for each Secondary Driver is still being met, as we are maintaining the second Secondary Driver listed. ","Utilization of Care Management function that integrates primary and behavioral health","","Because of multiple diagnoses for both behavioral health and medical conditions, behavioral health patients often do not seek care in the appropriate setting. Guiding patients to the proper care setting through care management will lead to improved medical and behavioral health care outcomes.","Provide care management to patients with schizophrenia.Patients with schizophrenia are often non-compliant and need additional care management.","Contact patients with schizophrenia that do not have a current PCP assigned and connect them to the PCP of their choice or update medical record to reflect existing PCP."," "," "," "," ",null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2","Because of multiple diagnoses for both behavioral health and medical conditions, behavioral health patients often do not seek care in the appropriate setting. Guiding patients to the proper care setting through care management will lead to improved medical and behavioral health care outcomes. Use of standardized E.H.R. documentation will allow providers across varying care settings to better coordinate their patients care needs.","No","","126675104.7.1","JQ","Provider had already said they were deleting this during DY8 R2, and we accepted. They did not make the change here. ","Y","NB","Made a change and requested the confiramtion. ","Needs More Information","Provider was approved to edit this Core Activity in DYR2, but did not make that approved change in this template. HHSC made requested changes and provider needs to either confirm that what was requested is reflected or suggest additional changes.","The changes requested are reflected.","JQ","Provider agreed so no further changes needed","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of Care Management function that integrates primary and behavioral health needs of individuals","CA-9","CA-9.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_127304703","127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private",412,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","HELP targets uninsured, high utilizers of emergency and acute services for enrollement into a chronic disease management program.  These uninsured patients generally are at higher risk for complications and co-morbidities.","Providing a mid-level provider to manage the chronic diseases (diabetes & heart disease) for these patients that generally have not had access to the appropriate level of care resulting in seeking routine care through the ED.","Providing point of service lab testing which allows provider to adjust medications as needed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","A mid-level provider using point-of-care lab testing allows for immediate changes to be made to medications helping the patients improve biometrics.","No","","127304703.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_127304703","127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private",413,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","127304703.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130606006","130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public",415,"Hospital Safety and Quality","","Continue","","Implementation of evidence-based practices to improve quality of care","","Wise Health System is adopting the Performance Excellence Framework using the Malcolm Baldrige Performance Excellence Criteria. This method will focus on improving our processes and methods to ensure hospital safety as a high reliability organization. All departments within WHS will adopt Safety Goals, will measure those goals, and will use the Excellence Framework to define and measure the performance of our processes.","Establish goals for improving hospital safety and reduce medical errors.","Create work committees divided by the criteria in the Baldrige Excellence Framework.  These Committees will answer the questions within the framework to meet the evidence based best practices illustrated within the framework.The activities will drive improvement and provide a better opportunity for reduced harm in medical errors within the organization.","Assess performance on regular basis - Leadership will make rounds to assess the performance of each department towards meeting these safety goals."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","The activities will drive improvement and provide a better opportunity for reduced harm in medical errors within the organization.","No","","130606006.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130606006","130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public",416,"Chronic Care Management","","Edit","We no longer have bundle A2 and feel that this core activity would better address bundle B2. We are changing this bundle to B2 and dropping the 3rd core activity. We have also provided updated details on the change ideas including the addition of all cardiac patients in change idea 1 and in change idea 2 we updated the number for telemanagement calls to 1-2 times a week.","Utilization of evidence‐based care management models for patients with complex needs","","The Wise Health System Care 360 model is a continuation from DY6. This project has matured over the last three years and continues to be a sustainable and vibrant program aimed at assisting our patients admitted into Wise Health System. The original program was created for principal diagnosis of Congestive Heart Failure (CHF), but after seeing the dramatic decrease in all-cause hospital-wide readmissions for CHF, WHS expanded the program to also include cardiac patients diagnosed with acute myocardial infarcation (AMI). For DY 7/DY8, Care 360 has evolved to become the 360 Care Management Program focusing on Chronic Care Management (CCM) and Transitional Care for patients diagnosed with the following conditions: CHF, AMI, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia (PN), and general 30 Day readmissions to WHS. After analyzing readmission data throughout the year, the 360 team identified a large readmission population from local Skilled Nursing Facilities (SNF). After reviewing the information,  the 360 Care Management team developed a RN role focusing on transitional care for patients being discharged from WHS to a SNF.","The secondary driver of this program will be expansion of services provided to show a growth from one diagnosis to now six different patient populations via care and coordination from one dedicated Nurse Practitioner and 5 Registered Nurses specialzing in each diagnosis.","Develop and implement Chronic Care Management (CCM) visits as an outpatient service for cardiac patients and increase the number of NP inpatient visits now all cardiac (CHF/AMI/CABG +pulmonary pts (COPD/PN).","Expand the number of telemanagement calls for COPD, PN and General Readmission patient populations from once per 30 days to now weekly (four times per month)","Create a Standard 360 Care Management protocol for inpatients admitted with the above diagnosis","Add the availabilty for an NP clinic visit within 7 days of hopsital discharge for a transitional care appointment","Implement Provider and Nurse education on the importance of involving the patient's caregiver in discharge teaching and transitional care mananagement practices."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","This program specializes in providing education to patients and helping them through the recovery process designed to both avoid admission to the ED and preventing a 30 day readmission through improved communication among providers, improved medication compliance, and improved care modeling/coaching. This intervention will help decrease the number of patients who would otherwise make an unnecessary visit to the ED or potentially been readmitted within 30 days of hospital discharge.","No","","130606006.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of evidence-based care management models for patients identified as having high-risk health care needs and/or individuals with complex needs (e.g., Primary care–integrated complex care management (CCM), Complex Patient Care Model Redesign- enhanced multidisciplinary care teams, The Transitional Care Model, etc.)","CA-8","CA-8.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130606006","130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public",714,"Maternal and Infant Health Care","","New","","Implement standard protocols for the leading causes of preventable death and complications","","The implementation and enforcement of standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans) will lead to better health outcomes for both mother and child.","Make changes in the management of inductions: In order to reduce primary C-sections we are in the process of reviewing and and revise as necessary our policies for induction/ceasarian section.","Revise policies, educate staff, and implement best practice protocols for management of inductions and stages of labor.","","","","","Implement and enforce standard protocols for the leading causes of preventable death and complications for mothers and infants through best practice guidelines for safe and timely administration of antenatal steroids.","Review, educate and reinforce best practice protocols of administration of antenatal steroids for staff and physicians.","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","We have found that the continual education of staff and physicians is effective for the appropriate use of antenatal steroids. The review and revision of the C-section protocols continues to drive us toward best practices.","No","","130606006.7.1","JQ","Provider's description of Core activity is almost identical to the core activity name, so it does not give any more clarity about the activity. Secondary driver 1 and its associated change idea also just say they will change policies, but does not say to what.  ","Y","NB","Accepting 1st reviewer results.","Needs More Information","HHSC requests additional detail on the Description of Core Activity, Secondary Driver 1, and Secondary Driver 1, Change Idea 1 to more clearly explain what policies or protocols have been revised and what the new protocols are. ","We are currently in the process of having our policies and procedures committee review the policies for induction/caesarian section. Once the policies are reviewed they will be updated with any new evidence based practices as necessary. Upon approval of the new policy, protocols will be put into place and education will be administered to staff and physicians as appropriate.","JQ","Checked with NB, updated the Secondary Driver 1 and Change Idea 1 with provider response, and including notice to provider that they will need to provide more detail in DY 9 reporting on what has changed","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically HHSC modified Secondary Driver 1 and Change Idea 1. However, HHSC may require additional details for this Core Activity during DY 9 reporting to update HHSC on what policies have changed and how they are being implemented. ","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130614405","130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private",418,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health",null,"Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","130614405.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130614405","130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private",421,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","130614405.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130724106","130724106.7.1",10,"130724106","Pecan Valley MHMR Region dba Pecan Valley Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",422,"Behavioral Health Crisis Stabilization Services","","Delete","Per HHSC's recommendation, Pecan Valley Centers is deleting this Core Activity with the name \"Other\" in order to select the standardized name \"Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model.\"","Other","Provision of Crisis Respite","Crisis Respite is 12-bed facility for adults suffering a behavioral health crisis. It is staffed 24 hours a day with a 6:1 client to staff ratio.  Pecan Valley's crisis respite accommodates individuals located within our six-county region and is located in Erath County. Admission to crisis respite is facilitated through Pecan Valley Center's crisis services. The recommended average length of stay is 5 to 7 days.","All clients at crisis respite receive the following services as a step-down from hospital discharge: mental health case management, psychosocial rehabilitation, pharmacological management, and continuous observation.","All clients at crisis respite without an identified PCP can be provided a referral to an appropriate PCP or local health program that accepts the MLIU population even when primary care needs are not currently present, allowing for the establishment of primary and behavioral health care integration, if/when ultimately needed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160","Crisis respite serves as a step-down facility for immediate follow-up after inpatient hospitalization to enhance continuity of care and ensure community tenure, meeting both the 7 and 30-day follow-up measure requirement.","No","","130724106.7.1","JQ","Provider had already said they were deleting this during DY8 R2, and we accepted. They did not make the change here. ","Y","NB","Provider requested to delete it. approving the deletion. Changed to accepted. ","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.","Other","CA-11","CA-11.5"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_130724106","130724106.7.1",10,"130724106","Pecan Valley MHMR Region dba Pecan Valley Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",715,"Availability of Appropriate Levels of Behavioral Health Care Services","","New","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","Pecan Valley Centers is actively pursuing CCBHC certification during the DY9 timeframe.  This Core Activity aligns the goals of DSRIP and those of a CCHBC, providing clear and consistent messaging related to the benefits of proper integration of behavioral health (encompassing mental health and substance use) and physical health. All thirteen measures associated with this Core Activity are either direct CCBHC reporting requirements currently or support the triple aim of CCBHC to reduce costs, improve outcomes, and provide a quality client experience.","All clients are provided timely screenings relevant to each aim at intake, hospital follow-ups, and/ or as required due to needs presentation (i.e. after crisis stabilization or hospital discharge), with document results used to inform care planning and follow-on services.","Centralizing assessment locations to standardize processes and/or implementing technological improvements to allow for the addition of assessment provision can help streamline client access to needed services and hospital follow-ups with qualified staff.","","","","","To ensure primary care (medical) needs are integrated with behavioral health (defined as the delivery of mental health and substance use services), networking assignment of a PCP (when one is not already present) with documented primary care follow-up is completed following assessments or as required due to needs presentation.","All clients without an identified PCP can be provided a referral to an appropriate PCP or local health program that accepts the MLIU population even when primary care needs are not currently present, allowing for the establishment of primary and behavioral health care integration, if/when ultimately needed.","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-147; M1-160; M1-257; M1-259; M1-261; M1-263; M1-266; M1-287; M1-317; M1-319; M1-342","The Core Activity Provision of care aligned with CCBHC model impacts all measures as they either double as direct CCBHC reporting requirements or support the triple aim of CCBHC to reduce costs, improve outcomes, and provide a quality client experience. \nSubstance use has commonly-known health risks and increased likelihood of use or abuse associated with mental health disorders should be identified early. In preparation for and as a CCBHC encompassing both behavioral health and physical health, screening can promote education and intervention services to reduce or eliminate the use of these substances, improving physical health and/ or increasing the effectiveness of mental health treatment. Similarly, screening for additional risk factors related to various mental and physical health diagnoses can allow for earlier intervention, improving individual and community health outcomes.","No","","130724106.7.1","JQ",null,"N","NB","not too many change ideas but clear what provider is  doing in DY9. leaving it as aceepted.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_131036903","131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private",424,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers all HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure)","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.)","131036903.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_131036903","131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private",426,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","131036903.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_131036903","131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private",427,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","131036903.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_136326908","136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private",430,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","HELP targets uninsured, high utilizers of emergency and acute services for enrollement into a chronic disease management program.  These uninsured patients generally are at higher risk for complications and co-morbidities.","Providing a mid-level provider to manage the chronic diseases (diabetes & heart disease) for these patients that generally have not had access to the appropriate level of care resulting in seeking routine care through the ED.","Providing point of service lab testing which allows provider to adjust medications as needed."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","A mid-level provider using point-of-care lab testing allows for immediate changes to be made to medications helping the patients improve biometrics.","No","","136326908.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_136326908","136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private",431,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyCare portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyCare allows access allows access to information across entities and departments and allows patient to access testing results.","MyCare currently has limited bi-directional functionality from the patient perspective.  Utilization of MyCare portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","136326908.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_138980111","138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",433,"Patient Centered Medical Home","","Edit","UNTHSC CPG has moved from a health coaching model to a nurse-led care coordination team.  Edits made to Core Activity #1 reflect the changes to remove health coaching language and add relevant secondary drivers that were previously under Core Activity #2.  Updates were also made to the language for secondary driver #3 to reflect planned curriculum for the primary care training program.  Additional drivers were added to capture new initiatives related to screening and management of chronic conditions.","Utilization of care teams that are tailored to the patient’s health care needs","","UNTHSC aims to utilize multidisciplinary teams to improve patient care across the system.  Clinical pharmacists will perform medication therapy management services for UNTHSC patients.  A nurse-led clinical care coordination team has been established to assist providers and patients with improvement of services and health outcomes.   Primary care training programs will enhance chronic care management and better integrate health coaching and clinical pharmacist services with primary care.","Medication therapy management services provided to UNTHSC patients","Implement clinical pharmacist led interventions for UNTHSC patients"," "," "," "," ","Routine screening for indicators of chronic disease","Electronic patient intake system utilized for screening"," "," "," "," ","Increased physician knowledge and competency regarding chronic care management, population health, and social drivers of health","Continue targeted primary care training program for UNTHSC Clinical Practice Group"," "," "," "," "," Management of chronic conditions and co-morbidities","Targeted lists developed to identify at-risk patients"," "," "," "," "," Increase immunization compliance for UNTHSC patients","Targeted lists created identifying patients needing follow-up"," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1; C1; D1; H1","The UNTHSC Clinical Practice Group has established a collaborative practice agreement which allows clinical pharmacists greater access to provide care to the patient population. The expansion of clinical pharmacist services across the system will ensure appropriate, non-duplicative medication therapy management, identifying medications with secondary effects, and increase medication compliance (medications filled, proper patient access, appropriate medications prescribed, affordable alternatives identified). The implementation of the health coaching team will impact Measure Bundles through appropriate care navigation to mitigate identified conditions (e.g. diabetes, congestive heart disease, tobacco and alcohol use, and depression).  Additionally, the team will have non-clinical influences on health, primarily through outreach to patients and assisting them in setting individual health goals. Providing a primary care training program to UNTHSC clinical practice group staff will enhance chronic care management and assist with the integration of health coaching and clinical pharmacist services within primary care.","No","","138980111.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care teams that are tailored to the patient’s health care needs, including non-physician health professionals, such as pharmacists doing medication management; case managers providing care outside of the clinic setting via phone, email, and home visits; etc.","CA-5","CA-5.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_138980111","138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",434,"Access to Primary Care Services","","Delete","UNTHSC CPG has moved from a health coaching model to a nurse-led care coordination team.  Edits made to Core Activity #1 and additional drivers were redundant to remaining relevant drivers under Core Activity #2.  Discontinuing this Core Activity and moving relevant drivers to Core Activity #1 allows for better tracking and explanation of activities related to DSRIP.  ","Provision of vaccinations to target population","","The UNTHSC Clinical Practice Group aims to utilize multidisciplinary teams to improve access to primary care services as well as provide necessary and appropriate vaccinations to the target population.","Health coaching team deployment for UNTHSC patients","Condition-specific screening modules utilized by health coaching team for UNTHSC patients","Targeted BMI counseling from members of the health coaching team"," "," "," ","Increase immunization compliance for UNTHSC patients","Clinical providers review immunization schedules for UNTHSC patients","Targeted lists created for patients needing follow up"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D1; C1","Clinical pharmacists, along with other clinical and non-clinical staff, will identify patients with gaps in vaccination coverage and provide targeted interventions to address the needs of patients.  Health coaching teams will focus on addressing the social determinants of health.  Additionally, the team will have non-clinical influences on health, primarily through outreach to patients and assisting them in setting individual health goals, either through face to face visits or through telephonic follow up services.","No","","138980111.7.1","JQ","Provider had already said they were deleting this during DY8 R2, and we accepted. They did not make the change here. ","Y","NB","Provider requested to delete it. approving the deletion. Changed to accepted. ","Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider’s deletion of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_186221101","186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private",436,"Chronic Care Management","","Edit","Removing change ideas that provider deleted in DY7 and DY8. These were originally removed as they were out of scope and/or were achieved during previous DSRIP activities.","Utilization of care management and/or chronic care management services","","Provider will continue to implement and build upon components of the Chronic Care Model (CCM) for patients with diabetes and heart disease, leveraging an interdisciplinary team of pharmacists, nurses, and patient educators to ensure continuity of care and education for the targeted patient population.","Ensure that hospital and clinic staff members are trained on providing chronic disease management education","Provide patient education materials on each unit and ensure annual training opportunities for related staff on diabetes education ","Provide chronic disease education (diabetes, HTN, CHF, etc.) for patients and families through classes and educational materials"," "," "," ","",null,""," "," "," ",null,null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Since diabetes and heart disease are included in this measure bundle, the provider's self-management activities will serve to empower the targeted patient population and lead to a decrease in ED visits and hospital readmissions among those patients with chronic illnesses.","No","","186221101.7.1","JQ","Provider deleted Secondary Driver 2, but not all the Change Ideas associated with it. Provider may have intended to keep the change idea but associate it with a different driver, but that was not clear","Y","NB","OK","Needs More Information","Provider deleted Secondary Driver 2, but not all associated Change Ideas for that Driver. Please confirm whether provider intended to delete that Change Idea \"Provide patient education resources for care teams on nursing units\", or associate it with another Driver. ","Correct, provider would like to delete the secondary driver and the associated change ideas","JQ","Deleted Secondary Driver 2 per provider's response. No further info needed. ","N",null,null,"Accepted","HHSC has deleted the associated Change Ideas for Secondary Driver 2 and the third Secondary Driver 3 and the associated Change Ideas. Provider may add back the third Secondary Driver during reporting as needed. Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_206106101","206106101.7.1",10,"206106101","Wise Clinical Care Associates","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",437,"Access to Primary Care Services","","Edit","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","Wise Health Clinics are adding primary care access into the Boyd clinic. This clinic is now open until 8 PM on weekdays and for four 4 hours on Saturday. We were able to recruit a physician who could take over some of the patients from one of the retiring physicians in Bridgeport. We will be opening a consolidated clinic in Decatur with the physician that was previously in the Haslet immediate care location. This clinic will also offer extended hours.","This increase in access will be measured by available same-day appointments.","The activity that will be supporting the increase in availability of same-day appointments will include an increase in provider hours as well as designating specific schedule slots for same-day appointment time."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","An increase of access to primary care should result in an increase in the screening for diabetes and allow for more chronic disease care.","No","","206106101.7.1","JQ","In Category C reporting, provider cited the closure of several primary care clinics and loss of providers as a reason they requested to discontinue a measure. It is unclear how they would be reporting and increase in primary care services while also indicating that as a significant loss of a system component. ","Y","NB","OK","Needs More Information","For Category C reporting, provider indicated a loss of a significant system component for primary care. This core activity description indicates increased access to primary care. Provider should clarify the changes it has experienced to primary care access and when those changes took place. ","We had two primary care providers leave the organization in August of 2019. These providers operated in two of our busiest primary care clinics and one of these clinics is specifically geared toward the MLIU population.  Our immediate care location opened in September 2018 and closed in June 2019 but billed as a primary care clinic. These patients were included in our Cat. B system reporting as primary care patients. We currently do not have an exact number of patients that were affected by this closure and loss of providers. The loss of these providers has the potential to greatly impact our MLIU rate for the C2 measures because there is now fewer providers to provide these screenings.","JQ","2/3: Provider did not address the question. Will email to follow up. 2/5: Provider sent updated language for the Core Activity description, and withdrew request to drop C2 measure bundle and does not want to adjust system definition, so no further information needed to approve this.","N",null,null,"Accepted","HHSC has updated the Core Activity description based on the provider response. ","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_216719901","216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public",439,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","We will review our current status of coordination of care for our patients, will identify any areas for improvement and will then implement any changes necessary to ensure coordination between our emergency department, primary care providers, transferring hospitals and inpatient facilities.","The secondary driver of our core activity is working in conjunction with our primary care offices in order to enhance the continuum of care for our patients.","Work with staff from the ER and our primary care offices to get everyone on the same page and get ideas as to how to better serve our patients and implement these ideas."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","This activity impacts the emergency communication transfer component and the documentation of current meds component of our Measure Bundle.  With increased communication between our ED and PCP offices, we will be better able to serve our patients. This better coordination of care will allow us to address any issues with admit to decision time from our ED.","No","","216719901.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_314080801","314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private",382,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure)","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.)","314080801.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_314080801","314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private",385,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to manageing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e.transportation, child care, access to health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliance and improving biometric scores.","No","","314080801.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_316296801","316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private",440,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","Provider refers HELP patients to the evidence-based Stanford Chronic Disease Self Management Program.  HELP program also includes disease specific education at each visit through cohort visits.","Locate CDSMP classes in low income, high need zip codes close to where patients live.","Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","CDSMP classes teach the patients skills needed to better manage their chronic diseases (diabetes and heart disease are primary focuses for HELP) including goal setting, action planning and adherence to dietary restrictions which allow the patient to lower biometric scores such as HbA1c and blood pressure)","Yes","Classes are provided through a collaboration of community partners including Area Agencies on Aging, public health departments, churches, etc.)","316296801.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_316296801","316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private",442,"Chronic Care Management","","Continue","","Utilization of enhanced patient portal for management of chronic conditions","","Provider offers MyChart portal to all patients presenting to the facility.  Providers up-to-date information regarding chronic diseases and blood pressure control.  MyChart allows access allows access to information across entities and departments and allows patient to access testing results.","MyChart currently has limited bi-directional functionality from the patient perspective.  Utilization of MyChart portal is low due to low visibility of the service.","Work with ITS to increase bi-directional functionality of MyCare to allow patients to input health information and track biometrics."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Bi-directional functionality would allow for a more accurate picture of diabetes and blood pressure management outside the clinical setting.","No","","316296801.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of enhanced patient portal that provides up to date information related to relevant chronic disease health or blood pressure control, and allows patients to enter health information and/or enables bidirectional communication about medication changes and adherence.","CA-8","CA-8.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 10_DY9-10 Regional Tracker - FINAL Tracker.xlsb","10_316296801","316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private",443,"Chronic Care Management","","Edit","","Provision of services to individuals that address social determinants of health","","Patient Navigators (Nurses, Social Workers or Community Health Workers) will be utilized to identify social determinants of health needs and work with patients to reduce barriers found to managing their chronic disease.","Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)","Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)","Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","By creating a program to address the social determinants of health, provider is reducing barriers to care, thus increasing compliances and improving biometric scores.","No","","316296801.7.1","JQ",null,"N","NB","changing to NMI and requesting additional details on SDofH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Provider will add additional change idea to Core activity 4: Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling).","JQ","Added change idea per provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added a new Change Idea to  Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health.","CA-8","CA-8.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_094131202","094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",446,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services","","Our Core Activity is to implement processes in our rural health clinic to work on quality measures and a Chronic Care Management program to meet patient quality measures and satisfaction through efficient, quality medical care. This core activity was chosen because it is closely related to our Meaningful Use measures, which are important in providing quality medical care that is effective, safe, efficient, patient-centered, equitable, and timely.","The first Secondary Driver selected is Screening for Tobacco Use and Cessation Counseling Intervention if identified as a tobacco user.","Our office requested tobacco-use status on all patients and provided patients with written information on tobacco cessation and verbal counseling if identified as a tobacco user. Our new standards will include billing the appropriate CPT code for Tobacco Cessation Counseling so we can better track the number of patients counseled and the date of the counseling."," "," "," "," ","Our second Secondary Driver for our Core Activity is increasing the percentage of patients age 65 and older who have an Advanced Care Plan or surrogate decision maker documented in our medical record, or documentation in the record that an advance care plan was discussed.","The office's intake staff will begin asking patients age 65 and older about their Advance Care Plan status when the patient presents for a check-up, and their answer will be reported to the provider."," "," "," "," ","The Secondary Driver for our Core Activity is increasing timely vaccination for age-appropriate vaccines.","Our office currently screens all eligible patients for influenza and pneumonia vaccination status during flu season, but we will begin running reports to assist in identifying eligible patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Our Core Activity of increasing access to primary care services, including screening and follow up services, impacts the selected Measure Bundle K-1 directly as the measure bundle objective is to improve provision of preventative care to improve patient health. Providing Age-appropriate screenings, counseling, vaccinations, and services directly affects patient health and safety and the quality of our patient care.","No","","094131202.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_112692202","112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public",447,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services","","Within this activity the goal is to continue our current screening processes as well as implement greater detailed screenings. This also will give patients access to increased education and resources.","Advance Care Plan Documentation in Medical Chart","Discussion on importance on these topics are addressed upon clinic intake with patients.  If they do not have advance care plans in place information regarding types and importance will be given to patients.  If patients do have advanced care plans in place we ask them to bring with them on next visit and copy is made and placed in the medical record."," "," "," "," ","Improve Pneumonia Vaccination Status for Older Adults","Upon clinic intake staff interviews patient on vaccination history which is documented in the EHR.  Patients are educated on importance of vaccine and benefits through one on one interaction with providers and staff.  Handouts provided if needed.",null," "," "," ",null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","There are multiple screening tools listed in this Core Activity for the measure bundle and this allows us to focus on those like controlling high blood pressure, tobacco screening and cessation education, foot exams for diabetic patients with a preventative approach for the MLIU population who do not  always have access to these types of resources and education.","No","","112692202.7.1","FG","This core activity could possibly be broken into multiple activities, as the secondary drivers don't seem to fit together cleanly. Secondary Driver 2: Tobacco Cessation and Intervention could be it's own core activity, CA-7.2 Prevention and Wellness: Implementation of strategies to reduce tobacco use. Secondary Driver 3: Improve Pneumonia Vaccination Status for Older Adults could be Core Activity CA-1.6 Access to Primary Care Services: Provision of vaccinations to target population. Additionally, in the \"Description of Measure Bundle\" column the provider describes multiple focus areas, two of which are not reflected at all in the secondary drivers or change ideas - controlling high blood pressure and foot exams for diabetic patients. ","Y","NB","Accepting 1st review results","Needs More Information","HHSC recommends removing Secondary Drivers 2 and 3 and adding them as separate core activities, CA-7.2 Prevention and Wellness: Implementation of strategies to reduce tobacco use and CA-1.6 Access to Primary Care Services: Improve Pneumonia Vaccination Status for Older Adults in order to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column. Additionally, the provider should review their Description of the Measure Bundle/Measure Impact response and consider incorporating the focus areas mentioned there into the Secondary Drivers of this Core Activity. ","Fisher County Hospital agrees with HHSC's recommendations to remove Secondary Driver 2 and replace it with Core Activity 7.2 Prevention and Wellness: Implementation of strategies to reduce tocacco use. The goal of screening patients for tabacco use and education on cessation in concurrent with prevention and wellness. We strive to make positive improvements in the overall health and wellness of our patient population by educating and promoting cessation of tobacco use. Impact Statement for CA 7.2: Prevention and wellness. By focusing on prevention and wellness we are able to improve the overall health population of our community/patients by improving on staff education and also patient's awareness of the importance of tobacco cessation, pneumonia vaccine compliance, and advanced directives. By implementing these life changes within the patient population, we are able to decrease patient's mortality rate and increase their overall health. Fisher County Hospital disagrees however with HHSC's recommendation to remove the 3rd secondary driver Pneumonia Vaccine Status for older adults to Core Activity 1.6 Access to Primary Care Services. We feel like this 3rd Secondary driver would be better to be under Core Activity 7.2 Prevention and Wellness and change the secondary driver to staff education. Our change idea would reflect our current policies and mimic our educational sessions that we have had throughout this reporting period to train employees, current and new, on educaiton of cessation teaching and documentation. Impact Statement for CA 1.6: Access to Primary Care. By improving access to primary care we are able to improve the overall health of our patient population. We are able to educate our patients on the importance of these life changes such as tobacco cessation, importance of pneumonia vaccine compliance, and advance directives. With increased access to primary care our patient population is able to get this education and services that they might not have been able to recieve had we not been able to improve their ability to seek care. ","FG","Removed Secondary Driver 2 and added it as a new Core Activity based on provider's agreement with NMI. Moved Secondary Driver 3 up to 2 in order to not leave gaps. Marking for second review due to provider's disagreement with removing Secondary Driver 3 (now in the Secondary Driver 2 position).\n\nAdded a note about the changes I made to the \"Final Comments to Provider\", the rest of the comment will need to be edited based on second review & final decision.","Y","NB","Acceptable - leaving it the way it is based on provider's response.","Accepted","HHSC has updated the Core Activity based on the provider response, specifically, Secondary Driver 2 has been removed and added as a separate Core Activity, \"Prevention and Wellness: Implementation of strategies to reduce tobacco use\".","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_112702904","112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public",448,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","Reduce the occurrence of pneumonia in the over 65 age population by screening for vaccination and encouraging vaccination for those not yet vaccinated","Clinic providers and staff will screen all patients with a visit who are over 65 years of age on all payer classes for one or more of the  pneumococcal vaccinations and document in the medical record if vaccination has been given in the last 5 years.  Provider will explain the need for the vaccination for this age and above and give the patient the option of receiving at that visit. This will be tracked by recording those who have received the vaccination, date they received it, and which vaccination was received by  those who received during the measurement period","standing order/policy in clinic to screen all patient over 65 for pneumococcal vaccination"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This activity ties into measure bundle K1-268 by monitoring the primary care clinic patients 65 or older that need to be protected from pneumonia and ensuring they have made an informed decision on getting the vaccination.","No","","112702904.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_406583101","126842708.7.1",11,"406583101","Stamford Hosp Dist dba Stamford Family Health Cent","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",453,"Access to Primary Care Services","","Edit","As of 7/9/18, our hospital closed, but we transferred the clinc and diagnostic services back to Stamford Hospital District to continue providing as many healthcare services as possible.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","We will continue to operate our urgent care clinic which provides an additional access point for our patient population that has historically used the emergency room as their primary care clinic.  The urgent care clinic is used as a entry way into our rural health clinic and creating a formal medical home with our rural health clinic.  This continues to be a true statement even with the hospital closure on 7/9/18.  Our NPs will accept patients as walk-ins as a means to introduce them to our exceptional care and convert them from a walk-in to an established patient that is receiving consistent and preventive care for any chronic health issues.","to provide preventative care, including tobacco cessation and intervention and pneumonia vaccine, as needed.","we are providing preventive care services, including tobacco cessation and intervention and pneumonia vaccines, in our urgent care clinic which is not provided in the ER","Walk in appointments will be the rule, not the exception to encourage a walk-in patient to become an established patient with Stamford as their medical home.","increase our focus on documenting those patients who have an Advance Care Plan documented in their medical records and then educating those who do not have this documented in their chart about the importance of ACPs."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Our rural health clinic continues to be an access point for primary and preventive care in order to decrease non-emeregent ER visits in our region.  Walk-in appointments allow patients more access to our NPs.","No","","126842708.7.1","FG","Provider edited Core Activity Title since DY8 Reporting - title changed from \"Provision of vaccinations to target population\" to \"Expanded Practice Access (e.g., increased hours, telemedicine, etc.)\". The majority of descriptions, secondary drivers, and change ideas did not change and the ones that did were edited only slightly. I think the updated title fits better with provider's drivers & change ideas than the version from DY8 reporting, but I am flagging for a second opinion. Additionally, the \"Description of Measure Bundle/Measure Impact\" answer does not specifically address how the core activity impacts the measure bundle.","Y","NB","OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_133244705","133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public",717,"Maternal and Infant Health Care","","New","","Provision of services to individuals that address social determinants of health","","This initiative serves to improve the health of both Moms and Newborns by addressing substance abuse issues early in pregnancy.  Our Social Worker noted that  more than 30% of births at our Hospital had substance abuse related issues and wanted to be more proactive in addressing these early in pregancy instead of being reactive by addressing after a birth.  A program called Labor of Love is in its very early stages to provide support and counseling to those Moms identified to have substance abuse issues.","Develop processes to identify Moms with possible sustance abuse issues early in pregnancy. Through early screening and identification of moms with alcohol and drug abuse, and successful enrollment in Labor of Love,the effect drugs and alcohol has on the newborn can be lessened or prevented. Drug and alcohol use during a pregnancy can cause low birth weight, premature birth, birth defects, SIDS, and drug or alcohol dependency in the newborn.  With early screening and providing support to the Mom during pregnancy, the use of these could be stopped, resulting in healthier babies.  ","Work with providers to include drug screening during the early stages of pregnancy","Educate providers about the Labor of Love program and get their buy-in to refer patients to the program","","","","Develop and implement processes to track the progress of Moms through pregnancy and birth and track indicators of the health of newborns of those Moms who participted in the program","Determine what indicators need to be tracked to determine success of the program and develop report to track the successes and failures","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","While the selected activity does not impact anything in our selected measure bundle, it does have a major impact on the target population for DSRIP, the MLIU populatuion. Substance abuse is a major problem area that impacts both mental and physical health, and in the case of newborns, the impact is multiplied.   We want to measure the success a program like this can obtain and the related cost savings from implementing such a program.","Yes","The program is open to surrounding communities, so there will be births that may not occur at the Hospital.  Statistical information only will be tracked from these outside births by the counselor providing the service.  The majority of the population receiving these services will be by a provider in our System Definition","133244705.7.1","FG","Provider writes in \"Description of Measure Bundle/Measure Impact\" column that the new core activity does not impact any of their selected measures or bundles. Additionally, activity is new and was not added during DY8 reporting.","Y","NB","changed to nNMI - with the request for SDoH description","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","For Secondary Driver 1, through early screening and identification of moms with alcohol and drug abuse, and successful enrollment in Labor of Love,the effect drugs and alchohol has on the newborn can be lessened or prevented. Drug and alcohol use during a pregnancy can cause low birth weight, premature birth, birth defects, SIDS, and drug or alcohol dependency in the newborn.  With early screening and providing support to the Mom during pregnancy, the use of these could be stopped, resulting in healthier babies.  The cost of a healthy newborn is minimal, while  one with any of the problems listed above is astronomical, and will often result in continued high costs for much of the newborn's life.  The Secondary Driver 2 will help measure the success of the program by measuring the health of the newborn with a Mom who was able to abstain from these substances.","FG","Provider's response mostly addressed NMI comment. Approving but flagging for second review for a double-check. Updated Secondary Driver 1 based on Provider Response.","Y","NB","Updated the not the provider. OK. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically, Secondary Driver 1. During the DY9 reporting, HHSC provider should submit detailed information for the change ideas. HHSC may request additional changes to Change Ideas based on DY9 reporting.","Provision of services to individuals that address social determinants of health.","CA-4","CA-4.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_133338707","133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",456,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","Expand upon description for this core activity to describe the service enahancements necessary to achieve CCBHC certification. This was changed to build out more of the work that will be the focus DY9 and DY10, after the completion of policy and procedure. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","Betty Hardwick Center is working toward readiness for CCBHC certification which involves a number of administrative and clinical enhancements to the service system, including Substance Use Services, Care Coordination, improved integration of physical health services, etc...","Review, develop and align policy and procedures with CCBHC model of care.","Review existing policy and procedures and identify gaps that require additions or updates.","Create new policy and procedure to bridge gaps to achieve improvement and uniformity throughout the Center."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-160","All of the measures are attained by staff efforts to assess, intervene and report client services and response to services. The improvement of our policy and procedure to align staff efforts toward successful achievement of measures is necessary for consistent patient care, quality and ultimately CCBHC certification.","No","","133338707.7.1","FG","Edited since DY8 review to add specific examples of enhancements to the service system in the \"Description of Core Activity\" column. Approving but flagging for second review.","Y","NB","Accepting provider's reporting. I don't like etc. in the description but overall is crear, not following up.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_133338707","133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",458,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","This core activity focuses on identifying clients who have a BMI outside of normal parameters and providing referrals and information to those for whom obesity is a concern. ","Educate staff and clients about the health implications for obesity and weight loss and prevention options.","Create and share resource information about weight management and healthy BMI. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-160","This core activity is directly related to M1-147 in that it focuses on patients with a high BMI.","No","","133338707.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce and prevent obesity in children and adolescents (e.g., Technology Supported Multi Component Coaching or Counseling Interventions to Reduce Weight and Maintain Weight Loss; Coordinated Approach to Child Health - CATCH; and SPARK among others)","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_133339505","133339505.7.1",11,"133339505","Central Texas MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public",444,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","The prevention and wellness core activity allows us to achieve our Category C goals with the implementation of evidence based strategies to empower patients to make lifestyle changes to stay healthy.  We also utilize community health workers to improve prevention efforts in order to meet our Category C goals.  We are able to implement interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.  These are all aspects of our core activity that will allow us to better serve our population.  We will continue to focus on the mental health of our consumers in order to continue to improve their quality of life.  We will also focus on their physical health and educate them on lifestyle changes that can be made as needed to help them feel better physically as well as mentally.  This core activity will allow us to meet both Category C measures chosen.","The secondary driver for our measure M1-160 Follow-Up After Hospitalization for Mental Illness, will be to provide diagnostic and engagement activities as appropriate after consumers are discharged from the hospital for mental illness.  The will be in done in order to assess how the patient is doing after being hospitalized and see what the next step will be for the consumer to manage mental health symptoms.","We will provide necessary services at clinic locations.  We will also provide services at other locations as appropriate.  Provide a flexible schedule for follow up appointments with licensed providers.  We utilize both face to face and telehealth models."," "," "," "," ","The secondary driver for our measure, M1-147 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up, will be to monitor the patient BMI and provide education to patients about their lifestyle and how they can maintain a healthy BMI if they are above or below the average BMI.","We will provide necessary services at clinic locations.  We monitor the BMI when consumers come in for an appointment with their provider.  We only monitor the BMI in our clinic.  It is not feasible to do this outside of the clinic."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-160","This core activity impacts both selected measures by allowing us to monitor, educate and engage patients.  This allows for prevention and wellness through implementation of strategies that empower patients to make changes that will affect their physical and their mental health.","No","","133339505.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_137074409","137074409.7.1",11,137074409,"Eastland Memorial Hospital","Hospital","Non‐State Owned Public",460,"Expansion of Patient Care Navigation and Transition Services","","Continue",null,"Enhancement in coordination between primary care, urgent care, and Emergency Departments","","Patients discharged to the care of their PCP or transferred from Eastland Memorial Hospital to another facility will have a complete and accurate transition record documented, transmitted, and verified.","Addition of a Patient Care Navigator to lead performance improvement activities following LEAN principles to improve overall coordination, documentation, and communication during transitions of care.","Standardized transitions of care documents will be created and implemented.","CQI tools will be utilized by the Patient Care Navigator to drive improvements to ensure the standardized document is being completed accurately, timely, and communicated to receiving providers."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","The addition of a dedicated Patient Navigator will focus on creating standard work to ensure discharges and transitions of care are documented consistently and accurately with all required information including a home medication list and the transitions record is communicated to and verified with the next provider or level of care.","No","","137074409.7.1","FG","Also see Cat C tab - provider is requesting to discontinue their K2 bundle and add a number of C1 measures. I approved adding the C1 measures but flagged for second review the request to discontinue the K2 bundle. If their Cat C requests are approved then this Core Activity can be dropped as it will no longer be applicable. ","Y","NB","Added the language for NMI","Needs More Information","Provider indicated that they are discontinuing this core activity along with the discontinuation of the corresponding Category C K2 bundle. Provider did not provider an adequate justification for deleting the measure, and has received an NMI. HHSC is similarly asking for additional information on the discontinuation of this core activity. Provider should clarify intent for this core activity, along with the associated measures, in the \"Provider Response\" column. ","EMHD recently  implemented a new EHR system that has  enhanced reporting capabilites and wanted to move from the K2 bundle to the C1 bundle.  However, we realized that we d0 not have the historical data needed to make the change and will therefore continue with the K2 bundle until we have enough historical data to make the change ","FG","Provider decided not to continue the K2 bundle in the Cat C tab, so edited the core activity to be continued instead of deleted. Confirmed via email with provider that they intended to continue this core activity. Approved and added note to provider.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response and Category C selections, specifically changing the core activity from \"Discontinue\" to \"Continue\" and the Measure Bundle Impacted back to K2. ","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_137074409","137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public",461,"Expansion of Patient Care Navigation and Transition Services","","Continue",null,"Identification of frequent ED users and use of care navigators","","Some patients are using Eastland Memorial Hospital Emergency Room as a primary care clinic for non-emergent complaints and these patients will be networked with a PCP and assisted in applying for healthcare coverage.","The Patient Care Navigator will identify, counsel and coordinate care for patients with frequent ER usage for non-emergent conditions.","The Patient Care Navigator will develop monitoring tools to identify patients in need of referral to a PCP as well as those that need assistance in finding healthcare coverage,","The Patient Care Navigator will make contact with these patients, counsel on appropriate use of ER for emergent conditions, and coordinate care with PCP."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","This Core Activity is targeted to the appropriate utilization and reduction of unnecessary Emergency Room visits as well as access to care to primary care for patients in our area that currently utilize the ER as their primary care clinic. While this Core Activity does align with the regional needs assessment, it does not directly support the K2 measures.","No","","137074409.7.1","FG","Also see Cat C tab - provider is requesting to discontinue their K2 bundle and add a number of C1 measures. I approved adding the C1 measures but flagged for second review the request to discontinue the K2 bundle. If their Cat C requests are approved then this Core Activity can be dropped as it will no longer be applicable. ","Y","NB","Added the language for NMI","Needs More Information","Provider indicated that they are discontinuing this core activity along with the discontinuation of the corresponding Category C K2 bundle. Provider did not provider an adequate justification for deleting the measure, and has received an NMI. HHSC is similarly asking for additional information on the discontinuation of this core activity. Provider should clarify intent for this core activity, along with the associated measures, in the \"Provider Response\" column. ","EMHD recently  implemented a new EHR system that has  enhanced reporting capabilites and wanted to move from the K2 bundle to the C1 bundle.  However, we realized that we d0 not have the historical data needed to make the change and will therefore continue with the K2 bundle until we have enough historical data to make the change ","FG","Provider decided not to continue the K2 bundle in the Cat C tab, so edited the core activity to be continued instead of deleted. Confirmed via email with provider that they intended to continue this core activity. Approved and added note to provider.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response and Category C selections, specifically changing the core activity from \"Discontinue\" to \"Continue\". ","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_138644310","138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private",464,"Maternal and Infant Health Care","","Continue","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","","Hendrick Medical Center has a total of 12 OB/GYN providers, including our mid-levels.  This group of providers is committed to reducing low birth weight and preterm births.  Also, by promoting the importance of prenatal care early in the pregnancy we hope to see our most vulnerable patients, those who are on Medicaid and who are uninsured seek prenatal care early in their pregnancies.","Timeliness of prenatal care and Behavioral Health Risk Assessment","We are working with the Practice Managers over our OB Clinics to get the proper assessments, including the Behavioral Health Risk Assessment criteria added to the new patient forms that will allow the patients to complete at their first prenatal visit.   We are confident the appropriate risk assessment is being performed but in the past it has not always been done at the initial prenatal visit.  We are going to make sure this gets done at the initial visit going forward."," "," "," "," ","Postpartum follow up care, including postpartum contraceptive care","A focus on more education concerning contraception methods will be provided throughout the pregnancy and will be followed up on during the post-partum follow up visit with their Obstetrician."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This Core Activity impacts the Measure Bundle by focusing on issues that will improve health of pregnant women and their babies.  By encouraging early prenatal care and effective screenings at the first prenatal visit we hope to ensure healthier pregnancies and healthier babies who are carried to term and are born with a normal healthy birth weight.  We also hope to see the health of women improve by encouraging more women, especially our most vulnerable patients in the MLIU population to follow up with post-partum care and contraceptive care.","No","","138644310.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_138644310","138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private",465,"Hospital Safety and Quality",null,"Edit","","Implementation of evidence-based practices to improve quality of care",null,"Implementation of evidence based strategies to reduce hospital acquired conditions (HAC)\nUtilization of the DMAIC process, Baseline data is collected from cases meeting appropriate measure specifications, followed by analysis of data, and implementation of process improvement as well as reevaluation.","HMC will continue to focus on reduction of urinary catheter placement","Encourage culture of safety with physicians and staff to reduce placement of unnecessary foleys.","Research available/appropriate alternatives to foley catheters and implement (trial currently underway for female alternative)"," "," "," ","HMC will continue to focus on reduction of urinary catheter dwell time","Further develop nurse-driven protocol for removing foleys that are no longer medically indicated.","HMC will continue to focus on monitoring foley utilization"," "," "," ","Continued focus on Wound Classification labeling improvement","Educate physicians/OR staff on validating the Wound class and reporting it correctly in the EMR."," "," "," "," ","HMC will also continue to focus on Bundle implementation","Research available/appropriate strategies to further reduce SSI incidence"," "," "," "," ","HMC will continue to focus on the reduction of Central Line placement","Encourage culture of safety with physicians and staff to reduce placement of unnecessary lines","Research available/appropriate alternatives to central lines and encourage use","HMC plans to continue a strong focus on Scrub the hub compliance","Periodically monitoring compliance with Swabcap device and sending out reminders/education to staff about scrubbing the hub."," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity will impact this measure bundle by providing activities, policies we already have in place that will protect our patients by reducing the amount of infections and compilations they are exposed to in the hospital setting.","No","","138644310.7.1","FG","I reviewed the Core Activity menu and think the \"Other\" activity title is appropriate but am flagging for a second opinion.","Y","NB","changed it to NMI and appropriate areas","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Prevention and Wellness to Hospital Safety and Quality. \n\nHHSC also revised Core Activity title from Other: Implementation of evidence based strategies to reduce hospital acquired conditions (HAC) to Expanded use of existing dental clinics for underserved population.\nIf the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. \n\nOn 1/23 HHSC clarified to the provider that the comment shoudl be:\nYou can include in your response that you clarified with HHSC on 1/23 and HHSC feedback is revised to:\nHHSC revised provider’s Core Activity Grouping by moving it from Prevention and Wellness to Hospital Safety and Quality. \n\nHHSC also revised Core Activity title from Other: Implementation of evidence based strategies to reduce hospital acquired conditions (HAC) to Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.) from Implementation of evidence based strategies to reduce hospital acquired conditions (HAC).\nIf the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed.\n","We agree to change the grouping of our final core activity to Hospital Safety and Quality.  Hendrick reached out to the Waiver Mailbox for clarification of the recommendation for the Core Activity Title, as the column was not updated to what the actual change was:HHSC encouraged us to include this feedback was revised on 1/23 and is as follows: HHSC also revised Core Activity title from Other:Implementation of evidence based strategies to reduce hospital acquired conditions (HAC) to Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluations, etc.) from Implementation of evidence based strategies to reduce hospital acquired conditions (HAC).  After recieving this clarification Hendrick agrees with all feedback from HHSC.","FG","Provider agreed with HHSC comment, approving. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_138950412","138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public",718,"Maternal and Infant Health Care","","New","","Provision of services to individuals that address social determinants of health","","To assist providers in an effort to encourage expectant mothers to receive prenatal care in the first trimester in an effort to improve the overall health of both the mother & infant prior to delivery, as well as during the postpartum (6 -8 weeks after delivery) period, improving the mother's mental health & the babies safety & nutrition needs.","Continue prenatal screenings & continue to encourage providers to provide prenatal screenings, making recommendations accordingly to the expectant mothers. ","Encouraging providers to note the screenings & responses from the expectant mothers.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","By focusing on the social determinants for the expectant mothers & infants, we are improving both the mother & infants' overall health.","No","","138950412.7.1","FG","I think this activity could be combined with the provider's other activity (466). This activity is addressing SDOH, but only for expectant mothers, so it could potentially be combined as an additional secondary driver in their overall core activity addressing maternal & infant health. Flagging for second review.","Y","NB","OK","Needs More Information","HHSC recommends adding this Core Activity as an additional Secondary Driver to the provider's other Core Activity, Maternal and Infant Health Care, due to the similar intentions of the Core Activities and in order to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column.","Provider DISAGREES with HHSC's recommendation.  Palo Pinto is choosing to continue with two Core Activities.","FG","Provider disagreed with HHSC's suggestion and wants to keep Core Activity as separate (possibly because doing so would mean provider only has one Core Activity). I think this is approvable but am flagging for second review.","Y","NB","they emailed the box. This is acceptable and provider will continue with core activities. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health.","CA-4","CA-4.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_281406304","281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private",467,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","CCMC's goal is to recruit either a family practice or internal medicine physician for its rural health clinic and coverage for patients who are admitted or observed to the hospital.","According to the RHP 11 Community Needs Assessment, shortages of health care professionals is the third highest need (CN.3).  Comanche County also is listed as a Medically Underserved Area; we are expanding access to primary care and preventative services by increasing hours of operation for our clinic to 7 p.m. four days a week and have added hours of operation for Saturday.","Develop relationships with state-wide medical schools and residency programs.  Continue to have students shadow physicians in our clinic to introduce them to the health system and possibly recruit them at the time of graduation.","Develop a Telepsych program for the Emergency Room and Teleneurology program in conjunction with St. Davids Hospital to provide extended service needs to the community."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","More primary care providers will allow more timely access to services.  Expansion will allow more patients to receive preventative care.","No","","281406304.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_337991901","337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public",450,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","We will be adding a part time social worker on our staff to assist us with coordinating discharge planning. This social worker will work closely with our nursing staff and providers to ensure the best possible advanced planning for discharge. This will also help the patient and family with coordinating services that they may require once discharged.","Transition our patients to an appropriate level of care","Build a list of best options depending on level of care"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The best way that this relates to our measure bundle is for the advance care plan. This way we can connect our patients with a full plan upon diagnosis, treatment and at all other stages.","No","","337991901.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 11_DY9-10 Regional Tracker - FINAL Tracker.xlsb","11_337991901","337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public",451,"Prevention and Wellness","","Edit","","Implementation of interventions focusing on social determinants of health","","These will be additional services provided to our patients from our social worker. She will coordinate with the patient and family to put interventions in place to help improve the choices that patients make once they are discharged from the hospital or clinic. We will also create a list of prevention type of tests/procedures bases on certain diagosis.","We will track our progress based on diagnosis. For example: Obesity, diabetes, depression.","We will have lists to work off of to ensure we are providing follow ups and keeping track of our patients diagnosis.","We recently joined TMF Health Quality institute to help guide us on improving the quality of care our patients receive in and outside our facility. TMF will be a great resource for chronic disease self-management, such as cardiac and vascular health, diabetes, and end-stage renal disease. It will also increase the quality of care transitions which will help us determine what the patient needs to care for themselves at home. We also have joined the American Case Management Association as a recourse for educating staff on how we can better assist our patients."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The best way that this relates to our measure bundle will be for measure ID K1-105, K1-112, K1-115 and K1-146. These are follow up and preventative care measures for individual diagnosis. This requires close monitoring in order for patients to stay well.","No","","337991901.7.1","FG",null,"N","NB","NMI and askign for more details on SDoH","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","We recently joined TMF Health Quality institute to help guide us on improving the quality of care our patients receive in and outside our facility. TMF will be a great resource for chronic disease self-management, such as cardiac and vascular health, diabetes, and end-stage renal disease. It will also increase the quality of care transitions which will help us determine what the patient needs to care for themselves at home. We also have joined the American Case Management Association as a recourse for educating staff on how we can better assist our patients.","FG","Updated Change Idea 2 based on provider response. Discussed with NB and she recommended approving but adding a note asking provider to add more details during DY9 reporting.","N",null,null,"Accepted","HHSC approved this Core Activity; however, HHSC may require additional details for this Core Activity during DY 9 reporting (e.g. more details showing what provider is doing for addressing social determinants of health and more details on what is stated in the Secondary Driver and Change Ideas and how they will be measured). Additionally, HHSC has updated the Core Activity based on the provider response, specifically, Secondary Driver 1: Change Idea 2.","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_065100201","065100201.7.1",12,"065100201","City of Amarillo","Local Health Department (LHD)","Non‐State Owned Public",470,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","Staff will provide the pneumococcal vaccination/ensure vaccination of patients 65 and older who receive clinical services through the public health department.  This will meet the critical need identified in the community needs assessment CN.12 Inadequate vaccinate of the population.","Provide pneumococcal vaccination/ensure vaccination of patients 65 and older who receive clinical services through the public health department's immunization program.","Incorporate pneumococcal vaccination into the immunization program provided through the public health department, as provided through the grandfathered measure."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-IT-12.4","This core activity meets the selected measure.  Staff will provide the pneumococcal vaccination/ensure vaccination of patients 65 and older who receive clinical services through the public health department\ns immunization program.  This will meet the critical need identified in the community needs assessment CN.12 Inadequate vaccinate of the population.","No","","065100201.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_084563802","084563802.7.1",12,"084563802","Texas Tech University Health Sciences Center AMA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",471,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Consists of screening and following up with primary care, ambulatory clinic patients for preventive care, chronic disease screening to include tobacco use, hemoglobin A1C (HBA1C) testing, Body Mass Index (BMI), and chlamydia (CHL).","Using patient data, identify, contact, confirm patients who may qualify for above screenings.","To query patient data within the EMR to identify patients in need of screening."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","By offering screening and follow up services, this Core Activity seeks to provide comprehensive, integrated primary care services that are focused on person-centered preventive care and chronic disease screening.","No","","084563802.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_084599202","084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",474,"Access to Primary Care Services","","Continue","","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","","Continuing on with our Patient Navigators, we will expand their services to all patients who meet the medical parameters for our Measure Bundles. They will act as hubs and referrers for these patients, and will also facilitate navigation of needed services, do assessments of need, and also support clinical staff in completing administrative tasks to record and document services for the overall reporting and improved health of our patients.","Providing a personal support agent for patients with difficulties of chronic disease, access issues, and other socio-economic risks is important to facilitate and maintain wellness.","Creation of a flagging mechanism in our data systems to alert navigators of a patient who needs assessment based on diagnosis and diagnostic results. This will allow the navigators to target patients effectively and objectively based on need."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The patient navigators will act as the primary liaison for patients in our numerators for our Measure Bundles. The will provide services equal to their certification, and also have the ability to refer patients to higher or extended services in our clinics or within the community. Their primary objective is to keep patients engaged in their wellness plans.","No","","084599202.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Increase in capacity and access to services by utilizing Community Health Workers (CHWs)/promotoras, health coaches, peer specialists and other alternative clinical staff working in primary care","CA-1","CA-1.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_084599202","084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",475,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications","","TTUHSC Lubbock is continuing with our data initiative (data warehouse) that will continue to thread in disparate data sets to create a database where applications can be built upon for workflow management. For optimal efficiency, it will be necessary to create workflows for patient navigators, nurse case managers, and whomever, to focus activities on patients with targeted needs. This ensures patients in need are served, and minimizes administrative bloat to TTUHSC areas.","Experience shows that poor data systems either leave patients unserved, or creates exhorbitant expenses to achieve 100% service.\nWe have implemented data structures that will allow us to more readily examine our outcomes and provide proactive data to our clinical teams that will not only tell them how they are performing for DSRIP but will also provide them with actionable patient listings for follow up. The tools that we are building to allow this include a DSRIP performance dashboard, trend analysis on performance outcomes and missed opportuniites that will tell clinics when they missed a chance to perform a DSRIP activity so that proper follow up can occur. The work in this core activity is the core to our Access to Primary Care Services activity. ","Tieing payer data, EMR data, and partner data to identify patients who fit Measure Bundles parameters, and then building workflows to allow support teams to effectively engage patients, and maintain their health."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The data warehouse is the universe of information that contains the patients and their medical parameters attributing them to numerators of our selected Measure Bundles. From these models, we will build workflows for TTUHSC Lubbock departments to more effectively coordinate the care of these patients. The goal is truly Triple Aim.","No","","084599202.7.1","NB","Update SC","Y","NB","Added language for NMI","Needs More Information","HHSC is requesting that the provider updates its Secondary Driver 1 description to make it clear what provider is doing. For example, provider could state that they are conducting data analysis or creating an environment for data analysis, etc. Provider should respond in the \"Provider Response\" column and indicate what changes would work best for this Core Activity. ","We have implemented data structures that will allow us to more readily examine our outcomes and provide proactive data to our clinical teams that will not only tell them how they are performing for DSRIP but will also provide them with actionable patient listings for follow up. The tools that we are building to allow this include a DSRIP performance dashboard, trend analysis on performance outcomes and missed opportuniites that will tell clinics when they missed a chance to perform a DSRIP activity so that proper follow up can occur. The work in this core activity is the core to our Access to Primary Care Services activity. ","NB","Added information submitted by the provider to SD #1. Was initially confused by the provider's description related to Access to Primary Care but understand it as activities in this Core activity support what provider is doing in Access to Primary Care Services. ","N",null,null,"Accepted","HHSC has updated Secondary Driver 1 based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_084897001","084897001.7.1",12,"084897001","Lubbock Regional MHMR Ctr dba StarCare Specialty","Community Mental Health Center (CMHC)","Non‐State Owned Public",477,"Chronic Care Management","","Edit","","Management of targeted patient populations with high risk for developing complications","","Co-morbidity of diabetes with schizophrenia and bi-polar disorder is a well-documented fact.  According to the American Psychological Association, this co-morbidity is attributable to the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles and poorer health care. StarCare Specialty Health System will take an integrated health care approach to helping patients with schizophrenia and bipolar disorder, manage their increased risk of developing diabetes.","The first Secondary Driver for the above Core Activity is:  StarCare Specialty Health System will follow the Health and Human Services/Department of State Health Services (HHSC/DSHS) practice guidelines regarding testing for and treatment of diabetes in patients with schizophrenia and bipolar disorder.","The first Change Idea for the above Secondary Driver for the above Core Activity is:  during each clinic visit, patients with schizophrenia or bipolar disorder will have their blood sugar tested.","StarCare will make referrals to its integrated clinic/primary care provider for management of diabetes symptoms for those patients showing elevated blood levels. ","StarCare’s primary care provider will make referrals, when appropriate, for patients to attend groups and classes focused upon diabetes management, healthy lifestyles and cooking.","StarCare’s psychiatric providers and primary care provider will, when appropriate, conduct joint treatment planning and case staffing activities to ensure optimal health for their shared patients. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-182","This core activity was selected because it is directly applicable to StarCare Specialty Health Systems corresponding Category C measures M1-182:  Diabetes Screening for People with Schizophrenia or Bi-Polar Disorder who are using antipsychotic medications (SSD-AD).  Diabetes screening is integral to helping patients with schizophrenia or bipolar disorder (targeted populations) manage their risk of developing the disease, the high prevalence of co-morbidity is well documented.","No","","084897001.7.1","NB","since this is probably already impelemented - does the provider need to update its Change Ideas?","Y","NB","Added language for NMI","Needs More Information","HHSC recommends that the provider adds Change Ideas to specify what if additional activities are impacting provider’s goals or if testing blood sugar remains the only change idea for DY9-10 Provider should respond in the \"Provider Response\" column and indicate if provider is making additional changes to this Core Activity or if it remains as submitted. ","Core Activity ID# 477\nIn response to the Health and Human Services Commission’s (HHSC) recommendations, StarCare Specialty Health System (StarCare) adds the following three (3) Change Ideas to Secondary Driver 1:\n\nChange Idea 2:  In addition to Change Idea 1:  to test the blood sugar levels of patients diagnosed with schizophrenia or bipolar disorder, StarCare will make referrals to its integrated clinic/primary care provider for management of diabetes symptoms for those patients showing elevated blood levels.  \n\nChange Idea 3:  In addition to Change Ideas 1 and 2, StarCare’s primary care provider will make referrals, when appropriate, for patients to attend groups and classes focused upon diabetes management, healthy lifestyles and cooking.\n\nChange Idea 4:  In addition to Change Ideas 1, 2 &3, StarCare’s psychiatric providers and primary care provider will, when appropriate, conduct joint treatment planning and case staffing activities to ensure optimal health for their shared patients. ","NB","Accepting provider's additions. Added Change ideas 2 and 3 and 4.","N",null,null,"Accepted","HHSC has updated Change Ideas based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_084897001","084897001.7.1",12,"084897001","Lubbock Regional MHMR Ctr dba StarCare Specialty","Community Mental Health Center (CMHC)","Non‐State Owned Public",478,"Availability of Appropriate Levels of Behavioral Health Care Services","","Continue","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","Certified Community Behavioral Health Clinics (CCBHCs) were created via Section 223 of the Protecting Access to Medicare Act, which created a demonstration project based upon the Excellence in Mental Health Act.  The CCBHC project created a new Medicaid Provider type the services of which focus upon an integrated approach toward the treatment of mental health and substance use disorders.  The Texas Health and Human Services Commission (HHSC) was awarded a planning grant by the Substance Abuse and Mental Health Services Administration (SAMHSA) to develop certification and payment methodologies for the integration of mental health and substance use disorder services into community centers.  Although not one (1) of the eight (8) states officially selected by SAMHSA to participate in the federally-funded CCBHC demonstration project, Texas has continued to make significant investments in the CCBHC model.  StarCare Specialty Health System (StarCare was selected to be one (1) of Texas pilot sites and received certification from HHSC as an official Texas CCBHC provider.  StarCare continues to work with HHSC to further develop and implement the CCBHC model in Texas.","The first Secondary Driver for the above Core Activity is:  StarCare Specialty Health System (StarCare) will continue to partner with the Health and Human Services Commission to further develop and implement the CCBHC model in Texas.","The first Change Idea for the above Secondary Driver for the above Core Activity is:  Senior Executive StarCare staff will participate in state-sponsored CCBHC activities and serve on state-level CCBHC working committees, while simultaneously maintaining service delivery levels that resulted in being certified as a CCBHC pilot site.","2nd Change Idea for 1st Secondary Driver:  StarCare will attend CCBHC training held during national and state-level conferences."," "," "," ","StarCare will work toward achieving the CCBHC vision of providing access to care at the right time and place, specifically improving time from first contact to initial evaluation (within 10 business days).","StarCare will provide telephonic or in-person preliminary screenings and risk assessments to determine the acuity of a persons needs.  For a person whose needs are routine, an appointment for a full evaluation will be scheduled within 10 business days.  For a person whose needs are more urgent or emergent, more immediate services will be initiated."," "," "," "," ","In accordance with the CCBHC model of care, StarCare will expand hours of operation to meet the needs of CCBHC patients.","StarCare will expand the hours during which patients can pick up their medications to 5:30p.m. at least one (1) day per week."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-390","This core activity was selected because it is directly applicable to StarCare Specialty Health Systems corresponding Category C measures M1-390:  Time to Initial Evaluation:  Mean Days to Evaluation, because this measures steward is the Health and Human Services Commission (HHSC) Certified Community Behavioral Health Clinic (CCBHC) Program.","No","","084897001.7.1","NB","Suggest reworking change Ideas for provider's review and feedback - since provider is including the history of CCBHCs more than its actual activities.","Y","NB","Accepting since there are specific change ideas included","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_094129604","094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public",481,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","1. Screen patients for tobacco use at each provider visit.  2.  Patients identified as smokers will receive a face to face counseling session by a provider.  3.  MCHD will netowrk with community resources (i.e. social services) to assist patients to reach our smoking cessation goals for our patients.  4.  Improve our electronic medical record to differentiate between smoking and non smoking patients and improve compliance. 5. Offer pharmacologic smoking cessation assistance","1. For Identification: Improve the EMR to capture smoking individuals among the patient population, and improve the intake workflow proces","Improvement of identification will occur through hard stops in the EMR through required fields","The EMR changes will be made so that the workflow is user friendly for the end user","Utilize EMR data to evaluate staff compliance of screening for tobacco use"," "," ","2. For Education: Improve capture of education on smoking cessation in the EMR, that communicates across the district","Alter the EMR to allow providers a place to document the patient-provider education session","Educate providers on upcoming changes and required documentation","Utilize EMR data to evaluate staff compliance of counseling for tobacco cessation"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The changes and processes described above will improve identification of smoking patients and will allow a place for documentation of the interventions.  Utilizing the EMR will assist in driving the process of identification and counseling.  Our ultimate objective is to have greater insight of the smoking population and determine if our processes are influencing behavior changes.","No","","094129604.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_094129604","094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public",482,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","1. Assess the status of pneumonia vaccination in adults 65 and older. 2. Utilize the EMR to document the status of vaccination 3. Improve compliance with CDC vaccination guidelines by utilizing the EMR to guide provider with clinical support 4. Improve education outreach to improve awareness of pneumonia vaccination and its importance","Improve assessment of pneumonia vaccine status in adults over 65","Alter the EMR to capture who has already received a pneumonia vaccine and identify who needs the vaccine","Utilize the EMR to allow for vaccination documentation to all providers, including a user friendly workflow where vaccine status is easily accessible"," "," "," ","Improve compliance with CDC pneumonia vaccination guidelines","Utilize EMR to provide clinical decision support within the documentation system at the time of care (i.e. weblinks to the CDC)","Improve community outreach and pneumonia vaccine awareness by increasing written education resources"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Appropriately assessing vaccination status of patients will allow MCHD to identify which patients need the vaccine and ultimately improve the overall health of the population, especially those with chronic illnesses.","No","","094129604.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_094180903","094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public",484,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","We have implemented a patient navigation program that reaches patients that present to our Emergency Department with medical needs that can be addressed through our clinics and other providers.  We are getting these clients in with a PCP who can monitor their medical needs without being treated in  the ER only.","The patient navigator is screening all private pay ER's for not only financial assistance but for PCP access.  IF the patient does not have a PCP, the navigator assigns and makes an appointment for the patient in one of our 3 clinics that LCHD operates.  Assigning a PCP ensures that the patients will have access to emergency medical care during business hours as well as continual well checks.","We are going to establish a check-out process in clinics and possibly in ER where the patients are given an appointment direct to the clinic for follow-ups so there care is continued past the ER visit.","We are planning to get the patient navigator set up in our systems scheduler so his appointments can be pre-set without him having to contact the patients directly after a clinic or ER visit.","LCHD clinic providers are now more focused and committed to giving preventative care.  Each patient over 18 will be screened for tobacco use and given documentation and education concerning the perils of tobacco.  LCHD owns and operates the local pharmacy so we would be able to offer tobacco cessation products at reduced prices.  With our 340B program, we offer discounted prescriptions to qualifying patients.   Our clinic staff have always done a great job with vaccines but LCHD providers will be more focused on all vaccines but specifically pneumo vaccines.   We will highlight each patient over 65 and document if they have received a pneumo vaccine and the date of vaccine.  LCHD also does flu vaccine clinics each year and we can offer pneumo vaccines there as well."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","The impact the project has made on our Medicaid/Low-Income has been great.  Our project navigator reaches 100% of the patients that are presented thru our Emergency Room that are private pay for a base screening and he also reaches out to 100% of the MLIU clients that present to our hospital-owned clinics that need financial assistance referred by any clinics.","No","","094180903.7.1","NB","are any components of the CA already completed? Request clarification","Y","NB","Accepting it since provider could continue the processes after they were established","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_109588703","109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public",485,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","This description of the enhancement in coordination between primary care and emergency departments is for increased communication between facilities, as well as, providers. This will ensure a smoother transition for patients, from the emergency department to other facilites, needing a higher level of care. This core activitywill also provide improved transitions back to the primary care physician after an emergency department encounter, observation or acute level stay in the hospital.","Redesign the transfer process, for patients transferring from our ED to another facility in order to verify that all vital information is shared with the receiving facility.","Ensure all seven of the specs of the measures K2-359 are provided in the transfer process via fax, phone, or by the patient or EMS/transfer company.\nA transfer packet worksheet encompassing all the specs (Contact Time, Patient Information, Contact Information, Vital Signs, Medication Information, Physician Generated Information, Nurses Notes, Tests Performed) has been created that the nurses fill out on all transfers. The nurses gather the information write it down, and use the packet to give report to the receiving hopsital. The hopsital then faxes the packet and medical record to the receiving facility.  What is being tested and assessed is the completion of the document upon a transfer. "," "," "," "," ","At each encounter ensure that all over-the-encounter and prescription medications the patient is taking are documented.","Utilize universal scripting for providers to ensure all the specs are met for the measure K2-287. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","This core activity impacts the selected measure bundle in the enhancement of coordination between primary care and emergency departments as increased communication between facilities, as well as, providers. This will ensure a smoother transition for patients, from the emergency department to other facilities, needing a higher level of care. This core activity will also provide improved transitions back the primary care physician after an emergency department encounter, observation or acute level stay in the hospital.","No","","109588703.7.1","NB","Clarify SD CI1 to specify 7 elelments","Y","NB","Included specific language","Needs More Information","HHSC is requesting that the provider updates its Secondary Driver 1 Change Idea 1 to include details on what exactly provider is doing (what information is included with the transfer). Provider is also encouraged to add additional Change Ideas to reflect what is being tested during the redesign of the transfer process.  Provider should respond in the \"Provider Response\" column and indicate what changes would work best for this Core Activity. ","A transfer packet worksheet encompassing all the specs (Contact Time, Patient Information, Contact Information, Vital Signs, Medication Information, Physician Generated Information, Nurses Notes, Tests Performed) has been created that the nurses fill out on all transfers. The nurses gather the information write it down, and use the packet to give report to the receiving hopsital. The hopsital then faxes the packet and medical record to the receiving facility.  What is being tested and assessed is the completion of the document upon a transfer. ","NB","Included provider's response in Change Idea 1. ","N",null,null,"Accepted","HHSC has updated Change Idea 1 based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_126840107","126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private",488,"Hospital Safety and Quality","","Edit","","Implementation of evidence-based practices to improve quality of care",null,"Description of Core Activity:       For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. ","Quality Improvement group will monitor and evaluate metric progress and determine activities needed for Performance Improvement.","Distribute quarterly progress updates to providers as part of the performance improvement plan.","Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Better tracking of our patients and providing consistent opportunity for Advance Care Planning in the clinic setting will help to improve the number of patients that have complete and accurate advance care plans in place before an emergency situation.","No","","126840107.7.1","NB","Suggest changes to provider for Other option","Y","NB","NMI and suggestions","Needs More Information","HHSC recommends that the provider revisits its Core Activity description to reflect activities that the provider is implementing to impact the measures selected by providers. In the current description, provider’s concentration is on Category C measures. The re-write of the description should help provider identify Core Activity Grouping and Title/area that work best for this Core Activity. Provider can consider using Hospital Safety and Quality Grouping and Area: Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.). Based on the change ideas increase to Primary Care Services may work as well. Please respond in the \"Provider Response\" column with the suggested changes.","Core Activity Grouping: Hospital Safety and Quality\n\nName of Core Activity:   Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation\n\nDescription of Core Activity:       For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. \n\nSecondary Drivers: Quality Improvement group will monitor and evaluate metric progress and determine activities needed for Performance Improvement.\n\nChange Idea 1:  Distribute quarterly progress updates to providers as part of the performance improvement plan.  \n\nChange Idea 2:  Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. ","NB","Updated based on the provider's response. ","N",null,null,"Accepted","HHSC has updated Core Activity based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_127313803","127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public",489,"Access to Primary Care Services","","Edit","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","We begin offering extended hours at the conclusion of the last waiver and are exploring the option to expand hours at both clinics.  In addtion, we have plans to bring on two more providers in the upcoming years further opening additional appointment times.","We will expand our clinic hours in order to improve availability of appointments.  This will allow us to impact a greater population of our community in that patients can be seen at more convenient times.","Expand clinic hours (When??)"," "," "," "," ","Continue to increase access to care by recruiting  additional providers.  ","Schedule follow-up appointments with these physicians after patents are discharged."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This activity impacts the Measure Bundles as it allows for expanded access to primary care services at our clinics, allowing the providers to focus on outcomes related to this bundle.","No","","127313803.7.1","NB","Change Idea 1 should become SD2. Make suggestion to the provider","Y","NB","Included specific language","Needs More Information","HHSC revised providers information the following way: 1) moved Secondary Driver 1: Change Idea 1 (In addition to the expansion of clinic hours, we will continue to recruit additional providers.  We will also schedule follow-up appointments with these physicians after patents are discharged.) to Secondary Driver 2 – created Change Idea in addition to the Secondary Driver. HHSC is requesting that the provider includes sufficient details in the response so the information for Secondary Drivers and Change Ideas can be included. Provider should respond in the \"Provider Response\" column.","There was no change indicated on the part of Lamb HC related to the core activity.  The proposed HHSC indicated changes are agreeable to Lamb Healthcare Center.  ","NB","Provider accepted the changes. No other follow up","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_127319504","127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private",491,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Decrease episodes of CAUTI, CLABSI and other hospital safety measure by the implementation of daily huddle to cascade best practices and expectations to clinical staff and promote collaboration to drive improvement","Awareness of incidences of potentially preventable episodes","Bring the right clinical leadership to identify root causes for episodes and creating shared accountability for driving improvement"," "," "," "," ","Focus on improvement in hand hygiene","Identify trends in hand washing practices and incorporate protocol to ensure proper hand washing prior to patient room entry for all staff with patient contact."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3; E2","This Core Activity is one of the primary tactics being deployed for improvement of Bundle","No","","127319504.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_127374005","127374005.7.1",12,"127374005","Central Plains Center for Mental Health Mental Ret","Community Mental Health Center (CMHC)","Non‐State Owned Public",492,"Prevention and Wellness","","Edit","","Utilization of whole health peer support","","We will utilize two of our MH peers to provide HRA's and to provide supportive group sessions to assist our adult MH consumers in achieving better health outcomes. Our MH peers have been providing whole health services by conducting Health Risk Assessments, referrals to primary care services, accompanying clients to doctor appointments and tests, conducting whole health support groups and exercise programs.","By providng these supports to our consumers who may use tobacco or have a high BMI, it gives our consumers an opportunity to make changes to their lifestyle that will improve their overall phyisical health.","Peers will provide improved access to primary care.","Peers will provide improved access to  tobacco cessation programs.","Peers will provide improved access to  whole health support groups.","r MH peer support services will seek to refer individuals identified as having a BMI that is too high to medical services, exercise activities and support."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147","Adults with mental illness die, on average, 29 years sooner than those without a mental illness.  By focusing on tobacco use we hope to assist our consumers to stop smoking.  Our MH peer support services will seek to refer individuals identified as having a BMI that is too high to medical services, exercise activities and support .","No","","127374005.7.1","NB","Provider should move portion of the SCCI1 into SD and create concrete change ideas that are tested through the intervention.","Y","NB","made changes - NMI","Needs More Information","HHSC separated Secondary Driver 1: Change Idea 1 (Peers will provide improved access to primary care, tobacco cessation programs, whole health support groups. Our MH peer support services will seek to refer individuals identified as having a BMI that is too high to medical services, exercise activities and support.)  into multiple Change Ideas. If provider disagrees with these changes, please respond in the \"Provider Response\" column. Provider can suggest additional changes to include sufficient details. ","Provider aggress to changes. ","NB","Provider agrees  with changes. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of whole health peer support, which could include conducting health risk assessments, setting SMART goals, providing educational and supportive services to targeted individuals with specific disorders (e.g., hypertension, diabetes, and health risks such as obesity, tobacco use, and physical inactivity)","CA-7","CA-7.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_127378105","127378105.7.1",12,"127378105","Texas Panhandle Mental Health Mental Retardation","Community Mental Health Center (CMHC)","Non‐State Owned Public",494,"Prevention and Wellness","","Delete","The Core Activity will continue as an agency initiative from the 1115 Waiver projects; however, due to discontinuation of some agency community health workers’ projects, this activities broader impact for DSRIP purposes was decreased. Due to challenges this activity will be deleted but changes to current and the addition of a new core activity will better reflect Agency DSRIP activities that have the most impact. When this Core Activity first continued as Waiver Project, TPC had two locations where 3 community workers provided integrated behavioral health at a primary care setting, were employed. However, one location at Regent Health Network (RHN) was discontinued by TPC since RHN decided to employ their own specialist instead, as they valued the success of the program. In addition, during DY8 the lead YES Waiver Coordinator for the Core activity resigned, which only left one worker at Care Today. When this Core Activity was originally selected it was to primarily highlight initiatives that impact children and adolescents, however, Care today alone serves a small percentage of this population.","Use of community health workers to improve prevention efforts","","Individuals living with serious mental illness face an increased risk of having chronic medical conditions and die on average 25 years earlier (NAMI); Consequently, to help improve prevention efforts, TPC currently employs two Integrated Primary and Behavioral Healthcare Specialists. Each is a graduate prepared Qualified Mental Health Professional. Both are working towards their licensing hours-one to become an LPC and the other to become a LCSW.  One of the Specialists is co-located at an Urgent Care Medical facility in Amarillo.    This community health worker (CHW) provides services for individuals experiencing behavioral health issues related to a diagnosis of Major Depression and other behavioral disorders. Staff will complete a crisis assessment including a Suicide Risk Assessment when individuals present in crisis.  In addition, efforts include the prevention or improvement of health conditions such as hypertension along with risk factors such as tobacco use and an unhealthy weight.   Staff provides support in helping a client work towards their whole health goals by providing: brief educational intervention targeted at maintaining both physical and mental health; creating behavioral activation plans that can help the client plan for success in their personal health and/or providing an additional level of accountability to help clients make progress on their objectives. The worker coordinates with other members of the patient\u0092s multidisciplinary care team which may include a primary care physician, peer support providers, psychiatrist, behavioral health case manager and nursing staff to provide continuity of care. In addition, The Youth Empowerment Services (YES) waiver is a 1915(c) Medicaid program that helps children and youth with serious mental, emotional and behavioral difficulties. The YES waiver provides intensive services delivered within a strengths-based team planning process called wraparound. Wraparound builds on family and community support and utilizes YES services help build the family\u0092s natural support network and connection with their community. The Wrap around provider, as a community health worker, acts as liaison between health care services and social services and assists children and families to gain access to needed services and provides knowledge through outreach and community health education. \n\n","Community health workers provide Integrated Behavioral Health and Primary Care Services to children and adolescents at one Primary Care location in order to help prevent or improve chronic conditions. Workers will provide self management support including strategies that emphasize the patient and families central role in managing health to make improvements in nutritional choices and increasing physical activity. Staff will work with parents and their families to set priorities and problem solve. Depending on the age and maturity of the children and youths involved, the strategies may include parental/family engagement and motivation. In addition,YES uses a planning process known as Wraparound, a form of intensive case management, to create a plan specifically for the child.  YES services are designed to identify and support the strengths of the child or youth.  The Wraparound process builds on support that the family and community provide.  This \u0093Child and Family Team,\u0094 may include family, friends, teachers, and other health professionals who want to help the child be successful.  Together, the team develops a plan of care to meet the specific needs and goals of the child.  Provider services included in YES Waiver are equine, art and music therapy.  Referrals in the community that may be identified and accessed include: medical care, immunizations, and other community activities and/or support.  Some of the children served may experience weight gain due to BH medications, poor nutritional habits or inactivity, consequently, education regarding healthy lifestyles may be provided informally individually or at community events and health fairs by the community health worker or as requested by the CHW.  ","The We Can (Ways to Enhance Children's Activity & Nutrition)  national education program provides parents and caregivers with tools, fun activities, and more to help them encourage healthy eating, increased physical activity, and reduced time sitting in front of the screen (TV or computer).  The community health worker will routinely disperse and discuss with patients nutritional tip sheets and other resources for parents and families from a recognized program like We Can such as Parent Tips: Help Your Kids Reduce Screen Time and Move More or UR What U Eat: Go Slow Whoa  https://www.nhlbi.nih.gov/health/educational/wecan/downloads.  They will also disseminate information at health fairs, community events or to other community partners."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-147; M1-211; M1-103; M1-105; M1-305; M1-319","The use of Community Health Workers providing integrated behavioral health and primary care in a primary care setting to improve prevention efforts is related to the CAT C Descriptions of the following measures:   Controlling High Blood Pressure M1-103; Tobacco Use: Screening & Cessation M1-105; BMI Adult: Screening & Follow Up M1-147; Children/Adolescents Weight Assessment & Counseling for Nutrition & Physical Activity M1-211; Child/Adolescent MDD: SRA M1-305 and M1-319 Adult MDD:SRA. Workers coordinate and follow care of individuals diagnosed with essential high blood pressure to ensure that patients have access to medications, when prescribed and provide interventions related to risk factors such as smoking, unhealthy weight, poor nutrition and lack of physical activity.  Tobacco cessation is provided by Certified Tobacco Treatment Specialist.  In addition, the specialist currently has a graduate level degree in a mental health related field and has specialized training to provide crisis assessments for patients who present in crisis, including persons diagnosed with Major Depressive Disorder. During this contact the worker will also complete a Suicide Risk Assessment and develop a necessary plan of action. The worker provides interventions that help improve or prevent health conditions and risk factors. YES Waiver Wraparound workers provide informal counseling regarding health education and promote healthy lifestyles individually and at community events. These workers use the same or similar tip sheets used when the M1-211 Children/Adolescents Weight Assessment & Counseling Measure is performed.","No","","127378105.7.1","NB","Health workers - Discontinue","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Use of community health workers to improve prevention efforts","CA-7","CA-7.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_127378105","127378105.7.1",12,"127378105","Texas Panhandle Mental Health Mental Retardation","Community Mental Health Center (CMHC)","Non‐State Owned Public",495,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","One change is that the provider has added three more jail location sites, from nine (9) to twelve (12), in the description of telehealth/telemedicine services, which is related in part, to the change idea of educating regional jail sites. Also, TPC has added one more regional hospital, changing the total from eight (8) to nine (9). In addition, TPC has achieved the goals established in the change idea, of educating all telehealth/telemedicine jail county sites (9) and other county jail sites in the region (5); therefore, the secondary driver was deleted for reporting purposes only, along with the corresponding change idea but these activities are ongoing outside of DSRIP reporting. A new driver and change idea was added in its place to reflect recent changes where prescribers perform parts II and III of the M1-211 Children/Adolescents Weight Assessment and Counseling for Nutrition and Physical Activity Measure. ","Utilization of telehealth/telemedicine in delivering behavioral services","","In order to provide appropriate levels of behavioral health care services to individuals living in the service area of the top 21 counties of the Texas Panhandle, 19 of which are considered rural, Texas Panhandle Centers (TPC) utilizes Telehealth/telemedicine /Telehealth/telemedicine for the delivery of care.  Pharmacological Management Services are provided by a Psychiatrist or an Advance Care Practitioner and their telehealth/telemedicine services, provided at an established medical site, may be used for all client visits. TPC has eight (8) originating sites (where the patient is located at a facility) in Amarillo, six (6) Behavioral Health sites in the regional clinics and five (5) Intellectual and Development Disability sites located at regional ASCI Workshops.  The agency also has established twelve (12) sites for jail services and nine (9) community hospital sites in overlapping or different counties of the service area. Crisis screening and intake services are provided by a Licensed Professional of the Healing Arts (LPHA) or by a Qualified Mental Health Professional (QMHP).  The Suicide Risk Assessment SRA (Columbia Suicide Severity Rating Scale, or C-SSRS), is completed during every LPHA visit (for children), intake and during a crisis assessment for everyone which is clinically valid and helps meets the MDD: SRA Child and Adult Measures.  In addition, in order to meet Parts II and III of M1-211 Children/Adolescents Weight Assessment and Counseling for Nutrition and Physical Activity Measure TPC now utilizes prescribers mainly for the rural sites to complete the Nutrition and Physical Activity Counseling.  After part I, BMI percentile is completed, the client/family is given educational information in person at the originating site which is then reviewed/discussed by the prescriber along with any other client specific information related to these topics from the distant site.       ","TPC currently has four (4) prescribers providing pharmacological services to Children and Adolescents, who are primarily diagnosed with ADHD, Disruptive Behavior Disorders, and Major Depression.  Telehealth/telemedicine services are provided to Behavioral Health clinics so that an appropriate level of services can be delivered.  \n  \n","Provision of Counseling:\n\nIn order to help ameliorate side effects of some prescribed behavioral health medications, such as weight gain, along with symptoms of some disorders, such as abnormal weight/appetite and activity level, Prescribers will provide Parts II and III of the M1-211 Measure, counseling for Nutrition and Physical Activity for Children & Adolescent individuals/families in the regional/rural locations via Telemedicine, who do not have access to face to face nursing services. Counseling will be provided at least 1 X annually either during an initial encounter or during a wellness visit, however, most prescribers perform the measure during all encounters as part of the encounter plan.  The BMI percentile is formulated at the originating site with results given to the prescriber, then the individual/family is given We Can tip sheets regarding eating healthy and moving more and tip sheets on calories needed each day, which are discussed by the prescriber during the encounter, relevant to the individual’s treatment. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-305; M1-319; M1-211","By utilizing telehealth/telemedicine in the delivery of behavioral services, TPC can offer appropriate levels of care to adults and children diagnosed with Major Depressive Disorder (MDD) who are at 25 times greater risk for suicide than the general population (American Association of Suicidology, Depression and Suicide Risk 2014).  These services impact the measures Child/Adolescent MDD: SRA M1-305 and Adult MDD:SRA M1-319 since the Suicide Risk Assessment, which is used to identify people of all ages at risk for suicide, especially those diagnosed with MDD, is completed during appointments such as intakes, pharmacological services and crisis assessments. In addition, prescribers also now complete Part II and III of the M1-211 Measure Weight Assessment and Counseling for Nutrition and Physical Activity . This measure was only 75% met in DY7 due to lack of qualified staff coverage but now with the use of telemedicine, the goal is 100% met.","No","","127378105.7.1","NB","review changes again","Y","NB","added recommendaiton ","Needs More Information","Provider should revisit its Change Ideas to make sure main items that the provider is doing are reflected in Change Ideas.  please respond in the \"Provider Response\" column with the suggested changes or an indication that the information should stay as submitted.","In order to better meet the Plans Core Activities requirements, the provider suggests the below changes for clarification based on the following:\n\nAlthough the main purpose of the delivery of telehealth/telemedicine is to provide Behavioral Health (BH) pharmacologic management services, an unfortunate side effect of some BH medications is weight gain, therefore, the change idea helps in both meeting quantitative DSRIP goals and also serves as supplemental education to help ameliorate medication side effects and in some cases symptoms of a disorder such as abnormal weight/appetite and activity level.  In order to better clarify this relationship between the Core Activity (main items) and the change idea, the provider proposes the following suggested change to the Change Idea:\n\nIn order to help ameliorate side effects of some prescribed behavioral health medications, such as weight gain, along with symptoms of some disorders, such as abnormal weight/appetite and activity level, Prescribers will provide Parts II and III of the M1-211 Measure, counseling for Nutrition and Physical Activity for Children & Adolescent individuals/families in the regional/rural locations via Telemedicine, who do not have access to face to face nursing services. Counseling will be provided at least 1 X annually either during an initial encounter or during a wellness visit, however, most prescribers perform the measure during all encounters as part of the encounter plan.  The BMI percentile is formulated at the originating site with results given to the prescriber, then the individual/family is given We Can tip sheets regarding eating healthy and moving more and tip sheets on calories needed each day, which are discussed by the prescriber during the encounter, relevant to the individual’s treatment. \n\nWe hope this change is satisfactory in meeting the NMI request.","NB","Updated the change idea. Provider's response accepted.","N",null,null,"Accepted","HHSC has updated Change Idea 1 based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_130725806","130725806.7.1",12,"130725806","West Texas Centers for MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public",468,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Utilization of telehealth/telemedicine in delivering behavioral services","","West Texas Centers utilizes telemedicine as its primary source of delivering behavioral health services to its 23-county catchment area.  The continued expansion of this core activity will increase physician availability across this very rural area, decrease appointment wait times and inappropriate law enforcement incarcerations and emergency room admissions.","Screening for risk factors associated with behavioral health.","To complete the suicide risk assessment for all clients with the qualifying diagnosis at each visit with mental health practioner to screen for risk factors. \nScreening clients for depression and suicide risk during appointment with behavioral health professionals will allow for the behavioral health professionals to provide immediate attention to potential problems or risks.  This in addition to rapid follow up after hospitalization will ensure increased continuity of care and improve outcomes."," Complete the PHQ-9 depression questionnaire for every client with a qualifying diagnosis at every visit with a qualified mental health professional to screen for risk factors. ","To have all clients releasing from a private or state mental health facility to complete intake at time of aftercare if they are not already in services with West Texas Centers. This is to ensure quicker access to full array of services."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-146; M1-160; M1-305; M1-319","As mentioned previously, West Texas Centers utilizes telemedicine in the  delivery of behavioral health services within it's 23-county catchment area.  The continued expansion of this core activity will allow WTC to bring appropriate behavioral health professionals/practitioners to the rural areas and screen for depression and suicide risk.","No","","130725806.7.1","NB","suggest including more concrete details","Y","NB","requested specifics","Needs More Information","Provider should revisit its Change Ideas to make sure main items that the provider is doing are reflected in Change Ideas.  please respond in the \"Provider Response\" column with the suggested changes or an indication that the information should stay as submitted.","Secondary Driver 1: Change Idea 1: \n    The first change idea for the above secondary driver for the above core activity is to complete the suicide risk assessment for all clients with the qualifying diagnosis at each visit with mental health practioner to screen for risk factors. \nSecondary Driver 1: Change Idea 2:\n   The second change idea for the above secondary driver for the above core activity is to complete the PHQ-9 depression questionnaire for every client with a qualifying diagnosis at every visit with a qualified mental health professional to screen for risk factors. \nSecondary Driver 1: Change Idea 3:\n    The third change idea for the above secondary driver for the above core activity is to have all clients releasing from a private or state mental health facility to complete intake at time of aftercare if they are not already in services with West Texas Centers. This is to ensure quicker access to full array of services.","NB","Accepted provider's responses and made changes. No additional follow up needed.","N",null,null,"Accepted","HHSC has updated Change Ideas based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of telehealth/telemedicine in delivering behavioral services","CA-9","CA-9.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_130826407","130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public",499,"Expansion of Patient Care Navigation and Transition Services","","Edit","The Memorandum of Transfer (M.O.T.) redesigned for patients transferring from our ED to another facility in order to verify that all needed information is shared to the receiving facility. This has been completed and will be deleted. We will now focus on training of the staff to achieve all required elements of K2-359: Emergency Transfer Communication Measure as well as implementation of case management in the emergency department.","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","DHCHD will improve transition services and experiences by implementing a patient navigation script, educating patients about what to expect during transitions, and scheduling appropriate follow up.","All elements of the emergency transfer communication measure will be documented and completed. ","Providers, nurses, and clerical staff will all receive standardized training during orientation about required elements of emergency transfer communication.","Nurses will be trained to utilize the telephones and computers in the patient rooms to ensure report is called and documented prior to patient discharge to another healthcare facility. "," "," "," ","At each encounter, a qualified clinician will assess all over-the-counter and prescription medications a patient is taking.","Utilize universal scripting and standardize medication reconcilliation process to ensure all measure specifications are met for measure K2-287."," Install and implement a prescription history database that is accessible to all providers and nurses involved in the patient's care."," "," "," ","  Case management will be implemented in the emergency department to ensure appropriate levels of care and follow up.","  Case management will complete utilization review at the time of service to ensure patients are receiving the appropriate level of care. Case management will also be scheduling appointments for follow up appointments with their primary care provider. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Improving transitions of care impacts emergency department admissions, transfers, and discharges as well as the quality of care the patient receives.","No","","130826407.7.1","NB","changes are similar to the changes in the reporting file","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_133544006","133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public",503,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","The provider will  implement a patient navigator program.  We will hire a patient navigator,  qualified to perform proper medical screenings by EMTALA policies and guidelines,  to transport non-emergent patients from our ED department to our RHC.  We researched and collaborated over this program and feel it will help decrease the patient load and cost of our ED department and help increase our clinic visits.  This new program will enhance our patient-centered approach to provide quality care to all patients and have a key improvement from Medicare and other insurance carriers. The coordination between primary care, urgent care, and Emergency Department will increase communication and care transitions for our patients.  Our program will help navigate a relationship with a clinic provider and our patients.  Our seven elements will be a part of our change idea.  We need to have most all of the 7 elements documented for our proper medical screening and documentation in the chart for the Nurse Practitioner at our RHC and for the navigator.Our new electronic health record has a InterFacility Transfer note available for nursing staff utilization.  We have initated training and appropriate utilization to increase documentation and provide assurance that the necessary documents of communication have been provided in a timely manner.","Utiliztion of the InterFacility Transfer note will be utilized to ensure all necessary communication documents have been provided from our ED to another facility.","Hiring a patient navigator"," Documentation of the seven elements of Measure Bundle K2-359."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Utilization of the Interfacilty Transfer Note will ensure the all necessary communication documents have been provided from our ED to the accepting facility.  Increase communication will provide more accurate continuum of care for the patient.","No","","133544006.7.1","NB","Secondary Driver Change Idea 1 will need to be udpated to clarify what is being done. I don't have sufficient information to update it for provider. ","Y","NB","added recommendaiton ","Needs More Information","HHSC recommends that the provider clarifies Secondary Driver Change Idea 1 to detail what is being done. Please respond in the \"Provider Response\" column with the suggested changes.","DSCHD has been using the InterFacility Transfer note to document our seven elements in our K2-359 Measure Bundle.  For all seven,  we have communicated and trained our staff to document all elements.  For example, for ETC-SUB-1 The nurses are documenting  the communication from the nurses to nurses and the physicians are documenting physicians to physicians and the staff is also documenting the communication in the patient chart.    Our ED Director is also auditing our charts to make sure the documentation and all elements are present in the chart and also in our interfacility transfer note.","NB","Provider's response was not clear. Asked to clarify.","Y","NB","NB  followed up with a provider and they sent the following updats. I was not sure where they wanted to reflect this information but it seemed more appropriate for Core Activity.\n\nWe would like to implement a patient navigator program.  We will hire a patient navigator,  qualified to perform proper medical screenings by EMTALA policies and guidelines,  to transport non-emergent patients from our ED department to our RHC.  We researched and collaborated over this program and feel it will help decrease the patient load and cost of our ED department and help increase our clinic visits.  This new program will enhance our patient-centered approach to provide quality care to all patients and have a key improvement from Medicare and other insurance carriers. The coordination between primary care, urgent care, and Emergency Department will increase communication and care transitions for our patients.  Our program will help navigate a relationship with a clinic provider and our patients.  Our seven elements will be a part of our change idea.  We need to have most all of the 7 elements documented for our proper medical screening and documentation in the chart for the Nurse Practitioner at our RHC and for the navigator.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC made changes to the Change Idea based on provider’s responses.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_136142011","136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public",504,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","This Core Activity will be addressed by providing more accessability of vaccinations and education to our MLIU population. This will allow the oppurtunity to educate our poplulation about the importance of preventative services such as immunizations.","The first Secondary Driver for the above Core Activity is education, which will be accomplished through outreach initiatives with the school system, senior citizen organizations, businesses, civic groups, churches, and shut-ins (such but not limited to Meals on Wheels recipients).","Increase outreach by communication, marketing and networking with the Dimmitt ISD families through the school nurses and specifically targeting senior citizen groups."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This Core Activity will impact the selected Measure Bundle by providing focused outreach for specific health concerns within our MLIU community.  The goal is to positively affect our patients' health outcomes by increasing accessibility to services such as immunizations, smoking cessation education, and advanced care plannning.  All of these measures will improve the quality of patients' lives, create beneficial relationships with the local health care system, and reduce healthcare costs not only for the patient but also the system.","No","","136142011.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_136492909","136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public",506,"Chronic Care Management","","Continue","","Implementation of a medication management program","","According to the on-line health resource, TherapyTribe, medication management is a treatment system used by doctors and pharmacists to ensure patients are receiving optimal therapeutic outcomes for the prescription medications they are taking.  This core activity was selected because it is directly applicable to Sunrise Canyon Hospitals corresponding Category C measure, H2-160:  Follow-up after hospitalization for mental illness.  Psychiatric medications prescribed while a patient is hospitalized are monitored, in addition to the patients transition from inpatient to outpatient care, during the patients Follow-up appointment.","The first Secondary Driver for the above Core Activity is A follow-up appointment within seven (7) days is made by a Sunrise Canyon Hospital staff person before a patient is discharged.","The first Change Idea for the above Secondary Driver for the above Core Activity is A the time of discharge, the discharge nurse gives each patient a written notice of the follow-up appointment made on his/her behalf."," "," "," "," ","The second Secondary Driver for the above Core Activity is A qualified mental health professional (QMHP) responsible for assisting each patient attend his/her follow-up appointment is assigned prior to the patients discharge from Sunrise Canyon Hospital.","The first Change Idea for the above second Secondary Driver for the above Core Activity is A the time of discharge, the discharge nurse will give each patient a written notice of the qualified mental health professional (QMHP) assigned to assist him/her with attending the 7-day follow-up appointment made on their behalf."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H2-160","This core activity was selected because it is directly applicable to Sunrise Canyon Hospitals corresponding Category C measure, H2-160:  Follow-up after hospitalization for mental illness.  Psychiatric medications prescribed while a patient is hospitalized are monitored, in addition to the patients transition from inpatient to outpatient care, during the patients follow-up appointment.","No","","136492909.7.1","NB","suggest reworking so CA is not a straight Cat C.","Y","NB","accepting - changes ideas have enough details. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a medication management program that serves patients across the continuum of care","CA-8","CA-8.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_136492909","136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public",507,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","This core activity was selected because it is directly applicable to Sunrise Canyon Hospitals corresponding Category C measure, M1-105:  Preventative Care and Screening:  Tobacco Use:  Screening and Cessation Intervention. Sunrise Canyon Hospitals strategy for implementing this core activity includes a variety of activities and interventions, including (but not limited to) tobacco use screening, individual and group patient education, nicotine replacement therapy, and support groups.","Patient Education.","All patients who report tobacco use will be given written materials about the health implications of tobacco use and about helpful hints for quitting."," "," "," "," ","Tobacco Use Screening.  Within eight (8) hours of admission into SRCH, nursing staff complete an initial nursing assessment, which includes assessment of patients tobacco use.","All patients reporting tobacco use will have a Tobacco Use Cessation Treatment/Order Form completed by a physician or physician extender within three (3) days of admission."," "," "," "," ","Nicotine Replacement Therapy.","Depending upon an individuals circumstances and preferences he/she may be offered/provided nicotine replacement treatment in the form of Varenicline, Bupropion XL or a nicotine transdermal patch."," "," "," "," ","Support Groups.","Depending upon an individuals circumstances and preferences he/she may be offered/provided individual and/or group support for tobacco use cessation."," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105","This core activity was selected because it is directly applicable to Sunrise Canyon Hospitals corresponding Category C measure, M1-105:  Preventative Care and Screening:  Tobacco Use:  Screening and Cessation Intervention. Sunrise Canyon Hospitals strategy for implementing this core activity includes a variety of activities and interventions, including (but not limited to) tobacco use screening, individual and group patient education, nicotine replacement therapy, and support groups.","No","","136492909.7.1","NB","Core Activity description need to be updated.","Y","NB","accepting as is. Change ideas have good details. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_137227806","137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public",509,"Access to Primary Care Services","","Edit","As our telemedicine program achieved previous goals, identified new needs, and faced new challenges, modifications to our secondary drivers were necessary.  These changes reflect lesions learned and our adaptations for the program to become self-sustaining and profitable while maintaining reach to our MLIU patients.  Our primary goal for the use of telemedicine techology for the remaining two years of DSRIP is for our clinics to become more provider based telemedicine sites than presenting based telemedicine sites.","Use telemedicine/telehealth to deliver specialty services","","In an attempt to aid our diabetic and chronically diseased patients gain control of their disease process the use of telemedicine/telehealth technology to monitor clinical status of and offer theraupetic treatment for diabetic and chronically diseased patients to be implemented.  ","Explore and remain observed of current legistation and policy regarding the eligibilty and feasibilty of our rural health clinic sites functioning as treating provider sites of telemedicine services.","Establish legistative and legal feasiblity of our rural health clinics operating as treating provider sites of telemedicine services for all insurance carriers we work with."," Develop and implement protocols for the operation of a treating provider based telemedicine program for the management of chronic disease thorough our rural health clinics."," "," "," ",null,null,null,null," "," ",null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","By extending our reach and improving our contact with diabetic and chronically diseased patients via the use of telemedicine technology, we intend to improve measurements pertaining to diabetic care as detailed in Measurement Bundle A1.","No","Behavioral health services are offered via telehealth technology using contracted mental health providers at various sites not located within our health care system (i.e. Texas Tech Health Science Center, Texas Tech's Department of Psychology, Therapractic Management Services).","137227806.7.1","NB",null,"N",null,null,"Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has deleted the Change Ideas associated with Secondary Driver #2 as it seems provider intended to delete it and moved Secondary Driver #3 to be #2. Please indicate in the \"Provider Response\" column if the changes are incorrect and an explanation of what should be updated.  ","Alas, although we have attempted to clarify changes to this core activity on our October 2019 report as well as on a follow-up communication with HHSC, there does appear to remain some confusion.  \n\nIn brief summary, this core activity replaced our previous second Core Activity.  We changed our telemedicine program from a specialty care focused program to an \"access to primary care services\" telemedicine program.  This change has been difficult for HHSC to reflect properly in our reporting and appears to continue to be an issue.  \n\nCore Activity Grouping (column GF) on this template is incorrect, and should be categorized as “access to primary care.”  \n\nSecondary Driver #1 (column GM) on this template is correct for our new second Core Activity.\n\nSecondary Driver #2 (column GS) on this template is incorrect and is an old \"hold over\" from our previous second Core Activity.\n\nYoakum County dba Yoakum County Hospital did not have a Secondary Driver #3 on its DY7-8 Plan nor do we have a Secondary Driver #3 for DY9-10 Plan.\n\nThe following is an extended discussion of our change in our second Core Activity we had with HHSC subsequent to October 2019.  Our appology for the length of the following discussion, but it is the only way we know how to recap and explain the confusion surrounding our change in second Core Activity:\n\nOn the October 2019 Category A reporting template there was a template error which prevented our accurate adjustment to Core Activity #2.  Specifically, the template allowed us to make adjustments to Core Activity #1 (Preventative Medicine), but when we tried to make adjustments to Core Activity #2 (telemedicine) no such adjustments were allowed.  \n\nA communication from Andrea Quinn on 11/13/2019, as pertaining to this issue, read:\n\nGood Afternoon,\n \nIn reviewing the Cat A Core Activities reporting template for Yoakum County Hospital (137227806), HHSC noticed that the provider’s second core activity was not displayed, so we never received reporting responses for this core activity.\n \nWould the provider please complete the responses for Core Activity #2 (rows 189 to 350) in the attached template and return it to HHSC by COB tomorrow, November 14th? If additional time is needed, please let us know.\n \nThanks,\n \nAndrea Quinn\nProgram Specialist\nHealthcare Transformation Waiver\nMedicaid and CHIP Services\n\nOur reply back to Andrea on 11/13/2019 read:\n\nI am having trouble with the reporting template.  After reviewing what may have occurred on the original template submitted for October 2019 reporting, this was the response that I had prepared:   \n\n\"The original template submitted did not auto-populate rows 189 - 350 for Core Activity #2; therefore, we submitted Core Activity #2 data under lines 4149 - 4310 as a \"new\" activity.  In order for the update template attached to this email to be complete, we also went back and refilled in the reporting for Core Activity #1.\"\n\nOK, so this was my intended response back to this email, and then I went about the task of completing the Category A template attached to this email.  Alas, just as I completed the template, filling in Core Activity #1 (as previously reported) and moving the Core Activity #2 information from our originally submitted template reported as a \"new\" activity to the ideally placed reporting area on rows 189 - 350 on the template attached to this email, this happened--the template flashed and gone were lines 189 - 350.  I am now left with a template that jumps from line 185 to 4149.  I believe this is a glitch in the reporting template, and is why we added Core Activity #2 as a \"new\" activity in the first place.\n\nTherefore, my question is, do you want us to try again with a different updated template (if one can be supplied) or will you accept our original Category A template submitted during October Reporting merely considering the \"new\" Core Activity as our Core Activity #2?\n\nI have attached the template that \"glitched\" as evidence to the existence of our gremlins.  \n\nSincerely,\n\nMark Anna\n\nTo this, Andrea replied on 11/14/2019 with:\n\nGood morning,\n \nThank you for the clarifying that you added the “new” core activity because of the template glitch.\n \nThe provider has two options:\n1.   HHSC can update the second core activity (Access to Specialty Care Services - Use telemedicine/telehealth to deliver specialty services) with the reporting responses provided for the “new” core activity from the provider’s October DY8 reporting submission if the provider is continuing with their second core activity.\na.   The provider would need to let us know if any secondary drivers or change ideas from the “new” core activity would need to move to the second core activity (Access to Specialty Care Services - Use telemedicine/telehealth to deliver specialty services).\n2.   If the provider ended the second core activity (Access to Specialty Care Services - Use telemedicine/telehealth to deliver specialty services) and is now focused on primary care (Access to Primary Care Services - Expanded Practice Access (e.g., increased hours, telemedicine, etc.)), then we would recommend deleting the previous second core activity. This would also require the provider to answer the questions listed below to close out the core activity. The provider’s responses can be submitted via email since the template is being temperamental.\na.   Please explain why the Core Activity is being discontinued.\nb.   Please discuss progress and challenges for the first Secondary Driver and its Change Ideas. (Required for each secondary driver/change idea grouping, so there should be three responses)\nc.   Please provide a progress update on the Core Activity.\nd.   What impact has this Core Activity had on its related measure bundle(s)/measure(s)?\n \nPlease let us know if you have any additional questions. Thanks!\n \nAndrea Quinn\nProgram Specialist\nHealthcare Transformation Waiver\nMedicaid and CHIP Services\n\nOur final reply back was:\n\nDear Andrea,\n \nThank you for your very helpful and understanding reply.  And you are correct with regard to option #2 above--we are actually closing our second core activity (Access to Specialty Care Services - Use telemedicine/telehealth to deliver specialty services) and will now be focusing on Access to Primary Care Services - Expanded Practice Access (telemedicine).  (It would appear the temperamental template knew better how to report this than I did.)\n \nTherefore, in order to close out our previous Second Core Activity, our reporting is:\n \na.   Please explain why the Core Activity is being discontinued.\n \nAs our telemedicine program achieved its DY6 and DY7 goals, we identified new needs and faced new challenges, and thus changes to our Second Core Activity were necessary.  These changes reflect lesions learned and adaptations needed for the program to become self-sustaining and profitable while maintaining reach to our MLIU patients.  Our primary goal for the use of telemedicine technology for the remaining two years of DSRIP is for our clinics to become more provider based for telemedicine services (primary care and chronic disease management) than the previous core activity dictated where we were merely a presenting based telemedicine site for specialty services (mental health).\n \n \nb.   Please discuss progress and challenges for the first Secondary Driver and its Change Ideas.\n \n1st Secondary Driver: Improve screening for depression of our diabetic and chronically depressed patients.\n \nFor the bulk of DY7 and DY8 we paid one of our contracted telemedicine service providers a fee of $40 per month for access to an electronic version of a depression screening tool plus an additional fee of $7 per screening used.  We were able to bill insurance for this screening, but reimbursement was minimal and did not cover our costs.  We were initially hopeful that this electronic tool would increase our screening ability for patients with a primary focus on diabetic depression screening.  Alas, the tool proved to be less than useful, not well received by clinic staff and providers, much more time consuming than a simple paper copy handout, poorly reimbursed, and ultimately not as practical as we had hoped.  In our move toward attaining telemedicine program sustainability we discontinued our use of electronic depression screening for diabetic patients when we ended our contract with the telemedicine service provider in May of 2019.  Depression screening for diabetic patients will be absorbed by normal clinic operation via pen and paper screening tool which has proved effective and within the current repertoire of our patients and providers. \n \n2nd Secondary Driver: Continue with telemedicine/telehealth training for program staff.\n \nTraining for telemedicine staff continued into DY7 evidenced by our program staff attending the 2018 Telehealth at the Crossroads Conference in San Antonio, Texas.  It was actually at this conference that the idea of moving our telemedicine program from a presenting site based to a provider site based program was solidified.  As the remainder of DY7 expired and time lapsed into DY8, our exploration into the feasibility of our rural health clinic providers becoming treating telemedicine providers continued, culminating with our decision to cease our telemedicine agreements with our treating/specialty providers and begin our program build toward our own treating telemedicine program.  Since during DY8 our program was in a state of transition, we did not attend the Telehealth Conference for 2019, but re-attendance for 2020 is very probable. \n \n3rd Secondary Driver: Continue to build and administer clinical relationships with behavioral health providers to offer telemedicine and telehealth services for our depressed patients (and other medical/mental health needs.) \n \nAgain, as we are moving our program from a presenting site based to a treating provider site based telemedicine program, the expense of contracting with clinical behavioral health providers (although beneficial to the patients who received services during the operation of our telemedicine program) was deemed financially non-sustainable.  The lesions learned during our presenting site telemedicine program, however, were invaluable and has laid the foundation for our move into a treating provider based telemedicine program for primary care and chronic disease management.\n \nc.   Please provide a progress update on the Core Activity.\n \nWith the changes we instituted during DY6 to our presenting site based, mental health oriented telemedicine program we were able to achieve our PPI goal for DY6 after having failed to achieve PPI goals in DY4 and DY5.  Carrying the success of our program into DY7, we continued providing mental health and counseling services to many patients, in spite of the fact that DSRIP had changed to the measurement bundle format, and our selected measurement bundle had little to do with mental health care.  As mentioned above, in DY7 and into DY8 we began to formulate a plan to take advantage of the knowledge we had gleaned from operating our telemedicine program and move said telemedicine program into a format where we could have more direct impact on our measurement bundle.  Thus, the decision to close out our presenting site oriented telemedicine program was made in order to build our telemedicine program into a sustainable, treating provider oriented program to have impact on diabetes and chronic disease.\n \nd.   What impact has this Core Activity had on its related measure bundle(s)/measure(s)?\n \nIt was initially hoped that our 1st secondary driver (improve screening for depression of our diabetic and chronically depressed patients) would improve measurement bundle outcomes, but alas, as mentioned above, with the poor acceptance and functionality of the selected electronic depression screening tool we do not feel our mental health oriented telemedicine program had significant impact on our measurement bundle (A1: Improve Chronic Disease Management: Diabetes).  Failure of our DY7 - DY8 telemedicine program to have impact on our measurement bundle outcomes is another reason why we are moving to a treating provider oriented telemedicine program.\n\nThank you for your help in rectifying this issue with our reporting.\n\nSincerely,\n\nMark Anna\n\nIt would appear that with the issues with the Category A reporting template, TWO Core Activities #2 have manifested on our October DY8 Core Activity Summary workbook.  The Core Activity #2 titled \"Use telemedicine/telehealth to deliver specialty services\" should be removed, leaving only one Core Activity #2 titled \"Expanded Practice Access (e.g., increased hours, telemedicine, etc.).\"  Core Activity #1 remains as presented on the workbook.","NB","sent a follow up to the provider with the requested response on 2/24/20","Y","NB","Made the changes and asked provider to respond if they disagree with changes. No response received. Accepting it based on NMI changes.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC made changes to the Change Idea based on provider’s responses.","Use telemedicine/telehealth to deliver specialty services.","CA-1","CA-1.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_137245009","137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private",510,"Maternal and Infant Health Care","","Edit","","Coordinated prenatal and postpartum care",null,"We will establish a line of communication between our Women's and Children's Clinics and the MCOs in our market. We will articulate our standard of seeing a new Medicaid patient within the first 42 days of their time on Medicaid (E1-232). We will work with the MCO staff members to make sure that all patients who want to be seen at our clinic are seen in the first 42 days.","We will prioritize scheduling for new prenatal visits (E1-232) with  appropriate time to complete all the behavioral health risk screenings at the first prenatal visit. (E1-300)","Appointment scheduling practices will be adjusted to make more visits available for new prenatal visits. New OB patients in the first trimester will be seen within 7 days of calling to make an appointment."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This core activity will directly help us increase the number of Medicaid patients who are seen for their first prenatal visit in the first trimester or within 42 days of enrollment in Medicaid (E1-232).  Adjusting our appointment scheduling practices to devote more time to the first prenatal visit will allow time for thorough completion of all required screenings and education (E1-300).","No","","137245009.7.1","NB","Include suggestions for other","Y","NB","suggested","Needs More Information","HHSC revised the Core activity name from Other: Partner with Managed Care Organization to more quickly identify new mothers who have just been enrolled in Medicaid, decreasing their time to first prenatal visit and improving outcomes for mother and child to Provision of coordinated prenatal and postpartum care. If the provider disagrees, please include your suggestions in the in the \"Provider Response\".","Provider agrees to change.","NB","Provider agreed with changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_137999206","137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public",513,"Prevention and Wellness","","Edit","The changes we made were to combine our first and second secondary drivers. The two drivers were very similar to one another causing redundancy. We took the one change idea from the second secondary driver that was not duplicative and added it to the first secondary driver change ideas. We also tweaked the language, where necessary, on the change ideas to encompass more of what we are doing.","Use of community health workers to improve prevention efforts","","Utilization of screening, health maintenance, coordination, and education by providers in the outpatient care setting to promote wellness and disease prevention focusing on vulnerable or at risk patient populations.  We have a community health worker (& care coordinators) 100% committed to engaging patients, providing education and scheduling preventive services, specifically cancer screenings & vaccinations. Along with doing this she is addressing “TRANSPORTATION” barriers to prevention and wellness and coordinating rides as appropriate.","With a focus on prevention & wellness, we will empower patients to be active participants in the management of their care and coordinate primary care and prevention services to improve their health outcomes. ","Engage patients in discussions that allow for the shared decision making in the necessity of medical screening and when preventative care is appropriate.","Provide education and therapies that align with evidence based practice that support prevention and wellness strategies.","Schedule regular patient follow-up to ensure preventative therapies or practices are well-established and effective.","  Identify barriers to prevention and wellness strategies and coordinate care appropriately"," ","","","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; C2; D1","Utilization of screening, health maintenance, and coordination of care in the outpatient care setting can help promote wellness and disease prevention by identifying potential harmful behaviors and empower patients to engage in activities and lifestyle modifications that improve overall health and wellness.","No","","137999206.7.1","NB","changes are similar to the changes in the reporting file","N","NB","One change idea relates to SDofH but asking for more details. ","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","We believe this Core Activity  might be better suited under the “Use of Community Health workers to improve prevention methods”. We have a community health worker (& care coordinators) 100% committed to engaging patients, providing education and scheduling preventive services, specifically cancer screenings & vaccinations. Along with doing this she is addressing “TRANSPORTATION” barriers to prevention and wellness and coordinating rides as appropriate.","NB","Asked provider to review and respond on 2/24","Y","NB","provider did not indicate what additional changes are needed. If additional updates are needed, HHSC will work with provider in DY9.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC made changes to the Change Idea based on provider’s responses.","Use of community health workers to improve prevention efforts","CA-7","CA-7.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_137999206","137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public",514,"Chronic Care Management","","Edit","The changes we made on Core Activity #2 were to combine our first, second and forth secondary drivers. The three drivers were very similar to one another causing redundancy. We modified the first secondary driver and change ideas to include “and/or diabetes”. After combining the 1st, 2nd and 4th secondary drivers we moved the 3rd secondary driver to the 2nd secondary driver place. We also tweaked the language, where necessary, on the change ideas to encompass more of what we are doing.","Management of targeted patient populations with high risk for developing complications","","Utilization of care management and/or navigation services to provide chronic disease management to vulnerable or at risk patient populations to provide education and resources to aid in chronic disease self-management.","Educate and monitor patients with poor blood pressure control and/or poor diabetic control (A1C>9%)","Monitor patients with elevated or poor blood pressure control and/or A1c poor control and provide education and coordination of routine care for identified patients.","Provide Blood Pressure education and counseling for identified patients.","Provide care coordinated services to aid in chronic disease self-management to ensure adequate follow up and ongoing education."," "," ","Provide structured chronic disease management education.","Offer 4, 6-week sessions annually for diabetic self-management focused on topics related to diet, exercise, and blood glucose monitoring for diabetic patients.",""," "," "," ",null,null," "," "," "," ",null,null," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","The Core Activity impacts the selected Measure Bundles by providing patients with the education and resources to successfully manage chronic disease conditions to avoid secondary complications or the need to access urgent or emergent care.","No","","137999206.7.1","NB","changes are similar to the changes in the reporting file","N",null,null,"Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has moved Secondary Driver #4 to be Secondary Driver #2 as the previous Secondary Driver #2 was deleted by the provider. Please indicate in the \"Provider Response\" column if these changes are incorrect and an explanation of what the changes should be. ","Our intent was to combine the 1st, 2nd and 4th Secondary Driver all into the 1st Secondary Driver. The third change idea on the 1st Secondary driver incorporates what was originally on the 4th Secondary driver: “Provide care coordinated services to aid in chronic disease self-management to ensure adequate follow up and ongoing education. So we would like the 4th secondary driver you moved to secondary driver position to be removed since it has been combined with the 1st Secondary driver. Secondary Driver #3 will then be in the 2nd Secondary driver position. On this, now 2nd Secondary driver, we would like the change idea to say, “Offer 4, 6-week sessions annually for diabetic self-management focused on topics related to diet, exercise, and blood glucose monitoring for diabetic patients”. We thought we made this language change in the original submission, but it is not showing that we did. Sorry. ","NB","Asked provider to review and respond on 2/24","Y","NB","I am still not clear if all of the changes are done for this core activity. If needed with can work with provider in October of DY9.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC made changes to the Change Idea based on provider’s responses.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_139461107","139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private",516,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Deploying specialized clinical staff to connect with targeted patients with care measures gaps to provide education on necessity of services and appointment scheduling assistance to get patients in for services to support care needs and to ensure follow-up care is obtained.","Idenitfying patients with recorded high blood pressure without a follow-up appointment","Review pursuit list to identify targeted group and do proactive outreach to schedule an appointment with the patient"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; C1; C2; A2","This Core activity reflects the methodology being deployed in support improvement for the bundles","No","","139461107.7.1","NB","See if sufficient detail is included via SD and change ideas or recommend adding additional details.","Y","NB","added","Needs More Information","Provider should revisit its Change Ideas to make sure main items that the provider is doing are reflected in Change Ideas.  please respond in the \"Provider Response\" column with the suggested changes or an indication that the information should stay as submitted.","The information should stay as submitted.","NB","Not doing additional follow up. minimally acceptable. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_139461107","139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private",517,"Hospital Safety and Quality","","Continue","","Implementation of evidence-based practices to improve quality of care","","Decrease episodes of falls, CLABSI and other hospital safety measure by the implementation of daily huddle to cascade best practices and expectations to clinical staff and promote collaboration to drive improvement","Reduction in Patient Falls","Staff will capture fall risks score in EMR and flag patients with high risks. Change care protocols to include communcation of high risks patient and idenify common practice for communicating to all staff high risks patients."," "," "," "," ","Awareness of incidences of potentially preventable episodes","Bring the right clinical leadership to identify root causes for episodes and creating shared accountability for driving improvement"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity is one of the primary tactics being deployed for improvement of Bundle","No","","139461107.7.1","NB","Update SD1","Y","NB","revisit change ideas","Needs More Information","Provider should revisit its Change Ideas to make sure main items that the provider is doing are reflected in Change Ideas.  please respond in the \"Provider Response\" column with the suggested changes or an indication that the information should stay as submitted.","The information should stay as submitted.","NB","Not doing additional follow up. minimally acceptable. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_197063401","197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private",520,"Chronic Care Management","","Delete","GPCH is discontinuing this activity because it believes that it has reached all of the patients in its small rural community. GPCH has had difficulties maintaining and increasing the registry because all of the patients that the hospital sees have been enrolled in the registry in prior years. Additionally, GPCH believes that the lack of patient engagement and involvement in this registry causes the patients to see little benefit from the registry. GPCH believes that its resources are better focused on other activities. ","Management of targeted patient populations with high risk for developing complications","","GPCH clinical staff created a longitudinal register database of health care utilization and services for Hutchinson County patients diagnosed with COPD. The goal is to identify previously undiagnosed COPD patients and intervene earlier in the disease to prevent hospitalization by providing education regarding chronic disease management, which should decrease the cost and impact of this disease. GPCH would like to expand on this database to include pre-COPD conditions and diabetes diagnoses, in order to capture more of the population with chronic illness. (revised October 2018)","GPCH will improve identification of individuals with COPD diagnosis, pre-COPD diagnoses, and diabetes diagnoses. (Revised October 2018)","GPCH will analyze additional COPD, pre-COPD diagnoses, and chronic illness diagnoses that typically accompany COPD, such as diabetes,  to determine whether a patient should be included in the chronic diseaseCOPD registry, in order to identify patients with COPD, or at-risk of COPD, or diabetes earlier, allowing GPCH to intervene at an earlier date and prevent hospitalizations.  (Revised October 2018)"," "," "," "," ","Provide education and community outreach to patients with COPD.","Create educational materials for patients with COPD or pre-COPD, that outline best practices in management of the disease and distribute them to COPD and pre-COPD patients identified. The educational materials will also stress the importance of COPD management in reducing the risk for: (1) avoidable hospitalizations; and (2) increased risk for other chronic diseases, such as diabetes.  GPCH will provide these educational materials to each newly identified patient when they are enrolled in the longitudinal register database, and to other patients that are seeing avoidable COPD-related hospitalizations throughout the year.","GPCH will participate in community outreach through : (1) early intervention efforts at community education forums and (2) through home visits by respiratory therapists, which are conducted when GPCH newly identifies a patient with COPD, and upon discharge, when a patient is admitted for an inpatient stay for a COPD-related issue."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2; A1","This core activity could help GPCH provide additional education to COPD patients in order to help them manage their disease.  This Core Activity should also help with ED diversion for these patients and patient navigation efforts.","No","","197063401.7.1","NB","Note for BP workgroup","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_197063401","197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private",521,"Maternal and Infant Health Care","","Edit","","Coordinated prenatal and postpartum care","","Improve quality and timeliness of pre-natal care and post-natal care to patients in the community.","Reduce missed pre-natal and post-natal care appointments to increase the amount of necessary maternal care services provided in the community.","GPCH will utilize the Solution Reach program to send out automatic appointment reminders to make patients aware of upcoming pre-natal and post-natal appointments and to reduce missed appointments.","GPCH staff will personally contact patients with post-partum follow-up calls to confirm they followed up with their physicians as directed and to answer any questions that the patients might have."," "," "," ","Improve pre-natal and post-partum care for patients in the community.","GPCH will create and distribute educational materials regarding the benefits of breastfeeding to new mothers that are seen in its clinics or hospital system.","GPCH will offer pre-natal classes at the hospital to provide general pre-natal education to patients and to provide classes designed to train patients on proper newborn care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","We do believe the maternal care will be improved upon the on-boarding of a second OB physician to increase the access to these services.   We have also began using Solution Reach, which is a program that automatically contacts the patient via text message or email to remind of upcoming appointments or to send out annual reminders for the patient to schedule thier annual exam.  This should cut down on our number of no-shows as well as help increase the care provided to our patients","No","","197063401.7.1","NB","determine if this is the best CA area (e.g. maternal care)","Y","NB","changed and NMId","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Access to Specialty Care Services to Maternal and Infant Health Care. \n\nHHSC also revised Core Activity title from Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services. to reduce hospital acquired conditions (HAC) to Provision of coordinated prenatal and postpartum care.\nIf the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate what changes are needed. \n","Provider agrees with the changes","NB","Provider accepted the changes. No other follow up","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_308032701","308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private",518,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","Expand the case management department with a transition care nurse (TCN).  The TCN will complete an assessment to identify services that will require involvement with community resources, cordination with primary care providers, and other care team members to ensure a smooth transition to home, home health, or skilled nursing.  TCN will work to educate patient and family on follow-up appointments, medication management, and other activities to prevent hospitalization and improve quality of live.","Decrease the number of visits in the ED for 30 day readmits due to poor home management of disease process and socioeconomic issues needing community resources by making sure that we are giving each patient that presents to our ED a thorough assessment of their present needs.","Our transition care nurse will work to make sure the patients medications are documented accurately and that patients are educated on medication management, follow-up appointments, and other activities to prevent hospitalization and to improve quality of life."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Decreasing the number of non-emergent visits in the ED will help improve flow of ED, decrease waiting time, decrease time for ED patient disposition, and improve 30 readmission rate","No","","308032701.7.1","NB","Adjust SD1 so it is not exactly Cat C goals.","Y","NB","Added general recommendation","Needs More Information","HHSC recommends that the provider clarifies Secondary Driver Change Idea 1 to detail what is being done. Please respond in the \"Provider Response\" column with the suggested changes.","Our transition care nurse will work to make sure the patients medications are documented accurately and that patients are educated on medication management, follow-up appointments, and other activities to prevent hospitalization and to improve quality of life.","NB","Provider did not include additional information. Leaving it as is. Not doing additional follow up.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_316076401","316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private",497,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","Ensure patients aged 65 or greater have received one or both of the PCV13 or PPSV23 vaccinations according to ACIP recommendations either at our facility or elsewhere.","Assess and document vaccination status in the patient's medical record","Completing the Immunization Screening from in our E.H.R. System","Provide immunization if deemed necessary and with patient consent."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","K1-268 is the Pneumonia Vaccination Status for Older Adults; by assesing their status we will be able to offer and provide the pneumonia vaccine.","No","","316076401.7.1","NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"NB",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 12_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","12_350190001","350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private",500,"Hospital Safety and Quality","","Edit","","Implementation of evidence-based practices to improve quality of care",null,"For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. ","Quality Improvement group will monitor and evaluate metric progress and determine activities needed for Performance Improvement.\n","Distribute quarterly progress updates to providers as part of the performance improvement plan."," Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Better tracking of our patients and providing consistent opportunity for Advance Care Planning in the clinic setting will help to improve the number of patients that have complete and accurate advance care plans in place before an emergency situation.","No","","350190001.7.1","NB","Suggest options for Other","Y","NB","NMI and suggestions","Needs More Information","HHSC recommends that the provider revisits its Core Activity description to reflect activities that the provider is implementing to impact the measures selected by providers. In the current description, provider’s concentration is on Category C measures. The re-write of the description should help provider identify Core Activity Grouping and Title/area that work best for this Core Activity. Provider can consider using Hospital Safety and Quality Grouping and Area: Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.). Based on the change ideas increase to Primary Care Services may work as well. Please respond in the \"Provider Response\" column with the suggested changes.","Core Activity Grouping: Hospital Safety and Quality\n\nName of Core Activity:   Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation\n\nDescription of Core Activity:       For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. \n\nSecondary Drivers: Quality Improvement group will monitor and evaluate metric progress and determine activities needed for Performance Improvement.\n\nChange Idea 1:  Distribute quarterly progress updates to providers as part of the performance improvement plan.  \n\nChange Idea 2:  Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. ","NB","made changes based on provider's response.","N",null,null,"Accepted","HHSC has updated Core Activity based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_020989201","020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public",524,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","We strive to enhance patient access to specialty care in the convenience of the patient's home provider or the patient home.  In the delivery of these services, we look to allieviate wait times that are typically associated with the financial indigency which ultimately leads to medical indigency.  Inherant to our senior population, travel is an obstacle in many cases.","The patient's access and utilitization of these services is hindered by their remote residency of, the deteriating physical and mental condition and ability to be compliant with integrated care plans.","Providing a satellite connection to the specialty care providers convenient to our population base."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","We will have access to specicalist on our medical staff  which will make the availability and turn around of specialty consults, resulting in proper disposition of the assigning and implementing proper care. Referring our patients to Specialist is sometimes met with a 2-3 month wait for an initial consultation.  By offering specialty care in the local setting, this would speed the process of diagnosis and treatment for our patients.  Therefore, less inappropriate ED utilization.     Providing specialty care in the outpatient setting will impact the volume and severity of ED visits.  More availability of specialty care and diagnostic testing will enhance patient care.  This will lead to identifying critical care diagnosis quicker in the outpatient setting.  This leading to a goal of the right care at the right time in the right setting.  We believe this will decrease the amount of unnecessary ED activity.","No","","020989201.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_091770005","091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public",526,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments",null,"Upon discharge provider will assure that patient will be followed up on by primary care provider of choice by referring to clinic or provider. This will be assured compliance by quality assurance committee. Random charts will be pulled monthly to assure complainace with this core activity.","We are a poor community and often patients are unable to obtain proper medical care. So our goal is to provide quality care for the community and surrounding areas.","Will forward the Emergency Room records to the patients provider of choice by nursing staff to assure continuity of care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","It will assure that there is no loss in continuity of care for patients wether being transferred to another facility or seen in follow up by their primary care provider. Patients information will be sent in a timely and secure manner.","No","","091770005.7.1","LK","Changed both the Core Activity Grouping and Core Activity Name to more closely align with activity being done","Y","NB","accepting 1st review results. ","Needs More Information","HHSC has updated the Core Activity Grouping from \"Access to Primary Care Services\" to \"Expansion of Patient Care Navigation and Transition Services\" to better align with the provider's described Core Activity. HHSC has updated the Core Activity Name from \"Other\" to \"Enhancement in coordination between primary care, urgent care, and Emergency Departments\" to better align with the provider's described Core Activity. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping/Name is appropriate.","Concho County accepts this change.","LK",null,"N",null,null,"Accepted","HHSC has suggested that provider reconsider the Core Activity Grouping for Core Activity 526 from \"Access to Primary Care Services\" to \"Expansion of Patient Care Navigation and Transition Services\" to better align with the provider's described Core Activity. Provider has accepted the change.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients ","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_109483102","109483102.7.1",13,"109483102","MHMR Svcs for the Concho Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public",527,"Prevention and Wellness","","Edit","","Implementation of strategies to reduce tobacco use","","Upon arrival at a scheduled appointment, the reception staff will review the patient's most recent demographic/screening assessment to determine if the person uses tobacco.  If so, the receptionist will communicate to the prescribing provider that a smoking cessation brief intervention is required.  After the prescriber has completed the 90792, 99213, 99214 or 99215 encounter with the patient they will then provide a brief intervention utilizing the 5Rs if the individual is not ready to make a quit attempt or utilize the 5As if a person is ready to make a quit attempt.  This brief motivational (5Rs) or goal directed (5As) intervention will be documented in the electronic health record.","Learn about how professional support and advice can make a difference in a quit attempt when combined with other strategies.","Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the U.S. Dept. of Health and Human Services CDC “Tips From Former Smokers” campaign to educate patients ready to make a quit attempt on the five reasons why calling a “quit line” can be the key to long term “quit” success. ",null," "," "," ","Provide information on quitting tobacco with the help of nicotine replacement therapy.","Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the website smokefree.gov in order to educate patients ready to make a quit attempt on: using nicotine replacement therapy to quit, the types of nicotine replacement therapy available and myths about nicotine replacement therapy.  ",null,null," "," ","Explore the feasibility of prescribing quit smoking medications on a case by case basis.","For patients ready to make a quit attempt, Psychiatric Nurse Practitioners at the clinics will discuss the types of quit smoking medications that are available and appropriate based on each person’s mental health diagnoses and recovery plan goals. During the appointment the practitioner and patient will make collaborative medication decisions in an effort to support a quit attempt. ","Try the anti-smoking medication Zyban (if appropriate for patient) as a change idea to test the secondary driver."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105","The core activity of \"Implementation of Strategies to Reduce Tobacco Use\" impacts the selected measure of smoking cessation in that  only 4-7% of smokers who quit \"cold turkey\" are successful in staying smoke free; the remaining smokers who want to successfully quit need a plan (per American Lung Association - Stop Smoking campaign).  A plan includes interventions, strategies and support for a successful quit effort.","No","","109483102.7.1","LK","Provider describes all of their Secondary Drivers as \"tries\" to achieve the desired intervention; it seems to reflect a lack of understanding of what a Secondary Driver is and how it should support the Core Activity being done. Flagging for 2nd review.","Y","NB","accepting 1st review results. ","Needs More Information","Provider's Change Ideas should align with and support the Secondary Driver and not be alternative actions if the Core Activity is not achieved/finished by the preceding Change Idea. Provider should review the definition of Change Ideas so that they are written in support of the Secondary Driver. Provider should make any changes in the \"Provider Response\" column.","For secondary driver #1: Learn about how professional support and advice can make a difference in a quit attempt when combined with other strategies - we propose to update the change idea to: Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the U.S. Dept. of Health and Human Services CDC “Tips From Former Smokers” campaign to educate patients ready to make a quit attempt on the five reasons why calling a “quit line” can be the key to long term “quit” success.  \nFor secondary driver #2: Provide information on quitting tobacco with the help of nicotine replacement therapy - we propose to update the change idea to: Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the website smokefree.gov in order to educate patients ready to make a quit attempt on: using nicotine replacement therapy to quit, the types of nicotine replacement therapy available and myths about nicotine replacement therapy.  \nFor secondary driver #3: Explore the feasibility of prescribing quit smoking medications on a case by case basis - we propose to update the change idea to: For patients ready to make a quit attempt, Psychiatric Nurse Practitioners at the clinics will discuss the types of quit smoking medications that are available and appropriate based on each person’s mental health diagnoses and recovery plan goals. During the appointment the practitioner and patient will make collaborative medication decisions in an effort to support a quit attempt. ","LK",null,"N",null,null,"Accepted","HHSC has suggested that provider review all Change Ideas as they were not aligned with provider's reported Secondary Drivers. Provider has submitted changes to Secondary Driver 1 Change Idea 1, Secondary Driver 2 Change Idea 1, and Secondary Driver 3 Change Idea 1 that adequately align with described Secondary Drivers. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_121781205","121781205.7.1",13,121781205,"L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public",529,"Chronic Care Management","","Continue","","Utilization of care management and/or chronic care management services","","We have employed a Chronic Care Management Coordinator/RN to identify patients with 2 or more chronic conditions.  Once those patients are identified, then we would like to enroll them in a chronic disease management program that includes education about disease management and the use of the clinic functions to assist in decreasing the inappropriate use of the emergency department.  We will also utilitze the Community Paramedic/Nurse Outreach program to assist in education, medication assistance, and other activities to alleviate the use of the Emergency Department.","To utilize the Chronic Care Management Coordinator to identify patients that qualify for the program and to assist in the navigation to our chronic care management program.  In reference to CNA -006, this acitvity should help alleviate the inappropriate use of the Emergency Department","employ a Chronic care management nurse in the RHC to assesspatients for inclusion in the Chronic care management program.  Once identified work with the Community Paramedic/ Nurse Outreach program for education, medication assistance/compliance and wellness checks."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","K1-268 Pneumonia vaccination status for older adults.  This function will help to reduce CNA -006.  Also K1-285 Advanced care plan to alleviae the unneccessary use of the emergency department.Another function of the Chronic Care Management Nurse is to identify and educate patients on health issues, i.e., the benefits of pneumonia vaccinations, advance care plans and disease management.  By identifying patients that need pneumonia vaccinations and advance care plans we are serving a two fold plan; one is to reduce the inappropriate use of the emergency room by attempting to prevent older adults from acquiring pneumonia and inviting older patients to discuss and initiate an advanced care plan also reducing ED use; two is that we identify these patients thru our Chronic care management and refer them to appropriate providers, our community paramedic and nurse outreach program which in turn should lead to improved rural access to preventative services.\n\nThe Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to: \nPromote timely access to appropriate care \nIncrease utilization of preventative care (K1-268, K1-285)\nReduce emergency room utilization and hospital readmissions\nIncrease comprehension through culturally and linguistically appropriate education • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)\nIncrease continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals \nIncrease patients’ ability for self-management and shared decision-making \nProvide medication reconciliation \nConnect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs \n \nPrimary Duties and Responsibilities\nServe as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources\nWork with patients to plan and monitor care:\nAssess patient’s unmet health and social needs (K1-105)\nDevelop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate) (K-285)\nMonitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed \nCreate ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time\nFacilitate patient access to appropriate medical and specialty providers\nEducate patient and family/caregiver(s) about relevant community resources \nFacilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed \nCultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals\nAssist with the identification of “high-risk” patients (the chronically ill and those with special health care needs)","No","","121781205.7.1","LK","This Core Activity named \"Utilization of care management and/or chronic care management services, including education in chronic disease self-management\" seems inconsistent/too loosely related to Measure K1-268: Pneumonia Vaccination for Older Adults. There are other more appropriate measures in the K1 Measure Bundle, such as K1-285 Advanced Care Plan, that should be reviewed. ","Y","NB","accepting 1st review results. ","Needs More Information","The Core Activity named \"Utilization of care management and/or chronic care management services, including education in chronic disease self-management\" seems too tangentially related to \"Measure K1-268: Pneumonia Vaccination for Older Adults\". Provider should review their Core Activity description to confirm that all the aspects of provider's Chronic Care Management program are thoroughly described. For the current description, there may be other, more appropriate measures in the K1 Measure Bundle, such as K1-285 Advanced Care Plan. Provider should make any changes in the \"Provider Response\" column.","The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to: \nPromote timely access to appropriate care \nIncrease utilization of preventative care (K1-268, K1-285)\nReduce emergency room utilization and hospital readmissions\nIncrease comprehension through culturally and linguistically appropriate education • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)\nIncrease continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals \nIncrease patients’ ability for self-management and shared decision-making \nProvide medication reconciliation \nConnect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs \n \nPrimary Duties and Responsibilities\nServe as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources\nWork with patients to plan and monitor care:\nAssess patient’s unmet health and social needs (K1-105)\nDevelop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate) (K-285)\nMonitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed \nCreate ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time\nFacilitate patient access to appropriate medical and specialty providers\nEducate patient and family/caregiver(s) about relevant community resources \nFacilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed \nCultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals\nAssist with the identification of “high-risk” patients (the chronically ill and those with special health care needs)","LK",null,"N",null,null,"Accepted","HHSC has suggested that provider review this Core Activity and its accompanying Secondary Drivers and Change Ideas to be certain that they align with Measure Bundle K1, provider's reported associated Measure Bundle. Provider submitted additional clarification which HHSC has added to \"Description of Measure Bundle/Measure Impact\". Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_121806703","121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public",530,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services","","Our facility plans to do a community screening to identify potential health risks.  We hope to be able to offer a one time follow up for patients with any abnormal results.","Our goal is to help patients that would otherwise not seek any preventative care identify health issues.","We plan to do a fingerstick glucose measurement at a health fair.  Individuals within a higher range will be referred to the hopsital for a free hemoglobin A1C test.  If A1C is within the diabetic range, then patient will be given a voucher for a follow up visit to the clinic.  ","Patients at risk of diabetes or who have diabetes would be given educational materials during the visit to help understand the importance of regular health maintenance visits.  We also have a dietician who can help them correct their nutrition habits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","By identifying patients with risks earlier, we hope to reduce the number of patients without routine primary care that tend to utilize the ED as their primary source.","No","","121806703.7.1","LK","Provider vaguely describes \"screening for health risks\" as their Core Activity but does not describe what screening they will administer, what risk factors they are trying to identify, or how they will follow up. The relationship between the Core Activity does not adequately describe relationship to improvement in Bundle K2.  ","Y","NB","accepting 1st review results. ","Needs More Information","Provider's description of Core Activity is too vague. In the \"Provider Response\" column\" provider should provide more detail about what types of screenings will be administered as part of this activity, what risk factors will be identified, and what follow-up will be conducted. ","We plan to do a fingerstick glucose measurement at the health fair.  Individuals within a higher range will be referred to the hopsital for a free hemoglobin A1C test.  If A1C is within the diabetic range, then patient will be given a voucher for a follow up visit to the clinic.  Patient would be given educational materials during the visit to help understand the importance of regular health maintenance visits.  We also have a dietician who can help them correct their nutrition habits.","LK","Provider was emailed for additional information regarding how they would specifically plan to edit their Secondary Drivers and Change Ideas in light of additional information submitted in response to NMI. HHSC emailed provider with suggestion to incorporate their NMI response into their Secondary Driver 1 and Secondary Driver 1, Change Idea 1. Provider responded on 02/10/2020 to approve of the suggested changes. \n\n2nd Reviewer should double check my suggested changes to Secondary Driver 1 and Secondary Driver 1: Change Idea 1 to provider.","Y","NB","accepted","Accepted","HHSC has suggested that provider clarify Secondary Drivers and change ideas to provide more detail. Provider has agreed to edit Secondary Driver 1 and Secondary Driver 1: Change Idea 1 to include the type of assessment they will be conducting and what risk factors they are attempting to identify and follow up with. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_130616909","130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public",533,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","By offering self-management education and resources, healthcare professionals can help patients raise their awareness of the impact of behavior change goals which, in turn, leads to better clinical outcomes and improved health status.","Improve clinical care and support self-management education","Offer patient education that includes self-management tools for diabetes by learning about nutrition, exercise, self-monitoring, diabetes medications, and resources.","Inform patients of medication assistance program that includes assistance with the purchasing of insulin for qualifying patients"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Interventions that are geared toward improving the management of diabetes, preventing or delaying the  onset of Type 2 diabetes, improving quality of life for people with diabetes, reduction of diabetes-related health disparities.Through our clinics (ex: during a vist), our goal is to create a link from providers and/or clinic staff to our target population to system resources.  Examples of this could be clinic staff and the patient reviewing a diabetes care checklist that includes information about resources within the system - Medication assistance program, financial screeners, Positive Lifestyle program.  We believe this process serves to benefit a patients' contuium of care from point of diagnosis to maintenance of or improved self-care.","No","","130616909.7.1","LK","Secondary Driver 1, Change Idea 1 suggests that this Core Activity might more appropriately be grouped under \"Chronic Disease Management\" versus \"Access to Primary Care Services\". Marking for 2nd review","Y","NB","Made changes to Grouping and Title","Needs More Information","HHSC has updated the Core Activity Grouping from \"Access to Primary Care Services\" to \"Prevention and Wellness\" to better align with the provider's described Core Activity. The Core Activity title has been updated from “Provision of screening and follow up services” to “Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self‐manage their chronic conditions”. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping is appropriate.","Provider is in agreement with the recommended grouping change.","LK",null,"N",null,null,"Accepted","HHSC has suggested that the provider update the Core Activity Grouping from \"Access to Primary Care Services\" to \"Prevention and Wellness\" to better align with the provider's described Core Activity. The Core Activity title has been updated from “Provision of screening and follow up services” to “Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self‐manage their chronic conditions”. Provider has approved these changes. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_137226005","137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private",535,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Utilization of a comprehensive intervention to address the needs of high‐risk patients","","Shannon intends to offer a care coordination program, transitional care program, and medication therapy management to targeted population of patients. By providing targeted services to patients through these programs, these patients will be less likely end up in the emergency department, hospitalized or readmitted to the hospital for a condition that could be potentially preventable.","Identify high risk patients who are in need of navigating the healthcare system and/or seeking to understand their chronic conditions. Once identified, services will be provided to educate and facilitate coordination of care and transition services to these patients.","Identify patients in need of transition services when discharged from the hospital. This services will ensure patients have their medications upon discharge, have scheduled their follow-up care, and address other needs identified following patient discharge."," "," "," "," ","The pharmacist will identify high-risk patients that are in need of Medication Therapy Management. Once identified, the pharmacist will provide these patients with various medication management services. The pharmacist will work with the primary care provider at the Access Clinic to develop an appropriate care plan for each patient.","When a patient presents at a follow-up appointment at the Access Clinic, a pharmacist will offer medication intervention services. These medication services will address medication discrepancies, medication compliance issues, medication reconciliation, medication education, and E.H.R. chart review. ","If a patient does not present to their discharge follow-up appointment at the Access Clinic, a pharmacist will attempt to provide Medication Therapy Management services over the phone to the patient."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2; A1; C1","It is important to receive preventive screenings and routine care. Care coordination and transition services can provide patient education and follow-up for patients that need assistance with navigating the healthcare system across their continuum of care. By working with patients with diabetes through care coordination and transition services, these patients will better understand and manage their chronic condition.At this time we will keep this core activity as the transitional care program and care coordination are more broad than patients with diabetes. The programs at Shannon target patients with chronic illness who need coordination to ensure their health care needs are being met and assistance with a care plan that can improve the patients overall health. The program works closely with patients and their caregivers, and can influence other aspects of their health other than the chronic illness by  educating about the need for cancer screening and assisting them in scheduling the needed tests. In addition, we have EMR system components in place that track screenings based on care plans to ensure screenings are scheduled when due.","No","","137226005.7.1","LK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LK","Provider has withdrawn addition of a new core activity to describe a Medication Management Therapy program and has instead incorporporated this activity into Core Activity 535 as Secondary Driver 2 for this activity.","N",null,null,"Accepted","Provider has added a new Secondary Driver 2 (inclusion of a Medication Therapy Management Program) for Core Activity 535 as well as Change Idea 1 (Medication therapy services offered by a pharmacist in person) and Change Idea 2 (Medication therapy services offered by a pharmacist over the phone). Provider is approved for additional Secondary Driver. Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of a comprehensive, multidisciplinary intervention to address the needs of high-risk patients.","CA-6","CA-6.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_179272301","179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private",537,"Hospital Safety and Quality","","Edit","","Implementation of evidence-based practices to improve quality of care",null,"For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. ","Quality Improvement group will monitor and evaluate metric progress and determine activities needed for performance improvement.","Distribute quarterly progress updates to providers as part of the performance improvement plan.","Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Better tracking of our patients and providing consistent opportunity for Advance Care Planning in the clinic setting will help to improve the number of patients that have complete and accurate care plans in place before an emergency situation.Goal of the prevention efforts are to increase access to Advance Care Planning, Tobacco Cessation and Pneumonia vaccinations for all patients as age appropriate by at least 2.5% in DY7 and at least 10% in DY8.","No","","179272301.7.1","LK","Description of Core Activity and Secondary Driver 1 essentially state that they are hiring additional staff to complete the activities of their three Cat C measures using just the language in the measures. The last Secondary Driver 1: Change Idea 1 describes 3 separate education campaigns to educate about their chosen Cat C measures. I don't know how to proceed.","Y","NB","accepting 1st review results. ","Needs More Information","\"Description of Core Activity\" and \"Secondary Driver 1\" appear identical to Category C Measures K1-105, K1-268, and K1-285. Provider must enter in the \"Provider Response\" column an updated Description of Core Activity and Secondary Driver 1 that address how the Category C measure will be impacted, e.g. if provider is hiring a Care Coordinator to provide education or explicitly identify gaps in care among the three measures, please specify what that Care Coordinator will be doing to improve the measure outcomes. The re-write of the description should help provider identify the Core Activity Grouping and Title/area that work best for this Core Activity. Provider can consider using \"Hospital Safety and Quality Grouping and Area: Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\"; or care coordination and transition can be considered an option. Based on the change ideas increase to Primary Care Services may work as well. Please respond in the \"Provider Response\" column with the suggested changes.","Core Activity Grouping: Hospital Safety and Quality\n\nName of Core Activity:   Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation\n\nDescription of Core Activity:       For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. \n\nSecondary Drivers: Quality Improvement group will monitor and evaluate metric progress and determine activities needed for performance improvement.\n\nChange Idea 1:  Distribute quarterly progress updates to providers as part of the performance improvement plan.  \n\nChange Idea 2:  Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. ","LK","After receiving their NMI responses, I believe this provider is probably referring to two separate Core Activites. One is developing a more robust quality monitoring system including E.H.R. enhancement, the hiring of additional staff, and implementing the use of NCQA worksheets. The other Core Activity is providing an education program, with three separate education campaigns as Secondary Drivers: 1.Distributing information to tobacco users, 2. Distributing information regarding pneumonia vaccinations, and 3. Distributing information about Advance Care Planning. Flagging for second review to clear with NB before making suggestion to provider to add additional Core Activity.","Y","NB","2/25 NB followed up with the provider and Megan Cody confirmed that these are the changes for the existing core activity. Made the changes.","Accepted","HHSC made adjustments to the Core Activity Grouping and Title based on the provider’s response. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_206083201","206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private",538,"Hospital Safety and Quality","","Edit",null,"Implementation of evidence-based practices to improve quality of care",null,"OFor DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. ","Quality Improvement group will monitor and evaluate metric progress and determine activities needed for performance improvement.","Distribute quarterly progress updates to providers as part of the performance improvement plan."," Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Better tracking of our patients and providing consistent opportunity for Advance Care Planning will help to improve the number of patients that have complete and accurate advance care plans in place improving transitions of care before an emergency situation.Goal of the prevention efforts are to increase access to Advance Care Planning, Tobacco Cessation and Pneumonia vaccinations for all patients as age appropriate by at least 2.5% in DY7 and at least 10% in DY8.","No","","206083201.7.1","LK","Description of Core Activity and Secondary Driver 1 essentially state that they are hiring additional staff to complete the activities of their three Cat C measures using just the language in the measures. The last Secondary Driver 1: Change Idea 1 describes 3 separate education campaigns to educate about their chosen Cat C measures. I don't know how to proceed.","Y","NB","accepting 1st review results. ","Needs More Information","\"Description of Core Activity\" and \"Secondary Driver 1\" appear identical to Category C Measures K1-105, K1-268, and K1-285. Provider must enter in the \"Provider Response\" column an updated Description of Core Activity and Secondary Driver 1 that address how the Category C measure will be impacted, e.g. if provider is hiring a Care Coordinator to provide education or explicitly identify gaps in care among the three measures, please specify what that Care Coordinator will be doing to improve the measure outcomes. The re-write of the description should help provider identify the Core Activity Grouping and Title/area that work best for this Core Activity. Provider can consider using \"Hospital Safety and Quality Grouping and Area: Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\"; or care coordination and transition can be considered an option. Based on the change ideas increase to Primary Care Services may work as well. Please respond in the \"Provider Response\" column with the suggested changes.","Core Activity Grouping: Hospital Safety and Quality\n\nName of Core Activity:   Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation\n\nDescription of Core Activity:       For DSRIP project, this provider has implemented quarterly system-wide hospital/clinic quality improvement virtual meetings to discuss measures and focus which include representatives from our 8 Critical Access Hospitals and 9 Rural Health Clinics.  Provider will be tracking and reporting on DSRIP and other metrics at least quarterly, a designated person (likely the care coordinator or other clinical staff acting as care coordinator until position is filled) will meet with providers and staff to review their current metric status and provide an educational opportunity on strategies to improve.  We will work with our informatics nurse to ensure that the EHR is tracking properly, the providers know how to enter information in the correct format to pull accurately, and that hard stops are added if necessary. Facilities will be utilizing an National Committee for Quality Assurance worksheet to assist in the organization of quality monitoring activities to include this performance improvement project. \n\nSecondary Drivers: Quality Improvement group will monitor and evaluate metric progress and determine activities needed for performance improvement.\n\nChange Idea 1:  Distribute quarterly progress updates to providers as part of the performance improvement plan.  \n\nChange Idea 2:  Develop and distribute educational materials for patients on advance care plans, tobacco cessation, and pneumonia vaccinations. ","LK","After receiving their NMI responses, I believe this provider is probably referring to two separate Core Activites. One is developing a more robust quality monitoring system including E.H.R. enhancement, the hiring of additional staff, and implementing the use of NCQA worksheets. The other Core Activity is providing an education program, with three separate education campaigns as Secondary Drivers: 1.Distributing information to tobacco users, 2. Distributing information regarding pneumonia vaccinations, and 3. Distributing information about Advance Care Planning. Flagging for second review to clear with NB before making suggestion to provider to add additional Core Activity.","Y","NB","Followed up with the prvovider and confirmed that they are revising their existing Core Activity.","Accepted","HHSC made adjustments to the Core Activity Grouping and Title based on the provider’s response. Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 13_DY9-10 Regional Tracker - FINAL Tracker.xlsb","13_322916301","322916301.7.1",13,322916301,"McCulloch County Hospital District dba Heart of Tx","Hospital","Private",536,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services","","Our facility plans to do a community screening to identify potential health risks.  We hope to be able to offer a one time follow up for patients with any abnormal results. Provider will conduct glucose measurement at the health fairs and provide a follow up plan for the individuasl tested.\n","Our goal is to help patients that would otherwise not seek any preventative care identify health issues.","We plan to do a fingerstick glucose measurement at a health fair.  Individuals within a higher range will be referred to the hopsital for a free hemoglobin A1C test.  If A1C is within the diabetic range, then patient will be given a voucher for a follow up visit to the clinic.  ","Patients at risk of diabetes or who have diabetes would be given educational materials during the visit to help understand the importance of regular health maintenance visits.  We also have a dietician who can help them correct their nutrition habits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","By identifying patients with risks earlier, we hope to reduce the number of patients without routine primary care that tend to utilize the ED as their primary source.","No","","322916301.7.1","LK","Provider vaguely describes \"screening for health risks\" as their Core Activity but does not describe what screening they will administer, what risk factors they are trying to identify, or how they will follow up. The relationship between the Core Activity does not adequately describe relationship to improvement in Bundle K2.  ","Y","NB","accepting 1st review results. ","Needs More Information","Provider's description of Core Activity is too vague. In the \"Provider Response\" column provider should provide more detail about what types of screenings will be administered as part of this activity, what risk factors will be identified, and what follow-up will be conducted. ","We plan to do a fingerstick glucose measurement at the health fair.  Individuals within a higher range will be referred to the hopsital for a free hemoglobin A1C test.  If A1C is within the diabetic range, then patient will be given a voucher for a follow up visit to the clinic.  Patient would be given educational materials during the visit to help understand the importance of regular health maintenance visits.  We also have a dietician who can help them correct their nutrition habits.","LK","Provider was emailed for additional information regarding how they would specifically plan to edit their Secondary Drivers and Change Ideas in light of additional information submitted in response to NMI. \n\n2nd Reviewer should double check my suggested changes to Secondary Driver 1 and Secondary Driver 1: Change Idea 1 to provider.","Y","NB","Updated the Core Activity description a little since this why the NMI was sent -changes to Change Ideas are OK. ","Accepted","HHSC has suggested that provider clarify Secondary Drivers and change ideas to provide more detail. Provider has agreed to edit Secondary Driver 1 and Secondary Driver 1: Change Idea 1 to include the type of assessment they will be conducting and what risk factors they are attempting to identify and follow up with. Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_081939301","081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",542,"Maternal and Infant Health Care","","Delete","Our Texas Tech Physicians department of Obstetrics and Gynecology has encountered difficulties in providing adequate services to our rural communities. The department has experienced a lack of faculty physicians due to retirement, relocation, and other unforseen circumstances.  While we were hopeful to achieve this activity and provide Maternal and Infant Care to our surrounding communities, unfortunately we were not successful and had to discontinue this program.","Other","Increasing access to care for women's health issues and prenatal care","Our goal is to increase access to care for womens's health issues and prenatal care.  This core activity revolves around getting the care out to the people who can't come to us.  We wanted to increase access to care by having physicians go to rural areas and see patients there.","Timeliness of prenatal and postnatal care for women","From an instiution stand point we are implemetning care coordinators in order to better track and forewarn providers of potential issues if possible."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This core activity will impact the timeliness of prenatal/postnatal care as well as the education for new mothers.","No","","081939301.7.1","KK","KK confirming that provider provided sufficient explanation for deletion of core activity.","Y","NB","it was accepted during the DY89 reporting","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"KK",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Other","CA-4","CA-4.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_081939301","081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",544,"Maternal and Infant Health Care","","Edit","","Provision of services to individuals that address social determinants of health","","Teaching new moms about best practices for themselves and their new babies will improve overall health. Also, educating teens about sexual education and letting them know what services we offer will help open doors for communication.\n"," Collaborate with Ector County Independent School District and University of Texas of the Permian Basin to educate the teens on sexual education and the services we offer. We have staff/residents that go to the schools/university  every year. They educate the 7th and 10th graders. They spend 3 days with 7th grade and one day with 10th grade and at UTPB."," Continue to offer centering classes/appointments. During centering, the physician will continue to include the patient in all aspects of her care. The participant  will workon relationship building, safety measures for the patient and baby and are encouragd to track their own health data and goals. They physician and participant will cover certain topics such as: nutrition, certain tests that are required, body changes, sexuality, domestic violence, labor and breastfeeding. The participant will also evaluate their outcomes on a notebook, which the centering teams provides."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Teaching new moms about best practicies for themselves and babies will improve overall health.  Also educating teens about sexual education and letting them know what services we offer will help open doors for communication.","No","","081939301.7.1","KK",null,"N","NB","Asking to clarify","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","Description: Teaching new moms about best practices for themselves and their new babies will improve overall health. Also, educating teens about sexual education and letting them know what services we offer will help open doors for communication.\n\nSecondary Driver 1- Collaborate with Ector County Independent School District and University of Texas of the Permian Basin to educate the teens on sexual education and the services we offer. We have staff/residents that go to the schools/university  every year. They educate the 7th and 10th graders. They spend 3 days with 7th grade and one day with 10th grade and at UTPB.\n\nSecondary Driver 1 Change Idea- Continue to offer centering classes/appointments. During centering, the physician will continue to include the patient in all aspects of her care. The participant  will workon relationship building, safety measures for the patient and baby and are encouragd to track their own health data and goals. They physician and participant will cover certain topics such as: nutrition, certain tests that are required, body changes, sexuality, domestic violence, labor and breastfeeding. The participant will also evaluate their outcomes on a notebook, which the centering teams provides.","KK","HHSC has updated the Core Activity based on the provider response, specifically the Description, Secondary Driver 1, amd Secondary 1  Driver - Change idea.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically the Description, Secondary Driver 1, and Secondary 1  Driver - Change idea.","Provision of services to individuals that address social determinants of health.","CA-4","CA-4.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_081939301","081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",545,"Maternal and Infant Health Care","","Delete","Our Texas Tech Physicians department of Obstetrics and Gynecology has encountered difficulties in providing adequate services to our rural communities. The department has experienced a lot of restructuring, changes to staff, and individual responsibilities due to other unforeseen circumstances.  While we were hopeful to achieve this activity and provide Maternal and Infant Care by screening patients and offering navigation services, unfortunately we were not successful and had to discontinue this program.","Other","Patient screening and navigation services to make sure patients get the procedures and coverage that they need.","Patient screeners screen patients for any payor source that we might be bale to qualify them for and also can match them with any community services that we have or know about.","Provide coverage/services for patients who couldn't otherwise afford it.","Care coordinators are needed to identify when these patients are coming in and offer any community or TTUHSC service that we can offer. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Being able to screen patients and get them qualified for any form of payor that we might have will help them get the services that they need and improve prenatal and postpartum care.","No","","081939301.7.1","KK","KK confirming that provider provided sufficient explanation for deletion of core activity.","Y","NB","it was accepted during the DY89 reporting","Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.",null,"KK",null,"N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Other","CA-4","CA-4.5"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_081939301","081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",721,"Expansion of Patient Care Navigation and Transition Services","","New","","Utilization of a comprehensive intervention to address the needs of high‐risk patients",""," Development of data structures in partnership with the Lubbock campus that will allow the implementation of a software application that will provide workflow to the Patient Navigation team. This Care Coordiation System (CCS) will be utilized by the Patient Navigators to help coordinate the care for our DSRIP patients. This CCS provide workflow that will drive engagement with DSRIP patients and clinical staff to complete DSRIP activities and will also provide outcome tools to ensure accountability within the clinics for DSRIP activities. In addition, the data structures being developed will allow us to implement additional data analytics tools focused on proactive performance outcomes. ","Develop and implement required the data structures for future use by software applications. ","Work with the Lubbock campus to define and establish data structures. ","","","",""," Develop and implement the CCS Application and the Data Analytics tools to allow for improved management of patients and achievement of DSRIP outcomes. ","Work with the Lubbock campus to define all requirements and build the software application that will allow the patient Navigation team to better manage the DSRIP patient population and work with the clinics to improve care and outcomes for these patients. ","Work with the Lubbock campus to implement data analytics tools that will allow us to proactivley measure DSRIP patient outcomes and improve them.","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; E1","We have seen significant improvement in our DSRIP outcomes since the implemenation of the care coordination system. We believe that without this workflow the team that is responsible for DSRIP would not have acheieved the performance that they did for 2018 and to date for 2019 encounters. This core activity is a great example of building technology to support team members to perform their work in a much more effective way than manual efforts that might have been used in the past. ","No","","081939301.7.1","KK",null,"N","NB","Making it an NMI. Provider deleted 5 Core Activities and the common message was  that the provider encountered  difficulties. Requesting that the provider adds how they will incorporate lessons learned from previous core activities. ","Needs More Information","Provider requested to delete 5 of its Core Activities and proposed to add this Core Activity as a new one. HHSC requests that the provider adds additional information either in Core Activity description or Secondary Drivers and Change ideas about how they will incorporate lessons learned from Core Activities that the provider is proposing to delete. Please respond in the \"Provider Response\" column with the suggested changes and responses.","Please see additional comments for the 3 sections noted in the NMI. These can be used to replace the current information submitted for this activity. \n\nDescription: Development of data structures in partnership with the Lubbock campus that will allow the implementation of a software application that will provide workflow to the Patient Navigation team. This Care Coordiation System (CCS) will be utilized by the Patient Navigators to help coordinate the care for our DSRIP patients. This CCS provide workflow that will drive engagement with DSRIP patients and clinical staff to complete DSRIP activities and will also provide outcome tools to ensure accountability within the clinics for DSRIP activities. In addition, the data structures being developed will allow us to implement additional data analytics tools focused on proactive performance outcomes. \n\n1st Secondary Driver - Develop and implement required the data structures for future use by software applications. \n\n1st Change Idea - 1st Secondary Driver - Work with the Lubbock campus to define and establish data structures. \n\n2nd Secondary Driver - Develop and implement the CCS Application and the Data Analytics tools to allow for improved management of patients and achievement of DSRIP outcomes. \n\n1st Change Idea - 2nd Secondary Driver - Work with the Lubbock campus to define all requirements and build the software application that will allow the patient Navigation team to better manage the DSRIP patient population and work with the clinics to improve care and outcomes for these patients. \n\n2nd Change Idea - 2nd Secondary Driver - Work with the Lubbock campus to implement data analytics tools that will allow us to proactivley measure DSRIP patient outcomes and improve them. \n\nThrough all of the efforts above we will make sure that we have learned from prior projects and that we maintain a structured project plan, training materials. clinic education and accountability to the plans we have laid out. ","KK","HHSC has updated the Core Activity based on the provider response, specifically the  Description, Secondary Driver 1. Secondary Driver 1 - Change Idea 1, Secondary Driver 2. amd Secondary Driver 2 - Change Idea 1","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically the  Description, Secondary Driver 1. Secondary Driver 1 - Change Idea 1, Secondary Driver 2. and Secondary Driver 2 - Change Idea 1","Utilization of a comprehensive, multidisciplinary intervention to address the needs of high-risk patients.","CA-6","CA-6.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_112684904","112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public",549,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes",null,"More specifically, this core activity will focus on educating patients on each of the bundle measures, as appropriate.  Patients will be questioned during clinical encounters as to their tobacco usage and counseled accordingly.  After proper screening educational material to deal with a patients tobacco use will be given, in order to find the appropriate treatment for the cessastion of tobacco for that patient.  Elderly patients will receive material describing the benefits of the pneumonia vaccination.  All appropriate patients will be given information concerning Advanced Care Planning.","Assessing patients to determine their tobacco usage, and their current knowledge of the need for pneumonia vaccine and advance care planning.","Provide appropriate educational pamphlets on tobacco cessation, the benefits of the pneumonia vaccine and information on advanced care planning."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","Promoting education on the topics in the Measure Bundle, therefore increasing patient participation in the selected measures.","No","","112684904.7.1","KK","KK would like to confirm that the \"Other\" title is appropriate for the Core Activity. After reviewing core activity menus and titles associated with Prevention and Wellness core activities, KK agrees that the \"Other\" designation should be used.","Y","NB","chnaged the area and NMIed","Needs More Information","HHSC has updated the Core Activity title from Other “Provide educational information on benefits of all three measures in the Rural Preventive Bundle.  Material will be provided for tobacco cessation, pneumonia vaccination and advance care planning, as appropriate for the patient population.” to  the title area on the menu “ Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self‐manage their chronic conditions”. If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping is appropriate.","Agree with the change.","KK","Provider has accepted HHSC changes to Core Activity.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_127298107","127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public",551,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Developing and implementing management interventions that are geared towards improving diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization by providing comprehensive diabetes care including foot exams, lab tests, monitoring and controlling blood pressure and hopefully reducing the rate of emergency department visits for diabetic patients.","Provider and staff education","Schedule and conduct group and individual hands-on training session and providing template handouts. We have recently converted our E H R system which still has problematic areas."," "," "," "," ","Patient education","Print out and discuss with patients disease and patient specific education materials from our software addition."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","This core activity will target the patient population with diabetes.  These patients will have access to primary care and education.  The A-1 measure bundle is the monitoring of blood work, blood pressure control and foot care.  The goal is to reduce short-term complications, long term complications and the rate of emergency room visits.","No","","127298107.7.1","KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_135235306","135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public",552,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","The community health needs assessment for RHP 14 identified the need for the prevention, education and services to address high mortality rates, chronic diseases, preventable conditions and unhealthy lifestyles.  RHP 14 has a significantly high rate of chronic conditions such as asthma, diabetes, and high blood pressure.  Focusing on improving the clinical outcomes of targeted and high-risk patients will have a positive effect on all of the Category C measure bundles selected. Medical Center Health System continues its focus on improving the clinical outcomes of its patients through emphasis on chronic disease management and care coordination services.  Enhancing its collaborative efforts both internally and externally will lead to improved clinical outcomes of both the county and region.","Utilization of chronic care management services for chronic disease self-management","Increase availability of educational opportunities for chronic disease management by offering more disease specific educational sessions throughout our health system, community events and system sponsored events while focusing on targeted disease specific  and underserved populations of the community.","Enhance access for targeted population for primary and urgent care services to decrease unnecessary and avoidable ER visits by working to eliminate barriers (financial, transportation, etc) to accessing needed healthcare services."," "," "," ","Identify and monitor targeted patient populations for proper primary care utilization and essential follow up to prevent unnecessary and avoidable emergency room and hospital admissions.","Develop essential reporting in new EMR to identify and provide better case management of targeted patient population","Implement primary care case management team to provide necessary follow up on targeted population in a primary care or specialty setting.","Establish internal chronic management team to enhance care coordination efforts between inpatient and outpatient populations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; G1; J1","The core activity selected: management of targeted patient populations, e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services will impact the selected bundles in the following ways.  For measures A1 and A2,having a core activity that focuses on improving outcomes and lifestyles of patients with chronic or high-risk diseases will result in providing patients with better access to care and resources to help self-manage their targeted conditions.  Improving the quality measures of the associated bundles will result in the targeted populations experiencing an improvement to their conditions, while decreasing the need for avoidable hospital and emergency room admissions.","No","","135235306.7.1","KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_136143806","136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public",554,"Access to Primary Care Services","","Edit","The changes were made to the core activity description to include a few more details on the activities conducted so far and to reflect our current approach to how the core activity is being implemented. ","Provision of services to individuals that address social determinants of health","","Midland County is designated as a medically underserved area and continues to have challenges in recruiting and retaining primary care providers. This challenge has had a huge impact on access to primary care services for our residents. Access to care not only requires insurance coverage, but also timely access to primary care providers especially for our low income and uninsured population. Through past community health needs assessments studies and our own internal data analysis, Midland County’s poor access to primary care services results in high utilization of the emergency department and hospital inpatient visits especially with potentially preventable health conditions. The most affected groups are the Medicaid, Low-Income and Uninsured populations. These patients have the most difficulty to see a primary care provider or a specialist in a timely manner. They also suffer from behavioral, social, and economic challenges that largely goes unaddressed and contributes to their overall health care challenges.\nIn response to these challenges and to support our selected category C bundles A1, A2, C2, and D1 projects, Midland Memorial Hospital and its healthcare partners have created the Equitable Care Alliance, a coalition of health care providers, social workers, the public health department, community leaders, governmental agencies and community support groups (NGOs) to help address social determinants of health.  This core activity will focus on 2 main areas; (i) access to primary care services and (ii) access to community resources to help address social determinants of health.        \n1.\tAccess to a primary care provider: One of the tenets for this core activity involves the establishment of a care transition and chronic disease management system to help identify, educate and connect high utilizers of hospital emergency departments with primary care providers and other community resources based on the needs of the patient. In collaboration with a local FQHC clinic and the hospital’s case management and social services department, we have designed a post-discharge follow-up voucher program that patients can use to access free medical care following an ER visit or hospital stay. In the past, patients in the target population most often do not seek follow-up care post-discharge.  This sometimes results in readmissions at both the emergency department and inpatient hospital stays. The free voucher covers basic diagnostics, labs, medications and office visits for qualified patients.  Through our Community Health Paramedic (CHP) program led by a Physician Assistant and the Midland Fire Department, high risk patients will receive a visit at home within 48 hours after discharge (Inpatient/ER) before their follow-up appointments. This is to ensure patients are following their treatment plan or discharge instructions that includes medication adherence and address any concerns they may have. There is also a free 24-hour Nurse Advisory call service where patients receive post-discharge follow-up calls from trained nurses to check on the progress of patients. Patients also can call the service line to schedule doctors’ appointments or receive free medical advice. Patients are triaged and directed to an appropriate level of care instead of calling the emergency service hotline or going to the emergency department for non-emergent conditions. Finally, the call center also serves as an answering service for our local providers to help patient who may have questions or need medical assistance during after office hours. \n\n2.\tAccess to Community resources to address social determinants:    The aim of the Equitable Care alliance is to work collaboratively to help connect our patients to available community resources to help address both their medical, economic and social needs that prevents patients from being healthy and well. The alliance has a focus on public education and community engagement activities that tries to address social determinants of health challenges as well as eliminate gaps in communication among coalition members so they can effectively serve patients. Through communications with coalition members, we concluded that we serve the same clients or patrons. For example, a diabetic patient with food insecurity that visits the food bank will have similar challenges to access medical care that will help manage his chronic disease. He/She will most likely use the emergency room for medical care and may need assistance with medications. Through coordination among coalition members we can identify and connect these patients to other community resources in a timely manner that will help address the challenges of social determinants.  \nThe alliance will build a reliable communication and a working structure that will connect patients to community resources that will help address such issues as food and nutrition insecurities, medication supply, housing and work programs. The alliance aims to increase communication and coordinate local resources to make sure patients are offered a comprehensive, coordinated primary care & preventive services focused on accountable care that improves quality of life and health outcomes especially for people facing social, cultural and economic barriers to stay healthy.","Form community partnerships and coalitions: The first secondary driver for the above core activity is to form a coalition of community partnerships and coalitions to address the challenges of social determinants of health.  In other for us to address social determinants of health challenges for our patients, there is the need to bring individuals, agencies, organizations and community members together in an atmosphere of support to systematically solve existing and emerging problems and incorporate their programs in the care delivery process for our most vulnerable patients in Midland County.\nThe coalition/partnership members will include the city council members, hospital district, primary care providers, federally qualified health center, housing authorities, social services, food banks, local public health department and community supports groups that provides social, economic, medical and cultural support services to the most vulnerable (Medicaid, low-income and uninsured) populations in the community.  Most organizations and programs operate in silos which makes it challenging for patients to receive comprehensive support or help they need. Thus, the lack of collaboration among stakeholders is doing little to serve the needs of patients. Through the community coalition efforts, we can help address some of the challenges of social determinants of health (SDOH) for our patients. The goal of the coalition is to align goals, share ideas or expertise, leverage resources and increase communication so patients can fully benefit from community resources which has the potential to improve the health and wellbeing of patients.\n                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        As a foundation to our first secondary driver, in CY2019 Midland County Hospital and a local FQHC clinic teamed up to design and implement a post-discharge follow-up voucher program to help connect patients to primary care providers and services (follow-ups) following an ER visit or hospital stay. The voucher program covers basic diagnostics and office visits for qualified MLIU patients as well as pharmaceuticals services under the 340B program. Patients are also assessed for other benefit programs such as Medicaid, County financial assistance program, State and federal benefits programs, RxAssist, Partnership for Prescription Assistance programs etc\nOne of the goals for the voucher program is to ensure continuity of care for our patients especially patients with chronic diseases that needs long-term care and management. The second was goal for this initiative is to connect patients to health, social and community resources that will aid in their recovery and wellness.  \nWe also run a free health clinic on Tuesdays and Thursdays at the local Senior Center and Casa de Amigos, a neighborhood community center. The free clinic event is to help address the issues of access to primary care services, early detection and help patients navigate through the health care system. There are also free screenings and flu vaccinations offered at these community events. \nOur goal is to use these initiatives and other collaborative ideas to address social determinants of health challenges that prevents our patients from staying healthy and well. ","The first change idea for the above secondary driver is to increase care coordination among providers and health facilities within our primary and secondary service areas for our MLIU population. Currently, the lack of coordination among providers is having an effect on the quality of care and frustrating for patients. Establishing a quality alliance group and increasing coordination in the treatment of our patients will greatly improve the efficiency of care as well as reduce unnecessary and redundant treatments, thereby lowering healthcare costs overall. Currently, the system is not perfect. There are many challenges in implementing a care coordination system including administrative burdens. Regardless of this challenge, implementing a better care coordination process is crucial to solving challenges such as high readmission rates, ED utilization for chronic diseases, increase screening for cancer and from increasing the quality of care patients receive to reducing unnecessary spending."," "," "," "," "," ",null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2; C2; D1","This core activity was selected with the aim of lending support to our selected category C bundles A1, A2, C2, and D1 projects.  Midland Memorial Hospital and its healthcare partners have created the Equitable Care Alliance with includes providers, social workers, public health department, other governmental agencies and community support groups (NGOs) who will connect with patients in the community to help identify and address both their medical and social needs especially for Medicaid Low Income and Uninsured patients. There is also a component of the alliance that will focus on patient education and community engagement activities that will gather information about community health needs so the alliance can direct resources to better serve the community. Projects A1-Chronic disease management, Diabetes and A2: Improved Chronic disease management, Heart Disease; will greatly benefit from the establishment of the care transition and chronic disease management department dedicated to help identify, educate and connect high utilizers of hospital emergency departments to primary care providers for at-risk patients. With the help from our local federally qualified health center, such patients will be referred to those clinics where their care will be better managed and improve health outcomes. This approach will help improve health outcomes and quality of life, prevent disease complications, and reduce unnecessary acute and emergency care utilization for our diabetic and heart disease patients. Projects C2: Primary Care Prevention - Cancer Screening and D1: Pediatric Primary Care will also benefit from the public education and the alliance with the local public health department, local providers, the school district and community advocacy groups to encourage preventative screenings and emphasize the importance of vaccinations for our pediatric population as a measure to avert future occurrence of a disease or illness. ","No","","136143806.7.1","KK",null,"N","NB","Asking to clarify","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please respond in the \"Provider Response\" column with the suggested changes.","First secondary Driver: \nForm community partnerships and coalitions: The first secondary driver for the above core activity is to form a coalition of community partnerships and coalitions to address the challenges of social determinants of health.  In other for us to address social determinants of health challenges for our patients, there is the need to bring individuals, agencies, organizations and community members together in an atmosphere of support to systematically solve existing and emerging problems and incorporate their programs in the care delivery process for our most vulnerable patients in Midland County.\nThe coalition/partnership members will include the city council members, hospital district, primary care providers, federally qualified health center, housing authorities, social services, food banks, local public health department and community supports groups that provides social, economic, medical and cultural support services to the most vulnerable (Medicaid, low-income and uninsured) populations in the community.  Most organizations and programs operate in silos which makes it challenging for patients to receive comprehensive support or help they need. Thus, the lack of collaboration among stakeholders is doing little to serve the needs of patients. Through the community coalition efforts, we can help address some of the challenges of social determinants of health (SDOH) for our patients. The goal of the coalition is to align goals, share ideas or expertise, leverage resources and increase communication so patients can fully benefit from community resources which has the potential to improve the health and wellbeing of patients.\n                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        NMI Response: Current activities to help address SDOH\nAs a foundation to our first secondary driver, in CY2019 Midland County Hospital and a local FQHC clinic teamed up to design and implement a post-discharge follow-up voucher program to help connect patients to primary care providers and services (follow-ups) following an ER visit or hospital stay. The voucher program covers basic diagnostics and office visits for qualified MLIU patients as well as pharmaceuticals services under the 340B program. Patients are also assessed for other benefit programs such as Medicaid, County financial assistance program, State and federal benefits programs, RxAssist, Partnership for Prescription Assistance programs etc\nOne of the goals for the voucher program is to ensure continuity of care for our patients especially patients with chronic diseases that needs long-term care and management. The second was goal for this initiative is to connect patients to health, social and community resources that will aid in their recovery and wellness.  \nWe also run a free health clinic on Tuesdays and Thursdays at the local Senior Center and Casa de Amigos, a neighborhood community center. The free clinic event is to help address the issues of access to primary care services, early detection and help patients navigate through the health care system. There are also free screenings and flu vaccinations offered at these community events. \nOur goal is to use these initiatives and other collaborative ideas to address social determinants of health challenges that prevents our patients from staying healthy and well. ","KK","HHSC has updated the Core Activity based on the provider response, specifically Secondary Driver 1.","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider response, specifically Secondary Driver 1.","Provision of services to individuals that address social determinants of health.","CA-1","CA-1.9"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_138364813","138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",539,"Access to Primary Care Services","","Continue","","Integrated physical and behavioral health care services","","This core activity will be the primary means by which we impact the physical health of our patients, specifically as it relates to our selected measures.  We contract with Midland Community Healthcare Services (MCHS) to provide these services in Midland and with Texas Tech University Health Sciences Center in Odessa.  MCHS provides on billing provides while Texas Tech provides 2 to 3 attending faculty who oversee a rotating group of residents.","Colocation of primary and behavioral health care providers - in both of our integrated care clinic locations we've colocated our primary care providers with our behavioral health providers.  This close proximity allows for increased communication and data share which results in better patient outcomes.","Steps will be taken to increase the communication between PBCC and contract provider staff.  These will include collaborative meetings which will assist in meeting our outcomes."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-115","These integrated care clinics were set up during the initial waiver period.  During the extension period, we will route appropriate patients for these measures to our integrated care clinics.  The treatment and care the patients receive there will be the mechanism we use to introduce positive change in our patients' health and outcomes and thus these measures.","No","","138364813.7.1","KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"KK",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_138364813","138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",722,"Availability of Appropriate Levels of Behavioral Health Care Services",null,"New",null,"Provision of services to individuals that address social determinants of health",null,"PBCC is designing a category C measurement improvement program by which we will evaluate our patients' health improvement for each of our selected measures.  By dedicating resouces specifically toward this core activity, we will be able to identify patients in our category C measures that are not meeting their health outcomes in real time and target specific interventions as needed.","Permian Basin Community Centers has staff dedicated to provide routine assessments and interventions for our patients, including BMI assessment, among others.","All children who receive behavioral health care services with us will receive interventions that address their education and understanding of how physical health and nutrition impact their overall health.  This is meant to address both \"education\" and \"health and health care\", 2 of the 5 key areas of social determinants of health as outlined in the CDC's health people 2020.  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-211","This core activity would be associated with measure M-211.",null,null,"138364813.7.1",null,null,null,null,null,null,null,"Permian Basin Community Centers proposes that this core activity be deleted in its entirety and be replaced with the group \"Availability of Appropriate Levels of Behavioral Health Care Services\" and title area \"Provision of services to individuals that address social determinants of health and/or family support services.\"  As a Secondary Driver, Permian Basin Community Centers has staff dedicated to provide routine assessments and interventions for our patients, including BMI assessment, among others.  As  a change idea, all children who receive behavioral health care services with us will receive interventions that address their education and understanding of how physical health and nutrition impact their overall health.  This is meant to address both \"education\" and \"health and health care\", 2 of the 5 key areas of social determinants of health as outlined in the CDC's health people 2020.   This core activity would be associated with measure M-211.",null,"HHSC has created a new Core Activity based on the provider response, including the provider's suggested group, title, secondary driver 1 and secondary driver 1 - change idea 1. HHSC accepts and has associated this core activity with measure M-211.",null,null,null,"Accepted","HHSC has created a new Core Activity based on the provider response, including the provider's suggested group, title, secondary driver 1 and secondary driver 1 - change idea 1. HHSC accepts and has associated this core activity with measure M-211. Provider will need to submit additional details on impact to M1-211 during DY9 reporting. ","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 14_DY9-10 Regional Tracker - FINAL Tracker.xlsb","14_138364813","138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",541,"Other","Other","Delete","","Other","Focused Efforts of Ensuring Improvement for Selected Measures","PBCC is designing a category C measurement improvement program by which we will evaluate our patients' health improvement for each of our selected measures.  By dedicating resouces specifically toward this core activity, we will be able to identify patients in our category C measures that are not meeting their health outcomes in real time and target specific interventions as needed.","PBCC will hire a staff member with appropriate expertise whose job responsibilities will include monitoring performance on all measures and interfacing with clinic staff in order to improve any outcome areas that are not performing at assigned levels.","Assigned staff will develop a dashboard indicator report for each assigned measure which will allow easy identification of areas that need attention."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-211; M1-103; M1-105; M1-115; M1-147","PBCC's staff member will use their expertise to quickly identify areas where intervention is needed, this staff member will meet clinic staff members in their locations in order to identify and fix any issues that are causing targets not to be achieved.","No","","138364813.7.1","KK","KK agrees that the \"Other\" designation should be used for this Core Activity title","N","NB","NMI - requesting to re-write and revisit.","Needs More Information","HHSC recommends that the provider revisits its Core Activity description to reflect activities that the provider is implementing to impact the measures selected by providers. In the current description, provider’s concentration is on Category C measures. The re-write of the description should help provider identify Core Activity Grouping and Title/area that work best for this Core Activity. Core Activity as submitted now is not accepted.  Please respond in the \"Provider Response\" column with the suggested changes.","Permian Basin Community Centers proposes that this core activity be deleted in its entirety and be replaced with the group \"Availability of Appropriate Levels of Behavioral Health Care Services\" and title area \"Provision of services to individuals that address social determinants of health and/or family support services.\"  As a Secondary Driver, Permian Basin Community Centers has staff dedicated to provide routine assessments and interventions for our patients, including BMI assessment, among others.  As  a change idea, all children who receive behavioral health care services with us will receive interventions that address their education and understanding of how physical health and nutrition impact their overall health.  This is meant to address both \"education\" and \"health and health care\", 2 of the 5 key areas of social determinants of health as outlined in the CDC's health people 2020.   This core activity would be associated with measure M-211.","KK","HHSC has deleted this core activity as suggested by provider in response.","N",null,null,"Accepted","Provider's deletion of the Core Activity for DY9-10 is accepted.","Other","CA-1","CA-1.10"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_065086301","065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public",558,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of services to individuals that address social determinants of health","","To improve continuum of care for health department's clients/patients within and beyond the existing system this core activity will be focused on coordinating a patient care navigation and transition services process.  Using a standardized referral interview process based on social determinants of health trained staff, academic collaborators, partner agencies and community health workers will identify persons in need of select health screening services, testing, and/or vaccinations. These persons are then connected to the needed service and tracked  using a voucher redemption process. The process will be used across all DSRIP activities in order to evaluate acess to care and cost-effectiveness from various cross sectors integrated to the health department's system. Specific evaluation areas include billing components, electronic health records, referral interview data, costs and overall impact on \"Category C\" measures.","Improve availability and access to preventive services.","Establishing a coordinated patient navigation process within health deparment's system and external collaboratos will increase services for clients/patients already accessing preventive care. Thus, a standardized referral interview will also require increasing services offered within existing health department' s clinics as this will be the window of opportunity to identifying other care needs. For example, a person coming in for a sexually transmitted disease test may also require provision of vaccines such as the Human Papilloma Virus or  identified as needing a cervical cancer screening.  The added services and coordinated navigation process would serve two-fold with added services and one stop shop for client/patient to receive all services during same visit or be referred to partner healtcare provider if service is not available within health department system.","Integrate a patient care coordinator/navigator within clinics to help implement process and directly assist clients/patients during their visit.  The coordinator/navigator will develop a resource directory and cross-training between programs such as the health education, 2-1-1 call center, laboratory, and all three clinics (HIV, STD, dental). This will help bridge health department's programs with city deparments including library, fire, parks and recreation, and community development as well as external healthcare providers. Building patient care navigation capacity will also improve follow-up resources to assure quality of services and continuum of care after internal and external screenings in case of abnormal results.","Add one to two health screening services to existing clinics including but not limited to cervical cancer screening, tobacco cessation, body mass index screening and controlling high blood pressure that are identified during the referral interview as needed screenings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-103; L1-105; L1-147; L1-268; L1-IT-12.6; L1-IT-12.1; L1-160; L1-IT-7.2; L1-346","Selected health measures will be services referred using the standardized health interview and integrated in the patient care navigation.  The contemplated impact from this core activity is that it will increase services and faciliate access to care as well as be a cost-effective tool to providing all services in one visit.","Yes","The expansion of care navigation services is linked to contracted clinics providing select cancer screenings. The contracted providers to include Hospitals of Providence, Rio Grande OB/GYN, and Healthy Horizons provide mammography, cervical cancer screenings, and colorectal cancer screenings to participants referred by the health department. The providers are not part of the health department's system but are a resource for services. These are external entities on their own practice that are not able to be integrated to the health department's system due to credentialing/licensure and liability procedures. Only clients served through the contract guidelines are accessible.  The health department doesn't have access to contracted clinics' system population or other healthcare services. Continuum of care and added services will be coordinated among the contracted clinics and health department to assure health data is maintained confidential and authorization for disclosure from client/patient is documented. This will aid with billing and contracting items as well as making sure client/patient receives needed follow-up care after screenings.","065086301.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flags. No changes. The \"Explanation of Provider Not in System Definition\" cell is flagged. I compared to previous response using len and equals formulas, but there doesn't appear to be a difference. Not sure that the title \"Provision of services to individuals that address social determinants of health\" matches what they are trying to do, but the other options under the grouping don't seem to fit either. Maybe the grouping \"Access to Primary Care Services\" and title \"Establishment of care coordination and active referral management that integrates information from referrals into the plan of care\", but that doesn't seem to address their focus on care navigation. Signoff and comments are currently standard accepted.","Y","NB","Accepting 1st reviewer recommendations. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of services to individuals that address social determinants of health.","CA-6","CA-6.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_084597603","084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",559,"Access to Primary Care Services","","Edit","","Provision of vaccinations to target population","","To facilitate the administration of vaccines and the growth of vaccination rates for our System population. This core activity will focus on developing a standardize vaccine standing protocol that will be followed by the healthcare team across the system. The objective of this protocol is to ensure the vaccination guidelines are followed and to prescribe and/or administer vaccines at the time of the encounter.   Additionally, a patient care navigation workflow will be established to perform pre-visit planning to identify patients who need vaccines and to schedule a vaccine appointment. To implement the above actions Provider will designate champions that will train the healthcare team and work with local pharmacies.","Increase the rate of vaccination prescriptions, regarding the pneumococcal vaccination prescriptions.","Educate the healthcare team (physicians and medical assistants) on the proper prescription workflow.","Create standing protocols to be followed by the physicians and medical assistance"," "," "," ","Collaborate with the local pharmacies, regarding the pneumococcal vaccination prescriptions.","Communicate TTUHSC El Paso vaccination goals to local pharmacies.","Define medical neighborhood (local) pharmacies, collaborating with TTUHSC El Paso"," "," "," ","Identify Target Patients, Children two years of age","Generate monthly reports for target patients (15-23 months)","Patients who are not vaccinated at the point of care, will be added to care coordinator vaccine follow up list"," "," "," ","Team building and education for the healthcare team","Identify and assign immunization champions in each clinic pod","Lecture/In- service on immunization recommendations for providers and staff","Regular clinic meetings incorporating immunization planning"," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; D1","This Core Activity \"Provision of vaccinations to target population\" impacts C1 \"Healthy Texans\" metrics associated with immunizations and D1 \"Pediatric Primary Care\" metrics associated with immunizations.","No","","084597603.7.1","AQ","Provider did not edit core activity during October DY8 reporting and had a review flag. Reporting reviewer comments: \"Provider has to revise its Core Activity, right now it shows its Cat C goal. Provider needs to state what they are doing to achieve it.\" Seems like they could combine the two vaccination core activities to minimize admin work, so I combined the information from core activities 559 and 560.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has combined the two vaccination focused core activities into one core activity. Provider should revise the Core Activity Description to summarize how they are going to achieve these measures instead of just stating the measures that will be impacted. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the combining of two core activities.","• Provider agrees with HHSC recommended change to combine the 2 vaccination focus core activities into one core activity\n\n• Provider has revised the Core Activity Description to summarize how provider is going to achieve these measures as follows: \"To facilitate the administration of vaccines and the growth of vaccination rates for our System population. This core activity will focus on developing a standardize vaccine standing protocol that will be followed by the healthcare team across the system. The objective of this protocol is to ensure the vaccination guidelines are followed and to prescribe and/or administer vaccines at the time of the encounter.   Additionally, a patient care navigation workflow will be established to perform pre-visit planning to identify patients who need vaccines and to schedule a vaccine appointment. To implement the above actions Provider will designate champions that will train the healthcare team and work with local pharmacies.\"\n\n• Provider does not plan to make any additional changes to Secondary Drivers and their associated Change Ideas based on the combining of two core activities.\n","AQ","Provider accepts revisions to combine immunization core activities and revised the Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC changed Core Activity Description based on provider's response.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_084597603","084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",561,"Access to Primary Care Services","","Delete","Provider is deleting this Core Activity \"Provision of screening and follow up services\" because it is related to measure E1-193 \"Contraceptive Care – Postpartum Women Ages 15–44\" that has been removed from the E1 \"Improve Maternal Care\" measure bundle for DY9-10.","Provision of screening and follow up services","","Provision of contraceptive care for women Metric: E1-193 Contraceptive Care  Postpartum Women Ages 15 44. women ages 15 through 44 who had a live birth, the percentage that is provided: Rate 1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately (i.e., injectables, oral pills, patch, ring, or diaphragm) effective method of contraception within 3 and 60 days of delivery, and Rate 2) A long-acting reversible method of contraception (LARC) within 3 and 60 days of delivery.","Patient engagement and education for postpartum LARCs within 60 days of delivery","Provide early and ongoing counselling regarding contracceptive care","Ensure patient uptake of PP long-acting reversible method of contraception (LARC) within 60 days of delivery","Ensure long term retention of method for 6 month and one year duration"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This Core Activity \"Provision of screening and follow up services\" impacts E1 \"Improved Maternal Care\" metrics associated with follow up services such as Contraceptive Care","No","","084597603.7.1","AQ","Provider edited core activity during October DY8 reporting and had a review flag. Provider's edit notes: \"Edited this Core Activity to change from “Immediate after delivery” to “within 60 days after delivery\", due to the fact that many patients prefer to have the LARC administered within 60 days, rather than immediately after delivery.\" Reporting reviewer comments: \"Provider has to revise its Core Activity, right now it shows its Cat C goal. Provider needs to state what they are doing to achieve it.\" Provider is deleting the core activity because it focused on measure E1-193 \"Contraceptive Care – Postpartum Women Ages 15–44\" that has been removed from the E1. ","N",null,null,"Needs More Information","Provider’s deletion of the Core Activity for DY9-10 is accepted. HHSC updated the core activity language to reflect the changes submitted during the October DY8 reporting period. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change.","Provider is in agreement with HHSC","AQ","Core activity deleted.","N",null,null,"Accepted","HHSC accepted provider’s deletion of the Core Activity for DY9-10. ","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_084597603","084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",723,"Access to Primary Care Services","","New","","Provision of screening and follow up services","","To maintain and improve maternal health during pregnancy with the intent to deliver healthy babies. This core activity will focus on implementing a patient care navigation workflow that will include the administration of pregnancy tests aim to identify  pregnancies during the early stages. The objective will be to schedule an immediate visit to begin the prenatal care upon identification of pregnancy.","Identify patients in our target population who may be pregnant","Acquire, offer and administer free pregnancy tests for patients in our target population ","Schedule an immediate prenatal visit during the first trimester or 48 days of enrollment for patients with a positive result","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","This Core Activity “Provide prenatal care during the first trimester or within 42 days of enrollment in the organization for all deliveries performed by TTUHSC EP providers” impacts measure bundle E-1 “Improve Maternal Care”, specifically measure E1-232 “Timeliness of Prenatal care”.","No","","084597603.7.1","AQ","Provider did not edit core activity during October DY8 reporting and had a review flag.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Description of Core Activity is too similar to the Cat C measure E1-232. Provider should revise the Core Activity Description to summarize how they are going to achieve these measures instead of just stating the measures that will be impacted. Please enter an updated description in the \"Provider Response\" column.","Provider has revised the Core Activity Description to summarize how provider is going to achieve these measures as follows: \"To maintain and improve maternal health during pregnancy with the intent to deliver healthy babies. This core activity will focus on implementing a patient care navigation workflow that will include the administration of pregnancy tests aim to identify  pregnancies during the early stages. The objective will be to schedule an immediate visit to begin the prenatal care upon identification of pregnancy.\"","AQ","Provider revised Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC changed Core Activity Description based on provider's response.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_094109802","094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private",563,"Chronic Care Management","","Edit","","Utilization of care management and/or chronic care management services","","LPDS care management program is a tool to provide target patient population with education and navigation services. The objective of this initiative is provide patients with self management education resources and support to reduce avoidable readmissions and unnecessary ED visits.","Reduce emergency care utilization and improve management of heart disease and comorbidities.","LPDS will provide comprehensive post discharge support as well as facilitate outpatient specialty clinic/primary care scheduling, visit confirmation, and patient education for patients with CHF"," "," "," "," ","Increase post discharge patient coordination for ED patients with chronic diseases and /or are high utilizers of the ED","LPDS will provide care navigation and post discharge navigation support for ED patients at risk of hospital readmission and /or frequent ED use."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; B2","The core activities directly support the two measure bundles by seeking to improve patient care coordination and clinical outcomes for heart failure patients and high risk patients  who use LPDS' emergency departments.","No","","094109802.7.1","AQ","Provider did not edit core activity during October DY8 reporting and had a review flag. Reporting reviewer noted: \"seems that the 1st secondary driver is similar to a Cat C. Need to adjust it.\" Cleaned up some of the information to remove identifying language (e.g., The first secondary driver…).","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has removed identifying language (e.g., The first secondary driver…) from Secondary Driver 1, Secondary Driver 1: Change Idea 1, and Secondary Driver 2. Secondary Driver 1 is also too similar to a Cat C measure. The provider should update Secondary Driver 1 and its associated Change Ideas to reflect activities the provider is implementing in order to reduce CHF readmissions. Additional details for Secondary Driver 1 and Secondary Driver 1: Change Idea 1 descriptions should be entered in the \"Provider Response\" column.","LPDS would like to revise the change idea to \"LPDS will provide comprehensive post discharge support as well as facilitate outpatient specialty clinic/primary care scheduling, visit confirmation, and patient education for patients with CHF\". LPDS would like to revise Driver 1 to : Reduce emergency care utilization and improve manaent of heart disease and comorbidities. ","AQ","Provider updated Secondary Driver 1 and Secondary Driver 1: Change Idea 1 to  reflect activities implemented","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC changed Secondary Driver 1 and Secondary Driver 1: Change Idea 1 based on provider's response.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_094109802","094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private",564,"Hospital Safety and Quality",null,"Edit","","Implementation of standard protocols to address leading cause of hospital infections and injuries",null,"LPDS will assess and implement procedures to help reduce hospital infection rates for its inpatient population, including CLABSI, CAUTI, SSI, and Post-Operative Sepsis rate.","LPDS will implement patient safety protocols, perform ongoing monitoring, and implement process improvements as needed","LPDS will train clinical and hospital staff on safety procedures and protocols","LPDS will collect and report surveillance data related to hospital infections on an ongoing basis","LPDS will implement process improvements based on surveillance data results"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3; J1","The core activity tracks, reports and improves on the hospital safety measures included in D3 and J1 , such as CLABSI, CAUTI, and SSI.","No","","094109802.7.1","AQ","Provider did not edit core activity during October DY8 reporting and had a review flag. Reporting reviewer noted: \"needs to move from other to the menu. Also CA needs to be clarified, right now it is all about Cat C.\" Changed the grouping from \"Other - Improve patient safety at Las Palmas and Del Sol inpatient facilities\" to \"Hospital Safety and Quality\" and title from \"Other - Utilization of quality centered measures to improve patient safety and outcomes for adult and pediatric inpatient population at LPDS' two inpatient facilities\" to \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls).\" The change in the grouping and title seems to address the concerns from reporting review. Please check to see if there is any additional feedback needed.","Y","NB","changed to NMI","Needs More Information","HHSC has updated the Core Activity Grouping from \"Other: Improve patient safety at Las Palmas and Del Sol inpatient facilities\" to \"Hospital Safety and Quality\" and the Core Activity Title from \"Other: Utilization of quality centered measures to improve patient safety and outcomes for adult and pediatric inpatient population at LPDS' two inpatient facilities\" to \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)\". Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the change to the core activity's grouping and title.","LPDS accepts HHSC's revisions. ","AQ","Provider accepts revisions to move activity on menu","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_130601104","130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private",566,"Maternal and Infant Health Care","","Edit","PMH updated Core Activity #1 to properly describe current practices. \n\nCore Activity #1: PMH updated the description to provide additional information related to Core Activity #1 including the intended impact.\n\nSecondary Driver #1: PMH updated the description to provide the full picture of improvement activities related to Secondary Driver #2.\n\nChange Idea #1:  PMH revised this description to provide more detail regarding the use of Antenatal Steroid Initiation Cards to improve tracking and documentation systems.\n\nChange Idea #2: PMH combined Secondary Driver #1 and Secondary Driver #2 because both relate to improving antenatal steroid tracking and documentation systems.  As a result, PMH is deleting Secondary Driver #2 and moving the related change idea to Change Idea #2 for Secondary Driver #1. PMH also updated the description of Change Idea #2 to provide additional information.\n\nImpact on Measures: Description updated to better describe the impact that Core Activity #1 will have on Bundle E2 – Maternal Safety, specifically Measure E2-151 Antenatal Steroids.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth",null,"PMH will develop and test methods to improve antenatal steroid tracking and documentation systems for patients at risk of preterm delivery. Establishing a documentation system to reliably record administration of antenatal is crucial to improving antenatal steroid treatment rates. Consistently recording antenatal steroid administration will help ensure that needed treatment is not missed or that too many doses of an antenatal steroid are not given, which can have harmful effects on the baby. In addition, standardizing data documentation and collection, improves the accuracy of state vital statistics records of prenatal care.","Implement processes to improve antenatal steroid tracking and documentation systems for patients at risk of preterm deliveries. Accurately recording data in the medical record is essential to providing safe care and ensuring that all care providers are making accurate and informed treatment decisions.","PMH will utilize a uniform Antenatal Steroid Initiation Card (“ASIC”) process to improve antenatal steroid tracking and documentation systems. PMH noticed hospital charts often do not reflect when a provider administered an antenatal steroid at a previous location, such as a doctor’s office or when a patient is being transferred from one hospital to another. PMH’s ASIC process will include detail to inform maternal care staff of the status of antenatal steroids administered to prior to admission. PMH will ensure standardized practices are in place for documenting the ASIC information within medical records, both electronic and paper charts—recording it in same place every time and using the same language. PMH will also provide education and training to the maternal care team on medical terminology, processes for data abstraction, and the importance of accuracy. PMH will utilize this information to ensure the maternal care team is properly documenting antenatal steroids administered prior to admission, and inform ongoing improvement activities by identifying best practices and areas for improvement."," PMH will improve antenatal steroid tracking and documentation systems by updating guidelines related to documenting medical decisions for not administering antenatal steroids. PMH’s electronic health record system includes a PeriGen's PeriWatch modular software system integration. PeriWatch gives PMH’s clinical team access to a continuum of documentation from prenatal through delivery, postpartum, newborn and Level 3 NICU. PeriWatch enables information flow from stage to stage to help reduce double charting and data errors. PMH will update the PeriWatch modular software system integration to include a section for properly documenting medical decisions for not administering antenatal steroids. PMH will also standardize guidelines for utilizing PeriWatch to ensure the maternal care team uses consistent terminology and charting practices to document medical decisions for not administering antenatal steroids. PMH will utilize this information to inform ongoing improvement activities. For example, Change Idea #2 will allow PMH to assess medical reasons for not administering antenatal steroids, and ensure the maternal care team is following clinical guidelines related to administering antenatal steroids to patients at risk of preterm delivery."," "," "," ","",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Core Activity #1 will have a positive impact on performance rates for the E2-151: Antenatal Steroid measure by improving tracking and documentation systems for antenatal steroids. Studies show properly documenting antenatal steroids administered prior to admission is key to ensuring all preterm infants receive appropriate antenatal steroid treatment to reduce perinatal morbidity and mortality. Additionally, the Joint Commission (i.e. Antenatal Steroid measure steward) recommends hospitals review documented reason for not initiating antenatal steroids as an approach for improving antenatal steroid performance rates. PMH is hopeful it will be able to improve antenatal steroid performance rates by following these evidence-based clinical studies and recommendations.","No","","130601104.7.1","AQ","Provider edited core activity during October DY8 reporting and had a review flag for \"Other\" title. Looks like updates are the same that were submitted for reporting. Provider's current title is \"Other - Improve antenatal steroid tracking and documentation systems for patients at risk of preterm delivery.\" Would recommend the menu title: \"Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)\". Please change if this doesn't make sense. Also, provider was flagged for TA during reporting review because their reporting submission was too similar to other providers in the healthcare system and not specific to the provider.","Y","NB","we can see if provider accepts. Changing to NMI though.","Needs More Information","HHSC has updated the Core Activity Title from \"Improve antenatal steroid tracking and documentation systems for patients at risk of preterm delivery\" to \"Implementation of evidence-based strategies to reduce low birth weight and preterm birth\" to better align with the provider’s described Core Activity. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the change to the Core Activity Title.","PMH accepts HHSC’s proposed update to the Core Activity Title.","AQ","Provider agrees with update to Core Activity Title.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_130601104","130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private",567,"Maternal and Infant Health Care","","Edit","PMH updated Core Activity #2 to properly describe current practices. \n\nCore Activity #2: PMH updated the description to provide additional information on existing and new initiatives.\n\nSecondary Driver #1: PMH revised this description to provide a better overview of Secondary Driver #1.\nChange Idea #1: Description revised to better explain how Change Idea #1 will reduce PMH’s Cesarean section rate.\n\nSecondary Driver #2: PMH revised this description to encompass all change ideas.\nChange Idea #1: Description edited to show how Change Idea #1 will reduce PMH’s Cesarean section rate.\nChange Idea #2: Description edited to show how Change Idea #2 will reduce PMH’s Cesarean section rate.\n\nSecondary Driver #3: PMH added Secondary Driver #3 to capture the OBHG initiative that focuses on expanding access to maternal care in the El Paso community. \nChange Idea #1: New addition to Secondary Driver #3. PMH has partnered with OB Hospitalist Group to implement a program consisting of twenty-four hour inpatient management services and obstetrics emergency department to provide for the professional obstetrician/gynecologist management of designated inpatients at PMH’s facilities and the triage, evaluation and management of patients arriving to PMH’s emergency department. PMH is confident that this program will contribute to reducing and preventing low risk cesarean sections.\n\nImpact on Measures: Description updated to better describe the impact that Core Activity #2 will have on Bundle E2 – Maternal Safety, specifically Measure E2-150 Cesarean Section.","Implement standard protocols for the leading causes of preventable death and complications",null,"PMH will provide education to providers and patients to promote vaginal deliveries. PMH will educate providers regarding the best practices in clinical decision-making for reducing unnecessary cesarean section by improving appropriate care and avoiding overtreatment. PMH will encourage providers to deter patients from opting for cesarean section deliveries by providing education regarding the benefits of vaginal deliveries and risks associated with cesarean section deliveries. PMH’s maternal care team will routinely provide evidence-based interventions to patients that prevent cesarean section deliveries and promote vaginal births.  PMH will also contract with an OBHG to provide twenty-four hour inpatient management and obstetrics emergency department services to improve obstetrician/gynecologist services and prevent unnecessary cesarean sections. The OBHG will help keep patients informed and comfortable throughout the birth process. ","Conduct ongoing training and education to the maternal care team to reduce unnecessary cesarean section deliveries.","PMH will conduct ongoing physician training and education activities to prevent unnecessary cesarean section deliveries.  PMH discusses the hospital’s performance rates for cesarean section deliveries with physicians during department meeting.  PMH also monitors cesarean section rates for individual physicians to determine whether additional training and education is needed to drive improvement.  Physician training and education will focus on evidence-based clinical practice guidelines for reducing unnecessary cesarean section deliveries.  PMH believes this process will increase physician accountability and improve future performance by giving physicians the tools they need to succeed.  Based on peer-reviewed studies related to improving hospital cesarean section rates, PMH is confident Change Idea #1 will have a positive impact on preventing unnecessary cesarean section deliveries."," "," "," "," ","Provide evidence-based intervention that promote vaginal deliveries when appropriate.","Promote the use of evidence-based interventions to promote vaginal deliveries and prevent cesarean section deliveries.  One strategy for reducing the primary cesarean surgery rate and length of labor is using a peanut-shaped exercise ball for women laboring under epidural analgesia.  Studies show the peanut ball is a successful nursing intervention that helps progress labor and support vaginal birth for women laboring under epidural analgesia.  Consistent with these findings, PMH’s maternal care team routinely provides peanut ball interventions during labor.  Other strategies used by PMH’s maternal care team include: (1) promoting ambulation during labor and (2) encouraging frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning.  Research shows these evidence-based interventions support vaginal birth and reduce primary cesareans. ","PMH will conduct ongoing training and education to the maternal care team regarding the Change Idea #1 cesarean section prevention techniques and other evidence-based interventions that promote vaginal deliveries.  As part of Change Idea #2, PMH will also assess maternal care staff competency regarding interventions that prevent cesarean section deliveries and conduct additional training as needed."," "," "," "," Increase access to maternal care services and assistance to physicians with assigned patients."," PMH is expanding access to maternal care for all pregnant women in the El Paso area by implementing a focused obstetrical and gynecological program utilizing an OB/GYN Hospitalist Group (“OBHG”). The OBHG provides in-house physician coverage (including performance of medical screening examination, evaluation and treatment, admission, and on-going inpatient management services) twenty-four (24) hours per day for unassigned Hospital obstetric patients and unassigned Hospital emergent gynecology patients or for assigned obstetric or gynecologic Hospital patients upon request of the attending physician or patient's physician. The OBHG also collaborates with PMH to optimize patient safety and risk management efforts. Additionally, the OBHG participates in PMH’s performance management and innovation initiatives related to increasing quality, efficiency, and effectiveness of care delivered to patients. As part of this participation, the OBHG provides PMH with periodic reports on the following National Quality Forum and Agency for Healthcare Research and Quality metrics:\n\n> NQF 469: Percentage of deliveries that are elective between 37 and 39 weeks gestation;\n> NQF 471: Percentage of Nulliparous women with a Term, Singleton, Vertex infant delivered via C-Section;\n> NQF 472: Percentage of patients undergoing C-Section who received antibiotics within 60 minutes of start of surgery;\n> AHRQ PSI #18: Obstetric Trauma Rate for Vaginal Trauma with instrument; 3rd and 4th degree lacerations; and\n> AHRQ PSI #19: Obstetric Trauma Rate for Vaginal Trauma without instrument; 3rd and 4th degree lacerations."," "," "," "," ",""," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","All three Secondary Drivers of Core Activity #2 seek to positively impact PMH’s E2-150 Cesarean Section measure by reducing the number of overall (and nulliparous) Cesarean sections performed (numerator inclusions). Each driver targets a different element of PMH’s Maternal Care to enact this impact: Driver #1 focuses on current physician education and awareness, Driver #2 focuses on the education of the Maternal Care staff as a whole, and Driver #3 adds a new source of physicians to change Maternal Care access and availability of service. Through this reduction of numerator inclusions, PMH expects this multi-faceted approach to reduce its nulliparous Cesarean section rate and improve its E2-150 performance. ","No","","130601104.7.1","AQ","Provider edited core activity during October DY8 reporting and had a review flag for \"Other\" title.  Looks like updates are the same that were submitted for reporting. Provider's current title is \"Other - Improve maternal and infant health outcome by providing education related to Cesarean Sections and expanding access to maternal care.\" Would recommend the menu title: \"Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)\". Please change if this doesn't make sense. Also, provider was flagged for TA during reporting review because their reporting submission was too similar to other providers in the healthcare system and not specific to the provider.","Y","NB","Agree. But changing to NMI","Needs More Information","HHSC has updated the Core Activity Title from \"Improve antenatal steroid tracking and documentation systems for patients at risk of preterm delivery\" to \"Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants\" to better align with the provider’s described Core Activity. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the change to the Core Activity Title.","PMH accepts HHSC’s proposed update to the Core Activity Title.  PMH would like to clarify the Core Activity Title from the original submission was “Improve maternal and infant health outcome by providing education related to Cesarean Sections and expanding access to maternal care” and not \"Improve antenatal steroid tracking and documentation systems for patients at risk of preterm delivery.\"","AQ","Provider agrees with update to Core Activity Title.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",569,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","This core activity will improve UMC Paitents' quality of life and reduce pain through lifestyle modification, psychological approaches, interventional pain management, and/or pharmacotherapy while recognizing current or potential substance abuse disorders. Improve providers ability to identify and manage chronic non-malignant pain using a function-based multimodal approach, and ability to screen for substance use disorder and connect individuals to appropriate treatment.  Additionally, UMC will develop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.  These activities will also provide comprehensive, integrated primary care services at UMC Clinics that are focused on person-centered preventive care and chronic disease screening.  These services will be in accordance with the state program - \"Health Texans\".","Standardize Workflows and Patient Identification for Diabetes and Heart Disease Patients","Educate and implement Lean Six Sigma Methodologies"," "," "," "," ","Standardize Screenings, Referral Process and follow-up scheduling for Diabetes and Heart Disease Patients","Improve electronic referral and scheduling processes"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; B1; C1; H3","These core activities will positively affect the outcomes for Chronic Disease Management, Patient Navigation, ED Diversion, Primary Care Prevention and Chronic Non-malignant Pain Management.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag. Secondary drivers and associated change ideas seem fine.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",570,"Access to Primary Care Services","","Edit","The only change to this core activity will be the Change Idea due to the fact that since the EMR at the ambulatory clinics was changed, the ability to modify dashboards is no longer an option.","Provision of vaccinations to target population","","This core activity will provide comprehensive, integrated primary care services at UMC Clinics that are focused on person-centered preventive care and chronic disease screening.  These services will be in accordance with the state program - \"Healthy Texans\".","Target specific patient population that are due for vaccines","Partner with a vendor to identify and contact patients who are out of compliance with their Adult immunizations."," "," "," "," ","Educate Patients on Vaccines and Recommendations according to age group(s)","Design, Train and implement vaccination education according to recommendations by the state HHSC."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1","These core activities will positively affect the outcomes for Primary Care Prevention in accordance with \"Healthy Texans\" criteria.","No","","138951211.7.1","AQ","Provider edited core activity during October DY8 reporting and no review flag. Edits appear to match the reporitng submission. Secondary drivers and associated change ideas seem fine.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",572,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","This core activity will implement improvements at UMC in the coordination of care between inpatient to outpatient, inpatient/outpatient to post-acute care, and inpatient/outpatient to home health care settings in order to improve health outcomes, and prevent increased health care costs and hospital readmissions.","Standardize processes and documentation for transitions of care","Standardize Nurse to Nurse handoff form and processes"," "," "," "," ","Increase Referrals to Home Health Services targeting patients at high risk for readmission","Partner with Home Health Agency(ies) to create customized care plans and education targeting high risk patients"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This core activity will positively affect the outcomes for Care Transitions and and Hospital 30 Day Readmissions, specifically in post discharge appointments.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag. Secondary drivers and associated change ideas seem fine. Corrected typo in Secondary Driver 1: Change Idea 1 field. The core activity description is the same as core activity 573 - should differenciate.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Provider should revise Description of Core Activity to be specific to this core activity and differentiate between the core activity that focuses on implementation of a care transition and/or a discharge planning program and post discharge support program. Otherwise, the provider may want to consider combining these two core activities if there is a title under \"Expansion of Patient Care Navigation and Transition Services\" that makes sense. HHSC corrected typo in Secondary Driver 1: Change Idea 1 field. Provider should include responses in the \"Provider Response\" column. ","This provider has considered the comments provided by HHSC for this core activity.  Please revise the Description of this Core Activity to read:\n“This core activity will implement improvements at UMC in the coordination of care between inpatient to outpatient, inpatient/outpatient to post-acute care, and inpatient/outpatient to home health care settings in order to improve health outcomes, and prevent increased health care costs and hospital readmissions.”\n","AQ","Provider revised Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider's responses, specifically the Description of the Core Activity.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",573,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Implementation of a care transition and/or a discharge planning program","","This core activity will implement improvements at UMC in the patient transition of care from inpatient to outpatient, inpatient/outpatient to post-acute care, and inpatient/ outpatient to home health care settings. This will improve patient health outcomes; and will prevent increased health care costs and hospital readmissions.","Evaluate workflows and processes and make improvements","Educate and utilize Lean Six Sigma Methodologies in evaluating discharge and reconciliation workflows"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This core activity will positively affect the outcomes for Care Transitions and Hospital Readmissions, specifically in Medication Reconciliation, ED Discharges, Inpatient Discharges and Post-Discharge Appointments.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag. Secondary drivers and associated change ideas seem fine. The core activity description is the same as core activity 572 - should differenciate.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Provider should revise Description of Core Activity to be specific to this core activity and differentiate between the core activity that focuses on an enhancement in coordination between primary care, urgent care, and Emergency Departments. Otherwise, the provider may want to consider combining these two core activities if there is a title under \"Expansion of Patient Care Navigation and Transition Services\" that makes sense. Provider should include responses in the \"Provider Response\" column. ","This provider has considered the comments provided by HHSC for this core activity.  Please revise the Description of this Core Activity to read:\n“This core activity will implement improvements at UMC in the patient transition of care from inpatient to outpatient, inpatient/outpatient to post-acute care, and inpatient/ outpatient to home health care settings.  This will improve patient health outcomes;  and will prevent increased health care costs and hospital readmissions.”\n","AQ","Provider revised Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider's responses, specifically the Description of the Core Activity.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",575,"Palliative Care","","Edit","","Provision of coordinated palliative care to address patients with end‐of‐life decisions",null,"This core activity will provide palliative and hospice care services to patients and their families and/or caregivers at UMC in order to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.","Educate on pharmacological / non-pharmalogical interventions","Educate patient/surrogate on signs and symptoms of constipation and when to utilize new methods of pharmacological/non-pharmacological interventions with continuous reassessment as needed."," "," "," "," ","Continuous education on signs and symptoms of dyspnea.","Establish 24/7 multidisciplinary palliative care teams as needed for emergencies, concerns or questions"," "," "," "," ","Develop a customized Plan of Care once root cause of Dyspnea is determined.","Create and educate a new automated Plan of Care for patients identified with Dyspnea."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This core activity will positively affect the outcomes for Palliative Care, specifically in Bowel Regimen. This core activity will positively affect the outcomes for Palliative Care, specifically in Dyspnea Screening. This core activity will directly impact the Dyspnea Screening and Dyspnea Treatment metrics (G1-362 and 363)as the customization and automation of the plan of care will allow more efficient and effective care.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and has a review flag for \"other\" title. Would recommend combining three of these \"other\" core activities into one: Utilize services assisting individuals with bowel regime, Utilize Services assisting individuals with dyspnea screening, and Utilize Services assisting individuals with dyspnea. Not sure if they would fit under menu title (e.g., Provision of coordinated palliative care to address patients with end‐of‐life decisions and care needs, Utilization of services assisting individuals with pain management) or if there is a general \"other\" title we could use (e.g., Identify services and educate patients and/or caregivers about care needs).","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has combined three \"other\" core activities (\"Utilize services assisting individuals with bowel regime\", \"Utilize Services assisting individuals with dyspnea screening\", and \"Utilize Services assisting individuals with dyspnea\") into one core activity. Provider should consider a new \"other\" Core Activity Title for this updated core activity or try to shift it on menu (e.g., \"Provision of coordinated palliative care to address patients with end‐of‐life decisions and care needs\"). Secondary Driver 1: Change Idea 1 for the two dyspnea core activities have been added as new Secondary Drivers and the \"Description of Measure Bundle/Measure Impact\" field has been updated to reflect the combined core activities. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the combining of three core activities. If the provider decides to keep the core activities separated, then the provider should revise Description of Core Activity to be specific to this core activity to differentiate between the core activities under the Palliative Care grouping and move the Core Activity Title on menu. Provider should include responses in the \"Provider Response\" column. ","This provider has accepted the changes made by HHSC in combining the “other” core activities into one core activity and the associated driver changes.  \nThis provider would like to revise the Core Activity Title to: “Provision of Coordinated Palliative Care to Address Patients with end-of-life decisions and Care Needs” (as recommended by HHSC).\n","AQ","Provider agrees with combining \"other\" palliative care core activities. Provider revised Core Activity Title. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider's responses, specifically the Core Activity Title.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",576,"Palliative Care","","Edit","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","This core activity will provide palliative and hospice care services to patients and their families and/or caregivers at UMC in order to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.","Enhance patient autonomy and control over treatment preferences.","Evaluation and Education by Hospice RN on Hospice Philosophy."," "," "," "," ","Develop customized plan of care based on beliefs and values as assessed."," Automated belief and values assessment and plan of care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This core activity will positively affect the outcomes for Palliative Care, specifically in Treatment Preferences. It will also impact measure G1-278 by automating this process, it will allow more efficient assessment of Beliefs and Values.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag. Combine with core activity 588 that has the title \"Other - Utilize services to assist individuals with spiritual support.\" Added its secondary driver and associated change ideas to this core activity.","Y","NB","I think provider might get confused, but we will work though responses.","Needs More Information","HHSC has combined two core activities that focus on end-of-life decisions and care needs into one core activity. Provider should revise the Core Activity Description to reflect this change. HHSC has added Secondary Driver 2 and Secondary Driver 2: Change Idea 1, as well as updated the Description of Measure Bundle/Measure Impact from the other core activity. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the combining of two core activities. If the provider decides to keep the core activities separated, then the provider should revise Description of Core Activity to be specific to this core activity to differentiate between the other core activities under the Palliative Care grouping.","This provider has accepted the changes made by HHSC in combining the “end-of-life decisions and care needs\" core activities into one core activity and the associated driver changes (as recommended by HHSC).","AQ","Provider agrees with HHSC's suggested changes.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",579,"Patient Centered Medical Home","","Edit","","Provision of coordinated services for patients under Patent Centered Medical Home model","","This core activity will focus on workflows in the UMC Primary Care Clinics that will accurately identify high-risk patients and bring them in for proper primary care and education. This will improve patient health outcomes; and will also prevent increased health care costs and hospital readmissions.","Evaluate clinic workflows and processes involved in diabetes care, heart disease care, and preventative care","Educate and implement Lean Six Sigma methodologies for improvement to clinic workflows and processes."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; A1; C1","This core activity will positively affect the outcomes for Chronic Care Management and Preventative Care, specifically in HBA1c control, High Blood Pressure, and BMI Screening.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag.  Secondary drivers and associated change ideas seem fine. Provider uses same core activity description for nearly all the Patient Centered Medical Home core activities - needs to revise to differenciate.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Provider should revise Description of Core Activity to be specific to this core activity and differentiate between the core activities under Patient Centered Medical Home. Revised description should be entered into the \"Provider Response\" column.","Please revise the Description of this Core Activity to read:\n“This core activity will focus on workflows in the UMC Primary Care Clinics that will accurately identify high-risk patients and bring them in for proper primary care and education.     This will improve patient health outcomes;  and will also prevent increased health care costs and hospital readmissions.”","AQ","Provider revised Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider's responses, specifically the Description of the Core Activity.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",580,"Patient Centered Medical Home","","Continue","","Utilization of care teams that are tailored to the patient’s health care needs","","This core activity will develop and implement chronic disease management interventions for UMC  that are geared toward improving management of heart disease and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.  Additionally, it will improve UMC Paitents' quality of life and reduce pain through lifestyle modification, psychological approaches, interventional pain management, and/or pharmacotherapy while recognizing current or potential substance abuse disorders. Improve providers ability to identify and manage chronic non-malignant pain using a function-based multimodal approach, and ability to screen for substance use disorder and connect individuals to appropriate treatment.","Modify and Expand the services offered by the UMC Inpatient Education Program","Schedule Diabetes and Heart Disease classes at all primary care facilities for those targeted patients who are non compliant with the DSRIP metrics."," "," "," "," ","Provide Education and Self Management to Chronic Patients with  Heart Disease, Non-Malignant Pain, and Depression","Contact and schedule all non compliant identified patients using an automated telephony system.","Design and implement core modules to address chronic patients and deliver them through our partnership with home health services"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; H3","This core activity will positively affect the outcomes for Chronic Care Management  and Non-Malignant Pain Management, specifically in Heart Disease, Clinical Depression, Pain Assessment, opioid therapy follow-up and risk for opiod misuse.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag.  Secondary drivers and associated change ideas seem fine.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care teams that are tailored to the patient’s health care needs, including non-physician health professionals, such as pharmacists doing medication management; case managers providing care outside of the clinic setting via phone, email, and home visits; etc.","CA-5","CA-5.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",582,"Prevention and Wellness","","Delete","","Implementation of interventions focusing on social determinants of health","","This core activity will provide comprehensive, integrated primary care services at UMC Clinics that are focused on person-centered preventive care and chronic disease screening.  These services will be in accordance with the state program - \"Health Texans\".  Additionally, it will Improve UMC Paitents' quality of life and reduce pain through lifestyle modification, psychological approaches, interventional pain management, and/or pharmacotherapy while recognizing current or potential substance abuse disorders. Improve providers ability to identify and manage chronic non-malignant pain using a function-based multimodal approach, and ability to screen for substance use disorder and connect individuals to appropriate treatment.","Design and implement a systematic outreach to the targeted population","Automated telephony with customized scripts and menus to provide a wider span of outreach."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C1; H3","This core activity will positively affect the outcomes for Preventative Care and Non-Malignant Pain Management , specifically in Pain assessment, Tobacco Cessation, HbA1c Testing, BMI Screening, Pneumonia and Influenza Vaccinations, Opioid Therapy Follow-Up, HPV Vaccinations, and Chlamydia Screening.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and has review flag. Reporting reviewer comments: \"I am not sure this is the best CA title since tthere is not much work done fo DSoH.\" I agree that this doesn't seem related to DSoH. Asking provider to clarify or propose a new grouping/title.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Provider should clarify how this core activity relates to social determinants of health. Secondary Driver 1 and Secondary Driver 1: Change Idea 1 do not seem like they would fit under this title. Provider should [1] include secondary driver(s) and associated change ideas that reflect the core activity's connection to social determinants of health, or [2] propose another title from the core activity menu that is a better fit. Please enter response in the \"Provider Response\" column.","This provider would like to request (if possible) to DISCONTINUE  and remove this Core Activity.  With the abundance of other core activies from this provider, is this a possibility?  The reason for this discontinuance (as HHSC has noted) is that the Drivers and Change Ideas were never fully developed and overlapped other existing drivers and change ideas.  This provider still has an abundance of core activities that address the same metrics in this core activity.","AQ","Provider requested to remove this core activity as it wasn't fully developed and overlaps other core activities. This seems fine.","Y","NB","Accepting the deletion","Accepted","HHSC accepted provider’s deletion of the Core Activity for DY9-10.","Implementation of interventions focusing on social determinants of health that can lead to improvement in well-being of an individual.","CA-7","CA-7.8"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",583,"Palliative Care","","Delete","","Other","Utilize Services assisting individuals with dyspnea screening.","Utilize Services assisting individuals with dyspnea screening","Continuous education on signs and symptoms of dyspnea.","Establish 24/7 multidisciplinary palliative care teams as needed for emergencies, concerns or questions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This core activity will positively affect the outcomes for Palliative Care, specifically in Dyspnea Screening.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and has a review flag for \"other\" title. Would recommend combining three of these \"other\" core activities into one: Utilize services assisting individuals with bowel regime, Utilize Services assisting individuals with dyspnea screening, and Utilize Services assisting individuals with dyspnea. Not sure if they would fit under menu title (e.g., Provision of coordinated palliative care to address patients with end‐of‐life decisions and care needs, Utilization of services assisting individuals with pain management) or if there is a general \"other\" title we could use (e.g., Identify services and educate patients and/or caregivers about care needs). Updated to \"Delete\"","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has combined three \"other\" core activities (\"Utilize services assisting individuals with bowel regime\", \"Utilize Services assisting individuals with dyspnea screening\", and \"Utilize Services assisting individuals with dyspnea\") into one core activity. HHSC has deleted this core activity. Secondary Driver 1: Change Idea 1 has been added as Secondary Driver 2: Change Idea 1 and the \"Description of Measure Bundle/Measure Impact\" field has been updated to reflect the combined core activities. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change.","This provider has accepted the changes made by HHSC for this Core Activity and associated drivers.","AQ","Provider agrees with combined core activities. This core activity has been deleted.","N",null,null,"Accepted","HHSC accepted provider’s deletion of the Core Activity for DY9-10.","Other","CA-12","CA-12.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",585,"Behavioral Health Crisis Stabilization Services","","Edit","","Provision of crisis stabilization services based on the best practices","","This core activity will establish a multi-modal approach in UMC’s Primary Care Clinics to assess and address substance use disorder and other related conditions.  This will be a joint effort between a community behavioral health network and UMC’s clinic.","Coordinate with Emergence Health Network to create crisis stabilization services","Implement  a workflow in the Primary Care Setting to stabilize patients identified by the EHN Team utilizing Critical Time Intervention Techniques through automated/integrated EMR Forms."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"H3","This core activitiy will positively affect the outcomes for Chronic Non-malignant pain management, specifically, screening for clinical depression (with follow-up) and evaluation for the risk of misuse of opioids.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and has review flag. Reporting reviewer comments: \"I think it can be combned with the CA 584 because the CA description is the same. Or the description should be adjusted.\" Secondary drivers and associated change ideas seem fine. Core Activity Description is the same for all Behavioral Health Crisis Stabilization Services core activities - NMI for custom description.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","Provider should revise Description of Core Activity to be specific to this core activity and differentiate between the core activities under Behavioral Health Crisis Stabilization Services. Revised description should be entered into the \"Provider Response\" column.","Please revise the Description of this Core Activity to read:\n“This core activity will establish a multi-modal approach in UMC’s Primary Care Clinics to assess and address substance use disorder and other related conditions.  This will be a joint effort between a community behavioral health network and UMC’s clinic.”\n\n","AQ","Provider revised Core Activity Description. Tracker has been updated.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider's responses, specifically the Description of the Core Activity.","Provision of crisis stabilization services based on the best practices (e.g., Critical Time Intervention, Critical Intervention Team, START model).","CA-11","CA-11.1"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",586,"Palliative Care","","Delete","","Other","Utilize Services assisting individuals with dyspnea.","This core activity will provide palliative and hospice care services to patients and their families and/or caregivers at UMC in order to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.","Develop a customized Plan of Care once root cause of Dyspnea is determined.","Create and educate a new automated Plan of Care for patients identified with Dyspnea."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This core activity will directly impact the Dyspnea Screening and Dyspnea Treatment metrics (G1-362 and 363)as the customization and automation of the plan of care will allow more efficient and effective care.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and has a review flag for \"other\" title. Would recommend combining three of these \"other\" core activities into one: Utilize services assisting individuals with bowel regime, Utilize Services assisting individuals with dyspnea screening, and Utilize Services assisting individuals with dyspnea. Not sure if they would fit under menu title (e.g., Provision of coordinated palliative care to address patients with end‐of‐life decisions and care needs, Utilization of services assisting individuals with pain management) or if there is a general \"other\" title we could use (e.g., Identify services and educate patients and/or caregivers about care needs). Updated to \"Delete\"","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has combined three \"other\" core activities (\"Utilize services assisting individuals with bowel regime\", \"Utilize Services assisting individuals with dyspnea screening\", and \"Utilize Services assisting individuals with dyspnea\") into one core activity. HHSC has deleted this core activity. Secondary Driver 1: Change Idea 1 has been added as Secondary Driver 3: Change Idea 1 and the \"Description of Measure Bundle/Measure Impact\" field has been updated to reflect the combined core activities. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change. If the provider decides to keep the core activities separated, then the provider should revise Description of Core Activity to be specific to this core activity to differentiate between the other core activities under the Palliative Care grouping.","This provider has accepted the changes made by HHSC for this Core Activity and associated drivers.","AQ","Provider agrees with combined core activities. This core activity has been deleted.","N",null,null,"Accepted","HHSC accepted provider’s deletion of the Core Activity for DY9-10.","Other","CA-12","CA-12.6"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",588,"Palliative Care","","Delete","","Other","Utilize services to assist individuals with spiritual support.","This core activity will provide palliative and hospice care services to patients and their families and/or caregivers at UMC in order to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.","Develop customized plan of care based on beliefs and values as assessed.","Automated belief and values assessment and plan of care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","This core activity will directly impact the G1-278 metric. Automating this process will allow more efficient assessment of Beliefs and Values.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and had review flag for \"Other\" title. Combine with core activity 576 that has the title \"Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.\" Secondary driver and associated change ideas, and Description of Measure Bundle/Measure Impact has been added to the other core activity.","Y","NB","Accepting 1st reviewer recommendations. ","Needs More Information","HHSC has combined two core activities that focus on end-of-life decisions and care needs into one core activity. HHSC has deleted this core activity. HHSC has added Secondary Driver 2 and Secondary Driver 2: Change Idea 1, as well as updated the \"Description of Measure Bundle/Measure Impact\" to the other core activity. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change. If the provider decides to keep the core activities separated, then the provider should revise \"Description of Core Activity\" to be specific to this core activity to differentiate between the other core activities under the Palliative Care grouping.","This provider has accepted the changes made by HHSC for this Core Activity and associated drivers.","AQ","Provider agrees with combined core activities. This core activity has been deleted.","N",null,null,"Accepted","HHSC accepted provider’s deletion of the Core Activity for DY9-10.","Other","CA-12","CA-12.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_138951211","138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public",589,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","This core activity will develop and implement chronic disease management interventions for UMC  that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.","Identify Diabetic and Heart Disease patients and perform outreach","Automated Telephony targeting Diabetes and Heart Disease Patients"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","This core activity will positively affect the outcomes for Chronic Disease Management, specifically, Diabetes Care and Heart Disease Care.","No","","138951211.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flag. Secondary drivers and associated change ideas seem fine.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_196829901","196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private",592,"Hospital Safety and Quality","","Edit","SPEMC updated Core Activity #3 to properly describe current practices. \n\nCore Activity #3: Description updated to provide additional information.\n\nSecondary Driver #1: Description unchanged.\nChange Idea #1: Description revised to better explain how Change Idea #1 assists in preventing patient hazards.\nChange Idea #2: Removed due to redundancy of purpose and intent relating to Change Idea #1.\n\nSecondary Driver #2: Description unchanged.\nChange Idea #1: Description edited to show how Change Idea #1 will maintain and improve the effectiveness of SPEMC’s infection control.\n\nImpact on Measures: Description updated to better describe the impact that Core Activity #3 will have on Bundle J1 – Hospital Safety, specifically Measures J1-218 through J1-220 (CLABSI, CAUTI, SSI) and Measure J1-221 Patient Fall Rate.","Implementation of standard protocols to address leading cause of hospital infections and injuries",null,"This core activity will focus on continuing the development of SPEMC’s DY2-6 Culturally Competent Care project to provide interventions that can lead to the improvement in well-being of an individual, such as interventions by Culturally and Linguistically Appropriate Services (CLAS) standard champions and continuous quality improvements to current processes. In DY8, the application of CLAS standards and process improvements serves to enhance the patient care experience through the application of cultural understanding by SPEMC staff and infection control through proactive processes. ","The patient's understanding of their care plan and the associated risks of care.","Continuation of Culturally Competent Care education using CLAS standards and other methods that can be applied to the prevention of patient falls and hospital acquired infections. By including content that demonstrates the use of cultural competence during care, SPEMC believes that its staff will be able to utilize this education to prevent patient hazards more effectively.",""," "," "," ","Application of Continuous Quality Improvement practices","Assessment and refinement of SPEMC’s inpatient device maintenance processes to further prevent hospital-acquired infections. Ongoing daily processes like rounding of inpatient devices, safety huddles, and reports of at-risk patients provide effective maintenance of infection control in the short term. In the long term, root-cause analyses, action plans that address findings of the analyses and monthly meetings of the Hospital Acquired Infection (HAI) Committee serve to assess and improve SPEMC’s infection control processes moving forward. "," "," "," "," ",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","Core Activity #3 positively impacts SPEMC’s performance rate in the measures of bundle J1. Specifically, the education on base CLAS standards and their application to infection control and fall prevention assisted in decreasing the numerator inclusions of Measures J1-218 through J1-221 (CLABSI, CAUTI, SSI, Patient Fall Rate). The short term utilization and long term assessment/refinement of SPEMC infection control processes significantly prevent the addition of numerator inclusions for Measures J1-218 through J1-220 (CLABSI, CAUTI, SSI).","No","","196829901.7.1","AQ","Provider edited core activity during October DY8 reporting and had a review flag for \"Other\" title. Reporting reviewer noted \"this is not prevention and wellness. This is hospital safetly.\" Looks like updates are the same that were submitted for reporting. Provider's current grouping is \"Prevention and Wellness\" and has been changed to \"Hospital Safety and Quality.\" Is this okay - since providers are restricted from changing grouping - or do we need to add as a new core activity? Provider's current title is \"Other - Further development of interventions that can lead to the improvement in well-being of an individual.\" Would recommend the menu title: \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)\". Also, provider was flagged for TA during reporting review because their reporting submission was too similar to other providers in the healthcare system and not specific to the provider.","Y","NB","accepting recommendation and changed to NNI","Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity Grouping from \"Prevention and Wellness\" to \"Hospital Safety and Quality.\" HHSC has also updated the Core Activity Title from \"Further development of interventions that can lead to the improvement in well-being of an individual.\" Would recommend the menu title: \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)\" to better align with the provider’s described Core Activity. Please provide an explanation in the \"Provider Response\" column if the provider disagrees with this change or would like to make any additional changes to Secondary Drivers and their associated Change Ideas based on the change to the Core Activity Title.","SPEMC accepts HHSC’s update to the Core Activity Grouping and recommended change to the Core Activity Title. ","AQ","Provider accepts changes to Core Activity Title","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 15_DY9-10 Regional Tracker - FINAL Tracker NB.xlsb","15_291854201","291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private",593,"Hospital Safety and Quality","","Continue","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Standardization of CVC dressing kits, hand hygiene campaign and iScrub hand hygiene monitoring tool. ","Staff will follow evidence based bundles for preventive infections including Central Line Acquired Bloodstream Infections (CLABSI); Catheter Associated Urinary Tract Infections (CAUTI); and Surgical Site Infections (SSI).","Staff will wash their hands prior to entering and when leaving patient rooms.","Staff will wash their hands prior to patient care and manipulating any patient device","Staff will use preapproved kits specific to caring for each respective bundle."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"D3","Will decrease hospital acquire infections, length of stay, health care cost and improve patient outcomes/decrease patient complications.","No","","291854201.7.1","AQ","Provider did not edit core activity during October DY8 reporting and no review flags. Core Activity information seems fine.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"AQ","No changes","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_084859002","084859002.7.1",16,"084859002","Heart of Texas Region MH & MR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",607,"Access to Primary Care Services","","Edit","","Integrated physical and behavioral health care services","","The Center will identify individuals within the system definition and will work to engage them in the integrated health clinic. The individuals will be able to access physical health and behavioral health services in one location. Physicians in both disciplines will work together to provide holistic care and will communicate with each other to provide higher quality care. Wellness screenings and targeted interventions will be available including smoking cessation, healthy meal preparation, excercize opportunities, group and individual counseling related to health conditions, nursing supports and information and referral.","Screening patients. Individuals will be screened regarding a variety of physical and behavioral health issues. Once issues are identified counseling will be provided and interventions offered. Both individual and group alternatives will be offered.","Conduct BMI screenings where we consult with those that are out of range and we discuss the benefits of exercising and we provide referrals to our In Shape program where they get one on one help. We also can refer to a dietary food group where they learn cooking tips for healthy meals at home with the Choose My Plate program.  ","Consumers with high blood pressure are referred to the previously mentioned In Shape program as well as consultation concerning the Dash Diet program to assist with healthy eating. We also provide referrals to their Primary Care Physician for continued follow-up. ","Provide annual labs where individuals with high cholesterol are given dietary and exercising tips. ","PHQ 9 depression screenings are done to identify those that may need counseling services along with referrals for medications that may be needed. ","Each client receives a tobacco usage assessment along with consultation on how smoking affects the consumers’ health. Identified clients use tobacco cessation program that can assist with helping them to quit. ",null,null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-105; M1-147; M1-257; M1-259; M1-160; M1-319","In M1-103 identifying individuals with hypertension and actively engaging them in treatment to control their blood pressure has a direct correlation to overall health. In M1-105 providing tobacco use screenings and offering preventative care and treatment alternatives also highly correlates to long term health issues. In M1-147 screening for BMI and offering treatment options to lower weight is again directly related to an individual's overall health. In M1 -257 identifying and treating both behavioral health and substance use disorders can significantly impact overall health. In M1-259 identifying and coordinating care between primary care providers and behavioral health providers has significant long-term health benefits.  In M1-160, follow up after hospitalization is less directly related to the core activity, but does tie into a person's integrated care. When untreated behavioral health issues can significantly impact a person's general health including their ability to comply with treatment for physical health issues. Finally, M1-319 similarly ties into the individual's state of mind and how that impacts all aspects of their health care treatment.","No","","084859002.7.1","LH","Change idea is not clear on what is being done so asking for more specificity","Y","NB","In agreement","Needs More Information","For Secondary Driver 1, Change Idea 1, provider indicated broad use of preventative and proactive alternatives for general wellness. Based on provider's DY7-8 experience, please indicate updates to the Change Idea language for specific alternatives or other interventions used in the \"Provider Response\" column. ","Each client receives a tobacco usage assessment along with consultation on how smoking affects the consumers’ health. We have a tobacco cessation program that can assist with helping them to quit. We do BMI screenings where we consult with those that are out of range and we discuss the benefits of exercising and we provide referrals to our In Shape program where they get one on one help. We also can refer to a dietary food group where they learn cooking tips for healthy meals at home with the Choose My Plate program. All consumers’ are screened for high blood pressure. Consumers with high blood pressure are referred to the previously mentioned In Shape program as well as consultation concerning the Dash Diet program to assist with healthy eating. We also provide referrals to their Primary Care Physician for continued follow-up. We provide annual labs where individuals with high cholesterol are given dietary and exercising tips. PHQ 9 depression screenings are done as well to identify those that may need counseling services along with referrals for medications that may be needed. ","LH","Provider's response was split into 5 Change Ideas","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically used provider's response to split out into 5 Change Ideas.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_111829102","111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private",608,"Chronic Care Management","","Edit","The Performing Provider is adding a second Secondary Driver and Change Idea to the Core Activity: Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services as reported in DY8 Round 2.  The new Secondary Driver is focused on intiatives in the ambulatory care space to improve management of the heart disease population and sepcifically drive performance in the related Category C measures.","Management of targeted patient populations with high risk for developing complications","","Management of high risk patient populations by using the expertise of existing committee structures to target clinical practice variation and/or gaps in the continuum of care.","Leverage the Network CHF Readmission Project to help improve management of heart disease.","Utilize EHR functionality to standardize documentation and decrease variation in clinical practice.","Utilize the existing CHF Readmission dashboard, prevention tools, and job aides to find opportunities to improve admission rates and ED visit rates for the target population."," Reorganize the existing Heart Failure Clinic to focus on preventing ED visits and admissions through remote patient monitoring and post-visit follow up protocols."," "," "," Implement a team-based care approach in the primary care setting to support blood pressure management."," A nurse navigator will be added to the care team to provide telecounseling to identified patients to reinforce education provided in the clinic and promote adherence to evidence-based care and follow-up intervals."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","Performing Provider will introduce recommended workflow changes aimed at improving documentation, screening and follow-up, and decreasing clinical variation which will allow for a more proactive response to the needs of the target population.","No","","111829102.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_121792903","121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public",597,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Access to Primary Care services is available for this community in the three Rural Health Clinics staffed with 15 primary care providers, seven of which are MD's.  They provide access to screening and followup services using evidence based practices and methods in the outpatient setting.  Follow up services are provided in an appropriate setting which may be a primary care clinic or one of the hospital based outpatient services like Medical Nutrition Therapy when a patients fails the BMI screen for example.  When needed and outside referral will be provided for the patient.  Patient Education in an important aspect of this process.","Coordinate the visit among staff to allow time to perform screens, identify opportunities for education or follow up.","The reminder flags for screening and follow up notifications will be enabled in the Electronic Record to foster better care coordination during the patient's visit.","Access the Krane's Patient Education library within the Electronic Record to improve the patient'shealth literacy."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; B2; C1; C2","The screening activities in this bundle impact each of the measure bundles in some way.  Examples include:  A1:  The diabetes bundle by identifying patients with abnormal A1c values so intervention can occur.  B2  Screening for pneumonia immunization and providing the vaccination is likely to prevent admissions and readmissions especially for our COPD chronic care patients.   C1 this is the bundle working to provide the screens and follow up patient care throughout the system.  C2:  Cancer screens will be incorporated into clinic visits and follow up.  Early detection has the potiential to impact all the bundles and further the Triple Aim goals.","No","","121792903.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_121792903","121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public",598,"Prevention and Wellness","","Continue","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","We will be providing a stepped up screening and follow up process throughout the system.  The effort is achored by our measure bundles and achieving the outcome measures improves the heath of the community.  We are mindful of the Triple Aim and the public or population  health goals to protect the population from disease, promote health in whatever way appropriate, and prevent disease in the first place.  This will take place primarily in the three clinics with all 15 providers engaged.  Lifestyle change success requires community support.","Community leaders expressed desire to work with the health care system to improve health in the community","Establish a Community Health Coalitioin to formally develop the stategy.","Establish Community Outreach physical activity groups through our Wellness Center","Expand the Wellness Panel laboratory tests and explanations to increase health literacy.","Implement strategies the Electronic Health Record provides like notifications and flags"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; B2; C1; C2","Examples include:  A1 is impacted because Diabetes is prevalent in this community and is increasing in numbers therefore screening to identify those at risk for early intervention is important.  B2 Keeping people well through screenings and follow up care along with education will reduce inappropriate ED visits. C2  Cancer screening activities prevent disease.  Cancer was identified in our Community Health Needs Assessment as a priority for the community.  C1 Primary Care is the system component most responsible and appropriate to conduct the screenings and initiate follow up care.","No","","121792903.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_134772611","134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public",602,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Identifying the population of patients with hypertension in order to improve the appropriate documentation of blood pressure readings, compliance with statin therapy and ultimately reduce hospital admissions related to heart disease and the number of preventable emergency room visits.","Utilize health coaches to identify patients with high blood pressure at each clinic appointment regardless of the nature of the appointment (acute or routine care).","Patients will have their blood pressure checked at each appointment and the current measurement will be displayed on the comprehensive visit sheet where the provider can visualize current blood pressure measurement and address any concerns at the time of the visit.","Providers will also utilize automated alerts if blood pressure is outside normal range."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2","Chronic care management is key to the success of this measure bundle as it relates to heart disease.  Monitoring blood pressure measurements at each encounter will enable the provider to proactively engage patient in preventive care strategies to reduce risk of hypertension and improve treatment options related to heart disease.","No","","134772611.7.1","LH","I think Core Activities 601 and 602 may be combined since they both refer to health coaches and utilizing data to inform care; however, I'm not sure this is the right advice since this Core Activity only impacts A2; I'm not sure of the difference between the selected Core Activity Names,and if combining, which would be more appropriate (i.e. utlization of care management and/or chronic care management services vs. management of targeted patient populations). ","Y","NB","Accepting 1st review results","Needs More Information","It appears that this Core Activity could be combined with the first Core Activity on Chronic Care Management with both under \"Utilization of care management and/or chronic care management services, including education in chronic disease self-management\". This Core Activity would be additional Secondary Drivers and Change Ideas under one Core Activity. Please indicate in the \"Provider Response\" column if provider would like to combine these Core Activities (if yes, then what the updated \"Description of Core Activity\" would be) or if provider would like to keep these as separate Core Activities. ","Provider would like to continue as separate core activities.","LH","Provider did not want to combine","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_134772611","134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public",603,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","Improve communication between hospital and emergency room departments with patient's primary care physician in the clinic. This includes timely follow up with patients following discharge for evaluation of medications and basic health status.","Provide better education to the patient prior to discharge related to medications, diagnosis and follow-up needed.  The discharge process has been improved to include certain types of information as required by the measure specifications.","The clinic scheduling department granted access to the emergency department to schedule appointments for patients before they were discharged from the emergency department which has improved the number of patients who are seen for follow-up care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Better verbal and written communication relatd to the transition record for the patient but also improved communication strategies between providers during the hospital discharge process will impact overall patient satisfaction and compliance with physician recommendations following their hospital stay.  These changes in the discharge planning process will also increase patient compliance with follow up visit with their primary care provider.","No","","134772611.7.1","LH","Seems the Core Activity is somewhat repetitive of bundle B1 measures so asking if provider can expand, but unsure if examples are ok or duplicative of provider's other Core Activities","Y","NB","Accepting 1st review results","Needs More Information","Secondary Driver 1, Change Idea 1 appears similar to Category C Measure Bundle B1. Provider must enter in the “Provider Response” column an updated Secondary Driver and Change Idea that address how the Category C measure will be impacted rather than the elements required in the Category C measures, e.g. provider education/training will be implemented based on feedback or challenges identified; additional staff will be added in the communication process to address gaps identified; coordination will be through a newly developed health coach/care team.","Following implementation of patient communications, the emergency department notified the primary care clinic of all discharges so that they could contact patients to schedule appointments.  Once the patient was discharged, it was determined that many of the patients were either unavailable by phone or simply did not want to schedule a follow up appointment.  As a result, the clinic scheduling department granted access to the emergency department to schedule appointments for patients before they were discharged from the emergency department which has improved the number of patients who are seen for follow-up care.","LH","Updated Change Idea based on provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updated Change Idea 1. HHSC approved this Core Activity; however, HHSC may require additional details for this Core Activity during DY9 reporting (e.g. updates on additional or changed activities to improve communication).","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_134772611","134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public",605,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","We will be utilizing a health maintenance module within the EMR to identify patients who are non compliant with recommended cancer screenings and also develop a program for patients who are uninsured and unable to afford expensive diagnostic cancern screenings alternative financial assistance.","Health coaches will use the health maintenance module on a weekly basis to notify patients who are not up to date with apprropriate cancer screenings.","Health coach will pre-arrange any preventive testing that needs to occur and assist the patient with any concerns or barriers related to cost."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Many of our patients who are scheduled for preventive cancer screenings either do not follow through with scheduled appointments or do not see a primary care provider on an annual basis.  Health coaches will not only address these issues with patients at their appointments but can use the EMR and health maintenance functions to identify and contact patients who need preventive screenings but have not been seen by a primary care provider.","No","","134772611.7.1","LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_137075116","137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private",595,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","To help meet the measures in K-1 Rural Preventative Care, the performing provider will implement processes for screening services for annual and follow up care for all patients. This process will involve screening for vaccines to include influenza and pneumonia, tobacco cessation with intervention, and advance directives to include follow up with documentation and education.","Provision of screening tools and protocols that are evidenced based to be used on all patients","Identify tools and protocols for Medical Staff to approve that will used for the patient population identified and implement these in practice and trend to see if effective"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","the implementation of screening all patients utilizing the selected screening tools and protocols will help improve preventative care as described in the Rural Preventative Care bundle","No","","137075116.7.1","LH","Leaning towards acceptable although CA Description is somewhat duplicative of K1 measures; however, Change Idea goes beyond the measures and is focused on testing out different protocols and tools for screening","Y","NB","Agree","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"LH",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 16_DY9-10 Regional Tracker - FINAL Tracker.xlsb","16_140714001","140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public",600,"Expansion of Patient Care Navigation and Transition Services","","Edit","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","The rural health physicians are contacted after a patient is admitted to emergency department/inpatient as unassigned to a primary care provider to allow the patient to choose a local provider to become their PCP so that a consistent monitoring of care occurs to reduce/prevent ER visits and appropriate follow up in a lower cost setting can be established.  The CEO and lead provider in the local urgent care meets every 1-2 months to discuss and implement improvements in the monitoring of the patient and to ensure records, results,etc are being transmitted timely and appropriately.","Screen unassigned patients that are admitted to emergency room and inpatient","Run monthly reports of the admissions logs for previously unassigned patients and a post log of the PCP being selected. After running the monthly report to identify unassigned patients, the rural health physicians (and their nurses) are contacted.  An effort is made to establish contact with the unassigned patient in order to allow the patient to choose a local provider to become their PCP which would lead to a consistent monitoring of care. If an unassigned patient chooses to not select a local provider as a PCP, we document the reasons to determine whether the clinic has addressable issues concerning patient care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Having better coordination between the different levels of care increases the identification of a complete and accurate medication list, reduces the time for a decision to admit to inpatient by having a primary care provider who understands the patients medical history more detailed than a emergency physician.","No","","140714001.7.1","LH","Seems there should be another step beyond running the report","Y","NB","In agreement","Needs More Information","Provider may consider updating Secondary Driver 1, Change Idea 1 to specify what is done/what are the next steps after the monthly report is done to improve care. Please indicate in the \"Provider Response\" column any changes. ","After running the monthly report to identify unassigned patients, the rural health physicians (and their nurses) are contacted.  An effort is made to establish contact with the unassigned patient in order to allow the patient to choose a local provider to become their PCP which would lead to a consistent monitoring of care.  Having a PCP has shown to improve patient care through better compliance and preventive measures.  This reduces/prevents ER visits and provides care in a lower cost setting such as a clinic.   Also, having a PCP reduces stress when ER or hospital admits are necessary; a primary care provider understands the patient’s medical history more detailed than an emergency physician.  If an unassigned patient chooses to not select a local provider as a PCP, we document the reasons to determine whether the clinic has addressable issues concerning patient care.","LH","Updated Change Idea based on provider's response","N",null,null,"Accepted","HHSC has updated the Core Activity based on the provider's response, specifically updated Change Idea 1. ","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_020841501","020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private",612,"Hospital Safety and Quality",null,"Edit","","Implementation of evidence-based practices to improve quality of care",null,"This core activity is a multi-pronged approach that includes operational planning as well as the standardization of order sets and protocols. The focus is on key operational and quality indicators to include ED Admit to Decision times and improving the consistency of documentation and vital patient information whena  patient is transferred to our facility as well as when a patient is transferred out of our facility to a different facility.","ED surge planning is the first driver of the ED Throughput Intensive. ED surge planning is a program that is designed help Conroe assess their current state, identify gaps, anticipate barriers and mitigate challenges by developing and implementing scenario triggers and controls.","Gain buy-in and implement the ED Surge plans for Conroe Regional Medical Center's Emergency Department"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","The ED Intensive Throughput will allow the ED team to identify and anticipate barriers to care, including communication, staffing, bed availability, consistency in response and procedures that are specific and responsive to CRMC's ED needs and aspirational goals. Conroe will focus on the improvement of key ED metrics, which include the selected measures of K2 and we anticipate improvements in each measure of K2 during PY1.","No","","020841501.7.1","PP",null,"N","NB","NMI and clarification","Needs More Information","HHSC revised provider’s Core Activity Grouping by moving it from Other (Emergency Department Throughput and Quality) to Hospital Safety and Quality. \n\nHHSC also revised provider’s Core Activity title by moving it from Other (ED Throughput Intensive) to the area on the menu: Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.). If the provider disagrees with the change, please provide an explanation in the \"Provider Response\" column and indicate whether another Core Activity Grouping and area are appropriate instead of \"Other\". \n\n","HCA Houston Healthcare Conroe does not have any objections to HHSC's reclassification of its Core Activity Grouping to \"Hospital Safety and Quality\" or the Core Activity title change to \"Implementation of evidence based practices to improve quality of care\".","PP","Provider agrees with HHSC's recommendation to update the Core Activity Grouping to \"Hospital Safety and Quality\" or the Core Activity title change to \"Implementation of evidence based practices to improve quality of care\". Approved and marked for 2nd review to validate.","Y","NB","Accepted","Accepted","HHSC confirms provider's response to update the Core Activity Grouping to Hospital Safety and Quality and the Core Activity title change to Implementation of evidence based practices to improve quality of care. ","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_020860501","020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private",614,"Access to Primary Care Services","","Delete","College Station Medical Center (now known as CHI St. Joseph Health College Station Hospital), was recently acquired by CHI St. Joseph Regional Health.  With this acquisition we are working towards aligning system goals and processes.  To do this we would like to align core activities and processes in the College Station Hospital with the current CHI St. Joseph Regional Hospital.   This core activity will no longer be part of the DSRIP process due to operational barriers.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","The Med has multiple outpatient primary care clinics (Clinics) located in College Station.  The Med currently employs physicians and mid-levels to provide care in these Clinics. The Med will increase Clinic hours and the number of providers and support staff at its Clinics located in College Station.  These changes increase patients\u0092 access to primary, non-emergency care and decreases visits to the ED.","Currently, the Clinics close at 5 pm Monday through Thursday.  Beginning in January 2019, the Clinics will stay open an additional three hours a day (i.e., from 5 pm to 8 pm) on Monday and Thursday. Further, the Med plans to expand the Clinics\u0092 weekend hours.  Specifically, the Clinic will be open from 8 am - 12 pm on Saturday.  With these changes, patients will have an additional ten (10) hours a week to access care at the Clinics.","The Med will hire additional administrative and clinical staff to support the Clinic's extra hours."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","The B2 measure bundle focuses on developing strategies to provide enhanced social support and culturally competent care to connect high risk patients to primary care or medical home sites, improve patient outcomes, and divert patients needing non-urgent care to appropriate settings. The Med seeks to do this by increasing both the hours and the number of providers at its Clinics, thereby enhancing patients\u0092 access to primary, non-emergency care.  This strategy will likely reduce ED visits by treating acute and chronic ambulatory issues before they increase in severity.   The expanded hours will also allow the Med to improve patient outcomes by offering the patient education on their chronic conditions to enable the patient to better manage their medical condition at home. By expanding the Clinic hours, the Med is helping to address the lack of primary care providers and limited access to primary care services in its community, and provide more options to patients for a patient home.","No","","020860501.7.1","PP","Provider did not request any changes to this core activity during DY8 Round 2. Now, they want to delete this core activity. As per Provider's explanation, \nCollege Station Medical Center was recently acquired by CHI St. Joseph Regional Health. With this acquisition they are working towards aligning system goals and processes and for that they would like to align core activities and processes in the College Station Hospital with the current CHI St. Joseph Regional Hospital. They want to remove this core activity due to operational barriers.\n\nProvider still meets the minimum requirements for having at least one core activity for B2 measure bundle. However, they did not provide specific reason for dropping this core activity. We need to request additional information.","Y","NB","OK","Needs More Information","HHSC is seeking additional information for changes in their new setting due to acquisition by CHI St. Joseph Regional Health and how it will impact the existing core activity and its secondary driver. Please respond in the \"Provider Response\" column with the suggested changes.","Due to the acquisition of the College Station Medical Center by CHI St. Joseph Health, we are not able to verify core activity performance prior to our acquistion in the fall of 2019.  Due to the acquistion of College Station Medical Center by CHI St. Joseph Health, the Core activities are to align with CHI St. Joseph Regional to align process at both facilities and implement the same success.  Within the new core activities and edited core activities, patients are still being provided access to primary care medical homes through the local FQHC to provide viable long term health care for this MLIU demographic.  College Station Medical Center previously had several outpatient clinics according to their system definition.  Through the acquistion of College Station Medical Center to CHI St. Joseph Health College Station Hospital, the Primary Care clinics are no longer part of CHI St. Joseph Health College Station.  ","PP","Provider's has submitted additional information on why they want to delete this core activity. Provider's response is reasonable and meets minimum requirements for the Core Activities. Marked for 2nd review to double check everything.","Y","NB","OK","Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_020860501","020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private",725,"Expansion of Patient Care Navigation and Transition Services","","New","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","The navigator will provide the support and infrastructure to enhance coordination and communication between the emergency room providers, primary care providers, and specialty providers.","Navigation team will provide increased communication across the continuum for the targeted patients through phone calls, sending of pertinent patient records and information, updates within the ED EHR system, and EHR modalities.","Follow-up appointments made before discharge from emergency room which can be successfully measured by the number of PCP appointments scheduled after the ED encounter.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","Improved communication and coordination between the emergency room, primary care and specialty providers will enhance the patients overall care, eliminating care and information gaps and providing a smooth transition back to primary and specialty care for condition management, therefore preventing future emergency room visits related to chronic disease conditions.","No","","020860501.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients ","CA-6","CA-6.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_081844501","081844501.7.1",17,"081844501","Tri-County Behavioral Healthcare","Community Mental Health Center (CMHC)","Non‐State Owned Public",611,"Behavioral Health Crisis Stabilization Services","","Delete","","Implementation of community‐based crisis stabilization alternatives","","Intensive evaluation and diversion services provide a community-based alternative for crisis evaluation and diversion screenings, assessments and activities, in an effort divert individuals in a mental health crisis from emergency rooms and local jails, as well as minimize placement in inpatient psychiatric facilities.","Risk assessments at the Psychiatric Emergency Center (PETC) to determine appropriate level of care for persons presenting with a psychiatric crisis.","Continued community education to inform the PETC as the appropriate alternative to assess individuals in crisis at the least restrictive crisis evaluation site."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","This core activity is provides for crisis intervention services where our selected measures address comorbid medical conditions and risky behaviors. The Intensive Evaluation and Diversion Program as an alternative evaluation and intervention to hospital emergency rooms, jails, and hospitals. This alternative site to hospitals and jails allows the individual to receive rapid evaluation, appropriate observation, and short term intervention and treatment to address the mental health crisis. This saves expensive hospital and emergency room resources, avoid inappropriate and unnecessary incarceration in jails, and more rapidly stabilize the mental health crisis and return the individual to less restrictive and more appropriate treatment for their mental health condition.","No","","081844501.7.1","PP","Provider did not select a measure for this Core Activity (Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.) Description for this Core Activity is: Intensive evaluation and diversion services provide a community-based alternative for crisis evaluation and diversion screenings, assessments and activities, in an effort divert individuals in a mental health crisis from emergency rooms and local jails, as well as minimize placement in inpatient psychiatric facilities. \nI reviewed Tri-County’s measures list and none of them can be tied to this Core Activity. I recommend applying M1-387 (Reduce Emergency Department visits for Behavioral Health and Substance Abuse) measure for this Core Activity. ","Y","NB","accepting 1s review results.","Needs More Information","HHSC recommends to add M1-387 (Reduce Emergency Department visits for Behavioral Health and Substance Abuse) measure for this Core Activity since this activity has not been tied to any mental health measures. Please respond in the \"Provider Response\" column.","Provider has decided to delete this core activity and not report on it in DY9-10. Per Texas DSRIP Measure Bundle Protocol DY 7-10 (7/31/19, pg. 5), \"In addition to reporting on Core Activities supporting Category C measures, a Performing Provider may include a Core Activity tied to the mission of the Performing Provider’s organization, even if the activity does not have a strong connection to the selected measures. Selection of a Core Activity not tied to the Measure Bundles or measures cannot be the only selection but can be chosen as an additional Core Activity that the Performing Provider is reporting\".  After reviewing HHSCs recommendation, we have concluded that we can not add the suggested measure as we would not have access to the ER data needed to achieve performance for this measure. In addition, this measure cannot be linked to nor is it material to the outcome measures we are reporting on under DSRIP.  Therefore, after review, we choose to delete this core activity for reporting purposes. We believe this will be allowed under the same Protocol document (pg 8). \"If a Performing Provider has more than one Core Activity in the initial selection, and the Performing Provider needs to delete one of these activities due to the changes, then the Performing Provider is not required to choose a replacement activity to report on.\"","PP","Provider requested to delete this core activity. I have updated the status to \"delete\" since the reqest is reasonable and meets Measure Bundle Protocol requirements. Marked for 2nd review to double check everything. ","Y","NB","2/25 followed up with the provider\n\n2/26 proivder response: Good morning,\n\nAt this time, we would like to proceed with the deletion of this Core Activity.\n\nThank you,\n","Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Implementation of community-based crisis stabilization alternatives that meet the behavioral health needs of the patients.","CA-11","CA-11.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_127267603","127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private",615,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","A team staffed at the ER will provide clinical and social services to patients who are frequent visitors to the ED.  The team will help navigate the patients to the appropriate level of care including urgent or express clinics, specialists, and primary care providers.","Create navigation team - RN Care Coordinator, Care Coordinator Associate, Social Worker","Implement navigation team in the emergency room to enhance coordination with ED staff members and increase patient enrollment by meeting the patient bedside.  This activity will be measured by the number of encounters the navigation team meets eligible patients bedside to enroll them in the navigation program.","Implement navigation team to provide care coordination after discharge from ED which will be measured by the number of enrollments in the navigation program and the number of primary care follow-up appointments made after discharge.",""," "," ","Define targeted population to enroll in the care navigation team program","Create standard criteria for eligible enrollment in navigation program determined by risk stratification based on complex conditions, social barriers, and the number of ED encounters per patient.  This will be measured by the number of enrolled patients by risk stratified level.","MLIU population who present to the emergency room for an acute or chronic ACSC  (deleted October 2018)","Define patient participation expectations for enrollment in program which include proper utilization of healthcare resources, consistent communication with the navigation team, and establishment with a primary care provider.  This can be measured by the number of completed primary care appointments, patients that completed the program, and patients dismissed from the program due to non-compliance of the enrollment expectations.",""," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","The core activity of building a navigation team will help reduce emergency room utilization by providing services to the selected targeted populations focusing on reducing chronic and acute ACSC visits to the emergency room. This will occur by providing the patients with proper ED use education and navigating the patients to a medical home to assist with preventing ED encounters that can be provided in the outpatient setting.","No","","127267603.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_127267603","127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private",617,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","Use population health analytic software to assist the navigator program in identification of target population of frequent ED users. Develop processes using real-time data and patient assessment to identify eligible patients to enroll in navigation program and to connect the patients to primary and preventive care.","Real-time identification of patients for navigator program by flagging patients with previous ACSC conditions","Align real-time analytics regarding identified patient population with DSRIP navigation program.  This will be measured by the number of care pathways opened within the software.","Create defined target population to be enrolled in program for navigation through risk stratification and ED utilization history.  This will be measured by how many patients are outreached from the defined population.","Utilize population health analytic software to identify patients for navigation program by flagging defined target patients within the population analytic software.  This will be successful through real time alerts of patients in the ED. This will be measured by the number of outreaches that occur bedside."," "," ","Utilize DSRIP navigation program to connect the patients to primary, preventive, express, and specialty care covering expense of those visits for the patient.  ","Align ED navigators to establish enhanced utilization of primary and preventive care services for patients by covering expenses of the visits for patients.  This is measured by the number of financial assistance given to patients to cover cost of appointments and healthcare needs that are completed in the outpatient setting."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","By using real-time data, assessments, and being able to cover costs for patients the navigation program will be able to help navigate patients to the appropriate level care for non-emergent needs, which will assist patients in having ACSC conditions managed and prevented in the appropriate settings.","No","","127267603.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_130982504","130982504.7.1",17,"130982504","Brazos Co Treasurer (Brazos County Health Departme","Local Health Department (LHD)","Non‐State Owned Public",618,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","One of the main services that we provide as a local health department is immunizations.  The focus of this service is to provide childhood and adult immunizations to clients that are low-income, uninsured.  Children (age 18 and younger) that receive immunizations at BCHD are either Medicaid recipients or uninsured.  Funding for this program comes from the Texas Department of State Health Services, which covers influenza immunizations for children, but not for adults.   Adults receiving immunizations at BCHD are uninsured. However, because our adult influenza immunizations are purchased each year with local funds, there is a fee for all clients to receive the vaccine even if they are low-income, uninsured.  DSRIP funds will expand our immunization program by providing free influenza immunizations to clients that are Medicaid, low-income, and/or uninsured.  Our goal is to target vulnerable populations, such as the homeless, individuals who are or who have recently been incarcerated, and those with chronic conditions.","BCHD staff will screen patients to determine immunization status.  If a client is not current on all of their adult vaccinations, those vaccines will be offered to the client during that visit.","BCHD staff will enter immunization status information for all of our STI clients into our electronic medical record system.  Our TB clients' immunization status will be documented in their paper file."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-269; L1-272","This core activity focuses on vaccinations to target populations, which aligns with the two measures we have chosen-Preventive Care & Screening: Influenza Immunization and Adults (18+years) Immunization Status.","No","","130982504.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_135226205","135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private",620,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Patients who establish care at one of the PCMH locations will receive coordinated and integrated primary care services. Through navigating patients to a PCMH, cancer screenings and other appropriate preventive services will be included as part of the care that patients receive. We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. Using social workers, navigators and other staff to also help educate patients on the importance of cancer screening will help to also increase adherence. We plan to socialize the cancer screening measures with the physicians on a regular data dashboard will also help to create reminders and encourage physicians to help remind patients to get their appropriate screenings. ","Access and convenience of screenings: improve adherence through access","We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. This can include, education through brochures and reminders through text messages and other means"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Through changing the focus of the health equation to preventive services and cancer screenings as part of a PCMH for this population, we expect to see better outcomes overall, less preventable cancer occurrences and earlier detection. Through incorporating a focused measure on cancer screening as part of the patient's care plan in the PCMH, adherance rates will increase. There will be an increased focus on these measures by the physicians and the care team to ensure patients are getting timely and appropriate screenings as part of their overall preventive care in the PCMH setting.","No","","135226205.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_136366507","136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public",621,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","Development of navigation and coordination services with primary care and substance abuse providers to expand access to care and ensure more timely and appropriate treatment","Screening of individuals for early identification of potential primary care and substance abuse needs","Hire additional medical staff to screen for primary care and substancew abuse needs","identify or create appropriate screening forms to be used during screening","Train staff on use screening forms and clinic workflow"," "," ","Provide education and/or referral to individuals for primary care as needs are identified","Identify educational materials to be used to promote lifestyles changes","Identify partners for primary care referrals and develop referral process"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-317","This core activity impacts the selected measures by utilizing assessment instruments to help identify health and substance abuse issues and provide patient education, consultation and referral related to identified health issues. This will prevent future emergency department utilization for treatment of these non-emergent conditions.","No","","136366507.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_136366507","136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public",622,"Behavioral Health Crisis Stabilization Services","","Edit","Provider clarified language on first change idea in ii.A to clarify that a risk assessment would be done on all who might be exihibiting high risk behavior and added 2nd change idea to clarify that a risk assessment would be done when a person is first diagnosed with major depression.","Implement models supporting recovery of individuals with behavioral health needs","","Implementation of a comprehensive suicide safe care system that will focus on suicide  prevention by utilizing evidence based screening tools to proactively assess for, and identify individuals who might be at elevated risk for suicide or a crisis episode, and providing them with the appropriate follow-up care and support.","Train staff on suicide safe care utilizing best practice models","Develop protocol for a mandatory course, with regular refreshers, for all staff on suicide care and prevention."," "," "," "," ","Develop process and protocol for screening and assessing individuals who may be at an elevated risk for suicide","Provide suicide risk screening and assessment of individuals during routine care visits who might be exhibiting signs suicide risk.","Provide suicide risk screening on individuals during first diagnosis of major depression."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-319","The core activity implements a model for recovery of individuals with behavioral health needs. The model/activity impacts the measure of assessment of risk to self or others by using an evidenced based model to routinely assess for suicide risk to reduce risk of future crises.","No","","136366507.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implement models supporting recovery of individuals with behavioral health needs","CA-11","CA-11.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_160630301","160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private",623,"Expansion of Patient Care Navigation and Transition Services","","Edit","Facilitate compatible electronic access to the patient's health record, Evaluate electronic health record vendors, supporting stakeholders in collaborative product selection were completed in DY7 & DY8. Removed additional Core Activities (originally #3, #4, & #5) - Expansion of Patient Care Navigation and Transition Services as the goals are the same as this Core Activity. The primary, secondary drivers and change ideas that were implemented under Core Activity #3, #4, & #5 have been added to this Core Activity. The name of Core Activity #1 has been changed to align more closely with the added primary and secondary drivers and change ideas from previous Core Activities.","Implementation of a care transition and/or a discharge planning program","","CHI St. Luke's Health - The Woodlands Hospital (SLWH) will create a multidisciplinary committee of primary and specialty care physicians and a care transition and/or a discharge planning program and post discharge support program. This includes the development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","Create a Transitions in Care Team for cross-continuum patient care management","Patient Rounding and Handoff that is safe, consistent, thorough, and effectively communicated.\nSLWH has implemented multidisciplinary rounds (MDR) including: nursing, hospitalist, case management, therapies, pharmacy, clinical documentation specialists. During MDR, the team identifies barriers to discharge and the discharge plan. When patients utilize the preferred provider network, electronic handoff is automated and standardized. Currently, when a follow up provider is delegated in the EHR, handoff is completed electronically. Going forward, SLWH hopes to further standardize the content and delivery of Patient Handoff to be used consistently across all facilities. ","Medication reconciliation upon admission and discharge that is safe, consistent, thorough, and effectively communicated. \nReview all admission and discharge medication reconciliation components from each agencies' electronic and/or paper record to identify variances to facilitate an accurate, complete, consistent reconciliation process.  \n","Post-Discharge Phone Support\nContract Nurses make post discharge phone calls, utilizing a risk score to triage breadth and depth of intervention needs.  The team consists of three bilingual RNs and one licensed Social Worker. Patients are called up to four times and are provided support, education, medication reconciliation, and physician appointments.  Patient-specific needs and resource allocation are identified and addressed. In addition, patients are referred to MCHD and TCC as appropriate. \n","Collaboration with Montgomery County Hospital District (MCHD \nSLWH collaborates with Montgomery County Hospital District (MCHD) and refers patients at high risk for readmission for paramedic home visits.  Paramedics provide \"boots on the ground\" services like assisting in medication reconciliation, helping complete complex paper work, obtaining medical equipment, and administering medications under physician orders. The MCHD Paramedic Home Visit Program uses the SLWH Zone Tools for patient education."," Appropriate Palliation\nSLWH’s Palliative Care Team plans to host End of Life Care education for facilities/agencies to attend.  This will consist of topics related to End of Life Care, such as correctly identifying patients appropriate for End of Life Care, approaching the patient/family/physician, and how care for these patients differs from patients with routine care, just to name a few. The Palliative Care team has joined the collaborative group that reports up to the Quality of Care Committee.  The Palliative Care team uses the SLWH Zone Tools for patient education.","Case Management Risk Assessment, Readmission Risk Assessment and Intervention, and Patient Education","Case Management Readmission Assessment\nCase Managers interview patients who are readmitted to learn the reasons for readmission then strategize to mitigate the barriers to care at home.  Resources such as TCC and MCHD are accessed, as needed and as appropriate.","Case Management Readmission Risk Assessment and Intervention \nCase Managers identify patients at high risk for readmission and make appointments for patients prior to discharge. Patients with high LACE scores and noted to be in the MLIU patient population are referred to the transitional care clinic by nursing, case management, or physician referral.   ","Patient Disease Specific Education  \nStaff nurses, TCC population health coach, and post-discharge nurses provide patients with disease specific education and triaged interventions using disease specific Zone Tools."," "," ","Create a Transitional Care Clinic and Post-Acute Care Program  \nThe Transitional Care Clinic allows the hospital to implement improvements in care transitions and coordination of care by providing post discharge appointments and assessments to high-risk patients with multiple needs.  Priority is given to the MLIU patient population.","Transitional Care Clinic\nThe Transitional Care clinic (TCC) ensures: \n1. Patient appointments are made prior to discharge occurring within seven days of discharge\n2. Medication reconciliation during and immediately post discharge\n3. Barriers to medication compliance are addressed\n4. Continued follow up appointments with specialists and primary care physicians are scheduled\n5. Additional patient needs are identified and Community resources are provided\n6. Hand-off to primary care and specialty physicians is completed"," Change Idea - Implement a Post-Acute Preferred Provider Network\nSLWH, along with its parent company CHI Texas Division, has established a comprehensive process for an integrated Preferred Provider Network (PPN) program. SLWH has created a rigorous credentialing process that includes quality, cost, and efficiency measures.  There are two tiers in the PPN for Home Health and SNF.  There is a third tier that represents geographically located post-acute providers that are frequently utilized by patients who are not participants in the PPN but who participate in Performance Improvement activities in collaboration with SLWH. In order to create an environment that enables quality improvement, the PPN providers participate in an accountability process that consists of quarterly, bi-monthly, and weekly communication meetings with SLWH. The post-acute provider’s quality and cost outcomes are monitored utilizing scorecards. The scorecards contain publicly reported quality data from the CMS Compare database and claims data.  Each entity has a scorecard, and there is a roll-up scorecard for the PPN. \nThe goals of the PPN are multiple: \n1. Provide the right care, at the right time, in the right setting, at the highest quality\n2. Utilize evidence based protocols and share clinical best practice across the continuum\n3. Regular meetings to review quality outcomes and improve transitions\n4. Collaborate during the evaluation and hand-off process. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Patient Hand-Off, Medication Reconciliation, post-discharge phone support, collaboration with MCHD, appropriate palliation, Case Management risk assessment, intervention and readmissions assessment, disease-specific patient education, the Transitional Care Clinic (TCC), and post-acute provider network maintenance will all affect Measure Bundle B1 – Care Transitions and Hospital Readmissions directly. The above Core Activity, Primary and Secondary Drivers, and Change Ideas all directly and indirectly affect patient outcomes to meet: Measure B1-124 Medication Reconciliation Post-Discharge, B1-141 Risk-Adjusted All-Cause 30 Day Readmissions for Targeted Conditions, B1-217 Risk Adjusted All-Cause Readmissions, B1-252 Transition Record with Specified Elements Received by Discharged Patients (ED Discharges), B1-253 Transition Record with Specified Elements Received by Discharged Patients (Inpatient), B1-287 Documentation of Current Medications in the Medical Record, and B1-352 Post-Discharge Appointment.","Yes","Although the majority of the activities will be performed and/or coordinated by providers within the SLWH System Definition, not ALL of the activities will be performed by providers within the System Definition. Some of the post-acute care services will be coordinated by providers within the SLWH System but will officially be provided by contracted entities outside of the SLWH System Definition. As these contracted entities have multiple other patient populations of which SLWH has no executive leadership, control, or ownership/partial ownership and has no data sharing nor rationale for data sharing over the patient populations outside of the SLWH Total PPP, these entities are not included in the SLWH System Definition.","160630301.7.1","PP","Provider has edited the Core Activity 623 and selected “Delete” for Core activities from 625-627.  The primary, secondary drivers and change ideas that were implemented under these core activities have been added to CA 623. And the name of this CA has been changed to align more closely with the added primary and secondary drivers and change ideas from previous Core Activities. These activities have been tied to B1 measure bundle.  Providers states the following: Facilitate compatible electronic access to the patient's health record, evaluate electronic health record vendors, supporting stakeholders in collaborative product selection were completed in DY7 & DY8. Removed additional Core Activities (originally #3, #4, & #5) - Expansion of Patient Care Navigation and Transition Services as the goals are the same as this Core Activity.   Everything looks okay and accepted provider’s selection. I have flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_160630301","160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private",624,"Access to Primary Care Services","","Delete","Provision of services to newborns with no access to primary care services due to no longer affected DSRIP outcomes. This measure is being continued outside of DSRIP.","Other","Provision of services to newborns with no access to primary care services","The Bridge Care Clinic was a previous project in DY2-6 and will be continued.  The Bridge Clinic provides quality care for babies in their first month of life while guiding parents through the process of obtaining medical insurance and choosing a Primary Care Provider for their child.The Bridge clinic, as its name describes, helps to bridge the gap between delivery and outpatient pediatric care for both the mother and child, and is available for all babies, regardless of insurance.","Access to a permanent primary care provider for continued well baby exams and treatments.","Clinic physician secures permanent primary care provider through referral to specific collaborating physicians."," "," "," "," ","Access to medical insurance for newborns born to mothers with limited or no financial resources.","Clinic physician and staff guide the mother/parents of the newborn through the process of obtaining medical insurance (specifically Medicaid)."," "," "," "," ","Access to temporary primary care provider and clinic services for first month of newborn's life.","The Bridge Clinic address conditions that left untreated could have fatal consequences.   Screening for jaundice, heart murmurs, & post partum depression and monitoring for adequate growth and development are all part of the routine visits provided.","Provide outpatient phototherapy through the use of a \"bilirubin blanket\" to reduce bilirubin levels for newborns with hyperbilirubinemia."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"None","The American Academy of Pediatrics recommends follow up within 3 to 5 days for most routine deliveries, and as soon as 24 hours for babies that are discharged early or with medical concerns. Despite this recommendation, many families are not able to immediately connect with a Pediatrician after their baby is discharged from the hospital. Applying for a childs Medicaid card can take several weeks, and it is extremely challenging to find a physician who will accept a new patient without established insurance.  Lacking medical care, babies are at risk of becoming ill and ending up in emergency rooms or readmitted to the hospital.  The longer a baby goes without establishing care, the greater this risk that they will seek an often more costly higher level of care for issues that are better addressed in a primary care setting. This core activity does help reduce hospital readmissions but it doesn't effect either the B1-141 or B1-217 measures because those are for patients 18 years of age and older.  Measures B1-124, B1-287 are also for patients 18 years of age and older but are done.  The last measure, B1-352 is for heart failure patients only and the clinic doesn't care for those newborns.","No","","160630301.7.1","PP","Per Provider's explanation: Provision of services to newborns with no access to primary care services due to no longer affected DSRIP outcomes. This measure is being continued outside of DSRIP. Provider wants to remove this CA - the information looks okay and I have accepted provider's selection. However, I have flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","OK","Accepted","Provider's deletion of this Core Activity is accepted. ",null,null,null,"N",null,null,"Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Other","CA-1","CA-1.10"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_160630301","160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private",625,"Expansion of Patient Care Navigation and Transition Services","","Delete","Removed Expansion of Patient Care Navigation and Transition Services as it is the same as Core Activity #1. These primary, secondary drivers and change ideas were implemented under Core Activity #1.","Utilization of a comprehensive intervention to address the needs of high‐risk patients","","The creation of a Transition Care Clinic will allow the hospital to implement improvements in care transitions and coordination of care by providing care to high-risk patients with multiple needs.  Priority will be given to patients with Medicaid or who are unfunded.  It will be run by either a medical group physican or advanced practive nurse practitioner that will be rotated out on a routine basis and will be open 7 days a week.","Create a Transition of Care Clinic to implement improvements in care transitions and coordination of care for any patient identified as high risk.  Priority will be given to those patients who have Medicaid and are unfunded.  It will be run by either a medical group physician or nurse practitioner that will be rotated out on a routine basis.","Patient identified in hospital through LACE scores and the 8P Screening Tool to be high-risk and Payor method as Medicaid or unfunded and elevated to clinic by nursing staff and/or physician referral.  Other payors will be referred as appointments are available.","Patient appointment made and given when patient is still inpatient and will occur within 72 hours after discharge.","Medication reconciliation from discharge medication list completed and identify compliance barriers for medication compliance.","Assist in scheduling follow up appointments with specialist and primary care physicians and identifying community resources.","Fax labs, tests results, and discharge summary to primary care and specialty physicians."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Creating a Transitions of Care clinic is the comprehensive, multidisciplinary intervention we have never had but needed to be able to make a bigger impact on our high-risk MLIU patient population.  This will directly impact care transitions within the system, specifically measures B1-217, Risk Adjusted All-Cause Readmissions; B1-141 Risk-Adjusted All-Cause 30 Day Readmissions for Targeted Conditions; B1-124, Medication Reconciliation Post-Discharge; and B1-352, Post-Discharge Appointment which will be addressed at the appointment.  Improved care transitions have a direct positive correlation to decreased readmission rates.","No","","160630301.7.1","PP","Provider has edited the Core Activity 623 and selected “Delete” for Core activities from 625-627.  The primary, secondary drivers and change ideas that were implemented under these core activities have been added to CA 623. And the name of this CA has been changed to align more closely with the added primary and secondary drivers and change ideas from previous Core Activities. These activities have been tied to B1 measure bundle.  Providers states the following: Facilitate compatible electronic access to the patient's health record, evaluate electronic health record vendors, supporting stakeholders in collaborative product selection were completed in DY7 & DY8. Removed additional Core Activities (originally #3, #4, & #5) - Expansion of Patient Care Navigation and Transition Services as the goals are the same as this Core Activity.   Everything looks okay and accepted provider’s selection. I have flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","OK","Accepted","Provider's deletion of this Core Activity is accepted. ",null,null,null,"N",null,null,"Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Utilization of a comprehensive, multidisciplinary intervention to address the needs of high-risk patients.","CA-6","CA-6.5"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_160630301","160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private",626,"Chronic Care Management","","Delete","The resources for this activity were adjusted according to directives from Common Spirit (National) and CHI Texas Division directives.   Teams were directed to focus efforts on deployment of a Readmissions Play Book handed down from Common Spirit (National Corporate). Thus, this Core Activity has been removed and aligned with Core Activity #1. ","Utilization of care management and/or chronic care management services","","DY2-6 Project:  Project RED Program will be continued as a core activity but will no longer be the sole responsibility of our Population Health Coach as she is taking on the role of RN Project Coordinator, managing the DSRIP grant and all of its core activities.  Project RED components will be decentralized to frontline staff and still remain the sole responsibility of the discharge phone call nurses as before.","Increased access to community and financial resources for any patients that are high-risk with multiple needs.","Hire a Licensed, Master's prepared Social Worker to help provide community and financial resources.  Referrals from nurses performing discharge phone calls.","Hire additional nurses (1 nonbilingual and 1 bilingual) to handle increased workload of patients and to be able to screen patients for referrals to Social Worker."," "," "," ","Education regardless of diagnosis to high-risk patients with chronic diseases.","Education regarding specific chronic disease and when to notify the doctor through the use of Disease Specific Zone Tools by staff nurses at discharge.This was previously done by our Population Health Coach alone.","Continue evidence-based classes for Diabetes Self-Management, Chronic Disease Self-Management, and A Matter of Balance: Fall Prevention.  Add additional Chronic Pain self-Management and Tai Chi for Arthritis classes to be taught by volunteers from the hospital staff and/or community that have been trained. Our Population Health Coach was also one of the trained leaders to teach these classes.","Continue post-discharge phone call education to patients as before but now not diagnosis focused but to be given to all patients with chronic diseases.  Disease Specific Zone Tools to be used for education."," "," ","Redefine screening tools used to identify hish-risk patients with chronic conditions and multiple needs since LACE score alone hasn't been a good indicator for this.","Combine Lace score and The 8P screening tool to identify patients who are hish-risk with chronic conditions and multiple needs upon admission to receive educational services and care at the Transitional Care Clinic."," "," "," "," ","Increase access to primary and specialty care providers","RN Program Coordinator, frontline nursing staff, and discharge phone call nurses to secure primary and specialty care providers  and make all follow up appointments for MLIU high risk patients with multiple needs."," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","Bundle measure B1-124, Medication Reconciliation Post-Discharge is already being done by our discharge phone call nurses.  Chronic disease education and classes increases patients' knowledge of their disease, improves self-management skills and compliance, therefore helping to reduce readmissions (B1-141, Risk-Adjusted All-Cause 30-Day Readmission for Targeted Conditions and B1-217, Risk Adjusted All-Cause 30-Day Readmission).  Frontline nursing staff will be added to assist with making follow up appointments and this will effect B1-352, Post-Discharge Appointment.","No","","160630301.7.1","PP","Provider has edited the Core Activity 623 and selected “Delete” for Core activities from 625-627.  The primary, secondary drivers and change ideas that were implemented under these core activities have been added to CA 623. And the name of this CA has been changed to align more closely with the added primary and secondary drivers and change ideas from previous Core Activities. These activities have been tied to B1 measure bundle.  Providers states the following: Facilitate compatible electronic access to the patient's health record, evaluate electronic health record vendors, supporting stakeholders in collaborative product selection were completed in DY7 & DY8. Removed additional Core Activities (originally #3, #4, & #5) - Expansion of Patient Care Navigation and Transition Services as the goals are the same as this Core Activity.   Everything looks okay and accepted provider’s selection. I have flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","OK","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Utilization of care management and/or chronic care management services, including education in chronic disease self-management","CA-8","CA-8.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_160630301","160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private",627,"Expansion of Patient Care Navigation and Transition Services","","Delete","Removed Expansion of Patient Care Navigation and Transition Services as it is the same as Core Activity #1. These primary, secondary drivers and change ideas were implemented under Core Activity #1. ","Implementation of a care transition and/or a discharge planning program",null,"CHI St. Luke's Health - The Woodlands Hospital will create a interfacility committee of representatives from various rehabs, skilled nursing facilities, home health and private caregivers agencies and assisted living facilities in our region to discuss, plan and implement activities to safely and effectively enhance patient care transitions so that the patient is never discharged from the health system.","Enhance End of Life Care for patients that qualify and are appropriate","CHI St. Luke's Health - The Woodlands Hospital's Palliative Care Team will host an End of Life Care summit for facilities/agencies to attend.  This will consist of educational topics related to End of Life Care, such as correctly identifying patients appropriate for End of Life Care, approaching the patient/family/physician, and how care for these patients differs from patients with routine care just to name a few."," "," "," "," ","Increase access to primary and specialty care providers post-discharge from facilities/agencies.","Coordinate effective interventions to address identified barriers to securing access to primary and secondary care providers for MLIU patients who are high risk and with multiple needs."," "," "," "," ","Patient Handoff that is safe, consistent, thorough, and effectively communicated.","Organize and implement a Rapid Improvement Event to standardiaze Patient Handoff."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","This interfacility committee and their core activities related to access to primary and secondary providers and standardizing Patient Handoff will have a direct effect on bundle measures B1-252, Care Transition:  Transition Record with Specified Elements Received by Discharged Patients and B1-352, Post-Discharge Appointments.  The End of Life Care summit  will indirectly effect B1-141, Risk-Adjusted All-Cause 30-Day Readmission for Targeted Conditions and B1-217, Risk-Adjusted All-Cause 30-Day Readmission.","No","","160630301.7.1","PP","Provider has edited the Core Activity 623 and selected “Delete” for Core activities from 625-627.  The primary, secondary drivers and change ideas that were implemented under these core activities have been added to CA 623. And the name of this CA has been changed to align more closely with the added primary and secondary drivers and change ideas from previous Core Activities. These activities have been tied to B1 measure bundle.  Providers states the following: Facilitate compatible electronic access to the patient's health record, evaluate electronic health record vendors, supporting stakeholders in collaborative product selection were completed in DY7 & DY8. Removed additional Core Activities (originally #3, #4, & #5) - Expansion of Patient Care Navigation and Transition Services as the goals are the same as this Core Activity.   Everything looks okay and accepted provider’s selection. I have flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","updated language.","Accepted","Provider's deletion of this Core Activity is accepted. ",null,null,null,"N",null,null,"Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_189791001","189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private",628,"Hospital Safety and Quality","","Edit","Huntsville Memorial Hospital (HMH) made changes to Change Idea #1, Change Idea #2, and Change Idea #3 for the first Secondary Driver. Change Idea #1 originally read: “Secret shoppers will be utilized to determine if hospital/clinic staff are using the appropriate hand sanitizing method.” HMH would like to edit this statement to read: “Observers will be utilized to determine if hospital/clinic staff are using the appropriate hand sanitizing method.” HMH recently redesigned the hand hygiene program associated with Core Activity #1 to address reoccurring hand hygiene challenges. Through this hand hygiene program redesign, HMH will be utilizing observers rather than secret shoppers. Change Idea #2 orginally read: \"Increate the number of hand sanitizer/dispensor stations throughout the hospital including non-clinical areas.\" During DY7, HMH completed Change Idea #2 by upgrading and adding sanitizer stations throughout the hospital in both clinical and nonclinical areas. Change Idea #2 has been completed and removed from the list of change ideas because at this time, HMH does not plan to coninue to increase the number of hand sanitizer stations in the hospital. HMH removed Change Idea #2 from the list of Change Ideas. HMH moved Change Idea #3 (\"Increase visitor signage regarding location of hand sanitizer stations\") to Change Idea #2. HMH then added a new Change Idea #3: \"Create a rewards program for hospital staff using the appropriate hand santizing method.\" Change Idea #3 will further incentivize hospital staff to use the appropriate hand sanitizing method. In addition, HMH added Change Idea #2 for the second Secondary Driver: \"Redesign isolation signagage regarding isolation types in patient rooms.\" Change Idea #2 will further help prevent the spread of infections.  ","Implementation of evidence-based practices to improve quality of care","","Huntsville Memorial Hospital will work to reduce the hospital's rate of infections for SSIs, CAUTIs, CLABSIs, and Post-Operative Sepsis by implementing improvements in our hand-hygiene program and increasing staff knowledge/education regarding infection prevention.","HMH will train/educate staff on appropriate times to use hand sanitizer gel versus hand washing.","Observers will be utilized to determine if hospital/clinic staff are using the appropriate hand sanitizing method.","Increase visitor signage regarding location of hand sanitizer stations.","Create a rewards program for hospital staff using the appropriate hand sanitizing method.",""," ","Increase staff knowledge & education regarding ways to prevent the spread of infection.","Educate and test employees on the importance of proper hand hygiene (testing required annually).","Redesign isolation signagage regarding isolation types in patient rooms. "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1; E2","Hand hygiene is critical to the safety of our patients, staff, and visitors because it is an important tool in preventing the spread of healthcare-associated infections. Implementing improvements in the hand hygiene program and increasing staff knowledge/education regarding infection prevention will only improve our infection rates. Specifically, this core activity should improve the infection rates tracked in the J1: Hospital Safety Measure Bundle, including central line-associated bloodstream infection rates, catheter-associated urinary tract infection rates, surgical site infection rates, and post-operative sepsis infection rates. In addition, hand hygiene is critical to the E2: Maternal Safety Bundle, specifically the cesarean section rates. Improved hand hygiene should result in a reduction of surgical site infections in women who have had a cesarean section. ","No","","189791001.7.1","PP","HMH made changes to CI 1, CI 2, and CI 3 for the first Secondary Driver. Change Idea #1 originally read: “Secret shoppers will be utilized to determine if hospital/clinic staff are using the appropriate hand sanitizing method.” HMH would like to edit this statement to read: “Observers will be utilized to determine if hospital/clinic staff are using the appropriate hand sanitizing method.” HMH recently redesigned the hand hygiene program associated with Core Activity #1 to address reoccurring hand hygiene challenges. Through this hand hygiene program redesign, HMH will be utilizing observers rather than secret shoppers. Change Idea #2 originally read: \"Increate the number of hand sanitizer/dispensor stations throughout the hospital including non-clinical areas.\" During DY7, HMH completed Change Idea #2 by upgrading and adding sanitizer stations throughout the hospital in both clinical and nonclinical areas. Change Idea #2 has been completed and removed. HMH moved Change Idea #3 (\"Increase visitor signage regarding location of hand sanitizer stations\") to Change Idea #2. HMH then added a new Change Idea #3: \"Create a rewards program for hospital staff using the appropriate hand sanitizing method.\" Change Idea #3 will further incentivize hospital staff to use the appropriate hand sanitizing method. In addition, HMH added Change Idea #2 for the second Secondary Driver: \"Redesign isolation signagage regarding isolation types in patient rooms.\" Change Idea #2 will further help prevent the spread of infections.  \nAccepted this new CA, and flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","Accepted.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provider Acknowledges.","PP","no action is required.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_189791001","189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private",629,"Hospital Safety and Quality","","Edit","Huntsville Memorial Hospital (HMH) added Change Idea #3 and Change Idea #4 to the first Secondary Driver. HMH added Change Idea #3: \"Implement a Falls Management Kit to better identify patients who are fall risk.\" HMH also added Change Idea #4: \"Educate all staff about hourly rounding in the Annual Competency Skills Fair.\" Both Change Idea #3 and Change Idea #4 will help HMH reduce the fall rate among the high-risk patient population. In addition, HMH will no longer be continuing the second Secondary Driver: \"Installation of “Call Don’t Fall” ceiling tiles above all patients’ beds.” During DY7, HMH installed 100% of the “Call Don’t Fall” ceiling tiles. During DY8, HMH analyzed the effectiveness of the “Call Don’t Fall” ceiling tiles on reducing the patient fall rate. HMH has completed and removed the second Secondary Driver from Core Activity #2.","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Reduce fall rate among high-risk patient population.\nImplementation and training of HMH's \"hourly rounding\" program which decreases the potential for falls by checking the basic needs of  the patients  on a routine and regular basis.  These needs include: bathroom breaks, re-positioning of patients, pain management and keeping all personal items within reach.  ","Require annual education and testing by all clinical and non-clinical staff on the importance of hourly rounding to decrease patient fall rates.","Require all employees to pass annually the net learning module which covers the importance of meeting patient needs to reduce our patient fall rates. ","Educate all staff to respond to call lights whenever they are on.","Implement a Falls Management Kit to better identify patients who are fall risk. ","Educate all staff about hourly rounding in the Annual Competency Skills Fair."," ","",null," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity of implementing an hourly rounding program should reduce the amount of patient falls experienced in the Huntsville Memorial Hospital, and therefore should reduce the fall rate over time. Required annual education by all clinical and non-clinical staff on the importance of hourly rounding aims to decrease the potential for falls by educating and reminding staff to check the basic needs of patients on a routine and regular schedule, such as their need for bathroom breaks, repositioning, pain management, and keeping all personal items within reach.","No","","189791001.7.1","PP","HMH has added Change Ideas 3 and 4 to the first Secondary Driver: CI 3: \"Implement a Falls Management Kit to better identify patients who are fall risk.” And CI 4: \"Educate all staff about hourly rounding in the Annual Competency Skills Fair.\" CI 3 and 4 will help HMH in reducing the fall rate among the high-risk patient population. \nIn addition, HMH removed the Secondary Driver: \"Installation of “Call Don’t Fall” ceiling tiles above all patients’ beds.” Provider installed 100% of the “Call Don’t Fall” ceiling tiles in DY7 and analyzed the effectiveness of this driver in DY8, so removed this driver. ","N",null,null,"Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has deleted Change Idea #1 under Secondary Driver #2 given that provider deleted Secondary Driver #2.","Provider Acknowledges these changes in response to the deletion of secondary driver #2.","PP","no action is required.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_189791001","189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private",630,"Prevention and Wellness","","Continue","Huntsville Memorial Hospital (HMH) is discontinuing Core Activity #3 because HMH is dropping the measure bundle that is impacted by this core activity. HMH is dropping C3: Hepatitis C Measure Bundle due to a “loss of significant system component.” A Federally Qualified Health Center (FQHC) will be coming to Huntsville, TX effective January 1, 2020. HMH anticipates a new healthcare provider for the Medicaid and low-income/uninsured patients in Walker County, TX will impact the hospital’s ability to report a significant volume for the C3: Hepatitis C Measure Bundle. HMH anticipates that many of the Medicaid and low-income/uninsured patients served by the HMH Rural Health Clinic (RHC) will seek care at the FQHC, significantly changing the volume and insurance type of our patient population. With the C3: Hepatitis C Measure Bundle primarily implemented in the clinic, HMH anticipates that any changes to the volume and insurance type of the patient population will affect the ability to report a significant volume for these Hepatitis C measures.","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Huntsville Memorial Hospital (HMH) would like to increase the Hepatitis A and Hepatitis B vaccination rates for those patients with a diagnosis of Hepatitis C.","The main secondary driver is to reduce the rate of Hepatitis A and Hepatitis B as secondary infections to Hepatitis C.","HMH will screen and vaccinate patients with a diagnosis of Hepatitis C with the Hepatitis A immunizations. ","HMH will screen and vaccinate patients with a diagnosis of Hepatitis C with the Hepatitis B immunizations."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C3","Proper screening and identification of patients at high-risk for Hepatitis C will allow us to treat as many at-risk patients as possible which should result in a reduction of healthcare costs for hospitalizations related to complications of liver cancer, cirrhosis of the liver, and liver disease.  In addition, these patients are at increased risk of developing Hepatitis A and Hepatitis B.  Proper screening of these individuals would allow for vaccination of this high-risk population, which should also reduce future healthcare costs.","No","","189791001.7.1","PP","There are multiple issues: Provider has selected \"Edit\" for this activity in DY8 Round 2 reporting and their explanation for changes does not match with RHP plan reporting. Provider has selected \"Delete\" in RHP plan because they have requested to drop the measure bundle C3: Hepatitis C. They received NMI for request for dropping C3. If the request is approved, provider may delete this core activity. If the request is not approved, provider will need to maintain this core activity or implement a new core activity that is tied to C3 measures.","Y","NB","updated language.","Needs More Information","Provider indicated that they are discontinuing this core activity along with the discontinuation of the corresponding Category C measure (C3 bundle). Provider did not provider an adequate justification for deleting the bundle, and has received an NMI. HHSC is similarly asking for additional information on the discontinuation of this core activity. Provider should clarify intent for this core activity, along with the associated measures, in the \"Provider Response\" column. ","After further analysis of community health needs in Walker County, HMH would like to continue the measure bundle. With further analysis conducted on the previous reporting year, HMH finds there to be a significant number of patients who satisfy the need for this measure. HMH retracts the previous request to drop the measure bundle. ","PP","Provider's response is reasonable. I have updated the status to \"continue\" as requested by the provider. It meets Cat C measue needs. Provider has withdrawn their request to discontinue Cat C measure. Marked for 2nd review to double check everything.","Y",null,null,"Accepted","HHSC has updated the Core Activity to continue as it was previously. Provider may make updates as needed during DY9 reporting.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_189791001","189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private",726,"Hospital Safety and Quality","","New","","Implementation of evidence-based practices to improve quality of care",null,"Huntsville Memorial Hospital (HMH) will work to improve maternal health care for patients through participation in the TexasAIM Initiative. AIM Maternal Safety Bundles are proven, evidence-based strategies used to improve maternal safety and health care quality. Specifically, HMH will implement elements of the TexasAIM OB Hemorrhage Bundle. ","HMH will educate Labor and Delivery nursing and physican staff on the Obstetic Hemorrhage bundle elements.","Particpate in quality improvement webinars, network/learning collaborative opportunities, technical assistance, etc. ","Report maternal safety measures to the TexasAIM data portal and the Texas Hopsital Association data portal.","","","","","","","","","","","","","","","","","","","","","","","","","","","",2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","Implementing elements of the TexasAIM OB Hemorrhage Bundle impact the E2: Maternal Safety Measure Bundle, specifically the E2-601 Hemorrhage Risk Assessment and E2-602 Quantified Blood Loss. AIM Maternal Safety Bundles are proven, evidence-based strategies used to improve maternal safety and health care quality. Education for Labor and Delivery nursing and physician staff, participation in learning opportunities with peer hospitals, and increased collection/reporting of maternal data measures are just a few strategies used to improve maternal health outcomes. Overall, participation in the TexasAIM Initiative should improve overall maternal health and safety for patients at the Huntsville Memorial Hospital (HMH).","No","","189791001.7.1","PP","Provider has selected \"Other\" for this new core activity and provided the following language: Implementation of evidence-based practices to improve quality of care (e.g., monitoring and evaluation, data sharing, etc.) Their core activity description as follows: Huntsville Memorial Hospital (HMH) will work to improve maternal health care for patients through participation in the TexasAIM Initiative. AIM Maternal Safety Bundles are proven, evidence-based strategies used to improve maternal safety and health care quality. Specifically, HMH will implement elements of the TexasAIM OB Hemorrhage Bundle. Accepted this new CA, and flagged for 2nd review whether second reviewer wants to make any changes. ","Y","NB","NMI and clarification","Needs More Information","HHSC requests that the provider considers a change that would bring its Core Activity on the menu. Provider can move a Core Activity Grouping by from Maternal and Infant Health Care to Hospital Safety and Quality with the Core Activity area -  Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.) instead of Other. Provider can also consider other groupings and area, such Maternal and Infant Health Care and Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans) as a Title/area. Please respond in the \"Provider Response\" column with the suggested changes.","HMH requests that the the core activity for this measure be moved to \"Implementation of Evidence-Based Practices to Improve Quality of Care\" instead of other. ","PP","Provider has submitted requested changes for their core activity - replace \"other\" with \"Implementation of Evidence-Based Practices to Improve Quality of Care\".  Approved and marked for 2nd review to validate.","Y",null,null,"Accepted","HHSC has updated the Core Activity Grouping to Hospital Safety and Quality and Core Activity Name to Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.) based on provider's response. Provider's selection of the Core Activity for DY9-10 is accepted. ","Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)","CA-14","CA-14.2"]
["DY7-8","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_198523601","198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",631,"Access to Primary Care Services","","Delete","As outlined at the end of DY8, while we have continued efforts to work with the AHSC Telehealth Counseling Center (TCC) to help our diabetic patients, we have noted that this has been extremely cost prohibitive and inefficient with very low patient engagement for these telehealth services. As part of ongoing plan and structuring within the health science center over the past year or more, we have been steadily transitioning into a more integrated approach and now have behavioral health services, provided by our psychiatry department, in our main clinic and patients can now have most of behavioral appointments in the primary care clinic setting. As a result of this, we began transitioning away from this specific telehealth service focus and are moving forward in DY9-10 with more traditional appointments through our integrated behavioral health setting as a means to better serve our patient population.","Use telemedicine/telehealth to deliver specialty services","","We will provide traditional behavioral health services in an office to diabetic patients diagnosed with depression, anxiety or PTSD.  We will also provide access to telehealth counseling services to patients within our provider system that would find such services beneficial.  These counseling sessions will use computer or telephone as an alternative or supplement to conventional behavioral health counseling services in an office setting.","Refer patients to Texas A&M Telehealth Counseling Center for telepsychology services","Increase patient engagement in behavioral health and counseling sessions."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","During traditional behavioral health counseling sessions or telehealth counseling sessions patients can address challenges they face because of their diabetes and behavioral health aspects such as depression and anxiety that may exacerbate their diabetes.","No","","198523601.7.1","PP","Provider did not request any changes to this core activity during DY8 Round 2. Now, they want to delete this core activity. As per Provider's explanation, access to telehealth counseling services has been extremely cost prohibitive and inefficient with very low patient engagement. As part of ongoing structuring within the health science center over the past year or more, they have been  transitioning into a more integrated approach, and now their psychiatry department provides behavioral health services in their main clinic. Patients can now have most of behavioral appointments in the primary care clinic setting. As a result of this, they began transitioning away from the telehealth service focus and are moving forward in DY9-10 with more traditional appointments through their integrated behavioral health setting to provider better services. Provider still meets the minimum requirements for having at least one core activity for A1 measure bundle.\n\n","Y","NB","updated language.","Accepted","Provider's deletion of this Core Activity is accepted. ",null,null,null,"N",null,null,"Accepted","HHSC has accepted provider's deletion of the Core Activity for DY9-10.","Use telemedicine/telehealth to deliver specialty services.","CA-1","CA-1.8"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_198523601","198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",632,"Patient Centered Medical Home","","Edit","As noted in the deletion of core activity #1, we are referring more to integrated behavioral health care rather than telehealth sessions (which will be used occasionally as needed). Additionally, as noted in the edits to Core Activity #4 below, we have created an internal care coordination team to include a patient relations administrator and community health workers to provide more efficient and expedient coordination/navigation services and are transitioning our work with BVCCP to broader outreach and assist with more external checks and services to assist with diabetic management. As a result of this change, we updated the change idea below (i.A) to read \"Identify patients for referral to the internal TAMP care coordination team, to BVCCP for external coordination services and outreach, integrated behavioral health services, and CPHA\" rather than the previous language, which read \" Identify patients for referral to BVCCP, TCC, and CPHA.\"","Provision of coordinated services for patients under Patent Centered Medical Home model","","The practice employs a systematic process for identifying patients by diagnosis or condition, utilizes evidence-based guidelines for care-management, and emphasizes care of the whole person over time and manages the patients care needs.","Build and run EMR reports with diabetic population set","Identify patients for referral to the internal TAMP care coordination team, to BVCCP for external coordination services and outreach, integrated behavioral health services, and CPHA"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Patient-centered care, self-management, patient empowerment, and team-based care are keys to better diabetes care and outcomes. Under this model, patients receive coordination of care with specialty providers, follow up on completion and results of labs and exams, and interventions for poor compliance, excessive utilization, and missed appointments.  Patients have specially planned visits to address comorbidities common in diabetes.","No","","198523601.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_198523601","198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",633,"Prevention and Wellness","","Continue","","Self‐management programs and wellness programs using evidence‐based designs","","Educational workshops and materials to those living with chronic disease to help find practical ways to deal with symptoms and emotional aspects of their disease, identify better nutritional and exercise options, learn ways of communicating with doctor and family about health, and prevent or delay complications.","Enroll patients in diabetes education courses through Texas A&M Center for Population Health and Aging or other clinic sources.","Increase patients' abilities to self-manage their disease."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Educational workshops provide an interactive group learning experience where patients learn coping strategies, action planning, behavior modeling, and decision-making to help them self- manage their disease through stress management, healthy eating, medication management, and exercise.  These tools promote better health status, improved communication with healthcare providers, and increased self-efficacy leading to better health outcomes for diabetic patients.","No","","198523601.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_198523601","198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",634,"Expansion of Patient Care Navigation and Transition Services","","Edit","As outlined at the end of DY8, managing the additional external resources associated with our BVCCP partnership and outsourcing all the overall, more general care coordination services to this program proved to be a challenge and somewhat cost prohibitive in terms of the number of patients being reached and the actual services provided having somewhat minimal impact on improving health outcomes. As a result, and given the value we do see in care coordination and collaboration, we have transitioned the partnership with the Brazos Valley Care Coordination Program from one involving more broad coordination and navigation services to one that represents a more outreach-based focus with external navigation services that will better service the diabetic population, particularly those who have trouble controlling both blood pressure and A1c, in the management of their diabetic condition. While we do expect that BVCCP may help the internal team with coordination services at times, we anticipate referrals to BVCCP on a more case-by-case basis with hands-on outreach and navigation via home visits by medical clinicians and nurses, in addition to their community health workers, for more closely monitoring comorbid conditiions such as hypertension and uncontrolled A1c. Internally, we have created a care coordination team led by a patient relations administrator working with two community health workers employed within the practice. This integrated team will provide general care coordination and navigation services for practice patients and our diabetic population. As a result of this transition for DY9-10, we have updated Core Activity #4 (now activity #3) as follows: \n(1) Description of the core activity was updated to change the sixth word from \"team\" to \"teams;\" (2) the first Secondary Driver (b.i.) was modified from \"Refer patients to Brazos Valley Care Coordination for navigation services\" to now read \"Refer patients to Brazos Valley Care Coordination for outreach and external navigation services;\" (3) the first change idea for the first Secondary Driver (b.i.A) was completely deleted and updated to read \" Help patients, and particularly uncontrolled patients, better manage their disease through more outreach-based coordination and navigation services to include home visits by medical clinicians and nurses for closer monitoring, assistance and education for comborbid conditions such as hypertension and markers such as hemoglobin A1c;\" (4) a new second Secondary Driver was added (b.ii.) for our internal coordination component and it reads \"Refer patients to the internal TAMP care coordination team for navigation and coordination services;\" (5) a new first change idea for the new second Secondary Driver was added (b.ii.A) that reads \"Help patients manage their disease through improved access to care and medications, transportation to appointments, and understanding of physician's instructions.\"   ","Provision of navigation services to targeted patients","","Care coordination and navigation service teams will help patients with obtaining basic health information, scheduling medical services (appointments and labs) at their primary care medical home to manage their condition(s),communicating with their healthcare team, finding community resources to help them stay healthy, including needed medications, reminding clients of their appointments and helping to find transportation to appointments.","Refer patients to Brazos Valley Care Coordination for outreach and external navigation services.","Help patients, and particularly uncontrolled patients, better manage their disease through more outreach-based coordination and navigation services to include home visits by medical clinicians and nurses for closer monitoring, assistance and education for comborbid conditons like hypertension and markers like elevated A1c"," "," "," "," ","Refer patients to the internal TAMP care coordination team for navigation and coordination services."," Help patients manage their disease through improved access to care and medications, transportation to appointments, and understanding of physician's instructions."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","The program aims to improve patient outcomes and decrease the number missed appointments, emergency department visits, and hospitalizations due to complications of diabetes by coordinating services with primary care and proving access to supportive health services. The program connects patients to a care coordinator who will work to provide options for accessing regular primary care and health resources to achieve and maintain a positive health status.  In particular, coordinators will follow up on HbA1c labs, at patients request go to appointments with primary care physician, answer questions about health and social concerns, and provide navigation to resources such as medications and diabetes education.","No","","198523601.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_311035501","311035501.7.1",17,"311035501","Montgomery County Public Health District","Local Health Department (LHD)","Non‐State Owned Public",635,"Prevention and Wellness","","Continue","","Implementation of evidence based strategies to reduce sexually transmitted diseases","","We will implement activities that are focused on reducing the incidence rates of Syphilis in the Montgomery County area. Based upon evidence based strategies from the CDC and NIH these activities may include increasing community outreach, improving education dispersed to the public, social marketing campaigns, increasing partner treatments, and targeting high-risk populations for testing. A primary target population of the public health district is the uninsured and those receiving limited healthcare care services. By increasing the education directed at these populations it is anticipated that there should be a reduction in the positive screening rates of Syphilis.","Some of the secondary drivers that may be utilized to support this core activity include social marketing campaigns, providing educational handouts in English & Spanish at area homeless shelters, increased testing within the at-risk locations of the county, improved delivery of community education, and increasing the rates of partner treatments.","First change ideas that will support the above secondary driver include implementing evidence based strategies targeting the incidence rates of syphilis. These strategies may incluide mobile screening for STD's within high risk areas of the the county, providing community education at shelters, health fairs, and other locations, increased clinic hours, and improving information delivery to partners of individuals with positive STD testing results."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-343","This core activity is directly targeting the outcome measure of reducing positive testing rates of Syphilis. STD testing and treatment are a core function of the public health district. By implementing evidence based strategies the public health district can be expected to witness a reduction in the rates of Syphilis in Montgomery County.","No","","311035501.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence based strategies to reduce sexually transmitted diseases.","CA-7","CA-7.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_311035501","311035501.7.1",17,"311035501","Montgomery County Public Health District","Local Health Department (LHD)","Non‐State Owned Public",636,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","This core activity will be focused upon improving the rates of Influenza Immunizations within Montgomery County. The social determinants of health include areas such as income level, education, community, social impact, and environments. By addressing many of these determinants of health it is expected that the health of the population can be improved. Providing education to the public on the health benefits of immunizations will be a focal point of this core activity. The general public may have misconceptions pertaining to the importance of immunizations and efforts should be directed at improving the true benefits of receiving an influenza immunization.","The first secondary driver for this core activity will be targeting increased hours of the clinic where influenza immunizations are available. Also, targeting high-risk, low-resource regions of the county for potential mobile shot clinics.","The first change ideas for the secondary driver is providing extended clinic hours during the week and offering weekend hours during the influenza season. Improving information delivery to the public regarding flu shot health benefits and locations to receive flu shots."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-269","This core activity has been specifically developed to improve the number of influenza immunizations delivered through the public health district. By targeting this service efforts should show improvements in the numbers of influenza immunizations provided to individuals.","No","","311035501.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_311035501","311035501.7.1",17,"311035501","Montgomery County Public Health District","Local Health Department (LHD)","Non‐State Owned Public",637,"Prevention and Wellness","","Continue","","Utilization of whole health peer support","","This core activity is being developed to address and improve the rates of Latent TB treatments that have been completed by individuals accepting a treatment regimen. The public health district receives referrals from outside entities along with the state to provide and deliver treatment of latent TB infections. By focusing on the population, there can be an improvement of the general health of the population.","The first secondary driver for this core activity will be improving contact with individuals referred for treatment. If no contact is made with the individual, then there is no ability to even accept or begin a treatment program. Also, improved education delivery to the patient and providing educational resources the patient can keep at home to refer to when needed.","The first change idea for this secondary driver will be to provide increased education to the patient upon the first meeting. Improved education will include the importance of beginning treatment and continuing treatment until the full course has been completed. Also, providing contact resources for the client to utilize when there are questions or concerns. Direct phone numbers for the TB nurse, specific directions on when to contact the TB nurse, and other information to encourage continued treatment."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-347","This core activity is being developed specficially to improve the completion rates of latent TB. By placing an emphasis on improving the number of intial contacts made and providing increased management of the individual, it can be possible to witness an increase in the number of individuals completing a treatment regimen.","No","","311035501.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of whole health peer support, which could include conducting health risk assessments, setting SMART goals, providing educational and supportive services to targeted individuals with specific disorders (e.g., hypertension, diabetes, and health risks such as obesity, tobacco use, and physical inactivity)","CA-7","CA-7.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_326725404","326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private",638,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Implementation of a care transition and/or a discharge planning program","","We will be implementing a paramedicine program focused on chronic disease patients and transitional care type services that also address the social determinants and behavioral needs as well providing primary care type services in the home. The paramedics will work with patients to transition them post discharge from the acute care setting and move from a focus on sick care to wellness and prevention.","Reducing Stigma/Raising Awareness around the importance of cancer screening and early detection","Have paramedics provide education directly, provide materials and in some cases provide the screening tests in the patient's home as part of comprehensive care provided to the patient"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2",": Paramedicine programs are meant to help assist patients in transitional care after they are discharged from the hospital and are moving from sick care to well care. As part of this, to promote prevention and screenings to prevent catastrophic life events, the paramedics who act as educators, support, clinicians, and other support will address the social and clinical needs of patients, will assist patients' to focus on prevention and will promote an overall lifestyle shift to self management and proactive care. The paramedics will also provide primary care services in the patient's home and as part of that, can facilitate access to screening and prevention. Since these programs focus on high risk/high dollar patients who typically do not partake in primary care and prevention type services the paramedics, who become their trusted source of care, will help patients to shift their thinking.","No","","326725404.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of a care transition and/or a discharge planning program and post discharge support program. This could include a development of a cross-continuum team comprised of clinical and administrative representatives from acute care, skilled nursing, ambulatory care, health centers, and home care providers.","CA-6","CA-6.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 17_DY9-10 Regional Tracker - FINAL Tracker.xlsb","17_326725404","326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private",639,"Patient Centered Medical Home","","Continue","","Provision of coordinated services for patients under Patent Centered Medical Home model","","Patients who establish care at one of the PCMH locations will receive coordinated and integrated primary care services. Through navigating patients to a PCMH, cancer screenings and other appropriate preventive services will be included as part of the care that patients receive. We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. Using social workers, navigators and other staff to also help educate patients on the importance of cancer screening will help to also increase adherence. We plan to socialize the cancer screening measures with the physicians on a regular data dashboard will also help to create reminders and encourage physicians to help remind patients to get their appropriate screening. ","Access and convenience of screenings: improve adherence through access","We are considering ways to make access to screenings more prevalent and top of mind for the patient, increase reminders and increase access to community and Baylor Scott & White resources to improve adherence. This can include, education through brochures and reminders through text messages and other means"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Through changing the focus of the health equation to preventive services and cancer screenings as part of a PCMH for this population, we expect to see better outcomes overall, less preventable cancer occurrences and earlier detection. Through incorporating a focused measure on cancer screening as part of the patient's care plan in the PCMH, adherence rates will increase. There will be an increased focus on these measures by the physicians and the care team to ensure patients are getting timely and appropriate screenings as part of their overall preventive care in the PCMH setting.","No","","326725404.7.1","PP",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,null,null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated services for patients under Patent Centered Medical Home (PCMH) model, which incorporates empanelment of patients to physicians, and management or chronic conditions and preventive care","CA-5","CA-5.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084001901","084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public",643,"Access to Specialty Care Services","","Edit","","Improvement in access to specialty care services with the concentration on underserved areas","","LifePath Systems will add staff, expand hours, and consider using telemedicine to improve access to care associated with limited transportation options throughout the County. Previously since 1999, the process for gaining access to behavioral health care in Collin County was centralized out of a Dallas County based system. Collin County has one of the fastest growing populations in the State, making transportation and communications about access to behavioral health services very challenging.","We are currently unable to serve all who come into our walk-in clinics each day. Thus we will extend hours and add intake staff to expand access to the front door entry into the system.","Expand Open Access Hours from 8am-3pm Monday thru Friday to 8am to 5pm Monday thru Friday","Hire a 3rd licensed clinician for each site in order to expand the number of intakes we can complete each day."," "," "," ","Add staff and consider providing services through telemedicine to expand our capacity for patients","Hire 2 QMHP-CS staff to provide field-based psychosocial rehabilitation services for up to 40 clients per staff member.","Expand ACT services by 2 staff members in order to increase ACT capacity from 30 clients to 50 clients served at one time.\nNew info: Expand ACT capacity to 100 clients by adding a 2nd ACT team for northern Collin County.  This team will be comprised of 5 team members and function out of our McKinney Office.","Consider feasibility of using additional physician extenders or telemedicine providers in order to increase access to psychiatric services."," "," ","Improve timely connections with persons discharged from psychiatric inpatient care locally and at State facilities by implementing continuity of care (COC) processes.","LifePath COC staff will collaborate daily with local and state inpatient facilities to develop a community support plan for individuals who are currently established participants of LifePath services, those who were admitted to inpatient facilities by recommendation of LifePath, and/or those who will be discharging to LifePath. \nFor individuals admitted to local facilities, LifePath COC will meet with individuals on the day of discharge to offer LifePath services and to schedule appropriate follow up appointments.","LifePath COC staff will provide monthly outreach and education with each contracted local hospital to establish open communication as well as troubleshoot issues and concerns as they arise.  LifePath COC staff will provide ongoing education to contracted hospitals on LifePath's array of services and how to access services.  \nMonthly site visits to Terrell State Hospital will occur by LifePath COC staff to promote active collaboration and communication to ensure successful community support planning."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-124; M1-342; M1-262; M1-390; M1-319; M1-305; M1-263; M1-105; M1-400; M1-147; M1-317; M1-259; M1-385; M1-386; M1-160","By improving the continuity of care (COC) process, we are able to improve medication reconciliations post hospital discharge, improve the time to an appointment post discharge, and improve follow-up after hospitalization.  By improving access to care both through intake/Open Access and intensive/field-based services, we increase the remaining measures. Part of the initial intake and the psychiatric assessment includes a risk/suicide assessments for all individuals, a psychosocial assessment, tobacco use screenings for adults and adolescents, and an alcohol use assessment.  Prescribers conduct BMI screenings on all initial and follow up med evals.  And the Specialty IDD/MH clinic conducts the AQoL assessment on all initial and follow up med evals. Intake staff obtain information on all clients concerning existing Primary Care Physicians and QMHPs update this information periodically.","No","","084001901.7.1","JQ","JQ: Description of core activity and of drivers were vague, so I used the concrete changes listed in the change ideas as the basis for edits to make more clear","Y","NB","Accepting 1st review results but changed to NMI","Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC made edits to descriptions of the core activity and some drivers to increase clarity. Please respond in the \"Provider Response\" column if provider feels these edits do not accurately capture activities or to make additional changes.","OK with edits.","JQ","Provider accepted edits and no other info is needed. ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084001901","084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public",644,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of services to individuals that address social determinants of health",null,"Improve access to care for individuals in Collin County by adding more field-based services.  Services have traditionally focused on clinic-based services.  With the increasing population and thus the increasing number of individuals identified as seriously and persitently mentally ill (SPMI), there is a need for more field-based intensive services.","Will expand the availability of field based services (psychosocial rehabilitation which includes illness management and recovery (IMR)) for those with severe and persistent mental illnesses (SPMI).  These will be defined as those who qualify for an LOC3 or higher package on the ANSA.","Will designate at least 4 QMHP staff members to start providing psychosocial rehabilitatative services in the field, including illness management and recovery (IMR).","Address lack of transportation by bringing psychosocial rehabilitation services directly to the client in the community (via field-based QMHP-CS) and by providing transportation vouchers or establishing a transportation service for those LOC3 individuals who lack transportation to the clinic for psychiatric services.","Address food insecurity by linking LOC3 individuals to food banks, free food pantries in the community, and community gardens.                                                                                                                                                                                \nAddress lack of access to primary health care services by assisting to coordinate medical appointments with local FQHC’s and charity care clinics and then assisting individuals with transportation to/from these appointments.\n","Address lack of stable housing by accessing current state grant funds to assist with short term (3 months) and long term (12 months) rental and or utility financial assistance or by referring individuals to our local Section 811 project for permanent supportive housing."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-259; M1-265; M1-266","QMHPs working with clients in the field will be responsible for ensuring that individuals with Schizophrenia have a Primary Care Physician and are following up with that physician, they will also work with individuals who have Schizophrenia on Housing and Independent Living Skills.  The field-based teams will be responsible for establishing a person centered recovery plan with the client that includes housing, employment, living skills (as necessary) and to work with other members of the team to ensure needs and strengths are addressed.","No","","084001901.7.1","JQ","Provider had selected \"other\" for their core activity title, so I changed to be one from the menu of core activities that I felt best fit, although there were several options that might have worked also. Provider's description of the measure bundle impact was the most clear, so that's what I based it on. I wasn't sure if I should have also copied some of that language into the driver or change idea descriptions as well, as it was helpful in clarifying what they were doing, but I did not want it to be too repetitive. ","Y","NB","Accepting 1st review results but changed to NMI","Needs More Information","HHSC made edits to the core activity grouping and description of the core activity. Please provide a response if provider feels these edits do not accurately capture activities. If provider keeps this Core Activity title then additional information is needed on how social determinants of health are addressed. Please include responses in the the \"Provider Response\" column.","OK with edits.","JQ","JQ: Provider kept Core Activity Title as edited, but did not provide additional information on how social determinants of health are addressed. Will email provider for follow up.  \n\n2/5: LifePath Systems would like to add the following change ides to the Seconday Driver for 644:  \n\nAddress lack of transportation by bringing psychosocial rehabilitation services directly to the client in the community (via field-based QMHP-CS) and by providing transportation vouchers or establishing a transportation service for those LOC3 individuals who lack transportation to the clinic for psychiatric services.\n          \nAddress food insecurity by linking LOC3 individuals to food banks, free food pantries in the community, and community gardens.                                                                                                                                                                                \nAddress lack of access to primary health care services by assisting to coordinate medical appointments with local FQHC’s and charity care clinics and then assisting individuals with transportation to/from these appointments.\n\nAddress lack of stable housing by accessing current state grant funds to assist with short term (3 months) and long term (12 months) rental and or utility financial assistance or by referring individuals to our local Section 811 project for permanent supportive housing.\n\nJQ updated tracker to reflect these additional change ideas. No further information needed. ","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added the proposed Change Ideas to Secondary Driver 1.  ","Provision of services to individuals that address social determinants of health and/or family support services.","CA-9","CA-9.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084001901","084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public",645,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","LifePath Systems is beginning the process of transitioning to a CCBHC model. We have established Spring 2020 as our goal date to apply for CCBHC certification with the state.","Identify work that must be done to fulfill all of the requirements of the CCBHC model","Establish a GANTT chart that identifies tasks to be completed and sets a timeline that corresponds with our center's goals.","Review Center policies and procedures to identify gaps. Implement new policies and/or procedures to close gaps.","Establish training and educational activities for all workforce members on the CBHC model.  Implement new trainings and educational activities to continue to gain buy-in and provide the best possible care for individuals we serve. ","Establish a care coordination program and implement within the next three months to close the loop on referrals to align with the CCBHC model.\n          \n","Review data collection process for addressing social drivers of health (SDoH) to identify gaps.  Implement new processes for collecting SDoH data to close gaps."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-400; M1-390; M1-386; M1-385; M1-342; M1-319; M1-317; M1-305; M1-263; M1-262; M1-259; M1-160; M1-147; M1-124; M1-105; M1-266; M1-265","CCBHCs are based on a behavioral health services model that strives to focus on outcomes and allowing centers to innovate in order to improve outcomes.  The care coordination focus will assist in addressing health factors (tobacco use, alcohol use, BMI, identification & assignment of a PCP) and ensure appropriate coordination of care between levels of care (medication reconciliation, follow up post hospitalization, time to initial evaluation).  Members of a CCBHC will be able to choose from a comprehensive range of high-quality services which will improve outcomes related to risk assessment, psychosocial assessment, housing assessments, independent living skills assessments, assessment & improvement of function status.  The evidenced-based practices required by the CCBHC model will have a positive effect on all of the measures.","No","","084001901.7.1","JQ",null,"N","NB","asking for additional details","Needs More Information","HHSC recommends that the provider revisits its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for CCBHC activities in addition to what is already described since provider might have already completed some of the steps included in the current change ideas. Please respond in the \"Provider Response\" column with the suggested changes.","LifePath Systems would like to add the following change ides to the Seconday Driver:  \n\nEstablish training and educational activities for all workforce members on the CBHC model.  Implement new trainings and educational activities to continue to gain buy-in and provide the best possible care for individuals we serve. \n          \nEstablish a care coordination program and implement within the next three months to close the loop on referrals to align with the CCBHC model.\n          \nReview data collection process for addressing social drivers of health (SDoH) to identify gaps.  Implement new processes for collecting SDoH data to close gaps.","JQ","Provider responded to comment and I updated the change ideas to reflect this new information . ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the change ideas for Secondary Driver 1. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084434201","084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public",640,"Access to Primary Care Services","","Continue","","Integrated physical and behavioral health care services","","In 2013, as one of TCCs initial 1115 Waiver projects, TCC established an Integrated Health Care Clinic in partnership with a local indigent health care clinic.  In doing so, this clinic has been very successful in providing primary medical care to individuals also served for behavioral health care issues.  The clinic has a Family Nurse Practitioner, a RN, a LCSW and Patient Care Coordinator and they treat acute and chronic medical conditions, as well as brief behavioral health conditions.  These services are also provided in conjunction with TCCs psychiatric providers and other nurse practitioners located at Great Texoma Health Clinic.  The LCSW provides brief counseling to address minor behavioral health concerns to patients of all of the practitioners at the clinic, and patients are regularly treated for additional counseling at TCCs Counseling Clinic or, for an identified severe and persistent mental illness, through the TCC Mental Health Clinic.  As a Core Activity, TCC will expand the existing, successful array of services to additional patients in this health care region and further align these services with the CCBHC treatment model. To accomplish this, TCC will continue the established Core Activities","Combine from multiple systems to utilize one electronic health record (EHR)","Increase utilization of available physician health information by behavioral health provider.","Incorporate adherence monitoring to improve cross-checking for patient behavioral and physical health conditions and needs"," "," "," ","Identify individuals with cooccurring disorders who are not receiving routine primary care","Incorporate questions in provider evaluation notes that identify any  co-occurring  physical disorders","Incorporate adherence monitoring to ensure referrals are made to the primary care physician for anyone without routine primary care"," "," "," ","Register anyone with one or more chronic health diseases in the Health Registry","Ensure the completion of Health Registry Forms for individuals receiving behavioral or primary health care services","Provide Disease Specific Education for individuals with one or more chronic health conditions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-103; M1-147","High Blood Pressure is considered a chronic health condition that contributes to high utilizations of health care services.  Individuals with mental illness and/or behavioral health needs often have untreated chronic physical health conditions due to impaired functional capacity and this core activity will improve identification, monitoring and treatment of these individuals.","No","","084434201.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Integrated physical and behavioral health care services","CA-1","CA-1.7"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084434201","084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public",641,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","In 2017, TCC began screening individuals for the following issues: depression, suicidality, substance use disorders, such as tobacco use and unhealthy alcohol use, and need for primary care or treatment for chronic medical conditions, including high blood pressure or obesity.  These screenings occur at intake and again during appointments with clinicians and/or psychiatric providers or medical care providers. Follow up treatment includes referrals to the appropriate health care provider, counseling and/or disease specific education by the clinician or prescriber, appropriate medications by a PCP, and appropriate acuity responses, including hospitalization if warranted.  These screenings comply with 1115 Waiver and MACRA measure-steward standards and are integrated at all levels of care at TCC for anyone over the age of three.  Rapid-cycle quality improvement (PDSA) is integrated Center wide and will continue to be refined. As a Core Activity, these screenings will be maintained and improved through the quality improvement process, protocols will be refined and numbers of screenings increased as well as percentage improvement in follow up compliance.","Screen individuals seeking behavioral health services for Body Mass Index (BMI)","Incorporate screening tool for BMI into Provider Psychiatric Evaluation Progress Note","Incorporate adherence monitoring to ensure Psychiatric Evaluations are completed with individuals seeking behavioral health services including the BMI assessment tool"," "," "," ","Screen individuals seeking behavioral heatlh services for tobacco use","Incorporate screening tool for tobacco use into an Initial Treatment Plan","Incorporate adherence monitoring to ensure Treatment Plans are completed with individuals seeking behavioral health services including the tobacco use tool."," "," "," ","Screen individuals seeking behavioral health services for unhealthy alcohol use.","Incorporate screening tool for unhealthy alcohol use into an Initial Treatment Plan","Incorporate adherence monitoring to ensure Treatment Plans are completed with individuals seeking behavioral health services including the unhealth alcohol use tool"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-147; M1-317","This core activity ensures the implementation of the selected screenings in order to comply with the measure goals.  These screenings are for evidence-based identified health risk factors that lead to acute and chronic diseases and, thus, an increased use of emergency rooms, hospital stays and death.  Early screenings and follow up treatment for more individuals will accomplish regional health goals of early prevention, detection and treatment of the potential resulting diseases.","No","","084434201.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_084434201","084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public",642,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","TCC utilized health care transformation opportunities in DY 1-6 to expand and improve services that are consistent with the CCBHC model.  For example, TCC began a Licensed Substance Abuse Facility that provides intensive outpatient substance abuse treatment and a fully Integrated Behavioral and Primary Care Clinic. TCC began rapid-cycle quality improvement and expanded it Center-wide as well as developing evidence-based protocols for registering, providing education and treating chronic care conditions in a Medical Home environment.  TCC expanded behavioral health services and began a Counseling Center facility that utilizes evidence-based treatment models to treat depression and other behavioral health concerns.  TCC also implemented a wraparound-style community-based program to help stabilize individuals with complex needs and who utilize the crisis services.  Implementing these services and protocols, when added to the core services for individuals with a severe and persistent mental illness, severe behavioral health issues and/or intellectual disabilities laid a solid foundation for the CCBHC model.   The Core Activity for DY 7 & 8 will be to further define and implement protocols and services that are consistent with the CCBHC model.","Utilize the New Integrated CCBHC Certification Criteria Readiness Tool (I-CCRT) to prepare the Center for CCBHC compliance","Monitor progress toward aligning Center operations with the CCBHC Model in weekly and monthly meetings","Implement color-coding system to track  implantation of the necessary changes toward CCBHC model compliance."," "," "," ","Implement the Non-Four Wall service design for behavioral health patients","Monitor services provided in the community or home compared to an office setting","Ensure 45% or more of patient services are provided in a community or home setting"," "," "," ","Incorporate Trauma-Informed Care into all aspects of patient contacts","Train all TCC staff in Trauma-informed Care Protocols","Train staff to incorporate a culture that includes a clinical approach that is focused on seeing and accommodating client needs (i.e., Patient-centered)."," "," "," ","Increase licensed staff to expand evidence-based services and meet anticipated demand for behavioral health care as a CCBHC. "," Increase LPC, LCSW or LMFT staff by one or more to improve access to behavioral health counseling and evidence-based treatment   \n","Increase primary care provider by 1 or more to improve access to Integrated Health Care \n","Increase psychiatric providers to increase access to providers who can prescribe psychiatric medication."," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-160","This core activity impacts the selected measure by improving access and availability of services.  Research has shown that continuity of care between inpatient psychiatric hospitalizations and stabilization within the community, with quick follow up that engages discharging patients with outpatient care, has been shown to reduce rehospitalizations and more expensive health care services. By aligning services with the CCBHC model that engages patients quickly and improves access to care, provides trauma-informed care and provides services where the patient is in the community, regional and transformational goals of reducing high cost health care will be accomplished.","No","","084434201.7.1","JQ",null,"N","NB",null,"Needs More Information","HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for CCBHC activities in addition to what is already described since provider might have already completed some of the steps included in the current change ideas (also there is reference to DY7-8 in the Core Activity description). Please respond in the \"Provider Response\" column with the suggested changes.","Provider requests to add a Secondary Driver 4 to address Appropriate Levels of Behavioral Health Care Services as follows:                       \n Secondary Driver 4-Increase licensed staff to expand evidence-based services and meet anticipated demand for behavioral health care as a CCBHC.                                                                                               Change Idea 1:  Increase LPC, LCSW or LMFT staff by one or more to improve access to behavioral health counseling and evidence-based treatment   \nChange Idea 2:  Increase primary care provider by 1 or more to improve access to Integrated Health Care \nChange Idea 3:  Increase psychiatric providers to increase access to providers who can prescribe psychiatric medication.","JQ","Provider responded to comment and I updated the change ideas to reflect this new information . ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the change ideas for Secondary Driver 1. ","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_169553801","169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private",646,"Patient Centered Medical Home","","Continue","","Utilization of care teams that are tailored to the patient’s health care needs","","In DY2-6 we focused on creating the services and infrastructure for a PCMH, now, through its establishment and success, we will continue to focus on primary care and prevention services helping patients who previously would forgo prevention, specialty care and other non-acute type services. We are considering ways to make access to screenings more convenient and integrated with other wellness type visits to help increase adherence. Using social workers, chronic care staff and other staff to also help educate patients on the importance of cancer screening will help to also increase adherence. We plan to socialize the cancer screening measures with the physicians on a regular data dashboard will also help to create reminders and encourage physicians to help remind patients to get their appropriate screenings. ","Access and convenience of screenings: improve adherence through access","\u0096 Create more access for screenings as part of the PCMH process through: community outreach processes such as: mobile mammography options (TBD), in home IFOBT testing and education and clinic outreach strategies to increase screening rates\n\n"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","Through changing the focus of the health equation to preventive services and cancer screenings as part of a PCMH for this population, we expect to see better outcomes overall, earlier detection, and fewer preventable cancer incidence/occurances. Through incorporating a focused measure on cancer screening as part of the patient's care plan in the PCMH, adherence rates will increase. The previous work from DY2-6 will assist in providing information/awareness and reduction of stigma to increase patient adherence to cancer screenings.","No","","169553801.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of care teams that are tailored to the patient’s health care needs, including non-physician health professionals, such as pharmacists doing medication management; case managers providing care outside of the clinic setting via phone, email, and home visits; etc.","CA-5","CA-5.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_179917301","179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",651,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Providers at the Health Clinic routinely screen and provide follow up services to all patients with diabetes. To support the acheivement of improved outcomes for diabetic, pre-diabetic, or patients at risk for exacerbation of the condition, providers will routinely review new patients screening for quality management and consistency. We will explore ways to improve the way we monitor and track patients' outcomes at the second visit and throughout their tenure with the Health Center. We follow all national clinical guidelines associated with the disease, minimally A1c blood levels and microalbumin. These measures and routine/every visit foot exam data will be quarterly reviewed in quality improvement teams. Eye exams are performed annually. We will monitor and ensure that follow-ups adhere to clinical standards or better.","Early and timely detection of factors contributing to exacerbation of Diabetes.","TQM reviews are conducted with providers and clinic staff to ensure 100% adherence to protocols."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","This Core Activity supports our mission to provide chronic disease management and the follow-up care of patients with diabetes and other comordities.  Regular screening and education with diabetic foot exams can prevent amputations and associated hospitalizations.","No","","179917301.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_179917301","179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",652,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Protocols will be established that engage the Health Center with hospitals and EDs in ways that enable us to evaluate and engage MLIU patients who may need additional education or support to maintain their community tenure and health so as to avoid hospital.  Providers establish relationship with fragile patients to sustain their ability to avoid hospital. The Health Center works in this way with patiens with other chronic conditions.","Identify patients with chronic illness or at high risk with medical complications in need of a medical home.","Secure and maintain communications with hospitals, EDs, ERs, case managers and other local service providers to facilitate and ensure follow up care."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",2,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","This core activity supports our measure bundle by identifying individuals in need of on-going management and at-risk for readmissions.  Providing a medical home for patients with chronic diseases reduces unecessary emergency care utilization.","No","","179917301.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_194997601","194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private",647,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","We will focus on underserved individuals diagnosed with diabetes that have an A1C greater than 9, that may have elected to forgo treatment due to financial barriers for medical care and medications.","Educate patients on medication assistance programs for diabetes medications","Monitor patients every 3 months or sooner if indicated","Provide patients with information on the medication assistance programs for diabetes medications."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","We will continue to work with an underserved population of individuals that have been unble to afford healthcare services and many times medications needed to manage their disease.  We will provide an affordable option, avoiding unnecessary ER visits when the disease is unmanaged. We will continue to  work closely with local hospitals to redirect unfunded patients to the clinic to manage their primary care. This will include management of unmanaged chronic conditions, such as diabetes, that may cause an individual to present to an ER or cause a preventable readmission with in 30 days of discharge.","No","","194997601.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_283637101","283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",648,"Maternal and Infant Health Care","","Edit","","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","","We will incorporate and document our activities to do so, EBP strategies to favorably impact outcomes for women whose health status includes predictors of low birth weight infants and preterm birth. We will evaluate the presence of those risk factors to ensure healthier pregnancies in women at risk for these outcomes and improve the health of infants and the gestational age at which they are born.","Effectively link women with any needed specialty or other primary care.\n","Evaluate the referral report from the referral-out source and do a follow-up with the patient and referral office as indicated\n","If no report is received based on expected appointment date and expected report date, conduct a follow up call with the patient and the referral source.\n","Continuously assess value and benefits of referral and treatment networks."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Improved access to prenatal care and postpartum care is essential in improving maternal care, as well as maternal and fetal outcomes","No","","283637101.7.1","JQ","While the provider included more detail in the core activity title itself, the secondary driver and change idea descriptions are vague. During DY8R2 the provider was told to provide more detail during the next reporting period on the progress and challenges for these field. ","Y","NB","added another statement at the end. OK with NMI","Needs More Information","Provider needs to make changes to its Secondary Driver 1 and Change Idea 1 to provide more concrete descriptions of how provider is effectively linking women with needed care. Please respond in the \"Provider Response\" column with the suggested changes.","We  have an established network of providers, some of which are specialty care and some of which are primary care. We make appointments for our patients with the referring office before the patient leaves our office. I receive a follow-up report from the referral source that is part of the patient’s file. \nIn Core Activity ID 648 Improve access to and compliance with prenatal care.\nFor Secondary Driver 1 Effectively link women with any needed specialty or other primary care.\nWe request to replace existing Change Idea 1 to be: Evaluate the referral report from the referral-out source and do a follow-up with the patient and referral office as indicated\nAdd Change Idea 2:  If no report is received based on expected appointment date and expected report date, conduct a follow up call with the patient and the referral source.\nAdd Change Idea 3: Continuously assess value and benefits of referral and treatment networks.\n","JQ","Provider responded to comment and I updated the change ideas to reflect this new information . ","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the change ideas for Secondary Driver 1. ","Implementation of evidence-based strategies to reduce low birth weight and preterm birth (Evidence-based strategies include Nurse Family Partnership, Centering Pregnancy, IMPLICIT: Interventions to Minimize Preterm and Low birth weight Infants through Continuous Improvement Techniques among others)","CA-4","CA-4.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_283637101","283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",649,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","This Clinic will provide early screening for medical conditions, as soon as the women present to the Clinic. We will screen for known and potential risk factors for adverse maternal and fetal outcomes. We will be more able to prevent maternal and fetal complications with improved detailed clinical data and health histories, and to follow these women, thereby improving prenatal, antenatal, and postnatal outcomes.","Utilize early patient screenings to prevent maternal and fetal complications.","Improve timeliness of access to prenatal care services at the earliest point of pregnancy confirmation","Use valid and reliable screening tools to detect risk for preventable conditions and chronic medical conditions"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Screening and risk evaluations provide information needed to treat each patient as an individual and to develop protocols for patients with like health profiles. This enables us to detect preventable medical conditions and managing chronic medical conditions and treat or counsel and educate patients. This is a foundation for improving maternal care and maternal and fetal outcomes","No","","283637101.7.1","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Acknowledged","JQ",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 18_DY9-10 Regional Tracker - FINAL Tracker.xlsb","18_283637101","283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",650,"Maternal and Infant Health Care","","Edit","","Provision of services to individuals that address social determinants of health",null,"Using the Behavioral Health Risk Assesment-CH each patient will be evaluated at each visit and at other most suitable times of care for behavioral health risks. Providers will review these risks for the most appropriate attention, referral, follow up care, with attention to any state requirements for addressing behavioral health risks in pregnant and post-partum patients.","Integrate EBP for perinatal patients with risks for depression, substance abuse, or other behavioral health indicators, using reliable and valid screening and intervention strategies.","Evaluate confidence and competence of personnel in assessing and addressing BH risks and provide additional support/training as needed.\n","Follow up as possible (contact information for the patient is current) with patients reporting elevated risks for problems in BH or social indicators, and any referred for emergency interventions.\n","Continually reassess the value and benefits of existing tools and methods of BH assessments.","For patients with identified risks related to domestic violence, substance abuse, depression, or housing or food insecurity, coordinate appointment with licensed social worker before patient leaves office. Follow up with social worker regarding need for further care, referrals, and progress."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","Behavioral Health Risk Assessments are a crucial component of the complete care plan for perinatal women, especially those with compelling exposure to poor social determinants of health. Without continuing professional development and on-going quality management processes being integrated into the clinic routine, insufficient attention may be given to developing prevention and effective and timely evidence-based interventions.","No","","283637101.7.1","JQ","Provider had filled in an \"other name\" even though they had selected from the menu of core activities. I deleted that \"other name\" (Behavioral Health Risk Assessment) and spelled out the corresponding acronym in the Core Activity description field so that it was clear what that meant. ","Y","NB","Accepting 1st review results but changed to NMI","Needs More Information","HHSC edited the Core Activity description to spell out the acronym and remove the unnecessary \"Other Name\" description. Please respond if provider disagrees with this change. HHSC recommends that the provider revisit its secondary drivers and change ideas to see if any information can be added (new secondary drivers and/or change ideas) to show what provider is doing for addressing social determinants of health since this is the Core Activity area. Please include responses in the the \"Provider Response\" column.","I agree with the change. Thank you for making that change. \nIn order to address the social determinants of health, our clinic continually assesses behavioral health factors with some focus on domestic violence risks, substance abuse risks, depression symptoms, and other social conditions such as housing, nutrition and social/family support throughout prenatal and postpartum care. We have created improved partnership and access to care with other providers, specifically social workers, to address these social issues. We provide access to a licensed social worker by coordinating an appointment with the social worker before the patient leaves our office. Close follow-up is done with the patient, with our office receiving information from the social worker regarding need for further care, referrals, and progress. In addition, we provide access to inpatient facilities if necessary.\nIn Core Activity ID 650 Integrate EBP for perinatal patients etc.\nFor Secondary Driver 1\nWe request to replace existing Change Ideas 1, 2, and 3 as below.\nChange Idea 1: Evaluate confidence and competence of personnel in assessing and addressing BH risks and provide additional support/training as needed.\nChange Idea 2: Follow up as possible (contact information for the patient is current) with patients reporting elevated risks for problems in BH or social indicators, and any referred for emergency interventions.\nChange Idea 3: Continually reassess the value and benefits of existing tools and methods of BH assessments.","JQ","2/3: Provider response is helpful, but they did not include some of the detail from response in their requested changes to their change ideas. Will email provider to suggest language integrating that. If provider accepts, add it to here. 2/5: Provider agreed with proposed additional language. No further information needed. ","N",null,null,"Accepted","HHSC has updated the Core Activity based on provider response, specifically HHSC added Change Idea 4.  ","Provision of services to individuals that address social determinants of health.","CA-4","CA-4.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_088189803","088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public",656,"Access to Specialty Care Services","","Continue","","Improvement in access to specialty care services with the concentration on underserved areas","","We are working on improving care in our emergency department, with improved communication and documentation focusing on improving patient outcomes and reducing unnecessary readmissions. We are hopeful that increased access to speciality care for our patient population will help us meet our goals for our ED initiative as well as providing other benefits to our patients. We are in rural area with little access to health care. Many of our patients do not have routine medical care. We are hopeful that by increasing access to specialists that we will not only reduce unnecessary visits to the ER, but also improve patient outcomes after an ER visit by providing local access to speciality care. Availability of speciality care can also help promote overall health and routine care for our patients. We are hoping to benefit from the increased focus on efficiency, documentation, and communication in our emergency department as well as our other departments and ancillary services.","To stregthen partnerships regionally and provide services that were previously unavailable to our population.","Solidify an arrangment for regular specialty services at our clinic."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","Increased speciality care services for our population may prevent unecessary emergency care. With regular speciality care available locally, our patients willl likley utilize the services and prevent issue from escalating to the point of emergency care.","No","","088189803.7.1","FG","\"Description of Measure Bundle/Measure Impact\" answer does not address how Core Activity will impact measure bundle. Approving but flagging for second review.","Y","NB","Accepting as is. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Improvement in access to specialty care services with the concentration on underserved areas, so providers can continue to increase access to specialty care in the areas with limited access to services.","CA-2","CA-2.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_094138703","094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public",657,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes",null,"We plan to develop stategies focused on providing patients with access to providers that can help them stop smoking, make sure they are receiving their pneumonia vaccinations and discuss Advance Care Planning.","Develop methods for identifying and providing intervention to patients that use tobacco","Use of the EMR to identify patients using tobacco","Provide smoking cessation counseling and/or treatment to identified patients."," "," "," ","Develop methods for identifying patients that need the pneumonia vaccine","Use posters to advertise the benefits of getting the pneumonia vaccination"," "," "," "," ","Develop methods for identifying and providing information to patients who do not have an Advance Care Plan","Use the EMR to identify patients over the age of 65 who do not have an Advance Care plan","The nurse will explain benefits of Advance Care planning to each patient over the age of 65 who doesn't have an Advance Care Plan"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity impacts the K1 measure bundle directly.  Pneumonia vaccination status for older adults is one of the selected measures for this bundle.","No","","094138703.7.1","FG","Core Activity Name is listed as \"Other\" with a second name as \"Implementation of evidence-based strategies to empower patients to make lifestyle changes\". This is the exact name of Core Activity CA-7.4. Changing activity name. ","Y","NB","Accepting 1st review recommendations.","Needs More Information","HHSC has updated the Core Activity from \"Prevention and Wellness/Other\" to \"Prevention and Wellness/Implementation of evidence-based strategies to empower patients to make lifestyle changes\" to better align with the provider’s described Core Activity. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and indicate whether another Core Activity is appropriate instead of “Other”.","Provider agrees with updated description","FG","Provider accepted HHSC's change. Approving.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_110856504","110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public",658,"Access to Primary Care Services","","Continue","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","We have added two new providers Dr. Agarwal and Jim Sowards FNP to our Rural health clinics and will be increasing the hours open to help with patients having more access to our providers without having to use emergency care services.","Assessment of needs from patient as to why they were needed to be seen in later hours","provision of physical exams as to underlining issue for recurring appointments"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","by increasing the hours at the clinic and finding the underlining issue for these late after hour appoinments we strive to decrease readmissions in the Emergency care department.","No","","110856504.7.1","FG","Answers for secondary drivers and \"Description of Measure Bundle/Measure Impact\" column are kind of vague - they generally make sense but don't offer much detail. Not sure if that warrants NMI or not so am flagging for second opinion.","Y","NB","Accepting as is. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_119874904","119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public",660,"Access to Primary Care Services","","Continue","","Provision of vaccinations to target population","","We aim to ensure that more patients have the opportunity to receive the vaccinations they need.  We will do this by reaching the patients of our rural health clinic.","Patient education on the benefits of timely vaccinations","Physicians will provide education to patients in need of vaccinations. We plan to have physicians expand their explanations of the benefits of vaccinations during rural health clinic appointments."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity directly impacts the achievement of our selected measures in the K1 measure bundle.  Pneumonia vaccination status for older adults is one of our selected measures for this bundle.","No","","119874904.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of vaccinations to target population","CA-1","CA-1.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_119874904","119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public",661,"Prevention and Wellness","","Continue","","Implementation of strategies to reduce tobacco use","","Tobacco use is detrimental to the health and wellness of patients.  This core activity aims to aid rural health clinic patients identifying as tobacco users in the cessation process with the hopes of reducing tobacco use and improving overall health and wellness.  We will achieve this by implementing a tobacco cessation counseling intervention protocol in our rural health clinic.","Implementation of a tobacco cessation counseling intervention protocol for rural health clinic visits when patients identify as tobacco users.","Measure the percentage of rural health clinic patients identifying as tobacco users receiving cessation counseling intervention during rural health clinic visits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity directly impacts the achievement of our selected measures in the K1 measure bundle. Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention is one of our selected measues for this bundle.","No","","119874904.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of strategies to reduce tobacco use (Example of evidence based models: 5R's (Relevance, Risks, Rewards, Roadblocks, Repetition) for patients not ready to quit; Ottawa Model; Freedom From Smoking Curriculum- American Lung Association among others)","CA-7","CA-7.2"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_119874904","119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public",727,"Access to Primary Care Services","","New","","Provision of screening and follow up services","","We aim to ensure that patients are receiving their annual wellness visits, screenings and follow ups as necessary. We will achieve this by reaching our rural health clinic patients with the help of a practice improvement corporation. Together we identify rural health clinic patients who have not received their annual wellness visits or necessary screenings and contact them to schedule these appointments. ","Scheduling wellness visits and screenings for rural health clinic patients","A medical wellness nurse along with the practice improvement corporation identify rural health clinic patients who have not received their annual wellness visits or necessary screenings and contact them via telephone to schedule these appointments.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity directly impacts the achievement of our selected measures in the K1 measure bundle. Advanced Care Planning, determining Pneumonia Vaccination Status for older adults, Tobacco Use: Screening and Cessation Intervention, and Controlling High Blood Pressure all occur during rural health clnic appointments. None of these measures could be achieved without annual wellness visits and screenings.","No","","119874904.7.1","FG","All responses make sense and core activity seems directly related to selected measures. Flagging because adding this Core Activity was not included in DY8 Reporting.\nAlso - all I changed in the \"Description of Measure Bundle\" column was deleting some extra empty lines.","Y","NB","it is a new CA.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC deleted extra spacing in the \"Description of Measure Bundle\" column. No response is needed from the provider. ",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_121777003","121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public",662,"Expansion of Patient Care Navigation and Transition Services","","Edit","We added additional changes ideas to our core activity, some in May 2019 and some in Aug/Sept 2019.  We made these changes in response to inadequate performance on the Maternal Health Bundle measures in 2018.  We realized we needed to provide additional Navigation services if we hoped to improve our performance on the Maternal Health Bundle.","Provision of navigation services to targeted patients","","As patients are identified as pregnant we will assign a patient navigator (who speaks the patients primary language).  This navigator will serve as liaison between the patient and the clinic to see that patients for appointments appropriately and direct patients to applicable resources.","Identify areas of possible improvement in maternal care that can be achieved via a patient navigator including: providing a Spanish speaking navigator, more timely initial prenatal care, attendance at post partum visits, education on Medicaid coverage, education on contraceptive options, linking patients with available community resources such as WIC.","Add a question to the patient intake interview for primary language spoken in the home for use in assigning an appropriate navigator.","Improve attendance at postpartum visits. Improved attendance at post partum visits allows us to perform depression screenings and provide education at the end of pregnancy for the patient regarding their insurance coverage for post-partum visits along with other services that are available for contraception coverage for CHIP patients. This is done via a face-to-face meeting at 35+ weeks of pregnancy and includes the following points:\n• If the patient has a possible contraceptive preference at this time, the Navigator lets them know if their insurance covers it and possible alternatives if she does not have coverage for her desired contraceptive.  \n• The Navigator lets the patient know that she will be contacting them while they are in the hospital for delivery to schedule their postpartum appointments and she lets them know that if for some reason they deliver at another facility to please call the navigator to schedule their postpartum appointments. This will circumvent two areas of challenge in scheduling post partum appointments. First, it removes the burden from the patient to call into the office for their appointment after they are discharged home, and second, it circumvents difficulty in contacting patients arising from limited cell phone minutes, full voice mail boxes, etc.\n• The navigator also verifies that their coverage has not lapsed, and if it has, she works with them to get it reinstated before delivery.  \n• If the patient has CHIP coverage, she advises them that even though their coverage terminates the last day of the delivery month that they still are entitled to two postpartum visits under the CHIP plan.","In order to improve the percentage of long acting reversible contraception (LARC) and sterilization achieved by our maternal patients, beginning May 2019 the patient navigator provides contraceptive navigation services including:\n• Ensuring that the prescription for the IUD or Nexplanon has been received by the appropriate specialty pharmacy and that the device is received in a timely fashion.\n• Helping CHIP patients complete the Bayer patient assistance program Mirena application and ensuring that it reaches Bayer. She also advises CHIP patients that we will insert the device at no expense to the patient.\n• For patients desiring sterilization she advises them of their insurance coverage and helps CHIP patients set up a payment plan for the cost.","In order to improve the timeliness of the initial prenatal appointments of our maternal patients, beginning in May of 2019 the patient navigator assists with Medicaid enrollment. Many patients seem to bog down in the enrollment process, finding it very complex. The navigator can explain language they do not understand, provide scanning and fax help, and advise the patient in what to expect. She preferentially schedules their initial prenatal appointment once their coverage is effective in order to achieve an initial prenatal visit with the first trimester or within 42 days of Medicaid enrollment.","To provide earlier education on Medicaid coverage that is specific to the earlier stages of prenancy and to link patients with available community resources, beginning in August 2019 the navigator meets with prenatal patients after their initial prenatal appointment (if not initial then within the first 2 appointment excluding the initial appointment. During the meeting the navigator:\n• Reviews their insurance coverage and provides any needed assistance\n• Educates the patient on the value-added services offered by their MCO (gift cards for visit attendance etc.) and the process to obtain the services on their part.\n• Educates the patient on community resources they may need such as; WIC, food back, ABBA"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","a. As we reviewed prenatal and postpartum charts for our baselines we noted that patients frequently started prenatal care late and missed appointments both before and after delivery.  If the patient does not attend the recommended appointments it is not possible to provide the recommended screenings.  Patient navigators will reduce barriers that keep patients from getting timely appointments, where we will provide the services needed to improve maternal care.","No","","121777003.7.1","FG","Notes from NB in DY8 reporting are \"Provider's Secondary Drive #1 and Change Ideas need clean up\". Added a note to provider asking them to edit responses - I wasn't sure exactly how to word it, so the comment will probably need editing. Additionally, \"Description of Measure Bundle/Measure Impact\" answer doesn't directly address how Core Activity will impact the measure bundle.  ","Y","NB","Accepting 1st review recommendations.","Needs More Information","Provider needs to make changes to its Secondary Driver 1 and corresponding Change Ideas. Provider should edit the Secondary Driver to encompass all Change Ideas. The Change Ideas should each address specific steps the provider will take to achieve the provider's goals and should address separate components of the Secondary Driver - currently the Change Ideas are not distinct and provider could consider combining some. ","2ndary driver\nIdentify areas of possible improvement in maternal care that can be achieved via a patient navigator including; providing a Spanish speaking navigator, more timely initial prenatal care, attendance at post partum visits, education on Medicaid coverage, education on contraceptive options, linking patients with available community resources such as WIC.\n\nChange idea 1\nAdd a question to the patient intake interview for primary language spoken in the home for use in assigning an appropriate navigator.\n\nChange idea 2\nContact obstetric patients while they are inpatients for delivery and schedule post-partum appointments.  This will circumvent two areas of challenge in scheduling post partum appointments.  First, it removes the burden from the patient to call into the office for their appointment after they are discharged home, and two it circumvents difficulty in contacting patients arising from limited cell phone minutes, full voice mail boxes etc.  Improved attendance at post partum visits allows us to perform depression screening and contraception family planning that are part of the post-partum visits.\n\nChange Idea 3\nThis change idea is to further improve attendance at postpartum visits and improve contraceptive and family planning.  To do this we will provide education at the end of pregnancy for the patient of their insurance coverage for post-partum visits and contraception along with other services that are available for contraception coverage for CHIP patients.  This is done via a face-to-face meeting at 35+ weeks of pregnancy and includes the following points.\n• contraceptive options with the patient.  If the patient has a possible contraceptive preference at this time, she let them know if their insurance covers it and possible alternatives if she does not have coverage for her desired contraceptive.  \n• The Navigator lets the patient know that she will be contacting them while they are in the hospital for delivery to schedule their postpartum appointments and she lets them know that if for some reason they deliver at another facility to please call the navigator to schedule their postpartum appointments. \n• The navigator also verifies that their coverage has not lapsed, and if it has, she works with them to get it reinstated before delivery.  \n• If the patient has CHIP coverage, she advises them that even though their coverage terminates the last day of the delivery month that they still are entitled to two postpartum visits under the CHIP plan.\n\nChange Idea 4\nTo improve the percentage of long acting reversible contraception (LARC) and sterilization achieved by our maternal patients we took additional actions specific to LARCs/sterilization. In May of 2019 the patient navigator began to provide contraceptive navigation services including;\n• Ensuring that the prescription for the IUD or Nexplanon has been received by the appropriate specialty pharmacy and that the device is received in a timely fashion.\n• Helping CHIP patients complete the Bayer patient assistance program Mirena application and ensuring that it reaches Bayer.  She also advises CHIP patients that we will insert the device at no expense to the patient.\n• For patients desiring sterilization she advises them of their insurance coverage and helps CHIP patients set up a payment plan for the cost.\n\nChange Idea 5\nIn order to improve the timeliness of the initial prenatal appointments of our maternal patients in May of 2019 the patient navigator began to assist with Medicaid enrollment.  Many patients seem to bog down in the enrollment process, finding it very complex.  The navigator can explain language they do not understand, provide scanning and fax help, and advise the patient in what to expect.  She preferentially schedules their initial prenatal appointment once their coverage is effective in order to achieve an initial prenatal visit with the first trimester or within 42 days of Medicaid enrollment.\n\n\nChange Idea 6\nTo provide earlier education on Medicaid coverage that is specific to the earlier stages of prenancy and to link patients with available community resources in August of 2019 the navigator began meeting with prenatal patients after their initial prenatal appointment (if not initial then within the first 2 appointment excluding the initial appointment. During the meeting the navigator\n• Reviews their insurance coverage and provides any needed assistance\n• Educates the patient on the value-added services offered by their MCO (gift cards for visit attendance etc.) and the process to obtain the services on their part.\n• Educates the patient on community resources they may need such as; WIC, food back, ABBA","FG","Edited Secondary Driver 1 and Change Ideas 1-5 based on provider response. Combined provider's suggested Change Ideas 2-3 into one (now Change Idea 2) because they were very similar & because provider suggested six Change Ideas and there is only space for five. I think provider response sufficiently addressed the NMI. Approving but flagging for second review to have a second opinion because provider made significant changes to their Secondary Driver and Change Ideas. ","Y","NB","Acceptable. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically Secondary Driver 1 and Change Ideas 1-5. HHSC also combined provider's suggested Change Ideas 2 and 3 into one Change Idea (under Change Idea 2). ","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_121777003","121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public",728,"Maternal and Infant Health Care","","New","","Coordinated prenatal and postpartum care","","NTMC will expand access to pre and post natal services to improve the continuum of pregnancy care from prenatal stage through delivery and postpartum care.","Increase access to prenatal & postpartum services for MLIU patients who deliver at NTMC.","Increase patient volume at Cooke County Medical Center through educational campaigns and outreach.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E1","By increasing the number of MLIU obstetric patients that we provide services to, we increase our opportunity to provide the services covered under the measures our our bundle, depression & abuse screening, glucose screening for gestational diabetes patients, and contraceptive education.","No","","121777003.7.1","FG","All responses make sense and Core Activity seems directly related to selected measures. Flagging because adding this Core Activity was not included in DY8 Reporting.","Y","NB","it is a new CA.","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated prenatal and postpartum care","CA-4","CA-4.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_127310404","127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public",663,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","We plan to use the EMR to identify the frequent ED users and provide them with education of non-emergent issues in an attempt to navigate them to appropriate health care.","Use EMR to identify frequent users and medications on record.","Review medication listed in the EMR to help identify possible needed education to prevent future ED visits."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","We will use EMR to track the patients and improve the medication reconciliation, transfer communication and decision to admit time to ED departure time.","No","","127310404.7.1","FG","\"Description of Measure Bundle/Measure Impact\" answer does not address how Core Activity will impact measure bundle. Approving but flagging for second review.","Y","NB","Accepting as is. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_127373205","127373205.7.1",19,127373205,"Helen Farabee Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",653,"Substance Use Disorder","","Edit","","Office-based additional treatment for uninsured individuals",null,"The Core Activity is the operation of outpatient substance use treatment programs established during DSRIP years 2-6. These six clinics throughout the region screen for substance use disorder conditions and provide individual and group treatment.  The clinics will be used to identify patients that need alcohol or other drug abuse treatment.","Create list of identified patients in each clinic and merge into master list.","Initiate alcohol or other drug treatment within 14 days of AOD diagnosis.","Provide ongoing preventive care and education to patients identified with unhealthy substance use."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-146; M1-319; M1-317; M1-165","Provider selected activities that impacted measures related to CCBHC certification. This was done to align ongoing waiver activity with our CCBHC efforts. The measures being impacted are required reporting measures for CCBHC clinics. ","No","","127373205.7.1","FG","After reviewing the Core Activity menu, I think the \"Other\" title within the \"Substance Use Disorder\" grouping is appropriate, but am flagging for a second opinion. Also flagging because they used the same answer for all three activities in the \"Description of Measure Bundle/Measure Impact\" column - not sure if their answer is specific enough.","Y","NB","askign for changes on Other, NMI","Needs More Information","Please respond in the \"Provider Response\" column with the suggested changes.","Provider selected activities that impacted measures related to CCBHC certification. This was done to align ongoing waiver activity with our CCBHC efforts. The measures being impacted are required reporting measures for CCBHC clinics.","FG","Updated \"Description of Measure Bundle/Measure Impact\" column based on provider response. Talked to NB, response was sufficient.\n\nContacted provider regarding \"Other\" designation (name was \"Implementation of drug treatment and ongoing preventive care and education\"). On 2/6/20 provider agreed to change \"Other\" to “Office-based additional treatment for uninsured individuals”. I updated the Core Activity Name. Approving but flagging for second review just to confirm that the new Core Activity name is a good fit (provider didn't want to make any changes to description or drivers).","Y","NB","Acceptable. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the Core Activity Name from \"Other\" to “Office-based additional treatment for uninsured individuals”. Additionally, based on the provider response HHSC updated the \"Description of Measure Bundle/Measure Impact\" column.","Office-based additional treatment for uninsured individuals","CA-10","CA-10.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_127373205","127373205.7.1",19,"127373205","Helen Farabee Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",654,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Patients that are overweight, sedentary, utilize tobacco products, or have unhealthy alcohol use will be provided with interventions that focus on the direct and indirect costs of engaging in those behaviors.  After screening for tobacco use, alcohol use, BMI, nutritional choices, and daily physical activity, education will be provided in an effort to prevent and/or manage the behaviors that are the root cause of an unhealthy lifestyle.","Create screening questions to identify patient needs.","Provide counseling, education and training related to alcohol and tobacco use.","Provide counseling on weight management, physical activity, and nutrition."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-165; M1-317; M1-146; M1-319","Provider selected activities that impacted measures related to CCBHC certification. This was done to align ongoing waiver activity with our CCBHC efforts. The measures being impacted are required reporting measures for CCBHC clinics. ","No","","127373205.7.1","FG","Flagging because they used the same answer for all three activities in the \"Description of Measure Bundle/Measure Impact\" column - not sure if their answer is specific enough. Everything else looks good.","Y","NB","goo general - NMIed","Needs More Information","Provider should include additional details in the  \"Description of Measure Bundle/Measure Impact\" column. Provider should include responses in the \"Provider Response\" column. ","Provider selected activities that impacted measures related to CCBHC certification. This was done to align ongoing waiver activity with our CCBHC efforts. The measures being impacted are required reporting measures for CCBHC clinics. ","FG","Updated \"Description of Measure Bundle/Measure Impact\" column based on provider response. Talked to NB, response was sufficient and am approving.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the  \"Description of Measure Bundle/Measure Impact\" column.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_127373205","127373205.7.1",19,"127373205","Helen Farabee Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public",655,"Availability of Appropriate Levels of Behavioral Health Care Services","","Edit","","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","","This Activity will screen for clinical depression, identify patients with major depressive disorder that might be a suicide risk, and monitor depression remission after 12 months of intervention.  Follow up services will be provided as needed.","Using a standardized screening tool to assess consumers for clinical depression.","The results of the screening may indicate different levels of intervention based on severity. These interventions (e.g. skills training, counseling, etc.) may be separated by Levels of Care in the Texas Resiliency and Recovery model. The appropriate level of care will be assigned in order to provide the required intervention."," "," "," "," ","Create a follow-up plan for identified patients to monitor for remission.","Create goals within follow-up plan for patients to be in remission after 12 months of treatment."," "," "," "," ","Identify clinically depressed patients that could be a suicide risk.","Assure that the appropriate level of care is provided based on age and level of care. The results of screenings may indicate different levels of intervention based on severity. These interventions (e.g. skills training, counseling, etc.) may be separated by Levels of Care in the Texas Resiliency and Recovery model. The appropriate level of care will be assigned in order to provide the required intervention."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-105; M1-165; M1-319; M1-146; M1-317","Provider selected activities that impacted measures related to CCBHC certification. This was done to align ongoing waiver activity with our CCBHC efforts. The measures being impacted are required reporting measures for CCBHC clinics. ","No","","127373205.7.1","FG","Notes from NB in DY8 reporting are \"Secondary Driver 1: Change Idea 1 and Secondary Driver 3: Change Idea 1- need clarifying, vague right now. How will they assure?\". Adding a note to the provider asking them to address this question. Also flagging because they used the same answer for all three activities in the \"Description of Measure Bundle/Measure Impact\" column - not sure if their answer is specific enough.","Y","NB","OK","Needs More Information","Provider needs to make changes to its Secondary Driver 1, Change Idea 1 and Secondary Driver 3, Change Idea 1 to address specific steps the provider will take to assure that the appropriate level of care is provided. Provider should include responses in the \"Provider Response\" column. ","Secondary Driver 1, Idea 1 and Secondary Driver 3, Idea 1: the results of the screeening may indicate different levels of intervention based on severity. These interventions (e.g. skills training, counseling, etc.) may be seperated by Levels of Care in the Texas Resiliency and Recovery model. The appropriate level of care will be assigned in order to provide the required intervention. ","FG","Updated \"Description of Measure Bundle/Measure Impact\" column based on provider response. Talked to NB, response was sufficient.\n\nAlso updated Change Idea 1 for Secondary Drivers 1 & 3 based on provider response. Changes sufficiently addressed the NMI, approving.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically the Secondary Driver 1: Change Idea 1, Secondary Driver 3: Change Idea 1, and the \"Description of Measure Bundle/Measure Impact\" columns.","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","CA-9","CA-9.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_135034009","135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public",665,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Provision of navigation services to targeted patients","","We plan to use data from our clinics and emergency room to target MLIU patients with chronic disease and unhealthy lifestyles that we can provide with additional services to assist them in managing or preventing a chronic disease.  We will also focus on our pediatric patients to improve their health through proper immunizations and disease treatment.  Our patient liaison/care navigators will track patients and encourage healthy lifestyles.","Identify patients with chronic disease, unhealthy lifestyles, and children in the at-risk population","Utilize patient liaisons in each clinic to identify patients that could benefit from focused services prior to their primary care visit.  The liaisons will work with patients and our 8 primary care providers to coordinate care and identify opportunities for improving lifestyle choices.  Emergency department staff and providers will also work with the liaisons to insure a primary care follow-up visit is made for patients identified in the ED and reduce emergency department visits for diabetes and heart disease."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A2; C1; A1","A1 and A2 are chronic disease measures.  C1  measures wellness activities.  By expanding our navigation services, we can more closely monitor our patients with chronic disease and monitor adults and children alike to encourage getting regular checkups, compliance with drug reigmens, and making good lifestyle choices.","No","","135034009.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of navigation services to targeted patients (e.g., patients with multiple chronic conditions, cognitive impairments and disabilities, Limited English Proficient patients, the uninsured, those with low health literacy, frequent visitors to the ED, and others)","CA-6","CA-6.1"]
["DY9-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_135034009","135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public",729,"Chronic Care Management","","New","","Utilization of pharmacist‐led chronic disease medication management services","","We plan to incorporate our 3 pharmacists into the care coordination process to review medications, provide additional patient education when needed, and make sure patients are procuring their medications.  ","Identify patients with poor outcomes that could be the result of a failed medication regimen.","Utilize EMR data to identify patients with poor outcomes, perform a clinical review of their medications, determine if patients are complying with their medication regimen through communication with retail pharmacists, and identify barriers, if any, to compliance.","","","","","","","","","","","","","","","","","","","","","","","","","","","","",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1; A2","Controlling diabetes and high blood pressure are generally accomplished through a medication regimen.  By adding pharmacists to the DSRIP Team that tracks and attempts to affect outcomes, we believe that we can learn more about issues facing these patients.","No","","135034009.7.1","FG","New Core Activity was also added in DY8 with no changes since then.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Utilization of pharmacist‐led chronic disease medication management services in collaboration with primary care and other health care providers","CA-8","CA-8.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_135237906","135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private",666,"Chronic Care Management","","Continue","","Management of targeted patient populations with high risk for developing complications","","Improve patients functional status, increase their ability to self-manage their condition, increase patient engagement, and reduce the need for acute care services.  Work closely with patients and their caregivers as well primary care, specialty, behavioral health, and social service providers.","Reduce ED visits, hospital visits and associated complications of the diabetic patient.","Refer to care navigators, and try checklist for comprehensive DM assessment.","Post results of practice groups compliance to measures","Provide patients with blood sugar monitoring tools","Set patient centered goals with patients that include their preferences and follow up on goal progress","Increase eye exams, foot exams, and HgB A1C testing as well as improve the results."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","By identifying and engaging high-risk patients, care management/navigation services can align patients with resources both in the acute and community setting for clinical intervention and long-term disease management. Additionally, high-risk patients are likely to benefit from interventions that address social determinants of health that impact disease progression and health care utilization patterns. This may include services such as diabetes management, preventive cancer screenings, and palliative care.","No","","135237906.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_135237906","135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private",667,"Access to Primary Care Services","","Continue","","Provision of screening and follow up services","","Ensure that the patient, the patient's care team and the patient's primary care provider are continually made aware of the patient's preventative cancer screenings.  Increasing awareness can help the patient and the provide decrease cancer rates in our region.","Increase cancer screening in the primary care setting.","Utilize the electronic medical record to track routine cancer screenings, pull reports to monitor compliance, contact patient to schedule needed screenings.","Utilize an electronic notification system to alert patients when they are behind on routine cancer screenings."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"C2","By identifying and engaging high-risk patients, care management/navigation services can align patients with resources both in the acute and community setting for clinical intervention and long-term disease management. Additionally, high-risk patients are likely to benefit from interventions that address social determinants of health that impact disease progression and health care utilization patterns. This may include services such as diabetes management, preventive cancer screenings, and palliative care.","No","","135237906.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_135237906","135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private",668,"Palliative Care","","Continue","","Provision of coordinated palliative care to address patients with end‐of‐life decisions","","Provide comprehensive specialty palliative care to patients suffering from life-limiting chronic illnesses to improve quality of life, align care and resources with disease progression, and reduce inappropriate utilization of acute care services at end-of-life by educating patients, providers, and community partners.","Ensure patient-centered medical care through identifying and communicating patient and family treatment preferences","Standardize the palliative care documentation process to identify patient and family treatment preferences","Integrate identifiers indicating patient preference for life-sustaining treatment in the electronic medical record","Normalize end-of-life care processes through educating patients, providers, and the community at large regarding palliative care, end-of-life issues, and advance directives"," "," ","Provide symptom management in the acute care setting to improve quality of life","Standardize symptom assessment tools for timely identification of symptoms such as pain and dyspnea","Facilitate symptom management through order sets, protocols, and collaboration between the multidisciplinary care team"," "," "," ","Identify high-risk patients that may benefit from palliative care services in the acute care setting","Integrate standardized risk assessments, such as the LACE score, in the electronic medical record for timely identification","Initiate referral orders based on risk assessment criteria to facilitate meaningful referrals"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"G1","Providing specialty inpatient palliative care to patients suffering from life-limiting chronic illnesses aligns with regional community needs to increase prevention, education, and services to address high mortality rates, chronic disease, preventable conditions, and unhealthy lifestyles. The integration of palliative medicine as a standard of care for chronically ill patients can normalize end-of-life care processes, align resources appropriate with disease progression, and ultimately reduce the cost of care.","No","","135237906.7.1","FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Provision of coordinated palliative care to address patients with end-of-life decisions and care needs.","CA-12","CA-12.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_138353107","138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public",669,"Access to Primary Care Services","","Edit","","Provision of screening and follow up services","","We plan to increase access to healthcare screenings and follow-up services in order to provide detection of diseases and health conditions, potentially before symptoms ever occur.  Routine healthcare screenings have the ability to provide our patients with early detection and treatment of a disease or condition, which in turn increases the chance that the disease can be successfully managed or even cured.","Increase access to annual wellness exams and/or health screening services to patients in the outpatient setting.","Rural Health Clinic staff will utilize EMR data to identify patients that are due for annual wellness exams/health screenings and these patients will be contacted and scheduled for these services."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K1","This core activity impacts Measure Bundle K1 by improving patient health through provision of health screenings and follow-up care in rural Texas.","No","","138353107.7.1","FG","For Secondary Driver 1, provider writes \"The core activity addresses access to primary care, which aligns with our bundle selection, K1 Rural Preventative Care.\" Not sure if this is specific enough, flagging for a second opinion.","Y","NB","Accepting 1st review recommendations.","Needs More Information","Provider needs to make changes to its Secondary Driver 1 to more fully address how the provider's goals for the Core Activity and what provider is doing to achieve these goals. ","SECONDARY DRIVER 1:  Increase access to annual wellness exams and/or health screening sevices to patients in the outpatient setting.                                                                                                       SECONDARY DRIVER 1 - CHANGE IDEA 1:  Rural Health Clinic staff will utilize EMR data  to identify patients that are due for annual wellness exams/health screenings and these patients will be contacted and scheduled for these services.","FG","Updated Secondary Driver & Change Idea 1 based on provider response. Approving.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC has updated the Core Activity based on the provider response, specifically Secondary Driver 1 and Change Idea 1. ","Provision of screening and follow up services","CA-1","CA-1.5"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 19_DY9-10 Regional Tracker - FINAL Tracker.xlsb","19_346945401","346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public",664,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Enhancement in coordination between primary care, urgent care, and Emergency Departments","","Expansion of navigation and transitions services will support all of the measures in our selected bundle.  Documentation of current medications in the medical record pertains to whether or not clinical staff documents the patient's currently prescribed medications within the electronic medical record for a unique patient visit.  This facilitates patient navigation between the ED, urgent care, clinic, and hospital, which will help reduce admit decision time and transfer communication.","Revise protocols and educate staff on new technology to facilitate patient navigation and transitions.","Develop policies and procedures to revise protocols that support new technology for medication management.  Assure that providers and staff are educated on the importance of current medication reconciliation in the EMR in order to facilitate a quicker admit decision time and/or emergency transfer."," "," "," "," ","Enhancing Technology:  Using an External Medication History to improve the accuracy of the documentation of current medications in the medical record.","Utilization of an external medication history optimization to our EMR via a 3rd party vendor.  Clinical staff will now be able to automatically retrieve data regarding a patient's filled prescriptions directly from a manageable list of pharmacies."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"K2","This External Medication History process takes advantage of the latest technology to access multiple Pharmacy databases, providing the most accurate, real-time, patient prescription data that is currently possible. We feel confident this will improve the percentage of Documentation of Current Medications in the Medical Record.","No","","346945401.7.1","FG","In \"Description of Measure Bundle/Measure Impact\" column provider doesn't address how Core Activity will impact the measure bundle. However, in \"Description of Core Activity\" column, provider writes \"Expansion of navigation and transitions services will support all of the measures in our selected bundle.\" Approving but flagging for second review.","Y","NB","Accepting as is. ","Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.",null,"FG",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Enhancement in coordination between primary care, urgent care, and Emergency Departments to increase communication and improve care transitions for patients","CA-6","CA-6.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_094186602","094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private",672,"Chronic Care Management","","Edit","The Mines Road Clinic was closed and replaced with the Hillside Health Center. This will serve as a resource for follow up care for patients seen in the Mobile Clinic. ","Management of targeted patient populations with high risk for developing complications","","The mobile unit and Hillside Health Center will be utilized as an access point and resources for screening diabetic patients and ensuring that they receive proper follow up care and resources. The Hillside Health Center will serve as a potential resource for follow up care after they are seen on the Mobile Clinic.","Screening patients for diabetes is the initial function of this project and will drive treatment and navigation services","Once screened and identified, the patient will be educated on their chronic disease and referred to appropriate resources to reduce the diabetes composite"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"A1","Chronic disease management is the foundation for managing a diabetic population and attempting to reduce the complications that typically result from diabetes such as IP admission and ED visits.","No","","094186602.7.1","BTM","Provider's edit was the same as DY8R2, which was accepted by NB. Accepting edit to description of core activity.","N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","No response is required.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Management of targeted patient populations; e.g., chronic disease patient populations that are at high risk for developing complications, co-morbidities, and/or utilizing acute and emergency care services","CA-8","CA-8.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_121989102","121989102.7.1",20,"121989102","Border Region MHMR Community Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",670,"Prevention and Wellness","","Edit","","Implementation of evidence-based strategies to empower patients to make lifestyle changes","","Border region will provide educational materials and outpatient services to individuals with diabetes.","Primary care staff will work individually and in groups to provide strategies in order to decrease and normalize blood pressure and A1C levels.","Behavioral health staff refers all clients to Primary Care clinic for additional screening and diagnosis based on A1C scores.  Lab work will be obtained in order to confirm diagnosis.","Clients will be referred to self-care classes in order to decrease and normalize their condition.","Clients will be referred to nutritional classes to make long-term improvements to their health."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-115; M1-103; M1-207","The selected core activity helps us attain the selected measures. Prevention and Wellness: Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and selfmanage their chronic conditions Clients will be referred to Primary Care Clinic to  receive a comprehensive evaluation including diagnosing and monitoring of blood pressure,  diagnostic workup for diabetes.  Identify A1C levels of clients identified with Diabetes and high blood pressure will be referred to diabetic self-management classes to empower them to make lifestyle changes to stay healthy and learn to manage their chronic conditions, this would include monitoring by Primary Care Clinic, attending nutritional classes and working towards improving their high blood pressure and decreasing their A1C levels.","No","","121989102.7.1","BTM","Changed core activity description to remove Cat C measure references and provide a high level summary of provider's activities. I think secondary driver 1 is very vague. I am not sure what the group classes are, nutritional?","Y","NB","Accepting 1st review results","Needs More Information","HHSC has updated provider's description of the core activity to focus on activities being completed under the core activity, rather than Cat C measures. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and provide an alternate description of the core activity. In addition, HHSC requests that provider updates the Secondary Driver 1 language to identify the group classes.","Provider is in agreement with HHSC's update.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Implementation of evidence-based strategies to empower patients to make lifestyle changes to stay healthy and self-manage their chronic conditions","CA-7","CA-7.4"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_121989102","121989102.7.1",20,"121989102","Border Region MHMR Community Center","Community Mental Health Center (CMHC)","Non‐State Owned Public",671,"Substance Use Disorder","","Edit","","Office-based additional treatment for uninsured individuals",null,"Screening, provision of educational materials and outpatient services for individuals identified with substance abuse disorders.","Primary care and substance abuse will work individually and in groups to provide strategies in order to work client to work towards recovery.  If needed LCDC will refer client to substance abuse facility for detox and treatment.  Clients will be provided with counseling services to meet their recovery goal.","Screening and assessment of all clients who receive services at Border Region.  Behavioral health staff refers all clients to Primary Care clinic and/or substance abuse for screening and diagnosis.  Lab work will be obtained in order to confirm substance abuse issue.","Clients will be refered to LCDCs to enroll and participate  self-care sessions in order to begin the recovery process.","Clients will be referred to nutritional classes to make long term improvements to their health.","Clients will be screened for tobacco usage and provided treatment options.  This will include patches, gum and counseling sessions."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"M1-261; M1-105","The selected core activity helps us attain the selected measures. Education and outpatient treatment of clients identified with substance use issues.  Border Region will evaluate clients for substance abuse and for tobacco use.  Clients will be referred for education and outpatient treatment on substance abuse and tobacco use as a primary prevention and intervention.","No","","121989102.7.1","BTM","Don't think there's a better option than \"other\" for the core activity. Changed core activity description to remove Cat C measure references and provide a high level summary of provider's activities.","Y","NB","OK but revisit other","Needs More Information","HHSC has updated provider's description of the core activity to focus on activities being completed under the core activity, rather than Cat C measures. If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and provide an alternate description of the core activity. HHSC requests that the provider considers a change that would bring its Core Activity on the menu. Could any of the existing options work? For example, \"Office-based additional treatment for uninsured individuals\". If the activity does not match the title (e.g. Medicaid clients are also served) that can be included in the Core Activity description. Please respond in the \"Provider Response\" column with the suggested changes or indicate whether another Core Activity is appropriate instead of “Other”.","E-mailed on 2/5/20: Provider is in agreement to change core activity name to \"Office-baed additional treatment ofr uninsured individuals\" and with HHSC's update to description.","BTM","Provider is in agreement to changes.","N",null,null,"Accepted","HHSC has updated the Core Activity name to \"Office-based additional treatment of uninsured individuals\" based on provider's e-mailed response on 2/5/20.","Office-based additional treatment for uninsured individuals","CA-10","CA-10.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_137917402","137917402.7.1",20,"137917402","City of Laredo","Local Health Department (LHD)","Non‐State Owned Public",673,"Access to Primary Care Services","","Edit","","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","","The Access to Primary Care Services Core Activity will allow us to enhance our clinical services, by  increasing our clinic's hours and staff, therefore, improving access to care for vulnerable  individuals with chronich disease or at high risk. One of our main goals is to promote prevention and early detection of chronic disease given their high prevalence in our community.","Additional clinic hours, additional support staff, primary care services promotion, new patient recruitment in different community settings, etc.","Extending our clinic's hours especially during our previously identified high volume days."," "," "," "," ","Increase the functionality and operations of the current clinical services.","The addition of support staff to our primary care clinic to provide more efficient healthcare delivery services."," "," "," "," ","Primary care services promotion to ensure our target population is being reached.","Outreach efforts will be conducted through different outlets such as social media, print media, television, and radio."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-115","By increasing our healthcare delivery capacity through additional hours, staff, and promotion, we aim to achieve better health outcomes for patients with Diabetes. We have standardized Hemoglobin A1c  testing at every clinical encounter as the main tool to assess treatment success and metabolic improvement of our existing patients and additional ones that may be referred to our clinic as a result of increased outreach efforts.","No","","137917402.7.1","BTM","Removed test info from the secondary driver 1 and change idea 1. It shows up as an edit, but I don't think it needs to be sent to provider. Just leaving it as \"Accepted\".","Y","NB",null,"Needs More Information","Provider's selection of the Core Activity for DY9-10 is accepted. HHSC edited Secondary Driver 1 and its Change Idea 1 to removed references to test info. If provider disagrees with the edits, please respond in the \"Provider Response\" column. ","Provider is in agreement with HHSC's update to description and would like to change the core activity name to Office-based additional treatment for uninsured individuals.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","CA-1","CA-1.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_137917402","137917402.7.1",20,"137917402","City of Laredo","Local Health Department (LHD)","Non‐State Owned Public",674,"Prevention and Wellness","","Continue","","Self‐management programs and wellness programs using evidence‐based designs","","Our primary care clinic has a policy that establishes that patients with chronic disease or at high-risk  must be referred to our Disease Self-Management (DSM) program in an effort to promote tratment compliance and positive health outcomes. Our evidence-based DSM program  offers diabetes and hypertension self-management education; hypertension and diabetes screenings; physical activity demonstrations such as Zumba classes and walking club, nutrition education classes that promote portion control, psychosocial case management, and peer support.","Disease Self-Management Education for individuals with Diabetes and Hypertension.","Education that targets the importance of disease prevention, medical homes, chronic disease treatment compliance.","Instruction on dietary and lifestyle changes to prevent and or improve health outcomes of individuals with hypertension and diabetes diagnoses."," "," "," ","Enhancement of patient referral process from the clinics to the Disease Self-Management program.","Increased DSM referral policy adherance by the clinical team that includes, physicians, mid-level providers, nurses, medical assistants, and clerks."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,1,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"L1-207","Increase Disease Self-Management (DSM) interventions in patients with diabetes and obesity diagnoses and or hypertension by using evidence-based programs. Our Healthy Living Viviendo Mejor (an evidenced based program) is designed for individuals with chronic disease or at high risk and it provides diabetes and hypertension self-management and education; physical activity, learning to eat and cook healthier, manage hypertension, provides for hypertension and diabetes screenings; physical activity,nutrition education, psychosocial case management and peer education. Through our DSM interventions we improve health outcomes such as blood pressure levels in individuals with diabetes and hypertension and lower A1C.","No","","137917402.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","No response is required.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Self-management programs and wellness programs using evidence-based designs (e.g., Stanford Small-Group Self-Management Programs for people with arthritis, diabetes, HIV, cancer, chronic pain, and other chronic diseases; SAMHSA's Whole Health Action Management among others)","CA-7","CA-7.1"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_162033801","162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private",675,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Expansion of access to medical advice and direction to the appropriate level of care","","The reasoning behind using this core activity is to reduce preventable hospital readmissions and transition patients to the appropriate level of care. By using our system components we will be able to improve our current metrics.","Continuous improvement by improving communication amongst providers and usage of EMR to prevent readmissions.","Coordination with Case Management for vulnerable populations. To improve coordination of care with Case Management Laredo Medical Center has implemented workflow processes for transition of care management.  This effort is being led by our ACEO by meeting weekly to ensure processes are being met, and follow up training is provided as needed.","Better utilization of EMR. To improve EMR utilization additional training will be implemented by clinical informaticist, our in-house expert, and additional resources will be made available to all staff.  This effort is being led by our ACEO.  Monitoring of completion and continuous oversight will be conducted on a monthly basis."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B1","The reasoning behind using this core activity is to reduce hospital readmissions and transition patients to the appropriate level of care. By using our hospital resources we will be able to improve our current metrics.","No","","162033801.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","No response is required.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Expansion of access to medical advice and direction to the appropriate level of care to reduce Emergency Department use for non-emergent conditions.","CA-6","CA-6.6"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_162033801","162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private",676,"Expansion of Patient Care Navigation and Transition Services","","Continue","","Identification of frequent ED users and use of care navigators","","This core activity allows for Laredo Medical Center to be able to utilize patient navigators and identify opportunities for improvement in reducing preventable ED visits that don't require that level of care.","Utilizing an effective patient care navigation program to reduce ED visits that don't require that level of care.","Enlisting patient navigators to work with case management and nursing to identify vulnerable patient populations"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"B2","This core activity will help Laredo Medical Center achieve better utilization of services and place patients in the right level of care.","No","","162033801.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","No response is required.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Identification of frequent ED users and use of care navigators as part of a preventable ED reduction program, which includes a connection of ED patients to primary and preventive care.","CA-6","CA-6.3"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_162033801","162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private",677,"Maternal and Infant Health Care","","Continue","","Implement standard protocols for the leading causes of preventable death and complications","","This core activity allows for Laredo Medical Center to partner with its medical staff to implement evidence based changes that will focus on maternal and infant safety.","Maternal and infant safety for our women's services patient population","Partnering with OBGYNs to reduce cesarean section rates and improve antinatal steroid utilization."," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"E2","This core activity allows for Laredo Medical Center to partner with its medical staff to implement evidence based changes that will focus on maternal and infant safety.","No","","162033801.7.1","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","No response is required.","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Develop and implement standard protocols for the leading causes of preventable death and complications for mothers and infants (Early Elective Delivery, Hemorrhage, Preeclampsia, and Supporting Vaginal Birth and Reducing Primary Cesareans)","CA-4","CA-4.2"]
["DY7-10","C:\\Users\\Noelle\\Desktop\\Work\\DY9-10 RHP Plans\\RHP 20_DY9-10 Regional Tracker - FINAL Tracker.xlsb","20_162033801","162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private",678,"Hospital Safety and Quality","","Edit","","Implementation of standard protocols to address leading cause of hospital infections and injuries","","Improving quality and safety outcomes by focusing on best practices for Laredo Medical Center patient population. LMC continues to work on plans to provide best quality of care.","Quality Improvement Council has focused on reducing CLABSI, CAUTI, Sepsis, SSI and patients falls.","Quality Improvement Council will be following evidence based guidelines to reduce the rates tied to safety"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "," ",0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,"J1","This Core Activity will allow Laredo Medical Center to continue to Improve quality and safety outcomes by focusing on best practices for its patient population. LMC continues to work on plans to provide best quality of care.","No","","162033801.7.1","BTM","Recommend changing from Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.) to Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls). NMI and note to provider.","Y","NB","Accepting 1st review results","Needs More Information","HHSC has updated provider's core activity to focus on activities being completed as described by the provider. Specifically, HHSC changed the core activity \"Implementation of evidence-based practices to improve quality of care (e.g., Quality Departments, monitoring and evaluation, etc.)\" to \"Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)\". If the provider disagrees with the change, please provide an explanation in the “Provider Response” column and provide an alternate description of the core activity to better align with the activity chosen. In addition, HHSC removed the reference to \"J1\" in Secondary Driver 1: Change Idea 1 and replaced it with \"safety\".","Laredo Medical Center concurs with the change in description of the core activity and replacement of J1 to safety","BTM",null,"N",null,null,"Accepted","Provider's selection of the Core Activity for DY9-10 is accepted.","Development and implementation of standard protocols and/or evidence-based practices to address leading causes of hospital infections and injuries (e.g., CLABSI, CAUTI, SSI, Sepsis, and Falls)","CA-14","CA-14.1"]

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["---------------->",null,"RHP","TPI","Million $",null,"Find Value","All Matched TPIs",null,null,"388701003","017624011.7.1","Hospital","Private",null,"---------------->",null,"TPI","Core Activity ID","Core Activity Grouping","Core Activity Name Short","DYs","DY9-10 Flag","Not in DY8 Flag",null,"Find Value","All Matched TPIs",null,null,"Analysis - ALL tab",null,null,null,null,null,null,null,null,null,null,null,null,null,"Y / N / NA",null,"Core Activity ID",null,"RHP",null,"RHP","TPI",null,null,null,"TPI",null,null,{"$f":"COUNTIF($AX$3:$AX$296,'Intervention Details'!D12)","v":0},null,null,{"$f":"'Intervention Details'!D27","v":0},null,"Core Activity ID","Secondary Driver 1","Secondary Driver 2","Secondary Driver 3","Secondary Driver 4","Secondary Driver 5","Drivers",null,null,null,1,2,3,4,5,"#",1,2,3,4,5,null,1,2,3,4,5,"#",1,2,3,4,5,null,1,2,3,4,5,"#",1,2,3,4,5,null,1,2,3,4,5,"#",1,2,3,4,5,null,1,2,3,4,5,"#",1,2,3,4,5,null,null,"Stakeholders",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Cat C Measures",null,null,"TPI Selected",{"$f":"'Intervention Details'!D13","v":0},{"$f":"COUNTIF(ET4:ET2973,EX2)","v":0},null,null,"Personnel"]
[null,null,1,"388701003",{"$error":"#N/A"},null,{"$f":"#REF!","v":{"$error":"#REF!"}},{"$f":"IFERROR(INDEX($D$3:$D$296,SMALL(IF($G$3=$C3:$C296,ROW($C3:$C296)-ROW($C$3)+1),ROW(1:296))),\"\")","v":""},null,null,"388347201","020812601.7.1","Hospital","Private",null,null,null,"388701003",1,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10",{"$f":"IF(OR(V3=\"DY7-10\",V3=\"DY9-10\"),\"Y\",\"N\")","v":"Y"},{"$f":"IF(V3=\"DY9-10\",\"Y\",\"N\")","v":"N"},null,{"$f":"'Intervention Details'!$D$13","v":0},"New",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Y",null,1,null,null,null,1,"388701003",{"$f":"IF('Intervention Details'!$D$12=AX3,MAX(AZ$2:AZ2)+1,0)","v":0},null,null,{"$f":"IFERROR(INDEX($AY$3:$AY$296,MATCH(BD3,$AZ$3:$AZ$296,0)),\"\")","v":""},{"$f":"IF(BD2+1>$BF$2,\"\",BD2+1)","v":""},null,null,null,null,null,null,1,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,{"$f":"COUNTA(BL3:BP3)","v":1},null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",{"$f":"SUM(CA3:CE3)","v":1},{"$f":"IF(OR(LEFT(BU3,1)=$BT$1,LEFT(BU3,1)=\"\"),0,1)","v":1},{"$f":"IF(OR(LEFT(BV3,1)=$BT$1,LEFT(BV3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BW3,1)=$BT$1,LEFT(BW3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BX3,1)=$BT$1,LEFT(BX3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BY3,1)=$BT$1,LEFT(BY3,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",{"$f":"SUM(CM3:CQ3)","v":0},{"$f":"IF(OR(LEFT(CG3,1)=$BT$1,LEFT(CG3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CH3,1)=$BT$1,LEFT(CH3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CI3,1)=$BT$1,LEFT(CI3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CJ3,1)=$BT$1,LEFT(CJ3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CK3,1)=$BT$1,LEFT(CK3,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",{"$f":"SUM(CY3:DC3)","v":0},{"$f":"IF(OR(LEFT(CS3,1)=$BT$1,LEFT(CS3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CT3,1)=$BT$1,LEFT(CT3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CU3,1)=$BT$1,LEFT(CU3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CV3,1)=$BT$1,LEFT(CV3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CW3,1)=$BT$1,LEFT(CW3,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",{"$f":"SUM(DK3:DO3)","v":0},{"$f":"IF(OR(LEFT(DE3,1)=$BT$1,LEFT(DE3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DF3,1)=$BT$1,LEFT(DF3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DG3,1)=$BT$1,LEFT(DG3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DH3,1)=$BT$1,LEFT(DH3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DI3,1)=$BT$1,LEFT(DI3,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",{"$f":"SUM(DW3:EA3)","v":0},{"$f":"IF(OR(LEFT(DQ3,1)=$BT$1,LEFT(DQ3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DR3,1)=$BT$1,LEFT(DR3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DS3,1)=$BT$1,LEFT(DS3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DT3,1)=$BT$1,LEFT(DT3,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DU3,1)=$BT$1,LEFT(DU3,1)=\"\"),0,1)","v":0},null,null,"State or local governments (e.g., incarceration/recidivism, etc.)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TPI","Measure ID",null,null,null,null,null,null,"Executive Leadership"]
[null,null,1,"388347201",{"$error":"#N/A"},null,null,"",null,null,"094108002","094108002.7.1","Hospital","Private",null,null,null,"388347201",2,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10",{"$f":"IF(OR(V4=\"DY7-10\",V4=\"DY9-10\"),\"Y\",\"N\")","v":"Y"},{"$f":"IF(V4=\"DY9-10\",\"Y\",\"N\")","v":"N"},null,null,{"$f":"IFERROR(INDEX($S$3:$S$722,SMALL(IF($Z$3=$R$3:$R$722,ROW($R$3:$R$722)-ROW($R$3)+1),ROW(1:722))),\"\")","v":""},null,null,"Focus Areas:",null,null,null,null,null,null,null,null,null,null,null,null,null,"N",null,2,null,1,null,1,"388347201",{"$f":"IF('Intervention Details'!$D$12=AX4,MAX(AZ$2:AZ3)+1,0)","v":0},null,null,"",{"$f":"IFERROR(IF(BD3+1>$BF$2,\"\",BD3+1),\"\")","v":""},null,null,null,null,1,9,2,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,{"$f":"COUNTA(BL4:BP4)","v":1},null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",{"$f":"SUM(CA4:CE4)","v":1},{"$f":"IF(OR(LEFT(BU4,1)=$BT$1,LEFT(BU4,1)=\"\"),0,1)","v":1},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CM4:CQ4)","v":0},{"$f":"IF(OR(LEFT(CG4,1)=$BT$1,LEFT(CG4,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CY4:DC4)","v":0},{"$f":"IF(OR(LEFT(CS4,1)=$BT$1,LEFT(CS4,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DK4:DO4)","v":0},{"$f":"IF(OR(LEFT(DE4,1)=$BT$1,LEFT(DE4,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DW4:EA4)","v":0},{"$f":"IF(OR(LEFT(DQ4,1)=$BT$1,LEFT(DQ4,1)=\"\"),0,1)","v":0},0,0,0,0,null,null,"Society (e.g., loss of productivity, substance abuse leading to school drop-out or incarceration, homelessness, environment, etc.)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-105",null,0,"N/A",null,null,null,"Clinical Staff",null,null,null,null,null,null,388701003,{"$f":"COUNTIF(ET4:ET2973,FI4)","v":9}]
[null,null,1,"094108002","Y",null,null,"",null,null,"387663301","094127002.7.1","Hospital","Private",null,null,null,"094108002",4,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,"Care coordination & care navigation",null,null,null,null,null,null,null,null,null,null,null,null,null,"Y / N",null,3,null,2,null,1,"094108002",{"$f":"IF('Intervention Details'!$D$12=AX5,MAX(AZ$2:AZ4)+1,0)","v":0},null,null,"",{"$f":"IFERROR(IF(BD4+1>$BF$2,\"\",BD4+1),\"\")","v":""},null,null,null,null,2,16,4,"Improve utilization of clinical decision support tools by clinicians across the system.","Improve screening rates to improve potential of outcomes for all payers including MLIU.",null,null,null,2,null,null,null,"Implementat EPIC across the required system:  All clinics and hospitals reporting must move to EPIC in order to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings","Develop expanded protocols for clinical staff and care management teams to impact patient care."," "," "," ",2,1,1,0,0,0,null,"Developing dash board to monitor compliance of health maintenance, screenings, immunizations, and bundle performance."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,"Employer of the patient",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-113",null,1,{"$f":"INDEX(EU4:EU2973,MATCH(VALUE($EX$2),ET4:ET2973,0))","v":{"$error":"#N/A"}},null,null,null,"Research/Analytic Staff",null,null,null,null,null,null,388347201,{"$f":"COUNTIF(ET5:ET2974,FI5)","v":15}]
[null,null,1,"387663301",{"$error":"#N/A"},null,null,"",null,null,"111411803","111411803.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"094108002",679,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY9-10","Y","Y",null,null,"",null,null,"Care management & navigation",null,null,null,null,null,null,null,null,null,null,null,null,null,"NA",null,4,null,3,null,1,"387663301",{"$f":"IF('Intervention Details'!$D$12=AX6,MAX(AZ$2:AZ5)+1,0)","v":0},null,null,"","",null,null,null,null,3,23,679,"Chronic Conditions Management – Heart Failure\nObjective:  Closely monitor those with heart failure diagnosis to decrease disease progression while improving the patient’s quality of life, thus preventing avoidable hospital admissions and lower cost.  \n",null,null,null,null,1,null,null,null,"Nurse Navigator completes an interactive contact with the patient or caregiver based on a schedule found to represent the highest return to acute: days 4-8, 10-14, and 19-23.  The Navigator follows an established protocol to specifically evaluate patient’s weight, vital signs, breathing capabilities, sleep posture, swelling in extremities, oxygen intake, diet and fluid restrictions, evaluates any chest discomfort, and provides ongoing education as provided and approved by the cardiology team.  Continuity of care is delivered with interaction between the patient and their cardiologist or primary care provider and home health provider if applicable.  The Navigator promotes patient compliance and independence with their own healthcare and becomes a resource for preventing avoidable hospital admissions and reducing cost.  ","","","","",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,"Other providers",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-147",null,{"$f":"EW5+1","v":2},{"$f":"INDEX(EU5:EU2974,MATCH(VALUE($EX$2),ET5:ET2974,0))","v":{"$error":"#N/A"}},null,null,null,"Administrative Staff",null,null,null,null,null,null,112667403,5]
[null,null,1,"111411803","Y",null,null,"",null,null,"112667403","112667403.7.1","Hospital","Private",null,null,null,"387663301",5,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,"Care transition",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5,null,4,null,1,"111411803",{"$f":"IF('Intervention Details'!$D$12=AX7,MAX(AZ$2:AZ6)+1,0)","v":0},null,null,"","",null,null,null,null,4,30,5,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,"Other stakeholders (Providers must indicate or describe the “other” stakeholder in their response to this question)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-268",null,{"$f":"EW6+1","v":3},{"$error":"#N/A"},null,null,null,"Maintenance Staff",null,null,null,null,null,null,94108002,20]
[null,null,1,"112667403","Y",null,null,"",null,null,"127278302","127278302.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"111411803",7,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,"Chronic care management",null,null,null,null,null,null,null,null,null,null,null,{"$f":"OFFSET($BC$2,1,0,MAX(BD3:BD40),1)","v":{"$error":"#REF!"}},null,null,null,6,null,5,null,1,"112667403",{"$f":"IF('Intervention Details'!$D$12=AX8,MAX(AZ$2:AZ7)+1,0)","v":0},null,null,"","",null,null,null,null,5,37,7,"Standardize screening and follow-up for clinical depression using the PHQ-9.","Standardize measurement process and follow-up for BMI identified outside of normal parameters.",null,null,null,2,null,null,null,"The evidence-based PHQ-9 was selected for use as the standardized screening instrument and a template will be developed for input of assessment results into the EHR. Individuals aged 12 and above who present for services are given a Client Self-Assessment (CSA) packet to complete which includes an initial 2-question screening for depression from the PHQ-9  - unless excluded for any of the following reasons: active diagnosis of Depression or Bi-polar Disorder within past year, refusal to participate, in an emergent or urgent situation, or functional capacity or motivation to improve may impact accuracy of responses (e.g. court-appointed individual, delirium status). Positive responses to the initial 2 questions will initiate a referral to licensed clinical staff for completion of the full PHQ-9 and referrals for appropriate assessment and clinical interventions. The full PHQ-9 is administered by licensed clinical staff who will receive training prior to using the instrument to ensure standardized implementation. A template will be developed to enter scores into the EHR, make referrals for appropriate follow-up, and also identify exclusions, if any, that precluded completion of the full PHQ-9.","Upon completion of the PHQ-9, licensed clinical staff will complete additional clinical assessments to confirm the initial diagnosis of depression or bi-polar disorder and make referrals. These may include counseling, referrals to psychiatric prescribers for evaluation of the need to initiate medication, education on the nature of the illness, or other cognitive-behavioral skills and interventions. Follow-up will be documented on the PHQ-9 template and entered into the EHR."," "," "," ",2,1,1,0,0,0,null,"All individuals 18 and older will have their BMI measured at each clinic visit, with the exception of individuals meeting any of the assessment exclusion criteria. Results will be entered into the EHR through a standardized template to be developed to accurately calculate BMIs outside normal parameters and that also identifies follow-up activities initiated as a result of assessment findings.  Criteria for exclusion from assessment are also included as part of the BMI screening instrument to ensure entry of that information into the EHR. Staff completing the BMI assessments will receive training on completion of the standardized BMI template and on use of the electronically calibrated scales to ensure measurements are accurately recorded.","Individuals identified to have a BMI outside of normal parameters on the BMI screening template will receive follow-up, which will include one or more of the following activities: education, referral to primary care giver, exercise counseling, and/or nutrition counseling. Follow-up activities initiated will be documented on the BMI screening template for entry into the EHR to track adherence to required protocols and for automated data reporting purposes."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-269",null,4,{"$error":"#N/A"},null,null,null,"Other Personnel Costs",null,null,null,null,null,null,387663301,9]
[null,null,1,"127278302","Y",null,null,"",null,null,"387381201","130612806.7.1","Hospital","Private",null,null,null,"112667403",3,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,"Chronic disease management",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7,null,6,null,1,"127278302",{"$f":"IF('Intervention Details'!$D$12=AX9,MAX(AZ$2:AZ8)+1,0)","v":0},null,null,"","",null,null,null,"Secondary Driver",null,null,3,"Improve utilization of clinical decision support tools by clinicians across the system.",null,null,null,null,1,null,null,null,"Manage Diabetes as a Chronic Condition on a more consistent basis","Implement EPIC across the required outpatient system.  All clinics reporting must fully engage in EPIC and have a plan to implement EPIC in the hospital within a reasonable time period.  The goal is to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings to manage chronic Diabetes."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-272",null,5,{"$error":"#N/A"},null,null,null,null,null,null,null,null,null,null,376537203,3]
[null,null,1,"387381201",{"$error":"#N/A"},null,null,"",null,null,"131038504","131038504.7.1","Hospital","Non‐State Owned Public",null,null,null,"127278302",8,"Prevention and Wellness","Use of community health workers to improve prevention efforts","DY7-10","Y","N",null,null,"",null,null,"Coordinated prenatal and postpartum care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8,null,7,null,1,"387381201",{"$f":"IF('Intervention Details'!$D$12=AX10,MAX(AZ$2:AZ9)+1,0)","v":0},null,null,"","",null,null,null,"Rows to unhide",{"$f":"IFERROR(INDEX($BJ$4:$BJ$8,MATCH(INDEX($BQ$3:$BQ$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!$BK$3:$BK$722,0)),'Dropdown Box Data'!$BI$4:$BI$8,0)),39)","v":39},null,8,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Conduct pre-visit planning for all patients prior to scheduled appointments at all primary care clinics.","Establish consistent pre-visit planning processes across all primary care clinics.","Establish consistent protocols across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages and labs prior to appointment."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-280",null,6,{"$error":"#N/A"},null,null,null,"Training and Education",null,null,null,null,null,null,111411803,2]
[null,null,1,"131038504","Y",null,null,"",null,null,"137921608","137921608.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"127278302",9,"Patient Centered Medical Home","Provision of coordinated services for patients under Patent Centered Medical Home model","DY7-10","Y","N",null,null,"",null,null,"Crisis residential program",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9,null,8,null,1,"131038504",{"$f":"IF('Intervention Details'!$D$12=AX11,MAX(AZ$2:AZ10)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,9,"Manage chronically ill and debilitated patients through appropriate, evidenced-based diagnostic testing on a scheduled basis.",null,null,null,null,1,null,null,null,"Establish templates and protocols to ensure patients are appropriately assessed and re-assessed consistent with evidence based practice associated with specific chronic disease management.","Conduct specific diagnostic testing based on diagnosis prior to appointment.","Identify patients requiring care management in all primary care clinics."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-389",null,7,{"$error":"#N/A"},null,null,null,"Licensing/Certification/Accreditation Fees",null,null,null,null,null,null,127278302,44]
[null,null,1,"137921608","Y",null,null,"",null,null,"138360606","138360606.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"127278302",10,"Palliative Care","Provision of coordinated palliative care to address patients with end‐of‐life decisions","DY7-10","Y","N",null,null,"",null,null,"Crisis Respite",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,10,null,9,null,1,"137921608",{"$f":"IF('Intervention Details'!$D$12=AX12,MAX(AZ$2:AZ11)+1,0)","v":0},null,null,"","",null,null,null,"Number of Changes 1",{"$f":"INDEX(BZ$3:BZ$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!BK$3:BK$722,0))","v":{"$error":"#N/A"}},null,10,"Manage the care needs of the palliative care population in appropriate settings.",null,null,null,null,1,null,null,null,"Improve the inpatient referral process with the goal of accepting the patient into the palliative care program prior to discharge from the hospital, with follow-up in the already established outpatient palliative care clinic.","Increase the palliative care patient population by continuing to educate colleagues in all primary and specialty care clinics, hospital and departments throughout the organization."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388701003,"C1-502",null,8,{"$error":"#N/A"},null,null,null,"Hiring Expenses",null,null,null,null,null,null,387381201,9]
[null,null,1,"138360606","Y",null,null,"",null,null,"138365512","138365512.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"127278302",11,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,"Data Analytics",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,11,null,10,null,1,"138360606",{"$f":"IF('Intervention Details'!$D$12=AX13,MAX(AZ$2:AZ12)+1,0)","v":0},null,null,"","",null,null,null,"Number of Changes 2",{"$f":"INDEX(CL$3:CL$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!BK$3:BK$722,0))","v":{"$error":"#N/A"}},null,11,"Identifying patients with behavioral health needs in the primary care setting.","Create a process to manage those patient who have behavioral health issues within the primary care setting.",null,null,null,2,null,null,null,"Imbed appropriate behavioral health standardized screening tools across all primary care clinics."," "," "," "," ",1,1,0,0,0,0,null,"Utilize community health workers to focus on the behavioral health population screenings and follow-up in each primary care clinic.","Establish consistent processes and behavioral health algorithms in each primary care clinic."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-111",null,9,{"$error":"#N/A"},null,null,null,"Staff Training and Development",null,null,null,null,null,null,131038504,8]
[null,null,1,"138365512","Y",null,null,"",null,null,"388696201","138374715.7.1","Hospital","Private",null,null,null,"127278302",12,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,"Diabetes outreach program and education",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,12,null,11,null,1,"138365512",{"$f":"IF('Intervention Details'!$D$12=AX14,MAX(AZ$2:AZ13)+1,0)","v":0},null,null,"","",null,null,null,"Number of Changes 3",{"$f":"INDEX(CX$3:CX$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!BK$3:BK$722,0))","v":{"$error":"#N/A"}},null,12,"Identify areas for improvement that impact maternal mortality rates. Direct causes of maternal mortality include, but may not be limited to hemorrhage, obstructed labor, and premature births; with socio-economic factors being a contributing factor.",null,null,null,null,1,null,null,null,"Create internal Task Force supported by accurate data and assessments to determine areas of focus an opportunities to improve."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-112",null,10,null,null,null,null,"Dues and Subscriptions",null,null,null,null,null,null,137921608,9]
[null,null,1,"388696201",{"$error":"#N/A"},null,null,"",null,null,"138913209","138913209.7.1","Hospital","Non‐State Owned Public",null,null,null,"127278302",13,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,"Expand and enhance access to primary care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,13,null,12,null,1,"388696201",{"$f":"IF('Intervention Details'!$D$12=AX15,MAX(AZ$2:AZ14)+1,0)","v":0},null,null,"","",null,null,null,"Number of Changes 4",{"$f":"INDEX(DJ$3:DJ$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!BK$3:BK$722,0))","v":{"$error":"#N/A"}},null,13,"Improve delivery of prenatal care. Women receiving no prenatal care are more likely to have a pregnancy-related death than women who receive prenatal care.","Improve physical and mental health of target population through provision of routine and postpartum care for mothers and newborns.",null,null,null,2,null,null,null,"Create evidenced-based, standardized protocols for delivering prenatal care."," "," "," "," ",1,1,0,0,0,0,null,"Create evidenced-based, standardized protocols for delivering prenatal and postpartum physical and mental health services."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-115",null,11,null,null,null,null,"Consulting-Training/Legal/Accounting",null,null,null,null,null,null,138360606,2]
[null,null,1,"138913209","Y",null,null,"",null,null,"387515501","139173209.7.1","Hospital","Private",null,null,null,"127278302",14,"Expansion or Enhancement of Oral Health Services","Expansion of school based sealant and/or fluoride varnish initiatives","DY7-10","Y","N",null,null,"",null,null,"Expanding access to hospice care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,14,null,13,null,1,"138913209",{"$f":"IF('Intervention Details'!$D$12=AX16,MAX(AZ$2:AZ15)+1,0)","v":0},null,null,"","",null,null,null,"Number of Changes 5",{"$f":"INDEX(DV$3:DV$722,MATCH('Intervention Details'!$D$27,'Dropdown Box Data'!BK$3:BK$722,0))","v":{"$error":"#N/A"}},null,14,"Lack of access to preventive dental services for children and adults.",null,null,null,null,1,null,null,null,"Increase \"Sealant Days\" offered at local schools to provide services to children."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-207",null,12,null,null,null,null,"Other Training and Education Costs",null,null,null,null,null,null,138365512,4]
[null,null,1,"387515501",{"$error":"#N/A"},null,null,"",null,null,"140425362","140425362.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"127278302",15,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-8","N","N",null,null,"",null,null,"Follow up appointment after discharge",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,15,null,14,null,1,"387515501",{"$f":"IF('Intervention Details'!$D$12=AX17,MAX(AZ$2:AZ16)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,15,"Number of diabetic patients who are not compliant with routine eye exams.",null,null,null,null,1,null,null,null,"Implement standing order during pre-visit planning for diabetic patients who are not compliant with yearly retinal exams."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-500",null,13,null,null,null,null,null,null,null,null,null,null,null,388696201,9]
[null,null,1,"140425362","Y",null,null,"",null,null,"387377001","208843701.7.1","Hospital","Private",null,null,null,"127278302",16,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,"Follow up with individuals discharged from a psychiatric facility",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,16,null,15,null,1,"140425362",{"$f":"IF('Intervention Details'!$D$12=AX18,MAX(AZ$2:AZ17)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,16,"Improve access to care to address lack of access to specialized care for children with asthma.",null,null,null,null,1,null,null,null,"Increase partnerships with local school districts to expand services to more children in RHP1.","Deploy mobile clinics focused on providing asthma self-management education"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"A1-508",null,14,null,null,null,null,"Office Operations",null,null,null,null,null,null,138913209,5]
[null,null,1,"387377001",{"$error":"#N/A"},null,null,"",null,null,"330811601","330811601.7.1","Hospital","Non‐State Owned Public",null,null,null,"127278302",680,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY9-10","Y","Y",null,null,"",null,null,"Hepatitis C treatment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,17,null,16,null,1,"387377001",{"$f":"IF('Intervention Details'!$D$12=AX19,MAX(AZ$2:AZ18)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,680,"Number of diabetic patients who are not compliant with routine eye exams.",null,null,null,null,1,null,null,null,"Implement standing order during pre-visit planning for diabetic patients who are not compliant with yearly retinal exams.","Implement a standardized Release of Information (ROI) form that contains local eye doctors to streamline request and receipt of outside records ","","","",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-105",null,15,null,null,null,null,"Non-Payroll Taxes",null,null,null,null,null,null,387515501,15]
[null,null,1,"330811601","Y",null,null,"",null,null,"366812101","366812101.7.1","Hospital","Private",null,null,null,"387381201",17,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,"Hospital Safety and Quality",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,18,null,17,null,1,"330811601",{"$f":"IF('Intervention Details'!$D$12=AX20,MAX(AZ$2:AZ19)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,17,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-113",null,16,null,null,null,null,"Office Equipment and Furniture",null,null,null,null,null,null,140425362,2]
[null,null,1,"366812101","Y",null,null,"",null,null,"376537203","376537203.7.1","Hospital","Non‐State Owned Public",null,null,null,"131038504",19,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,"Implement models supporting recovery of individuals with behavioral health needs",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,19,null,18,null,1,"366812101",{"$f":"IF('Intervention Details'!$D$12=AX21,MAX(AZ$2:AZ20)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,19,"Establish screening and referral processes. Referral system between the ED and Primary Care Clinic: Patients in the Hunt Regional Medical Center Emergency Department are screened to determine if they have a primary care provider. Patients who do not have a medical home are seen by the ED navigators and provided a referral and appointment to establish primary care at the Community Health Service Agency Greenville Primary Care office.","Medication assistance:  The ED navigators have identified high medical and social need patients often do not have the resources to obtain medication. We have developed and implemented a medication assistance program to connect patients with pharmaceutical assistance programs, refer patients to our primary care FQHC partner to access medications at 340B pricing, and purchase patients medications until long term arrangements are made.",null,null,null,2,null,null,null,"Screen individuals to determine if they have a primary care provider.  Upon registration in the Emergency Department, patients are asked if they currently have a primary care provider.  Patients without a primary care provider are flagged in the ED electronic health record on the ED status board with a red flag.  The ED Navigators prioritize navigation services to patients without a PCP.","Referral and appointments. Patients without a PCP are given a list of community PCPs to choose from. The ED navigators make the patient a follow-up appointment prior to leaving the ED during business hours and call the patient back with the appointment when after hours."," "," "," ",2,1,1,0,0,0,null,"Identification of high risk patients that require medication","Refer high risk patients that require medical assistance to FQHC to obtain the medication"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-147",null,17,null,null,null,null,"Insurance",null,null,null,null,null,null,387377001,9]
[null,null,1,"376537203","Y",null,null,"",null,null,"019053001","019053001.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"131038504",20,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,"Implementation of a medication management program",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20,null,19,null,1,"376537203",{"$f":"IF('Intervention Details'!$D$12=AX22,MAX(AZ$2:AZ21)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,20,"Safety net stabilization:  The Outpatient BH Clinic will provide prompt mental health stabilization and support including medication management and psychosocial counseling for patients with urgent psychiatric needs until they are able to obtain follow-up care with a local mental health provider.",null,null,null,null,1,null,null,null,"System integration for behavioral health referrals: Patients with serious mental illness may be referred to the Outpatient Behavioral Health Clinic from system primary care practices and the Emergency Department for same-day assessment, stabilization, and medication management."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-268",null,18,null,null,null,null,"Office Supplies",null,null,null,null,null,null,330811601,10]
[null,null,2,"019053001","Y",null,null,"",null,null,"094092602","094092602.7.1","Hospital","State Owned Public",null,null,null,"137921608",21,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,"Implementation of strategies to reduce tobacco use",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,21,null,20,null,2,"019053001",{"$f":"IF('Intervention Details'!$D$12=AX23,MAX(AZ$2:AZ22)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,21,"Community Healthcore has developed a robust system of care that includes a full array of community-based behavioral health services that are aligned to CCBHC and Joint Commission Standards. Community Healthcore currently operates clinics and programs in all nine counties in the target area and is licensed as a Texas Local Mental Health Authority. (Note: State licensing regulations align with major components of CCBHC, especially in the areas of staffing, credentialing, cultural competence, and linguistic requirements.) Following is an abbreviated list of services provided by Community Healthcore: \nI. Existing: crisis mental health services, 24-hour mobile crisis teams, ACT Teams, emergency crisis intervention services, crisis stabilization (screening, assessment, diagnosis, including risk assessment). \nII. Existing: patient-centered treatment planning, risk assessment and crisis planning. \nIII. Existing: outpatient mental health and substance use treatment. Established cooperative relationships with judicial officials/court systems and provide Assisted Outpatient Treatment when ordered. \nIV. Existing: targeted case management and care management services. \nV. Existing: outpatient psychiatric rehabilitation services, structured therapeutic activities, counseling, medication management, recovery-oriented services and family therapy.\n",null,null,null,null,1,null,null,null,"Community Healthcore would like to incorporate best practices associated with risk stratification, and population health methodologies for the purposes of evaluation, identification, and treatment."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-269",null,19,null,null,null,null,"Postage",null,null,null,null,null,null,366812101,5]
[null,null,2,"094092602","Y",null,null,"",null,null,"094148602","094148602.7.1","Hospital","Private",null,null,null,"138360606",22,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,"Increase in utilization of mobile clinics",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,22,null,null,null,2,"094092602",{"$f":"IF('Intervention Details'!$D$12=AX24,MAX(AZ$2:AZ23)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,22,"Maintain AADE accreditation and CDC pending recognition to demonstrate program quality","Enrollment, participation and completion of classes offered at the Center",null,null,null,2,null,null,null,"Maintain client records according to the National Diabetes and CDC Diabetes Prevention guidelines","Submit yearly reports to AADE and CDC to maintain good standing"," "," "," ",2,1,1,0,0,0,null,"Increase awareness of the services and classes offered at the Center","Training and/or retainment of passionate and skilled educators to facilitate the classes","Analyze participant class surveys, along with pre & post biometric data to evaluate program quality and effectiveness and make improvements, when needed"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-272",null,20,null,null,null,null,"Advertising/Marketing",null,null,null,null,null,null,19053001,3]
[null,null,2,"094148602","Y",null,null,"",null,null,"094164302","094164302.7.1","Hospital","Private",null,null,null,"138360606",23,"Access to Primary Care Services","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","DY7-10","Y","N",null,null,"",null,null,"Integrated physical and behavioral health care services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,23,null,null,null,2,"094148602",{"$f":"IF('Intervention Details'!$D$12=AX25,MAX(AZ$2:AZ24)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,23,"Patient education on proper usage of ED utilization","Work with medical providers and social service agencies to adopt program and implement","Cloud-based Navigation Tool that can be shared among multiple medical and social services partners","Partner with a local hospital to integrate program among ED staff when uninsured patients present to the ED with potentially preventable diagnosis.",null,4,null,null,null,"Create a guide book for patients to refer to when in doubt of when to use the ED","Ensure clinics provide patients with information on how they can be reached after hours","CHW education to patients in an effort to increase compliance with primary care provider"," "," ",3,1,1,1,0,0,null,"Selection of clinics and social service aencies who show an interest in participating"," Maintain regular and open communication with clinic and social service partners to ensure patients who are referred receive the care they need"," "," "," ",1,1,0,0,0,0,null,"Integrate the cloud-based system in all parter organizations and provide user training"," "," "," "," ",1,1,0,0,0,0,null,"Work with hospital lead ED staff to implement CommUNITY Cares Program and establish ED workflow to refer uninsured patients into the program",""," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-280",null,21,null,null,null,null,"Consulting-Training/Legal/Accounting",null,null,null,null,null,null,94092602,30]
[null,null,2,"094164302","Y",null,null,"",null,null,"096166602","096166602.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"138365512",33,"Behavioral Health Crisis Stabilization Services","Implement models supporting recovery of individuals with behavioral health needs","DY7-10","Y","N",null,null,"",null,null,"Maternal Care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,24,null,null,null,2,"094164302",{"$f":"IF('Intervention Details'!$D$12=AX26,MAX(AZ$2:AZ25)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,33,"Behavioral health patients in crisis need an alternative to costly acute care","Growing need for child and adolescent behavioral health services",null,null,null,2,null,null,null,"Implement crisis intervention services to capture patients in a conducive environment and conduct assessments, in order to determine an appropriate follow up care plan"," "," "," "," ",1,1,0,0,0,0,null,"Implement a children's telepsych program for children/adolescents to have a designated psychiatric provider"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-389",null,22,null,null,null,null,"Travel/Transportation",null,null,null,null,null,null,94148602,7]
[null,null,2,"096166602","Y",null,null,"",null,null,"112671602","112671602.7.1","Hospital","Private",null,null,null,"138365512",34,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,"Patient educational materials or campaigns about preventive care (e.g. immunizations, preventive screenings, etc.)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,25,null,null,null,2,"096166602",{"$f":"IF('Intervention Details'!$D$12=AX27,MAX(AZ$2:AZ26)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,34,"Prescription medications from multiple providers can create adverse drug reactions and ineffective holistic health maintenance.",null,null,null,null,1,null,null,null,"Utilize new EMR to implement medication management across locations","Recurring primary care maintenance, in conjunction with behavioral care, ensures compliance with appropriate medication utilization"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388347201,"C1-502",null,23,null,null,null,null,"Translation Costs",null,null,null,null,null,null,94164302,2]
[null,null,2,"112671602","Y",null,null,"",null,null,"130983309","130983309.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"388696201",24,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,"Patient navigation",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,26,null,null,null,2,"112671602",{"$f":"IF('Intervention Details'!$D$12=AX28,MAX(AZ$2:AZ27)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,24,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112667403,"A1-112",null,24,null,null,null,null,"Corporate Office Overhead",null,null,null,null,null,null,96166602,12]
[null,null,2,"130983309","Y",null,null,"",null,null,"131030203","131030203.7.1","Hospital","Non‐State Owned Public",null,null,null,"138913209",25,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,"Pediatric Care Management",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,27,null,null,null,2,"130983309",{"$f":"IF('Intervention Details'!$D$12=AX29,MAX(AZ$2:AZ28)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,25,"Based on the Community Needs Assessment we identified a chronic disease burden in our region with higher rates of high blood pressure in our region than the average state rate.",null,null,null,null,1,null,null,null,"To work with physicians to establish practice foundations for effective hypertension control and focus on quality improvement efforts as well as proactively monitoring and managing hypertension through population health management."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112667403,"A1-115",null,25,null,null,null,null,"Program Supplies",null,null,null,null,null,null,112671602,10]
[null,null,2,"131030203","Y",null,null,"",null,null,135222109,"135222109.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"387515501",26,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,"Peer support services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,28,null,null,null,2,"131030203",{"$f":"IF('Intervention Details'!$D$12=AX30,MAX(AZ$2:AZ29)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,26,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages.\n"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112667403,"A1-207",null,26,null,null,null,null,"Activity Costs",null,null,null,null,null,null,130983309,2]
[null,null,2,135222109,"Y",null,null,"",null,null,"136367307","136367307.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"140425362",27,"Access to Primary Care Services","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","DY7-10","Y","N",null,null,"",null,null,"Prevention of CJ recidivism",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,29,null,null,null,2,135222109,{"$f":"IF('Intervention Details'!$D$12=AX31,MAX(AZ$2:AZ30)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,27,"The Community Health Workers will monitor compliance of patients who recieve the home blood pressure kits to ensure proper use and effectiveness. The Community Health Worker will track patients who receive FOBT stool cards or FIT tests to ensure patient has submitted card/test back to the clinic. Community Health Workers will report the findings quarterly as part of the Quality Assurance Program. Areas of improvement will be identied and addressed with a timeline to implement changes if necessary.",null,null,null,null,1,null,null,null,"To work with the Medical Director, Physicians, Nurse Practitioners and other clinical staff to implement standing orders for patients with a diagnoses hypertension (HTN) to receive at home BP kits and patients 50-75 years of age receive FOBT/FIT screening for Colorectal Cancer. Patients will be monitored by Community Health Workers who will record activities in the Elecrtonic Health Record. Standing orders will be ammended and/or revised as necessary as part of the QA process."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112667403,"A1-500",null,27,null,null,null,null,"Other Office Costs",null,null,null,null,null,null,131030203,9]
[null,null,2,"136367307","Y",null,null,"",null,null,"136381405","136381405.7.1","Hospital","Non‐State Owned Public",null,null,null,"140425362",28,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,"Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,null,null,null,2,"136367307",{"$f":"IF('Intervention Details'!$D$12=AX32,MAX(AZ$2:AZ31)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,28,"Continued partnership with Paris Regional Medical Center for the Paris-Lamar County Health District to be a referral source for patients who present at the emergency room for a non-emergent issue. This continued partnership will increase patient awareness of available services offered at the Paris-Lamar County Health Department which will increase overall primary care capacity and reduce emergency department usage for non emergent issues.",null,null,null,null,1,null,null,null,"The Paris-Lamar County Health District to work with Paris Regional Medical Center to create a combined referal/discharge document for non emergent patients that present at the Emergency Department directing them to the Paris-Lamar County Health District for Primary Care. Referred patients would be documented in the EHR to assist in tracking the number of patients no longer accessing the emergency department for primary care."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112667403,"A1-508",null,28,null,null,null,null,null,null,null,null,null,null,null,135222109,10]
[null,null,2,"136381405","Y",null,null,"",null,null,"138296208","138296208.7.1","Hospital","Private",null,null,null,"387377001",32,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,"Provision of crisis stabilization services based on the best practices",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,31,null,null,null,2,"136381405",{"$f":"IF('Intervention Details'!$D$12=AX33,MAX(AZ$2:AZ32)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,32,"Screen all eligible patients appropriately based on age, gender and diagnosis.",null,null,null,null,1,null,null,null,"Establish consistent standing orders across all primary care clinics that allow automated orders for screening tests and procedures if appropriate with the goal of improving screening percentages."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"A1-112",null,29,null,null,null,null,null,null,null,null,null,null,null,136367307,13]
[null,null,2,"138296208","Y",null,null,"",null,null,"139172412","139172412.7.1","Hospital","Private",null,null,null,"330811601",29,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-8","N","N",null,null,"",null,null,"Provision of screening and follow up services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,32,null,null,null,2,"138296208",{"$f":"IF('Intervention Details'!$D$12=AX34,MAX(AZ$2:AZ33)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,29,"Extended primary care capacity will enable us to identify additional patients at risk for unmanaged diabetes.  The identification of new patients will enable us to provide additional patient education content to more patients.","Develop additional evidence based clinical interventions for diabetes patients.","Extended primary care capacity will also provide increased access for patient care to all diabetes patients.  More specifically, our Certified Diabetes Educator has become a direct member of the patient care team for those identified at risk for unmanaged diabetes.",null,null,3,null,null,null,"Develop new print, on-line and in person education formats for patients.","Develop new print, on-line and in person education formats for patients."," "," "," ",2,1,1,0,0,0,null,"Offer frequent and timely blood glucose monitoring during visits/interactions within our healthcare system.","Implement a patient data mining initiative of our EMR to identify patients having a diabetes diagnosis and who have not seen a provider within the last 6-months.  Patient will be either manually called by a Clinical Nurse or receive a letter alerting the patient to contact their provider to schedule an office visit.","Work in conjunction with TMC Bonham Clinic Providers to initiate interventions for identified patients.","Establish structured diabetic clinic encounter to monitor and treat patients who have had a diabetes diagnosis."," ",4,1,1,1,1,0,null,"Development of personalized diabetes management education for patients.","Initiate monthly contact with patients who have been diagnosed with diabetes to address uncontrolled diabetes."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"A1-115",null,30,null,null,null,null,"Technology",null,null,null,null,null,null,136381405,3]
[null,null,2,"139172412","Y",null,null,"",null,null,"200683501","200683501.7.1","Hospital","Private",null,null,null,"330811601",30,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,"Provision of services to individuals that address social determinants of health",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,33,null,null,null,2,"139172412",{"$f":"IF('Intervention Details'!$D$12=AX35,MAX(AZ$2:AZ34)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,30,"Develop additional evidence based clinical interventions for diabetes patients when patients are seeing our specialist physicians.","Extended specialty care capacity will enable us to identify additional patients at risk for unmanaged diabetes. The identification of new patients will enable us to provide additional patient education content to more patients.",null,null,null,2,null,null,null,"Work in conjunction with Specialist Providers to initiate interventions for identified patients.","Offer frequent and timely blood glucose monitoring during visits/interactions within our healthcare system.","Create a mechanism where patients who are diagnosed with diabetes, who see a specialist provider and who have a Bonham Clinic primary care provider are initially identified/flagged for an intervention.  The Bonham Clinic providers will be notified that a clinical intervention needs to occur to assist patients who have uncontrolled diabetes.","Implement a patient data mining initiative of EMR to identify patients having a diabetes diagnosis and who have not seen a provider within the last 6-months.  Patient will be either manually called by a Clinical Nurse or would receive a letter encouraging patient to schedule an appointment."," ",4,1,1,1,1,0,null,"Develop new print, on-line and in person education formats for patients.","Development of personalized diabetes management education for patients."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"A1-207",null,31,null,null,null,null,"Information Technology",null,null,null,null,null,null,138296208,3]
[null,null,2,"200683501","Y",null,null,"",null,null,"284333604","284333604.7.1","Hospital","Private",null,null,null,"330811601",31,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,"Provision of vaccinations to target population",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,34,null,null,null,2,"200683501",{"$f":"IF('Intervention Details'!$D$12=AX36,MAX(AZ$2:AZ35)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,31,"Patients who utilize our inpatient facility are measured on key measures related to their inpatient stay.",null,null,null,null,1,null,null,null,"Create a reliable assessment tool that enables us to identify those who are at risk for CLABSI, CLAUTI, Sepsis and patient falls.\n","Create reliable care interventions - for example, outlining clear evidence based indications/guidelines for urinary catheter utilization will decrease use and risk of infection.  Similarly, developing guidelines for utilization of pressure pads and sitters will help to decrease falls.","Create reliable patient and family education materials - especially for patients at increased risk for falls - will reduce the number of falls at home."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"A1-500",null,32,null,null,null,null,"Program Devices/Technology",null,null,null,null,null,null,139172412,4]
[null,null,2,"284333604","Y",null,null,"",null,null,"020817501","020817501.7.1","Hospital","Private",null,null,null,"330811601",681,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY9-10","Y","Y",null,null,"",null,null,"Substance Abuse Treatment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,35,null,null,null,2,"284333604",{"$f":"IF('Intervention Details'!$D$12=AX37,MAX(AZ$2:AZ36)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,681,"Possible extended primary care capacity will enable us to identify additional patients at risk for unmanaged diabetes. The identification of new patient will enable us to provide additional patient education content to more individuals.","Develop additional evidence-based clinical interventions for diabetes patients.","Extended primary care capacity will also provide increased access for patient care to all diabetes patients. More specifically, our Certified Diabetes Educator has become a direct member fo the patient care team for those identified at-risk for unmanaged diabetes.",null,null,3,null,null,null,"Develop new print, on-line and in person education formats for patients.","","","","",1,1,0,0,0,0,null,"Implement a patient data mining initiative in the EMR to identify patients with a diagnosis of diabetes who have not seen a provider within the last six months. Patients will be either manuyally called by a clinical nurse or receive a letter alerting the patient to contact their provider to schedule an office visit."," "," "," "," ",1,1,0,0,0,0,null,"Initiate monthly contact with patients who have been diagnosed with diabetes to address uncontrolled diabetes.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"A1-508",null,33,null,null,null,null,"Utilities/Telecommunication/Etc.",null,null,null,null,null,null,200683501,7]
[null,null,3,"020817501","Y",null,null,"",null,null,"020834001","020834001.7.1","Hospital","Private",null,null,null,"366812101",18,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,"Targeted dental intervention",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,36,null,null,null,3,"020817501",{"$f":"IF('Intervention Details'!$D$12=AX38,MAX(AZ$2:AZ37)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,18,"Improve utilization of clinical decision support tools by clinicians across the system.","Improve screening rates.",null,null,null,2,null,null,null,"Implementat EPIC across the required system:  All clinics and hospitals reporting must move to EPIC in order to be able to practice evidenced based medicine in the care and treatment of patients, and successfully track compliance with health maintenance and preventative screenings","Develop expanded protocols for clinical staff and care management teams."," "," "," ",2,1,1,0,0,0,null,"Developing dash board to monitor compliance of diabetes and bundle performance."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"B2-242",null,34,null,null,null,null,"Other Technology Costs",null,null,null,null,null,null,284333604,8]
[null,null,3,"020834001","Y",null,null,"",null,null,"081522701","081522701.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"366812101",682,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY9-10","Y","Y",null,null,"",null,null,"TB screening and treatment",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,37,null,null,null,3,"020834001",{"$f":"IF('Intervention Details'!$D$12=AX39,MAX(AZ$2:AZ38)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,682,"Chronic Conditions Management – Heart Failure\nObjective:  Closely monitor those with heart failure diagnosis to decrease disease progression while improving the patient’s quality of life, thus preventing avoidable hospital admissions and lower cost.  ",null,null,null,null,1,null,null,null,"Nurse Navigator completes an interactive contact with the patient or caregiver based on a schedule found to represent the highest return to acute: days 4-8, 10-14, and 19-23.  The Navigator follows an established protocol to specifically evaluate patient’s weight, vital signs, breathing capabilities, sleep posture, swelling in extremities, oxygen intake, diet and fluid restrictions, evaluates any chest discomfort, and provides ongoing education as provided and approved by the cardiology team.  Continuity of care is delivered with interaction between the patient and their cardiologist or primary care provider and home health provider if applicable.  The Navigator promotes patient compliance and independence with their own healthcare and becomes a resource for preventing avoidable hospital admissions and reducing cost.  ","","","","",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"B2-392",null,35,null,null,null,null,null,null,null,null,null,null,null,20817501,15]
[null,null,3,"081522701","Y",null,null,"",null,null,"082006001","082006001.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private",null,null,null,"376537203",6,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,"Telehealth/telemedicine",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,38,null,null,null,3,"081522701",{"$f":"IF('Intervention Details'!$D$12=AX40,MAX(AZ$2:AZ39)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,6,"To establish Emergency Room patients with primary care when it is identified that no primary care provider exists for the patient in question to ensure continuity of care. Improve Transition of care processes with receiving facility.",null,null,null,null,1,null,null,null,"Any E.R. patient that is identified with not having a Primary Care Provider while in the Emergency Room will be scheduled with a provider of their choice or one of FMC Rural Clinic Providers before being discharged from the E.R. and within the recommended time frame for follow up as noted by the Emergency Room Physician's documentation. A checklist will be utilized in an effort to improve continuity of care."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"B2-393",null,36,null,null,null,null,"Facility",null,null,null,null,null,null,20834001,34]
[null,null,3,"082006001","Y",null,null,"",null,null,"093774008","093774008.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"019053001",36,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,"Use telemedicine/telehealth to deliver BH services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,39,null,null,null,3,"082006001",{"$f":"IF('Intervention Details'!$D$12=AX41,MAX(AZ$2:AZ40)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,36,"Provide patients with advanced scheduling options and increase opportunity for comprehensive primary and specialty care availability.",null,null,null,null,1,null,null,null,"Assign all patients to a color team to allow for continuity of care and better management of provider panels.","Open provider schedules 6 months out to allow for scheduling of future appointments.","Increase ability for OB and Family Planning services and education thru contracted provider.","Contracting with providers outside our scope to expand specialty care to our patients."," ",4,1,1,1,1,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-105",null,37,null,null,null,null,"Rent/Mortgage/Depreciation",null,null,null,null,null,null,81522701,13]
[null,null,3,"093774008","Y",null,null,"",null,null,"094187402","094187402.7.1","Hospital","Private",null,null,null,"094092602",37,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,"Use telemedicine/telehealth to deliver specialty services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,40,null,null,null,3,"093774008",{"$f":"IF('Intervention Details'!$D$12=AX42,MAX(AZ$2:AZ41)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,37,"Knowledge Gaps Exist for Patients, Providers and Staff regarding appropriate ED utilization.","Ambulatory Care Management practices are not standardized across all clinics/service lines.",null,null,null,2,null,null,null,"Develop additional self-management education that describes (at the symptom level) when it is appropriate to go directly to the ED rather than contact their provider in clinic.","Educate providers and staff on where symptom level guidance, to be used to help triage patients who call either the clinic or the Access center, can be located."," "," "," ",2,1,1,0,0,0,null,"Increase utilization of Epic-based risk scoring tool to identify individuals who would be prioritized for Care Management efforts."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-113",null,38,null,null,null,null,"Utilities/Telecommunication/Etc.",null,null,null,null,null,null,82006001,10]
[null,null,3,"094187402","Y",null,null,"",null,null,"111810101","111810101.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",null,null,null,"094092602",38,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,"Utilization of mobile clinics that can provide access to BH care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,41,null,null,null,3,"094187402",{"$f":"IF('Intervention Details'!$D$12=AX43,MAX(AZ$2:AZ42)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,38,"In the Diabetic population, there are known knowledge gaps regarding self-care and nutrition.","Closing care gaps in the ambulatory population to keep them (as much as possible) out of higher acuity settings.",null,null,null,2,null,null,null,"Enhance the patient engagement opportunities to include additional efforts to ensure timely HbA1C testing and follow-up, including a symptom-driven educational strategy to better support these individuals on an ambulatory basis."," "," "," "," ",1,1,0,0,0,0,null,"Utilize analytic data to develop outreach lists (call, text and/or secured messaging) to reach patients with known health maintenance gaps."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-147",null,39,null,null,null,null,"Building Maintenance and Repairs",null,null,null,null,null,null,93774008,10]
[null,null,3,"111810101","Y",null,null,"",null,null,"112672402","112672402.7.1","Hospital","State Owned Public",null,null,null,"094148602",39,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,"Utilization of pharmacist‐led chronic disease medication management services",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,42,null,null,null,3,"111810101",{"$f":"IF('Intervention Details'!$D$12=AX44,MAX(AZ$2:AZ43)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,39,"The 1st secondary driver in support of the core activity is to reduce hospital readmissions (all cause and target conditions such as CHF) for patients served by BHSETs system.","The 2nd secondary driver in support of the core activity is to improve and expand patient referrals to patient navigation services for hospital and ED patients at high risk of hospital readmissions.",null,null,null,2,null,null,null,"BHSET will provide post discharge patient navigation services targeting hospital and ED patients with chronic diseases who are at high risk of hospital readmissions.","BHSET will design customized navigation services for each patient with goal to maintain patient in the community and avoid hospital readmissions."," "," "," ",2,1,1,0,0,0,null,"BHSET will enhance education and training for medical and nursing staff regarding the new patient referral process.","BHSETs Smart Health clinic will triage patient navigation referrals made by hospital and ED staff and emphasize getting needed services and appointments to targeted patients with chronic conditions such as CHF in a timely manner."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-268",null,40,null,null,null,null,"Janitorial/Landscaping/Repairs",null,null,null,null,null,null,94187402,11]
[null,null,3,"112672402","Y",null,null,"",null,null,"113180703","113180703.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"094164302",55,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,"Utilization of services assisting individuals with pain management",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,43,null,null,null,3,"112672402",{"$f":"IF('Intervention Details'!$D$12=AX45,MAX(AZ$2:AZ44)+1,0)","v":0},null,null,"","",null,null,null,null,null,null,55,"Establish a patient navigator program",null,null,null,null,1,null,null,null,"WHMC hire up to two full-time equivalent personnel to establish a patient navigator program.","Screen and evaluate ED patients without a primary care provider and assist these individuals to connect to a primary care provider.","Screen and evaluate Medicaid and Low Income and Uninsured patients to assist with follow up care."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-269",null,41,null,null,null,null,"Other Facility Costs",null,null,null,null,null,null,111810101,51]
[null,null,3,"113180703","Y",null,null,"",null,null,"127300503","127300503.7.1","Hospital","Private",null,null,null,"096166602",40,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,"Wound care",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,44,null,null,null,3,"113180703",{"$f":"IF('Intervention Details'!$D$12=AX46,MAX(AZ$2:AZ45)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,40,"Increase referrals to primary care services from the behavioral health outpatient clinics.","Utilize internal resources to direct clients to health and wellness programs",null,null,null,2,null,null,null,"Add the primary care clinic to the electronic internal referral form","Educate behavioral health staff on the services available to clients provided by the primary care clinic."," Educate behavioral health staff on the services available to clients provided by third-party primary care providers."," "," ",2,1,1,0,0,0,null,"Implementation of educational workshops and outreach programs to address key wellness measures"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-272",null,42,null,null,null,null,null,null,null,null,null,null,null,112672402,27]
[null,null,3,"127300503","Y",null,null,"",null,null,"127303903","127303903.7.1","Hospital","Non‐State Owned Public",null,null,null,"096166602",41,"Prevention and Wellness","Self‐management programs and wellness programs using evidence‐based designs","DY7-10","Y","N",null,null,"",null,null,"Other",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,45,null,null,null,3,"127300503",{"$f":"IF('Intervention Details'!$D$12=AX47,MAX(AZ$2:AZ46)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,41,"Utilize internal resources to direct clients to health and wellness programs","Engage clients to participate in these support services.",null,null,null,2,null,null,null,"Implementation of educational workshops and outreach programs to address key wellness measures"," "," "," "," ",1,1,0,0,0,0,null,"Identify potential clients that would benefit from support services."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-280",null,43,null,null,null,null,"Equipment",null,null,null,null,null,null,113180703,27]
[null,null,3,"127303903","Y",null,null,"",null,null,"130959304","130959304.7.1","Hospital","Non‐State Owned Public",null,null,null,"096166602",42,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,46,null,null,null,3,"127303903",{"$f":"IF('Intervention Details'!$D$12=AX48,MAX(AZ$2:AZ47)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,42,"Assess client's risk of external determinants of health and wellness",null,null,null,null,1,null,null,null,"Identify and address housing situation and provide alternative options, if needed","Identify and offer treatment for potential risk of harm to self or others in the community","Identify and provide treatment options for substance use disorders"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-389",null,44,null,null,null,null,"Vehicle Acquisition/Lease Costs",null,null,null,null,null,null,127300503,12]
[null,null,3,"130959304","Y",null,null,"",null,null,"133355104","133355104.7.1","Hospital","Non‐State Owned Public",null,null,null,"112671602",43,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,47,null,null,null,3,"130959304",{"$f":"IF('Intervention Details'!$D$12=AX49,MAX(AZ$2:AZ48)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,43,"Develop and implement clinical pathways in participation with Texas AIM Plus Program",null,null,null,null,1,null,null,null,"Develop and implement standing orders and evidence-based protocol","To have staff educated on standard protocol"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C1-502",null,45,null,null,null,null,"Vehicle Maintenance/Repair Costs",null,null,null,null,null,null,127303903,17]
[null,null,3,"133355104","Y",null,null,"",null,null,"135033210","135033210.7.1","Hospital","Private",null,null,null,"112671602",44,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,48,null,null,null,3,"133355104",{"$f":"IF('Intervention Details'!$D$12=AX50,MAX(AZ$2:AZ49)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,44,"Develop and implement clinical pathways including a nurse-driven catheter and falls protocol, and the establishment of an interdisciplinary infection prevention team",null,null,null,null,1,null,null,null,"Develop and implement standing orders and evidence-based protocol","To have staff educated on standard protocol"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C2-106",null,46,null,null,null,null,"Vehicle Insurance",null,null,null,null,null,null,130959304,5]
[null,null,3,"135033210","Y",null,null,"",null,null,"137805107","137805107.7.1","Hospital","Private",null,null,null,"130983309",56,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,49,null,null,null,3,"135033210",{"$f":"IF('Intervention Details'!$D$12=AX51,MAX(AZ$2:AZ50)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,56,"Provide breast cancer screening for women and follow-up services after review of test results when medically indicated.","Provide hypertension screening for all patient encounters and follow-up services when hypertension is identified in the clinical setting",null,null,null,2,null,null,null,"Improved internal processes relative to patient preventive health screening timeliness and follow-up.","Improved patient education relative to the importance of preventive health screenings."," "," "," ",2,1,1,0,0,0,null,"Improved internal processes relative to patient preventive health screening timeliness and follow-up.","Improved patient education relative to the importance of blood pressure control.","Connect individuals to lifestyle modification resources."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C2-107",null,47,null,null,null,null,"Vehicle Depreciation",null,null,null,null,null,null,133355104,37]
[null,null,3,"137805107","Y",null,null,"",null,null,"137909111","137909111.7.1","Hospital","Non‐State Owned Public",null,null,null,"131030203",45,"Prevention and Wellness","Self‐management programs and wellness programs using evidence‐based designs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,50,null,null,null,3,"137805107",{"$f":"IF('Intervention Details'!$D$12=AX52,MAX(AZ$2:AZ51)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,45,"Provide education sessions to patients with diabetes. We plan on utilizing our licensed clinic personnel who will be in charge of these one-on-one sessions as well as collaborating with local dietary institutions on having them develop a Diabetes cook book with several recipes that we can give away during the sessions.",null,null,null,null,1,null,null,null,"In pursuit of this, our licensed clinic personnel will conduct the Diabetes health educative sessions as well as doing follow ups with these patients.","Development of a diabetes cook book by local dietary institutions"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94108002,"C2-186",null,48,null,null,null,null,"Equipment Costs (non-administrative)",null,null,null,null,null,null,135033210,3]
[null,null,3,"137909111","Y",null,null,"",null,null,"137949705","137949705.7.1","Hospital","Private",null,null,null,"131030203",46,"Maternal and Infant Health Care","Coordinated prenatal and postpartum care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,51,null,null,null,3,"137909111",{"$f":"IF('Intervention Details'!$D$12=AX53,MAX(AZ$2:AZ52)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,46,"With the goal to improve and serve our Primary Service area population, we are planning to utilize our EHR system to automate text message communications with our patient population.","Having noticed that most of our maternal patients go to our clinics and are not aware of the pregnancy classes held at the hospital and the low rate of prenatal visits, lack of education on contraception methods and low rates of postpaturm visits we are considering being more aggressive in creating awareness of these classes.",null,null,null,2,null,null,null,"We will support our text messaging campaign with personalized clinical and management staff phone follow up.","Creating awareness of the Community Health Education for our target popluation (pregnant women)"," "," "," ",2,1,1,0,0,0,null,"We are pursuing a focused marketing/education campaign in both English and Spanish within our clinics which will include pre and post natal education information, class schedules and contraception methods."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-105",null,49,null,null,null,null,"Equipment Depreciation",null,null,null,null,null,null,137805107,31]
[null,null,3,"137949705","Y",null,null,"",null,null,"139135109","139135109.7.1","Hospital","Private",null,null,null,135222109,47,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,52,null,null,null,3,"137949705",{"$f":"IF('Intervention Details'!$D$12=AX54,MAX(AZ$2:AZ53)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,47,"Identify individuals with specified diagnoses and/or at-risk features.","Increase prescriber schedule fill rates for Revenue Cycle Management.","Develop/document follow-up plans for individuals identified with specified diagnoses and/or at-risk features.","Increase COPSD screenings and case management services.","Increase Substance Abuse referrals for OSAR screenings.",5,null,null,null,"Identify an age-appropriate, standardized screening/assessment instrument to be implemented for usage.","Build/program the selected screening/assessment tool into the EHR.","Train staff to proficiently administer and score the screening/assessment tool.","Develop reports to track assessment administration and scoring."," ",4,1,1,1,1,0,null,"Select a single scheduling point for appointments at the two largest clinics.","Select a single contact for medical record distribution.","Conduct reminder calls prior to the follow-up appointments.","Modify work flow, or work in appointments through walk-in services.","Increase hours of operation through decentralization of intake services.",5,1,1,1,1,1,null,"Identify and select follow-up plan options for implementation.","Build/program the selected follow-up plans into the EHR.","Realign clinic workflow to efficiently accommodate assimilation of the assessemnt and follow-up plan options into the workflow.","Develop reports to track assignment of follow-up plans."," ",4,1,1,1,1,0,null,"Identify dually diagnosed individuals for COPSD screenings.","Develop/program an EHR report to track progress of screenings."," "," "," ",2,1,1,0,0,0,null,"Re-train staff to make referrals, as appropriate.","Develop/program a report in the EHR to track referrals."," "," "," ",2,1,1,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-113",null,50,null,null,null,null,"Other Equipment Costs",null,null,null,null,null,null,137909111,12]
[null,null,3,"139135109","Y",null,null,"",null,null,"140713201","140713201.7.1","Hospital","Private",null,null,null,"136367307",35,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,53,null,null,null,3,"139135109",{"$f":"IF('Intervention Details'!$D$12=AX55,MAX(AZ$2:AZ54)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,35,"Burke intends to employ clinicians in a care coordinator capacity, whose role is to focus clinical attention on gaps in care for individuals who are identified as having high needs and/or high risks for mental health and primary care services.  Care coordination activities include going beyond simply making referrals to providers (both within Burke’s spectrum of care and externally) by focusing on barriers that may prevent or pose a challenge to the individual, and ensuring that referrals are completed (i.e. closing the loop on referrals).  High need and/or high risk for mental health and primary care is defined as individuals (both children and adults) who demonstrate moderate to severe scores on the Child and Adolescent Needs and Strengths Assessment (CANS)/Adult Needs and Strengths Assessment (ANSA) domains related to Behavioral Health Needs and the Physical/Medical domain, or who have been identified as recent or frequent utilizers of higher levels of care (i.e. psychiatric hospitalization, medical hospitalization/emergency department utilization).  Coordination of care is an unfunded evidence-based practice that is an integral activity in addressing all the needs of an individual throughout a spectrum of care, and is a critical aspect in the CCBHC model of care.  According to SAMHSA: ‘Care coordination is the cornerstone of many healthcare redesign efforts, including primary and behavioral healthcare integration. It involves bringing together various providers and information systems to coordinate health services, patient needs, and information to help better achieve the goals of treatment and care. Research shows that care coordination increases efficiency and improves clinical outcomes and patient satisfaction with care.’"," Burke intends to expand and enhance its Informatics and Data Analytics capacity in order to focus on social drivers of health.  Burke captures a tremendous volume of data within its Electronic Health Record (EHR) which can be utilized to identify social drivers of health, including potential/actual barriers that prevent or increase the difficulty of an individual receiving care or care equal to those less impacted.  Through expanding and enhancing our Informatics and Data Analytics capacity, Burke could provide care coordinators with enriched data capabilities when coordinating needs, risks, and potential barriers to meeting the individual’s care needs.",null,null,null,2,null,null,null,"Burke intends to adopt and implement a care coordination model of care.  Care coordination requires moving beyond a standard approach of case management in which needs are identified and referrals are made.  Clinicians who are providing care coordination activities take a more deliberate approach in organizing the individual’s care needs, both within Burke’s internal care providers and with external providers.  Care coordination activities include follow-up with individuals and providers to identify barriers to receiving identified care needs and ensuring that referrals to care are not just made, but every attempt to assist the individual with keeping/attending referrals is made.  ","Burke plans to hire and train staff in the care coordination model.","Burke intends to identify individuals with high needs for both mental health and primary care services.  This high need and/or high risk target population includes both children and adults who have been assessed using the CANS/ANSA and who demonstrate actionable scores (i.e. scores of 2 or 3) in the Behavioral Health Needs domains as well as the Physical/Medical domain.  This target population can also include individuals for whom recent and/or frequent utilization of higher levels of care (i.e. psychiatric hospitals, medical hospitals, and/or emergency departments) has been identified.  Another factor considered in the identification of individuals who are often at high risk are social drivers of health (i.e. poverty, food insecurity, housing insecurity and other negative conditions that exists in places where people live)."," "," ",3,1,1,1,0,0,null," Burke intends to hire an additional Data Analytics professional.  This position will be able to mine data pertinent to individuals who have been identified as having high risk and/or high need for mental health and primary care.  Data and reports can be tailored to assist care coordinators in effectively identifying social drivers of health as well as any gaps in care for the targeted population."," Burke plans to identify health information exchanges (HIEs) and other resources that could assist in coordinating referrals for the targeted population of individuals with identified high risks and/or high needs for behavioral health and primary care.  Burke intends to continue to negotiate with managed care organizations (MCOs) to exchange information on shared populations, including hospital admissions and emergency room visits. "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-147",null,51,null,null,null,null,null,null,null,null,null,null,null,137949705,7]
[null,null,3,"140713201","Y",null,null,"",null,null,"158771901","158771901.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"136381405",48,"Prevention and Wellness","Self‐management programs and wellness programs using evidence‐based designs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,54,null,null,null,3,"140713201",{"$f":"IF('Intervention Details'!$D$12=AX56,MAX(AZ$2:AZ55)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,48,"Staff development and inservice to ensure understanding of the new education program as well as implementing new practices to maintain continuity within the program",null,null,null,null,1,null,null,null,"Staff training to include introduction of the new patient education material, required practices in identifying the need for patient education as well as documentation of the need and the steps taken to provide patient education"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-268",null,null,null,null,null,null,"Construction/Renovation",null,null,null,null,null,null,139135109,38]
[null,null,3,"158771901","Y",null,null,"",null,null,"181706601","181706601.7.1","Hospital","Private",null,null,null,"136381405",49,"Prevention and Wellness","Other","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,55,null,null,null,3,"158771901",{"$f":"IF('Intervention Details'!$D$12=AX57,MAX(AZ$2:AZ56)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,49,"Cost will be relating factor for patients considering the vaccination.",null,null,null,null,1,null,null,null,"A list of possible resources that are available to assist in the cost as well as a price list of pharmacies where vaccinations can be received."," "," "," "," ",1,1,0,0,0,0,null,"",""," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,140713201,2]
[null,null,3,"181706601","Y",null,null,"",null,null,"212060201","212060201.7.1","Hospital","Private",null,null,null,"138296208",50,"Maternal and Infant Health Care","Coordinated prenatal and postpartum care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,56,null,null,null,3,"181706601",{"$f":"IF('Intervention Details'!$D$12=AX58,MAX(AZ$2:AZ57)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,50,"Increase access to prenatal and post partum services for MLIU patients who deliver at CHRISTUS hospital",null,null,null,null,1,null,null,null,"Increase patient volume at CHRISTUS OB clinic through educational campaigns and outreach","Increase staffing at the CHRISTUS OB Clinic to accommodate service expansions"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,158771901,16]
[null,null,3,"212060201","Y",null,null,"",null,null,"296760601","296760601.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"139172412",53,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,57,null,null,null,3,"212060201",{"$f":"IF('Intervention Details'!$D$12=AX59,MAX(AZ$2:AZ58)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,53,"For ED throughput, a sampling of patients are given to report through our Premier reporting system. For HF follow-ups, the first driver is identifying the appropriate patients.",null,null,null,null,1,null,null,null,"Making the follow-up appointment for the patient and discharging them with education materials.The EMR does not support reminders for staff or best practice alerts to support staff in making follow-up appointments prior to discharge"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,181706601,8]
[null,null,3,"296760601","Y",null,null,"",null,null,"311054601","311054601.7.1","Hospital","Private",null,null,null,"139172412",54,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,58,null,null,null,3,"296760601",{"$f":"IF('Intervention Details'!$D$12=AX60,MAX(AZ$2:AZ59)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,54,"Screening patients for qualifications (age and immunziation status).",null,null,null,null,1,null,null,null,"Immunizing all qualified patients before discharge.","Scheduling follow-ups for evaluation, therapy or possible admission."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,212060201,8]
[null,null,3,"311054601","Y",null,null,"",null,null,"377705401","377705401.7.1","Hospital","Private",null,null,null,"200683501",51,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,59,null,null,null,3,"311054601",{"$f":"IF('Intervention Details'!$D$12=AX61,MAX(AZ$2:AZ60)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,51,"Improve Care Coordination",null,null,null,null,1,null,null,null,"Develop target population list for patients in need of prevention services from ED visits..","Contact patients and schedule primary care appointments."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387663301,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,377705401,3]
[null,null,3,"377705401","Y",null,null,"",null,null,"020811801","020811801.7.1","Hospital","Private",null,null,null,"284333604",683,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,60,null,null,null,3,"377705401",{"$f":"IF('Intervention Details'!$D$12=AX62,MAX(AZ$2:AZ61)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,683,"prevent person to person transmission of infections via hand hygiene program and other evidence based procedures",null,null,null,null,1,null,null,null,"Implementation of a hand hygiene program","Implementation of policies and procedures regarding reduction and prevention of HAI",null,null,null,2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,0,0,0,0,0,0,null,null,null,null,null,null,0,0,0,0,0,0,null,null,null,null,null,null,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,376537203,"K2-287",null,null,null,null,null,null,null,null,null,null,null,null,null,296760601,6]
[null,null,4,"020811801","Y",null,null,"",null,null,"020973601","020973601.7.1","Hospital","Private",null,null,null,"284333604",52,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,61,null,null,null,4,"020811801",{"$f":"IF('Intervention Details'!$D$12=AX63,MAX(AZ$2:AZ62)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,52,"Improved communication and continuity of care regarding clients throughout all Liberty Dayton Regional Medical Center locations","Increase throughput time in the Emergency Department for follow up care in community or for admission","Implementation of transfer communication tool for consistant handoff communication of transferred patients",null,null,3,null,null,null,"Implementation and training of facility wide EMR system"," "," "," "," ",1,1,0,0,0,0,null,"Moving of patients from the ED immediately after admission","Hire staffing for post discharge follow up of certain populations to prevent unnecessary returns or admissions"," "," "," ",2,1,1,0,0,0,null,"utilization of customized hand off communication tool for all patients transferred to another health care facility"," "," "," "," ",1,1,0,0,0,0,null,null,null," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,376537203,"K2-355",null,null,null,null,null,null,null,null,null,null,null,null,null,311054601,3]
[null,null,4,"020973601","Y",null,null,"",null,null,"020991801","020991801.7.1","Hospital","Non‐State Owned Public",null,null,null,"020817501",57,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,62,null,null,null,4,"020973601",{"$f":"IF('Intervention Details'!$D$12=AX64,MAX(AZ$2:AZ63)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,57,"Connect Patients to Primary and preventive care services","Identify frequent ED users and use navigators as part of a preventable ED reduction program.","Increase access to care management and/or chronic care management and self-management",null,null,3,null,null,null,"Care navigators main function will be to provide adults without a PCP educational materials and community resources, as well as assist them in making primary and preventative care appointments, determining the assistance necessary to keep those appointments, and to work with patients and their families to assure that their access to support (financial, transportation, in-home care, etc) is adequate."," "," "," "," ",1,1,0,0,0,0,null,"HCA Houston Healthcare South will identify adult patients with high rates of ED utilization The Care Coordinator will target those patients visiting the ED for education and intervention aimed at preventing future ED use for non-emergent ambulatory care sensitive conditions and/or preventing conditions from becoming emergent in the first place."," "," "," "," ",1,1,0,0,0,0,null,"Patients will receive self- management education and chronic care management. The Care Coordinator will be dedicated to providing those services. This will increase access to information and resources that adults in Harris County would not otherwise be able to utilize for less emergent healthcare needs."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,376537203,"K2-359",null,null,null,null,null,null,null,null,null,null,null,null,null,20811801,3]
[null,null,4,"020991801","Y",null,null,"",null,null,"080368601","080368601.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"020817501",58,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,63,null,null,null,4,"020991801",{"$f":"IF('Intervention Details'!$D$12=AX65,MAX(AZ$2:AZ64)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,58,"Increase sepsis bundle compliance for patients that have a case of sepsis or are at risk of developing sepsis.",null,null,null,null,1,null,null,null,"Increase the number of patients who receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) resuscitation and management bundles after presenting with symptoms of sepsis or septic shock."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111411803,"M1-146",null,null,null,null,null,null,null,null,null,null,null,null,null,20973601,19]
[null,null,4,"080368601","Y",null,null,"",null,null,"094118902","094118902.7.1","Hospital","Private",null,null,null,"020817501",684,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,64,null,null,null,4,"080368601",{"$f":"IF('Intervention Details'!$D$12=AX66,MAX(AZ$2:AZ65)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,684,"Reduce the incedence and effects of post partum hemmorhage (PPH) through education and collaboration to improve the clinical readiness, recognition and response to PPH",null,null,null,null,1,null,null,null,"Develop a standardized post partum hemmorhage(PPH) protocol/safety bundle identifying the roles/duties of the OB team and rapid response for high risk, critical management for the hemmorhage crisis","","","","",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111411803,"M1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,20991801,3]
[null,null,4,"094118902","Y",null,null,"",null,null,"094222903","094222903.7.1","Hospital","Private",null,null,null,"020834001",59,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,65,null,null,null,4,"094118902",{"$f":"IF('Intervention Details'!$D$12=AX67,MAX(AZ$2:AZ66)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,59,"Educate Memorial Hermann patients and external community about the triage line.",null,null,null,null,1,null,null,null,"Community promotions at events and other external activities, paid online advertisement, promotion on Memorial Hermann websites."," "," "," "," ",1,1,{"$f":"IF(OR(LEFT(BV67,1)=$BT$1,LEFT(BV67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BW67,1)=$BT$1,LEFT(BW67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BX67,1)=$BT$1,LEFT(BX67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BY67,1)=$BT$1,LEFT(BY67,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CH67,1)=$BT$1,LEFT(CH67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CI67,1)=$BT$1,LEFT(CI67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CJ67,1)=$BT$1,LEFT(CJ67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CK67,1)=$BT$1,LEFT(CK67,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CT67,1)=$BT$1,LEFT(CT67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CU67,1)=$BT$1,LEFT(CU67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CV67,1)=$BT$1,LEFT(CV67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CW67,1)=$BT$1,LEFT(CW67,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DF67,1)=$BT$1,LEFT(DF67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DG67,1)=$BT$1,LEFT(DG67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DH67,1)=$BT$1,LEFT(DH67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DI67,1)=$BT$1,LEFT(DI67,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DR67,1)=$BT$1,LEFT(DR67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DS67,1)=$BT$1,LEFT(DS67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DT67,1)=$BT$1,LEFT(DT67,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DU67,1)=$BT$1,LEFT(DU67,1)=\"\"),0,1)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-111",null,null,null,null,null,null,null,null,null,null,null,null,null,80368601,4]
[null,null,4,"094222903","Y",null,null,"",null,null,"112673204","112673204.7.1","Hospital","Private",null,null,null,"020834001",60,"Availability of Appropriate Levels of Behavioral Health Care Services","Increasing access to services by utilizing qualified staff","DY7-10",{"$f":"IF(OR(V68=\"DY7-10\",V68=\"DY9-10\"),\"Y\",\"N\")","v":"Y"},{"$f":"IF(V68=\"DY9-10\",\"Y\",\"N\")","v":"N"},null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,66,null,null,null,4,"094222903",{"$f":"IF('Intervention Details'!$D$12=AX68,MAX(AZ$2:AZ67)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,60,"The proper identification of patients at our facilities in need of this program.",null,null,null,null,{"$f":"COUNTA(BL68:BP68)","v":1},null,null,null,"Education of front line staff at all emergency department and nursing floors on how to identify patients experiencing a behavioral health crisis."," "," "," "," ",{"$f":"SUM(CA68:CE68)","v":1},{"$f":"IF(OR(LEFT(BU68,1)=$BT$1,LEFT(BU68,1)=\"\"),0,1)","v":1},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CM68:CQ68)","v":0},{"$f":"IF(OR(LEFT(CG68,1)=$BT$1,LEFT(CG68,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CY68:DC68)","v":0},{"$f":"IF(OR(LEFT(CS68,1)=$BT$1,LEFT(CS68,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DK68:DO68)","v":0},{"$f":"IF(OR(LEFT(DE68,1)=$BT$1,LEFT(DE68,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DW68:EA68)","v":0},{"$f":"IF(OR(LEFT(DQ68,1)=$BT$1,LEFT(DQ68,1)=\"\"),0,1)","v":0},0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,94118902,15]
[null,null,4,"112673204","Y",null,null,"",null,null,"121775403","121775403.7.1","Hospital","Non‐State Owned Public",null,null,null,"020834001",61,"Availability of Appropriate Levels of Behavioral Health Care Services","Increasing access to services by utilizing qualified staff","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,67,null,null,null,4,"112673204",{"$f":"IF('Intervention Details'!$D$12=AX69,MAX(AZ$2:AZ68)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,61,"Increasing the education and management of psychiatric medications for this population.",null,null,null,null,1,null,null,null,"Process improvement on education and follow up for patients prescribed psychiatric medications."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,94222903,{"$f":"COUNTIF(ET69:ET3038,FI69)","v":4}]
[null,null,4,"121775403","Y",null,null,"",null,null,"121808305","121808305.7.1","Hospital","Non‐State Owned Public",null,null,null,"020834001",62,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,68,null,null,null,4,"121775403",{"$f":"IF('Intervention Details'!$D$12=AX70,MAX(AZ$2:AZ69)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,62,"Expand the integrated behavioral health and primary care program to additional primary care clinics",null,null,null,null,1,null,null,null,"Analyze pilot program performance and identify additional locations where these services are needed."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,112673204,3]
[null,null,4,"121808305","Y",null,null,"",null,null,"130958511","130958511.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"020834001",63,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,69,null,null,null,4,"121808305",{"$f":"IF('Intervention Details'!$D$12=AX71,MAX(AZ$2:AZ70)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,63,"Expand and/or adjust Convenient Care Center hours as needed based on patient volume and demand to offer after-hours and limited weekend primary care.",null,null,null,null,1,null,null,null,"Track patient volume and demand at the Convenient Care Centers to determine whether expanding or adjusting clinic hours will effectively increase access to primary care and reduce unnecessary ED visits."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,121775403,38]
[null,null,4,"130958511","Y",null,null,"",null,null,"132812205","132812205.7.1","Hospital","Private",null,null,null,"020834001",64,"Palliative Care","Provision of coordinated palliative care to address patients with end‐of‐life decisions","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,70,null,null,null,4,"130958511",{"$f":"IF('Intervention Details'!$D$12=AX72,MAX(AZ$2:AZ71)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,64,"Increase the number of patients utilizing palliative care.",null,null,null,null,1,null,null,null,"Continue to educate physicians on palliative care services that are available for their patients."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,121808305,3]
[null,null,4,"132812205","Y",null,null,"",null,null,"135233809","135233809.7.1","Hospital","Non‐State Owned Public",null,null,null,"020834001",65,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,71,null,null,null,4,"132812205",{"$f":"IF('Intervention Details'!$D$12=AX73,MAX(AZ$2:AZ72)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,65,"Continue to monitor risks, errors, and near misses in the hospital.",null,null,null,null,1,null,null,null,"Utilize systems including EMR reports to track outstanding risks, errors, or potential errors in the hospital."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,130958511,3]
[null,null,4,"135233809","Y",null,null,"",null,null,"135254407","135254407.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"081522701",66,"Behavioral Health Crisis Stabilization Services","Implementation of community‐based crisis stabilization alternatives","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,72,null,null,null,4,"135233809",{"$f":"IF('Intervention Details'!$D$12=AX74,MAX(AZ$2:AZ73)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,66,"Through crisis screenings, identify patients in need of crisis stabilization services and appropriate for the Crisis Center to reduce hospital recidivism and increase jail diversion.",null,null,null,null,1,null,null,null,"Utilize a crisis screening tool including medical exclusionary criteria to determine appropriateness for the Crisis Center."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,132812205,39]
[null,null,4,"135254407","Y",null,null,"",null,null,"136436606","136436606.7.1","Hospital","Private",null,null,null,"081522701",67,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,73,null,null,null,4,"135254407",{"$f":"IF('Intervention Details'!$D$12=AX75,MAX(AZ$2:AZ74)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,67,"Implement a medication adherence process for chronic conditions (i.e., uncontrolled hypertension or diabetes).",null,null,null,null,1,null,null,null,"Implement processes in clinic workflow that incorporates patient education delivery."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,135233809,4]
[null,null,4,"136436606","Y",null,null,"",null,null,"137907508","137907508.7.1","Hospital","Non‐State Owned Public",null,null,null,"082006001",68,"Prevention and Wellness","Utilization of whole health peer support","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,74,null,null,null,4,"136436606",{"$f":"IF('Intervention Details'!$D$12=AX76,MAX(AZ$2:AZ75)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,68,"Screening patients for BMI and tobacco use during visits.","Develop and implement a health behavior intervention protocol based on evidence-based strategies to reduce and prevent obesity in adolescents.","Train social workers and medical staff in obesity counseling",null,null,3,null,null,null,"Record BMI and tobacco use in EMR system and implement alerts to flag patients out of normal range"," "," "," "," ",1,1,0,0,0,0,null,"Incorporate smart phrases from evidence-based research to best support providers' comfort and quality in providing nutrition, physical activity and tobacco counseling and education."," "," "," "," ",1,1,0,0,0,0,null,"Improve current training materials to meet patient needs"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,135254407,5]
[null,null,4,"137907508","Y",null,null,"",null,null,"138305109","138305109.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"093774008",69,"Expansion or Enhancement of Oral Health Services","Expanded use of existing dental clinics for underserved population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,75,null,null,null,4,"137907508",{"$f":"IF('Intervention Details'!$D$12=AX77,MAX(AZ$2:AZ76)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,69,"Increase awareness on the general knowledge of oral health, importance of oral health and self-efficacy","Increase clinic capacity to meet the expansion needs","Increase patient recall to ensure clients are meeting suggested dental care guidelines",null,null,3,null,null,null,"Outreach to vulnerable populations through schools and community events"," "," "," "," ",1,1,0,0,0,0,null,"Formalize partnership for workforce development with community stakeholders and dental providers"," "," "," "," ",1,1,0,0,0,0,null,"Ensure clients are scheduled and seen every six months for routine cleanings/examinations"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,136412710,3]
[null,null,4,"138305109","Y",null,null,"",null,null,"020947001","020947001.7.1","Hospital","Private",null,null,null,"093774008",70,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,76,null,null,null,4,"138305109",{"$f":"IF('Intervention Details'!$D$12=AX78,MAX(AZ$2:AZ77)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,70,"Increase compliance for post-partum care for women seen in home-visitation","Ensure adequate screening for tobacco use, BMI, and blood pressure of clients who access our services in the clinic setting","Increase awareness on the general knowledge of sexual behaviors and safe-sex, importance of healthy sexual practices and self-efficacy","Continue standardized STD screening processes for clients accessing services",null,4,null,null,null,"Strengthen relationships with providers to get glucose screenings","Establish partnerships with behavioral health providers","Assist clients with securing a payer source for primary care services","Ensure timeliness of follow-up for post-partum mothers"," ",4,1,1,1,1,0,null,"Strengthen screening and follow-up protocol a) provider education; b) QA","Connect clients to care coordination group for service linkage","Standardize tobacco cessation counseling in clinic setting"," "," ",3,1,1,1,0,0,null,"Outreach to women in family planning, e.g. Healthy Texas Women","Provide education to clients on healthy sexual practices"," "," "," ",2,1,1,0,0,0,null,"Increase clinic capacity to screen population accessing services","QA to ensure clients are being appropriately screened"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,136436606,5]
[null,null,5,"020947001","Y",null,null,"",null,null,"085144601","085144601.7.2","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"093774008",71,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,77,null,null,null,5,"020947001",{"$f":"IF('Intervention Details'!$D$12=AX79,MAX(AZ$2:AZ78)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,71,"Increase 3HP enrollment of clients targeted for treatment","Increase clincial evaluation of clients targeted for treatment",null,null,null,2,null,null,null,"Identify high risk populations through testing and contact investigations (e.g. congregate settings: homeless shelters, universities, immigrants)","Provide education on 1) importance of treatment; 2) general knowledge of 3HP and DOT"," "," "," ",2,1,1,0,0,0,null,"Provide transportation for clinical appointment for potential clients","Provide translational services to clients trageted for treatment","Provide education on the importance of clinical evaluations"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,137907508,16]
[null,null,5,"085144601","Y",null,null,"",null,null,"094113001","094113001.7.1","Hospital","Private",null,null,null,"093774008",72,"Access to Primary Care Services","Establishment of care coordination and active referral management","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,78,null,null,null,5,"085144601",{"$f":"IF('Intervention Details'!$D$12=AX80,MAX(AZ$2:AZ79)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,72,"Increase primary care access for clients without medical homes","  Establish partnership with local Care Navigation teams (e.g. Links, Connect)",null,null,null,2,null,null,null,"Establish new partnerships with primary care providers","Enhance ongoing relationships with referring providers and PCPs","Enhance bi-directional referral protocol with providers","Standardize the referral processes to and from providers"," ",4,1,1,1,1,0,null,"  Enhance bidirectional referral protocols for individuals with pre-diabetes"," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,138305109,7]
[null,null,5,"094113001","Y",null,null,"",null,null,"111810101","111810101.7.2","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",null,null,null,"093774008",73,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,79,null,null,null,5,"094113001",{"$f":"IF('Intervention Details'!$D$12=AX81,MAX(AZ$2:AZ80)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,73,"Expansion of educational services offered by the local health department","Offer tobacco cessation counseling and follow-up to clients","Increase awareness on the general knowledge of diabetes, importance of diabetes management and self-efficacy",null,null,3,null,null,null,"Develop and update BP, abnormal BMI, tobacco cessation and prevention activities","Host monthly wellness resource seminars, e.g. BP management, DASH diet, alcohol reduction, nutrition, active living, weight management, tobacco cessation","Conduct evidence-based health education series, e.g. Nutrition Ed/DASH, CDSM, Weight Management","Host Pop-up Conversation Series on BP, BMI management topics"," ",4,1,1,1,1,0,null,"Increase collaborations with local resources, e.g. Quit Line, MD Anderson, etc.","Promotion of internal services offered and link to Health Education"," "," "," ",2,1,1,0,0,0,null,"Monitor blood pressure from all diabetic clients we engage","Offer medication adherance education to participants","Implement self-monitoring blood pressure curriculum","Capture HbA1c from all diabetic and pre-diabetic clients","Provide chronic disease self-management educational sessions and trainings",5,1,1,1,1,1,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,20947001,5]
[null,null,5,"111810101","Y",null,null,"",null,null,"112716902","112716902.7.1","Hospital","Private",null,null,null,"093774008",74,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,80,null,null,null,5,"111810101",{"$f":"IF('Intervention Details'!$D$12=AX82,MAX(AZ$2:AZ81)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,74,"Offer referrals for pre-hypertensive and hypertensive clients","Offer referrals for BMIs that are outside of normal parameters","Effectiveness of Care Coordination Services offered to clients",null,null,3,null,null,null,"Increase collaborations with local resources for individuals with blood pressure readings outside of the normal parameters","Promotion of internal services offered and link to Health Education"," "," "," ",2,1,1,0,0,0,null,"Increase collaborations with local resources for individuals with BMIs outside of the normal parameters","Promotion of internal services offered and link to Health Education"," "," "," ",2,1,1,0,0,0,null,"Ensure staff has/completes Community Health Worker Certification","Training in Patient Navigation and specific subject matters","Develop curriculum for continuing education for staff in care coordination"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C2-106",null,null,null,null,null,null,null,null,null,null,null,null,null,85144601,46]
[null,null,5,"112716902","Y",null,null,"",null,null,"135035706","135035706.7.1","Hospital","Private",null,null,null,"094187402",75,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,81,null,null,null,5,"112716902",{"$f":"IF('Intervention Details'!$D$12=AX83,MAX(AZ$2:AZ82)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,75,"Increase access to care management resources and/or self management education for ED patients.","Identify frequent ED users and patients with ACSC and use navigators as part of a preventable ED visit reduction program.","Connect ED Patients to Primary and preventive care services",null,null,3,null,null,null,"Patients will receive self- management education and chronic care management. The care coordinator will be dedicated to providing those services. This will increase access to information and resources that adults in Harris County would not otherwise be able to utilize for less emergent healthcare needs."," "," "," "," ",1,1,0,0,0,0,null,"HCA Houston Healthcare West will identify adult patients with high rates of ED utilization. The Care Coordinator will target those patients visiting the ED for education and intervention aimed at preventing future ED use for non-emergent ambulatory care sensitive conditions and/or preventing conditions from becoming emergent in the first place.","Identify patients with specific chronic and acute ACSCs and use navigators to ensure patients with ACSCs are educated regarding their conditions and connect them with a primary care setting for management of their condition."," "," "," ",2,1,1,0,0,0,null,"The care coordinator's main function will be to provide educational materials and community resourced to adults without a PCP in the ED setting.","The care coordinator will assist identified patients in making primary and preventative care appointments, determining the assistance necessary to keep those appointments.","The care coordinator will work with patients and their families to help ensure that their access to support (financial, transportation, in-home care, etc) is adequate."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C2-107",null,null,null,null,null,null,null,null,null,null,null,null,null,94113001,32]
[null,null,5,"135035706","Y",null,null,"",null,null,"136332705","136332705.7.1","Hospital","Non‐State Owned Public",null,null,null,"094187402",76,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,82,null,null,null,5,"135035706",{"$f":"IF('Intervention Details'!$D$12=AX84,MAX(AZ$2:AZ83)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,76,"Increase sepsis bundle compliance for patients that have a case of sepsis or are at risk of developing sepsis.",null,null,null,null,1,null,null,null,"Implement Sepsis Bundle protocol to increase the number of patients who receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) resuscitation and management bundles after presenting with symptoms of sepsis or septic shock."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"C2-186",null,null,null,null,null,null,null,null,null,null,null,null,null,112716902,15]
[null,null,5,"136332705","Y",null,null,"",null,null,"138708601","138708601.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"094187402",685,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,83,null,null,null,5,"136332705",{"$f":"IF('Intervention Details'!$D$12=AX85,MAX(AZ$2:AZ84)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,685,"Reduce the incedence and effects of post partum hemmorhage (PPH) through education and collaboration to improve the clinical readiness, recognition and response to PPH",null,null,null,null,1,null,null,null,"Develop a standardized post partum hemmorhage(PPH) protocol/safety bundle identifying the roles/duties of the OB team and rapid response for high risk, critical management for the hemmorhage crisis","","","","",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"D4-139",null,null,null,null,null,null,null,null,null,null,null,null,null,135035706,5]
[null,null,5,"138708601","Y",null,null,"",null,null,"160709501","160709501.7.1","Hospital","Private",null,null,null,"111810101",77,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,84,null,null,null,5,"138708601",{"$f":"IF('Intervention Details'!$D$12=AX86,MAX(AZ$2:AZ85)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,77,"Identify patients who are eligible for screening and offer eligible patients an appointment","Improve time to referral and follow up by enlisting support from referral coordinator and/or care teams","Educate patients on importance and benefits of screening",null,null,3,null,null,null,"Provide providers and clinic staff with access to preventive care dashboards including gap assessments.  Dashboards provide real time visualizations for health outcomes that highlights individual-, clinic-, and department-level performance.  Additionally, providers can drill down to the patient as the unit of analysis."," "," "," "," ",1,1,0,0,0,0,null,"Update referral and follow up procedures and workflows to ensure referral status is checked regularly, in addition to at pre- and post- visit planning"," "," "," "," ",1,1,0,0,0,0,null,"Maximize patient education opportunities during pre- and post- visit planning and provide screening reminders","Provide patients with educational brochures and other visual cues (e.g., posters in waiting rooms, point of care report)"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"D4-353",null,null,null,null,null,null,null,null,null,null,null,null,null,136332705,7]
[null,null,5,"160709501","Y",null,null,"",null,null,"343698201","343698201.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"111810101",78,"Patient Centered Medical Home","Provision of coordinated services for patients under Patent Centered Medical Home model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,85,null,null,null,5,"160709501",{"$f":"IF('Intervention Details'!$D$12=AX87,MAX(AZ$2:AZ86)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,78,"Assign each patient to a single provider panel with consent from patient to initiate patient centered planning","Assess practice supply and demand regularly and re-balance patient load as needed","Use panel data and registries to proactively contact, educate, and track patients by disease status, risk status, need, etc.",null,null,3,null,null,null,"Employ Murray 4-cut method to those patients without a documented primary care provider (PCP).  This method is evidence-based and systematic for assigning patients to a single provider after a thorough assessment of supply and demand is conducted.  This recognized linkage between the provider and patient promotes continuity of care.","Obtaining consent for provider assignment will be reviewed with clinic staff and patients."," "," "," ",2,1,1,0,0,0,null,"Determine ideal panel sizes for each practice; reconcile actual versus ideal panel sizes"," "," "," "," ",1,1,0,0,0,0,null,"Manage panels across a comprehensive set of disease and risk levels (population health)"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"D4-375",null,null,null,null,null,null,null,null,null,null,null,null,null,138708601,21]
[null,null,5,"343698201","Y",null,null,"",null,null,"020844901","020844901.7.1","Hospital","Private",null,null,null,"111810101",79,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,86,null,null,null,5,"343698201",{"$f":"IF('Intervention Details'!$D$12=AX88,MAX(AZ$2:AZ87)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,79,"Establish scope of practice and define roles for care teams that reflect the skills and abilities of team members","Provide convenient access points to link patients to provider and care team whenever possible","Establish and provide organizational support for care teams that are accountable to patient panels",null,null,3,null,null,null,"Set expectations for care delivered outside of the clinic","Evaluate capacity for internal/external referrals and modify care team duties accordingly"," "," "," ",2,1,1,0,0,0,null,"Expand implementation of same-day appointments to additional clinic location(s)","Utilize the nurse triage line (available 24 hours per day/7 days per week) for urgent clinical advice after hours"," "," "," ",2,1,1,0,0,0,null,"Assess training needs regularly and provide cross training to ensure care teams are able to meet patient needs consistently"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E1-232",null,null,null,null,null,null,null,null,null,null,null,null,null,160709501,32]
[null,null,6,"020844901","Y",null,null,"",null,null,"020844903","020844903.7.1","Hospital","Private",null,null,null,"111810101",80,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,87,null,null,null,6,"020844901",{"$f":"IF('Intervention Details'!$D$12=AX89,MAX(AZ$2:AZ88)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,80,"Educate patients/parents on the importance of immunizations","Use care teams to identify and reach out to patients who are due for immunization/booster",null,null,null,2,null,null,null,"Train care teams on educating patients on the importance of maintaining vaccinations up-to-date"," "," "," "," ",1,1,0,0,0,0,null,"Train clinic leadership (e.g., physicians, case managers, practice managers) on the use of web-based dashboards/smart registries that can identify gaps in care","Train clinical staff (e.g., community health workers, medical assistants) on verifying immunization status at pre visit phone calls"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E1-235",null,null,null,null,null,null,null,null,null,null,null,null,null,343698201,19]
[null,null,6,"020844903","Y",null,null,"",null,null,"085144601","085144601.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"111810101",81,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,88,null,null,null,6,"020844903",{"$f":"IF('Intervention Details'!$D$12=AX90,MAX(AZ$2:AZ89)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,81,"Document integrated treatment plans in the electronic health record","Enhance integration meetings among primary care providers and behavioral health providers on a regular basis",null,null,null,2,null,null,null,"Educate providers on how to use and properly document in the integrated treatment plan"," "," "," "," ",1,1,0,0,0,0,null,"Train primary care providers and staff on behavioral health assessment and treatment","Train behavioral health providers in short duration treatment and in physical health diagnosis, especially for common chronic conditions"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E1-300",null,null,null,null,null,null,null,null,null,null,null,null,null,20844901,10]
[null,null,6,"085144601","Y",null,null,"",null,null,"091308902","091308902.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"112672402",82,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,89,null,null,null,6,"085144601",{"$f":"IF('Intervention Details'!$D$12=AX91,MAX(AZ$2:AZ90)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,82,"Continue screening patients for colorectal cancer using take-home FITs and provide appropriate diagnostic follow-up to patients who test positive and are diagnosed with cancer.","Continue offering breast cancer screening and appropriate diagnostic follow-up through Project VALET mobile mammography program.",null,null,null,2,null,null,null,"Provide refresher trainings for clinic staff regarding FIT testing guidelines and procedures."," "," "," "," ",1,1,0,0,0,0,null,"Use patient reminder calls to decrease the no-show rates for screening services in the mobile mammography van."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E2-150",null,null,null,null,null,null,null,null,null,null,null,null,null,20844903,10]
[null,null,6,"091308902","Y",null,null,"",null,null,"094154402","094154402.7.1","Hospital","Private",null,null,null,"112672402",83,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,90,null,null,null,6,"091308902",{"$f":"IF('Intervention Details'!$D$12=AX92,MAX(AZ$2:AZ91)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,83,"Improve the readmission rate and patient satisfaction",null,null,null,null,1,null,null,null,"Contacting 100% of patients following disharge","Creating a standardized evaluation process"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E2-151",null,null,null,null,null,null,null,null,null,null,null,null,null,91308902,13]
[null,null,6,"094154402","Y",null,null,"",null,null,"112688004","112688002.7.1","Hospital","Private",null,null,null,"112672402",84,"Palliative Care","Utilization of services assisting individuals with pain management","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,91,null,null,null,6,"094154402",{"$f":"IF('Intervention Details'!$D$12=AX93,MAX(AZ$2:AZ92)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,84,"Implement a system for pain management in patients taking opioids.",null,null,null,null,1,null,null,null,"Document findings of a comprehensive pain assessment for patients taking opioids","Actively engage patients in decision making  to find effective alternatives for pain management."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"E2-A01",null,null,null,null,null,null,null,null,null,null,null,null,null,94154402,18]
[null,null,6,"112688004",{"$error":"#N/A"},null,null,"",null,null,"112742503","112742503.7.1","Hospital","Private",null,null,null,"112672402",85,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,92,null,null,null,6,"112688004",{"$f":"IF('Intervention Details'!$D$12=AX94,MAX(AZ$2:AZ93)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,85,"Compliance with Hand Hygiene for CLAUTI and CLABSI without MBI",null,null,null,null,1,null,null,null,"Feedback on Hand Hygiene rates for both CLAUTI and CLABSI without MBI","Electronic Health Record data capture in OneConnect system"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"F1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,112688004,3]
[null,null,6,"112742503","Y",null,null,"",null,null,"119877204","119877204.7.1","Hospital","Non‐State Owned Public",null,null,null,"112672402",686,"Expansion or Enhancement of Oral Health Services","Expanded use of existing dental clinics for underserved population","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,93,null,null,null,6,"112742503",{"$f":"IF('Intervention Details'!$D$12=AX95,MAX(AZ$2:AZ94)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,686,"Assessment and improvement of current documentation practices for dental services within the community clinic E.H.R.",null,null,null,null,1,null,null,null,"Use relevant dental codes to document procedures previously documented in the patient's notes field.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"F1-226",null,null,null,null,null,null,null,null,null,null,null,null,null,112742503,2]
[null,null,6,"119877204","Y",null,null,"",null,null,"121782006","121782006.7.1","Hospital","Non‐State Owned Public",null,null,null,"113180703",86,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94,null,null,null,6,"119877204",{"$f":"IF('Intervention Details'!$D$12=AX96,MAX(AZ$2:AZ95)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,86,"Review of CCBHC Measures to identify which measures need to be implemented at the Harris Center for certification.","Make changes to clinical workflow and staffing patterns to implement additional screenings, assessments, or documentation to collect data for CCBHC certification.","Submit an application for the CCBHC certification.",null,null,3,null,null,null,"Post and hire a Director of CCBHC certification to lead our organization through certification preparation and the certification process.","Determine DSRIP measures that have been implemented that meet the CCBHC requirements.","Identify the additional CCBHC measure that will need to be implemented.","Work with program staff and IT to implement the additional measures to track performance."," ",4,1,1,1,1,0,null,"Determine where in the clinical process data should be collected for each of the new CCBHC measures.","Work with IT to pull the collected data for tracking and reporting."," "," "," ",2,1,1,0,0,0,null,"Complete a mock certification audit to determine any deficiencies that could impact certification approval.","Make identified changes or modifications as a result of the mock audit for any measures that did not pass the audit."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"F1-227",null,null,null,null,null,null,null,null,null,null,null,null,null,119877204,8]
[null,null,6,"121782006","Y",null,null,"",null,null,"121990904","121990904.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"113180703",87,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of telehealth/telemedicine in delivering behavioral services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,95,null,null,null,6,"121782006",{"$f":"IF('Intervention Details'!$D$12=AX97,MAX(AZ$2:AZ96)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,87,"Set-up a system internally to accommodate telemedicine services per the Medicaid guidelines.","Secure telemedicine psychiatric services potentially for both our outpatient and some of our crisis service programs.","Set-up telemedicine equipment in the clinics and/or crisis services for the telemedicine services.",null,null,3,null,null,null,"Modify our current billing codes to support billing Medicaid and insurances for providing the telemedicine services.","Modify our current staffing workflow to accommodate Medicaid telemedicine requirements.","Identify which clinics and/or crisis services the telemedicine services will be expanded to."," "," ",3,1,1,1,0,0,null,"Response for Proposal (RFP) posted to seek  telemedicine psychiatry providers interested in contracting to provide the identified services."," "," "," "," ",1,1,0,0,0,0,null,"Identify which site location and offices will be used for telemedicine services.","Purchase and install the necessary telemedicine equipment to activate the service."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"F2-224",null,null,null,null,null,null,null,null,null,null,null,null,null,121782006,5]
[null,null,6,"121990904","Y",null,null,"",null,null,"127294003","127294003.7.1","Hospital","Private",null,null,null,"113180703",88,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96,null,null,null,6,"121990904",{"$f":"IF('Intervention Details'!$D$12=AX98,MAX(AZ$2:AZ97)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,88,"Expand primary care clinic services within two additional behavioral health clinics.","Promote a culture that values integrated physical and behavioral health care for the treatment of individuals with a mental illness.","Step up to the next SAMHSA Integration Model Level of Integrated Care.",null,null,3,null,null,null,"Facilitate primary care integration in the two additional clinics utilizing either an FQHC or hiring of a Primary Care Physician.","Identify space in two projected clinics to create an office for primary care services."," "," "," ",2,1,1,0,0,0,null,"Action plan to create and deploy a integrated physical health & behavioral health training to be completed at new employee orientation and annually for mental health providers."," "," "," "," ",1,1,0,0,0,0,null,"Identify current SAMHSA Integration Model Level of Integrated Care in our current collaborative care project.","Work on the elements needed to move to the next Level of Integrated Care."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"F2-229",null,null,null,null,null,null,null,null,null,null,null,null,null,121990904,11]
[null,null,6,"127294003","Y",null,null,"",null,null,"133257904","133257904.7.1","Hospital","State Owned Public",null,null,null,"127300503",89,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,97,null,null,null,6,"127294003",{"$f":"IF('Intervention Details'!$D$12=AX99,MAX(AZ$2:AZ98)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,89,"Enhance services through further development of a multi-disciplinary care transitions team. The team must include medical director(s), nurse practitioner(s), nurse navigator(s), pharmacy, case management, and clerical assistant(s). Utilize the team to risk stratify patients and improve discharge planning to mitigate readmission risks by implementing a risk stratification model.","Implement care transition pilot interventions for patients needing post-acute care management.","Maintain and increase partnerships with post-acute care providers to better service various patient needs.",null,null,3,null,null,null,"Improve selection of interventions for successful and efficient discharge planning through a risk-stratification model that utilizes the BSLMC EMR. Align the model with triggers for early identification and mitigation of patient risk. Improve risk mitigation during patients' inpatient experience based on risk identifiers noted by the risk-stratification model.","Expand the current team to include inpatient management of improved medication reconciliation and post-discharge care coordination."," "," "," ",2,1,1,0,0,0,null,"Implement a pilot of Home Health Preferred Providers, i. Expand preferred providers, train them in BSLMC processes for patient education, medication reconciliation, post-discharge assessment, and readmission risk mitigation, ii. Provide guidance to the Preferred Providers on BSLMC's Strategic Pathways/Protocols.","Implement a pilot of Hospice/Palliative Care. This program intends to better identify those patients at-risk who would also benefit from earlier inpatient and/or outpatient hospice and palliative care intervention."," "," "," ",2,1,1,0,0,0,null,"Increase number/types patients referred to San Jose Clinic, the safety-net clinic for the uninsured which BSLMC has long-partnered since the beginning of the DSRIP 1.0 program. In DSRIP 1.0 this partnership focused on the uninsured CHF patients, going into DSRIP 2.0, BSLMC is working to expand services to other at-risk, uninsured patients.","Collaborate with the Clinically Integrated Network (CIN) for post-acute visits. This collaboration already exists for patients who have designated Primary Care and Specialty Care providers within CIN, but BSLMC will attempt to increase the referral base to CIN providers for those patients hospitalized who do not have existing PCP and Specialty Care Providers delegated to ensure more rapid follow-up and connectivity to a medical home.","Implement post-acute follow-up appointment electronic scheduling with BSLMC partner – Baylor College of Medicine (BCM). Work with the CIN to investigate expansion of this model into providers outside of the BSLMC DSRIP system into the greater CHI texas Division system. Work with HHSC and the HIE to investigate the potential for expansion of this model into other providers outside of the BSLMC immediate system. "," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-276",null,null,null,null,null,null,null,null,null,null,null,null,null,127294003,3]
[null,null,6,"133257904","Y",null,null,"",null,null,"133340307","133340307.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"127300503",90,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,98,null,null,null,6,"133257904",{"$f":"IF('Intervention Details'!$D$12=AX100,MAX(AZ$2:AZ99)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,90,"Create a multi-disciplinary team to review all hospital safety measures, develop a routine monitoring and reporting mechanism for each, design strategies for improving outcomes, and create an implementation process to include adjustments and changes to action items as needed",null,null,null,null,1,null,null,null,"Create a multi-disciplinary team that meets monthly to review hospital safety data, including CLABSI, CAUTI, SSI, Patient Fall Rates, and Post-Op Sepsis Rates, review cases, determine fall-out cases and create action plans. \n1. An executive sponsor, a physician champion, nursing leadership, Quality/Safety, Infection Prevention, Environmental Services supervisors, education staff are all included on the team.\n2. Ad hoc members include: pharmacy, lab, materials/supply, IT","Implement routine monitoring to prevent infection (CLABSI, CAUTI, SSI):\n1. Hand hygiene\n2. Contact Precaution compliance to mitigate hospital-based infection\n3. Antibiotic Stewardship","Monitor the completion of Routine Rounds (CLABSI, CAUTI, Fall)\n1. Maintenance/prevention Rounds\n2. Device Rounds","Monitor the routine education of hospital staff to ensure inclusion of:\n1. Annual staff education regarding infection transmission, infection rates, and infection prevention interventions with routine updates monthly","5. Monitor implementation of the CLABSI Prevention Action Items: \na. Prompt removal femoral lines\nb. Roll-out of Swab Caps on high-risk units\nc. Physician team reviewing PI practices for HD tunneled lines\nd. I Save the Line campaign assessing line patency.\ne. New change Ideas:\ni. Standardized CVC insertion and maintenance checklists.\nii.  Implement Days without Harm Dashboard, posts on the Quality website, and Huddle boards.\niii. Increase use of midline and extended dwell peripheral IVs, including staff education on medications that cannot be transfused through midlines. \niv. Monitor Hemodialysis (HD) catheter access by HD and bedside nursing to ensure appropriate utilization.\nv. Implement daily CHG Bathing on all patients with Central lines, including policy updates and staff training.\n6. Monitor implementation of the CAUTI Prevention Action Items: \na. Nurse-driven protocol for indwelling catheter removal to curb CAUTI. \nb. Nurse Manager rounding/daily indwelling catheter audits\nc. Pilot PUREwick external female catheter\nd. New change Ideas:\ni. New process to review hospital acquired infections as they are coded and then present to the CLABSI/CAUTI Steering Committee for trends and initiatives.\nii. Implement nursing and PCA competencies focused on peri-care and catheter care \niii. Implement a standardized insertion/maintenance bundle and a data dashboard.\niv. Implement a two-person Foley insertion\nv. Create improved awareness of the process for Foley removal inpatients with retention/obstruction issues. BSLMC is currently investigating best practices to create staff training. \n7. Monitor implementation of the SSI Prevention and Post-Op Sepsis action Items: \na. Pre-op Blood Glucose testing on all patients\nb. Chlorhexidine Gluconate (CHG) pre-op bathing as nurse-drive protocol. \nc. Using ClipVac for intraoperative hair removal.\n8. For Post-Op Sepsis improvement, the multidisciplinary team has worked on:\na. Chart reviews to identify process failures \nb. Escalation of case issues through medical staff services, as warranted \nc. Implement improvement in clinical documentation & coding of admission types to accurately identify patient risks\nd. Hand hygiene \ne. Implement a multidisciplinary rounding tool for critical care units that includes assessment of mechanical ventilation, glucose, nutrition, antibiotics, skin condition need for central line, need for Foley catheter, need for all other lines all of which are clinical areas that put the patient at risk for Post-Operative Sepsis.  \nf. Pre-op Glucose Testing for all surgical patients. It is being initially rolled out to all elective colorectal patients. \ng. Re-educate through the Staff Nurse Council and Nurse Manager Council on importance and requirement for utilization of the Chlorhexidine Gluconate (CHG) pre-op bathing as a nurse-drive protocol. Create a Huddle Power Minute so this can be discussed at unit daily huddles. \nh. ClipVac for intraoperative hair removal and documentation added to BSLMC EMR \n9. Monitor implementation of the Fall Prevention Action Items: \na. Fall Management policy and procedure revised to incorporate a patient population based approach to falls prevention and fall related injury\ni. Fall Management policy and procedure revised to incorporate a patient population based approach to falls prevention and fall related injury\nb. Bathroom modifications to include raised toilets, grab bars, and more bedside commodes \nc. Universal Fall Precautions for all patients\nd. Reviewing injury risk tools to better identify patients at risk\ne. Hourly nurse rounding to include:\ni. Monitored restroom for fall-risk patients\nii. Bed alarm check\nf. New Change Ideas:\ni. Incorporate Fall Morse Score at bedside shift report and on transfer to any unit/procedure\n1. Utilize high-risk report to identify patients with Morse Score > 45 and validate that high-risk interventions are in place - discuss every shift                                  \n2. Implement weekly reporting of Days Without Harm Dashboard at Tier 2 Huddle          \n3. Post-fall management to include immediate notification to Manager/Director \nii. Implement a positive method to motivate staff to maintain or improve their good work, recognize units that reach 100 days with zero falls",5,1,1,1,1,1,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-277",null,null,null,null,null,null,null,null,null,null,null,null,null,133257904,7]
[null,null,6,"133340307","Y",null,null,"",null,null,"135151206","135151206.7.1","Hospital","Non‐State Owned Public",null,null,null,"127303903",91,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,99,null,null,null,6,"133340307",{"$f":"IF('Intervention Details'!$D$12=AX101,MAX(AZ$2:AZ100)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,91,"OakBend will implement protocols and educate staff and physicians to ensure that they understand the new bundle and strategies involved for providing high-quality care for patients and track data related to individual rates of Cesarean reduction, hemorrhage reduction and percentage of antenatal steroids being administered to maternity patients.",null,null,null,null,1,null,null,null,"On a regular basis, OakBend will convene and report data results to labor and delivery physicians and staff pertaining to metrics being measured and implement process improvements as necessary to address identified issues."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-278",null,null,null,null,null,null,null,null,null,null,null,null,null,133340307,20]
[null,null,6,"135151206","Y",null,null,"",null,null,"136141205","136141205.7.1","Hospital","Non‐State Owned Public",null,null,null,"127303903",92,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,100,null,null,null,6,"135151206",{"$f":"IF('Intervention Details'!$D$12=AX102,MAX(AZ$2:AZ101)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,92,"A specially trained Registered Nurse or Case Worker who will act as a personal healthcare coordinator to navigate patients healthcare needs, resulting in overall health improvement and potential cost savings.",null,null,null,null,1,null,null,null,"Assign and train RN or Case Worker to perform patient navigation services.","Maintain an inventory of resources and supports that the patient needs."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-361",null,null,null,null,null,null,null,null,null,null,null,null,null,135151206,3]
[null,null,6,"136141205","Y",null,null,"",null,null,"136430906","136430906.7.1","Hospital","Private",null,null,null,"127303903",93,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,101,null,null,null,6,"136141205",{"$f":"IF('Intervention Details'!$D$12=AX103,MAX(AZ$2:AZ102)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,93,"Develop plan for committee to meet regularly and gain buy-in for the committee to authorize action in response to safety concerns or refer the actions to another group, such as the executive medical staff, that can muster resources and will take action.","Develop committee meeting protocols for structure as a second secondary driver.","Develop committee action protocols as the third secondary driver.",null,null,3,null,null,null,"Identify and appoint chairpersons to lead committee on patient safety initiatives.","Develop charter to guide committee activities and key focus areas supporting patient safety.","Develop plan to gain buy in from clinicians to participate in safety initiatives."," "," ",3,1,1,1,0,0,null,"Form recurring agenda to discuss specific safety issues.","Determine roles of clinicians as committee members in meeting content development, meeting discussion, and meeting follow up."," "," "," ",2,1,1,0,0,0,null,"Develop safety protocols as the first change idea for the secondary driver.","Identify actors in safety action plans as the second change idea for the secondary driver.","Develop action timeline and report back on the plan."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-362",null,null,null,null,null,null,null,null,null,null,null,null,null,136141205,33]
[null,null,6,"136430906","Y",null,null,"",null,null,"136491104","136491104.7.1","Hospital","Private",null,null,null,"130959304",94,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,102,null,null,null,6,"136430906",{"$f":"IF('Intervention Details'!$D$12=AX104,MAX(AZ$2:AZ103)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,94,"Access to after hours and weekend hours along with transportation to and from clinics",null,null,null,null,1,null,null,null,"Extend contract with MEHOP (FQHC) to ensure extended hours.  Partner with local agencies to identify transportation option & ensure outreach and communication aligned with access points."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"G1-363",null,null,null,null,null,null,null,null,null,null,null,null,null,136430906,3]
[null,null,6,"136491104","Y",null,null,"",null,null,"137251808","137251808.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"130959304",95,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,103,null,null,null,6,"136491104",{"$f":"IF('Intervention Details'!$D$12=AX105,MAX(AZ$2:AZ104)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,95,"Access to education and tools for healthy choices of food and activity","Implementation of diabetes medication management best practices within community partner practices utilizing provider outreach and ACO network structure.",null,null,null,2,null,null,null,"Establish educational programs utilizing ambulatory clinics and Community Based Organizations (CBO) to maximize access to fresh foods and understanding the ability to eat healthy on a budget & in a time crunch","Establish relationships with local grocery stores and farmers to build the concept of farmers markets and local sourced foods and provide sources for coupons, etc.","Utilize Diabetic educator in the hospital to expand outreach into the ambulatory setting"," "," ",3,1,1,1,0,0,null,"Identify diabetes medication management best practices that are adaptable to rural settings","Utilize hospital process improvement efforts to communicate & implement diabetes medication management best practices within our community practices utilizing hospital based analytics to drive outreach"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"H1-146",null,null,null,null,null,null,null,null,null,null,null,null,null,136491104,7]
[null,null,6,"137251808","Y",null,null,"",null,null,"138411709","138411709.7.1","Hospital","Non‐State Owned Public",null,null,null,"133355104",98,"Chronic Care Management","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,104,null,null,null,6,"137251808",{"$f":"IF('Intervention Details'!$D$12=AX106,MAX(AZ$2:AZ105)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,98,"Incentivize patient participation in their own health outcomes by creating a \"Wall of Wellness\" at each of our health center locations to showcase patients who have managed and improved their A1c scores.","Identification of appropriate documentation practices to capture accurate patient data in order to monitor patient adherance and track outcomes","Further coordination of care for the Diabetes Multidisciplinary Program to bridge clinical practice and self management in order to improve quality of care, patient outcomes, and system capacity.","Expansion of Community Health Worker Home Visit program to increase knowledge, teaching skills, addressing psychosocial needs, and providing social and environmental support to improve self-management among those with Type 2 Diabetes, as well as prevention among those with high-risk indicators.","Staff development and education to ensure appropriate management and navigation of patients to the right care at the right time",5,null,null,null,"Reward patients that have managed their diabetes and improved their HbA1c goals by 2 percent with a recognition presentation, small gifts, and displaying their picture on the \"Wall of Wellness\" with success stories meant to inspire other patients to take control of their health."," Partner with Healthy Heart, Healthy You (HHHY) a remote blood pressure monitoring program to highlight patients on the Wall of Wellness who have successfully graduated the program. These patients have successfully lowered and are now maintaining a healthy blood pressure. "," "," "," ",1,1,0,0,0,0,null,"Update existing methods for capturing specific data elements to facilitate the monitoring of patient outcomes"," "," "," "," ",1,1,0,0,0,0,null,"Utilize case management to assess barriers associated with achieving optimal health outcomes","Integrate point of care pharmacy to assist with medication adherence and adjustments as needed.","Same-day access to patient education and/or nutrition counseling to promote diabetes self-management","Nursing staff to provide patients with a DM program education folder that will serve as a source of information to help guide and organize self-management","PCP initiated intervention (lab orders, referrals, medications, etc.) to improve health outcomes",5,1,1,1,1,1,null,"Community Health Worker home assessment of diabetes knowledge and self-management behaviors to drive educational and clinical interventions.","Screening for social determinants of health to identify barriers and provide resources in order to improve self-management."," "," "," ",2,1,1,0,0,0,null,"Standardize system-wide protocols for the appropriate management and coordination of services. This is being addressed through the refinement of our initial intake processes that address diagnoses, PCP assignment, initial assessments and treatments. We have also refined our maintenance processes to address appointment scheduling, pre-visit planning, follow-up assessments and f/u treatments. Trouble shooting protocols are also in place to address inactive patients, adherence issues, treatment issues, as well as, ED visits and admissions."," "," "," "," ",1,1,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"H1-255",null,null,null,null,null,null,null,null,null,null,null,null,null,137251808,24]
[null,null,6,"138411709","Y",null,null,"",null,null,"159156201","159156201.7.1","Hospital","Private",null,null,null,"133355104",99,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,105,null,null,null,6,"138411709",{"$f":"IF('Intervention Details'!$D$12=AX107,MAX(AZ$2:AZ106)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,99,"Improved tracking systems to identifiy patients needing screening and follow-up","Intensive outreach and patient education interventions to reach the most marginalized patients.",null,null,null,2,null,null,null,"Utilizing Health Information Technology to identify patients in need of screenings and/or follow-up services.","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," ",2,1,1,0,0,0,null,"Provide a team-based approach to identifying patients that require cancer screening and include patient navigators/CHWs for outreach and education","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"H1-286",null,null,null,null,null,null,null,null,null,null,null,null,null,138411709,6]
[null,null,6,"159156201","Y",null,null,"",null,null,"212140201","212140201.7.1","Hospital","Non‐State Owned Public",null,null,null,"133355104",100,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,106,null,null,null,6,"159156201",{"$f":"IF('Intervention Details'!$D$12=AX108,MAX(AZ$2:AZ107)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,100,"Reliable planning, communication, and collaboration across operational service areas","Improved tracking systems for the identification of patients needing screening and follow-up",null,null,null,2,null,null,null,"Training in effective communications, care transition, and discharge planning"," "," "," "," ",1,1,0,0,0,0,null,"Utilizing Health Information Technology to identify patients in need of screenings and/or follow-up services.","Implement notification process to communicate effective messages that promote screening compliance behaviors."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127278302,"H1-317",null,null,null,null,null,null,null,null,null,null,null,null,null,159156201,20]
[null,null,6,"212140201","Y",null,null,"",null,null,"217884004","217884001.7.1","Hospital","Private",null,null,null,"133355104",101,"Palliative Care","Transitioning of palliative care patients from acute hospital care to other settings","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,107,null,null,null,6,"212140201",{"$f":"IF('Intervention Details'!$D$12=AX109,MAX(AZ$2:AZ108)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,101,"Implement standardized documentation practice that includes comprehensive assessments and screenings that allow for improved patient outcomes and quality of life","Develop integrated workflows that promote effective and collaborative multi-disciplinary functionality",null,null,null,2,null,null,null,"Identify standardized screening tools and establish a response protocol for every clinical setting","Educate clinicians on use of the identified screening tools and response protocol","Modify documentation practices to capture specified components related to the continuum of care of the patient"," "," ",3,1,1,1,0,0,null,"Educate staff on the importance of effective communication, integrated workflows, and how to drive improvement","Reinforce effective communication, planning, and collaboration of the multi-disciplinary teams"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,212140201,6]
[null,null,6,"217884004",{"$error":"#N/A"},null,null,"",null,null,"112717702","112717702.7.1","Hospital","Private",null,null,null,"133355104",102,"Patient Centered Medical Home","Provision of coordinated services for patients under Patent Centered Medical Home model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,108,null,null,null,6,"217884004",{"$f":"IF('Intervention Details'!$D$12=AX110,MAX(AZ$2:AZ109)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,102,"Integration and coordination of preventive care services in the primary care setting","Data driven decision making to determine the best strategies to achieve the triple aim of reducing healthcare costs, advance population health, and improve the experience of care","Improved tracking systems to identify patients that meet the criteria for appointments and immunizations",null,null,3,null,null,null,"Analyze programs and clinical practices to target high cost populations and services to align with metrics","Workforce education and development to improve workflows that align operations with best practices","Identification of barriers to patients' access to care"," "," ",3,1,1,1,0,0,null,"Utilize health information data that influences and informs policy and operational decision making","Appropriate stakeholder engagement to support efforts and inspire change"," "," "," ",2,1,1,0,0,0,null,"Apply best practice advisories to patients that meet certain requirements for scheduling appointments and ordering medications or immunizations"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,217884004,4]
[null,null,7,"112717702","Y",null,null,"",null,null,"121789503","121789503.7.1","Hospital","Private",null,null,null,"133355104",103,"Maternal and Infant Health Care","Coordinated prenatal and postpartum care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,109,null,null,null,7,"112717702",{"$f":"IF('Intervention Details'!$D$12=AX111,MAX(AZ$2:AZ110)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,103,"Implement tracking systems to identify patients that meet the criteria for follow-up appointments and screenings","Effective prevention and management of conditions during pregnancy, childbirth and the early newborn period",null,null,null,2,null,null,null,"Identify standardized screening tools and establish a response protocol for every clinical setting","Educate clinicians and office staff on use of the identified screening tools and response protocol","Modify documentation practices to capture specified components related to the continuum of care of the patient"," "," ",3,1,1,1,0,0,null,"Integration and coordination of services with primary and specialty care based on maternal early warning signs (MEWS)","Provide appropriately timed perinatal depression and anxiety awareness education to women and family members"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,297342201,14]
[null,null,7,"121789503","Y",null,null,"",null,null,"133542405","133542405.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"133355104",104,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,110,null,null,null,7,"121789503",{"$f":"IF('Intervention Details'!$D$12=AX112,MAX(AZ$2:AZ111)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,104,"Develop an infrastructure for transitions that promotes quality care and effective communication","Develop integrated workflows that promote effective and collaborative multi-disciplinary functionality","Provide standardized documentation that encourages patient responsibility and allows for improved access to coordinated and preventive services",null,null,3,null,null,null,"Assign responsibilities to appropriate staff to ensure that the patient recieves the proper care","Provision of up-to-date, accessible information about patients and plans of care"," "," "," ",2,1,1,0,0,0,null,"Educate staff on the importance of effective communication, integrated workflows, and how to drive improvement","Reinforce effective communication, planning, and collaboration of the multi-disciplinary teams"," "," "," ",2,1,1,0,0,0,null,"Involve patients and family in shared goal setting process","Identify expressed wishes and ensure these are communicated within care teams"," "," "," ",2,1,1,0,0,0,null,"",""," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,112717702,5]
[null,null,7,"133542405","Y",null,null,"",null,null,"137265806","137265806.7.1","Hospital","Private",null,null,null,"135033210",105,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111,null,null,null,7,"133542405",{"$f":"IF('Intervention Details'!$D$12=AX113,MAX(AZ$2:AZ112)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,105,"Educate patients on tobacco use and cessation, pneumonia risk, and benefits of advance care plan.","The first Secondary Driver for the Core Activity is screening for tobacco use, pneumonia vaccination, and presence of advance care plan.  Advanced Directives is screened in both the outpatient and inpatient settings giving patient education for their end of life care. The Smoking Cessation screening provides information to patients on the risks of lung cancer, heart disease and respiratory illnesses.  The pneumonia vaccine screening benefits people over 65 years of age and is beneficial to those in danger of pneumococcal disease.",null,null,null,2,null,null,null,"Train personnel to educate patients for tobacco use and cessation, pneumonia risk, and benefits of advance care plan.","Deploy educational material to patients via EHR on Tobacco Cessation, Pneumonia and Advance Care Planning."," "," "," ",2,1,1,0,0,0,null,"The first Change Idea is to train personnel to do screenings.","Build screener in EHR and in patient forms, so patients health record can be created and managed by authorized providers in a digital format capable of being shared with other providers in the system."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,121789503,5]
[null,null,7,"137265806","Y",null,null,"",null,null,"186599001","186599001.7.1","Hospital","Private",null,null,null,"137805107",106,"Availability of Appropriate Levels of Behavioral Health Care Services","Increasing access to services by utilizing qualified staff","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112,null,null,null,7,"137265806",{"$f":"IF('Intervention Details'!$D$12=AX114,MAX(AZ$2:AZ113)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,106,"Continue to recruit and onboard qualified staff enabling the clinics to operate at expanded hours.",null,null,null,null,1,null,null,null,"Utilize Human Resource recruiters to identify qualifed staff","Offer development opportunities to current staff who are able and willing"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,133542405,21]
[null,null,7,"186599001","Y",null,null,"",null,null,"307459301","307459301.7.1","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private",null,null,null,"137805107",107,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,113,null,null,null,7,"186599001",{"$f":"IF('Intervention Details'!$D$12=AX115,MAX(AZ$2:AZ114)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,107,"Perform social determinants of health screenings on all patients that are seen",null,null,null,null,1,null,null,null,"Develop a screening tool for social determinants of health designed for the Medicaid and uninsured populations"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,137265806,32]
[null,null,7,"307459301","Y",null,null,"",null,null,"344398801","344398801.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"137805107",108,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,114,null,null,null,7,"307459301",{"$f":"IF('Intervention Details'!$D$12=AX116,MAX(AZ$2:AZ115)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,108,"Increasing the awareness and utilization of school-based clinics by MLIU students.",null,null,null,null,1,null,null,null,"Efforts to increase awareness and identification of MLIU students at participating schools.","Tracking utilization of the school based clinics by MLIU students."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,186599001,10]
[null,null,7,"344398801","Y",null,null,"",null,null,"020957901","020957901.7.1","Hospital","Private",null,null,null,"137805107",109,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,115,null,null,null,7,"344398801",{"$f":"IF('Intervention Details'!$D$12=AX117,MAX(AZ$2:AZ116)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,109,"Continue to monitor risks, errors, and near misses in the hospital.",null,null,null,null,1,null,null,null,"Utilize systems including EMR reports to track outstanding risks, errors, or potential errors in the hospital."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387381201,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,307459301,36]
[null,null,8,"020957901","Y",null,null,"",null,null,"081771001","081771001.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"137909111",110,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,116,null,null,null,8,"020957901",{"$f":"IF('Intervention Details'!$D$12=AX118,MAX(AZ$2:AZ117)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,110,"Provide access to care during non-traditional hours for patients who work, care for children, do not have transportation, or face other challenges that make it difficult for them to seek care during typical business hours.","Since Calhoun County is a designated Primary Care and Mental Health HPSA area, Memorial Medical Center is committed to the recruitment and retention of primary and specialty care providers in the community.",null,null,null,2,null,null,null,"Our RHC offers extended hours (M-F, 7am - 7pm and Sat., 7am - 5pm).  With the extended hours our patients will have access to care during non-traditional hours for patients who work, care for children, do not have transportation, or face other challenges that make it difficult for them to seek care during typical business hours.","We will monitor utilization patterns during these extended hours to optimize the use of staff and to ensure we are meeting the needs of those we serve."," "," "," ",2,1,1,0,0,0,null,"Analyze service gaps to identify recruitment opportunities in primary and specialty care.","Coordinate with third-party recruitment firms to recruit qualified medical providers to our community."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,344398801,11]
[null,null,8,"081771001","Y",null,null,"",null,null,"088334001","088334001.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"137949705",111,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,117,null,null,null,8,"081771001",{"$f":"IF('Intervention Details'!$D$12=AX119,MAX(AZ$2:AZ118)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,111,"Social workers will schedule follow-up appointments with patients in primary care setting","Teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way to confirm that you have explained things in a manner your patients understand. We will use teach back for social workers scheduling appointments to ensure patients are aware of the key information taught.",null,null,null,2,null,null,null,"EPIC documentation through social workers in \"discharge summary\" flowsheet"," "," "," "," ",1,1,0,0,0,0,null,"We will use an EPIC report to measure teach back completion"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,20957901,5]
[null,null,8,"088334001","Y",null,null,"",null,null,"094119702","094119702.7.1","Hospital","Private",null,null,null,"139135109",112,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,118,null,null,null,8,"088334001",{"$f":"IF('Intervention Details'!$D$12=AX120,MAX(AZ$2:AZ119)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,112,"Human Papillomavirus Vaccine rates are monitored monthly on a Plan-Do-Study-Act (PDSA) document for Patient Centered Medical Home (PCMH) recognition.  Each primary care practice has a process to show improvement for this measure and this process is shared monthly to decide if any changes need to be made.\n\nTexas Children's Pediatrics will be shifting the focus for Fiscal Year 2019 to the Immunizations for Adolescents measure.\nImmunizations Measure for Adolescent rates are monitored monthly on a Plan-Do-Study-Act (PDSA) document for Patient Centered Medical Home (PCMH) recognition.  Each primary care practice has a process to show improvement for this measure and this process is shared monthly to decide if any changes need to be made. ","Childhood and adolescent patients receive calls at appropriate well child ages and practice staff call patients to come in for well child visits/immunization to improve immunization rates.",null,null,null,2,null,null,null,"HPV-patients are called to follow-up for the series vaccines and patients are given the Merck text message reminder to help them remember to follow-up. Staff educate parents on the importance of vaccine."," "," "," "," ",1,1,0,0,0,0,null,"Childhood and adolescent patients-calls are automated to families monthly to remind them of needed appointments. Practice staff will contact patients for upcoming and missed appointments."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,81771001,15]
[null,null,8,"094119702","Y",null,null,"",null,null,"094151004","094151004.7.1","Hospital","Private",null,null,null,"139135109",113,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,119,null,null,null,8,"094119702",{"$f":"IF('Intervention Details'!$D$12=AX121,MAX(AZ$2:AZ120)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,113,"A multidisciplinary education team is developing educational material regarding nutrition and physical activity for certified diabetes educators and Registered Dietitians to deliver to patients. The team meets bi-monthly to develop and implement targeted interventions to support the high risk population.","A multidisciplinary High Risk care team working in parallel is developing implementation strategies to improve behavioral health support for patients at high risk for complications leading to hospital admissions.",null,null,null,2,null,null,null,"The Education team will create and/or modify over 100 new education handouts, and make available through an internal intranet, as well as on the internet for patients. The handouts will be developed by evaluating key topics essential to diabetes curriculum and lifelong learning through a multidisciplinary team. ",""," "," "," ",1,1,0,0,0,0,null,"To increase the identification of high risk individuals, the high risk team is instituting preventative measures with behavioral health support."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,88334001,2]
[null,null,8,"094151004","Y",null,null,"",null,null,"126844305","126844305.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"139135109",114,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,120,null,null,null,8,"094151004",{"$f":"IF('Intervention Details'!$D$12=AX122,MAX(AZ$2:AZ121)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,114,"Texas Childrens will utilize its Asthma Care Process Team (CPT) to monitor and manage the asthma population and improve care.  The CPT will develop standardized Aims to guide providers in standardizing and improving care for the chronic asthma population.","The CPT will also develop an Asthma Registry to make this data accessible to care providers at the point of service and drive improved care decisions.  Improved management of the population will be accomplished through visualization tools for tracking of progress towards goals and a registry within the EMR for real-time guidance to physicians and advanced practitioners. The registry will increase the efficiency and timeliness of population management activities such as bulk messaging. Care coordination efforts will also utilize these tools to streamline timely care for avoidance of ED visits and admissions. The registry will provide visibility overall to the persistent asthma patient population to insure prompt and appropriate medication management.",null,null,null,2,null,null,null,"The Texas Childrens Asthma Care Process Team leadership will train care teams on the global aims the system is striving to achieve and monitoring for best practice.  Improvement against these aim measures will be regularly tracked and discussed during CPT meetings and shared with physician leadership."," "," "," "," ",1,1,0,0,0,0,null,"Asthma dashboards will be built out of the Asthma registry to provide real time, actionable data to physician and nurse teams and improve preventive care and proactive management of high risk asthma patients."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,94119702,2]
[null,null,8,"126844305","Y",null,null,"",null,null,"126936702","126936702.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"139135109",115,"Palliative Care","Provision of coordinated palliative care to address patients with end‐of‐life decisions","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,121,null,null,null,8,"126844305",{"$f":"IF('Intervention Details'!$D$12=AX123,MAX(AZ$2:AZ122)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,115,"All new palliative care consults will receive comprehensive palliative care assessments, and evidence based treatment plan interventions (including pharmacologic and non-pharmacologic). Palliative care consults provide a pain assessment based on the appropriate evidence based pain scale for the childs age and development (FACES, FLACC, Numeric, CRIES and PIPP).",null,null,null,null,1,null,null,null,"Building an electronic consultation document that will identify all the palliative care measures including appropriate screening for dyspnea and pharmacologic and non-pharmacologic interventions for dyspnea based on the evidence available in pediatrics. Palliative Care Measures data will be reviewed by a multidisciplinary Palliative Care team monthly, identify gaps, and conduct rapid cycle PDSAs."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"H4-182",null,null,null,null,null,null,null,null,null,null,null,null,null,94151004,3]
[null,null,8,"126936702","Y",null,null,"",null,null,"137249208","137249208.7.1","Hospital","Private",null,null,null,"139135109",116,"Maternal and Infant Health Care","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,122,null,null,null,8,"126936702",{"$f":"IF('Intervention Details'!$D$12=AX124,MAX(AZ$2:AZ123)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,116,"Promote access to early and comprehensive pre-natal evaluation, screening, & interventions.","Promote access for post-partum evaluation, screening and interventions within 8 weeks of delivery.",null,null,null,2,null,null,null,"Create and implement standardized documentation tools to support behavioral health screenings."," "," "," "," ",1,1,0,0,0,0,null,"Enhance provider and staff awareness of progress through regular communication of metric data, identification of gaps, and development and implementation of rapid cycle PDSAs."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"H4-258",null,null,null,null,null,null,null,null,null,null,null,null,null,126844305,24]
[null,null,8,"137249208","Y",null,null,"",null,null,"192622201","192622201.7.1","Hospital","Private",null,null,null,"139135109",117,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,123,null,null,null,8,"137249208",{"$f":"IF('Intervention Details'!$D$12=AX125,MAX(AZ$2:AZ124)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,117,"Promote provider and staff awareness of progress toward goals through regular communication of relevant process and outcome quality improvement data.","Implement evidence-based patient safety bundles such as but not limited to those supported by Alliance for Innovation on Maternal Health (AIM).",null,null,null,2,null,null,null,"Interdisciplinary collaboration at the Texas Childrens Hospital Pavilion for Women to improve and enhance existing processes.","Enhance data transparency through regular communication of continuous quality improvement progress."," "," "," ",2,1,1,0,0,0,null,"Participation in collaboratives focused on reduction of maternal morbidity and mortality, such as but not limited to Texas Department of State Health Services (DSHS), Texas Collaborative for Healthy Mothers and Babies, March of Dimes Healthy Babies are Worth the Wait, Houston Endowment Reducing Maternal Mortality, and Alliance for Innovation on Maternal Health (AIM)."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131038504,"H4-260",null,null,null,null,null,null,null,null,null,null,null,null,null,126936702,7]
[null,null,8,"192622201","Y",null,null,"",null,null,"220798701","220798701.7.1","Hospital","Private",null,null,null,"139135109",118,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,124,null,null,null,8,"192622201",{"$f":"IF('Intervention Details'!$D$12=AX126,MAX(AZ$2:AZ125)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,118,"Our PI HAC team will target PDSA cycles aimed at utilizing high reliability leadership methods to continue to reduce pressure injuries.","Our team will continue work on reducing ADEs by targeting improvements related to administration of medications."," Our team will continue work on reducing ADEs by targeting the provision of outpatient (discharge) medications through our dedicated pediatric outpatient (retail) pharmacy.",null,null,3,null,null,null,"The PI HAC team will engage with our department of patient and family services to identify a best practice for using patient and family input to guide improvements to the four bundle elements (skin assessment, device rotation, patient positioning, appropriate bed surface, and moisture management)."," "," "," "," ",1,1,0,0,0,0,null,"The ADE HAC team will use smart pump analysis to eliminate errors during pump programming.  Staff will be required to scan the pump and the medication prompting the pump to automatically set."," "," "," "," ",1,1,0,0,0,0,null,"  The Hospital will use a Meds to Beds program to eliminate errors during outpatient prescription filling."," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,137249208,3]
[null,null,8,"220798701","Y",null,null,"",null,null,"312239201","312239201.7.1","Hospital","Private",null,null,null,"139135109",119,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,125,null,null,null,8,"220798701",{"$f":"IF('Intervention Details'!$D$12=AX127,MAX(AZ$2:AZ126)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,119,"Care coordination  bringing together specialists in CP both medical and surgical to enhance care to this patient population.  Include PT presence in CP and spasticity clinics.","Appropriate navigation  to assist families in navigating a complex system where some appointments are scheduled on the same day in the same place versus needing to get tests/other visits accomplished outside the main clinics.",null,null,null,2,null,null,null,"Care coordinator  RN (individual with clinical knowledge of population a must).  Patients seen in CP clinic/spasticity clinic with only a physiatrist are set up for appropriate multi-disciplinary evaluations at the appropriate times and at the appropriate locations.  The coordinator assists with guiding next steps after diagnostic testing and interventions are performed and prepares the family for specific aspects of that childs care with anticipatory guidance."," "," "," "," ",1,1,0,0,0,0,null,"Appropriate Navigation  RN (individual with clinical knowledge of population a must).  Seeing the correct specialists to address the issues that the individual child with CP has.  This will vary by patient and severity of involvement.  Some children will already have an established diagnosis of CP and can be assessed initially by a physiatrist for management and treatment options.  At a very young age surgeries would usually not be indicated but surveillance and optimizing health and community participation would be emphasized.  As the children age, their surgical needs increase.  The likelihood of pain and musculoskeletal deformities increases with time."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,183086102,14]
[null,null,8,"312239201","Y",null,null,"",null,null,"353712801","353712801.7.1","Hospital","Private",null,null,null,"140713201",120,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,126,null,null,null,8,"312239201",{"$f":"IF('Intervention Details'!$D$12=AX128,MAX(AZ$2:AZ127)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,120,"Social workers will identify super utilizers, assess social determinants, and strategize patient navigation",null,null,null,null,1,null,null,null,"Social workers will schedule follow-up appointments for patients and include EPIC documentation through social workers in \"discharge summary\" flowsheet"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-160",null,null,null,null,null,null,null,null,null,null,null,null,null,192622201,2]
[null,null,8,"353712801","Y",null,null,"",null,null,"009784201","009784201.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"158771901",121,"Expansion or Enhancement of Oral Health Services","Expansion of school based sealant and/or fluoride varnish initiatives","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127,null,null,null,8,"353712801",{"$f":"IF('Intervention Details'!$D$12=AX129,MAX(AZ$2:AZ128)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,121,"The utilization of Community Health Workers to aid in partnership development and case management.","HCPHES will utilize a stage gate approach in applying project management best practices in implementing the youth dental program specifically utilizing a phased release process over the lifecycle of the program.",null,null,null,2,null,null,null,"Community Health Workers (CHW) will be an integral component of the project and will be utilized to strengthen relationships with schools and communities, assist in event planning logistics, and most importantly, provide navigation and referral services to participants to guide them to additional preventive and treatment options. CHW will follow-up with clients following each assessment to evaluate their progress and offer guidance and navigation to the next level of care, as applicable. CHW will have a demonstrated presence in this project and are well suited to interact with community partners and project participants to ensure the project is administered in a way that is culturally and linguistically appropriate to the targeted population."," "," "," "," ",1,1,0,0,0,0,null,"In each stage gate we will focus on continuous stakeholder feedback from various data collection points including iterative reviews of lessons learned captured from project deliverables in remediating any future challenges and/or risks. In addition, given the majority of the population we serve are Medicaid/low income uninsured individuals, our program will be tailored to overcome the unique challenges/barriers that may exist such as transportation, communication, availability, and location."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-211",null,null,null,null,null,null,null,null,null,null,null,null,null,220798701,5]
[null,null,9,"009784201","Y",null,null,"",null,null,"020908201","020908201.7.1","Hospital","Private",null,null,null,"158771901",122,"Prevention and Wellness","Other","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,128,null,null,null,9,"009784201",{"$f":"IF('Intervention Details'!$D$12=AX130,MAX(AZ$2:AZ129)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,122,"Optimize the use and accessibility of mobile screening and vaccination clinics",null,null,null,null,1,null,null,null,"A significant proportion of Harris County residents are uninsured and many lack the resources or face geographic and logistical barriers in accessing primary health care and basic health screenings. The project seeks to intervene within the HCPHES jurisdiction by delivering high quality screenings, immunizations for eligible children and adults, and track referral services offered to communities and residents directly. HCPHES plans to continue to collect and capture data related to the number of  unique community/ mobile events conducted each quarter, number of unique individual impacted, and school based immunization compliance rates within targeted MLIU schools."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-261",null,null,null,null,null,null,null,null,null,null,null,null,null,312239201,2]
[null,null,9,"020908201","Y",null,null,"",null,null,"020943901","020943901.7.1","Hospital","Private",null,null,null,"158771901",123,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,129,null,null,null,9,"020908201",{"$f":"IF('Intervention Details'!$D$12=AX131,MAX(AZ$2:AZ130)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,123,"Optimize the use and enrollment of \"at-risk\" age appropriate children into the evidence based intervention.",null,null,null,null,1,null,null,null,"Increase the number of school based intervention sites within MLIU communities to increase enrollment and program completion."," "," "," "," ",1,1,{"$f":"IF(OR(LEFT(BV131,1)=$BT$1,LEFT(BV131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BW131,1)=$BT$1,LEFT(BW131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BX131,1)=$BT$1,LEFT(BX131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BY131,1)=$BT$1,LEFT(BY131,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CH131,1)=$BT$1,LEFT(CH131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CI131,1)=$BT$1,LEFT(CI131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CJ131,1)=$BT$1,LEFT(CJ131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CK131,1)=$BT$1,LEFT(CK131,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CT131,1)=$BT$1,LEFT(CT131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CU131,1)=$BT$1,LEFT(CU131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CV131,1)=$BT$1,LEFT(CV131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CW131,1)=$BT$1,LEFT(CW131,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DF131,1)=$BT$1,LEFT(DF131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DG131,1)=$BT$1,LEFT(DG131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DH131,1)=$BT$1,LEFT(DH131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DI131,1)=$BT$1,LEFT(DI131,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DR131,1)=$BT$1,LEFT(DR131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DS131,1)=$BT$1,LEFT(DS131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DT131,1)=$BT$1,LEFT(DT131,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DU131,1)=$BT$1,LEFT(DU131,1)=\"\"),0,1)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-305",null,null,null,null,null,null,null,null,null,null,null,null,null,353712801,5]
[null,null,9,"020943901","Y",null,null,"",null,null,"020967802","020967801.7.1","Hospital","Private",null,null,null,"158771901",124,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10",{"$f":"IF(OR(V132=\"DY7-10\",V132=\"DY9-10\"),\"Y\",\"N\")","v":"Y"},{"$f":"IF(V132=\"DY9-10\",\"Y\",\"N\")","v":"N"},null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,130,null,null,null,9,"020943901",{"$f":"IF('Intervention Details'!$D$12=AX132,MAX(AZ$2:AZ131)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,124,"Enhance the provision of tobacco prevention efforts to current/former/and would be smokers",null,null,null,null,{"$f":"COUNTA(BL132:BP132)","v":1},null,null,null,"Monitor the number of individuals receiving the 2A's and R intervention and enrolling into fresh start","Increase the number of trained fresh start facilitators."," "," "," ",{"$f":"SUM(CA132:CE132)","v":2},{"$f":"IF(OR(LEFT(BU132,1)=$BT$1,LEFT(BU132,1)=\"\"),0,1)","v":1},1,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CM132:CQ132)","v":0},{"$f":"IF(OR(LEFT(CG132,1)=$BT$1,LEFT(CG132,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CY132:DC132)","v":0},{"$f":"IF(OR(LEFT(CS132,1)=$BT$1,LEFT(CS132,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DK132:DO132)","v":0},{"$f":"IF(OR(LEFT(DE132,1)=$BT$1,LEFT(DE132,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DW132:EA132)","v":0},{"$f":"IF(OR(LEFT(DQ132,1)=$BT$1,LEFT(DQ132,1)=\"\"),0,1)","v":0},0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-317",null,null,null,null,null,null,null,null,null,null,null,null,null,9784201,8]
[null,null,9,"020967802",{"$error":"#N/A"},null,null,"",null,null,"020979302","020979302.7.1","Hospital","Private",null,null,null,"158771901",125,"Access to Specialty Care Services","Use telemedicine/telehealth to deliver specialty services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131,null,null,null,9,"020967802",{"$f":"IF('Intervention Details'!$D$12=AX133,MAX(AZ$2:AZ132)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,125,"Provide education to patients on proper utilization of VDOT system and tools.",null,null,null,null,1,null,null,null,"VDOT program will be evaluated for medication adherance"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-319",null,null,null,null,null,null,null,null,null,null,null,null,null,20908201,{"$f":"COUNTIF(ET133:ET3102,FI133)","v":10}]
[null,null,9,"020979302","Y",null,null,"",null,null,"094140302","094140302.7.1","Hospital","Private",null,null,null,"181706601",126,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,132,null,null,null,9,"020979302",{"$f":"IF('Intervention Details'!$D$12=AX134,MAX(AZ$2:AZ133)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,126,"Utilization of the ED to treat exacerbations of psychiatric conditions and simulataneously address medical co-morbidity needs",null,null,null,null,1,null,null,null,"The unit will address the needs of both the medical and behavioral health of these patients and will discharge them with care plans for both conditions for follow-up and disease management."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137921608,"M1-400",null,null,null,null,null,null,null,null,null,null,null,null,null,20943901,20]
[null,null,9,"094140302","Y",null,null,"",null,null,"094192402","094192402.7.1","Hospital","Private",null,null,null,"212060201",127,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,133,null,null,null,9,"094140302",{"$f":"IF('Intervention Details'!$D$12=AX135,MAX(AZ$2:AZ134)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,127,"Provide Diabetes Self-Management Education & Support services to patients with a diagnosis of Type 1 or Type 2 diabetes through Rice’s Diabetes Education program.  ",null,null,null,null,1,null,null,null,"Provide Diabetes Self-Management Education (“DSME”) to diabetic patients regarding health and nutrition, and the importance of HbA1c, Blood Pressure, and Foot Care screenings. DSME is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care.  This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.  The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.  Based on its prior experience with DSME and peer reviewed studies, Rice anticipates Change Idea #1 will improve health outcomes for diabetic patients and reduce utilization rates for preventable complications.  ","Provide ongoing support to diabetic patients to improve health outcomes and prevent complications by ensuring timely preventative care exams and screenings for diabetic patients.  Change Idea #2 includes electronic and manual processes for identifying diabetic patients that are due for a preventative care exam and/or HbA1c, Blood Pressure, and Foot Care screenings.  On a weekly basis, Rice’s Clinical Care Initiatives Coordinator generates electronic reports utilizing the Clinic Financial System to identify diabetic patients that are due for a preventative care exam and/or screening(s).  Rice uses the electronic reports to produce and send notification letters to the patients with contact information to schedule the preventative care exam and/or screening for which the diabetic patient is due.  On a daily basis, Rice’s Clinical Care Initiatives Coordinator reviews patients scheduled for clinic appointments and performs a manual chart review to determine status of preventative care exams and screenings for diabetic patients.  Rice updates each diabetic patient’s chart with an alert that includes a description of the status for preventative care exams and/or screening with a schedule showing the date(s) the preventative care exams and/or screening will be due.  Based on prior experience and peer-reviewed studies, Rice believes the processes for informing patients of preventative care exam and screening schedules will help increase the number of diabetic patients receiving timely services to manage health outcomes, reduce related complications, and ensure prudent healthcare utilization."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138360606,"IT-10.3.e",null,null,null,null,null,null,null,null,null,null,null,null,null,20967802,10]
[null,null,9,"094192402","Y",null,null,"",null,null,"111905902","111905902.7.1","Hospital","Private",null,null,null,"212060201",128,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,134,null,null,null,9,"094192402",{"$f":"IF('Intervention Details'!$D$12=AX136,MAX(AZ$2:AZ135)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,128,"Implement electronic and manual processes to improve cancer-screening rates by identifying patients that are due for cancer screening and informing patients of cancer screening schedules.",null,null,null,null,1,null,null,null,"Change Idea #1 includes electronic and manual processes for identifying diabetic patients that are due for a Breast Cancer, Cervical Cancer, and Colorectal screenings.  The tracking system for the electronic and manual processes takes into account unique factors that inform cancer screening schedules (e.g. individual and family medical history and other cancer risk indicators).  On a weekly basis, Rice’s Clinical Care Initiatives Coordinator generates electronic reports utilizing the Clinic Financial System to identify patients that are due for cancer screenings.  Rice uses the electronic reports to produce and send notification letters to the patients with contact information to schedule timely cancer screenings.  On a daily basis, Rice’s Clinical Care Initiatives Coordinator reviews patients scheduled for clinic appointments and performs a manual chart review to determine status of each patient’s cancer screening.  Rice updates each patient’s chart with an alert that includes a description of the status for cancer screenings with a schedule showing the date(s) the next cancer screening is due.  As part of this process, Rice informs patients of the pros and cons of different screening options.  Based on prior experience and peer-reviewed studies, Rice believes the processes for tracking cancer screening and informing patients of cancer screening schedules will help increase the number of patients receiving timely cancer screenings."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138360606,"L1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,20979302,5]
[null,null,9,"111905902","Y",null,null,"",null,null,"121758005","121758005.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"296760601",129,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,135,null,null,null,9,"111905902",{"$f":"IF('Intervention Details'!$D$12=AX137,MAX(AZ$2:AZ136)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,129,"Establish engagement with referred clients by enrolling them into a navigation team approach to improve health outcomes for the client","Improving chronic disease understanding and self-management","Community Health Worker assessment and referral for mitigation of health impacting social determinants",null,null,3,null,null,null,"Consistent medical home with proactive care provided by a navigation team","Establish connections with specialty care providers, such as urology, optometry, wound care, general surgery, hematology and cardiology"," "," "," ",2,1,1,0,0,0,null,"Incentivized chronic disease education and self-management courses","Establishing patient specific goals (e.g. weight, exercise, nutrition)","Availability to patients of a registered dietician to better assist them with nutrition and their diets"," "," ",3,1,1,1,0,0,null,"Collaboration with and referral to social service agencies within the community"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138365512,"M1-125",null,null,null,null,null,null,null,null,null,null,null,null,null,94140302,10]
[null,null,9,"121758005","Y",null,null,"",null,null,"121776205","121776204.7.1","Hospital","Private",null,null,null,"296760601",130,"Behavioral Health Crisis Stabilization Services","Provision of crisis stabilization services based on the best practices","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,136,null,null,null,9,"121758005",{"$f":"IF('Intervention Details'!$D$12=AX138,MAX(AZ$2:AZ137)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,130,"A network of needed clinical and support services, in the community, for individuals and families.","Specialized Crisis Intervention Team (CIT) that is trained and supported to address behavioral health crises, in the community.",null,null,null,2,null,null,null,"Establish collaborative partnerships and information sharing to expand clinical resources and social supports","Follow up and continuity of care to connect individuals and families to needed supports and services"," "," "," ",2,1,1,0,0,0,null,"Provide ongoing training to CIT to support response and intervention system","Expand crisis intervention training to first responders to enhance cross systems knowledge and coordinated response"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138365512,"M1-287",null,null,null,null,null,null,null,null,null,null,null,null,null,94192402,5]
[null,null,9,"121776205",{"$error":"#N/A"},null,null,"",null,null,"121988304","121988304.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"296760601",131,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137,null,null,null,9,"121776205",{"$f":"IF('Intervention Details'!$D$12=AX139,MAX(AZ$2:AZ138)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,131,"Engage clients in chronic illness self- management, healthy lifestyles, preventive care, and positive healthcare decisions","Identify patients who are at risk for inequalities in social determinants of health that are impacting their health through coordination of care, referrals for service provision",null,null,null,2,null,null,null,"Provide comprehensive chronic disease education course","Establish patient specific goals (e.g. weight, exercise, nutrition)","Empower the client for good medication management:  the right way to administer, when it needs to be administered, proper storage, handling, disposal, etc."," "," ",3,1,1,1,0,0,null,"Implement use of a standarized tool to identify at risk clients","Collaboration with and referral to social service agencies within the community"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138365512,"M1-305",null,null,null,null,null,null,null,null,null,null,null,null,null,111905902,5]
[null,null,9,"121988304","Y",null,null,"",null,null,"126679303","126679303.7.1","Hospital","Private",null,null,null,"296760601",132,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138,null,null,null,9,"121988304",{"$f":"IF('Intervention Details'!$D$12=AX140,MAX(AZ$2:AZ139)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,132,"Systematically screen all clients to identify those who need further intervention","Reduce tobacco, drug and alcohol use in identified patients",null,null,null,2,null,null,null,"Monitor the number of CAGE AID screening assessments performed. CAGE-AID (Adapted to Include Drugs) is a version of the CAGE alcohol screening questionnaire, adapted to include drug use.  It assesses likelihood and severity of alcohol and drug abuse. This four item screening tool takes approximately 1 minute to administer and score. The target population for the CAGE-AID is adult patients and can be administered by patient interview or self-report in a primary care setting.","Connect the client with appropriate level of care"," "," "," ",2,1,1,0,0,0,null,"Engage patients in motivational interviewing and cessation classes","Provide medication to assist with reduction of tobacco, drug and alcohol use"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138365512,"M1-319",null,null,null,null,null,null,null,null,null,null,null,null,null,121758005,8]
[null,null,9,"126679303","Y",null,null,"",null,null,"126686802","126686802.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"296760601",133,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,139,null,null,null,9,"126679303",{"$f":"IF('Intervention Details'!$D$12=AX141,MAX(AZ$2:AZ140)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,133,"Same day appointment availability slots to expand access","Maintain a full provider team dedicated to the expanded clinic hours",null,null,null,2,null,null,null,"Monthly reports on availability and usage of same day appointment slots","Develop a contingency plan for days (or parts of the day) when demand far outstrips the availability of physicians"," "," "," ",2,1,1,0,0,0,null,"Develop a contingency plan for days when providers are out of office to ensure there are enough available providers for the capacity need","Dashboard report of staff capacity and usage of same day appointment slots"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,121776205,9]
[null,null,9,"126686802","Y",null,null,"",null,null,"127295703","127295703.7.1","Hospital","Non‐State Owned Public",null,null,null,"296760601",134,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,140,null,null,null,9,"126686802",{"$f":"IF('Intervention Details'!$D$12=AX142,MAX(AZ$2:AZ141)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,134,"Screen clients (youth and adults) enrolled in Behavioral Health Services for social determinants of health.","Intensive case management services provided to clients",null,null,null,2,null,null,null,"Process for integrating social determinants of health data into program management","Expand resources for meeting social determinants of health"," "," "," ",2,1,1,0,0,0,null,"Connect individuals (youth and adults) and families to needed supports and services, provide follow up and evaluate needs on an ongoing basis to ensure that social determinants of health are met.","Process for information sharing among agencies that provide services that address social determinants of health, in order to facilitate access to those services and supports"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,121988304,15]
[null,null,9,"127295703","Y",null,null,"",null,null,"135032405","135032405.7.1","Hospital","Private",null,null,null,"296760601",135,"Behavioral Health Crisis Stabilization Services","Implement models supporting recovery of individuals with behavioral health needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,141,null,null,null,9,"127295703",{"$f":"IF('Intervention Details'!$D$12=AX143,MAX(AZ$2:AZ142)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,135,"Complete the CANS (Child and Adolescents Needs and Strengths) and ANSA (Adult Needs and Strengths Assessment) to assess needs and strengths. These assessments are multi-purpose tools developed for behavioral health services to support decision making in level of care and individualized service planning, which facilitates quality improvement initiatives and allows for monitoring of the outcomes of services.","Patient support/continuity of care of services for clients enrolled in the program",null,null,null,2,null,null,null,"Use CANS and ANSA data to assess individual outcomes and modify service plans, accordingly"," "," "," "," ",1,1,0,0,0,0,null,"Develop, implement and evaluate the follow up/after care process and use the data to assess client functioning/recovery and identify additional needed services and supports, for clients enrolled in the program"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,126679303,7]
[null,null,9,"135032405","Y",null,null,"",null,null,"135234606","135234606.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"296760601",136,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,142,null,null,null,9,"135032405",{"$f":"IF('Intervention Details'!$D$12=AX144,MAX(AZ$2:AZ143)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,136,"Assess and reduce patient barriers to completion of screening procedure","Leverage the Health Information Technology Systems",null,null,null,2,null,null,null,"Educate patients at the time of referral as to the complete expectations of colonosocpy screening, which included an effective bowl preparation prior to reporting for the procedure. The clinic will ensure brochure availabilty and address patient concerns at the time of the referral.","Connect with community resources for education regarding the need for colonoscopy screening and to counteract fear."," "," "," ",2,1,1,0,0,0,null,"Implement reports to identify and notify patients due for screening and patients that are hard to reach","Ensure current and reliable data of family history, diagnoses, and symptoms"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,126686802,45]
[null,null,9,"135234606","Y",null,null,"",null,null,"136360803","136360803.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"311054601",97,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,143,null,null,null,9,"135234606",{"$f":"IF('Intervention Details'!$D$12=AX145,MAX(AZ$2:AZ144)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,97,"Screen for tobacco use, pneumonia vaccination for adult 65 or older, and presence of advance care plan.","Educate patients on tobacco use and smoking cessation options and related resources, pneumonia risk for older adult, and the benefits of having advance care plan.",null,null,null,2,null,null,null,"Train multiple levels of healthcare providers, including physicians, mid-levels, and nurses to perform screening as documented in hospital's clinical protocols.","Utilize EMR to build screener templates, allowing reportable data to be captured."," "," "," ",2,1,1,0,0,0,null,"Identify available and appropriate educational material to be use by ECMH as our standards.","Train multiple levels of healthcare providers, including physicians, mid-levels, and nurses to deliver education to patients as documented in hospital's clinical protocols."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,127295703,36]
[null,null,9,"136360803","Y",null,null,"",null,null,"137252607","137252607.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"377705401",96,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,144,null,null,null,9,"136360803",{"$f":"IF('Intervention Details'!$D$12=AX146,MAX(AZ$2:AZ145)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,96,"ED surge planning is the first driver of the ED Throughput Intensive. ED surge planning is a program that is designed help Conroe assess their current state, identify gaps, anticipate barriers and mitigate challenges by developing and implementing scenario triggers and controls.","Educate and train staff on ED transfer communication criteria",null,null,null,2,null,null,null,"Gain buy-in for the ED surge plans for Tomball Regional Medical Center's emergency department","Assess current emergency department flow and processes within emergency department","Identify optimal emergency department flow, staffing, and proccesses","Identify surge scenarios that incorporate changes in staffing, bolus, ancillary service delays, bed availability for consistent pre-planned responses to issues","Change policies and procedures and work with rest of facility to incorporate ED surge plan into housewide surge plan and track efficacy",5,1,1,1,1,1,null,"Develop a checklist to assist staff in identifying all required elements when a patient is transferred","Provide training and guidance on utilization of checklist and monitor compliance"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,135032405,12]
[null,null,9,"137252607","Y",null,null,"",null,null,"138910807","138910807.7.1","Hospital","Private",null,null,null,"020811801",142,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,145,null,null,null,9,"137252607",{"$f":"IF('Intervention Details'!$D$12=AX147,MAX(AZ$2:AZ146)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,142,"Increase number of patients that are aware of the harmful effects of tobacco use and how to get cessation assistance",null,null,null,null,1,null,null,null,"Screen all patients for tobacco use and provide counseling and cessation assistance"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,135234606,9]
[null,null,9,"138910807","Y",null,null,"",null,null,"139485012","139485012.7.1","Hospital","Private",null,null,null,"020973601",143,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,146,null,null,null,9,"138910807",{"$f":"IF('Intervention Details'!$D$12=AX148,MAX(AZ$2:AZ147)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,143,"Improve response to and outcomes of obstetric hemorrhage","Reduce unnecessary primary cesarean section deliveries",null,null,null,2,null,null,null,"Update Obstetric Hemorrhage - Code Hemorrhage Policy to include assessment of risk factors for obstetric hemorrhage, utilize quantitative and cumulative blood loss evaluation to identify proper stages of obstetric hemorrhage, and utilize evidence based treatment protocols.  Change idea #1 will help improve outcomes of women with obstetric hemorrhage by ensuring processes and procedures are in place to identify and respond to obstetric hemorrhage events. ","CCMCs Labor and Delivery leadership team will conduct Code Hemorrhage Drills and utilize Code Hemorrhage Event Records to identify successes and opportunities for improvement.  Both successes and opportunities will be applied to ongoing training and educational activities related to obstetric hemorrhage.  Change idea #2 improves obstetric hemorrhage outcomes by utilizing performance assessment to inform continuous quality improvement activities.","Conduct on-going assessment, training and education to an interdisciplinary team of nurses and physicians regarding assessment and management of obstetric hemorrhage.  This includes assessing for hemorrhage risk factors, measuring and documenting quantitative and cumulative blood loss, identifying stages of hemorrhage, and evidenced based treatment goals.  CCMC provides bi-annual obstetric hemorrhage education to all obstetric staff, and provides ongoing education to the interdisciplinary team after each Code Hemorrhage Drill, Code Hemorrhage Event, at staff meetings, in the OB Unit newsletter, and at its annual competency fair.  Change Idea #3 will improve obstetric hemorrhage outcomes by ensuring CCMCs staff have adequate assessment and management competencies to intervene during an obstetric hemorrhage event. "," "," ",3,1,1,1,0,0,null,"Update and implement Elective Induction and Cesarean Section Policy that addresses completion of 39 weeks or more gestation to include favorable cervical criteria requirements to allow scheduling induction of labor if there is no medical indication.  Favorable cervical criteria, defined as a Bishop Score equal to or greater than 6 for multiparas and equal to or greater than 8 for nulliparous, will be required to proceed with scheduling an elective induction of labor.  Elective induction of labor is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable cervix at induction.  CCMC anticipates Change Idea #1 will reduce unnecessary cesarean deliveries by reducing its number of elective inductions in women that do not present with favorable cervical criteria.  ","Post monthly and year-to-date graphs that represent the nulliparous term singleton vertex (NTSV) cesarean delivery rates for each physician and physician group at CCMC in comparison to an attainable goal.  Posting monthly and updated year-to-date graphs will raise physician awareness of NTSV cesarean rates for themselves, their group, and each of their colleagues.  Change Idea #2 should decrease unnecessary cesarean deliveries by creating competition among the physicians to have lower rates.   ",""," "," ",2,1,1,0,0,0,null,null,null,null," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,136360803,2]
[null,null,9,"139485012","Y",null,null,"",null,null,"209345201","209345201.7.1","Hospital","Private",null,null,null,"020973601",144,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,147,null,null,null,9,"139485012",{"$f":"IF('Intervention Details'!$D$12=AX149,MAX(AZ$2:AZ148)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,144,"Chronic Disease Registry for CHF, COPD, DM, and CAD","LACE screening tool utilized on every initial RN assessment with score placed on Patient Dashboard in all inpatient care areas","Patient Call Manager as tool for follow up contact with both inpatients and ED patients after discharge with the intent of making sure discharge instructions are understood, patients have their medications, have made follow up appoints, and answer any questions relating to their care to drive reduction in ED utilization. ",null,null,3,null,null,null,"Specific questions for each chronic disease that address patient compliance with medications, diet, monitoring, and follow up appointments.  Change Idea #1 provides a guide for staff contacting patients that is specific to their chronic disease, improves chronic disease management, and reduces preventable ED visits related to chronic disease.","Patients entered into the Chronic Disease Registry are proactively contacted based on disease status by CHW to assess their basic knowledge and management of the chronic disease.  Change Idea #2 will reduce preventable ED visits related to chronic disease by increasing knowledge and disease management."," "," "," ",2,1,1,0,0,0,null,"LACE score greater than 11 triggers PCM follow up phone call to be done by CHW within 24 hours post discharge with the intent of making sure our patients have their medications, make their follow up PCP appointments, and see if they have any other questions related to their care.  Change Idea #1 will reduce preventable ED visits by connecting patients to primary care.","Behavioral Health discharges with LACE score greater than 11 receive follow-up phone calls by clinical staff tracked in PCM with the intent of reminding patients of their aftercare appointments, reviewing medications, coping skills, and immediate concerns for the patients safety.  Change Idea #2 will reduce ED visits by assuring behavioral health patients remain safe and are coping well post discharge.","LACE score greater than 11 triggers Case Management to ask additional questions during interview regarding date of last admission, reason for admission in patients own words, name of their PCP, last PCP visit date, taking all medications as prescribed, If not why, name of pharmacy, pharmacy prescription coverage, method of transportation to appointments, contact name and number for transport home on discharge, and caregiver name/number for inclusion in discharge planning process.  Change Idea #3 will decrease preventable ED visits by assuring patients’ needs are assessed and addressed prior to discharge from the hospital."," "," ",3,1,1,1,0,0,null,"To assure follow up contact with discharged patients does not get neglected, CCMC will utilize monthly reporting to unit leadership to drive staff engagement in the process.  Monthly reports are by unit and break out attempted and completed calls.  These reports are also discussed at bi-monthly leadership meetings to keep the importance of making patient contacts an ongoing effort.  CCMCs goal is 100% of discharged patients have attempted contact.  Change Idea #1 will decrease ED utilization by making sure patients are contacted after discharge, understood their discharge instructions, and have made their follow up appointments.","",""," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,388696201,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,137252607,23]
[null,null,9,"209345201","Y",null,null,"",null,null,"391575301","364710901.7.1","Hospital","Private",null,null,null,"020973601",145,"Behavioral Health Crisis Stabilization Services","Implementation of community‐based crisis stabilization alternatives","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,148,null,null,null,9,"209345201",{"$f":"IF('Intervention Details'!$D$12=AX150,MAX(AZ$2:AZ149)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,145,"Monitor attendance of PHP and IOP and contact those who do not participate",null,null,null,null,1,null,null,null,"Identify barriers for participation in or completion of programs in order to increase patient compliance with ordered treatments for PHP and IOP.  Patients can remain in the programs if reasonable and excusable barriers are identified and can be overcome, if there is not a reasonable or excusable barrier that can be overcome the patient can be discharged from the program to open the slot for another patient.  Change Idea #1 will increase access to care for behavioral health and substance abuse by assisting patients overcome barriers to access.","Define process for clients enrolled into PHP or IOP programs and do not attend.  CCMCs protocol for patients that do not attend scheduled PHP/IOP appointments is: if a patient misses a minimum of 3 appointments staff call multiple times until they speak to the patient, if the patient is unable to be reached the information is passed to the Outpatient Manager, The Director of Intake, and the treatment team before being discharged from the program.  Change Idea #2 aims to increase patients' compliance with ordered treatments so the PHP and IOP programs can be successful at decreasing readmissions and ED utilization."," "," "," ",2,1,1,0,0,0,null,null," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138913209,"A2-103",null,null,null,null,null,null,null,null,null,null,null,null,null,138910807,41]
[null,null,9,"391575301",{"$error":"#N/A"},null,null,"",null,null,"020950401","020950401.7.1","Hospital","Private",null,null,null,"020991801",146,"Access to Primary Care Services","Expanded Practice Access (e.g., increased hours, telemedicine, etc.)","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,149,null,null,null,9,"391575301",{"$f":"IF('Intervention Details'!$D$12=AX151,MAX(AZ$2:AZ150)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,146,"Renovating the rural health clinics will allow for better patient flow and allow for more patients to be seen",null,null,null,null,1,null,null,null,"Increasing the number of patient rooms and expanding the waiting room to accomidate more patients and family."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138913209,"A2-210",null,null,null,null,null,null,null,null,null,null,null,null,null,139485012,22]
[null,null,10,"020950401","Y",null,null,"",null,null,"021184901","021184901.7.1","Hospital","Private",null,null,null,"020991801",147,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,150,null,null,null,10,"020950401",{"$f":"IF('Intervention Details'!$D$12=AX152,MAX(AZ$2:AZ151)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,147,"Provide in person counseling on the effects of tobacco use and why tobacco cessation is important for the patients health",null,null,null,null,1,null,null,null,"Provide counseling while patient is at our facility. We will also provide educational material for the patients to take with them."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138913209,"A2-404",null,null,null,null,null,null,null,null,null,null,null,null,null,209345201,2]
[null,null,10,"021184901","Y",null,null,"",null,null,"081599501","081599501.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"080368601",148,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,151,null,null,null,10,"021184901",{"$f":"IF('Intervention Details'!$D$12=AX153,MAX(AZ$2:AZ152)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,148,"All Adults enrolled into care with Coastal Plains will be screened for BMI at each behavioral health visit.  This is related to Category C Measure M1-147.","Adults with diabetes will have HbA1c level checked at behavioral health visit.  This is related to Category C Measure M1-115.",null,null,null,2,null,null,null,"All BMI data will be documented and entered in Coastal Plains electronic medical record to assist provider in identifying individuals with BMI's that are beyond normal parameters."," "," "," "," ",1,1,0,0,0,0,null,"Coastal Plains plans to implement assessments in its' electronic medical record to flag and/or assist in monitoring individuals with high HbA1c screenings."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138913209,"A2-501",null,null,null,null,null,null,null,null,null,null,null,null,null,344925801,3]
[null,null,10,"081599501","Y",null,null,"",null,null,"083149703","083149703.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"080368601",149,"Substance Use Disorder","Office-based additional treatment for uninsured individuals","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,152,null,null,null,10,"081599501",{"$f":"IF('Intervention Details'!$D$12=AX154,MAX(AZ$2:AZ153)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,149,"All adults screened and identified as unhelathy alcohol users will be referred to SUD provider at each clinic location. This is related to Category C Measure M1-317.","All adults will be screened for tobacco use and those who are users will be offered tobacco cessation intervention counseling.  This is related to Category C Measure M1-105.",null,null,null,2,null,null,null,"Coastal Plains plans to implement criteria in its' electronic medical record to flag and/or assist in monitoring individuals with SUD issues.  We also plan to ensure a referral process is in place for individuals identified as having a SUD."," "," "," "," ",1,1,0,0,0,0,null,"Coastal Plains' electronic medical record will flag tobacco users and referrals will be provided to Navigators who will will offer tobacco cessation classes at each clinic."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138913209,"A2-509",null,null,null,null,null,null,null,null,null,null,null,null,null,391575301,12]
[null,null,10,"083149703","Y",null,null,"",null,null,"094105602","094105602.7.1","Hospital","Private",null,null,null,"094118902",687,"Access to Primary Care Services","Provision of screening and follow up services","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,153,null,null,null,10,"083149703",{"$f":"IF('Intervention Details'!$D$12=AX155,MAX(AZ$2:AZ154)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,687,"Increase opportunities for blood pressure and blood sugar monitoring.  Implement measures to prevent diabetes complications","Assess every hospitalized patient every shift for foley care, central line maintenance, fall risk assessment, and proper surgical site care to prevent hospital acquired conditions.",null,null,null,2,null,null,null,"Computer programming to trigger follow-up reminders for foot exams, sugar follow-ups, order lab in OP PCP Clinics.  ","Standing orders for patients with diabetes risk factors and screens will be in chart for blood sugars on every visit.","Implement in-office instrumentation for HbA1c monitoring","","",3,1,1,1,0,0,null,"Bedside shift report in presence of patient where safety factor checklist is reviews and precautions in place.   Chart to reflect fall risk assessment and line care."," "," "," "," ",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-111",null,null,null,null,null,null,null,null,null,null,null,null,null,20950401,10]
[null,null,10,"094105602","Y",null,null,"",null,null,"094193202","094193202.7.1","Hospital","Private",null,null,null,"094118902",150,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,154,null,null,null,10,"094105602",{"$f":"IF('Intervention Details'!$D$12=AX156,MAX(AZ$2:AZ155)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,150,"Increased Access to Care by PCP","Increase opportunities for blood pressure/blood sugar monitoring to prevent chronic disease complications","Optimize use of Clinic Computer system for regular monitoring of chronic patients","Prevent/minimize Hospital Acquired Conditions that increase suffering, LOS, Costs if Pt needs hospitalization",null,4,null,null,null,"Apply with GMEC to increase number of residents in program to 8 per year","Faculty recruitment to meet requirements for expanded number of residents","Complete scheduling/expansion plans as needed for additional number of residents","NP scheduled for surrounding county visits with chronic patients each week","Plan for clinic hour extensions beyond 5:00 p.m. if needed with more residents",5,1,1,1,1,1,null,"Introduce bedside glucose testing to Residency Clinic; NP to provide BP & Sugar monitoring in remote clinics","B/P monitoring all visits; repeat B/P if out of parameters.   Protocol development for sugar & B/P monitoring all visits","Pts who were hospitalized for chronic conditions to have F-U appt scheduled before leaving hospital within 3-7 days","NP to schedule Follow up visits in community clinics and to work FQHC clinic to monitor patients with chronic disease","Residency case manager to assist obtaining resources for essential supplies (BS monitor, meds, etc.) when indicated",5,1,1,1,1,1,null,"Use computer triggers and reminders to assure patients complying with ongoing monitoring","Reprogram computer to trigger new reminders with changes in patient assessment/condition","Laboratory testing to be scheduled at prescribed intervals for optimal management of condition","Call back system by staff to patients who fail to meet appointments","Provision of needed resources by case management for patients needing assistance",5,1,1,1,1,1,null,"Nurse driven protocol use for foley removal; reasons for continuation to be reviewed all change of shift reports","Sterile technique on insertion of all central lines, all PICC lines at bedside and in invasive areas","Clinical Pharmacy review of antibiotic management by patient when hospitalized","Infection Prevention follow-up on any suspected surgical wounds","Adherence to fall prevention program approved by Medical Staff.",5,1,1,1,1,1,null,null,null,null,null,null,0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,21184901,10]
[null,null,10,"094193202","Y",null,null,"",null,null,"112677302","112677302.7.1","Hospital","Private",null,null,null,"094222903",151,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,155,null,null,null,10,"094193202",{"$f":"IF('Intervention Details'!$D$12=AX157,MAX(AZ$2:AZ156)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,151,"Refer patients that have tested positive for possible alcohol abuse","Patients are screened with a depressed, alcohol, and substance abuse too, and where positive, are referred to a mental health provider that is located on site.  ",null,null,null,2,null,null,null,"Implement an alcohol abuse screening tool in order to identify patients with possible alcohol abuse"," ",null," "," ",1,1,0,0,0,0,null," The mental health provider will provide alcohol and substance abuse counseling, and refer patients who score positive for depression to outside resources or to counselors within the hospital system.  Licensed counselors will begin providing group therapy sessions in DY9, as well as implementing telemedicine in Q2 of DY9.  "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,81599501,22]
[null,null,10,"112677302","Y",null,null,"",null,null,"120726804","120726804.7.1","Hospital","Private",null,null,null,"112673204",152,"Access to Primary Care Services","Increase in capacity and access to services by utilizing alternative care or alternative clinical staff","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,156,null,null,null,10,"112677302",{"$f":"IF('Intervention Details'!$D$12=AX158,MAX(AZ$2:AZ157)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,152,"The first secondary driver for primary care services is to continue to reach more patients in the rural community.",null,null,null,null,1,null,null,null,"The first change idea is to add an aditional provider in order to assist in reaching more patients."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,83149703,11]
[null,null,10,"120726804","Y",null,null,"",null,null,"121794503","121794503.7.1","Hospital","Private",null,null,null,"112673204",153,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,157,null,null,null,10,"120726804",{"$f":"IF('Intervention Details'!$D$12=AX159,MAX(AZ$2:AZ158)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,153,"The first secondary driver for the specialty care activity is to focus on improving our outcomes for diabetic patients and reduce obesity in patients.",null,null,null,null,1,null,null,null,"The hospital could implement a screening of patients for diabetes with availability of standing orders for such screening."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,94105602,5]
[null,null,10,"121794503","Y",null,null,"",null,null,"121822403","121822403.7.1","Hospital","Private",null,null,null,"121775403",154,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,158,null,null,null,10,"121794503",{"$f":"IF('Intervention Details'!$D$12=AX160,MAX(AZ$2:AZ159)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,154,"Refer patients that have tested positive for possible alcohol abuse",null,null,null,null,1,null,null,null,"Implement an alcohol abuse screening tool in order to identify patients with possible alcohol abuse"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,94193202,5]
[null,null,10,"121822403","Y",null,null,"",null,null,"126675104","126675104.7.1","Hospital","Non‐State Owned Public",null,null,null,"121775403",155,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,159,null,null,null,10,"121822403",{"$f":"IF('Intervention Details'!$D$12=AX161,MAX(AZ$2:AZ160)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,155,"Increase screenings on high risk patients in Spohn clinics",null,null,null,null,1,null,null,null,"Increase provider and patient education on importance of screening and follow up"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,112677302,16]
[null,null,10,"126675104","Y",null,null,"",null,null,"127304703","127304703.7.1","Hospital","Private",null,null,null,"121775403",156,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,160,null,null,null,10,"126675104",{"$f":"IF('Intervention Details'!$D$12=AX162,MAX(AZ$2:AZ161)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,156,"Spohn will reduce targeted safety event rates through performance improvement activities",null,null,null,null,1,null,null,null,"Spohn will record and analyze data to identify trends and conduct interventions accordingly."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,120726804,10]
[null,null,10,"127304703","Y",null,null,"",null,null,"130606006","130606006.7.1","Hospital","Non‐State Owned Public",null,null,null,"121808305",157,"Expansion of Patient Care Navigation and Transition Services","Expansion of access to medical advice and direction to the appropriate level of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,161,null,null,null,10,"127304703",{"$f":"IF('Intervention Details'!$D$12=AX163,MAX(AZ$2:AZ162)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,157,"Expand clinic hours and days and redirect non-emergent patients",null,null,null,null,1,null,null,null,"Expand hours in the clinic to be more available for walk-in patients"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,121794503,10]
[null,null,10,"130606006","Y",null,null,"",null,null,"130614405","130614405.7.1","Hospital","Private",null,null,null,"130958511",169,"Expansion of Patient Care Navigation and Transition Services","Expansion of access to medical advice and direction to the appropriate level of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,162,null,null,null,10,"130606006",{"$f":"IF('Intervention Details'!$D$12=AX164,MAX(AZ$2:AZ163)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,169,"The administering of HgbA1c, Blood Pressure and BMI testing in a moilized unit , capturing data that is tracked over a period of 3, 6, 9, 12 months. Consulting and referring patients to primary care when needed and making sure all participants are staying active and eating healthy. Educating the participants of healthy and safe exercises that are within the individual patients physical ability, promoting group activities and incentive driven goals.",null,null,null,null,1,null,null,null,"CCNCPHD will be rolling out this mobilized concept of testing HgbA1c, Blood Pressure, and BMI as a way to maximizing  outreach efforts in Nueces County and surrounding Coastal Bend rural areas. One very important and essential change idea was that CCNCPHD  changed its methods of capturing data from paper forms to  electronically in real time. The Bod Pod Trailer which will house sensitive electronical testing equipment will also contain the latest WiFi equipment, lap tops, and signiture pads, enabling all data to be  entered electronically via internet and password encrypted secured sites.","CCNCPHD staff will need training on hooking up and unhooking  mobilized Bod Pod  Trailer Unit, as well as towing and parking training, all staff will be trained in the operations of the Bod Pod Trailer , from operable lighting and generator start ups and A/C operations for keeping the trailer temperature at an operable temperature. additional Bod Pod training will take place for staff operating the electronical equipment Bod Pod and Fit-Mate testing componenets.","CCNCPHD will be eliminating the use of paper forms and streamlining the process out in the  field , to provide a more efficient and modernized process for our patients."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,121822403,3]
[null,null,10,"130614405","Y",null,null,"",null,null,"130724106","130724106.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"130958511",170,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,163,null,null,null,10,"130614405",{"$f":"IF('Intervention Details'!$D$12=AX165,MAX(AZ$2:AZ164)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,170,"Program Incentives have been a necessary secondary driver that have been added to our monthly classes to increase client participation. Fitness challenges have encouraged participation in our chronic disease management program.  We offer fitness incentives to our 3 top monthly winners which has encouraged many others to join the challenges.   Friendly competition between participants keeps them active and healthy.  Our Health Promotions Coordinator has organized 9 fitness challenges thus far with over 155 participants.  The challenges vary from most walking distance, workouts, calories burned, running distance, strides, and many more. Participation in these fitness challenges has further improved our outreach to our target population and supported our chronic care management services goal.  \nWe have significantly improved attendance by supplementing our classes with Diabetes Bingo.  Incorporating Diabetes Bingo has added an exciting and interactive activity to our class agenda which has been responsible for an increase in popularity in our community.  The Bingo games are knowledge based and participants are learning important diabetes information while also having fun.  All prize incentives are specific to our program goals to encourage healthy habits.",null,null,null,null,1,null,null,null,"The first change idea to the fitness challenge incentive program is to have multiple challenges occurring at the same time to encourage max participation.  Participants had to wait for the next monthly challenge before they could join one.  We determined that once we had a group of at least 15 willing participants, then we could immediately start a new challenge. Ultimately, the goal is to have as many people actively exercising while learning to manage their chronic diseases.  \nWe found that participants were mastering the diabetes knowledge in the bingo games.  Therefore, we introduced new topics to expand their knowledge about chronic disease management.  The new topics include nutrition, fitness, hypertension, and obesity.   ",""," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,126675104,36]
[null,null,10,"130724106","Y",null,null,"",null,null,"131036903","131036903.7.1","Hospital","Private",null,null,null,"132812205",158,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,164,null,null,null,10,"130724106",{"$f":"IF('Intervention Details'!$D$12=AX166,MAX(AZ$2:AZ165)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,158,"Increasing the staff available to provide services will be key in accomplishing the Core Activity",null,null,null,null,1,null,null,null,"Hire and/or convert a part-time staff to support the program in satellite locations"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,127304703,10]
[null,null,10,"131036903","Y",null,null,"",null,null,"135036506","135036506.7.1","Hospital","Private",null,null,null,"132812205",159,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,165,null,null,null,10,"131036903",{"$f":"IF('Intervention Details'!$D$12=AX167,MAX(AZ$2:AZ166)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,159,"Educate clinical staff on changes and implement systematic changes to the Electronic Medical Record",null,null,null,null,1,null,null,null,"Technical support staff changes the documentation in the transition record and submits for approval to the clinical and medical education staff","Revise the after visit summary (transition record) for inpatient and emergency department services which will include additional patient care information."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,130606006,19]
[null,null,10,"135036506","Y",null,null,"",null,null,"136326908","136326908.7.1","Hospital","Private",null,null,null,"132812205",160,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,166,null,null,null,10,"135036506",{"$f":"IF('Intervention Details'!$D$12=AX168,MAX(AZ$2:AZ167)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,160,"Continuous staffing training and education on the eletronic medical records",null,null,null,null,1,null,null,null,"Documentation of Committee formation and membership"," The hospital has individual workgroups for all SPS Measures (D3 measure bundle) that reviews the results and findings with all applicable system areas on a routine basis. Measures are reported through a Dashboard in Qlik and managed by the Quality Department."," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,130614405,10]
[null,null,10,"136326908","Y",null,null,"",null,null,"138980111","138980111.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"132812205",161,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,167,null,null,null,10,"136326908",{"$f":"IF('Intervention Details'!$D$12=AX169,MAX(AZ$2:AZ168)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,161,"Update the existing EMR Safety and Injury Preventation navigation section of a patient's record to  current healthcare standards",null,null,null,null,1,null,null,null,"Create a policy for Patients at Risk for Self-harm and/or Suicide that will address Patient Safety and Injury Prevention"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387515501,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,130724106,13]
[null,null,10,"138980111","Y",null,null,"",null,null,"186221101","186221101.7.1","Hospital","Private",null,null,null,"132812205",162,"Palliative Care","Provision of coordinated palliative care to address patients with end‐of‐life decisions","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,168,null,null,null,10,"138980111",{"$f":"IF('Intervention Details'!$D$12=AX170,MAX(AZ$2:AZ169)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,162,"Create a palliative care patient registry in the electronic medical records",null,null,null,null,1,null,null,null,"Meet with IT frastructure to discuss the creation of a palliative care registry"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,140425362,"IT-1.7",null,null,null,null,null,null,null,null,null,null,null,null,null,131036903,10]
[null,null,10,"186221101","Y",null,null,"",null,null,"206106101","206106101.7.1","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",null,null,null,"132812205",688,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,169,null,null,null,10,"186221101",{"$f":"IF('Intervention Details'!$D$12=AX171,MAX(AZ$2:AZ170)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,688,"Through the creation of an orderset, communication of asthma coordination will be sent immediately to Case Management per the Asthma Action Plan. This will help to prevent future emergency department visits and hospitalizations. The Asthma Coordinator will review the patient's visit information and make any appropriate follow-ups with the patient",null,null,null,null,1,null,null,null,"n Asthma Committee Charter was created to improve the delivery of care to asthma patients specifically in the Emergency Department and Inpatient/Observation setting. The Asthma Action Plan was created by the Committee to improve asthma education through community alliance. The Asthma Action Plan is triggered through the EMR system via Physician Orderset.","","","","",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,140425362,"L1-107",null,null,null,null,null,null,null,null,null,null,null,null,null,135036506,13]
[null,null,10,"206106101","Y",null,null,"",null,null,"216719901","216719901.7.1","Hospital","Non‐State Owned Public",null,null,null,"135233809",163,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,170,null,null,null,10,"206106101",{"$f":"IF('Intervention Details'!$D$12=AX172,MAX(AZ$2:AZ171)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,163,"Vaccines, Screenings, Exams, Counseling, and Education: The hospital has implemented a tool to ensure that we are capturing the necessary patient population.  If patients meet the criteria, we are abstracting data into our screening tool to ensure they get the appropriate vaccines, screenings, exams, and counseling.",null,null,null,null,1,null,null,null,"Select and implement a screening tool to aid in the identification of chronic conditions.","Abstract patient data to ensure proper health maintenance."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,136326908,10]
[null,null,10,"216719901","Y",null,null,"",null,null,"314080801","314080801.7.1","Hospital","Private",null,null,null,"135254407",137,"Chronic Care Management","Implementation of a medication management program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,171,null,null,null,10,"216719901",{"$f":"IF('Intervention Details'!$D$12=AX173,MAX(AZ$2:AZ172)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,137,"To achieve better outcomes on medication management and improve continuum of care.",null,null,null,null,1,null,null,null,"The nurses and/or doctor will verify and document all medications; prescriptions, over the counters, herbals, and vitamin/mineral/dietary supplements and must contain the medications' name, dosage, frequency, and route of administration in the medial record.  This is to include additions, changes, and discontinuation of medications. ",""," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,138980111,32]
[null,null,10,"314080801","Y",null,null,"",null,null,"316296801","316296801.7.1","Hospital","Private",null,null,null,"135254407",138,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,172,null,null,null,10,"314080801",{"$f":"IF('Intervention Details'!$D$12=AX174,MAX(AZ$2:AZ173)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,138,"Conducts screening of patients at intake to identify level of alcohol consumption","Provide local resources and counseling for identified individuals with a score of 8 or higher on the Audit Questionaire.",null,null,null,2,null,null,null," Screen every individual for preventive care and screening;  unhealthy alcohol use; screening and brief counseling using 'the Audit Questionairre'."," "," "," "," ",0,0,0,0,0,0,null,"Provide brief intervention and refer to treatment programs.","Provide brief counseling and material to alcohol users considered heavy to excessive drinkers. "," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,186221101,2]
[null,null,10,"316296801","Y",null,null,"",null,null,"020992601","020992601.7.1","Hospital","Non‐State Owned Public",null,null,null,"135254407",139,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,173,null,null,null,10,"316296801",{"$f":"IF('Intervention Details'!$D$12=AX175,MAX(AZ$2:AZ174)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,139,"GBC will use the Columbia Suicide Severity Rating Scale (C-SSRS) to identify individuals at risk of suicide.",null,null,null,null,1,null,null,null,"Upon evaluation of C-SSRS Gulf Bend Center staff will identify whether the consumer is at risk to self or to others. A) All individuals are screened with the C-SSRS at each contact to identify individuals at risk of suicide. B) Individuals who present in crisis have 24-hour access to mobile crisis intervention services to assist in the de-escalation of the behavioral health crisis and refer the customer to outside entities as needed.","GBC will ensure staff have training on administering CSSRS.  This will include nurses, case management, crisis, and health practitioners. ",null," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,206106101,8]
[null,null,11,"020992601","Y",null,null,"",null,null,"094131202","094131202.7.1","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",null,null,null,"135254407",140,"Prevention and Wellness","Implementation of interventions focusing on social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,174,null,null,null,11,"020992601",{"$f":"IF('Intervention Details'!$D$12=AX176,MAX(AZ$2:AZ175)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,140,"Gulf Bend Center will increase and strengthen consumer awareness of the long-term effects that will contribute to health conditions related to smoking. Gulf Bend Center provides Smoking Cessation counseling with an RN.  (First Change Idea for the above Secondary Driver) Gulf Bend Center will screen all individuals for tobacco use and if positive for use we provide educational material and brief counseling along with recommending Smoking Cessation Counseling. ","Gulf Bend Center continues to promote positivity by implementing a Tobacco-free environment which creates a safer, healthier facility for consumers and staff. Gulf Bend will continue to have trained staff to provide Smoking Cessation education and counseling. ",null,null,null,2,null,null,null,"Gulf Bend Center will screen all individuals for tobacco use and if positive for use we provide educational material and brief counseling along with recommending Smoking Cessation Counseling."," "," "," "," ",1,1,0,0,0,0,null,"Gulf Bend Center will be fully committed to maintaining health and safe environment for staff and clients served by the center. Gulf Bend Center will also, continue to provide resources to obtain NRT assistance with achieving a positive lifestyle change. Care Coordinators and Case Managers will follow up with individuals to ensure they are attending counseling and identify barriers to smoking cessation. "," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,216719901,3]
[null,null,11,"094131202","Y",null,null,"",null,null,"112692202","112692202.7.1","Hospital","Non‐State Owned Public",null,null,null,"135254407",141,"Availability of Appropriate Levels of Behavioral Health Care Services","Other","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,175,null,null,null,11,"094131202",{"$f":"IF('Intervention Details'!$D$12=AX177,MAX(AZ$2:AZ176)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,141,"Provide follow up appointment and community resources for clients.",null,null,null,null,1,null,null,null,"Improve communication between treatments teams and hospitals to facilitate aftercare.","Provide clients with access to a mental health provider, resources for case management, counseling, and basic needs. "," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,314080801,10]
[null,null,11,"112692202","Y",null,null,"",null,null,112692202,"112692202.7.1","Hospital","Non‐State Owned Public",null,null,null,"136436606",164,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,176,null,null,null,11,"112692202",{"$f":"IF('Intervention Details'!$D$12=AX178,MAX(AZ$2:AZ177)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,164,"Spohn will implement recommended practice in association with the OB Hemorrhage Collaborative",null,null,null,null,1,null,null,null,"Spohn will compare recommended practices to Spohn's current practices to create an implementation plan for the recommended practices"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,316296801,10]
[null,null,11,112692202,"Y",null,null,"",null,null,"112702904","112702904.7.1","Hospital","Non‐State Owned Public",null,null,null,"137907508",165,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,177,null,null,null,11,112692202,{"$f":"IF('Intervention Details'!$D$12=AX179,MAX(AZ$2:AZ178)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,165,"We will use our Community Health Worker to help drive this core activity",null,null,null,null,1,null,null,null,"CHW will provide education, follow up, and connection with community resources for frequent ED patients to reduce over all healthcare costs."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,20992601,3]
[null,null,11,"112702904","Y",null,null,"",null,null,"406583101","126842708.7.1","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public",null,null,null,"138305109",166,"Prevention and Wellness","Self‐management programs and wellness programs using evidence‐based designs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,178,null,null,null,11,"112702904",{"$f":"IF('Intervention Details'!$D$12=AX180,MAX(AZ$2:AZ179)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,166,"Staff will refer individuals to the Peer Run Day Center, lived experience",null,null,null,null,1,null,null,null,"Individuals will be able to participate in group interventions and experiece the group dynamic to help foster change"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387377001,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,94131202,4]
[null,null,11,"406583101",{"$error":"#N/A"},null,null,"",null,null,"133244705","133244705.7.1","Hospital","Non‐State Owned Public",null,null,null,"138305109",167,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of telehealth/telemedicine in delivering behavioral services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,179,null,null,null,11,"406583101",{"$f":"IF('Intervention Details'!$D$12=AX181,MAX(AZ$2:AZ180)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,167,"Psychiatric evaluation including for substance abuse and medication management will be provided via telehealth and our medication clinics",null,null,null,null,1,null,null,null,"Medication education and rehab and case management for co ocurring substance use disorders will be provided by members of the clients' treatment teams."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,112692202,3]
[null,null,11,"133244705","Y",null,null,"",null,null,"133338707","133338707.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"138305109",168,"Prevention and Wellness","Implementation of interventions focusing on social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,180,null,null,null,11,"133244705",{"$f":"IF('Intervention Details'!$D$12=AX182,MAX(AZ$2:AZ181)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,168,"face to face contacts monthly occurring in the individual's natural environment",null,null,null,null,1,null,null,null,"monthly contacts with collateral contacts to determine the needs and functioning of individuals"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,112702904,3]
[null,null,11,"133338707","Y",null,null,"",null,null,"133339505","133339505.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"020947001",175,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,181,null,null,null,11,"133338707",{"$f":"IF('Intervention Details'!$D$12=AX183,MAX(AZ$2:AZ182)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,175,"Outpatient clinic services via the Diabetes Management Center (DMC) are the first driver of chronic care management.  The services provided at the DMC are diabetes education, meal planning, glucose screenings, hemoglobin A1C testing, insulin teaching, coping skills and guidance to help patients find a plan that helps them reach healthy goals.  Patients will improve their health by learning how to manage blood glucose levels, monitor their blood pressure readings, and understand their medications, decrease risk of disease complications and overall diabetes self-management.  DMC understands that all of these components are necessary in order for patients to achieve better health outcomes. ",null,null,null,null,1,null,null,null,"Diabetes Management Center (DMC) monitors patient progress at the end of four visits within a 3 month time frame.  The DMC expects to see a significant reduction in Hemoglobin A1C rates and blood pressure rates for the population being served.  The DMC evaluates clinical data in order to determine which patients did not show progress.  The DMC will then follow up with those patients to share results, identify missed opportunities, and re-educate within a 6-month time frame. These important steps will lead to the improvement that is necessary to achieve better health outcomes for the target population."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,121053602,3]
[null,null,11,"133339505","Y",null,null,"",null,null,"136325111","136325111.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",176,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,182,null,null,null,11,"133339505",{"$f":"IF('Intervention Details'!$D$12=AX184,MAX(AZ$2:AZ183)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,176,"Assist patients to adhere to the clinical advice and directions of their provider.","Implement group interventions to promote lifestyle changes.",null,null,null,2,null,null,null,"Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance and assist in addressing the social determinants."," "," "," "," ",1,1,0,0,0,0,null,"Provide opportunities for community-based Diabetes Self-Management Education and other group interventions","Provide opportunities for chronic disease support groups"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,406583101,3]
[null,null,11,"136325111","Y",null,null,"",null,null,137074409,"137074409.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",177,"Chronic Care Management","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,183,null,null,null,11,"136325111",{"$f":"IF('Intervention Details'!$D$12=AX185,MAX(AZ$2:AZ184)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,177,"Provide resources that support patients with accessing services and supplies needed for chronic care management.",null,null,null,null,1,null,null,null,"Patient navigators and community health workers connect individuals to transportation services to help patients attend group classes, PCP appointments, lab appointments, and other visits.","Identify individuals in need of financial support for medications, copays, lab costs, and other exam costs. SWs provide financial resources through Compassion Funds process to participants identified as needing this type of support.  "," Social Workers conduct assessments to identify barriers that impact individuals with their self-management goals and connect patients to community resources. "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,133244705,5]
[null,null,11,137074409,"Y",null,null,"",null,null,"137074409","137074409.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",178,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,184,null,null,null,11,137074409,{"$f":"IF('Intervention Details'!$D$12=AX186,MAX(AZ$2:AZ185)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,178,"1. Increase opportunities for patients to receive needed specialty care services and enhance care coordination for specialist referrals",null,null,null,null,1,null,null,null,"Enhance or implement a specialist referral tracking process. Close the loop on referrals to specialists including receiving and documenting the report from the specialist and identifying when patients have not completed the referral.","Identify specialists and/or resources for low/no cost specialty care services."," Implement specialty care services in primary care settings to expand the services that patients can receive in their medical home and improve completion of these referrals.  "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"J1-218",null,null,null,null,null,null,null,null,null,null,null,null,null,133338707,3]
[null,null,11,"137074409","Y",null,null,"",null,null,"138644310","138644310.7.1","Hospital","Private",null,null,null,"085144601",179,"Access to Specialty Care Services","Provision of services to individuals that address social determinants of health","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,185,null,null,null,11,"137074409",{"$f":"IF('Intervention Details'!$D$12=AX187,MAX(AZ$2:AZ186)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,179,"Promote eye exam visits to patients with diabetes.",null,null,null,null,1,null,null,null,"Provide transportation to patients with diabetes to attend eye exam appointments","CHWs to provide education to patients with diabetes referred to the CCM program on the importance of receiving an eye exam and re-connect participants to their medical home when patients have not been to their appointments"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"J1-219",null,null,null,null,null,null,null,null,null,null,null,null,null,133339505,2]
[null,null,11,"138644310","Y",null,null,"",null,null,"138950412","138950412.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",180,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,186,null,null,null,11,"138644310",{"$f":"IF('Intervention Details'!$D$12=AX188,MAX(AZ$2:AZ187)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,180,"Pro-actively identify patients in need of navigation services","Link patients with appropriate community services",null,null,null,2,null,null,null,"Define target populations to receive navigation services","Create reports from EHR and define report distribution and intervals","Create and/or update workflows for patient outreach"," "," ",3,1,1,1,0,0,null,"Employ patient navigators to assist patients during clinic visits and home visits","Provide training and materials for providers and staff","Provide specific informational materials to patients","Implement tracking methodology for community referrals"," ",4,1,1,1,1,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"J1-220",null,null,null,null,null,null,null,null,null,null,null,null,null,136325111,3]
[null,null,11,"138950412","Y",null,null,"",null,null,"281406304","281406304.7.1","Hospital","Private",null,null,null,"085144601",181,"Prevention and Wellness","Use of community health workers to improve prevention efforts","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,187,null,null,null,11,"138950412",{"$f":"IF('Intervention Details'!$D$12=AX189,MAX(AZ$2:AZ188)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,181,"Community Health Workers provide healthy lifestyle education in the patient’s home to prevent complications from high blood pressure and uncontrolled diabetes.","Community Health Workers promote cancer screenings (colorectal, breast, cervical) to clinic patients by providing tailored educational modules in their homes and connecting them to clinic screenings and addressing barriers to attendance.",null,null,null,2,null,null,null,"Deploy Community Health Workers to patient homes to offer tailored in-home education to patients about healthy lifestyle change, with a focus on physical activity and nutrition.","Community Health Workers connect patients to free exercise classes, healthy cooking classes, weight-loss support groups and online support groups."," "," "," ",2,1,1,0,0,0,null,"Community Health Workers identify patient barriers to attending clinic cancer screening appointments (transportation, funding, fear) & connect patients with clinic social services and other resources to assure they received their screening tests.","",""," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"J1-221",null,null,null,null,null,null,null,null,null,null,null,null,null,137074409,3]
[null,null,11,"281406304","Y",null,null,"",null,null,"337991901","337991901.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",689,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,188,null,null,null,11,"281406304",{"$f":"IF('Intervention Details'!$D$12=AX190,MAX(AZ$2:AZ189)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,689,"Assist patients to adhere to the clinical advice and directions of their provider.","Implement group interventions to promote lifestyle changes.","Provide individual interventions through CHWs to assess, support, and as needed, provide referrals to address barriers to clinical care and self-management.",null,null,3,null,null,null,"Multidisciplinary Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance.","","","","",1,1,0,0,0,0,null,"Provide opportunities for community-based self support management of chronic disease and lifestyle changes ","","","","",1,1,0,0,0,0,null,"Utilize Motivational Interviewing (MI) as a technique to engage patients in self-management.","Community Health Workers administer appropriate surveys (e.g. Physical Activity, Healthy Eating, Medication Adherence, Environmental Assessment, PHQ-9) and implement workflows to connect patients to appropriate services.","","","",2,1,1,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,330811601,"J1-506",null,null,null,null,null,null,null,null,null,null,null,null,null,138644310,22]
[null,null,11,"337991901","Y",null,null,"",null,null,"065100201","065100201.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"085144601",690,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,189,null,null,null,11,"337991901",{"$f":"IF('Intervention Details'!$D$12=AX191,MAX(AZ$2:AZ190)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,690,"Pro-actively identify patients in need of navigation services. \n\nThis Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Su Clinica and Rio Grande State Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition. Due to low health literacy in the clinics' population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","Link patients with appropriate community service(s).",null,null,null,2,null,null,null,"Use EHR data along with community services data to define target populations to receive navigation services.","Continue to enhance reports from EHR and other data sources and improve report distribution and intervals to perform frequent gap analysis.","","","",2,1,1,0,0,0,null,"Employ patient navigators and care managers to assist patients during clinic visits and home visits.","Provide training and materials for providers and staff.","Provide specific informational materials to patients.","Implement tracking methodology for community referrals."," ",4,1,1,1,1,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,366812101,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,138950412,4]
[null,null,12,"065100201","Y",null,null,"",null,null,"084563802","084563802.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"094113001",182,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,190,null,null,null,12,"065100201",{"$f":"IF('Intervention Details'!$D$12=AX192,MAX(AZ$2:AZ191)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,182,"Identify patient population with chronic diseases such as diabetes and heart disease that are at high risk of developing complications, co-mornidities, and/ or utilizing acute and emergency care services.",null,null,null,null,1,null,null,null,"Effectively navigate patients to the most appropriate health care setting and provide education as needed. Furthermore, provide chronic disease self-management education to patients as applicable."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,366812101,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,281406304,5]
[null,null,12,"084563802","Y",null,null,"",null,null,"084599202","084599202.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"094113001",183,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,191,null,null,null,12,"084563802",{"$f":"IF('Intervention Details'!$D$12=AX193,MAX(AZ$2:AZ192)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,183,"Review discharge report with patient and caregivers and provide education where necessary. Set up appointment with patient's PCP prior to patient discharge.",null,null,null,null,1,null,null,null,"Prior to discharge, assure patient has follow up appointment with PCP"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,366812101,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,337991901,3]
[null,null,12,"084599202","Y",null,null,"",null,null,"084897001","084897001.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"094113001",184,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,192,null,null,null,12,"084599202",{"$f":"IF('Intervention Details'!$D$12=AX194,MAX(AZ$2:AZ193)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,184,"Review discharge report with patient and caregivers and provide education where necessary. Set up appointment with patient's PCP prior to patient discharge.",null,null,null,null,1,null,null,null,"Prior to discharge, review transition record with patient and caregiver"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,366812101,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,65100201,4]
[null,null,12,"084897001","Y",null,null,"",null,null,"094117105","094117105.7.1","Hospital","Non‐State Owned Public",null,null,null,"094113001",185,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,193,null,null,null,12,"084897001",{"$f":"IF('Intervention Details'!$D$12=AX195,MAX(AZ$2:AZ194)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,185,"Identify, screen and provide education for patients identified as tobacco users and/ or BMI outside of normal parameters. Provide patients with HbA1c testing and cancer screenings. ",null,null,null,null,1,null,null,null,"Upon visit, review patients medical record and provide appropriate screenings and follow up services"," "," "," "," ",1,1,{"$f":"IF(OR(LEFT(BV195,1)=$BT$1,LEFT(BV195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BW195,1)=$BT$1,LEFT(BW195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BX195,1)=$BT$1,LEFT(BX195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BY195,1)=$BT$1,LEFT(BY195,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CH195,1)=$BT$1,LEFT(CH195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CI195,1)=$BT$1,LEFT(CI195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CJ195,1)=$BT$1,LEFT(CJ195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CK195,1)=$BT$1,LEFT(CK195,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CT195,1)=$BT$1,LEFT(CT195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CU195,1)=$BT$1,LEFT(CU195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CV195,1)=$BT$1,LEFT(CV195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CW195,1)=$BT$1,LEFT(CW195,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DF195,1)=$BT$1,LEFT(DF195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DG195,1)=$BT$1,LEFT(DG195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DH195,1)=$BT$1,LEFT(DH195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DI195,1)=$BT$1,LEFT(DI195,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DR195,1)=$BT$1,LEFT(DR195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DS195,1)=$BT$1,LEFT(DS195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DT195,1)=$BT$1,LEFT(DT195,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DU195,1)=$BT$1,LEFT(DU195,1)=\"\"),0,1)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,366812101,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,84563802,9]
[null,null,12,"094117105","Y",null,null,"",null,null,"094129604","094129604.7.1","Hospital","Non‐State Owned Public",null,null,null,"094113001",186,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10",{"$f":"IF(OR(V196=\"DY7-10\",V196=\"DY9-10\"),\"Y\",\"N\")","v":"Y"},{"$f":"IF(V196=\"DY9-10\",\"Y\",\"N\")","v":"N"},null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,194,null,null,null,12,"094117105",{"$f":"IF('Intervention Details'!$D$12=AX196,MAX(AZ$2:AZ195)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,186,"Identify patients who meet qualifications to have vaccinations for Pneumonia, influenza, and Human Papillomavirus",null,null,null,null,{"$f":"COUNTA(BL196:BP196)","v":1},null,null,null,"Upon visit, determine patient's vaccination staus, provide patient education on vaccinations, and provide vaccination if requested."," "," "," "," ",{"$f":"SUM(CA196:CE196)","v":1},{"$f":"IF(OR(LEFT(BU196,1)=$BT$1,LEFT(BU196,1)=\"\"),0,1)","v":1},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CM196:CQ196)","v":0},{"$f":"IF(OR(LEFT(CG196,1)=$BT$1,LEFT(CG196,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(CY196:DC196)","v":0},{"$f":"IF(OR(LEFT(CS196,1)=$BT$1,LEFT(CS196,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DK196:DO196)","v":0},{"$f":"IF(OR(LEFT(DE196,1)=$BT$1,LEFT(DE196,1)=\"\"),0,1)","v":0},0,0,0,0,null," "," "," "," "," ",{"$f":"SUM(DW196:EA196)","v":0},{"$f":"IF(OR(LEFT(DQ196,1)=$BT$1,LEFT(DQ196,1)=\"\"),0,1)","v":0},0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,19053001,"L1-107",null,null,null,null,null,null,null,null,null,null,null,null,null,84599202,10]
[null,null,12,"094129604","Y",null,null,"",null,null,"094180903","094180903.7.1","Hospital","Non‐State Owned Public",null,null,null,"094113001",187,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,195,null,null,null,12,"094129604",{"$f":"IF('Intervention Details'!$D$12=AX197,MAX(AZ$2:AZ196)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,187,"Proactively identify rates of concern and implement corrective actions",null,null,null,null,1,null,null,null,"Provide ongoing prevention education to staff including new hires at time of orientation","Implement initiatives to improve patient fall rates. "," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,19053001,"L1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,84897001,{"$f":"COUNTIF(ET197:ET3166,FI197)","v":4}]
[null,null,12,"094180903","Y",null,null,"",null,null,"109588703","109588703.7.1","Hospital","Non‐State Owned Public",null,null,null,"111810101",171,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,196,null,null,null,12,"094180903",{"$f":"IF('Intervention Details'!$D$12=AX198,MAX(AZ$2:AZ197)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,171,"Assist patients to adhere to the clinical advice and directions of their provider.","Implement group interventions to promote lifestyle changes.",null,null,null,2,null,null,null,"Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance and assist in addressing the social determinants."," "," "," "," ",1,1,0,0,0,0,null,"Provide opportunities for community-based Diabetes Self-Management Education and other group interventions","Provide opportunities for chronic disease support groups"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,19053001,"L1-186",null,null,null,null,null,null,null,null,null,null,null,null,null,94117105,3]
[null,null,12,"109588703","Y",null,null,"",null,null,"112704504","112704504.7.1","Hospital","Non‐State Owned Public",null,null,null,"111810101",172,"Chronic Care Management","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,197,null,null,null,12,"109588703",{"$f":"IF('Intervention Details'!$D$12=AX199,MAX(AZ$2:AZ198)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,172,"1. Provide resources that support patients with accessing services and supplies needed for chronic care management.",null,null,null,null,1,null,null,null,"Patient navigators and community health workers connect individuals to transportation services to help patients attend group classes, PCP appointments, lab appointments, and other visits.","Identify individuals in need of financial support for medications, copays, lab costs, and other exam costs. SWs provide financial resources through Compassion Funds process to participants identified as needing this type of support.  "," Social Workers conduct assessments to identify barriers that impact individuals with their self-management goals and connect patients to community resources. "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A1-112",null,null,null,null,null,null,null,null,null,null,null,null,null,94121303,3]
[null,null,12,"112704504","Y",null,null,"",null,null,"126667806","126667806.7.1","Hospital","Non‐State Owned Public",null,null,null,"111810101",173,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,198,null,null,null,12,"112704504",{"$f":"IF('Intervention Details'!$D$12=AX200,MAX(AZ$2:AZ199)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,173,"Pro-actively identify patients in need of navigation services","Link patients with appropriate community service(s)",null,null,null,2,null,null,null,"Define target populations to receive navigation services","Create reports from EHR and define report distribution and intervals","Create and/or update workflows for patient outreach"," "," ",3,1,1,1,0,0,null,"Employ patient navigators to assist patients during clinic visits and home visits","Provide training and materials for providers and staff","Provide specific informational materials to patients","Implement tracking methodology for community referrals"," ",4,1,1,1,1,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,94129604,3]
[null,null,12,"126667806","Y",null,null,"",null,null,"126840107","126840107.7.1","Hospital","Private",null,null,null,"111810101",174,"Prevention and Wellness","Use of community health workers to improve prevention efforts","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,199,null,null,null,12,"126667806",{"$f":"IF('Intervention Details'!$D$12=AX201,MAX(AZ$2:AZ200)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,174,"Community Health Workers provide healthy lifestyle education in the patient’s home to prevent complications from high blood pressure and uncontrolled diabetes.","Community Health Workers promote cancer screenings (colorectal, breast, cervical) to clinic patients by providing tailored educational modules in their homes and connecting them to clinic screenings and addressing barriers to attendance.",null,null,null,2,null,null,null,"Deploy Community Health Workers to patient homes to offer tailored in-home education to patients about healthy lifestyle change, with a focus on physical activity and nutrition.","Community Health Workers connect patients to free exercise classes, healthy cooking classes, weight-loss support groups and online support groups.",""," "," ",2,1,1,0,0,0,null,"Community Health Workers identify patient barriers to attending clinic cancer screening appointments (transportation, funding, fear) & connect patients with clinic social services and other resources to assure they received their screening tests.",""," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A1-207",null,null,null,null,null,null,null,null,null,null,null,null,null,94180903,3]
[null,null,12,"126840107","Y",null,null,"",null,null,"127313803","127313803.7.1","Hospital","Non‐State Owned Public",null,null,null,"111810101",691,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,200,null,null,null,12,"126840107",{"$f":"IF('Intervention Details'!$D$12=AX202,MAX(AZ$2:AZ201)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,691,"Assist patients to adhere to the clinical advice and directions of their provider.","Implement group interventions to promote lifestyle changes.","Provide individual interventions through CHWs to assess, support, and as needed, provide referrals to address barriers to clinical care and self-management.",null,null,3,null,null,null,"Multidisciplinary Care teams including CHWs, non-physician health professionals, and case managers will identify barriers that affect a patients adherence to medical guidance.","","","","",1,1,0,0,0,0,null,"Provide opportunities for community-based self support management of chronic disease and lifestyle changes ","","","","",1,1,0,0,0,0,null,"Utilize Motivational Interviewing (MI) as a technique to engage patients in self-management.","Community Health Workers administer appropriate surveys (e.g. Physical Activity, Healthy Eating, Medication Adherence, Environmental Assessment, PHQ-9) and implement workflows to connect patients to appropriate services.","","","",2,1,1,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,109588703,3]
[null,null,12,"127313803","Y",null,null,"",null,null,"127319504","127319504.7.1","Hospital","Private",null,null,null,"111810101",692,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,201,null,null,null,12,"127313803",{"$f":"IF('Intervention Details'!$D$12=AX203,MAX(AZ$2:AZ202)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,692,"Increase opportunities for patients to receive needed specialty care services and enhance care coordination for specialist referrals",null,null,null,null,1,null,null,null,"Enhance or implement a specialist referral tracking process. Close the loop on referrals to specialists including receiving and documenting the report from the specialist and identifying when patients have not completed the referral.","Identify specialists and/or resources for low/no cost specialty care services.","Implement specialty care services in primary care settings to expand the services that patients can receive in their medical home and improve completion of these referrals.  ","","",3,1,1,1,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A1-508",null,null,null,null,null,null,null,null,null,null,null,null,null,112704504,3]
[null,null,12,"127319504","Y",null,null,"",null,null,"127374005","127374005.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"111810101",693,"Expansion of Patient Care Navigation and Transition Services","Provision of navigation services to targeted patients","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,202,null,null,null,12,"127319504",{"$f":"IF('Intervention Details'!$D$12=AX204,MAX(AZ$2:AZ203)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,693,"Pro-actively identify patients in need of navigation services. This Core Activity addresses all selected measure bundles A1, A2, and C2. Thus, the target population for this core activity includes adult patients of Brownsville Community Health Center and Hope Family Health Center who have diabetes, heart disease, and adult patients eligible for cancer screening. Patients with chronic conditions (such as diabetes and heart disease) benefit from navigation to services that will help the patient manage their condition.  Due to low health literacy in the clinics’ population, most would benefit from outreach and education about the importance of cancer screenings and management of chronic conditions.","Link patients with appropriate community service(s).",null,null,null,2,null,null,null,"Use EHR data along with community services data to define target populations to receive navigation services.","Continue to enhance reports from EHR and other data sources and improve report distribution and intervals to perform frequent gap analysis.","","","",2,1,1,0,0,0,null,"Employ patient navigators and care managers to assist patients during clinic visits and home visits.","Provide training and materials for providers and staff.","Provide specific informational materials to patients.","Implement tracking methodology for community referrals.","",4,1,1,1,1,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A2-103",null,null,null,null,null,null,null,null,null,null,null,null,null,126667806,3]
[null,null,12,"127374005","Y",null,null,"",null,null,"127378105","127378105.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"112716902",188,"Expansion of Patient Care Navigation and Transition Services","Identification of frequent ED users and use of care navigators","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,203,null,null,null,12,"127374005",{"$f":"IF('Intervention Details'!$D$12=AX205,MAX(AZ$2:AZ204)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,188,"Case manager workers contact Emergency Department patients with specified ambulatory care sensitive conditions to ensure connection and follow up with a primary care physician.","  ACSC Diabetes as top conditions for Chronic ACSC Emergency Room visits, Rio is looking reduce emergency visits and divert patients to proper follow up care to ACSC conditions patient population.",null,null,null,2,null,null,null,"Contact patients with specified ambulatory care sensitive conditions and attempt to schedule those patients for an appointment in our family medicine clinic or get them connected with their PCP."," "," "," "," ",1,1,0,0,0,0,null,"  Emergency Room case workers & diabetes center educators are working togeter to help ACSC Diabetes patients improve their diabetes self-care skill and create conscientiousness about diabetes risks, importance of following up with PCP and enhance quality of life."," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A2-210",null,null,null,null,null,null,null,null,null,null,null,null,null,126840107,3]
[null,null,12,"127378105","Y",null,null,"",null,null,"130618504","130618504.7.1","Hospital","Non‐State Owned Public",null,null,null,"112716902",189,"Maternal and Infant Health Care","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,204,null,null,null,12,"127378105",{"$f":"IF('Intervention Details'!$D$12=AX206,MAX(AZ$2:AZ205)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,189,"Reduce complications from Gestational Diabetes for expecting mothers.",null,null,null,null,1,null,null,null,"Gestional Diabetes in an expectant mothers will be confirmed via a glucose screening that will be ordered within one hour and after three hours of the first screening."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A2-404",null,null,null,null,null,null,null,null,null,null,null,null,null,127313803,4]
[null,null,12,"130618504","Y",null,null,"",null,null,"130725806","130725806.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"112716902",190,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,205,null,null,null,12,"130618504",{"$f":"IF('Intervention Details'!$D$12=AX207,MAX(AZ$2:AZ206)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,190,"For CLABSI, active surveillance of all central lines in the adult ICU. For CAUTI,active surveillance of all central lines in the adult and pediatric ICUs. Surveillance will rotate.","Identify patients who develop SSIs after surgery.",null,null,null,2,null,null,null,"Infection control practitioner will review all central lines of the ICU's by physically looking at the line  & dressing and speaking with the primary care nurse about medical necessity for the line."," "," "," "," ",1,1,0,0,0,0,null,"Antibiotics given within 1 hr. prior to incision. Pre-operative skin preparation with chlorhexidine  or iodophor."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A2-501",null,null,null,null,null,null,null,null,null,null,null,null,null,127319504,10]
[null,null,12,"130725806","Y",null,null,"",null,null,"130826407","130826407.7.1","Hospital","Non‐State Owned Public",null,null,null,"135035706",191,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,206,null,null,null,12,"130725806",{"$f":"IF('Intervention Details'!$D$12=AX208,MAX(AZ$2:AZ207)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,191,"Increase the number of patients who are scheduled and show up to follow up visits.",null,null,null,null,1,null,null,null,"Training Staff to schedule patients timely for their follow up appointments. Provide education to our patients."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"A2-509",null,null,null,null,null,null,null,null,null,null,null,null,null,127374005,2]
[null,null,12,"130826407","Y",null,null,"",null,null,"133250406","133250406.7.1","Hospital","Non‐State Owned Public",null,null,null,"136332705",192,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,207,null,null,null,12,"130826407",{"$f":"IF('Intervention Details'!$D$12=AX209,MAX(AZ$2:AZ208)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,192,"The secondary driver will be coordinating proper patient discharge planning with the providers and the other health care facilities or caregivers upon transition of care.  This will include the availability to print and verbalize discharge education and instructions to the appropriate personnel who will resume the care of the patient once discharged from our facility.",null,null,null,null,1,null,null,null,"The change idea that would be associated with this core activity would be to have the all the policies reviewed when it comes to discharge planning of the patient. We will change the standard policies to incorporate the transition of the proper documentation and education needed be given to the proper individuals or facility assuming care of the patient upon discharge."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,127378105,6]
[null,null,12,"133250406","Y",null,null,"",null,null,"133544006","133544006.7.1","Hospital","Non‐State Owned Public",null,null,null,"136332705",193,"Access to Specialty Care Services","Use telemedicine/telehealth to deliver specialty services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,208,null,null,null,12,"133250406",{"$f":"IF('Intervention Details'!$D$12=AX210,MAX(AZ$2:AZ209)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,193,"We will be signing a secondary contract to have the specialists available via telemedicine so they can aid in the care plans of the patients and consult with the hospitalist to ensure positive outcomes for the patient. They will have access to live patient data via secure access to our EMR so they can make informed decisions about the patients care.",null,null,null,null,1,null,null,null,"We will be purchasing new software to facilitate the access to telemedicine to ensure patient care and safety. We will also be reconfiguring 1 to 2 computers on wheels to make available to the medical care group placed in charge of the patients care. This will allow them to securely communicate with the specialist to develop a care plan and discharge plan."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-113",null,null,null,null,null,null,null,null,null,null,null,null,null,130618504,3]
[null,null,12,"133544006","Y",null,null,"",null,null,"136142011","136142011.7.1","Hospital","Non‐State Owned Public",null,null,null,"138708601",194,"Access to Primary Care Services","Integrated physical and behavioral health care services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,209,null,null,null,12,"133544006",{"$f":"IF('Intervention Details'!$D$12=AX211,MAX(AZ$2:AZ210)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,194,"Identify clients with chronic illnesses (e.g. screening for HbA1c, BMI, blood pressure) to establish appropriate treatment plans and provide follow up services to monitor treatment effectiveness.",null,null,null,null,1,null,null,null,"Screen all eligible clients for chronic conditions (diabetes, obesity, hypertension, and substance use) and, if present, provide follow up services to monitor symptoms."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,130725806,4]
[null,null,12,"136142011","Y",null,null,"",null,null,"136330112","136330112.7.1","Hospital","Non‐State Owned Public",null,null,null,"138708601",195,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,210,null,null,null,12,"136142011",{"$f":"IF('Intervention Details'!$D$12=AX212,MAX(AZ$2:AZ211)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,195,"Identify clients with needs assessed through routine screening; ensuring follow up and supports are provided with a focus on improving overall quality of care and positive health outcomes.","Develop a care coordination model and process across all levels of care.",null,null,null,2,null,null,null,"Provide patient education to identify symptoms and conditions associated with their assessed needs: substance use disorder, chronic care conditions, mental illness."," "," "," "," ",1,1,0,0,0,0,null,"In preparation for state-wide implementation of the CCBHC model as the standard for Texas Community Centers, care coordination guidelines, risk stratification, and other tools will be developed."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-268",null,null,null,null,null,null,null,null,null,null,null,null,null,130826407,3]
[null,null,12,"136330112","Y",null,null,"",null,null,"136492909","136492909.7.1","Hospital","Non‐State Owned Public",null,null,null,"138708601",196,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,211,null,null,null,12,"136330112",{"$f":"IF('Intervention Details'!$D$12=AX213,MAX(AZ$2:AZ212)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,196,"Identify clients with chronic illnesses for associated screening: HbA1c test, BMI, Blood Pressure.",null,null,null,null,1,null,null,null,"Screen all eligible clients for chronic conditions and, if present, provide follow up services to monitor symptoms."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-269",null,null,null,null,null,null,null,null,null,null,null,null,null,133250406,3]
[null,null,12,"136492909","Y",null,null,"",null,null,"137227806","137227806.7.1","Hospital","Non‐State Owned Public",null,null,null,"160709501",197,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,212,null,null,null,12,"136492909",{"$f":"IF('Intervention Details'!$D$12=AX214,MAX(AZ$2:AZ213)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,197,"Care coordination  for patients suffering from diabetes and related complications/comorbidities",null,null,null,null,1,null,null,null,"Care coordination guidelines will be integrated within the clinic to allow for patients to have opportunities to receive guidance and resourses.  These would enable care coordinators to better manage the patients current conditions that would require education and/or follow-up care."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-272",null,null,null,null,null,null,null,null,null,null,null,null,null,133544006,3]
[null,null,12,"137227806","Y",null,null,"",null,null,"137245009","137245009.7.1","Hospital","Private",null,null,null,"160709501",198,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,213,null,null,null,12,"137227806",{"$f":"IF('Intervention Details'!$D$12=AX215,MAX(AZ$2:AZ214)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,198,"Follow-up protocols for patients post screenings and assessments.",null,null,null,null,1,null,null,null,"Follow-up protocols are being improved on to ensure that patients are receiving all necessary screenings."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-280",null,null,null,null,null,null,null,null,null,null,null,null,null,136142011,3]
[null,null,12,"137245009","Y",null,null,"",null,null,"137343308","137343308.7.1","Hospital","Private",null,null,null,"160709501",199,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,214,null,null,null,12,"137245009",{"$f":"IF('Intervention Details'!$D$12=AX216,MAX(AZ$2:AZ215)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,199,"Increased patient engagement through enhanced services.",null,null,null,null,1,null,null,null,"Increasing availability to clinicians will provide opportunities to drive patients to the right care settings according to the patients' presented conditions. This will be conducted through telephonic or telemedicine capabilities to provide increased clinician availability to those seeking help."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-389",null,null,null,null,null,null,null,null,null,null,null,null,null,136330112,3]
[null,null,12,"137343308","Y",null,null,"",null,null,"137999206","137999206.7.1","Hospital","Non‐State Owned Public",null,null,null,"160709501",200,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,215,null,null,null,12,"137343308",{"$f":"IF('Intervention Details'!$D$12=AX217,MAX(AZ$2:AZ216)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,200,"Referral and follow-up processes for patients determined to have or in risk of developing cancer",null,null,null,null,1,null,null,null,"Referral and follow-up protocols are being assessed to determine the effectiveness of patient communication and service turnaround"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C1-502",null,null,null,null,null,null,null,null,null,null,null,null,null,136492909,2]
[null,null,12,"137999206","Y",null,null,"",null,null,"139461107","139461107.7.1","Hospital","Private",null,null,null,"160709501",201,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,216,null,null,null,12,"137999206",{"$f":"IF('Intervention Details'!$D$12=AX218,MAX(AZ$2:AZ217)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,201,"A process for ensuring patient receives steroids and determining what method of delivery will be pursued (vaginal vs. C-section).",null,null,null,null,1,null,null,null,"Constant review of antenatal steroid metrics and C-section rates as it pertains to the MFM patient population to determine if better cross communication can be obtained regarding delivery of management of services."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C2-106",null,null,null,null,null,null,null,null,null,null,null,null,null,137227806,5]
[null,null,12,"139461107","Y",null,null,"",null,null,"189947801","189947801.7.1","Hospital","Non‐State Owned Public",null,null,null,"160709501",202,"Chronic Care Management","Utilization of evidence‐based care management models for patients with complex needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,217,null,null,null,12,"139461107",{"$f":"IF('Intervention Details'!$D$12=AX219,MAX(AZ$2:AZ218)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,202,"Improved care coordination with primary and specialist physicians, ancillary services and various care settings  ",null,null,null,null,1,null,null,null,"Through the establishment of a pediatric multispecialty clinic, patients will see multiple providers within the same setting, promoting care management discussions with primary care physicians and specialists. Additionally, through care coordination, patients will be guided in their condition management and triage episodes of care to the appropriate care settings."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C2-107",null,null,null,null,null,null,null,null,null,null,null,null,null,137245009,9]
[null,null,12,"189947801","Y",null,null,"",null,null,"197063401","197063401.7.1","Hospital","Private",null,null,null,"343698201",203,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,218,null,null,null,12,"189947801",{"$f":"IF('Intervention Details'!$D$12=AX220,MAX(AZ$2:AZ219)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,203,"Educate patients regarding benefits of screenings and preventive care",null,null,null,null,1,null,null,null,"Schedule more mobile clinic outings to make care more accessible"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"C2-186",null,null,null,null,null,null,null,null,null,null,null,null,null,137343308,3]
[null,null,12,"197063401","Y",null,null,"",null,null,"308032701","308032701.7.1","Hospital","Private",null,null,null,"343698201",204,"Access to Specialty Care Services","Improvement in access to specialty care services with the concentration on underserved areas","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,219,null,null,null,12,"197063401",{"$f":"IF('Intervention Details'!$D$12=AX221,MAX(AZ$2:AZ220)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,204,"Increase the number of specialty providers by hiring more SOM faculty",null,null,null,null,1,null,null,null,"Develop specialty fellowships to attract and retain more providers"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-108",null,null,null,null,null,null,null,null,null,null,null,null,null,137999206,38]
[null,null,12,"308032701","Y",null,null,"",null,null,"316076401","316076401.7.1","Hospital","Private",null,null,null,"343698201",205,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of mobile clinics that can provide access to BH care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,220,null,null,null,12,"308032701",{"$f":"IF('Intervention Details'!$D$12=AX222,MAX(AZ$2:AZ221)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,205,"Increase use of mobile clinic to provide more access in underserved areas",null,null,null,null,1,null,null,null,"Schedule more mobile clinic outings to make care more accessable"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-211",null,null,null,null,null,null,null,null,null,null,null,null,null,139461107,28]
[null,null,12,"316076401","Y",null,null,"",null,null,"322879301","322879301.7.1","Hospital","Private",null,null,null,"020844901",218,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,221,null,null,null,12,"316076401",{"$f":"IF('Intervention Details'!$D$12=AX223,MAX(AZ$2:AZ222)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,218,"Early recognition of hemorrhage in the pregnant patient          ","Address lack of adequate prenatal care.    ","Reduce unnecessary elective deliveries prior to 39 weeks","Timely intervention of the hemorrahage in the pregnant patient",null,4,null,null,null,"Utilize drills and simulation to ensure proficiency in assigning hemorrhage risk and response to maternal hemorrhage. This change idea is designed to supplement the nurses’ annual review, identify opportunities for improvement and ensure there is a clear understanding of role responsibilities during an actual event."," "," "," "," ",1,1,0,0,0,0,null,"Educate all Women’s Services Associates and Providers on the Severe Hypertensive bundle to evaluate and respond appropriately to the signs and symptoms of hypertension and pre-eclampsia"," "," "," "," ",1,1,0,0,0,0,null,"Ensure that providers are educated and following processes to utilize algorithm requiring Physician Department Chair and Women’s Services Director approval prior to scheduling elective deliveries. Infants born at 37 weeks of gestation do not fare as well as infants born at 39 weeks of gestation and have higher rates of short-term complications.  Additionally, women who have had prior cesarean deliveries are at higher risk for uterine rupture. This change idea is designed to reduce elective inductions which will help to reduce the risk and need for additional cesareans.  "," "," "," "," ",1,1,0,0,0,0,null,"Implement code for Mass Transfusion Protocol (MPT) at each of Santa Rosa’s campuses. ","Maintain and improve a drill team to ensure regular drilling of the post-partum hemorrhage process. This change idea is designed to ensure that Santa Rosa’s providers are trained to timely intervene when hemorrhage is present.","Educate providers regarding Obstetrical Hemorrhage Protocol and ensure processes are followed to timely intervene in post-partum hemorrhage cases "," "," ",3,1,1,1,0,0,null,null,"",""," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-212",null,null,null,null,null,null,null,null,null,null,null,null,null,189947801,3]
[null,null,12,"322879301","Y",null,null,"",null,null,"350190001","350190001.7.1","Hospital","Private",null,null,null,"020844901",219,"Prevention and Wellness","Other","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,222,null,null,null,12,"322879301",{"$f":"IF('Intervention Details'!$D$12=AX224,MAX(AZ$2:AZ223)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,219,"Reducing adverse drug events","Prevent Hospital Acquired Pressure Ulcers                                            ","Prevent Hospital Acquired Infections                                                                 ",null,null,3,null,null,null,"Maintain and improve the multi-disciplinary pain management team to continue providing tools for the healthcare team that aid in reducing adverse drug events, such as over-sedation."," "," "," "," ",1,1,0,0,0,0,null,"Encourage patient turning every two hours through turning schedules and getting patients up and moving as often as possible."," "," "," "," ",1,1,0,0,0,0,null,"Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections.","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance. "," "," ",3,1,1,1,0,0,null,"",""," "," "," ",0,0,0,0,0,0,null,null,"",""," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-237",null,null,null,null,null,null,null,null,null,null,null,null,null,197063401,14]
[null,null,12,"350190001","Y",null,null,"",null,null,"020989201","020989201.7.1","Hospital","Non‐State Owned Public",null,null,null,"020844901",694,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,223,null,null,null,12,"350190001",{"$f":"IF('Intervention Details'!$D$12=AX225,MAX(AZ$2:AZ224)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,694,"Reducing adverse drug events                                                                             ","Prevent Hospital Acquired Pressure Ulcers                                                           ","Prevent Hospital Acquired Infections                                                                              ",null,null,3,null,null,null,"Maintain and improve the multi-disciplinary pain management team to continue providing tools for the healthcare team that aid in reducing adverse drug events, such as over-sedation.","","","","",1,1,0,0,0,0,null,"Encourage patient turning every two hours through turning schedules and getting patients up and moving as often as possible.","","","","",1,1,0,0,0,0,null,"Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections.","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance. ","","",3,1,1,1,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-271",null,null,null,null,null,null,null,null,null,null,null,null,null,281514401,5]
[null,null,13,"020989201","Y",null,null,"",null,null,"022793601","022793601.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"020844903",220,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,224,null,null,null,13,"020989201",{"$f":"IF('Intervention Details'!$D$12=AX226,MAX(AZ$2:AZ225)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,220,"Address lack of adequate prenatal care","Reduce unnecessary elective deliveries prior to 39 weeks","Early recognition of hemorrhage                                                                                                                    ","Timely intervention of the hemorrhage                                                                                              ",null,4,null,null,null,"Update and expand educational programs in place for physician offices and health departments of prenatal care through the expansion of Maternal Fetal Medicine Clinics (MFMs), pursuit of Maternal Levels of Care Designation and exploring additional opportunities for growth through the TexasAIM cohort. This change idea is designed to improve provider training and education, which will address lack of adequate prenatal care in CHofSA’s community."," "," "," "," ",1,1,0,0,0,0,null,"Ensure that providers are educated and following processes to utilize algorithm requiring OB in Chief and Women’s Services Director approval prior to scheduling elective deliveries.  Infants born at 37 weeks of gestation do not fare as well as infants born at 39 weeks of gestation and have higher rates of short-term complications.  Additionally, women who have had prior cesarean deliveries are at higher risk for uterine rupture. This change idea is designed to reduce elective inductions which will help to reduce the risk and need for additional cesareans.  "," "," "," "," ",1,1,0,0,0,0,null,"Ensure nursing and physicians have access to education on early recognition of hemorrhage.  This change idea is designed to boost the skill sets of physicians and nurses and to improve CHofSA’s OB Hemorrhage Patient Safety Measure."," "," "," "," ",1,1,0,0,0,0,null,"Maintain and improve the post-partum hemorrhage code (“Mass Transfusion Protocol”) to notify all providers needed in post-partum hemorrhage cases. The MTP is a component of the Hemorrhage code. Early recognition and intervention is key to preventing worsening hemorrhage. The MTP is activated if the patient has dire need of multiple transfusions."," Implement and maintain a drill team to ensure regular drilling of the post-partum hemorrhage process. This change idea is designed to ensure that CHofSA’s providers are trained to timely recognize and  intervene when hemorrhage is present."," Provide ongoing education to providers regarding Obstetrical Hemorrhage Protocol and ensure processes are followed to timely intervene in post-partum hemorrhage cases. "," "," ",1,1,0,0,0,0,null,null,"",""," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-284",null,null,null,null,null,null,null,null,null,null,null,null,null,308032701,3]
[null,null,13,"022793601","Y",null,null,"",null,null,"091770005","091770005.7.1","Hospital","Non‐State Owned Public",null,null,null,"020844903",221,"Hospital Safety and Quality","Implementation of evidence-based practices to improve quality of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,225,null,null,null,13,"022793601",{"$f":"IF('Intervention Details'!$D$12=AX227,MAX(AZ$2:AZ226)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,221,"Prevent Hospital Acquired Pressure Ulcers","Reduce adverse drug events","Prevent Hospital Acquired Infections                                                                                    ",null,null,3,null,null,null,"Conduct regular reviews of nursing sensitive indicators and frequent skin assessments to identify high risk patients for Hospital acquired pressure ulcers. ",""," "," "," ",1,1,0,0,0,0,null,"Improve processes utilized by the multi-disciplinary team to identify tools to reduce adverse drug events"," "," "," "," ",1,1,0,0,0,0,null,"Continue work through TST program for hand hygiene compliance and measurement using lean six sigma methods to hardwire hand hygiene.  Hand hygiene is a great way to prevent infections; however, studies show that on average, healthcare providers clean their hands less than half of the times they should.  This change idea is designed to promote hand hygiene compliance to prevent hospital acquired infections. ","Continue to evaluate and deep dive any HAI to determine whether hand hygiene could have prevented the HAI and share findings with Infection Prevention teams in order to prevent similar events in the future.","Provide additional patient and family education on how hand hygiene prevents infections and continue to evaluate additional ways to increase patient and family compliance"," "," ",3,1,1,1,0,0,null,null," "," "," "," ",0,0,0,0,0,0,null,null,"",""," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-400",null,null,null,null,null,null,null,null,null,null,null,null,null,316076401,3]
[null,null,13,"091770005","Y",null,null,"",null,null,"109483102","109483102.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"085144601",209,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,226,null,null,null,13,"091770005",{"$f":"IF('Intervention Details'!$D$12=AX228,MAX(AZ$2:AZ227)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,209,"In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.","Manage a targeted population of diabetes patients that are at high risk for developing complications, co-morbidities, and have a history or potential high utilization of acute and emergency services.","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for closing diabetes care gaps: eye exam, foot exam, A1C, blood pressure, BMI.",null,null,3,null,null,null,"Population Health Management Team will conduct pre-visit chart review using the diabetes registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for diabetes care and maintenance.","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review diabetes care gaps."," "," ",3,1,1,1,0,0,null,"Using a diabetes registry built in the electronic medical health record, identify and contact patients with gaps in care for diabetes screenings and/or follow up care.","Provide diabetes self-management education to engage patients as health care partners in identifying risk factors by self-monitoring of foot health, glucose, and blood pressure.","Use diabetes registry information to identify social determinants that contribute to poorly controlled diabetes","Work collaboratively to develop practice wide standard work protocols for Diabetes Care Management."," ",4,1,1,1,1,0,null,"Create standard work processes for diabetes bundle measure that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94092602,"D1-503",null,null,null,null,null,null,null,null,null,null,null,null,null,322879301,2]
[null,null,13,"109483102","Y",null,null,"",null,null,121781205,"121781205.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",210,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,227,null,null,null,13,"109483102",{"$f":"IF('Intervention Details'!$D$12=AX229,MAX(AZ$2:AZ228)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,210,"Using care gap registry built in electronic health medical record, identify and educate patients with a BMI out of range (Normal Parameters:  Age 65 years and older BMI >= 23 and < 30 Age 18  64 years BMI >= 18.5 and < 25), patients identified as tobaco users, and patients who received HbA1c testing during the measurement year.","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for identifying, monitoring, and caring for patients with out of range BMI, A1C, or use tobacco.","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.",null,null,3,null,null,null,"Provide patient with self-management education to engage patients as health care partners in identifying risk factors for those with out of range BMI, A1C, or tobacco use.","Practices will review use of tobacco (of any type) from patient  social history (via the report) and determine if intervention was performed if positive for tobacco use.","Determine percentage of patients who received intervention if positive for tobacco use","Practices will review to determine if last Hgb A1c measurment was documented within the past year and determine percentage of patients who received an HbA1c."," ",4,1,1,1,1,0,null,"Create standard work processes for preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," ",2,1,1,0,0,0,null,"Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management.","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review preventative measures in the prevention of heart disease, diabetes, and effects of tobacco use."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-124",null,null,null,null,null,null,null,null,null,null,null,null,null,350190001,3]
[null,null,13,121781205,"Y",null,null,"",null,null,"121806703","121806703.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",211,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,228,null,null,null,13,121781205,{"$f":"IF('Intervention Details'!$D$12=AX230,MAX(AZ$2:AZ229)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,211,"Using patient care gap registry built in electronic medical health record and the SAIRS registry, identify patients who may be due for Pneumonia, Influenza HPV vaccinations or Chlamydia screening.","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.",null,null,null,2,null,null,null,"Using patient data, identify, contact, confirm patients who may qualify for immunizations/screening.","Proactively attempt to obtain and record out medical records for immunizations or screenings received outside UT Health."," "," "," ",2,1,1,0,0,0,null,"Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide preventative education related to immunizations and screenings.","Population Health Management Team will follow up with post visit activities to ensure patient received immunizations, provided outside records, or completed screenings, determine understanding of visit instructions, and next steps for their care plan.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for upcoming appointments and review immunization and screening status."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-141",null,null,null,null,null,null,null,null,null,null,null,null,null,20989201,3]
[null,null,13,"121806703","Y",null,null,"",null,null,"130089906","130089906.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",212,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,229,null,null,null,13,"121806703",{"$f":"IF('Intervention Details'!$D$12=AX231,MAX(AZ$2:AZ230)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,212,"Manage a targeted population of patients with a blood pressure outside of the goal (<140/90), and monitor those on statin therapy that are at high risk for developing complications or co-morbidities, thus reducing heart failure admission rate and reducing the rate of Emergency Department visits for CHF, Angina, and Hypertension.","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for closing heart disease care gaps \t\t\t\t\t\t\n","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.  \t\t\t\t\t\t",null,null,3,null,null,null,"Using a patient registry built in the electronic medical health record, identify and contact patients that have had a blood pressure that is out of goal range or is on statin therapy\t\t\t\t\t\t","Provide hypertension self-management education to engage patients as health care partners in identifying risk factors of heart disease. \t\t\t\t\t\t","Create the ability for a patient to self monitor and report blood pressrue readings in My Chart, a secured patient portal with results directly forwarded to primary care physician.\t\t\t\t\t"," "," ",3,1,1,1,0,0,null,"Create standard work processes for heart disease bundle measure that will be assigned, worked and validated by a designated primary care clinical practice. \t\t\t\t\t\t\n","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices.  \t\t\t\t\t\t\n"," "," "," ",2,1,1,0,0,0,null,"Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management \t\t\t\t\t\t\n","Population Health Management Team will follow up with post visit activities to ensure patient attended scheduled appointments, completed screenings, determine understanding of visit instructions, and next steps for their care plan.\t\t\t\t\t\t\n","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Practice Team to review patient status for upcoming appointments and review heart disease care gaps   \t\t\t\t\t\t\n"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-217",null,null,null,null,null,null,null,null,null,null,null,null,null,22793601,2]
[null,null,13,"130089906","Y",null,null,"",null,null,"130616909","130616909.7.1","Hospital","Non‐State Owned Public",null,null,null,"085144601",213,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,232,null,null,null,13,"130089906",{"$f":"IF('Intervention Details'!$D$12=AX232,MAX(AZ$2:AZ231)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,213,"Utilize PHQ 2 screning tool at every visit and PHQ 9 screening tool when warranted to determine a diagnosis of clinical depression and care plan for diagnosis.","Determine care plan for patients diagnosed with PHQ9 <9","Identify patients whose behavioral health is not in remission","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan for identification and management of behavioral health conditions.","In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy.",5,null,null,null,"Through our EMR, EPIC, utilize a PHQ-2, which progresses to PHQ-9 if score is greater than 0","PCP provided counseling, will re-assess next visit; PCP provided medication adjustment/consult, will re-assess next visit; referral to BHC; refer to PCC Psychiatry; Refer to external Psychiatry; Refer to external Psychotherapy;","To identify remission at 6 months, track patients with a diagnosis of MDD or dysthymia AND initial PHQ-9 score 10+","Consult with Primary Care Physician to make follow up calls to patients."," ",4,1,1,1,1,0,null,"Create behavioral health professional standard work to follow up 2x per month"," "," "," "," ",1,1,0,0,0,0,null,"Create standard work process for behavioral health professionals to manage and change course for treatment  that is not improving condition of the patient.","Create standard work process and training of all clinical staff for identification and management of suicide risk."," "," "," ",2,1,1,0,0,0,null,"Create standard work processes for behaviroal health preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.","To develop consistency of standard work across the enterprise, standard work processes mastered in assigned clinical practices will be shared and training provided to each of the other clinical practices."," "," "," ",2,1,1,0,0,0,null,"Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient or clinic regarding PHQ2 and PHQ9 screenings and follow up actions based on results.","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Pracrice Team to review patient status for behavioral health screenings and follow up care plan."," "," "," ",2,1,1,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-252",null,null,null,null,null,null,null,null,null,null,null,null,null,91770005,3]
[null,null,13,"130616909","Y",null,null,"",null,null,"137226005","137226005.7.1","Hospital","Private",null,null,null,"085144601",214,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,233,null,null,null,13,"130616909",{"$f":"IF('Intervention Details'!$D$12=AX233,MAX(AZ$2:AZ232)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,214,"In an effort to increase time with patients during office visits, build upon relationship centered care, and improve patient experience, work collaboratively with Population Health Management Team (PHMT) in determining In Reach and Out Reach activities with a Pre-Visit/Visit/Post-Visit strategy\t\t\t\t\t\n","Using care gap registry built in electronic medical health record, identify patients that are in need of critical screenings or have had screening with no follow up documented\t\t\t\t","Create a Measure Bundle Task Force consisting of Chairs, Medical Directors, Practice Managers, Quality and Operations Leadership to best determine strategic plan to promote critical and prevenative cancer screenin]\t\t\t\t\t\t\n",null,null,3,null,null,null,"Identify patients:  Women 21-64 who have a cervix and have not had cervical cytology in the last 3 years or co-testing in the past 5 year\t\t\n","Identify patients:  50-75 years of age who have not had:                                                                                               -Fecal occult blood test (FOBT) during the measurement year. \n- Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n- Colonoscopy during the measurement year or the nine years prior to the measurement year.\t\t\t\t\t\n","Identify patients: Women 50-74 who have breasts and have not had a mammogram ( no time period is specified\t\t\t\t\n"," "," ",3,1,1,1,0,0,null,"Create standard work processes for preventative measures that will be assigned, worked and validated by a designated primary care clinical practice.\t\t\t\t\t\t\n"," "," "," "," ",1,1,0,0,0,0,null,"Population Health Management Team will follow up with post visit activities to ensure follow up appointments scheduled and attended, outside records provided, screenings completed, determine understanding of visit instructions, and next steps for their care plan.\t\t\t\t\t\t\n","Daily huddle calls will take place between dedicated Population Health Management Team and Clinical Practice Team to review patient status for the completion of preventative cancer screenin. \t\t\t\t\t\t\n","Population Health Management Team will conduct pre-visit chart review using the care gap registry and outreach to patient in an effort to synchronize care provided, review care gaps, collect external records, schedule appointments, and provide education for heart disease, medication, and therapy management\t\t\t\t\n"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-253",null,null,null,null,null,null,null,null,null,null,null,null,null,109483102,2]
[null,null,13,"137226005","Y",null,null,"",null,null,"179272301","179272301.7.1","Hospital","Private",null,null,null,"085144601",215,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,234,null,null,null,13,"137226005",{"$f":"IF('Intervention Details'!$D$12=AX234,MAX(AZ$2:AZ233)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,215,"Screen all patients, aged 18 years and older for unhealthy alcohol use with systematic method, at every visit. \t\t\t\t\t\t\n",null,null,null,null,1,null,null,null,"If score of 4 or more (men) or 3 or more (women), discuss and gauge readiness to change drinking habits.\t\t\t\t\t\t\n","If readiness is not determined, indicate that's okay and if they change their minds, we have resources to help (provide written info).  If readiness is determined, provide information on available resources to help (provide written info); Alert PCP.\t\t\t\t\t\n"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-287",null,null,null,null,null,null,null,null,null,null,null,null,null,121781205,3]
[null,null,13,"179272301","Y",null,null,"",null,null,"206083201","206083201.7.1","Hospital","Private",null,null,null,"085144601",216,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,235,null,null,null,13,"179272301",{"$f":"IF('Intervention Details'!$D$12=AX235,MAX(AZ$2:AZ234)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,216,"Work collaboratively with Primary Care and Behavioral Health to determine symptoms, level of impairment, other psychiatric disorders, and child's strengths in coping\t\t\t\t\t\t\n",null,null,null,null,1,null,null,null,"Conduct diagnostic interviews with patient and parents\t\t\t\t\t\t\n","Conduct physical exam of child along with review of psychological and lab tests\t\t\t\t\t\t\n","Use parent and teacher rating scale to further assess the presence of ADHD\t\t\t\t\t\t\n"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94148602,"B1-352",null,null,null,null,null,null,null,null,null,null,null,null,null,121806703,3]
[null,null,13,"206083201","Y",null,null,"",null,null,316360201,"316360201.7.1","Hospital","Private",null,null,null,"085144601",217,"Substance Use Disorder","Utilization of Prescription Drug Monitoring program","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,236,null,null,null,13,"206083201",{"$f":"IF('Intervention Details'!$D$12=AX236,MAX(AZ$2:AZ235)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,217,"Monitoring and follow up of pain medication use, documentation, pain assessment and follow up, and Opioid Therapy evaluation and follow up.",null,null,null,null,1,null,null,null,"Screen for depression and address positive screens using PHQ2 and 9.","Inquire about pain score and document plan of action for results","Eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94164302,"B2-242",null,null,null,null,null,null,null,null,null,null,null,null,null,130089906,7]
[null,null,13,316360201,"Y",null,null,"",null,null,322916301,"322916301.7.1","Hospital","Private",null,null,null,"091308902",222,"Prevention and Wellness","Implementation of interventions focusing on social determinants of health","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,237,null,null,null,13,316360201,{"$f":"IF('Intervention Details'!$D$12=AX237,MAX(AZ$2:AZ236)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,222,"Establish effective relationships/communication with program clients.","Identify client barriers that accelerate encounters with law enforcement and establish alternatives by connecting the client with community resources.",null,null,null,2,null,null,null,"Establish weekly contact with program clients to document progress towards improved social well-being and address ongoing concerns and challenges."," "," "," "," ",1,1,0,0,0,0,null,"Develop a standardized list of community resources that can be made available to clients for addressing social determinants of health."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94164302,"B2-392",null,null,null,null,null,null,null,null,null,null,null,null,null,130616909,5]
[null,null,13,322916301,"Y",null,null,"",null,null,"081939301","081939301.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"091308902",223,"Prevention and Wellness","Implementation of evidence based strategies to reduce sexually transmitted diseases","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,238,null,null,null,13,322916301,{"$f":"IF('Intervention Details'!$D$12=AX238,MAX(AZ$2:AZ237)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,223,"Increase the utilization of mobile clinics to enhance access to services.","Provision of follow up services for individuals at risk of re-infection for Syphilis and un-complicated Gonorrhea.",null,null,null,2,null,null,null,"Utilize Metro Health's Mobile Health Unit to provide sexual health screenings, education and on the spot treatment for patients at high risk of contracting and/or spreading sexually transmitted infections.","Develop a routine testing schedule based on incidence rates of STD/HIV in Bexar County and ensure schedule is easily accessible to the public."," "," "," ",2,1,1,0,0,0,null,"Establish a standardized clinic protocol for conducting follow up calls to remind individuals who have tested positive for and were treated for Gonorrhea and primary or secondary Syphilis to return for follow up testing at the recommended intervals."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-103",null,null,null,null,null,null,null,null,null,null,null,null,null,137226005,17]
[null,null,14,"081939301","Y",null,null,"",null,null,"112684904","112684904.7.1","Hospital","Non‐State Owned Public",null,null,null,"091308902",224,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,239,null,null,null,14,"081939301",{"$f":"IF('Intervention Details'!$D$12=AX239,MAX(AZ$2:AZ238)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,224,"Screen clients for tobacco use and identify individuals who are tobacco users who require tobacco education/resources.","Establish appropriate referral networks for tobacco cessation services for adolescents and adults who identify as tobacco users.",null,null,null,2,null,null,null,"Implement a standardized screening tool for Metro Health clinics."," "," "," "," ",1,1,0,0,0,0,null,"Develop provider materials to be distributed at clinics."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-105",null,null,null,null,null,null,null,null,null,null,null,null,null,179272301,3]
[null,null,14,"112684904","Y",null,null,"",null,null,"112711003","112711003.7.1","Hospital","Private",null,null,null,"091308902",225,"Expansion or Enhancement of Oral Health Services","Utilization of targeted dental intervention for underserved population in alternate setting","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,240,null,null,null,14,"112684904",{"$f":"IF('Intervention Details'!$D$12=AX240,MAX(AZ$2:AZ239)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,225,"Improve access to dental services for children with unmet dental needs. ","Incorporate case management services for children identified as having urgent or unmet dental needs beyond the scope of the program.",null,null,null,2,null,null,null,"Provide limited oral health evaluations, sealants and fluoride varnish applications to school aged children. "," "," "," "," ",1,1,0,0,0,0,null,"Partner with Dental Managed Care organizations to help link families to a main dental home. "," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-115",null,null,null,null,null,null,null,null,null,null,null,null,null,206083201,3]
[null,null,14,"112711003","Y",null,null,"",null,null,"127298107","127298107.7.1","Hospital","Non‐State Owned Public",null,null,null,"091308902",695,"Access to Primary Care Services","Provision of vaccinations to target population","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,241,null,null,null,14,"112711003",{"$f":"IF('Intervention Details'!$D$12=AX241,MAX(AZ$2:AZ240)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,695,"Identify individuals who have not been vaccinated for influenza.",null,null,null,null,1,null,null,null,"All patients who come to the clinic for immunizations services will be screened to determine if they have been immunized against influenza.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-147",null,null,null,null,null,null,null,null,null,null,null,null,null,316360201,3]
[null,null,14,"127298107","Y",null,null,"",null,null,"135235306","135235306.7.1","Hospital","Non‐State Owned Public",null,null,null,"094154402",226,"Access to Specialty Care Services","Use telemedicine/telehealth to deliver specialty services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,242,null,null,null,14,"127298107",{"$f":"IF('Intervention Details'!$D$12=AX242,MAX(AZ$2:AZ241)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,226,"Timely delivery of tPA to eligible patients (delivery within 60 minutes of arrival).",null,null,null,null,1,null,null,null,"Provide training programs and resource materials to \"Spoke\" facilities that their administration and medical staff can use to develop treatment protocols."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-211",null,null,null,null,null,null,null,null,null,null,null,null,null,322916301,3]
[null,null,14,"135235306","Y",null,null,"",null,null,"136143806","136143806.7.1","Hospital","Non‐State Owned Public",null,null,null,"094154402",227,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of telehealth/telemedicine in delivering behavioral services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,243,null,null,null,14,"135235306",{"$f":"IF('Intervention Details'!$D$12=AX243,MAX(AZ$2:AZ242)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,227,"Improve timeliness of treatment for Behavioral Health patients presenting in the Emergency Department.","Provide outpatient services for those patients who have not yet identified a permanent behavioral health provider.",null,null,null,2,null,null,null,"Expand the Behavioral Health Assessment Referral Center capability to further improve throughput and timeliness of treatment."," "," "," "," ",1,1,0,0,0,0,null,"Establish an outpatient transition clinic to provide post-discharge care for patients within seven days of discharge to bridge needed care."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-259",null,null,null,null,null,null,null,null,null,null,null,null,null,81939301,9]
[null,null,14,"136143806","Y",null,null,"",null,null,"138364813","138364813.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"094154402",228,"Chronic Care Management","","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,244,null,null,null,14,"136143806",{"$f":"IF('Intervention Details'!$D$12=AX244,MAX(AZ$2:AZ243)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,228,null,null,null,null,null,0,null,null,null,null," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-260",null,null,null,null,null,null,null,null,null,null,null,null,null,402628801,3]
[null,null,14,"138364813","Y",null,null,"",null,null,"176354201","176354201.7.1","Hospital","Non‐State Owned Public",null,null,null,"094154402",229,"Other","Other","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,245,null,null,null,14,"138364813",{"$f":"IF('Intervention Details'!$D$12=AX245,MAX(AZ$2:AZ244)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,229,"Decrease CLABSI rates through focus on maintenance protocols, insertion criteria, and removal of CLABSI catheters.","Decrease Catheter Associated Urinary Tract Infection (CAUTI) rates through focus on protocols to reduce the number of Foley Catheters.","Improve sepsis metrics through focus on evidence based order sets, appropriate device use to optimize fluid administration, and regular communication to Emergency Department medical leadership.","Improve maternal outcomes through reduction of Cesarean Section Rate.",null,4,null,null,null,"Share best practices for central line management and appropriate utilization."," "," "," "," ",1,1,0,0,0,0,null,"Develop protocols for catheter removal as well as those for appropriate insertion in the Emergency Department."," "," "," "," ",1,1,0,0,0,0,null,"Monitor sepsis bundle performance and other key metrics such as timely delivery of antibiotics through Sepsis dashboard reports."," "," "," "," ",1,1,0,0,0,0,null,"Develop campus action plans for reduction and communicate expectations to medical staff."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-261",null,null,null,null,null,null,null,null,null,null,null,null,null,112684904,3]
[null,null,14,"176354201","Y",null,null,"",null,null,"065086301","065086301.7.1","Local Health Department (LHD)","Non‐State Owned Public",null,null,null,"094154402",696,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,246,null,null,null,14,"176354201",{"$f":"IF('Intervention Details'!$D$12=AX246,MAX(AZ$2:AZ245)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,696,"Decrease CLABSI rates through focus on maintenance protocols, insertion criteria, and removal of CLABSI catheters.","Decrease Catheter Associated Urinary Tract Infection (CAUTI) rates through focus on protocols to reduce the number of Foley Catheters.","Improve sepsis metrics through focus on evidence based order sets, appropriate device use to optimize fluid administration, and regular communication to Emergency Department medical leadership.","Improve internal and external interdisciplinary communication processes to improve throughput.",null,4,null,null,null,"Share best practices for central line management and appropriate utilization.","","","","",1,1,0,0,0,0,null,"Develop protocols for catheter removal as well as those for appropriate insertion in the Emergency Department.","","","","",1,1,0,0,0,0,null,"Monitor sepsis bundle performance and other key metrics such as timely delivery of antibiotics through Sepsis dashboard reports.","","","","",1,1,0,0,0,0,null,"Develop facility interdisciplinary teams to include hospitalists, facility chief medical officers, pharmacy, radiology, and respiratory therapy to review processes affecting LOS metrics.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-265",null,null,null,null,null,null,null,null,null,null,null,null,null,112711003,17]
[null,null,15,"065086301","Y",null,null,"",null,null,"084597603","084597603.7.1","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public",null,null,null,"094154402",697,"Maternal and Infant Health Care","Implement standard protocols for the leading causes of preventable death and complications","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,247,null,null,null,15,"065086301",{"$f":"IF('Intervention Details'!$D$12=AX247,MAX(AZ$2:AZ246)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,697,"Improve maternal outcomes through reductions of the Casarean Section rate.",null,null,null,null,1,null,null,null,"Develop campus action plans for reduction and communicate expectations to medical staff.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-319",null,null,null,null,null,null,null,null,null,null,null,null,null,127298107,5]
[null,null,15,"084597603","Y",null,null,"",null,null,"094109802","094109802.7.1","Hospital","Private",null,null,null,"112688004",232,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,248,null,null,null,15,"084597603",{"$f":"IF('Intervention Details'!$D$12=AX248,MAX(AZ$2:AZ247)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,232,"Update processes within the ED to improve transfer communication and medication reconciliation.","Educate patients on appropriate use of ED and primary care services.Patients do not know where to seek appropriate care.",null,null,null,2,null,null,null,"Include topics in regular staff meeting agendas.","Provide staff training on appropriate EMR documentation.","Provide real-time staff training during patient care visit.","Conduct daily audits of documentation."," ",4,1,1,1,1,0,null,"Provide educational materials to patients","Provide list of alternatives for urgent care"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-340",null,null,null,null,null,null,null,null,null,null,null,null,null,135235306,33]
[null,null,15,"094109802","Y",null,null,"",null,null,"127376505","127376505.7.1","Community Mental Health Center (CMHC)","Non‐State Owned Public",null,null,null,"112742503",234,"Behavioral Health Crisis Stabilization Services","Implement models supporting recovery of individuals with behavioral health needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,249,null,null,null,15,"094109802",{"$f":"IF('Intervention Details'!$D$12=AX249,MAX(AZ$2:AZ248)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,234,"Mitigate patient risk factors to increase patient support",null,null,null,null,1,null,null,null,"The first change idea for improving follow-up care at the 7 day/30 day mark is peforming a focused patient risk assessment","The second change idea for improving follow-up care at the 7 day/30 day mark is contacting the patient within 72-hours after discharge to understand how the patient and family is doing with their coping skills, medication management and compliance with other medical orders and appointments."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,96166602,"M1-341",null,null,null,null,null,null,null,null,null,null,null,null,null,136143806,21]
[null,null,15,"127376505","Y",null,null,"",null,null,"130601104","130601104.7.1","Hospital","Private",null,null,null,"112742503",235,"Behavioral Health Crisis Stabilization Services","Implement models supporting recovery of individuals with behavioral health needs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,250,null,null,null,15,"127376505",{"$f":"IF('Intervention Details'!$D$12=AX250,MAX(AZ$2:AZ249)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,235,"Develop a tool kit of HIPPA documents, Clarity CGC patient needs and other supports to meet with key community providers in strategic areas of our county (as we know close to home is important to our patients and their compliance to appointments) to help engage their support and services.",null,null,null,null,1,null,null,null,"Engage our community relations team to consistently meet with these providers to help them stay engaged and understand and address concerns."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112671602,"E2-150",null,null,null,null,null,null,null,null,null,null,null,null,null,136145310,3]
[null,null,16,"084859002","Y",null,null,"",null,null,"111829102","111829102.7.1","Hospital","Private",null,null,null,"121782006",241,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,256,null,null,null,16,"084859002",{"$f":"IF('Intervention Details'!$D$12=AX256,MAX(AZ$2:AZ255)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,241,"The use of the patient registry will help improve clinical care and support diabetes self-management education.",null,null,null,null,1,null,null,null,"Use the patient registry to help identify social / environmental factors that contribute to a patients poorly-controlled diabetes.","Use the patient registry to help integrate physical and behavioral health to improve health of people with diabetes and behavioral health issues."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112671602,"J1-221",null,null,null,null,null,null,null,null,null,null,null,null,null,127376505,16]
[null,null,17,"020841501","Y",null,null,"",null,null,"020860501","020860501.7.1","Hospital","Private",null,null,null,"133257904",245,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,263,null,null,null,17,"020841501",{"$f":"IF('Intervention Details'!$D$12=AX263,MAX(AZ$2:AZ262)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,245,"Good communication between care teams and patients to support patient engagement in making lifestyle changes."," No formal process for assessment of patient functioning/quality of lide at admission and discharge",null,null,null,2,null,null,null,"Consistently review current patient education/counseling practices, processes intervention approaches."," "," "," "," ",1,1,0,0,0,0,null,"Implement and routinely assess functional status/quality of life through a standardized measurement tool"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,131030203,"A1-500",null,null,null,null,null,null,null,null,null,null,null,null,null,121792903,21]
[null,null,17,"311035501","Y",null,null,"",null,null,"326725404","326725404.7.1","Hospital","Private",null,null,null,"136141205",253,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,273,null,null,null,17,"311035501",{"$f":"IF('Intervention Details'!$D$12=AX273,MAX(AZ$2:AZ272)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,253,"Improve documentation in the electronic health record.","Assess immunization education materials and promote education about vaccinations among staff, providers, and patients. ",null,null,null,2,null,null,null,"Potential improvements include data entry standardization, reviewing/updating standard operating procedures as needed, and staff training."," "," "," "," ",1,1,0,0,0,0,null,"Ensure appropriate distribution of education materials and implement/continue education activities to inform staff, providers, and patients about the importance of providing/receiving recommended vaccinations."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,135222109,"M1-305",null,null,null,null,null,null,null,null,null,null,null,null,null,135226205,3]
[null,null,19,"135034009","Y",null,null,"",null,null,"135237906","135237906.7.1","Hospital","Private",null,null,null,"159156201",268,"Prevention and Wellness","Other","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,289,null,null,null,19,"135034009",{"$f":"IF('Intervention Details'!$D$12=AX289,MAX(AZ$2:AZ288)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,268,"Increase hand hygiene compliance throughout system.",null,null,null,null,1,null,null,null,"Increase hand hygiene observations with wide-spread secret shopper program.","Unit directors monitor and report out on hand foam usage each month.","Provide hand wipes for patients at the bedside to encourage patient hand hygiene"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,136367307,"M1-286",null,null,null,null,null,null,null,null,null,null,null,null,null,112707808,3]
[null,null,20,"137917402","Y",null,null,"",null,null,"162033801","162033801.7.1","Hospital","Private",null,null,null,"133542405",271,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,295,null,null,null,20,"137917402",{"$f":"IF('Intervention Details'!$D$12=AX295,MAX(AZ$2:AZ294)+1,0)","v":0},null,null,null,null,null,null,null,null,null,null,271,"Identify and address high-risk populations that have a demonstrated need for substance use or co-occurring services in order to drive targeted, evidence-based interventions.","Promote linkages to care post hospital inpatient discharge.","Expand access to routine mental health services within an integrated clinic setting.",null,null,3,null,null,null,"Implementation of risk stratification methods and population health management practices to conduct effective care coordination and to meaningfully impact health outcomes.",""," "," "," ",1,1,0,0,0,0,null,"Identification of patients in need of an inpatient visits or follow-up coordination post inpatient encounter.",""," "," "," ",1,1,0,0,0,0,null,"Expand access optimization efforts to increase the number of individuals who receive routine services after hours and on the weekends at integrated clinics.",""," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,138296208,"E1-235",null,null,null,null,null,null,null,null,null,null,null,null,null,135237906,14]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"307459301",280,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,306,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,280,"Develop competitive contracts that incentivizes the use of the whole care team.",null,null,null,null,1,null,null,null,"Improve behavioral health screening process to identify patients appropriate for referral to behavioral health care team.","Improve pain management screening and documentation."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,200683501,"K2-355"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"094119702",306,"Expansion of Patient Care Navigation and Transition Services","Expansion of access to medical advice and direction to the appropriate level of care","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,321,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,306,"Educate patients of the services we provide in this particular area\n",null,null,null,null,1,null,null,null,"make resources, signs, and open communications that can educate our community more on what services we offer and how to utilize them\n"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20817501,"J1-218"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"126844305",285,"Behavioral Health Crisis Stabilization Services","Implement models supporting recovery of individuals with behavioral health needs","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,327,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,285,"Coordinate training for at least 500 staff, school personnel and community members for the early identification and intervention of behavioral health symptoms.  Updated October 2018.","Expand access to Certified Peer Specialists, Veteran Peers, Family Partners and Peer Recovery Coaches by hiring at least one new peer support position per year, or by collaborating with a partner to provide this service.  Updated October 2018.","Explore new and strengthen existing models for supporting recovery by fortifying or adding at least one new recovery-focused, peer-led curriculum, project, or program per year.  Updated October 2018.",null,null,3,null,null,null,"Provide at least three trainings per year to educate law enforcement, school personnel, emergency departments and emergency responders on BTCS available service array.  Updated October 2018.  ","Provide Mental Health First Aid (MHFA and YMHFA) and Applied Suicide Intervention Skills Training (ASIST) to at least 400 people per year.  Updated October 2018."," "," "," ",2,1,1,0,0,0,null,"Increase access to peer support and family partner services during crisis stabilization and follow-up by dedicating at least one position for this purpose during DY7.  Updated October 2018.  ","Participate on the Texas HHSC Peer Support Stakeholder Workgroup at least once per month until its conclusion to define the scope of peer support, along with training, certification and supervision requirements.  Updated October 2018."," "," "," ",2,1,1,0,0,0,null,"Measure progress outcomes for individuals involved in Assertive Community Treatment by the end of Demonstration Year 8.  Updated October 2018.","Expand the availability of substance use services in acute crisis units by adding at least one onsite (in-person or televideo) substance use service per year at an Extended Observation Unit or Respite Center.  Updated October 2018.","Continue to develop financial sustainability for the adult transitional homes through a comprehensive sustainability assessment by the end of Demonstration Year 7, which includes strategies for implementation in DY8.  Updated October 2018."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20834001,"B1-141"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"020943901",315,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,345,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,315,"Implement CLASBI evidence based care bundle components","Improve early identification of sepsis and early directed goal therpay for surgical patients.","Compliance with basic standards of urinary catheter care","STOP SSI bundle procedures to reduce surgical site infections in cardiac, hip and knee surgical patients",null,4,null,null,null,"Implement standardized checklist for insertion for actions pre-insertions, during and post-insertion","make available a standard CVC kit to ensure optimal products used (foley, dressings, CHG)","Implement daily review of necessity for central line and protocols for removal"," "," ",3,1,1,1,0,0,null,"Screen patient pre and post surgical procedure to identify sepsis symptoms."," "," "," "," ",1,1,0,0,0,0,null,"implement standardized best practice insertion techniques for urinary catheters","Improve aherence to nurse protocol for shift assessment of catheter need and removal per protocol"," "," "," ",2,1,1,0,0,0,null,"improve pre-surgical screening for Staphylococcus aurea (SA) to idenify patients postive for MSSA or MRSA","improve compliance with decolonization of SA for positive screened patients with nasal mupirocin and CHG bathing prior to surgical procedures"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20834001,"H2-160"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"020979302",327,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,353,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,327,"STOP SSI bundle procedures to reduce surgical site infections in cardiac , hip and knee surgical patients","Compliance with basic standard of urinary catheter care","Implement CLASBI evidence based care bundle components","Improve compliance with hourly nurse rounding to address 4 P's(potty, position, pain and possession) to reduce patient falls","Improve early identification of sepsis and early directed goal therpay for surgical patients.",5,null,null,null,"implement pre-surgical screening for Staphylococcus aureua(SA) to identify patients postive for MSSA or MRSA","improve compliance with decolonization of SA for positive screened patients with nasal mupirocin and CHG bathing prior to surgical procedures"," "," "," ",2,1,1,0,0,0,null,"implement standardize  best practice insertion techniques for urinary catheter","Enhance adherance to nurse protocol for shift assessment of catheter need and removal per protocol","implement appropriate CAUTI workup with reflex testing protocols"," "," ",3,1,1,1,0,0,null,"implement standardized checklist for insertion  for actions pre-insertation , during and and post insertion","make available a  standard CVC kit to ensure optimnal products used (foley, dressings and CHG)","implement daily review of necessity for central line and protocols for removal"," "," ",3,1,1,1,0,0,null,"Post weekly audits in units."," "," "," "," ",1,1,0,0,0,0,null,"Screen patient pre and post surgical procedure to identify sepsis symptoms."," "," "," "," ",1,1,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20834001,"H2-510"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"111905902",331,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,359,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,331,"Compliance with basic standard of urinary catheter care","STOP SSI bundle procedures to reduce surgical site infections in cardiac , hip and knee surgical patients","Implement CLASBI evidence based care bundle components","Improve compliance with hourly nurse rounding to address 4 P's(potty, position, pain and possession) to reduce patient falls","Improve early identification of sepsis and early directed goal therpay for surgical patients.",5,null,null,null,"implement standardize  best practice insertion techniques for urinary catheter","Enhance adherance to nurse protocol for shift assessment of catheter need and removal per protocol","implement appropriate CAUTI workup with reflex testing protocols"," "," ",3,1,1,1,0,0,null,"implement pre-surgical screening for Staphylococcus aureua(SA) to identify patients postive for MSSA or MRSA","improve compliance with decolonization of SA for positive screened patients with nasal mupirocin and CHG bathing prior to surgical procedures"," "," "," ",2,1,1,0,0,0,null,"implement standardized checklist for insertion  for actions pre-insertation , during and and post insertion","make available a  standard CVC kit to ensure optimnal products used (foley, dressings and CHG)","implement daily review of necessity for central line and protocols for removal"," "," ",3,1,1,1,0,0,null,"Post weekly audits in units."," "," "," "," ",1,1,0,0,0,0,null,"Screen patient pre and post surgical procedure to identify sepsis symptoms."," "," "," "," ",1,1,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,81522701,"M1-105"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"126686802",339,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,369,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,339,"Enhance the discharge process within the hospital to ensure appropriate transition of care",null,null,null,null,1,null,null,null,"Collaborate with IR to build a discrete documentation process for documenting within an External Appointment Field in the EMR system, giving the capability to schedule and document appointments that occur outside the system due to patient travel limitations, patient preference, or continuity of care. "," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,81522701,"M1-305"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"137252607",712,"Availability of Appropriate Levels of Behavioral Health Care Services","Provision of care aligned with Certified Community Behavioral Health Clinic (CCBHC) model","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,386,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,712,"Implement preventative care screenings and care protocols targeted towards impacting medical and behavioral health.",null,null,null,null,1,null,null,null,"Test standing order for behavioral health screenings.","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,93774008,"L1-207"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"138910807",359,"Availability of Appropriate Levels of Behavioral Health Care Services","Utilization of Care Management function that integrates primary and behavioral health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,392,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,359,"The BHCM will conduct a structured comprehensive assessment to assess various psychosocial domains and elicit information about the patients broader level of behavioral health functioning.  At the completion of the assessment, the BHCM, in collaboration with the family, will develop a care plan which includes the patient and familys behavioral goals, barriers to reaching these goals and strategies to address these barriers.  The care plan may include:  brief-short term psychotherapy sessions conducted in-person or virtually, to include the patient and the patients family, referrals to community resources if needed, and advocate with providers, school personnel or community resources.",null,null,null,null,1,null,null,null,"The assessment, the BH CM, in collaboration with the family, develops a care plan which includes the patient and familys behavioral goals, barriers to reaching those goals and strategies to address those barriers. The care plan may include: 1) brief-short term psychotherapy sessions conducted in-person or virtually between the BH CM, the patient and the patients family, focused on behavioral activation, motivational interviewing, psycho-educational counseling, cognitive-behavioral and solution-focused interventions. These interventions have demonstrated efficacy in short-term settings; 2) referrals to community resources (psychiatry, support groups, etc.), including regular telephonic follow-up phone calls to ensure the family has connected with the resources, the resources are meeting the familys needs, and the family is effectively working with on their care plan; 3) advocacy with providers, school personnel or community resources."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,93774008,"L1-347"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"391575301",713,"Hospital Safety and Quality","Implementation of standard protocols to address leading cause of hospital infections and injuries","DY9-10","Y","Y",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,402,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,713,"Falls protocols. Risk scale is built into EMR. Falls care plans are measures in place to minimize fall risk for patients in the hospital. ",null,null,null,null,1,null,null,null,"Addition of a Safety committee to review processes for driving PT Safety measures","","","","",1,1,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,"","","","","",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111810101,"A1-207"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"112677302",387,"Palliative Care","Transitioning of palliative care patients from acute hospital care to other settings","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,418,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,387,"Develop a plan for continuity of care and seamless transfer.  This plan will include all care provided by entity and recommended care plan post discharge/transfer.",null,null,null,null,1,null,null,null,"Work with appropriate receiving entity and/or patient and family to educate regarding the treatment plans and treatment preferences of the patient."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111810101,"C3-328"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"121794503",398,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,429,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,398,"Providing a mid-level provider to manage the chronic diseases (diabetes & heart disease) for these patients that generally have not had access to the appropriate level of care resulting in seeking routine care through the ED.",null,null,null,null,1,null,null,null,"Providing point of service lab testing which allows provider to adjust medications as needed."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111810101,"D1-503"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"126675104",402,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,433,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,402,"Improve the early detection of common health concerns through the use of standard screening tools/protocols.","Provide additional screening and follow up services for high risk population",null,null,null,2,null,null,null,"Standardize screening and follow-up processes across all care settings"," "," "," "," ",1,1,0,0,0,0,null,"Enhance the use of registries for high risk patients to track compliance with standard screening and follow-up protocols (this change idea is specific to H1 and H2)"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,111810101,"E1-300"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"130614405",418,"Chronic Care Management","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,450,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,418,"Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)",null,null,null,null,1,null,null,null,"Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112672402,"F1-227"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"136326908",429,"Chronic Care Management","Utilization of care management and/or chronic care management services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,463,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,429,"Locate CDSMP classes in low income, high need zip codes close to where patients live.",null,null,null,null,1,null,null,null,"Partner with key stakeholders in identified zip codes to address potential barriers to attending classes (i.e., child care)."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,112672402,"J1-220"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"136326908",432,"Chronic Care Management","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,466,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,432,"Must form collaborative networks to address social determinants of health (i.e., transportation, child care, access health food, etc.)",null,null,null,null,1,null,null,null,"Develop at least one program to address social determinants of heatlh (i.e., Garden on the Go, community gardens, etc.)"," Provider will establish one new external partner to address patients' SDOH needs (i.e., transportation, housing, mental health/counseling)."," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,113180703,"M1-105"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"314080801",384,"Chronic Care Management","Utilization of enhanced patient portal for management of chronic conditions","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,476,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,384,"The portal has limited bi-directional functionality from the patient perspective.  Utilization of the portal is low due to low visibility of the service.",null,null,null,null,1,null,null,null,"Work with IT to increase bi-directinoal functionality of the portal to allow patients to input helath information and track biometrics"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,113180703,"M1-261"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137074409,460,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,497,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,460,"Addition of a Patient Care Navigator to lead performance improvement activities following LEAN principles to improve overall coordination, documentation, and communication during transitions of care.",null,null,null,null,1,null,null,null,"Standardized transitions of care documents will be created and implemented.","CQI tools will be utilized by the Patient Care Navigator to drive improvements to ensure the standardized document is being completed accurately, timely, and communicated to receiving providers."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127300503,"B1-252"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"138644310",462,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,499,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,462,"Reduction of utilization of ED for preventable diabetes and also reduction in short/long term complication hospital admissions.  We also believe patients will be healthier and will be more compliant with their primary care provider's instructions.  Patients will be more educated and will make better choices.","eye exams, foot exams, tracking A1c and BP conttrol",null,null,null,2,null,null,null,"Implement policies in primary care clinics to register diabetic patients  for the various nutrition and educational classes. This will also help curb hospitilization for short and long term complications."," "," "," "," ",1,1,0,0,0,0,null,"By PCP's diligence to conduct and document eye and foot exams for diabetics and A1C and blood pressure control, there will be better follow up and management of diabetic patients that will lead to better health."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127300503,"B1-287"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"065100201",469,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,509,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,469,"Provide chlamydia screening for women 16-24 years of age, identified as sexually active to address critical need CN 9 identified in the community needs  assessment.","Provide tobacco screening and cessation counseling to identify adults ready to quit using and refer them for cessation services.","Provide patient follow-up and treatment tailored to each patient's need to increase latent tuberculosis treatment completion.",null,null,3,null,null,null,"Include routine chlamydia testing for all women 16-24 years of age, identified as sexually active."," "," "," "," ",1,1,0,0,0,0,null,"Incorporate tobacco screening and cessation counceling/referral for adults into all clinical services provided through public health."," "," "," "," ",1,1,0,0,0,0,null,"Incorporate TB nurse case management and support staff activities to encourage completion of latent tuberculosis treatment."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127303903,"B1-252"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"094129604",481,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,520,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,481,"1. For Identification: Improve the EMR to capture smoking individuals among the patient population, and improve the intake workflow proces","2. For Education: Improve capture of education on smoking cessation in the EMR, that communicates across the district",null,null,null,2,null,null,null,"Improvement of identification will occur through hard stops in the EMR through required fields","The EMR changes will be made so that the workflow is user friendly for the end user","Utilize EMR data to evaluate staff compliance of screening for tobacco use"," "," ",3,1,1,1,0,0,null,"Alter the EMR to allow providers a place to document the patient-provider education session","Educate providers on upcoming changes and required documentation","Utilize EMR data to evaluate staff compliance of counseling for tobacco cessation"," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,127303903,"J1-506"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"127374005",492,"Prevention and Wellness","Utilization of whole health peer support","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,532,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,492,"By providng these supports to our consumers who may use tobacco or have a high BMI, it gives our consumers an opportunity to make changes to their lifestyle that will improve their overall phyisical health.",null,null,null,null,1,null,null,null,"Peers will provide improved access to primary care.","Peers will provide improved access to  tobacco cessation programs.","Peers will provide improved access to  whole health support groups.","r MH peer support services will seek to refer individuals identified as having a BMI that is too high to medical services, exercise activities and support."," ",4,1,1,1,1,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,133355104,"B1-124"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"136142011",504,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,542,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,504,"The first Secondary Driver for the above Core Activity is education, which will be accomplished through outreach initiatives with the school system, senior citizen organizations, businesses, civic groups, churches, and shut-ins (such but not limited to Meals on Wheels recipients).",null,null,null,null,1,null,null,null,"Increase outreach by communication, marketing and networking with the Dimmitt ISD families through the school nurses and specifically targeting senior citizen groups."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,133355104,"D1-108"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"139461107",516,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,556,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,516,"Idenitfying patients with recorded high blood pressure without a follow-up appointment",null,null,null,null,1,null,null,null,"Review pursuit list to identify targeted group and do proactive outreach to schedule an appointment with the patient"," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,133355104,"G1-277"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"109483102",527,"Prevention and Wellness","Implementation of strategies to reduce tobacco use","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,570,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,527,"Learn about how professional support and advice can make a difference in a quit attempt when combined with other strategies.","Provide information on quitting tobacco with the help of nicotine replacement therapy.","Explore the feasibility of prescribing quit smoking medications on a case by case basis.",null,null,3,null,null,null,"Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the U.S. Dept. of Health and Human Services CDC “Tips From Former Smokers” campaign to educate patients ready to make a quit attempt on the five reasons why calling a “quit line” can be the key to long term “quit” success. ",null," "," "," ",1,1,0,0,0,0,null,"Psychiatric Nurse Practitioners at the clinics will provide and discuss information from the website smokefree.gov in order to educate patients ready to make a quit attempt on: using nicotine replacement therapy to quit, the types of nicotine replacement therapy available and myths about nicotine replacement therapy.  ",null,null," "," ",1,1,0,0,0,0,null,"For patients ready to make a quit attempt, Psychiatric Nurse Practitioners at the clinics will discuss the types of quit smoking medications that are available and appropriate based on each person’s mental health diagnoses and recovery plan goals. During the appointment the practitioner and patient will make collaborative medication decisions in an effort to support a quit attempt. ","Try the anti-smoking medication Zyban (if appropriate for patient) as a change idea to test the secondary driver."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137805107,"B1-252"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"081939301",542,"Maternal and Infant Health Care","Other","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,583,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,542,"Timeliness of prenatal and postnatal care for women",null,null,null,null,1,null,null,null,"From an instiution stand point we are implemetning care coordinators in order to better track and forewarn providers of potential issues if possible."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137805107,"F2-224"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"127298107",551,"Chronic Care Management","Management of targeted patient populations with high risk for developing complications","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,592,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,551,"Provider and staff education","Patient education",null,null,null,2,null,null,null,"Schedule and conduct group and individual hands-on training session and providing template handouts. We have recently converted our E H R system which still has problematic areas."," "," "," "," ",1,1,0,0,0,0,null,"Print out and discuss with patients disease and patient specific education materials from our software addition."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137805107,"H2-510"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"065086301",558,"Expansion of Patient Care Navigation and Transition Services","Provision of services to individuals that address social determinants of health","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,602,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,558,"Improve availability and access to preventive services.",null,null,null,null,1,null,null,null,"Establishing a coordinated patient navigation process within health deparment's system and external collaboratos will increase services for clients/patients already accessing preventive care. Thus, a standardized referral interview will also require increasing services offered within existing health department' s clinics as this will be the window of opportunity to identifying other care needs. For example, a person coming in for a sexually transmitted disease test may also require provision of vaccines such as the Human Papilloma Virus or  identified as needing a cervical cancer screening.  The added services and coordinated navigation process would serve two-fold with added services and one stop shop for client/patient to receive all services during same visit or be referred to partner healtcare provider if service is not available within health department system.","Integrate a patient care coordinator/navigator within clinics to help implement process and directly assist clients/patients during their visit.  The coordinator/navigator will develop a resource directory and cross-training between programs such as the health education, 2-1-1 call center, laboratory, and all three clinics (HIV, STD, dental). This will help bridge health department's programs with city deparments including library, fire, parks and recreation, and community development as well as external healthcare providers. Building patient care navigation capacity will also improve follow-up resources to assure quality of services and continuum of care after internal and external screenings in case of abnormal results.","Add one to two health screening services to existing clinics including but not limited to cervical cancer screening, tobacco cessation, body mass index screening and controlling high blood pressure that are identified during the referral interview as needed screenings."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137909111,"C1-269"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"138951211",570,"Access to Primary Care Services","Provision of vaccinations to target population","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,616,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,570,"Target specific patient population that are due for vaccines","Educate Patients on Vaccines and Recommendations according to age group(s)",null,null,null,2,null,null,null,"Partner with a vendor to identify and contact patients who are out of compliance with their Adult immunizations."," "," "," "," ",1,1,0,0,0,0,null,"Design, Train and implement vaccination education according to recommendations by the state HHSC."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,137949705,"H2-510"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"138951211",578,"Patient Centered Medical Home","Integration of care management and coordination for high‐risk patients","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,624,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,578,"Design and execute systematic out-reach to targeted patient populations",null,null,null,null,1,null,null,null,"Automated Telephony messages to targeted patient populations."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,139135109,"D1-389"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"138951211",588,"Palliative Care","Other","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,634,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,588,"Develop customized plan of care based on beliefs and values as assessed.",null,null,null,null,1,null,null,null,"Automated belief and values assessment and plan of care."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,139135109,"D4-375"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"134772611",603,"Expansion of Patient Care Navigation and Transition Services","Enhancement in coordination between primary care, urgent care, and Emergency Departments","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,649,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,603,"Provide better education to the patient prior to discharge related to medications, diagnosis and follow-up needed.  The discharge process has been improved to include certain types of information as required by the measure specifications.",null,null,null,null,1,null,null,null,"The clinic scheduling department granted access to the emergency department to schedule appointments for patients before they were discharged from the emergency department which has improved the number of patients who are seen for follow-up care."," "," "," "," ",1,1,{"$f":"IF(OR(LEFT(BV643,1)=$BT$1,LEFT(BV643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BW643,1)=$BT$1,LEFT(BW643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BX643,1)=$BT$1,LEFT(BX643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(BY643,1)=$BT$1,LEFT(BY643,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CH643,1)=$BT$1,LEFT(CH643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CI643,1)=$BT$1,LEFT(CI643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CJ643,1)=$BT$1,LEFT(CJ643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CK643,1)=$BT$1,LEFT(CK643,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(CT643,1)=$BT$1,LEFT(CT643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CU643,1)=$BT$1,LEFT(CU643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CV643,1)=$BT$1,LEFT(CV643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(CW643,1)=$BT$1,LEFT(CW643,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DF643,1)=$BT$1,LEFT(DF643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DG643,1)=$BT$1,LEFT(DG643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DH643,1)=$BT$1,LEFT(DH643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DI643,1)=$BT$1,LEFT(DI643,1)=\"\"),0,1)","v":0},null," "," "," "," "," ",0,0,{"$f":"IF(OR(LEFT(DR643,1)=$BT$1,LEFT(DR643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DS643,1)=$BT$1,LEFT(DS643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DT643,1)=$BT$1,LEFT(DT643,1)=\"\"),0,1)","v":0},{"$f":"IF(OR(LEFT(DU643,1)=$BT$1,LEFT(DU643,1)=\"\"),0,1)","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,139135109,"G1-362"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"081844501",610,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,661,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,610,"Utilize assessment data to drive decisions supporting best strategies to make life style changes.",null,null,null,null,1,null,null,null,"Provide referrals and educational materials regarding nutrition, tobacco use and/or substance use.","Recommend life style modifications to clients as a preventative approach."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,158771901,"L1-211"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"135226205",619,"Expansion of Patient Care Navigation and Transition Services","Implementation of a care transition and/or a discharge planning program","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,667,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,619,"Reducing Stigma/Raising Awareness around the importance of cancer screening and early detection  ",null,null,null,null,1,null,null,null,"Provide educational pamphlets and reminders via phone/text about importance of preventive services/cancer screenings in primary care "," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,158771901,"L1-280"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"160630301",625,"Expansion of Patient Care Navigation and Transition Services","Utilization of a comprehensive intervention to address the needs of high‐risk patients","DY7-8","N","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,673,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,625,"Create a Transition of Care Clinic to implement improvements in care transitions and coordination of care for any patient identified as high risk.  Priority will be given to those patients who have Medicaid and are unfunded.  It will be run by either a medical group physician or nurse practitioner that will be rotated out on a routine basis.",null,null,null,null,1,null,null,null,"Patient identified in hospital through LACE scores and the 8P Screening Tool to be high-risk and Payor method as Medicaid or unfunded and elevated to clinic by nursing staff and/or physician referral.  Other payors will be referred as appointments are available.","Patient appointment made and given when patient is still inpatient and will occur within 72 hours after discharge.","Medication reconciliation from discharge medication list completed and identify compliance barriers for medication compliance.","Assist in scheduling follow up appointments with specialist and primary care physicians and identifying community resources.","Fax labs, tests results, and discharge summary to primary care and specialty physicians.",5,1,1,1,1,1,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,181706601,"H2-216"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"084434201",641,"Access to Primary Care Services","Provision of screening and follow up services","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,693,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,641,"Screen individuals seeking behavioral health services for Body Mass Index (BMI)","Screen individuals seeking behavioral heatlh services for tobacco use","Screen individuals seeking behavioral health services for unhealthy alcohol use.",null,null,3,null,null,null,"Incorporate screening tool for BMI into Provider Psychiatric Evaluation Progress Note","Incorporate adherence monitoring to ensure Psychiatric Evaluations are completed with individuals seeking behavioral health services including the BMI assessment tool"," "," "," ",2,1,1,0,0,0,null,"Incorporate screening tool for tobacco use into an Initial Treatment Plan","Incorporate adherence monitoring to ensure Treatment Plans are completed with individuals seeking behavioral health services including the tobacco use tool."," "," "," ",2,1,1,0,0,0,null,"Incorporate screening tool for unhealthy alcohol use into an Initial Treatment Plan","Incorporate adherence monitoring to ensure Treatment Plans are completed with individuals seeking behavioral health services including the unhealth alcohol use tool"," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,296760601,"L1-115"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"283637101",648,"Maternal and Infant Health Care","Implementation of evidence-based strategies to reduce low birth weight and preterm birth","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,699,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,648,"Effectively link women with any needed specialty or other primary care.\n",null,null,null,null,1,null,null,null,"Evaluate the referral report from the referral-out source and do a follow-up with the patient and referral office as indicated\n","If no report is received based on expected appointment date and expected report date, conduct a follow up call with the patient and the referral source.\n","Continuously assess value and benefits of referral and treatment networks."," "," ",3,1,1,1,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,311054601,"K1-285"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"127373205",654,"Prevention and Wellness","Implementation of evidence-based strategies to empower patients to make lifestyle changes","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,712,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,654,"Create screening questions to identify patient needs.",null,null,null,null,1,null,null,null,"Provide counseling, education and training related to alcohol and tobacco use.","Provide counseling on weight management, physical activity, and nutrition."," "," "," ",2,1,1,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20973601,"H2-319"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"137917402",674,"Prevention and Wellness","Self‐management programs and wellness programs using evidence‐based designs","DY7-10","Y","N",null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,725,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,674,"Disease Self-Management Education for individuals with Diabetes and Hypertension.","Enhancement of patient referral process from the clinics to the Disease Self-Management program.",null,null,null,2,null,null,null,"Education that targets the importance of disease prevention, medical homes, chronic disease treatment compliance.","Instruction on dietary and lifestyle changes to prevent and or improve health outcomes of individuals with hypertension and diabetes diagnoses."," "," "," ",2,1,1,0,0,0,null,"Increased DSM referral policy adherance by the clinical team that includes, physicians, mid-level providers, nurses, medical assistants, and clerks."," "," "," "," ",1,1,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null," "," "," "," "," ",0,0,0,0,0,0,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,80368601,"M1-147"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94118902,"A2-210"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,94118902,"J1-221"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,121775403,"C1-502"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,121775403,"E1-235"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,121775403,"H2-160"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,121808305,"K2-359"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,132812205,"A1-207"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,132812205,"B2-392"]
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{"sheet":"Cat B System Master","index":10,"n_rows":1390,"n_cols":13,"rows_kept":1390,"cut":false,"hidden":true,"merged":[]}
["Project ID","RHP","TPI","Performing Provider Name","Performing Provider Type","Ownership","Business Component","Required/Optional","Included in System Definition (Y/N)?","DY9-10 Description of System Component","Updated?","Date Revised?","Additional HHSC Notes\n(from other DSRIP processes)"]
["330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","TMC Bonham Hospital is a 25-bed critical access hospital with a medical staff that includes both primary care and specialty physicians. The facility is a Critical Access Hospital, offering both inpatient and outpatient services along with 24-hour emergency services.  Also, TMC Bonham also operates a Swing Bed Program that offers around-the-clock care for patients transitioning between an acute care hospital stay and discharge to home. The Swing Bed Program provides 24-hour skilled nursing care plus the benefit of rehabilitation. Services include specialized wound care, IV antibiotic therapy, physical therapy, occupational therapy, speech therapy and education/monitoring of new medications."]
["330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department at TMC Bonham Hospital is open 24 hours a day, seven days a week to treat patients. The facility has a skilled staff to treat patients with emergency medical care, emergency surgery, cardiac care, stroke care and respiratory services along with all other urgent care needs.  Our Emergency Department is a Texas-approved Level 3 Support Stroke Facility.  TMC Bonham provides resuscitation, stabilization and assessment of stroke victims and either provides the treatment or arranges for immediate transfer to a higher level of stroke care.   Also, the Texas Department of Health Services has designated TMC Bonham as a Level IV Trauma Facility. That means the hospital can provide resuscitation, stabilization and assessment of injured patients and either provides treatment or arranges for appropriate transfer to a higher level designated trauma facility. "]
["330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Bonham Specialty Clinic is located directly across the street from our hospital. The clinic is open Monday through Thursday from 8 a.m. to 5 p.m. and Friday from 8 a.m. to noon.  We specialize in family practice medicine, including women’s health screenings, school physicals, annual checkups, chronic disease management including diabetes, men’s health screening, worker’s compensation cases, general health issues and podiatry. "]
["330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["330811601.7.1",1,"330811601","Fannin County Hosp Auth dba TMC Bonham Hosp","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138365512.7.1",1,"138365512","Andrews Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","As a Community Mental Health Center, home-based services are a business component that provides opportunities for our population to obtain behavioral and mental health services in their own home or community.  Our core mental health services are designed to treat Bipolar Disorder, Major Depression, and Schizophrenia.  Additional behavioral health services include Autism Outreach and Intellectual and Developmental Disabilities (IDD).  Andrews Center employs well-trained behavioral health care professionals who are equipped with a wide variety of abilities. They are trained to address many types of mental health, primary care, and community issues.\n"]
["138365512.7.1",1,"138365512","Andrews Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","As a Community Mental Health Center, office/clinic is a business component that provides behavioral health and primary care outpatient services within the physical confines of our offices and clinics throughout our service area.  Andrews Center emphasizes a holistic approach to caring for our clients.  In addition to our core behavioral therapies, we provide integrated primary care services to improve the overall health of our population and reduce the need for costly hospital services.  All of our services and locations strive to improve the overall health of our patient population, including our Medicaid and low-income or uninsured (MLIU) clients."]
["017624011.7.1",1,"017624011","Quitman Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital."]
["017624011.7.1",1,"017624011","Quitman Hospital LLC","Hospital","Private","Emergency Department","Required","Y","All services provided within the ED."]
["017624011.7.1",1,"017624011","Quitman Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided at the East Texas Physicians Quitman, Mineola, and Grand Saline. "]
["017624011.7.1",1,"017624011","Quitman Hospital LLC","Hospital","Private","Maternal Department","Required","N",""]
["017624011.7.1",1,"017624011","Quitman Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patients may be admitted to the hospital."]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Emergency Department","Required","Y","Tyler has two ED locations. This system component will be all services provided at the main ED and the South Tyler ED."]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","UT Health Tyler (formerly ETMC) operates UT Health Behavioral Health Center."]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Maternal Department","Required","Y","All services provided in the maternal department. "]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020812601.7.1",1,"020812601","Tyler Regional Hospital LLC","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Diabetes and Primary Care managed at East Texas Physicians Group at 6210 S. Broadway (family & internal medicine), 2210 Three Lakes Pkwy., (family & internal medicine), 1000 E. Fifth Street (endocrinology), 1000 E. Fifth Street (internal medicine), 435 N. Doctor M Roper Parkway- Bullard (family medicine), 125 Hwy. 31 East - Chandler (family medicine),  406 E. Hwy 243- Canton, 18118 FM 344 - Flint (family medicine), 2416 S. Main (family medicine) / 14069 FM 849 - HAWL, and 602 Hwy. 110 North - Whitehouse (family medicine)"]
["094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private","Inpatient Services","Required","Y","This includes CHRISTUS Trinity Mother Frances Hospital - Tyler; Jacksonville, Winnsboro, and South Tyler."]
["094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private","Emergency Department","Required","Y","This includes the Emergency Departments at CHRISTUS Trinity Mother Frances Hospital - Tyler; Jacksonville, Winnsboro, South Tyler, and Canton.","Y","2020-07-27"]
["094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This includes all the clinics attached to the hospitals and CHRISTUS Trinity Clinic legacy locations including those in Jacksonville and Winnsboro and the Tyler market and with the new addition of the Palestine clinic."]
["094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private","Maternal Department","Required","Y","Hospitals located in Tyler, Jacksonville, and Winnsboro have maternal departments but not the South Tyler location."]
["094108002.7.1",1,"094108002","Mother Frances Hospital Regional Healthcare Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","We only have one Urgent Care Clinic."]
["094127002.7.1",1,"094127002","Carthage Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital."]
["094127002.7.1",1,"094127002","Carthage Hospital LLC","Hospital","Private","Emergency Department","Required","Y","All services provided within the ED."]
["094127002.7.1",1,"094127002","Carthage Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided at the three 3 East Texas Physicians Carthage RHC clinics."]
["094127002.7.1",1,"094127002","Carthage Hospital LLC","Hospital","Private","Maternal Department","Required","N",""]
["094127002.7.1",1,"094127002","Carthage Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["111411803.7.1",1,"111411803","Anderson Cherokee Community MHMR Center (ACCESS)","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Services are provided in the homes of individuals served and at other locations in the community selected by the individuals and families served. Populations served in home-based services include adults and youth with a mental and/or emotional illness and adults and youth having an intellectual and/or developmental disability. Services include evidence-based skills training to promote independent living in the community and improved quality of life and also include supportive employment and housing assistance, service coordination."]
["111411803.7.1",1,"111411803","Anderson Cherokee Community MHMR Center (ACCESS)","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Clinic services are offered 8 am to 5 pm Monday through Friday in each County (Anderson and Cherokee) to adults and youth with a mental and/or emotional illness and to adults and youth having an intellectual and/or developmental disability. Services include medication related services provided by psychiatrists and nurse practitioners, lab services, short-term counseling and behavior therapy by licensed counselors, service coordination, skills training, Youth Empowerment Services (YES Waiver), prescription assistance programs, peer support,  benefits assistance, services to veterans and military families, family education, supportive employment and housing services, outreach and referrals, supported living assistance, day habilitation, Community First Choice services for Medicaid recipients with disabilities. Outpatient substance abuse assessments and counseling are available for adults. After hours services include access to crisis services including 24/7 crisis hotline and availability of a Mobile Crisis Outpatient Team (MCOT) which assess crises, makes referrals as needed and/or provides support services.  Fees for services are charged based on an “ability to pay” basis with a sliding fee schedule and charges to Medicaid and other 3rd party insurers. "]
["112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private","Inpatient Services","Required","Y","Hospitals in Longview and Marshall with 574 beds - General acute care services that include medical, surgical, intermediate care, and intensive care."]
["112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private","Emergency Department","Required","Y","Level III and Level IV Trauma  Centers, freestanding Emergency Centers."]
["112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Multi-specialty clinic that includes primary care, cardiology, and surgical specialties. Legacy clinics and additions in the Longview ministry which are clinics generally Gregg, Harrison, Panola, and Upshur Counties."]
["112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private","Maternal Department","Required","Y","Longview Hospital has a maternal department and a NICU."]
["112667403.7.1",1,"112667403","The Good Shepherd Hospital dba Good Shepherd Medic","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","One location that provides services 7 days a week and 11 hours per day."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","All primary care clinics owned and operated by the University of Texas Health Science Center at Tyler."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","All specialty care clinics owned and operated by the University of Texas Health Science Center at Tyler."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","Y","Hospital owned and operated by the University of Texas Health Science Center at Tyler."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Specialty Clinics","Optional","Y","UTHSCT will contract with CHRISTUS St. Michael Texarkana to use Genesis Primecare Texarkana Obstetrics Clinic."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Primary Care Clinics","Optional","Y","UTHSCT will contract with CHRISTUS St. Michael Texarkana to use Genesis Primecare Texarkana Primary Care Clinic."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Other - Tyler Junior College Dental Hygiene Clinic","Optional","Y","Tyler Junior College Dental Hygiene Clinic includes the main hygiene clinic located on campus along with \"Sealant Day\" clinics at local schools or outreach events. "]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Other - CHRISTUS St. Michael Texarkana Hospital","Optional","Y"," CHRISTUS St. Michael Texarkana Hospital is a 312 bed hospital located in Texarkana, TX.  "]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Other - CHRISTUS St. Michael Texarkana Emergency Department","Optional","Y","CHRISTUS St. Michael Emergency Department is a Level 3 Trauma Center located in Texarkana, TX."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Other - Genesis Primecare Texarkana Dental Clinic","Optional","Y","Genesis Primecare Texarkana is an FQHC with a full service dental clinic."]
["127278302.7.1",1,"127278302","University of Texas Health Center at Tyler","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Other-St. Paul Children's Foundation","Optional","Y","St. Paul Children's Foundation is a non-profit provider of medical and dental services for children in Tyler, TX."]
["130612806.7.1",1,"130612806","Jacksonville Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital."]
["130612806.7.1",1,"130612806","Jacksonville Hospital LLC","Hospital","Private","Emergency Department","Required","Y","All services provided within the ED."]
["130612806.7.1",1,"130612806","Jacksonville Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided at the East Texas Physicians Jacksonville, Frankston, and Rusk (RHC's)"]
["130612806.7.1",1,"130612806","Jacksonville Hospital LLC","Hospital","Private","Maternal Department","Required","Y","All services provided in the maternal department. "]
["130612806.7.1",1,"130612806","Jacksonville Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Hunt Regional Medical Center (HRMC) at Greenville is a short term acute care hospital licensed for 181 inpatient beds. During fiscal year 2017, HRMC had 32,194 inpatient days, 7,865 inpatient admissions, and 2,455 observation visits. Hunt Regional Medical Center provides the following inpatient services: Intensive Care, Telemetry- Stepdown, Telemetry- Observation, Medical/Surgical, and a Level III Neonatal Intensive Care Unit.   HRMC also operates an Acute Rehabilitation Unit. "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Hunt Memorial Hospital District (HMHD) operates 3 separate Emergency Departments (ED) in Hunt County. The Emergency Department at HRMC Greenville is a Level IV trauma center and provided 41,502 visits in FY 2017. Hunt Regional Emergency Medical Center at Commerce, a freestanding ED in northern Hunt County provided 9,873 visits and Hunt Regional Emergency Department at Quinlan, a freestanding ED in southern Hunt County provided 14,565 visits. "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","HMHD owns Hunt Regional Medical Partners (HRMP) who provide primary and specialty care in Hunt and Rains County. HRMP primary care sites include Internal Medicine in Greenville, Family Practice in Greenville and (2) Rural Health Clinics in Emory and Quinlan, Texas. HRMP specialty practices include general surgery, gastroenterology, neurology, urology, and orthopedic care. HMHD also operates an outpatient Transitional Behavioral Health Clinic to provide mental health stabilization and support for patients with urgent psychiatric needs until they are able to obtain follow-up care with a local mental health provider.  HRMC at Greenville provides outpatient transitional care for select high risk chronic condition patients in the Discharge Clinic. HRMC at Greenville operates an Outpatient Podiatry Clinic for uninsured patients needing podiatry follow-up. "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Women’s Center at Hunt Regional Medical Center Greenville provides labor and delivery, obstetrics, and newborn nursey services.  HRMC delivered 1,164 infants in FY 2017. "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Hunt Memorial Hospital District (HMHD) operates an urgent care clinic, QuickCare in Greenville. During FY 17 QuickCare provided 3,612 visits. "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Contracted Primary Care Clinics","Optional","Y","HMHD partners and contracts with the Greenville Community Health Service Agency, a designated Federally Qualified Health Center (FQHC) to increase primary care capacity in Hunt County.  "]
["131038504.7.1",1,"131038504","Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville","Hospital","Non‐State Owned Public","Other - Outpatient Ambulatory Services","Optional","Y","Hunt Memorial Hospital District (HMHD) operates the additional outpatient ambulatory services within our system: \n• Cardiac and Pulmonary Rehab \n• Cardiopulmonary and Sleep Lab \n• Diabetes Management \n• Day Surgery \n• Outpatient and Outreach Laboratory \n• Home Health- nursing, physical therapy, and occupational therapy\n• Wound Care/Hyperbarics  \n• Infusion Center \n• OP Behavioral Health at Commerce- individual and group therapy \n• Cancer Center- radiation \n• Diagnostic Imaging Centers (3) - X-ray, CT, MRI, ultrasound, mammography, interventional radiology, nuclear medicine \n• Cardiac Catheterization Lab \n• Outpatient Rehabilitation- physical, occupational, and speech therapy \n• Occupational Health \n• FIT Steps  (Cancer Rehab)\n"]
["137921608.7.1",1,"137921608","Sabine Valley Reg MHMR Ctr dba Community Healthcor","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The home-based services from this provider are mainly Early Childhood Intervention services.  Some other child and adult outpatient services occur within the home."]
["137921608.7.1",1,"137921608","Sabine Valley Reg MHMR Ctr dba Community Healthcor","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The largest system component is adult and child/adolescent mental health outpatient services. These services occur at roughly 10 different locations throughout the catchment area, either by stand-alone CHC offices or in partnership with other providers."]
["138360606.7.1",1,"138360606","Northeast Texas Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","N",""]
["138360606.7.1",1,"138360606","Northeast Texas Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","NET Health offers immunization services to all age groups on a walk-in bases. Our immunization department gives an average of 14,000 vaccines annually and ensures access to low cost immunization services. The department also includes the Tuberculosis Elimination Program that has approximately 2,000 visits per year. "]
["138360606.7.1",1,"138360606","Northeast Texas Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Other - Center for Healthy Living","Optional","Y","The Center for Healthy Living offers health education, cancer prevention, and health navigation services to the Smith County Community. It is staffed by 4 Community Health Workers and a Certified Health Education Specialist. "]
["138374715.7.1",1,"138374715","Pittsburg Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital."]
["138374715.7.1",1,"138374715","Pittsburg Hospital LLC","Hospital","Private","Emergency Department","Required","Y","All services provided within the ED."]
["138374715.7.1",1,"138374715","Pittsburg Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided at the East Texas Physicians Pittsburg RHC's: Pittsburg, Pittburg 2, and Mt Pleasant."]
["138374715.7.1",1,"138374715","Pittsburg Hospital LLC","Hospital","Private","Maternal Department","Required","N",""]
["138374715.7.1",1,"138374715","Pittsburg Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in our (Acute) Medical Surgical Unit, Behavior Health Unit, & Rehabilitation Unit."]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","All services in our Emergency Department."]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","All services in our outpatient Primary Care Clinic, Rural Health Clinic, Cardiology Clinic, Orthopedic Clinic, Neurology Clinic, Internal Medicine and Nephrology Clinic."]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","All services in our OB and Labor & Delivery Unit."]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138913209.7.1",1,"138913209","Titus County Memorial Hospital dba Titus Regional","Hospital","Non‐State Owned Public","Other - Outpatient Services","Optional","Y","All services in an outpatient setting including, Outpatient Ancillary Services, Same Day Surgery, Recurring Therapy, and Observation Services."]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patients may be admitted to the hospital."]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Emergency Department","Required","Y","Athens has two ED locations. This system component will be all services provided at the main ED and the Cedar Creek Lake ED. "]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","UT Health Athens operates the Cancer Institute  located in Tyler, TX."]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Maternal Department","Required","Y","All services provided in the maternal department. "]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["139173209.7.1",1,"139173209","Athens Hospital LLC","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Diabetes and Primary Care managed at East Texas Physicians Cedar Creek Lake clinic. "]
["140425362.7.1",1,"140425362","Paris Lamar County Health Department","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","The Paris-Lamar County Health Department (PLCHD) provides primary health care services in Lamar County, serving a 907.19 square mile area with a population of approximately 50,000. As a health department preventive medical treatment is the primary focus but other services include immunizations, family planning, screening and treatment of sexually transmitted disease and care of non-emergent medical issues. The PLCHD services a large number (95%-98.5%) of uninsured, underinsured, Medicaid eligible, impoverished and otherwise under-resourced individuals, with the remaining 5%-10% of the patient population self pay or private insurance. Assistance is also available for qualifying, low income families through available grant funding. "]
["140425362.7.1",1,"140425362","Paris Lamar County Health Department","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","The Paris-Lamar County Health Department (PLCHD) provides Texas Vaccine for Children and Adult Safety Net Immunization services for children and adults living in Lamar County.  "]
["208843701.7.1",1,"208843701","Henderson Hospital LLC","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital."]
["208843701.7.1",1,"208843701","Henderson Hospital LLC","Hospital","Private","Emergency Department","Required","Y","All services provided within the ED."]
["208843701.7.1",1,"208843701","Henderson Hospital LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided at East Texas Physicians Henderson (RHC)."]
["208843701.7.1",1,"208843701","Henderson Hospital LLC","Hospital","Private","Maternal Department","Required","Y","All services provided in the maternal department. "]
["208843701.7.1",1,"208843701","Henderson Hospital LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Inpatient Services","Required","Y","CHRISTUS Mother Frances Hospital - Sulphur Springs 96 bed acute care facility with medical/surgical floors, ICU and all other support services. "]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Emergency Department","Required","Y","CHRISTUS Mother Frances Hospital - Sulphur Springs Emergency Department which includes 19 total rooms, with two rooms designated for trauma, additional we have 3 minor care rooms.  "]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","CHRISTUS Trinity Clinic - Sulphur Springs and Emory which includes 10 clinics (including both primary care and specialty care) and 35 providers.  As of 8.29.2019, this component also includes our FQHC clinic.","Y","2020-07-27"]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Maternal Department","Required","Y","CHRISTUS Mother Frances Hospital - Sulphur Springs maternal department includes 8 Labor-Delivery-Recovery-Postpartum Rooms and 4 C-Section Recovery Rooms includes a Level 2 Nursery and 2 operating rooms for C-sections.  "]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","CHRISTUS Mother Frances Urgent Care Center located in Sulphur Springs provides urgent care services to our community.  "]
["366812101.7.1",1,"366812101","Christus Hopkins Health Alliance","Hospital","Private","Other - FQHC","Optional","Y","An FQHC opened in Sulphur Springs in 2020 and will be coordinating with CHHA to provide services to patients who do not have a primary care provider for pediatrics, adult and maternal health.  "]
["376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Freestone Medical Center is a 37 bed licensed rural hospital. Inpatient services include, discharge planning, case management, 24 hour per day hospitalist coverage and around the clock nursing staff. On average, the inpatient unit admits approx. 475 patients per year. "]
["376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Freestone Medical Center Emergency Department has 9 beds, 2 of which are trauma/treatment beds. The E.R. is open 24 hours per day with an E.R. physician on-site at all times. FMC is currently designated as a Level 4 trauma center as of February 2019.  Annually, FMC E.R. department sees approx. 8500 patient encounters. FMC is the only E.R. in Freestone County with the nearest ED being Parkview Regional Hospital in Mexia, Texas in Limestone County.  "]
["376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Freestone Rural Health Clinic is integrated with Freestone Medical Center in Fairfield, Texas. During 2019, the clinic employed three physicians and 5 mid-level providers. Currently, the Rural Health Clinic has 4 physicians and 5 mid-levels.  In Dec. 2018, FRHC opened a satellite clinic in nearby Teague, Tx. to better serve that population.  Patient encounters for FY 2019 totaled approx. 21,000 visits for Oct. 1, 2018 - Sep. 30, 2019. The clinic routinely has visiting physicians in the specialties of Cardiology, Orthopedics, Podiatry, General Surgery, Urology and ENT.  "]
["376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["376537203.7.1",1,"376537203","Fairfield Hospital District dba Freestone Medical ","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["019053001.7.1",2,"019053001","Coastal Health Wellness","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Coastal Health & Wellness is Galveston County's Community Health Center.  As of March 2018, we operate two permanent clinics, one in Texas city and one in Galveston.  The Texas City location  provides easy access to mainland patients, while the  Galveston clinic is co-located in a Community Center along with other social service agencies, which allows patients the opportunity for one-stop shopping for access to services other than medical, dental and behavioral health care.   "]
["019053001.7.1",2,"019053001","Coastal Health Wellness","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Immunization services are provided at both the Texas City and Galveston locations."]
["019053001.7.1",2,"019053001","Coastal Health Wellness","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Coastal Health and Wellness will continue to partner with Galveston County Health District Public Health Nurses, and Emergency Preparedness, to utilize the Mobile Clinic for health fairs, screenings, and in the event of an emergency or natural disaster.  Previously the mobile clinic was providing services in remote locations of Galveston County, particularly the Bolivar peninsula and the Bayshore area.  Demand for services in those areas has declined as to make it no longer economically feasible to continue using the Mobile Clinic in those areas.  "]
["019053001.7.1",2,"019053001","Coastal Health Wellness","Local Health Department (LHD)","Non‐State Owned Public","Other - Contracted FQHC","Optional","Y","Coastal Health and Wellness will continue its  contractual arrangement with the FQHC we partnered with for our DY2-6 DSRIP project."]
["094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public","Inpatient Services","Required","Y","As of October 2019, UTMB has 443 staffed inpatient beds across four (4) locations. Additionally, UTMB has 105 staffed inpatient beds specifically for individuals in the custody of the Texas Department of Criminal Justice (TDCJ). Per the guidance regarding the ability to exclude individuals with incarcerations greater than 45 days, UTMB chooses to omit from the DSRIP system definition those individuals accessing UTMB while under the control of TDCJ; these individuals will thus be excluded from all Category C metrics as well."]
["094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public","Emergency Department","Required","Y","As of October 2019, UTMB has 24 hour Emergency Department (ED) capabilty co-located at the four (4) inpatient locations. Per the guidance regarding the ability to exclude individuals with incarcerations greater than 45 days, UTMB chooses to omit from the DSRIP system definition those individuals accessing UTMB while under the control of TDCJ or whose only access to UTMB services is while in the custody of a local law enforcement agency; these individuals will thus be excluded from all Category C metrics as well."]
["094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","As of October 2019, UTMB has approximately 80 outpatient clinics, primarily in Galveston and Brazoris counties. These clinics are a combination of primary and specialty care offerings; our overall practice also offers some visits that are delivered via telemedicine. The ambulatory component of UTMB's Regional Maternal Child Health Program (RMCHP) network is a part of this system; please note that is does include one location in RHP 5 that only offers high risk GYN services. Per the guidance regarding the ability to exclude individuals with incarcerations greater than 45 days, UTMB chooses to omit from the DSRIP system definition those individuals accessing UTMB while under the control of TDCJ or whose only access to UTMB services is while in the custody of a local law enforcement agency; these individuals will thus be excluded from all Category C metrics as well."]
["094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public","Maternal Department","Required","Y","UTMB has labor and delivery capability at three (3) inpatient locations. The ambulatory component is captured in the system definition for Owned or Operated Outpatient Clinics. Per the guidance regarding the ability to exclude individuals with incarcerations greater than 45 days, UTMB chooses to omit from the DSRIP system definition those individuals accessing UTMB while under the control of TDCJ or whose only access to UTMB services is while in the custody of a local law enforcement agency; these individuals will thus be excluded from all Category C metrics as well."]
["094092602.7.1",2,"094092602","University of Texas Medical Branch - Galveston","Hospital","State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","UTMB's Urgent Care locations are considered Ambulatory clinics, and thus all encounters are treated as outpatient visits. Please see the system definition for Owned or Operated Outpatient Clinics."]
["094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private","Inpatient Services","Required","Y","The Inpatient Services division of the Baptist Hospitals of Southeast Texas (BHSET) system includes the following components: Critical Care Services, Medical-Surgical Units, Telemetry Units, Pediatric Unit, Fannin Behavioral Health Center, and the 15-bed Acute Care Rehabilitation Unit. \n\nCritical Care Services is composed of the Intensive Care Unit (ICU) and the Cardio-Vascular Intensive Care Unit (CVICU) that nets a total of 25-beds.  Seventeen (17) beds are allocated to general medical-surgical cases and eight (8) for cardiovascular cases requiring intensive care services.  The unit is operated on a 24-hour basis, seven days a week.  \n\n3 Sabine is operational on a 24-hour basis, seven days a week, encompasses 8 ICU Step-down beds (312-320) and 19 Telemetry beds on the 3 Sabine tower.  Patient population serviced ranges from adult to geriatrics. Patients may be admitted by physicians’ orders from Emergency Department, Surgery, Recovery Room, other units, and other hospitals or direct from physician’s offices.  \n\n 2NE and 2NW are Medical-Surgical units.  2N, 3T, 4S, 4T, 4NW and 5NE have Telemetry capabilities.  All units are operational on a 24-hour basis, seven days a week.  Patient population serviced ranges from adult to geriatrics.  \n\n2NW is a designated Certified Joint Replacement Unit. \n\n4T is the designated Bariatric Center, Peritoneal Dialysis, and Brachytherapy (cesium, gold seeds, buccal, intacavitary), Unit. \n\n4S is the designated Stroke Unit and utilizes Tele-Neurology for inpatients with seizures, small bleeds, Trans Ischemic Attacks (TIA)/Cerebral Vascular Accidents (CVA), acute paralysis, unexplained stupor/coma, and/or altered consciousness with unknown cause. \n\nBaptist Rehabilitation Unit (“Rehab”) is a 15-bed inpatient acute rehabilitation center designed to accommodate specific patient populations appropriate for general physical rehabilitation.  Age range for patients accepted in Baptist Rehab is 18 years and above.  Baptist Rehab is designed to provide a full continuum of rehabilitation services for patients whose primary diagnosis include but not limited to: stroke, spinal cord injury, congenital deformities, amputation, total joint replacement, polyarthritis, rheumatoid arthritis, burns, multiple trauma, fracture, brain injury, neurological disorders, including multiple sclerosis, polyneuropathy, muscular dystrophy, and Parkinson’s Disease. \n\nThe Pediatrics Department is a 17 bed unit which serves children aged birth to 18 years.  Continuous cardiac monitoring is available on five bed for patients with an increased level of acuity Respiratory monitoring is available on all beds via continuous pulse oximetry with central monitoring capability. Most commonly treated problems include respiratory problems and gastrointestinal issues.  The standards of care are age specific and address growth and developmental needs of children and educational needs of parents.  \n\nThe Behavioral Health Center utilizes an interdisciplinary team approach.  Each program focuses on different aspects of emotional disturbances or maladaptive behaviors based on diagnostic criteria, age groups, and need for continuous treatment on an inpatient or outpatient basis.  \n"]
["094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private","Emergency Department","Required","Y","The Emergency Services Department (ED) utilizes a multidisciplinary team approach for provision of patient care. Patients are divided into five (5) level triage (acuity) system based on the Emergency Severity Index (ESI) Tool. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five (5) groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needed. The ED consists of forty-one treatment areas which are divided into an acute area, a less acute area, (Minor Care) and the Pedi ED.  However, all beds can be monitored and used for either the acute or the less acute patient. Patients served include all age groups from Neonate to Elderly.  Care is provided to meet routine, urgent and emergent medical problems. "]
["094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The Outpatient Clinics owned and/or operated by Baptist Hospitals of Southeast Texas include: The Cancer Center / Regional Cancer Network, Baptist Physician Network (BPN) and SmartHealth Clinic. \n\nThe Baptist Regional Cancer Network provides cancer care from prevention and screening, genetics testing and counselling, to survivorship, to the end of life for young adult, adult and geriatric patient populations. The Baptist Regional Cancer Network encompasses the departments of the Dauphin Women’s Center, Julie and Ben Rogers Cancer Institute, Altus Cancer Center and Cancer Center of SE Texas, Port Arthur which includes medical oncology, hematology, radiation oncology, infusion and cancer registry. The most frequent treatments delivered are for breast, lung, colon, prostate, head and neck, and metastatic cancers. \n\nThe Baptist Physician Network works within our health system to provide the following care services: Family Medicine; Rheumatology; Cardiology; Tele-Neurology; Psychiatry (in partnership with Baptist Behavioral Health); Oncology (in partnership with The Regional Cancer Center). Patient care within the Baptist Physician Network (BPN) is provided by a skilled team of providers, including physicians and nurse practitioners / advanced practice providers. BPN shares in the mission of Baptist Hospitals of Southeast Texas to “perform sacred work” in all family and specialty care areas. \n\nThe SmartHealth Clinic program is a transitional care program focused on care of vulnerable and at risk patient populations.  The program provides a wide variety of transitional health services, across multiple settings, to a diverse group of patients.  The program consists of two main components; the SmartHealth Clinic and the Patient Navigation Program.  The clinic currently accepts patients by referral/consultation, who have a previously diagnosed chronic illness (Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Myocardial infarction, End Stage Renal Disease, Pneumonia, Sepsis, Uncontrolled Hypertension, HIV/AIDS and Hepatitis C).  \n\nThe Outpatient Infusion Clinics provide administration of intravenous and injectable medications such as chemotherapy for both oncology and non-oncology patients; Reclast for osteoporosis; administration of blood products and therapeutic phlebotomy; and supportive care for outpatients with a variety of illnesses including cancer patients, and those requiring long term antibiotic therapy. We also provide therapy for patients with autoimmune diseases requiring Remicade, IVIG, Orencia, and Actemra, infusions.\n"]
["094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private","Maternal Department","Required","Y","Labor and Delivery is equipped and prepared to provide patient care services in a designated unit with 7 LDRs and 4 Triage beds. There is immediate availability of two Operating rooms for obstetrical surgery and a two-bed recovery room.  There are 27 postpartum/gynecology beds.  There are adequate support areas for these patients.  Labor and Delivery is established to provide care for the antepartum, intrapartum, and postpartum patient requiring medical and nursing interventions and for the newborn requiring routine or specialized nursing care. \n\nThe Mother-Baby Unit is a 27 room unit in which includes rooming-in for well newborns. The unit is open 24 hours per day, 7 days per week to provide patient care.  Patient care is focused on the medical and nursing care associated with the childbirth experience with a focus on the post-partum period and newborn care.  The Mother-Baby Unit encompasses the needs of women in various stages of life.  Reproductive health, prenatal services, antepartum and post-partum care, newborn care, pre and post op care, and associated educational needs are identified as services for women’s health care needs.  \n\nThe NICU is a 12-bed unit, with 6 beds designated for Neonatal Intensive Care, and 6 beds designated for Intermediate Care located on the 3rd floor of the Neches tower. The NICU is located adjacent to the labor and delivery unit which allows rapid response when necessary. The NICU provides comprehensive care to infants of all gestational ages with mild to critical illnesses or requiring sustained life-support. The NICU utilizes a multidisciplinary approach to patient care which include daily rounding with all care team members to ensure that patient and parent needs are being met with the best outcome. \n\n\n"]
["094148602.7.1",2,"094148602","Baptist Hosp of SE TX dba Mem Hermann Bapt Beaumon","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private","Inpatient Services","Required","Y","WHMC is a full service acute care hospital licensed for 149 beds and with 145 active physicians on staff.  All specialties are offered with the exception of Neurosurgery.  WHMC's offerings and departments include cardiac catheter labs, open heart surgery, robotic surgery, a Women's Center, orthopedics, wound care, a sleep lab, imaging with CT and MRI, and a Level II neonatal nursery."]
["094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private","Emergency Department","Required","Y","We offer a 24/7  Emergency Room, which averaged 65 visits per day last year, and is currently designated \"In Pursuit\" of Level IV Trauma certification.   We are also in pursuit of Stroke Certification."]
["094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The Diagnostic Center at WHMC is less than a mile from the main campus, offering a full range of diagnostics: CT, MRI, Radiology, Ultrasound, Digital Mammography, and pre-admit testing for surgery.  The Ambulatory Surgery Center at WHMC does pain management procedures and some cosmetic surgery.  The Wound Healing Center/Sleep Disorders Laboratory at WHMC has hyperbaric and traditional wound care services.  The OP Rehabilitation Center at WHMC is about 3 miles from campus and offers PT, OT, and Speech Therapy services.  "]
["094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private","Maternal Department","Required","Y","The Women's Center at WHMC offers full service deliveries and has two Operating Room C-Section suites.   We delivered 1,030 babies in the calendar year of 2017.  The Level II NICU is currently pursuing Level III certification to accept more acute newborns in our area."]
["094164302.7.1",2,"094164302","Woodland Heights Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["096166602.7.1",2,"096166602","Spindletop Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Spindletop Center defines system as \"All clients receiving services through our mental health clinics\".  These clients received at least one service during the demonstration year through one of our clinics.  As of March 2018, the clinics are Orange Outpatient, Daybreak Youth Services, South County Outpatient, Beaumont Outpatient, and Community Services.  In addition to clinic based services, Spindletop Center offers non-clinic/home-based services.  The need of the client determines the frequency and location of the services.  Based on the client's need, in addition to the services provided in the clinic, staff meet the client in the non-clinic setting and are able to focus the services provided on meeting the client's goals in the client's environment.  A few of the services provided are assessments, case management, medication management, referrals to internal and community services, and living skills training, such as, coping skills, budgeting, and nutrition."]
["096166602.7.1",2,"096166602","Spindletop Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Spindletop Center defines system as \"All clients receiving services through our mental health clinics\".  These clients received at least one service during the demonstration year through one of our clinics.  As of March 2018, the clinics are Orange Outpatient, Daybreak Youth Services, South County Outpatient, Beaumont Outpatient, and Community Services.  Our clinics offer a wide range of services.  A few of the services provided are assessments, case management, medication management, referrals to internal and community services, and living skills training, such as, coping skills, budgeting, and nutrition.  We also offer whole health peer support, Whole Health Action Management (WHAM), and other evidence based training opportunities for our clients."]
["112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private","Inpatient Services","Required","Y","As of March 2018, CHI St. Luke’s Health Brazosport is a part of the Texas division of CHI St. Luke’s Health. CHI St. Luke’s Health Brazosport Hospital has 154 licensed inpatient beds, with a full-service line of acute care, intensive care, telemetry, rehabilitation, imaging, wound healing, and laboratory services."]
["112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private","Emergency Department","Required","Y","As of March 2018, CHI St. Luke’s Health Brazosport has one emergency services department with 28 emergency services bed within the system. The Brazosport Emergency department has a Level III Trauma designation, with direct access to the hospital and support departments."]
["112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","As of March 2018, CHI St. Luke’s Health Brazosport provides physicians services through Brazosport Regional Family Medicine Clinic (BRFMC). BRFMC is comprised of family medicine clinics at three locations to serve Brazoria County residents. BRFMC clinics are staffed by Baylor College of Medicine physicians."]
["112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private","Maternal Department","Required","Y","As of March 2018, CHI St. Luke's Health Brazosport provides labor and delivery services within the system through the Dow Women's Center. The Dow Women's Center has 10 private rooms where the labor, delivery, recover, and postpartum processes are completed. The Women's Center also provides educational classes and training for new mothers."]
["112671602.7.1",2,"112671602","Brazosport Regional Health System","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","As of March 2018, CHI St. Luke’s Health Brazosport provides urgent care services through Brazosport Regional Family Medicine Clinic. The system has one urgent care clinic that is supported by Baylor College of Medicine physicians and providers."]
["130983309.7.1",2,"130983309","Angelina County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Acute and chronic primary health care services for adults & children, well-child services, women’s gynecological health, preventive health screenings, STI/TB testing and treatment services that are provided at our two clinic locations in Lufkin. "]
["130983309.7.1",2,"130983309","Angelina County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Vaccine administration services for uninsured children at the clinic located on Shands Drive in Lufkin."]
["130983309.7.1",2,"130983309","Angelina County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public","Other - CHI St. Luke's Health Memorial Breast and Cervical Cancer Screening (BCCS) Program","Optional","Y","Referral partner program that provides women's health services including mammograms and cervical cancer screenings for the low income, uninsured.  We have discussed possible overlap with the CHI Memorial system definition and patients included in measure counts with our Anchor Office and CHI Memorial Lufkin. We understand the CHI Memorial Lufkin will not be utilizing the contracted program in their DSRIP measures"]
["131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","We are a full service, general acute care County hospital with services that include the ER, Perioperative, Cath lab, NICU, Critical care (IMC/ICU), Dialysis, Cardiac Rehab, Medical Imaging, Women's wellness, Therapy and Cardiac Pulmonary services. In order to explain our percentage change in MLIU, we would like to note that we have more recently acquired private provider offices into our group that historically only accepted private insurance. By incorporating these offices into our group, they have indeed brought  a new pool of private insurance into our mix, but by joining our group,  they are now accepting MLIU patients. In doing this, we are actually able to provide more specialty care and primary care for our MLIU population. "]
["131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Nacogdoches Memorial has a Level III Trauma designation and averages 2,400 visits per month. We serve counties that include Nacogdoches, Shelby, Angelina, San Augustine, Rusk, Cherokee and Houston County.\n"]
["131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","As of October 2019, Nacogdoches Memorial Hospital has a total of 9 clinics averaging about 3000 visits per month. Eight of these clinics are located within Nacogdoches and one is in Garrison. Our clinic services include Family Medicine, Internal Medicine, Women's Health including Midwives and OB/GYN Services, General and Vascular Surgery, and Urology services."]
["131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Women's and Children's Center at Nacogdoches Memorial Hospital was designed to be one of the most family-centered, comfortable, and attractive labor and delivery programs available in the East Texas area. Featuring 8 Labor & Delivery Suites,  two state-of-the-art C-Section suites that are available for mothers needing surgical assistance in delivering their baby,  11- bed postpartum unit that provides specialized care for mothers and babies after delivery and the four-bed antepartum unit that provides specialized care for mothers experiencing complications of pregnancy, such as premature labor, gestational diabetes and pregnancy-induced hypertension. In addition to this as of October 2019, we have our 7 midwives based at our Care First Women’s Clinic who are very much involved with the maternal patients in terms of prenatal visits, deliveries and postpartum visits. "]
["131030203.7.1",2,"131030203","Nacogdoches County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["135222109.7.1",2,"135222109","The Gulf Coast Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","This Community Mental Health Center business component includes services provided to individuals in their homes and/or in their communities within GCC’s system of care which extends throughout Galveston and Brazoria Counties.  Services are provided to individuals with diagnoses in the areas of mental health, substance use, intellectual and developmental disabilities, and autism.  Mode of service provision may include face-to-face and virtual encounters."]
["135222109.7.1",2,"135222109","The Gulf Coast Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","This Community Mental Health Center business component includes services provided to individuals within the structural/physical confines of GCC’s offices and clinics throughout Galveston and Brazoria Counties.  Services are provided to individuals with diagnoses in the areas of mental health, substance use, intellectual and developmental disabilities, and autism.  Mode of service provision may include face-to-face and virtual encounters."]
["135222109.7.1",2,"135222109","The Gulf Coast Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","This optional Community Mental Health Center business component includes services provided to individuals discharged from Gulf Coast Center’s Contracted Inpatient Beds at St. Joseph’s Behavioral Health Hospital in Houston, and whose residence is in Galveston or Brazoria County.  The Contracted Inpatient Beds are retained pursuant to contractual agreement between St. Joseph’s Mental Health Hospital and Gulf Coast Center, and funded by HHSC.  Service provision may include outpatient visits and intensive outpatient encounters, and is provided by a mental health practitioner.  Mode of service provision may include face-to-face and virtual encounters."]
["136367307.7.1",2,"136367307","Burke Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","As a Texas CCBHC center, Burke has aligned its Category B system definition with the SAMHSA-approved definition of CCBHC service provision.  As such, Burke describes this system component as any mental/behavioral health service provided by Burke staff to an individual in the home setting during the measurement period. "]
["136367307.7.1",2,"136367307","Burke Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","As a Texas CCBHC center, Burke has aligned its Category B system definition with the SAMHSA-approved definition of CCBHC service provision. Burke has locations throughout our 12 county service delivery area (Angelina, Houston, Jasper, Nacogdoches, Newton, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, and Tyler counties).  Burke includes all mental/behavioral health services provided by Burke staff to individuals in any Burke mental health setting throughout our 12 county service delivery area during the measurement period. "]
["136367307.7.1",2,"136367307","Burke Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Hospital","Optional","Y","As mentioned previously, Burke covers a 12 county service delivery area.  Frequently, Burke provides crisis mental/behavioral health services to individuals who are in local emergency departments/hospitals.  As such, Burke describes this system component as any mental/behavioral health crisis service provided by Burke staff in any hospital setting within Burke's 12 county service delivery area during the measurement period. "]
["136367307.7.1",2,"136367307","Burke Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community-Based Mental Health Services","Optional","Y","Burke provides mental/behavioral health services in an array of locations in the community.  Burke provides mental/behavioral health skills training, case management and therapy to children at their school setting, mental/behavioral psychosocial rehabilitation services to adults at local food banks and/or grocery stores, prescriber services to individuals incarcerated at county jails.  Burke meets with individuals and provides a full array of mental/behavioral health services in any community setting that best meets the individual's needs.  As such, Burke describes this system component to any mental/behavioral health service provided by Burke staff to an individual at any community-based setting within Burke's 12 county service delivery area during the measurement period. "]
["136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Tyler County Hospital District accepts admissions to its medical inpatient wing for medical care, diagnostic and therapeutic services. Our services do not include labor and delivery or ICU. As of February 2018, we are licensed for 49 beds but currently staff for 25."]
["136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The emergency department accepts all patients seeking diagnostic services and medical care. As of February 2018, we are set-up with eight beds to service our patients. The emergency department holds a Level IV Trauma Designation.  "]
["136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Tyler County Hospital Rural Health Clinic provides primary care and diagnostic services including lab, ECG and radiology. We currently provide a mixture of scheduled and sick visits to our patients. "]
["136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["136381405.7.1",2,"136381405","Tyler County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private","Inpatient Services","Required","Y","This system component will include all services in all units at CHRISTUS Hospital to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services. "]
["138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private","Emergency Department","Required","Y","This system component will include all services in all units at CHRISTUS Hospital Emergency Department locations, including: St. Mary's Outpatient Center and St. Elizabeth Hospital. "]
["138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This service component includes 14 clinics - OB Clinic, 2 Center's for Health Management, 3 Orthopedic Clinics, Pain Management, Cardiology, Neuro-Spine, Plastic Surgery, Pulmonary, Lactation, MOHS, and Weight Management as well as outpatient centers in MidCounty and Beaumont."]
["138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private","Maternal Department","Required","Y","This system component includes all maternal care services offered at CHRISTUS Hospital, including labor and delivery, nursery, OB/GYN services, and NICU services.  "]
["138296208.7.1",2,"138296208","Christus Hospital (prev St. Elizabeth)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","This service component includes the CHRISTUS Minor Care clinic in Beaumont."]
["139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private","Inpatient Services","Required","Y","As of March 2018, CHI St. Luke's Health-Memorial offers a wide array of inpatient services, including three acute care hospitals, Heart and Stroke Care Center, Cancer Center, Imaging Centers, Four Emergency Rooms, Education Center, Wound Care Center, Outpatient Therapy Center, Surgery Center, Sleep Center, Cardiac Rehabilitation Center. All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services. The hospital offers outpatient services."]
["139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private","Emergency Department","Required","Y","At the time of this submission, CHI St. Luke's Health-Memorial Emergency Care consists of three emergency rooms and a hospital-based off campus ER, has dedicated imaging and laboratory departments, and a highly qualified staff of emergency physicians, nurse practitioners and registered nurses. All emergency services provided to a patient in an emergent situation. "]
["139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private","Maternal Department","Required","Y","As of 2018, CHI St. Luke's Health-Memorial has a fully integrated women's center that offers obstetrics and gynecology care, labor and delivery and digital mammography. "]
["139172412.7.1",2,"139172412","Memorial Medical Center Lufkin","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private","Inpatient Services","Required","Y","Sabine County Hospital is a Critical Access Hospital licensed for 25 beds by the Texas Department of Health and Human Services and compliant with all applicable regulatory requirements for inpatient, outpatient and Swing Bed programs, which it provides. Outpatient Services provided at the hospital include, Radiology, Laboratory, IV Therapy, and Physical Therapy."]
["200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private","Emergency Department","Required","Y","The hospital has a designated Level IV Trauma Center (Expires 3/1/2020)."]
["200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","As of November 2019, the system contains one Rural Health Clinic, Toledo Bend Family Medicine.  Both clinics, located in Hemphill, Texas, devoted to keeping the whole family healthy through a variety of services including: annual check-ups, athletic physicals and well-child exams, sick visits, blood pressure maintenance and care, diabetes maintenance and care, and more. "]
["200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private","Maternal Department","Required","N",""]
["200683501.7.1",2,"200683501","Preferred Hospital Leasing Hemphill Inc","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private","Inpatient Services","Required","Y","Liberty Dayton Regional Medical Center has one inpatient facility located in Liberty Texas.  The hospital is a 25 bed critical access hospital serving Liberty and surrounding cities and counties.  We provide inpatient, observation, and swing bed services within the facility."]
["284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private","Emergency Department","Required","Y","Our facility consists of a 7 bed/24 hour physician staffed emergency department within the hospital facility."]
["284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Liberty Dayton Medical Clinic is a  certified Rural Health Clinic located within the hospital.  It is staffed by 1 physician and 3 mid-level providers.  The clinic serves patients days per week."]
["284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private","Maternal Department","Required","N",""]
["284333604.7.1",2,"284333604","Liberty-Dayton Regional Medical Center LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Inpatient Services","Required","Y","Bayshore Medical Center's services include Bariatrics, Behavioral Health, Cardiovascular, Imaging, Rehabilitation, Sleep Medicine, Women’s Care and Wound Care"]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Emergency Department","Required","Y","Bayshore has 3 Emergency departments. One ED is located on Bayshore Medical Center's main campus and there are 2 additional free standing emergency departments."]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Midwifery Clinics- Two Clinic locations that specialize in the wellbeing of women during pregnancy, labor, birth, and the postpartum period. Services include the following: Basic Primary Care for Women, Well Woman Care and Exams, Delivery Services , Pregnancy Tests, Gynecological Evaluations, Pre-conception, Prenatal and Post-partum follow up, HIV and STD Screenings, Family Planning and Contraception Planning"]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Maternal Department","Required","Y","Inpatient units and services consisting of Labor & Delivery, Obstetrics and Gynecology, and outpatient Midwives clinics."]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020817501.7.1",3,"020817501","CHCA Bayshore LP dba Bayshore Medical Center","Hospital","Private","Other - Outpatient Product Lines","Optional","Y","Outpatient product Lines consist of Diagnostic Imaging, Nuclear Medicine, Lab/Path/Transfusions, Therapy, CT Scan, Cardiac Testing, Cardiac Rehab, Outpatient Surgery, Chemotherapy and Cardiac Cath."]
["020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private","Inpatient Services","Required","Y","This required system component includes inpatient services at Memorial Hermann Greater Heights Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann The Woodlands Hospital, and Memorial Hermann Southeast Hospital. "]
["020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private","Emergency Department","Required","Y","This required system component includes emergency department services at Memorial Hermann Greater Heights Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann The Woodlands Hospital, and Memorial Hermann Southeast Hospital. "]
["020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This required system component includes Memorial Hermann Medical Group (MHMG) Clinics and all Memorial Hermann Community Benefit Neighborhood Clinics. These clinics include MHMG Alvin, MHMG Atascocita, MHMG Bellaire, MHMG CCC Katy, MHMG CCC Sienna Plantation, MHMG CCC Spring, MHMG CCC Summer Creek, MHMG Central Pearland, MHMG Clear Lake, MHMG Conoco Phillips, MHMG Conroe, MHMG Copperfield, MHMG Cypress, MHMG Downtown, MHMG El Campo, MHMG Fairfield, MHMG Family Practice, MHMG Fannin, MHMG Firethrone, MHMG Friendswood, MHMG Goodman, MHMG Greater Heights, MHMG Heights, MHMG Imperial Oaks, MHMG Katy, MHMG Kingwood Town Center, MHMG League City, MHMG Manvel, MHMG Memorial City Executive Health, MHMG Memorial City, MHMG Needville, MHMG Northeast, MHMG Pearland, MHMG Phillips 66, MHMG Rosenberg, MHMG Southeast, MHMG Southeast Medical, MHMG Skin, MHMG Sugarland, MHMG Spring, MHMG Sterling Ridge, MHMG Southwest, MHMG Sweetwater, MHMG Texas Medical Center (TMC), MHMG Upper Kirby, MHMG Wharton, MHMG Woodlands, Memorial Hermann Neighborhood Health Center - Northeast, Memorial Hermann Neighborhood Health Center - Greater Heights.\n    \n"]
["020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private","Maternal Department","Required","Y","This required system component includes maternal departments at Memorial Hermann Greater Heights Hospital, Memorial Hermann Southwest Hospital, Memorial Hermann The Woodlands Hospital, and Memorial Hermann Southeast Hospital.  "]
["020834001.7.1",3,"020834001","Memorial Hermann Hospital System (The Woodlands)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Memorial Hermann Urgent Care Clinics are stand-alone clinics staffed exclusively with MHMG Physicians (Employed Physicians). These clinics also cover the same geographic areas as the outpatient clinics. The eight Memorial Hermann Urgent Care locations are: Memorial Hermann Urgent Care Benders Landing, Clear Lake, Friendswood, Fulshear, Spring, Tanglewood, Telfair, & Washington Avenue. "]
["081522701.7.1",3,"081522701","Texana Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Services provided in the six county area served by Texana Center to people with behavioral health issues and intellectual and developmental disabilities.  "]
["081522701.7.1",3,"081522701","Texana Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Services provided in the six county area served by Texana Center to people with behavioral health issues and intellectual and development disabilities.  Included in this component are the following clinics:  Behavioral Healthcare Clinic at Rosenberg, Behavioral Healthcare Clinic at Sugar Land, Behavioral Healthcare Clinic at Bay City, Behavioral Healthcare Clinic at Wharton, Behavioral Healthcare Clinic at Columbus, and the Behavioral Healthcare Clinic at Brookshire"]
["081522701.7.1",3,"081522701","Texana Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","Texana Center receives funding from HHSC to purchase beds in local (primarily Houston) psychiatric hospitals for individuals who meet inpatient criteria during a crisis screening.  Currently, these hospitals include West Park Springs in Richmond, West Oaks Hospital, Behavioral Hospital of Bellaire, Sun Behavioral Houston, Intracare North, Houston Behavioral Healthcare Hospital  and St. Joseph's Hospital all in Houston."]
["082006001.7.1",3,"082006001","Baylor College of Medicine Grants and Contracts De","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Primary Care Clinics","Required","Y","BTHC currently operates a network of NINE health clinics. These clinics are located in two county hospitals (Ben Taub and Lyndon B. Johnson), three high school campuses (Wisdom High School in the Gulfton Area, Milby High School in the East End, and Worthing High School in South East Houston), one charter school (Tejano Center in South East Houston) and three community centers (Lawn in Acres Home, Cavalcade in Kashmere Gardens, and Cullen Health Center in Third Ward). The clinics all still provide both primary and reproductive health care services."]
["082006001.7.1",3,"082006001","Baylor College of Medicine Grants and Contracts De","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Specialty Care Clinics","Required","Y","BTHC currently operates a network of NINE health clinics. These clinics are located in two county hospitals (Ben Taub and Lyndon B. Johnson), three high school campuses (Wisdom High School in the Gulfton Area, Milby High School in the East End, and Worthing High School in South East Houston), one charter school (Tejano Center in South East Houston) and three community centers (Lawn in Acres Home, Cavalcade in Kashmere Gardens, and Cullen Health Center in Third Ward). The clinics all still provide both primary and reproductive health care services."]
["082006001.7.1",3,"082006001","Baylor College of Medicine Grants and Contracts De","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Hospital","Required","N",""]
["082006001.7.1",3,"082006001","Baylor College of Medicine Grants and Contracts De","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Private"," Owned or Operated Urgent Care Clinics","Required","N",""]
["093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Our local public health clinics provide safety net services to 1) prevent the spread of disease, and 2) promote the health and well-being of the communities we serve. Here is the list of clinics and the services provided at each one:\nNorthside\n• Family Planning\n• STD\n• Immunizations\n• Tuberculosis\n• Dental\nLa Nueva Casa de Amigos\n• Family Planning\n• Immunizations\n• Dental\nMagnolia\n• Dental\nSharpstown\n• Family Planning\n• STD\n• Immunizations\n• Dental\nSunnyside\n• Family Planning\n• STD\n• Immunizations\n• Tuberculosis\n• Dental"]
["093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Our local public health department provides safety net immunization services for individuals and works closely with local health providers to support their vaccination efforts. They are provided in the following clinics:\n• Northside Health Center\n• La Nueva Casa de Amigos\n• Sharpstown\n• Sunnyside\n"]
["093774008.7.1",3,"093774008","City of Houston","Local Health Department (LHD)","Non‐State Owned Public","Other - Non-clinical Services","Optional","Y","Our local health department offers educational and other supportive services outside of the clinical setting that promote the health and well-being of the community.  These services include, but are not limited to, chronic disease and diabetes self-management education, service navigation, and transitional care services. The diabetes self-management education occurs at Third Ward Multiservice Center. Other settings for the non-clinical services are  client homes or in community venues such as community centers, churches, schools, etc."]
["094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private","Inpatient Services","Required","Y","West Houston Medical Center (WHMC) is a full-service hospital serving the West Houston community for over 30 years. The Joint Commission accredited facility provides a range of care including: neurosurgery services; inpatient surgery, rehabilitation and diagnostic services; bariatric/weight loss surgery; senior care; wound care; sleep disorder services; cardiovascular care, women’s services and more. West Houston offers hospital based outpatient services; surgeries, diagnostic imaging, lab work, chemotherapy, cath lab, therapy, and education"]
["094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private","Emergency Department","Required","Y","West Houston Medical Center has 1 emergency Department located in the main campus"]
["094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private","Maternal Department","Required","Y","\nLabor and Delivery, Gynecology, and Support and Education Services"]
["094187402.7.1",3,"094187402","CHCA West Houston LP dba West Houston Medical Cent","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","All primary care (e.g., family medicine, internal medicine, pediatrics) clinic locations owned by UT Physicians."]
["111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","All multi-specialty (e.g., behavioral health, psychiatry, obstetrics/gynecology, endocrinology, cardiology, hepatology) clinic locations owned by UT Physicians.  "]
["111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Hospital","Required","N",""]
["111810101.7.1",3,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Inpatient Services","Required","Y","MD Anderson provides inpatient care to cancer patients at its hospital in the Texas Medical Center. The specific units to be included in inpatient services are: P6 - GI Surgical/Sarcoma,P7 - Telemetry/Thoracic Surgery,P8 - Rehab/Neuro,P9 - Urology & Orthopedics, P11 - H&N/Breast Surgery,P12 - GU, GI, Endocrinology, Intensive Care Unit,Pediatrics,Pediatric ICS,G10E - Gynecologic/Radiation,G10W - Melanoma/Sarcoma,G11E - Leukemia, G12 - Leukemia,G12NW - Palliative Care,G15 - Lymphoma/Myeloma,G16 - Leukemia,G17 - Stem Cell,G18 - Stem Cell and G22 - Medical Oncology."]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Emergency Department","Required","Y","MD Anderson provides medical emergency services which include, but are not limited to a sudden change in mental or physical status or development of a new symptom requiring immediate attention. The Emergency Department is located at the hospital in the Texas Medical Center."]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","These clinics are designed for cancer care and primarily are housed at the main campus in the Texas Medical Center with additional regional clinics located in RHP3 that include Bay Area, Katy, The Woodlands, and Sugar Land provide cancer diagnostic and treatment services."]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Maternal Department","Required","N",""]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["112672402.7.1",3,"112672402","UT MD Anderson Cancer Center","Hospital","State Owned Public","Contracted Primary Care Clinics","Optional","Y","This component  is comprised of four community primary care clinic locations of Spring Branch Community Health Centers. These are 1) Hillendahl Clinic, 2) Pitner Clinic, 3) West Houston Clinic and 4) the Cy-Fair Clinic. Spring Branch also provides dental services.\n"]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Services provided in the community to all individuals served at The Harris Center, which includes those services provided in the home."]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Services provided either in the office or at a behavioral health psychiatric clinic for individuals served at The Harris Center."]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","School-based Clinic","Optional","Y","We provide behavioral health services at co-location sites with a number of school districts in Harris County."]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","Inpatient contracted psychiatric services at local psychiatric hospitals for local inpatient beds."]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - State-funded Community Hospital","Optional","Y","Inpatient contracted psychiatric services at Harris County Psychiatric Center. "]
["113180703.7.1",3,"113180703","The Harris Center for Mental Health and IDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Individuals who are being discharged from any State funded psychiatric hospital back to our community."]
["127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private","Inpatient Services","Required","Y","Baylor St. Luke’s Medical Center is an acute-care, non-profit, inpatient hospital system that provides a multitude of services. Baylor St. Luke’s Medical Center owns/partially owns:\nHospital inpatient 909 licensed beds at Main and McNair Campuses servicing:\na. Cancer Care\nb. Complementary/Alternative Medicine\nc. Cosmetic & Reconstructive Surgery\nd. Ear, Nose & Throat (ENT)\ne. Emergency Services\nf. Endocrinology\ng. Eye Care (Ophthalmology)\nh. Gastroenterology\ni. Heart Care\nj. Imaging\nk. Infectious Diseases\nl. Liver Disease\nm. Neurosciences\nn. Orthopedic Care\no. Pain Management\np. Primary Care\nq. Pulmonology\nr. Rehabilitation\ns. Sleep Medicine\nt. Transplant\nu. Urology\nv. Women's Health - gynecology only\nw. Wound Care \nx. Diagnostic and Therapeutic Radiology Department\ny. Inpatient 30-bed Rehabilitation Unit at McNair\nz. McNair Inpatient Orthopedics","Y","2020-03-10"]
["127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private","Emergency Department","Required","Y","a. Baylor St. Luke's Medical Center's Emergency Department\nb. Community Emergency Departments\ni. Holcombe\nii. Pearland\nc. McNair Campus ED","Y","2020-03-10"]
["127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","a. Ambulatory Surgical Centers\ni. Outpatient Surgical Center at Baylor St. Luke’s Medical Center\nii. Jamail – Outpatient Surgical Center\niii. McNair – Outpatient Endoscopy Center\niv. O’Quinn – Outpatient Surgical Center\nv. O’Quinn Outpatient Endoscopy\nb. Diagnostic and Therapeutic Radiology Department\nc. Outpatient Cardiac Rehab\nd. Multiple Specialty Care Outpatient Clinics, including:\ni. Kirby Glen Diagnostic & Treatment Center and Radiation Therapy & CyberKnife®\na) Services include:\n1. The Cancer Center\n2. Infusion Therapy\n3. Radiation Oncology and CyberKnife®\n4. Radiology Services \n5. Diagnostic Imaging – MRI, CT, X-Ray\n6. Peripheral Vascular Laboratory Services \n7. Diagnostic Imaging\n8. Center for Sleep Medicine\nii. THI Outpatient Clinic\niii. Transitional Care Clinic\niv. HLTTC – Heart, Lung Transplant Treatment Center\nv. Kidney Transplant Program\nvi. Abdominal Transplant and Liver Disease Clinic\nvii. Executive Health Assessment Program\ne. McNair Pre-op and Recovery unit\nf. McNair Operating Rooms\ng. McNair Inpatient Orthopedics\nh. McNair Diagnostic Radiology\ni. McNair Oncology Infusion\niv.\tMcNair Oncology Clinics:\na)\t Date Opened all opened the same date 9/1/2019\nb)\tOncology Clinics include:\n1.\tHematology :  Provider exams, treatment planning, bone marrow biopsies\n2.\tMedical Oncology:  Provider exams, treatment planning\n3.\tSurgical Oncology: Provider exams, pre-post op care, procedures\n4.\tWoman’s :  Provider exams, pre-post op care, procedures\n5.\tOncology Infusion Center: Provide chemotherapy and infusion services to cancer patients\n6.\tBreast Imaging Department: Provides Mammography services :  Screening mammography, diagnostic mammography, stereotactic biopsies, ultrasonography","Y","2020-09-01"]
["127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private","Maternal Department","Required","N",""]
["127300503.7.1",3,"127300503","St. Luke's Episcopal Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Short term acute care facility - 58 staffed beds utilizing all sub-specialties (cardio, medicine, neurology, ortho, pulmonary, surgery, urology) - general & ICU.  Facility includes ancillary departments of Radiology, Rehabilitation, Wound Care, Oncology, and Nuclear Medicine. - Location 104 7th Street, Bay City TX 77414."]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Level III Trauma Center  - Location 104 7th Street"]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","MRMC operates a Medical Assistance Program (MAP Clinic) for low-income and uninsured patients to receive primary and preventative care services. The clinic originated as a public health clinic but now operates as an indigent clinic for Matagorda residents.  Those that do not qualify for MAP (residence status, income, and resources) are referred to the local FQHC (MEHOP) for services.  This clinic does not bill for services but does document in a paper medical record as it is an indigent requirement of the hospital district. "]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The maternity department is a part of the hospital inpatient or emergency department and is not representative of an outpatient or ambulatory setting. "]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Urgent Care Center, owned & operated by MRMC, opened May 2018 with weekend only hours of 9am - 6pm.  All patients and payers will be accepted and it is anticipated to relieve ED utilization of non-emergent conditions.   Urgent Care Center visits, like all other visits to an MRMC system component, will be included in the Category C measure calculations per the MBP & specifications.  "]
["130959304.7.1",3,"130959304","Matagorda County Hospital District dba Matagorda R","Hospital","Non‐State Owned Public","Contracted Primary Care Clinics","Optional","Y","The existing contract that was established through the DSRIP Primary Care Expansion project (1.3) will continue with Matagorda Episcopal Health Outreach Program (MEHOP) which is the local FQHC who extended hours to nights and weekends for the DSRIP program.  "]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient service starts when a patient is formally admitted to a hospital with a doctor’s order, i.e. care of patients whose condition requires admission to a hospital. Harris Health Hospital Inpatient Services are provided at Ben Taub Hospital, LBJ Hospital, and Quentin Mease Hospital."]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","This department provides triage, treatment and support for trauma and emergency patients of all ages in an acute care setting. Emergency services are provided at Ben Taub Hospital and LBJ Hospital."]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","An outpatient clinic is the part of a hospital designed for the treatment of outpatients, but do not require a bed or to be admitted for overnight care.  Outpatient services are provided at the following locations: Acres Home Health Center, Aldine Health Center, Baytown Health Center, Casa De Amigo Health Center, Cypress Health Center, Danny Jackson Health Center, E.A. “Squatty” Lyons Health Center, El Franco Lee Health Center, Gulfgate Health Center, Martin Luther King Jr. Health Center, Northwest Health Center, Settegast Health Center, Strawberry Health Center, Thomas Street Health Center, Vallbona Health Center, Margo Hilliard Alford Clinic, Monroe Clinic, Robindell Clinic, Sareen Clinic, Sunset Heights Clinic, Bayland Geriatric Center, Riverside Dialysis Center, Outpatient Specialty Center at LBJ, and Smith Clinic. Our system definition includes all outpatient locations, including Pediatric & Adolescent Health Center - Bear Creek, Pediatric & Adolescent Health Center - C.E. Odom, and Pediatric & Adolescent Health Center – Pasadena, Ben Taub Tower, and the Dental Center,"]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The department of a hospital that provides care for women during pregnancy and childbirth as well as for newborn infants.  These locations include both Ben Taub and LBJ Hospitals, and all outpatient sites: Acres Home Health Center, Aldine Health Center, Baytown Health Center, Casa De Amigo Health Center, Cypress Health Center, Danny Jackson Health Center, E.A. “Squatty” Lyons Health Center, El Franco Lee Health Center, Gulfgate Health Center, Martin Luther King Jr. Health Center, Northwest Health Center, Settegast Health Center, Strawberry Health Center, Thomas Street Health Center, Vallbona Health Center, Margo Hilliard Alford Clinic, Monroe Clinic, Robindell Clinic, Sareen Clinic, Sunset Heights Clinic, and Smith Clinic.  "]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133355104.7.1",3,"133355104","Harris County Hospital District","Hospital","Non‐State Owned Public","School-based Clinics","Optional","Y","Clinic sites located on school campuses, which provide preventive and primary health care services to children and adolescents. Locations: Almantha Clark Taylor Health Clinic, Goose Creek Health Clinic, Robert Carrasco Health Clinic, Sheldon Health Clinic, and Southside Health Clinic."]
["135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private","Inpatient Services","Required","Y","The System Component is Columbus Community Hospital.  The hospital is a 40-bed, non-profit facility.  Inpatient units include the Medical/Surgical floor and Obstetrical Department."]
["135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private","Emergency Department","Required","Y","The System Component is the Emergency Room at Columbus Community Hospital.  "]
["135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The System Component are two Rural Health Clinics owned and operated by Columbus Community Hospital.  The clinics are Columbus Medical Clinic and Four Oaks Medical Clinics and provide services including family medicine, internal medicine, obstetrics, and gynecology."]
["135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private","Maternal Department","Required","Y","The System Component is the Obstetrical Unit owned and operated by Columbus Community Hospital.  "]
["135033210.7.1",3,"135033210","Columbus Community Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Inpatient Services","Required","Y","This required system component includes inpatient services at Memorial Hermann Texas Medical Center (TMC) Hospital."]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Emergency Department","Required","Y","This required system component includes emergency department services at Memorial Hermann Texas Medical Center (TMC) Hospital."]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Maternal Department","Required","Y","This required system component includes maternal departments at Memorial Hermann TMC Hospital. "]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","School-based Clinics","Optional","Y","This optional system component includes all Memorial Hermann School-based Health Centers located within five school districts in the Greater Houston Area. These Memorial Hermann School-based Health Centers include: Alief Health Center, Burbank Health Center, Elrod Health Center, Hogg Health Center, Kruse Health Center, Lamar Health Center, Nimitz Health Center, Sharpstown Health Center, Terry Health Center, WAVE Health Center. This system component also includes Memorial Hermann’s School-based Health Center Mobile Dental van which serves these clinics on a rotating schedule."]
["137805107.7.1",3,"137805107","Memorial Hermann Hospital Southwest dba Memorial H","Hospital","Private","Other - Mental Health Crisis Clincs","Optional","Y","This optional system component includes all Memorial Hermann Mental Health Crisis Clinics. The three Memorial Hermann Mental Health Crisis Clinics are Spring Brand Mental Health Crisis Clinic, Meyerland Mental Health Crisis Clinic, and Northeast Mental Health Crisis Clinic."]
["137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Memorial Medical Center provides inpatient services which is defined as medical services that requires admission into our hospital for care.  This includes our Medical-Surgical unit, and Intensive Care unit to which a patient may be admitted to the hospital for general medical or surgical care, also including diagnostic and therapeutic services.  Inpatient services will consist of all services in all units other than the Maternal unit.  Maternal services will be included in our Maternal business component of the organization."]
["137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Memorial Medical Center has an Emergency department which is located inside the hospital.  The department offers medical treatment specializing in emergency medicine.  The department provides acute care of patients who present without prior appointment; either by their own means or by ambulance to our Emergency Department for immediate care."]
["137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Memorial Medical Center has a Rural Health Clinic which is located outside of the hospital.  Memorial Medical Clinic is an entity of our hospital designed to provide medical services to individuals in an outpatient clinic setting.  As of September 23, 2019, Memorial Medical Center has opened a second Clinic inside the hospital."]
["137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Our Labor and Delivery unit is a system component and involves all maternal services offered at our hospital.  A department of the hospital that provides care for women during labor and delivery, recovery, and postpartum care.  The maternal department also includes the care of newborn infants."]
["137909111.7.1",3,"137909111","Memorial Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private","Inpatient Services","Required","Y","Inpatient services are defined as services which require a doctor's order admitting you into the hospital for a variety of reasons. San Jacinto Hospital has 16 inpatient units (HMSJ ACUTE PT, HMSJ IP REHAB, HMSJ SNF, HMSJ 2 EAST, HMSJ 2 SOUTH, HMSJ INTERMEDIATE CARE, HMSJ IP WOUND CARE, HMSJ OR CV, HMSJ SICU, HMSJ AMB SURG CNTR, HMSJ ASU PREOP, HMSJ 2 WEST, HMSJ 3 WEST, HMSJ AOD, HMSJ ICU, HMSJ OBSERVATION 2). Houston Methodist Hospital has 51 inpatient units (Alkek 7, Alkek 8, Alkek 9, Dunn 10E, Dunn 3 ICU (SLICU), Dunn 4W, Dunn 7E, Dunn 8E, Dunn 9E, Fondren 10 ICU/IMU, Fondren 11, Fondren 12, Fondren 2 MICU, HMH ENDOSCOPY, HMH EYE HOLDING, HMH FONDREN HEART FAIL, HMH 17HEART TRANSPLT, HMH LABOR DELIVERY D6W, HMH PANCREAS TRANSP, HMH TMH TRANSPLT, HMH WP IP REHAB 10, HMH WP IP REHAB 9, Jones 10, Jones 11, Jones 8, Jones 9, MAIN 3NW AOD, MAIN 3NW OVERFLOW, Main 3SW, Main 4NW, Main 4SW, Main 6NW, Main 6SW, Main 7NE Psychiatry, Main 7SW, Main 8N, Main OR, Main PACU, WP IP 8 SNF, HMH OPC ENDOVASCULAR, Walter Tower 15 Inpatient BMT, Walter Tower 17 Neurosurgical Acute Care, Walter Tower 18 Eddy Scurlock Stroke, Walter Tower 19 Cardiovascular, Walter Tower 20 Cardiovascular, Walter Tower 14 Acute Care Oncology, Walter Tower 10 CICU, Walter Tower 9 CVICU, Walter Tower 11 NICU, Walter Tower 21 VIP, Walter Tower CVOR.). Patients can recieve inpatient services of the following specialties: Cardiac Intensive Care, Cardiology, Critical Care Medicine, General Internal Medicine, General Surgery, Hematology and Oncology, Intensive Care, Neurology, Obstetrics and Gynecology, Orthopedic Surgery, Psychiatry, Rehabilitation, Surgical Intensive Care, Transplant, and Urology."]
["137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private","Emergency Department","Required","Y","Emergency department is defined as medical treatment facility specializing in emergency medicine. It serves the acute care of patients who present without prior appointment who arrive either by their own means or by that of an ambulance. Within our system Emergency Departments are either located in a hospital or free standing.  This includes 4 Emergency departments at Houston Methodist Hospital (HMH HOSPITAL ED, HMH KIRBY SW FWY ED, HMH PEARLAND ECC, HMH VOSS ED) and one at SJ (HMSJ ED)."]
["137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Outpatient clinics are defined as outpatient service locations which may take place at an inpatient or outpatient physical location.  These services are strictly outpatient but may be services within a Medical Office Building, shared Inpatient/Outpatient space, or free standing location.  Methodist owns and operates over 278 outpatient departments clinics  across 34 distinct locations.\n"]
["137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private","Maternal Department","Required","Y","The maternal department in our hospital is one that provides care for women during pregnancy and childbirth as well as for newborn infants.  There are four maternal departments at Houston Methodist San Jacinto (HMSJ L&D PROCEDURES, HMSJ L&D TRIAGE, HMSJ LABOR DELIVERY, HMSJ NURSERY) and two in Houston Methodist Hospital (HMH NURSERY, and HMH NURSERY LEVEL II).\n"]
["137949705.7.1",3,"137949705","Houston Methodist Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private","Inpatient Services","Required","Y","Texas Children’s Hospital is an internationally recognized, full-care pediatric hospital located in the Texas Medical Center in Houston. With 650 beds and 3 hospitals, Texas Children's has over 3.3 million patient encounters each year. The following is a list of departments that make up our inpatient services.\nInpatient services at TCH Medical Center Campus\nInpatient services at TCH West Campus\nInpatient services at TCH The Woodlands Campus\nPediatric Hospital Medicine\nPalliative Care Service\nCancer Treatment at Wallace Tower (Clinical Care Tower)\nInfusion Center at Wallace Tower (Clinical Care Tower)\nPathology 3 at Wallace Tower\nCardiology Diagnostics at West Campus\nChildren's Sleep Center at West Campus\nCT Imaging at West Campus\nInfusion Center at West Campus\nInterventional Radiology at West Campus\nInterventional Radiology at West Campus\nMR Imaging at West Campus\nNeurosurgery at West Campus\nUltrasound Imaging at West Campus\nX-Ray Third Floor at West Campus\nX-Ray Fifth Floor at West Campus\nX-Ray/Fluoroscopy Imaging at West Campus\nChildrens Sleep Center at The Woodlands\nCT Imaging at The Woodlands\nInfusion Center at The Woodlands\nInterventional Radiology at The Woodlands\nInterventional Radiology Clinic at The Woodlands\nMR Imaging at The Woodlands\nPathology at The Woodlands\nRadiology Main Suite at The Woodlands\nUltrasound Imaging at Woodlands Campus\nX-Ray/Fluoroscopy Imaging at The Woodlands\nUltrasound Imaging at The Woodlands\nX-Ray Imaging at The Woodlands\nBone Marrow Transplant Unit at West Tower\nCardiology Diagnostics at West Tower\nChildren's Sleep Center at West Tower\nCT Imaging at West Tower\nCV Clinical Research Core at West Tower\nHome Peritoneal Dialysis at West Tower\nIn-Center Hemo Dialysis at West Tower\nInterventional Radiology at West Tower\nIR Imaging Clinic at West Tower\nMR Imaging at West Tower\nThe Newborn Center Level 3 at West Tower\nOccupational Therapy at West Tower\nPathology at West Tower\nPediatric Intensive Care Unit at West Tower\nPhysical Therapy at West Tower\nUltrasound Imaging at West Tower\nX-Ray/Fluoroscopy Imaging at West Tower\nX-Ray Imaging 20 - Cardiology at West Tower"]
["139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private","Emergency Department","Required","Y","Emergency Center at The Woodlands\nEmergency Center at West Campus\nEmergency Center at West Tower\n"]
["139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Texas Children's Hospital provides care in more than 40 pediatric subspecialties and treats children across the state, nation and world for the most complex conditions. Below is a list of departments that make up our outpatient services. \nTexas Children's Pediatrics Cy-Fair\nTexas Children's Pediatrics Sugar Land\nAdol/Spor/Yng Woman's at Health Center Cy-Fair\nAdol/Spor/Yng Woman's at Health Center Sugar Land\nAdol/Spor/Yng Woman's at Wallace Tower (Clinical Care Tower)\nAdolescent Medicine at West Campus\nAllergy and Immunology at Health Center Sugar Land\nAllergy and Immunology at Specialty Care Kingwood\nAllergy and Immunology at The Woodlands\nAllergy and Immunology at The Woodlands\nAllergy and Immunology at Wallace Tower (Clinical Care Tower)\nAllergy and Immunology at West Campus\nBone Marrow Transplant at West Tower\n\nBreast Clinic at Wallace Tower (Clinical Care Tower)\nCancer Center at The Woodlands\nCancer Center at Wallace Tower (Clinical Care Tower)\nCancer Center at West Campus\nCancer Genetics at Wallace Tower (Clinical Care Tower)\nCardiac Development Outcomes Program at West Tower\nCardiology at Health Center Clear Lake\nCardiology at Health Center Cy-Fair\nCardiology at Health Center Sugar Land\nCardiology at Specialty Care Kingwood\nCardiology at The Woodlands\nCardiology at The Woodlands\nCardiology at West Campus\nCardiology at West Tower\nChest Wall Deformity Clinic at Wallace Tower (Clinical Care Tower)\nChildhood Obesity at Health Center Cy-Fair\nChildhood Obesity at West Campus\nChildren's Sleep at West Campus\nCleft Palate Clinic at Wallace Tower (Clinical Care Tower)\nComplex Care Clinic at Wallace Tower (Clinical Care Tower)\nComplex Care Clinic at West Campus\n\nCraniofacial Clinic at Wallace Tower (Clinical Care Tower)\nCraniosynostosis Clinic at Wallace Tower (Clinical Care Tower)\nDental at Wallace Tower (Clinical Care Tower)\nDermatology at Health Center Sugar Land\nDermatology at The Woodlands\nDermatology at Wallace Tower (Clinical Care Tower)\nDermatology at West Campus\nDevelopmental Pediatrics\nDevelopmental Pediatrics at Health Center Sugar Land\nDevelopmental Pediatrics at The Woodlands\nDevelopmental Pediatrics at Wallace Tower (Clinical Care Tower)\nDiabetes and Endocrine at The Woodlands\nDiabetes and Endocrine at West Campus\nEcho at West Campus\nEndocrine at Health Center Clear Lake\nEndocrine at Health Center Cy-Fair\nEndocrine at Health Center Sugar Land\nEndocrine at The Woodlands\nEndocrine at Wallace Tower (Clinical Care Tower)\nEpilepsy Monitoring Unit at West Tower\nGastroenterology Hepatology and Nutrition at Health Center Clear Lake\nGastroenterology Hepatology and Nutrition at Health Center Cy-Fair\nGastroenterology Hepatology and Nutrition at Health Center Sugar Land\nGastroenterology Hepatology and Nutrition at Specialty Care Kingwood\nGastroenterology Hepatology and Nutrition at The Woodlands\nGastroenterology Hepatology and Nutrition at The Woodlands\nGastroenterology Hepatology and Nutrition at Wallace Tower (Clinical Care Tower)\nGastroenterology Hepatology and Nutrition at West Campus\nGeneral Pediatric Outpatient Consult Services at Wallace Tower (Clinical Care Tower)\nGenetics at The Woodlands\nGenetics at Wallace Tower (Clinical Care Tower)\nHand Clinic at Specialty Care Bellaire\nHand Clinic at West Campus\nHematology & Oncology Center at The Woodlands\nHematology at Wallace Tower (Clinical Care Tower)\nHematology Oncology Unit at West Tower\nInfectious Disease at The Woodlands\nInfectious Disease at The Woodlands\nInfectious Disease at Wallace Tower (Clinical Care Tower)\nInfectious Disease at West Campus\nIntraoperative Monitoring at West Tower\nMetabolic Disorders at Wallace Tower (Clinical Care Tower)\nMultidisciplinary Pain Management at Wallace Tower (Clinical Care Tower)\nNeurofibromatosis at Wallace Tower (Clinical Care Tower)\nNeurology\nNeurology at Health Center Clear Lake\nNeurology at Health Center Cy-Fair\nNeurology at Health Center Sugar Land\nNeurology at The Woodlands\nNeurology at The Woodlands\nNeurology at Wallace Tower (Clinical Care Tower)\nNeurology at West Campus\nNeurophysiology at Health Center Clear Lake\nNeurophysiology at Health Center Cy-Fair\nNeurophysiology at Health Center Sugar Land\nNeurophysiology at The Woodlands\nNeurophysiology at The Woodlands\nNeurophysiology at West Campus\nNeurophysiology at West Tower\nNeurosurgery at Wallace Tower (Clinical Care Tower)\nOphthalmology at Health Center Cy-Fair\nOphthalmology at Health Center Sugar Land\nOphthalmology at The Woodlands\nOphthalmology at The Woodlands\nOphthalmology at Wallace Tower (Clinical Care Tower)\nOphthalmology at West Campus\nOrthodontics at Wallace Tower (Clinical Care Tower)\nOrthopedic Surgery at Specialty Care Bellaire\nOrthopedics at Health Center Clear Lake\nOrthopedics at Health Center Cy-Fair\nOrthopedics at Health Center Sugar Land\nOrthopedics at Specialty Care Kingwood\nOrthopedics at Specialty Care Upper Kirby\nOrthopedics at The Woodlands\nOrthopedics at The Woodlands\nOrthopedics at Wallace Tower (Clinical Care Tower)\nOrthopedics at West Campus\nOtolaryngology at Health Center Clear Lake\nOtolaryngology at Health Center Cy-Fair\nOtolaryngology at Health Center Sugar Land\nOtolaryngology at Specialty Care Bellaire\nOtolaryngology at Specialty Care Eagle Springs\nOtolaryngology at The Woodlands\nOtolaryngology at The Woodlands\nOtolaryngology at Wallace Tower (Clinical Care Tower)\nOtolaryngology at West Campus\nPediatric and Adolescent Gynecology at Health Center Sugar Land\nPediatric and Adolescent Gynecology at Wallace Tower (Clinical Care Tower)\nPediatric and Adolescent Gynecology at West Campus\nPediatric Anesthesia Screening Service at The Woodlands\nPediatric Anesthesia Screening Service at Wallace Tower (Clinical Care Tower)\nPediatric Anesthesia Screening Service at West Campus\nPediatric Anesthesia Screening Service at West Tower\nPediatric Gynecology at The Woodlands\nPediatric Surgery at Health Center Clear Lake\nPediatric Surgery at Health Center Cy-Fair\nPediatric Surgery at Health Center Sugar Land\nPediatric Surgery at Pearland\nPediatric Surgery at Specialty Care Kingwood\nPediatric Surgery at The Woodlands\nPediatric Surgery at The Woodlands\nPediatric Surgery at Wallace Tower (Clinical Care Tower)\nPediatric Surgery at West Campus\nPheresis at West Tower\nPhysical Medicine and Rehabilitation at Health Center Cy-Fair\nPhysical Medicine and Rehabilitation at Health Center Sugar Land\nPhysical Medicine and Rehabilitation at The Woodlands\nPhysical Medicine and Rehabilitation at The Woodlands\nPhysical Medicine and Rehabilitation at Wallace Tower (Clinical Care Tower)\nPhysical Medicine and Rehabilitation at West Campus\nPhysical Medicine and Rehabilitation at West Tower\nPlastic Surgery at Health Center Clear Lake\nPlastic Surgery at Health Center Cy-Fair\nPlastic Surgery at Health Center Sugar Land\nPlastic Surgery at Specialty Care Kingwood\nPlastic Surgery at The Woodlands\nPlastic Surgery at The Woodlands\nPlastic Surgery at Wallace Tower (Clinical Care Tower)\nPlastic Surgery at West Campus\nPrader-Willi at Wallace Tower (Clinical Care Tower)\nPsychiatry\nPsychiatry at Health Center Sugar Land\nPsychiatry at The Woodlands\nPsychiatry at Wallace Tower (Clinical Care Tower)\nPsychiatry at Wallace Tower (Clinical Care Tower)\nPsychology\nPsychology\nPsychology at Health Center Sugar Land\nPsychology at Specialty Care Upper Kirby\nPsychology at The Woodlands\nPsychology at The Woodlands\nPsychology at West Campus\nPsychology Houston Pediatric Associates\nPublic Health Pediatrics at Wallace Tower (Clinical Care Tower)\nPulmonary Medicine at West Campus\nPulmonology at Health Center Clear Lake\nPulmonology at Health Center Cy-Fair\nPulmonology at Health Center Sugar Land\nPulmonology at Specialty Care Kingwood\nPulmonology at The Woodlands\nPulmonology at The Woodlands\nPulmonology at Wallace Tower (Clinical Care Tower)\nRenal at Health Center Cy-Fair\nRenal at Wallace Tower (Clinical Care Tower)\nRenal at West Campus\nResident's Primary Care Group at Wallace Tower (Clinical Care Tower)\nRetrovirology at Wallace Tower (Clinical Care Tower)\nRetrovirology Travel at West Campus\nRetrovirology Travel Clinic at Wallace Tower (Clinical Care Tower)\nRheumatology at Health Center Clear Lake\nRheumatology at Health Center Cy-Fair\nRheumatology at Health Center Sugar Land\nRheumatology at The Woodlands\nRheumatology at The Woodlands\nRheumatology at Wallace Tower (Clinical Care Tower)\nRheumatology at West Campus\nSkeletal Dysplasia at Wallace Tower (Clinical Care Tower)\nSpasticity Management at Wallace Tower\nSpina Bifida at Wallace Tower (Clinical Care Tower)\nSports Medicine at Specialty Care Kingwood\nSports Medicine at The Woodlands\nSports Medicine at The Woodlands\nSports Medicine at West Campus\nSports Medicine Physical Therapy at The Woodlands\nStone Clinic at Wallace Tower (Clinical Care Tower)\nStone Clinic at West Campus\nTexas Children's Pediatrics Ashford\nTexas Children's Pediatrics Barker Cypress\nTexas Children's Pediatrics Baytown\nTexas Children's Pediatrics- Behavioral Wellness\nTexas Children's Pediatrics Cinco Ranch\nTexas Children's Pediatrics Cohan and Masharani\nTexas Children's Pediatrics Conroe\nTexas Children's Pediatrics Corinthian Pointe\nTexas Children's Pediatrics Cypress\nTexas Children's Pediatrics Cypresswood\nTexas Children's Pediatrics East\nTexas Children's Pediatrics Fannin\nTexas Children's Pediatrics FM 1960 After Hours\nTexas Children's Pediatrics FM 2920\nTexas Children's Pediatrics Friendswood\nTexas Children's Pediatrics Grand Parkway\nTexas Children's Pediatrics Green Park\nTexas Children's Pediatrics Gulfgate\nTexas Children's Pediatrics Gulfton \nTexas Children's Pediatrics Heights\nTexas Children's Pediatrics Houston Pediatric Associates\nTexas Children's Pediatrics Humble-Atascocita\nTexas Children's Pediatrics Humble-Fall Creek\nTexas Children's Pediatrics Humble-Kingwood\nTexas Children's Pediatrics Katy\nTexas Children's Pediatrics Kingsland\nTexas Children's Pediatrics Kingwood\nTexas Children's Pediatrics Lakewood\nTexas Children's Pediatrics Leass and McKillip\nTexas Children's Pediatrics Medical Plaza\nTexas Children's Pediatrics Memorial\nTexas Children's Pediatrics Midtown\nTexas Children's Pediatrics Missouri City\nTexas Children's Pediatrics Nanes\nTexas Children's Pediatrics North Shore\nTexas Children's Pediatrics Palm Center\nTexas Children's Pediatrics Pasadena\nTexas Children's Pediatrics Pearland\nTexas Children's Pediatrics Pediatric Medical Group\nTexas Children's Pediatrics Piney Point\nTexas Children's Pediatrics Post Oak\nTexas Children's Pediatrics Rayford\nTexas Children's Pediatrics Ripley House\nTexas Children's Pediatrics Shadow Creek Ranch\nTexas Children's Pediatrics Spring Branch\nTexas Children's Pediatrics Sterling Ridge\nTexas Children's Pediatrics Thaller and Shuman\nTexas Children's Pediatrics The Woodlands\nTexas Children's Pediatrics Town and Country at West Campus\nTexas Children's Pediatrics West Houston\n\nBaylos Pediatrics Westchase\nUltrasound Imaging at Specialty Care Upper Kirby\nUrology at Health Center Clear Lake\nUrology at Health Center Cy-Fair\nUrology at Health Center Sugar Land\nUrology at Specialty Care Kingwood\nUrology at Specialty Care Upper Kirby\nUrology at The Woodlands\nUrology at The Woodlands\nUrology at Wallace Tower (Clinical Care Tower)\nUrology at West Campus\nVannie E Cook\nX-Ray Imaging at Specialty Care Upper Kirby\n\n\n"]
["139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private","Maternal Department","Required","Y","At Texas Children’s Pavilion for Women, we care for women and children from preconception, to long after the birth of the child. We are dedicated to obstetrics, gynecology, and fetal intervention because we know to improve the health of children, we must start with mothers. The Pavilion for Women is a 15-story, 1.3 million-square-foot facility with 106 patient beds and the capacity to deliver 5,000 babies annually. Below is a list of departments that make up the Maternal Services.\nBaylor Gynecology - Pavilion for Women\nBaylor Gynecology/Oncology - Pavilion for Women\nBaylor Maternal Fetal Medicine - Pavilion for Women\nBaylor Obstetrics/Gynecology - Pavilion for Women\nBaylor REI/IVF - Pavilion for Women\nBaylor Uro/Gynecology - Pavilion for Women\nCT Imaging - Pavilion for Women\nFamily Fertility Center - Pavilion for Women\nFetal Center - Pavilion for Women\nFetal Center Echo - Pavilion for Women\nInfusion Center - Pavilion for Women\nInterventional Radiology - Pavilion for Women\nIR Imaging Clinic - Pavillion for Women\nLabor & Delivery Operation Room - Pavilion for Women\nLabor & Delivery Unit - Pavilion for Women\nLactation Support - Pavilion for Women\nMaternal Fetal Medicine - Methodist Hospital\nMaternal Fetal Medicine - Northwest\nMaternal Fetal Medicine - Sugar Land\nMaternal Fetal Medicine - West Houston\nMaternal Fetal Medicine at The Woodlands\nMEG - Pavilion for Women\nMR Imaging - Pavilion for Women\nNICU - Pavilion for Women\nObstetrics/Gynecology - Pearland\nOperating Room - Pavilion for Women\nPALLIATIVE CARE SERVICE\nPartners In OB-Gyn Care\nPathology - Pavilion for Women\nPhysical Therapy - Pavilion for Women\nPre-Admission Testing - Pavilion for Women\nPsychiatry - Pavilion for Women\nTexas Children's Maternal Fetal Medicine - Baytown\nThe Women's Place - NW\nUltrasound Imaging - Pavilion for Women\nWomen's Assessment Center - Pavilion for Women\nWomen's Services - Pavilion for Women\nWomen's Specialists of Houston\nWomen's Specialty - Pavilion for Women\nX-Ray Imaging 4 - Pavilion for Women"]
["139135109.7.1",3,"139135109","Texas Children's Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Texas Children's Urgent Care clinics are open Monday through Friday, 4:30 to 11 p.m. and Saturday and Sunday, 12 to 8 p.m. The clinics are staffed by board certified pediatricians who have privileges at Texas Children's Hospital. Pediatricians diagnose and treat a wide variety of ailments, illnesses and conditions, including: asthma, strep throat, fever, minor burns, influenza, ear infections, allergic reactions and more. Procedures provided include: antibiotic injections, breathing treatments, fracture care and splinting, IV (intravenous) fluids, lab services, laceration repair and x-rays on-site. Below is a list of our urgent care locations. \nTexas Children's Urgent Care - The Vintage\nTexas Children's Urgent Care - Heights\nTexas Children's Urgent Care - Main Campus\nTexas Children's Urgent Care - Memorial\nTexas Children's Urgent Care - Pearland\nTexas Children's Urgent Care - Cinco Ranch\nTexas Children's Urgent Care - East\nTexas Children's Urgent Care - Fairfield\nTexas Childrens Urgent Care - The Woodlands"]
["140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private","Inpatient Services","Required","Y","Inpatient services are defined as units at Houston Methodist Willowbrook which require a doctor's order admitting you into the hospital for a variety of reasons. Methodist Willbrook has 20 inpatient units (HMWB CF OP SURGERY, HMWB CF PREOP, HMWB ACUTE PT, HMWB CARDIO IMAGING, HMWB ENDOSCOPY, HMWB ICU – MICU, HMWB NSY NICU LEVEL II, HMWB NSY NICU LVL III, HMWB OBS UNIT, HMWB OR SURGERY, HMWB PHARMACY, HMWB RESP CARE, HMWB SICU M3NE, HMWB US, HMWB W3NW, HMWB WN5W, HMWB WN6E, HMWB WN6W, HMWB WN7E, and HMWB WN7W)."]
["140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private","Emergency Department","Required","Y","Emergency department is defined as medical treatment facility specializing in emergency medicine. It serves the acute care of patients who present without prior appointment who arrive either by their own means or by that of an ambulance. Within our system Emergency Departments are either located in a hospital or free standing. Methodist willowbrook has 3 Emergency departments: HMWB CYPRESS ED, HMWB HOSPITAL, and HMWB SPRING ED.\n"]
["140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N"]
["140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private","Maternal Department","Required","Y","The maternal department in our hospital is one that provides care for women during pregnancy and childbirth as well as for newborn infants. Methodist Willowbrook has 1 maternal department offering 5 areas of service: HMWB LABOR DLVRY M2NW, HMWB LD ANTE PARTUM, HMWB MOTHER BABY, HMWB NSY NICU LVL III and HMWB NURSERY.\n   \n    \n    \n"]
["140713201.7.1",3,"140713201","Methodist Willowbrook","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Harris County Public Health operates three grant based community clinics (Listed Below). Clinics are non-primary care, offering preventative wellness interventions, screenings, assessments, and education. Services include, DSHS Family planning, Title X reproductive health, and Title V dental services ( Only provided at 1.5 clinics). In addition HCPH operates one refugee health screening, and one TB chest clinic (Listed below).\n\nCommunity Clinics\n\nBaytown Health Clinic\n1000 Lee Drive\nBaytown, Texas 77520\n\nHumble Health Clinic\n1730 Humble Place Drive\nHumble, Texas 77338\n\nSoutheast Health Clinic\n3737 Red Bluff\nPasadena, Texas 77503\n\nDental Clinics\n\nHumble Dental Clinic\n1730 Humble Place Drive\nHumble, Texas 77338\n\nSoutheast Dental Clinic\n3737 Red Bluff\nPasadena, Texas 77503\n\nTB Chest Clinic\nAntoine TB Clinic\n5815 Antoine Drive\nHouston, Texas 77091\n\nSoutheast TB Clinic\n3737 Red Bluff\nPasadena, Texas 77503\n\nRefugee Health \n\nRefugee Outreach Center\n7447 Harwin Drive\nHouston, Texas 77036\n\n\n\n"]
["158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Immunizations are provided at the three Harris County community based clinics and Refugee Health Clinic                                                                                                                                                   Community Clinics\n\nBaytown Health Clinic\n1000 Lee Drive\nBaytown, Texas 77520\n\nHumble Health Clinic\n1730 Humble Place Drive\nHumble, Texas 77338\n\nSoutheast Health Clinic\n3737 Red Bluff\nPasadena, Texas 77503\n\n\nRefugee Health \n\nRefugee Outreach Center\n7447 Harwin Drive\nHouston, Texas 77036\n"]
["158771901.7.1",3,"158771901","Harris County Public Health & Environmental Services","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Waiver 1.0 made way for Harris County Public Health to break away from the fixed clinical establishment, and take essential wellness educations and screenings outside the fixed structure and into the community. The mobile outreach team is comprised of the following programs ( Childhood Obesity Reduction, Tobacco Counseling, Mobile Health, Child school-based Dental Screenings, Lead poisoning education). HCPH made heavy investments in mobile outreach through the  purchase of one medical specialty unit and one dental specialty unit. Both to allow for expansion of service offerings. "]
["181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private","Inpatient Services","Required","Y","Short term acute care facility that includes 248 staffed beds utilizing  sub-specialties (cardio, medicine, ortho, gynecology, surgery) - general & ICU.  Facility includes ancillary departments of Behavioral Health, Sports Rehabilitation, Wound Care, and Radiation Oncology."]
["181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private","Emergency Department","Required","Y","SJMC has 2 emergency departments - one is located at the downtown campus and one is located at the Heights campus. The ED is a certified Level 3 trauma center, certified primary stroke center, and provides telemedicine partnerships with the UT neuroscience department for stroke victims. The ED has 26 patient rooms and treats 2500-2800 patients per month. "]
["181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","SJMC has several ambulatory clinics including a wound center, radiation oncology, and sports rehabilitation. "]
["181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private","Maternal Department","Required","Y","SJMC has a robust maternity service which offers classes for perspective parents (breastfeeding, childbirth, newborn etc.), neonatal ICU, obgyn care, and labor and delivery. "]
["181706601.7.1",3,"181706601","St Joseph Medical Center LLC","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","The system includes inpatient services from 3 hospitals which are located at Jackson Street, Williams Way, and in Wharton. In addition, the system includes a Skilled Nursing Facility co-located with the main hospital on Jackson Street. These facilities comprise the sites of care for individuals needing care which extends overnight. Over half of our inpatient hospital admissions come through the emergency department. "]
["127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The system includes 4 ED departments at Jackson, Williams Way, Grand Parkway, and Wharton.  OakBend's Emergency Department is responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care.  It is the only no wait hospital ER in the Greater Houston Area.  The Emergency Care Centers are affiliated with local nursing schools to provide clinical rotations for RN and EMT students of all levels. OakBend's air ambulance has transfer agreements in place with several Texas Medical Center hospitals for the care of severely injured trauma patients and pediatric patients. "]
["127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The outpatient clinics are owned or operated by OakBend Medical Group which includes 6 clinics offering both primary and specialty care. Additionally, the medical group operates 4 ambulatory surgery centers and 20 physical therapy clinics. The number of both surgery centers and physical therapy clinics may fluctuate based on ownership changes. OakBend also provides outpatient services at our hospital locations and these services are included in our system definition."]
["127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Maternal department at OakBend Medical Center includes Labor and Delivery, Postpartum, Antepartum, and level II NICU."]
["127303903.7.1",3,"127303903","Oak Bend Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private","Inpatient Services","Required","Y","Inpatient services at Rice Medical Center include patients that are: Medical/Inpatient, Nursery/Inpatient, Obstetrics/Inpatient, Surgical/Inpatient, and Swing Bed.  "]
["212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency department sees an estimated total of 800 patients during the year. "]
["212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Rice owns two outpatient clinics: Rice Medical Associates (located in Eagle Lake) and Rice Medical Associates-East Bernard (located 17 miles from Eagle Lake). Rice classifies its FastTrack Clinic under this system component although it is billed as an outpatient department visit within the hospital. "]
["212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private","Maternal Department","Required","N",""]
["212060201.7.1",3,"212060201","Rice Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","FBC Clinical Health Services (CHS) outpatient locations\nFort Bend County clinic services are provided in two county buildings.  In the main clinic location (Rosenberg Annex), TB prevention and control, STD treatment and partner elicitation, and  HIV risk reduction services are provided. At the second clinic location (Missouri City Annex), TB prevention and control and  HIV risk reduction services are provided.  FBC does not own or operate any primary care clinics."]
["296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","FBC Clinical Health Services (CHS) immunization locations\nFort Bend County offers immunizations in three county buildings: Nancy Drake Clinic (Rosenberg, TX), Fort Bend County Missouri City Annex (Missouri City, TX), and Fort Bend County North Annex (Katy, TX)\nVaccines provided by the Texas Vaccines for Children program are offered only to individuals who are uninsured or Medicaid recipients. Only flu vaccine purchased by the county is offered without restriction to payer type. Part of the program mandate is to encourage all recipients to develop a relationship with a medical home because FBC CHS does not provide any primary care services.  The locations are for immunizations only with no medical assessment or diagnostic work available.  FBC does not own or operate any primary care clinics."]
["296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","• Mobile Outreach:  Crisis Intervention Services (CIT)\no CIT is jointly administered by the FBC Sherriff’s office and Behavioral Health Services.  The program involves law enforcement officers trained in mental health crises, answering mental health related 911 calls, and redirecting mental health issues away from the criminal justice system and toward appropriate mental healthcare.  Other Sherriff’s office mobile services are not connected to mental or physical healthcare and should not be considered part of FBC’s client care landscape.\n• Mobile Outreach:  EMS\no Fort Bend County’s emergency medical services respond to 911 health emergencies.  Fort Bend County considers EMS pre-hospital care and transportation to care. \no Fort Bend County EMS and CIT are both components of the County’s emergency response system activated through the 911 communication system. As a result, both entities may respond to the same call for service, however, Fort Bend County HHS and BHS have worked to delineate calls at dispatch level to avoid unnecessary multiple first responders arriving at the scene."]
["296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public","Other - Access Health FQHC Adult Family Practice Clinics in Richmond and Missouri City","Optional","Y","FBC contracts with Access Health FQHC in Richmond and Missouri City for adult care only.  Access Health’s clinics have adult-only clinics within them.  Children and OB/GYN are services within Access Health but are not contracted services with FBC so they are excluded from the FBC DSRIP system."]
["296760601.7.1",3,"296760601","Fort Bend County","Local Health Department (LHD)","Non‐State Owned Public","Other - FBC Behavioral Health Services Department","Optional","Y","o FBC Behavioral Health Services Department, located at 301 Jackson Street is an intake office. Much of the care provided after intake is in other community-based settings. FBC includes these service delivery sites in the system definition. \no Organizationally, Behavioral Health Services is part of Fort Bend County’s Administration of Justice Division, not part of FBC Health and Human Services.  It is owned and operated by FBC.  The following services are part of Behavioral Health Services:\no Recovery and reintegration:  for adults with mental health disorders who are involved in criminal justice and need intensive case management and wrap around services.  Services originate upon intake at 301 Jackson Street but also occur in the home, in court, and in jail.  This population is part of the DSRIP projects.  \no Juvenile diversion:  same as above but for children.  Services originate upon intake at 301 Jackson Street but also occur in the home, in court, in school, and in jail.  This population is part of the DSRIP projects.  \no Crisis Intervention Team:  jointly administered with the FBC Sherriff’s office.  Clients do not originate in intake at 301 Jackson St.  They originate from CIT responding to mental health crises throughout the county as a result of 911 calls.\no Individuals receiving court ordered forensic assessment services (e.g. competency to stand trial assessments) are not included in our system definition.\no  Children and parents involved in our CPS courts that  receive court ordered services are not included in our system definition. "]
["311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private","Inpatient Services","Required","Y","ECMH operates 26 inpatient beds for short term acute care and swing beds, including 4 ICU beds. Geographically, the hospital is classified as small rural hospital, located 71 miles southwest of The Medical Center in Houston, the hospital is also classified as Sole Community Hospital since Nov 2017. ECMH has an average daily census of 9.7 in the current fiscal year, with 20% in the payor groups of MLIU. Services provided include surgeries, advanced imaging, lab, pulmonary, cardiology, sleep lab, dialysis and other ancillary services."]
["311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private","Emergency Department","Required","Y","ECMH operates a level 3 ED unit with 8 patient beds. It is open 24-7 accepting local patients as well as all ambulance transfers. The ED unit services an average of 1,000 patients per month, staff with Emergency medicine trained physicians, RNs and other support personnel."]
["311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","As an integral part of ECMH, ECMH operates outpatient clinic under the legal name of Mid Coast Medical Clinic, MCMC. MCMC is a wholly owned subsidiary of ECMH. MCMC has greatly expanded services by adding new locations. 4 new locations have been added since the last reporting period. Several of MCMC clinics are licensed by Medicare as Rural Health Clinics, others are free standing clinics. MCMC clinic locations include El Campo (3), Wharton (3), Bay City (1), Louise (1), Blessing (1), and Palacios (1). MCMC employs a total of 25 family practice physicians and mid-level providers as well as several specialty physicians. In the current reporting period, MCMC has an average monthly patient visits exceeding 5,500. Data reporting for all current and future periods will be inclusive of all clinic locations within the system definition of ECMH."]
["311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private","Maternal Department","Required","N"]
["311054601.7.1",3,"311054601","El Campo Memorial Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private","Inpatient Services","Required","N",""]
["377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private","Emergency Department","Required","N",""]
["377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private","Maternal Department","Required","N",""]
["377705401.7.1",3,"377705401","North Houston-TRMC LLC dba Tomball Reg Med Ctr","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private","Inpatient Services","Required","Y","Spohn Beeville's system definition will include all inpatients, observation patients, and all patients visiting the facility for outpatient procedures."]
["020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private","Emergency Department","Required","Y","Spohn Beeville's system definition will include all patients visiting the Emergency Department."]
["020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Spohn Beeville's system definition will include the Spohn Beeville primary care clinic."]
["020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private","Maternal Department","Required","Y","Spohn Beeville's system definition will include any maternal patients admitted to the hospital or visiting the Emergency Department."]
["020811801.7.1",4,"020811801","Christus Spohn Hospital Beeville","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Inpatient Services","Required","Y","Corpus Christi Medical Center provides comprehensive inpatient services for Medical/Surgical, ICU/CCU, rehab, and behavioral health."]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Emergency Department","Required","Y","Corpus Christi Medical Center has four designated Emergency Departments in the vicinity, including 2 free standing EDs"]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Corpus Christi Medical Center offers intensive outpatient programs (IOP) and partial hospitalization programs (PHP) through outpatient behavioral health.   There are two IOP programs and two PHP programs at the Bayview campus.  There is one IOP program at the Northwest campus.  Corpus Christi Medical Center also offers an outpatient cardiac rehab program at the Heart Hospital campus and an outpatient infusion center at the Bay Area campus.  "]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Maternal Department","Required","Y","Corpus Christi Medical Center has over 4,000 deliveries annually and a Level III NICU."]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020973601.7.1",4,"020973601","Corpus Christi Medical Center","Hospital","Private","Other - Hospital Outpatient Services","Optional","Y","Owned and operated services to include but not limited to Cardiac Testing , Labs, Imaging and Diagnostic services, Same Day Surgeries and Pain Management "]
["020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","25 bed med/surg tele floor.  Staffed with RN's and LVN's."]
["020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","4 bed Level IV trauma ER with doctor on staff at all times."]
["020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","3 rural health care clinics staffed with Doctors and Mid-level practitioners"]
["020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["020991801.7.1",4,"020991801","Refugio County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["080368601.7.1",4,"080368601","Coastal Plains Community MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Coastal Plains Community Center (CPCC) provides targeted case management, intensive case management, respite, community living supports, psychosocial rehabilitation, individual skills training, crisis, peer supports, and veterans' services to eligible individuals in their homes.  Coastal Plains has seven (7) integrated clinics where direct service providers report to as their worksite before heading out to provide home-based services.  All data provided by all Center staff is recorded in Coastal Plains' electronic health record."]
["080368601.7.1",4,"080368601","Coastal Plains Community MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","CPCC provides psychiatric evaluations, medication education, navigation, counseling, intake/screening, targeted case management, intensive case management, community living supports, individual/group psychosocial rehabilitation, individual/group skills training, crisis, individual/group peer supports, and veterans' services to eligible individuals.  Coastal Plains has seven (7) integrated clinics where direct service providers meet with individuals enrolled into services.  In addition, Coastal Plains contracts with primary care and substance abuse providers to deliver these services in all of its' seven (7) locations.  All data provided by all Center staff is recorded in Coastal Plains' electronic health record."]
["094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private","Inpatient Services","Required","Y","All services in all Units to which a patient may be admitted to the hospital for general medical or surgical care, ICU care, or IP Rehab care including diagnostic and therapeutic service (excludes Maternal Services below).    Acute Care inpatient locations include four med surg Units, an ICU and an IP Rehab Unit at  one facility (Navarro), and one Med Surg Unit at DeTar North."]
["094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private","Emergency Department","Required","Y","All services for patients who present to the Emergency Department for immediate care.   This can be related to trauma or emergency care but is also used by people with lesser illnesses.  An Emergency Severity Index Triage system is used to assign the degree of urgency.  DeTar operates emergency departments in two separate facilities--21 beds at Navarro and 7-beds at North."]
["094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","DeTar operates two clinics:   a Senior Care Clinic that is a department of the hospital and provides PCP services to those over 65 and the  DeTar Family Medicine Residency Clinic.  The latter a Family Medicine residency clinic with Texas A&M University.  Primary care provider services are conducted by these residents and the faculty to people of all ages."]
["094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private","Maternal Department","Required","Y","All  services in a LDRP Unit, Mom Baby Unit, and Level III NICU to which mothers and infants may be admitted to the hospital for general OB and surgical care (C-Section) including diagnostic and therapeutic service.   These services are offered at DeTar North location only."]
["094118902.7.1",4,"094118902","DeTar Hospital (Victoria of Tx)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private","Inpatient Services","Required","Y","Spohn's system definition includes all patients admitted as an inpatient and observation patients at the Spohn Alice hospital. Spohn is also including patients visiting the facility for outpatient procedures."]
["094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private","Emergency Department","Required","Y","Spohn's system definition includes all patients visiting the Spohn Alice Emergency Department."]
["094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Spohn's system definition includes all patients visiting the outpatient clinic owned by Spohn Alice, referred to as the Freer clinic."]
["094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private","Maternal Department","Required","Y","Spohn's system definition  includes all maternal inpatients and any pregnant patients visiting the Spohn Alice Emergency Room."]
["094222903.7.1",4,"094222903","Christus Spohn Hospital Alice","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private","Inpatient Services","Required","Y","Yoakum Community Hospital has several inpatient departments, including: nursey, intensive care unit, radiology, surgery, and geriatric counseling."]
["112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private","Emergency Department","Required","Y","Yoakum Community Hospital has a 24-hour emergency department and was the first hospital in the area to receive a level 4 trauma designation by the Texas Department of Health. We have met the Texas Department of Health's standard of care for treating emergencies and our staff has specialized training in cardiac, pediatric, and trauma emergencies."]
["112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Yoakum Community Hospital has several outpatient clinics such as: MRI, wound care, digital mammography, orthopedics, gynecology, podiatry, nephrology, gastroenterology, and diet consults.\n\nCardiology, Dermatology, ENT, Endocrinology, Counseling, Neonatology, Spinal surgery, Surgery, Urology."]
["112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private","Maternal Department","Required","N",""]
["112673204.7.1",4,"112673204","Yoakum Community Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Spohn will include all inpatients, hospital outpatients, and observation patients at Spohn Memorial, Shoreline and South."]
["121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Spohn will include all patients visiting a Spohn Emergency Department."]
["121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Spohn will include all patients visiting the Spohn Northside, Northside Extension (Quick Care), Family Medicine Academic Center, Padre Island, Robstown, and Westside Family Health Centers. Spohn will also include all outpatient cancer center patients as well as specialty care clinic patients. Spohn Memorial provides prenatal services and specialty OB services."]
["121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Spohn will include all maternal patients visiting the facility either as an inpatient or in the Emergency Department"]
["121775403.7.1",4,"121775403","Spohn Health System dba Spohn Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","JCHD operates 17 inpatient beds."]
["121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","JCHD operates an Emergency Department."]
["121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","JCHD operates a Rural Health Clinic, Home Health Agency, and EMS department."]
["121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["121808305.7.1",4,"121808305","Jackson County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["130958511.7.1",4,"130958511","Nueces County","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","The Corpus Christi-Nueces County Public Health District (CCNCPHD) is a local health department that provides clinical and educational services primarily in Nueces county and surrounding Kleberg, San Patricio, Jim Wells counties.  Our goal is consistent with the RHP4 mission and quality goals as well as CMS’s triple aim to:  improve care for individuals, including access to care, quality of care, and health outcomes;  improve health for the population and lower costs through improvements without any harm to individuals, families, or communities.  \nThe following clinics make up the CCNHPHD organization:\n\n1. Immunizations Clinic\nThe Immunizations clinic provides Texas vaccines for children up to and including age 18.  They also provide routine vaccines for adults including Hepatitis A and B, Meningococcal, Influenza, Polio, etc. and travel vaccines such as Typhoid and Yellow Fever.  They provide education to our community on the importance and benefits of being vaccinated.\n\n2. STD Clinic\nThe STD clinic provides multiple services to the community assuring patient health and treatment are of the highest confidentiality.  Areas of testing include providing examinations, testing, diagnosis, treatment, and counseling for sexually transmitted diseases, HIV-AIDS and other related problems.  \n\n3.Community Health Clinic \nThe Community Health Clinic provides health services to the community including pregnancy testing, pelvic examinations, breast and cervical cancer screenings, HIV screenings, birth control contraceptives, physicals, and family planning.\n\n4. Tuberculosis Clinic \nThe TB Clinic provides health services to the community including TB skin testing, chest X-ray, referrals, medications for Tuberculosis, laboratory services for cases, and other services as needed.\n\n5. 1115 Waiver Program\nThe 1115 Waiver Program provides free wellness screenings to the community, including HbA1C, Blood Pressure, and BMI screenings.   Also, the program provides diabetes self-management education and community resource referrals. The goal of the 1115 Waiver Program is to overcome the high risk of the increasing epidemic of chronic diseases and obesity in our community by providing the necessary education and tools needed to combat them.   \n\n6. WIC\nThe WIC Program provides testing and screening for anemia, height, weight and nutritional deficiencies for the low-income indigent population.  WIC also provides nutrition education, breast feeding counseling, and food cards for nutritious foods."]
["130958511.7.1",4,"130958511","Nueces County","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","The Immunizations clinic provides Texas vaccines for children up to and including age 18.  They also provide routine vaccines for adults including Hepatitis A and B, Meningococcal, Influenza, Polio, etc. and travel vaccines such as Typhoid and Yellow Fever.  They provide education to our community on the importance and benefits of being vaccinated."]
["130958511.7.1",4,"130958511","Nueces County","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","CCNCPHD has a Mobile Bod Pod trailer component which is used to provide much needed BMI , Hypertension , and  A1c screenings for our target populations in the rural areas of Nueces County, where transportation and access to quality healthcare is challenging. The Bod Pod Trailer is stationed at various pre-determined venue parking lots where CCNCPHD will perform testing.\nIn addition, a mobile medical clinic has been donated by the Texas A&M University Colonia’s Program to drastically extend our services to the rural areas of Nueces County for the people who have limited transportation to the services within the city of Corpus Christi.  Our efforts have brought many more interested stakeholders to the table who are willing to join us in this endeavor.  The intent it to begin seeing patients in the beginning of 2020."]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Inpatient Services","Required","Y","The inpatient services would include the Driscoll Children's Hospital Neonatal Intensive Care Unit, Pediatric Intensive Care Unit and the four (non-intensive care) Adult and Pediatric Units. "]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Emergency Department","Required","Y","Driscoll Children's Hospital has an emergency department located on the main campus in Corpus Christi TX.  "]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Driscoll Children's Hospital owns and operates the following outpatient clinics: the Corpus Christi locations (Pulmonology, GI, Cardiology, Endo/Diabetes, Neurology, Sports Medicine, Behavioral Med, Nephrology, Dialysis, Transplant,  Logistics, Rheumatology, IV Rx, Infection Disease, Hem/Oncology, High Risk Program and COG Research), the Victoria Clinic (Endo, GI, Nephrology, Surgery, Urology, Neurology), Laredo Clinic (Endo, GI, Nephrology, Surgery, Urology, Plastics), the Harlingen clinic (Surgery and Plastics), the Brownsville clinic (Nephrology, GI, Plastics, NeuroSurgery, Neurology, Surgery, Urology, and Hem/Oncology), and the McAllen clinic (GI, Plastic, Neurology, Neurosurgery, Nephrology)"]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Maternal Department","Required","N",""]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Driscoll Children's Hospital has a Urgent Care within Corpus Christi TX called Saratoga Urgent Care.  "]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Contracted Specialty Clinics","Optional","Y","Additional Specialty clinics would include:  Children's Physician Services of South Texas - High Risk Program (Laredo & Brownsville), Corpus Christi clinics (Psychiatry, Dermatology, ENT, Plastics, Urology), McAllen clinics (Urology), Driscoll Maternal Fetal Medicine Group - All locations; and Driscoll Valley Physician Group"]
["132812205.7.1",4,"132812205","Driscoll Children's Hospital","Hospital","Private","Contracted Primary Care Clinics","Optional","Y"," Victoria After Hours clinic; McAllen Quick Care clinic "]
["135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","The facility is licensed for 25 beds which are utilized for inpatient, observation and swing bed patients. "]
["135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The facility has a 5 bed Emergency Department open 24 hours a day/7 days a week. We are classified as a level IV Trauma facility. "]
["135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","All services in our rural health clinic for which a patient may seek service for family medicine and/or pediatric care."]
["135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["135233809.7.1",4,"135233809","Lavaca Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","As a Community Mental Health Center and Local Mental Health Authority, Gulf Bend Center provides targeted case management, routine case management, intensive case management, respite, community living supports, psychosocial rehabilitation, skills training, med education, crisis response, crisis and hospital follow-up, pathway (suicide prevention) and peer supports to eligible individuals in their homes as per TRR UM Guidelines.   Services are recorded in Gulf Bend Center’s EHR.  "]
["135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","As a Community Mental Health Center and Local Mental Health Authority (Title 7 of the Texas Health and Safety Code §534.053), Gulf Bend Center provides Hotline, Screening, Psychiatric Diagnostic Interview Examination, Pre-Admission Assessment, Routine Case Management, Intensive Case Management, IDD Service Coordination, Community Living Supports, Counseling, Peer Support, Family Supports, Respite Services, Supplemental Nursing Services, Pharmacological Management (E&M), Provision of Medication, Crisis Intervention Services, Medication Training and Support, Psychosocial Rehabilitative Services, Skills Training and Development Services, Supported Employment, Supported Housing, Safety Monitoring (Pathway Suicide Assessment), Crisis Follow-up and Relapse Prevention (Psychiatric Hospital Follow-Up) to all eligible individuals with Behavioral Health Needs.  As a CMHC working towards accreditation as a CCBHC Gulf Bend Center is adding Care Coordination and SUD (Substance Use Disorder) services to it array of services.  Gulf Bend Center provides Office/Clinic services through our main office/clinic in Victoria Texas and Counseling and Psychiatric services in our Port Lavaca Texas clinic.  Services are recorded in Gulf Bend Center’s EHR."]
["135254407.7.1",4,"135254407","Gulf Bend MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","To satisfy our role as a LMHA per requirements of Title 7 of the Texas Health and Safety Code §534.053, Gulf Bend Center facilitates access to State Operated Psychiatric hospital and additionally contracts with regional psychiatric hospitals to provide private psychiatric beds and rapid crisis stabilization bed days for patients in crisis.  Gulf Bend Center’s Crisis Response staff are engaged to respond to crisis events to screen and assess patient’s needs and eligibility for acute psychiatric hospitalizations regardless of funding.  Gulf Bend Center follows these patients Continuity of Care where the treating hospital provides discharge planning documentation.   These discharges and follow-ups are tracked by Gulf Bend’s EHR, Registry, HHSC CARE system and Encounter Data."]
["136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private","Inpatient Services","Required","Y","Spohn's system definition includes all patients admitted as an inpatient and observation patients at the Spohn Kleberg hospital. Spohn is also including patients visiting the facility for outpatient procedures."]
["136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private","Emergency Department","Required","Y","Spohn's system definition includes all patients visiting the Spohn Kleberg Emergency Department."]
["136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Spohn Kleberg provides outpatient services at the hospital including lab, radiology, physical therapy, wound care, emergency services, and observation services.  Spohn does not have any freestanding owned or operated outpatient clinics in the Spohn Kleberg system."]
["136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private","Maternal Department","Required","Y","Spohn's system definition  includes all maternal inpatients and any pregnant patients visiting the Spohn Kleberg Emergency Room."]
["136436606.7.1",4,"136436606","CHRISTUS Spohn Hospital Kleberg","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Citizens Medical Center is an acute care hospital located in Victoria County Texas in RHP 4"]
["137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Citizens operates an Emergency Department within the acute care hospital "]
["137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Citizens owns primary and specialty care clinics in the Victoria County region. "]
["137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Citizens has a maternal department and cares for Level II newborns in our hospital. "]
["137907508.7.1",4,"137907508","County of Victoria dba Citizens Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138305109.7.1",4,"138305109","Nueces County MHMR Community Ctr dba Behavioral Hl","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","We are a community based mental health and intellectual and developmentally disabilities services provider. The majority of our services are provided in the community including homes, schools, and other natural environments. "]
["138305109.7.1",4,"138305109","Nueces County MHMR Community Ctr dba Behavioral Hl","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Services provided include outpatient psychiatric clinic, rehab, case management, assessment and intake services. "]
["020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private","Inpatient Services","Required","Y","Columbia Valley Regional has designated inpatient services, it includes beds for Medical/Surgical, ICU/PCU, Neonatal ICU, Pediatric and comprehensive medical rehabilitation. "]
["020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private","Emergency Department","Required","Y","Columbia Valley Regional has one designated Emergency Department on site. "]
["020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Columbia Valley Regional has a designated diabetes management clinic for patients to receive diabetic services.  "]
["020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private","Maternal Department","Required","Y","Maternity, Labor & Delivery Services include a Level III NICU (neonatal intensive care unit), Neonatologist, NICU and Respiratory Therapist, Comprehensive breast-feeding support. Gynecology (GYN) Services include: Gyn surgery, including minimally invasive procedures (laparoscopy), Birth control counseling and services, Menopause , Management, and Mammogram & Women’s Imaging"]
["020947001.7.1",5,"020947001","Columbia Valley Regional Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Inpatient Services","Required","Y","South Texas Health System offers inpatient care at McAllen Medical Center, McAllen Heart Hospital, Edinburg Regional Center, Edinburg Children’s Hospital and South Texas Behavioral Health Center. Altogether, STHS offers the community more than 714 beds where patients can be treated for and recuperate from illness.  Specialties include: Anesthesiology, Bariatric Surgery, Cardiology, Cardiology Interventional, Electrophysiology, Emergency Medicine, Endocrinology, Gastroenterology, Gynecology, Hand Surgery, Hematology/ Oncology,  Hyperbaric Medicine, Infectious Disease, Internal Medicine, Internal/ Pediatric Medicine, Neonatology, Nephrology, Neurology, Neurology & Endovascular, Neuroradiology, Neurosurgery, Obstetrics/ Gynecology, Oncology, Ophthalmology, Oral/ Maxillofacial Surgery, Orthopedic Surgery, Otolaryngology, Pain Management, Pathology, Pediatric Allergy/ Immunology, Pediatric Cardiology, Pediatric Cardiothoracic Surgery, Pediatric Critical Care, Pediatric Emergency Medicine, Pediatric Endocrinology, Pediatric/ Gastroenterology, Pediatric Hematology/ Oncology, Pediatric Infectious Diseases, Pediatric Neurology, Pediatric Otolaryngology, Pediatric Pulmonology, Pediatric Urology, Pediatric Radiology, Pediatrics, Physiatry, Pulmonary Critical Care, Pulmonary Medicine, Radiation Oncology, Radiology, Radiology Interventional, Rehabilitation Medicine, Reproductive Endo/ Infertility, Robotic Surgery, Sleep Medicine, Surgery General, Surgery Cardiothoracic, Surgery Cardiovascular, Tele-Neurology, Tele-Psychiatry, Tele-Radiology, Trauma Surgery, Urology, Virtue-Retinal Disease, and Wound Care. "]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Emergency Department","Required","Y","a. South Texas Health System has several emergency rooms that are open around-the-clock. ECH is the only hospital in RHP5 offering pediatric emergency services. The ER is staffed with specialty trained pediatric nurses and physicians and supported by a dedicated team of pediatric intensivists. ERMC has an ER just for adults. In addition, it is an accredited chest pain center and primary stroke center, and offers advanced imaging capabilities with its 3T MRI. MHH ER accommodates all emergencies but specializes in cardiac emergencies. MMC is a designated Level II Trauma Center for Hidalgo County and its ER treats people of all ages.  Furthermore, STHS has standalone ER’s with the capability of treating life-threatening injuries as well as chest pain emergencies."]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","South Texas Health System offers specialty outpatient clinics at several hospitals to help patients in the areas of diabetes and metabolic disorders, wound care, rehabilitation women’s services and family medicine. \na. Pediatric Endocrinology and Diabetes Institute: The Pediatric Endocrinology and Diabetes Institute, adjacent to Edinburg Children’s Hospital, focuses on diagnosing and managing hormonal disorders in children. \nb. Pediatric Comprehensive Care Clinic: The Pediatric Comprehensive Care Clinic of Edinburg Children’s Hospital provides primary care to children with higher risk, chronic illnesses. It is designed to safely transition children from acute care to primary care. \nc. South Texas Diabetic and Metabolic Institute: The South Texas Diabetic and Metabolic Institute at Edinburg Regional Medical Center promotes weight loss and a healthier lifestyle to help patients with metabolic disorders, diabetes and those who are overweight or obese. \nd. Wound Healing Center: The Wound Healing Center at Edinburg Regional Medical Center offers advanced treatment options, including hyperbaric medicine, to treat slow or non-healing wounds. \ne. Wound Care and Hyperbaric Services: The multidisciplinary team of physicians- including internal medicine, podiatrists and cardiologists- use comprehensive wound care and individualized treatment plans that incorporate some of the most advanced wound care therapies available today. \nf. McAllen Family Residency Clinic: The McAllen Family Medicine Residency Clinic Provides quality medical care for the entire family. A joint venture between McAllen Medical Center and the newly formed University of Texas Rio Grande Valley School of Medicine, the clinic specializes in obstetrics, pediatrics and geriatrics.  \ng. Outpatient Rehabilitation Center: Physical therapists at the Outpatient Rehabilitation Center of McAllen Medical Center help patients recovering from severe injury or illness gain their optimal level of function and independence. \nh. STHS Women’s Center: Affiliated with McAllen Center, offers a comprehensive range of women’s pregnancy, gynecology, health wellness information and resources to support women of all ages. \n\n"]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Maternal Department","Required","Y","a. The Birthing Center at McAllen Medical Center: Specialized nurses are trained in advanced cardiac life support; basic, intermediate and advanced fetal monitoring; triage, charge, surgery and recovery care; perinatal, lactation and postpartum education; and early baby care, including sudden infant and death syndrome (SIDS), shaken baby syndrome and postpartum depression. \nb. The Women’s Corner at Edinburg Regional Medical Center, offers specialty maternity and neonatal care as well as a midwifery program.\n"]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094113001.7.1",5,"094113001","McAllen Hospitals LP dba Edinburg Regional Medical","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Valley Care Clinics is a system of primary care offices serving the four counties of RHP 5 with 82 employed physicians. The clinics offer a range of primary care services, advanced technology and diagnostic testing to help patients find proper treatment and a chance at a better outcome. We will be working with VCC to enhance the primary/ preventive care services in RHP5. "]
["111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Primary Care Clinics","Required","N",""]
["111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Specialty Care Clinics","Required","N",""]
["111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Hospital","Required","N",""]
["111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["111810101.7.2",5,"111810101","Unv of Tx HSC at Houston-UTHSC Sponsored Projects","Physician Practice affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Contracted Primary Care Clinics","Optional","Y","The system component will include outpatient services from two Primary Care Clinics; one in Cameron and the other one is in Hidalgo County.  Brownsville Community Health Center (BCHC) is Federally Qualified Health Center which provides comprehensive primary health care services to the uninsured or underserved populations. In addition to Hope Family Health Center (HFHC) which provides primary and preventative medical services to only the uninsured residents of the Rio Grande Valley."]
["112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private","Inpatient Services","Required","Y","Rio Grande Regional (RGRH) has inpatient services for Medical, Surgical,  ICU, NICU, Pediatric, Rehabilitation."]
["112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private","Emergency Department","Required","Y","Rio Grande Regional Hospital (RGRH) has three 24/7 Emergency Care Centers. Main hospital  Emergency Room includes a Level III Trauma Center.  Two ER centers located in McAllen/ Mission and Edinburg area."]
["112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Rio Grande Regional Hospital counts with four Woman Clinics, one Family Practice Clinic and one Diabetes Specialty Care Center that offer preventive care and overall health care management. "]
["112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private","Maternal Department","Required","Y","Rio Grande Regional Hospital offers comprehensive women's health services, providing a full range of OB/GYN expertise, from prenatal care, labor and delivery through postpartum care."]
["112716902.7.1",5,"112716902","Columbia Rio Grande Healthcare dba Rio Grande Regi","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N"]
["135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private","Inpatient Services","Required","Y","Knapp Medical Center has been serving the healthcare needs of Mid-Valley residents for five decades.  Knapp Medical Center currently is a 227 bed  not-for-profit acute care hospital.  Our primary service area includes Donna east to La Feria and Monte Alto south to the Rio Grande River.  More than 200 physicians serve on the Knapp Medical Staff.   "]
["135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private","Emergency Department","Required","Y","The Emergency Department medical team consists mainly of physicians and nurses who are specially trained for emergency medicine.  This emergency team is specifically trained to treat all types of medical emergencies.  Knapp Medical Center has been designated a Level III Trauma Center by the Texas Department of State health Services to provide resuscitation, stabilization, assessment and treatment to injury victims."]
["135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Currently we have 5 outpatients clinics Neurology, Family Practice, GI, Orthopedic and Urology.  "]
["135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private","Maternal Department","Required","Y","Within the maternal department of the hospital we perform routine OB deliveries, C-Sections, Level II NICU and Nursery."]
["135035706.7.1",5,"135035706","Knapp Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Starr County Hospital District DBA as Starr County Memorial Hospital is located in Starr County which encompasses a population of 60,158.The hospital is licensed for 48 inpatient beds which include obstetric care. Of the 48 designated beds a total of 38 beds are designated for inpatient and observation status patients. Of those designated beds a total of 13 are private room and 25 are designated as semi-private rooms. All rooms are equipped with wall mounted oxygen supply as well as wall mounted suctioning capabilities. Of the designated inpatient and observation room we have a total of 12 rooms with wall mounted cardiac monitors for constant cardiac evaluation both in the room and at the nursing stations. Medical services are currently provided by primary and internal medicine physicians."]
["136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The hospital emergency department is licensed for 10 beds. All beds are equipped with wall mounted suctioning and oxygen along with full cardiac monitoring systems. The ED is supported by ancillary departments that are adjacent to the ED such as laboratory as well as the radiology department. The ED also has a full time mobile digital X-Ray unit in the department. The ED hosts a full time triage center which incorporates the ED physician to help facilitate the MSE( medical screening exams). The Emergency Department is certified as a Level IV Trauma Center."]
["136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The hospital owns and operates two hospital based rural health clinics which serve the Starr County area. One clinic is within the hospital building and is open 12hrs a day 6 days of the week and 8 hrs. on the seventh day. This hospital based clinic has two full time providers a mid-level and a physician. The clinic also employs four part time providers which include two mid-levels and two physicians. All providers at this clinic provide family medicine and obstetric care. We have a second location which is located in Roma, Texas. This clinic is open 8 hrs. a day for 5 days week and 4hrs on Saturday. The clinic employs 20 full time employees and 4 full time providers which breaks down to 3 mid-level providers and 1 physician. These providers provide primary care, preventative care, and chronic care management services to all age groups."]
["136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The obstetrical services are currently provided by primary care physicians with educational training and years of experience in delivering babies. Prenatal care is provided by them at the Rural Health clinic located within the hospital. The physicians are also certified to perform C-sections when medically necessary.  Anesthesiologists are available 24 hrs./day 7days/week. The hospital just received designation as a Level 1 Neonate Nursery. The nursing staff is very competent and qualified to provide the obstetrical care during the delivery, post-partum, and nursery care."]
["136332705.7.1",5,"136332705","Starr County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138708601.7.1",5,"138708601","Tropical Texas Behavioral Health","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","TTBH Outpatient Services offers a full range of mental health, intellectual development disabilities (IDD), and substance use services and supports to adults and children residing in Cameron, Hidalgo, and Willacy counties. Services are provided in accordance with Health and Human Services Commission (HHSC) guidelines and are individualized according to the specific strengths, needs, abilities, and preferences of each client and family served.  Home-based (community) services are face-to-face and include:\n• Intake and Assessment\n• Case Management\n• Cognitive Behavioral Therapy (CBT)\n• Medication Use Services\n• Nursing Services\n• Pharmacy Services\n• Skills-Training\n• Psychosocial Rehab\n• Crisis Services"]
["138708601.7.1",5,"138708601","Tropical Texas Behavioral Health","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","TTBH Outpatient Services offers a full range of mental health, primary care, intellectual development disabilities (IDD), and substance use services and supports to adults and children residing in Cameron, Hidalgo, and Willacy counties. Services are provided in accordance with Health and Human Services Commission (HHSC) guidelines and are individualized according to the specific strengths, needs, abilities, and preferences of each client and family served. Office-based services are face-to-face and include:\n• Intake and Assessment\n• Case Management\n• Cognitive Behavioral Therapy (CBT)\n• Medication Use Services\n• Nursing Services\n• Pharmacy Services\n• Skills-Training\n• Psychosocial Rehab\n• Crisis Services"]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Inpatient Services","Required","Y","Inpatient system inclusion encompasses all inpatient services within DHR facilities.  This includes DHR Main, Women’s Hospital at Renaissance, the Behavioral Hospital at Renaissance, and the Rehab Hospital at Renaissance with the exception of the maternal department. "]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Emergency Department","Required","Y","DHR has only one emergency department.  Patient data pertaining to services occurring within that area is collected. "]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Please see the lists below for the corrected components of the owned and operated outpatient clinics. \n\nOWNED OR OPERATED CLINICS:\nOperated Clinics Include- \n• DHR Health ALS Clinic\n• Bariatric and Metabolic Institute at Renaissance Edinburg\n• Cancer Center at Renaissance\n• DHR Center for Maternal Fetal Medicine\n• DHR Health Surgery Institute\n• Diabetes & Endocrinology Institute at Renaissance – Pedi\n• Diabetes & Endocrinology Institute at Renaissance Edinburg\n• Diabetes Wellness Center – Edinburg\n• ENT Institute at Renaissance, Edinburg\n• GME OB-GYN/Women's Health\n• Gynecology Oncology\n• Liver & Pancreas Surgery/Organ Transplantation\n• Neuro-interventional Radiology\n• Neurology Institute at Renaissance Edinburg\n• Neurosurgery Institute at Renaissance\n• Neurospine Institute at Renaissance\n• Orthopedic Institute at Renaissance\n• Orthopedic Wellness- Edinburg (Elzaim)\n• Physical Medicine & Rehabilitation\n• Plastic and Reconstructive Surgery at Renaissance\n• Renaissance Gastroenterology\n• Renaissance Orthopedic Trauma Institute, Edinburg 1\n• Renaissance Orthopedic Trauma Institute, Edinburg 2\n• Renaissance Transplant Institute\n• RTI Liver Specialty Center\n• The Eye Institute at Renaissance\n• Urology Institute at Renaissance\n• DHR Orthopedic & Sports Therapy Institute\n• Outpatient Rehab\n• Clinic-TAVR\n• Vein Institute at Renaissance\n\nOutpatient Services include-\n• Lone Star Radiology (O)\n• Offsite Imaging Center (O)\n• Women's Imaging Center\n• DHR Radiology (O)\n• Dove Imaging Center\n• Dove Women's Imaging Center\n• Med Point Radiology (O)\n• Oncology PET CT (O)\n• Care Link-TCM(O)\n• Oncology Infusion (O)\n• Outpatient  (O)\n• Mid Valley Radiology (O)\n• Respiratory Therapy (O)\n• Cath Lab (O)\n• Laboratory (O)\n• Wh Outpatient Services (O)\n• Care Link Edinburg (O)\n• Special Procedures-Rad (O)\n• Oncology Laboratory (O)\n• Care Link Mission (O)\n• WH Developmental (O)\n• Outpatient Infusion Center\n• Hyperbaric (O)\n• Oncology Center (O)\n• Behavioral Outpatient (O)\n• Radiation San Benito\n• Outpatient Surgery\n• Rio Grande Heart Specialists\n• Valley Cardiology Associates\n• Cardiology Consultants\n• Pedi Oncology\n• DHR Outpatient Services\n• Stoma Therapy\n\nAmbulatory Surgery Centers include-\n• DS Surgery\n• DS Endoscopy"]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Maternal Department","Required","Y","All maternal services take place at the Women’s Hospital at Renaissance. Services include labor and delivery, NICU, gynecology and surgery."]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Please see the lists below for the corrected components of the owned or operated urgent care clinics.\n\nOWNED OR OPERATED URGENT CARE CLINICS:\n• DHR Urgent Care (Dove)\n• DHR Urgent Care (2nd Street)\n• DHR Urgent Care (Mission)"]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Contracted Specialty Clinics","Optional","Y","Please see the lists below for the corrected components of the contracted specialty clinics. \n\nCONTRACTED SPECIALTY CLINICS:\n• Bariatric and Metabolic Institute, Rio Grande City\n• Cardiothoracic Surgery\n• Cardiovascular Surgery\n• Diabetes and Endocrinology Institute at Renaissance, Mission\n• Diabetes Wellness Center, Mission\n• ENT Institute at Renaissance, McAllen\n• ENT Institute at Renaissance, Mission\n• Heart Institute at Renaissance\n• Heart Institute at Renaissance - Valley Heart Consultants\n• Neurology Institute at Renaissance, Medpoint\n• Pediatric Nephrology & Hypertension\n• Pediatric Orthopedic Surgery\n• Pediatric Pulmonology\n• Pediatric Neurosurgery\n• Pharr Behavioral Counseling Center\n• PSJA Employee Health Center\n• Renaissance Counseling Center\n• Renaissance Gastroenterology, Mission\n• Renaissance Gastroenterology, Weslaco\n• Renaissance Specialty Clinic, Weslaco\n• Renaissance Specialty Clinic, Brownsville\n• Renaissance Specialty Clinic, Mission\n• Renaissance Specialty Clinic, Rio Grande City\n• Renaissance Specialty Clinic, Weslaco\n• Rheumatology Institute at Renaissance"]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","School-based Clinics","Optional","Y","School clinics contracted by DHR to provide patient services. These include-\n\n• ECISD School Based Clinic\n• PSJA School Based Clinic\n"]
["160709501.7.1",5,"160709501","Doctor's Hospital at Renaissance","Hospital","Private","Contracted Palliative Care Programs","Optional","Y","Hospice and palliative care services contracted by DHR. This includes-\n\n• Renaissance Hospice and Palliative Care"]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","UT Health RGV Internal Medicine & Neurology, UT Health RGV Primary Care at Laguna Vista, UT Health RGV at Jackson Road, UTRGV Unimovil, UTRGV Employee Health Center (Harlingen), AHEC Bob Clark Health Center, AHEC La Victoria Center, AHEC San Carlos Center, UTRGV Employee Health Center (Edinburg)"]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","UT Health RGV Pediatric Specialty, UT Health RGV Rheumatology, UT Health RGV Internal Medicine and Neurology, UT Health RGV Surgery and Women's Specialty, John Austin Pena Memorial Center, UT Health RGV ENT (Harlingen), UT Health RGV Infectious Disease Center, UT Health RGV Pediatric Urology (Edinburg), UT Health RGV Pediatric Urology (Harlingen), "]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Specialty Clinics","Optional","Y","DHR Ob/Gyn Clinic, DHR Ob/Gyn Subspecialty Clinic, DHR General Surgery Center, Doctor Hospital at Renaissance ER, Doctor Hospital at Renaissance OP & DS, Doctors Hospital at Renaissance IP, Edinburg Children's Hospital IP, ER Knapp Medical Center, Harlingen Medical Center IP, Harlingen Medical Center OP & DS, IP Missionr Regional Med Center, John Knox Village, Knapp Medical Center IP, Knapp Medical Center OP & DS, Knapp Specialty Mental Health, McAllen Medical Center IP, McAllen Medical Center OP, McAllen Nursing Center, McAllen Specialty Mental Health, Mid Valley Nursing & Rehab, Rio Grande Regional IP, Rio Grande Regional OP & DS, The Women's Hospital at Renaissance ER, The Women's Hospital at Renaissance IP, The Women's Hospital at Renaissance OP & DS, Valley Baptist Medical Center IP, Valley Baptist Medical Center OP & DS"]
["343698201.7.1",5,"343698201","University of Tx Rio Grande Valle","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Primary Care Clinics","Optional","Y","VBMC Internal Medicine Program, Knapp Family Medicine Clinic, DHR Internal Medicine Clinic, DHR Family Health Center, McAllen Family Medicine Residency Center "]
["085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","N",""]
["085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","N",""]
["085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["085144601.7.2",5,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Primary Care Clinics","Optional","Y","We will continue to contract with two Primary Care Clinics in Cameron County. \nSu Clinica is a Federally Qualified Health Center with 4 outpatient clinics serving patients in Cameron and Willacy counties. \nRio Grande State Center Outpatient Clinic is a safety net clinic located in Cameron County.  "]
["020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private","Inpatient Services","Required","Y","CHRISTUS Santa Rosa Health System will include all inpatient services departments at CHRISTUS Santa Rosa Hospital - Westover Hills, CHRISTUS Santa Rosa Hospital - Medical Center; CHRISTUS Santa Rosa Hospital - New Braunfels, and CHRISTUS Santa Rosa Hospital - Alamo Heights."]
["020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private","Emergency Department","Required","Y","This component will include the emergency departments within CHRISTUS Santa Rosa Hospital-Westover Hills, CHRISTUS Santa Rosa Hospital–Medical Center, CHRISTUS Santa Rosa Hospital–New Braunfels, CHRISTUS Santa Rosa Hospital–Alamo Heights; as well as its free-standing emergency centers to include:  CHRISTUS Santa Rosa Emergency Center–Alon and CHRISTUS Santa Rosa Emergency Center– Creekside."]
["020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This system component will include all owned and operated outpatient clinics at: 1) CHRISUS Santa Rosa Hospital-Westover Hills (Weight Loss Clinic, Cardiology Clinic and Outpatient Physical Therapy); 2) CHRISTUS Santa Rosa Hospital-Medical Center (Sports Medicine Clinic, Orthopedic HOPD, and TOT Therapy), 3) CHRISTUS Santa Rosa Hospital – New Braunfels (Cardiology HOPD and Physical Therapy). Additionally, it will include CHRISTUS Santa Rosa Family Health Center – Westover Hills."]
["020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private","Maternal Department","Required","Y","This system component will include the maternal department at CHRISTUS Santa Rosa Hospital - Westover Hills and at CHRISTUS Santa Rosa Hospital - New Braunfels. CHRISTUS Santa Rosa Hospital - Medical Center and CHRISTUS Santa Rosa Hospital - Alamo Heights do not provide maternal services; therefore, they were not included in this component."]
["020844901.7.1",6,"020844901","CHRISTUS Santa Rosa Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private","Inpatient Services","Required","Y","The Children's Hospital of San Antonio will include all inpatient service departments within its hospital located in downtown San Antonio."]
["020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private","Emergency Department","Required","Y","This component will include the Emergency Department located within The Children's Hospital of San Antonio, as well as its two free standing emergency centers:  Children's Hospital of San Antonio Emergency Center - Westover Hills and Children's Hospital of San Antonio Emergency Center - Stone Oak (scheduled to open in April/May 2018)."]
["020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This component will include all CH of SA owned and operated outpatient clinics to include Pediatric Specialty Clinics located on the CH of SA campus, pediatric specialty clinics located on the CHRISTUS Santa Rosa Hospital - Westover Hills campus, pediatric specialty clinics located on the CHRISTUS Santa Rosa Hospital - New Braunfels campus, pediatric specialty clinics located in the Shops at La Cantera and in the newly added Sonterra Building (scheduled to open in April/May 2018).  Additionally, it will include all CHRISTUS Pediatric Physician Group locations."]
["020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private","Maternal Department","Required","Y","This component will include the maternal department located in The Children's Hospital of San Antonio."]
["020844903.7.1",6,"020844903","CHRISTUS Santa Rosa Health Care (Children's Hospit","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","UT Health owns and operates primary care practices that include internal medicine, family medicine, pediatric and specialized geriatric care."]
["085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","UT Health has a group of over 100 specialty and sub-specialty that are highly trained and board-certified physicians and surgeons work together to provide the highest quality of compassionate, patient-centered care."]
["085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["085144601.7.1",6,"085144601","University of Texas Health Science Center SA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Metro Health currently operates two clinics, 1) STD/HIV clinic and 2) a Tuberculosis (TB) prevention and treatment facility. The former operates as a walk-in clinic dedicated to the prevention, detection and treatment of sexually transmitted in infections in the community.  Metro Health’s TB clinic similarly is dedicated to the prevention, detection and treatment of active and latent TB disease. "]
["091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Metro Health currently operates one immunizations walk-in facility located on the Westside of San Antonio. This facility focuses of the prevention of vaccine-preventable diseases with a particular emphasis on the MLIU population by targeting pockets of low immunization rates in San Antonio. "]
["091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Metro Health has several program areas that rely on mobile outreach operations in order to identify and target areas of higher need and/or risk within the community in order to provide services to the most vulnerable populations. In particular, this includes our STD/HIV mobile outreach team which provides screening and at times treatment out in the field and immunizations mobile outreach who often provide vaccinations at community events. "]
["091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public","Other - School based oral health clinics","Optional","Y","\nMetro Health provides school based oral health services in order to improve access to preventive dental services by providing services in non-traditional settings to include early childhood education settings and economically disadvantaged public schools.  Clinics are currently operated year round in the majority of school districts within Bexar County with an emphasis on school districts that represent lower income areas of the City. "]
["091308902.7.1",6,"091308902","City of San Antonio Health Department","Local Health Department (LHD)","Non‐State Owned Public","Other - Community based programs","Optional","Y","Metro Health currently operates several community based programs that seek to improve community health in San Antonio by implementing primary and secondary  prevention strategies towards reducing the overall burden of chronic disease, obesity and diabetes, maternal and child health and community violence.  These programs include Metro Health's Healthy Neighborhoods promotora program, Diabetes prevention and management, Metro Health's Baby Cafe focused on improving breastfeeding initiation and duration, and the Stand UP San Antonio program which focuses on reducing violence in high risk neighborhoods and reducing recidivism rates.  "]
["094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private","Inpatient Services","Required","Y","Inpatient services provided by Methodist Hospital and its campuses (TPI 094154402).  Campuses include Methodist Hospital, Methodist Children's Hospital, Methodist Specialty and Transplant Hospital, Metropolitan Methodist Hospital, Northeast Methodist Hospital, and Methodist Texsan Hospital."]
["094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private","Emergency Department","Required","Y","Emergency Department Services provided by Methodist Hospital and its campuses (TPI 095154402), including two free-standing ERs."]
["094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Hospital-based ancillary departments of Methodist Hospital (TPI 094154402). These departments include Behavioral Health Outpatient Services, Outpatient Imaging Services, Outpatient Laboratory Services, Outpatient Surgery Services, and Outpatient Physical Therapy."]
["094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private","Maternal Department","Required","Y","Please see Hospital Inpatient above.  Methodist provides maternal services at the following campuses:  Methodist Hospital and Metropolitan Methodist Hospital."]
["094154402.7.1",6,"094154402","Methodist Hlthcare Sys of SA Southwest Texas Metho","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Methodist Hospital operates a single urgent care clinic - Methodist Community Health Center."]
["112688002.7.1",6,"112688002","Frio Hospital Association Inc dba Frio Regional Ho","Hospital","Private","Inpatient Services","Required","Y","Inpatient Services is the care of patients whose condition requires admission to a hospital."]
["112688002.7.1",6,"112688002","Frio Hospital Association Inc dba Frio Regional Ho","Hospital","Private","Emergency Department","Required","Y","Emergency Department services is the care of patients who have an injury, a sudden illness, or an illness that quickly gets much worse."]
["112688002.7.1",6,"112688002","Frio Hospital Association Inc dba Frio Regional Ho","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["112688002.7.1",6,"112688002","Frio Hospital Association Inc dba Frio Regional Ho","Hospital","Private","Maternal Department","Required","Y","Maternal Department services is the care of  female patients during pregnancy, childbirth, and the postpartum period."]
["112688002.7.1",6,"112688002","Frio Hospital Association Inc dba Frio Regional Ho","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private","Inpatient Services","Required","Y","Clarity Child Guidance Center is comprised of a Crisis Assessment Center meant as a ED diversion, a 66-bed inpatient acute hospitalization unit, a partial hospitalization facility and provides outpatient services."]
["112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private","Emergency Department","Required","N",""]
["112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Clarity Child Guidance Center has one outpatient clinic which provides outpatient services for children ages 3-17 and partial hospitalization services for kids 12-17."]
["112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private","Maternal Department","Required","N",""]
["112742503.7.1",6,"112742503","Southwest Mental Hlth Ctr (Clarity Child Guidance","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in units, excluding the women's maternity unit, to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The VVRMC Emergency Department is a level 4 trauma center consists of 12-beds plus four express care beds."]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Rural Health Clinic consists of family, pediatric, obstetric-gynecological, and primary care walk-in services."]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Maternal Department consists of one triage room, 5 Labor, delivery, and recovery rooms, 2 observation rooms, 13 post-partum beds, and a level one designated nursery."]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["119877204.7.1",6,"119877204","Val Verde Regional Medical Center","Hospital","Non‐State Owned Public","Contracted Specialty Clinics","Optional","Y","Amistad Medical Professional Specialty Clinic includes orthopedic, cardiology, general surgery, urology, and psychiatric services."]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient Services - departments included are Medical Surgical, Obstetrics, and Intensive Care Unit. Within these units, patients are seen with statuses of inpatient, observation, and swingbed. There are approximately 1500 admissions each year."]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency Department - the ED serves level 1 through 5 patients, hosting approximately 21,000 visits annually."]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","UMSA (Uvalde Medical & Surgical Associates) - UMSA is a specialty physician practice with expertise in cardiology, general surgery, orthopeadic surgery and sports medicine, occupational and corporate medicine services, and primary care.\nHealth Care Clinic of Sabinal - the newest addition to the UMH system, this clinic has 1 physician and 1 physician assistant."]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Maternal Department - considered part of Inpatient Services, this department is made of Labor & Delivery rooms / services, and also Post Partum rooms / care. There are approximately 400 deliveries per year at UMH."]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["121782006.7.1",6,"121782006","Uvalde County Hosp Authority dba Uvalde Memorial H","Hospital","Non‐State Owned Public","Contracted Palliative Care Programs","Optional","Y","Yes was selected on this component because Palliative Care patients are included in the system definition. The Palliative Care Program is operated under the wing of Hospice Care within UMH, so it is not a contracted component, but it is a Palliative Care Program."]
["127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private","Inpatient Services","Required","Y","All patients admitted into Peterson Hospital as an acute inpatient stay."]
["127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private","Emergency Department","Required","Y","All patients treated in Peterson Health's Emergency Department."]
["127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Peterson Regional Medical Center owned and operated Outpatient Clinics include Peterson Medical Associates which includes Peterson Womens Associates our Cat C Measurement Bundle."]
["127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private","Maternal Department","Required","Y","Department within the Peterson Health providing inpatient OB care."]
["127294003.7.1",6,"127294003","Sid Peterson Memorial Hospital dba Peterson Region","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Peterson Medical Associates, part of the Peterson Health System, operates one Urgent Care Clinic in Kerrville."]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Inpatient Services","Required","Y","Seventy-five (75) private beds are available to provide patient care.  Patients may be admitted through court order or upon referral for tuberculosis or other infectious, contagious diseases where hospitalization is appropriate. The following services are provided to patients: \nCardiopulmonary\nChaplain\nFood Service/Dietetics\nLaboratory Services\nOutpatient Services\nMedical Records\nPatient Care Services\nPharmacy\nPatient Fitness\nRadiology\nRecreation\nSocial Services\nSubstance Abuse Counseling\nCommunity Relations/Volunteer Services\n"]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Emergency Department","Required","N",""]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","TCID manages two (2) outpatient clinics.\nTB Out-Patient Clinic:  This is a very small volume clinic seeing 11 individual patients in 2017 with 22 annual encounters.\nHansen's Out-Patient Clinic: Volume is also small with 92 individual patients seen in 2017 with 111 encounters.\n\n"]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Maternal Department","Required","N",""]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133257904.7.1",6,"133257904","DSHS (Texas Center for Infectious Disease)","Hospital","State Owned Public","Contracted Specialty Clinics","Optional","Y","TCID partners and contract with the City of San Antonio Metropolitan Health District (SAMHD) to screen and test populations at high-risk for TB and to treat those with identified TB infection in San Antonio/Bexar County.  Their work supports TCID’s sole Cat C measure.  Patient level data including health insurance characteristics, testing results and treatment outcomes are tracked in a project database."]
["133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Services provided in the home via face to face or televideo delivery, and entered into the  EHR. "]
["133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Services provided in the office/Clinic setting, via face to face or televideo delivery, and entered into the EHR.  "]
["133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Only those individuals who are discharged from the state hospitals that HCMHDD is responsible for the follow-up services will be included in the system of care.  The data for this inclusion will come from the CARE system.  "]
["133340307.7.1",6,"133340307","Hill Country Community MHMR dba hill Country MHDD","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community","Optional","Y","Services provided in the community setting, via face to face or televideo delivery, and entered into the EHR.  (This may include but is not limited to; community centers, parks, libraries, churches, schools, jails, hospitals, sober-living homes, outreach centers, etc.) "]
["135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Patients admitted into our inpatient setting with patient status in our hospital EMR, Meditech, of IN or INO (Inpatient or Inpatient Observation). "]
["135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Patients admitted into our Emergency Department setting with patient status in our hospital EMR, Meditech, of ER (Emergency Room). "]
["135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Patients with a face-to-face encounter within our clinic system, as shown through our clinic EMR, eClinicalWorks. We currently operate 4 primary care clinic locations with 8 providers, a mixture of physicians, nurse practitioners and physician assistants. Our current clinic locations are Main Campus Family Practice, North Campus Family Practice/Pediatrics, La Vernia Family Practice, South Campus Family Practice.  We also operate 8 specialty clinics at the current time - Wound Care, Urology, General Surgery, Gastroenterology, ENT, Orthopedics, Cardiology and Pain Management. "]
["135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["135151206.7.1",6,"135151206","Wilson County Mem Hosp Floresville dba Conally Mem","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","We operate one urgent care clinic, La Vernia Urgent Care. Encounters from this component will be determined by running reports from our clinic system EMR, eClinicalWorks."]
["136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient services provided at University Hospital including, but not limited to, acute care and therapeutic services."]
["136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency services provided at University Hospital’s adult and pediatric emergency departments including, but not limited to, acute care and therapeutic services. "]
["136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Outpatient services provided at Health System clinics including, but not limited to, acute care, primary care, specialty care, and therapeutic services."]
["136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Maternal services provided at University Hospital and at Health System clinics including, but not limited to, pre-natal, labor and delivery, and post-natal services.\n"]
["136141205.7.1",6,"136141205","University Health System  (Bexar County Hospital D","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Urgent Care services provided at Health System clinics including, but not limited to, acute care and therapeutic services. "]
["136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private","Inpatient Services","Required","Y","Hill Country Memorial (HCM) is an 86-licensed bed community hospital. The facility includes a five-suite Operating Room and an ICU. Within the facility, HCM utilizes hospitalists to care for admitted patients. This business component also will be used to include services rendered within the facility, including day surgery, imaging and labs among others."]
["136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private","Emergency Department","Required","Y","HCM has a single Emergency Department that is part of the Hospital and therefore is part of our Category B System Definition. This department is located within the hospital and while staffed by HCM employees, HCM contracts providers through a third party."]
["136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","HCM offers outpatient care in many services, including ENT, General Surgery, OB, Orthopedic Surgery, Pain Management, Pulmonology, Urology, Vascular Surgery and Primary Care. The HCM Medical Group includes more than twenty providers."]
["136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private","Maternal Department","Required","Y","HCM's Maternity Department serves the larger HCM Service Area and offers private delivery rooms. This department is serviced by both providers employed by HCM and community providers."]
["136430906.7.1",6,"136430906","Hill Country Memorial Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","HCM also operates two Urgent Care-style clinics - called our Immediate Care Clinics - one in Fredericksburg and one in Llano, which opened early in 2018."]
["136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical, surgical, behavioral health or rehab care."]
["136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private","Emergency Department","Required","Y","All outpatient visits for services received by patients in the emergency department of the hospital.  Excludes patients who are subsequently admitted as Inpatient to the hospital as those encounters are counted above in the definition of Inpatient Services."]
["136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient visits for services received by patients at hospital's behavioral health IOP (Intensive Outpatient Program) clinic located in downtown San Antonio."]
["136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private","Maternal Department","Required","Y","All services in all units to which a patient may be admitted to the hospital for maternal care {excluding newborns/nursery}.  All outpatient visits for services received by patients presenting in the hospital's maternity department that are admitted and placed in an observation status."]
["136491104.7.1",6,"136491104","Southwest General Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","As a Community Mental Health Center, home-based services are a business component that provides opportunities for our population to obtain behavioral and mental health services in their own home or community. All services in all units where an individual received at least one face-to-face or virtual encounter within the “home” confines of our system during each applicable DY timeframe. CHCS will follow Measure Bundle Protocol Version 5: Required and Optional System Components for CMHCs and Attachment J: Program Funding and Mechanics Protocol (16.a.) and will not count phone calls, text messages, or any undocumented encounters."]
["137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","As a Community Mental Health Center, office/clinic is business component that provides behavioral health and primary care outpatient services within the physical confines of our offices and clinics throughout San Antonio, TX. All services and all units where least one face-to-face or virtual encounter for mental health and/or primary care services are provided to our children, adolescents and our adult population within the clinics will represent this business component. CHCS will follow Measure Bundle Protocol Version 5: Required and Optional System Components for CMHCs and Attachment J: Program Funding and Mechanics Protocol (16.a.) and will not count phone calls, text messages, or any undocumented encounters. "]
["137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","CHCS utilizes Contracted Inpatient Beds to provide inpatient psychiatric care to those clients requiring a higher level of care. We received discharge paperwork indicating the admission and discharge dates. CHCS is responsible for the follow-up services for individuals who are discharged from these beds.  Data is secured through the sate data base: CARE system. \n"]
["137251808.7.1",6,"137251808","The Center for Health Care Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","CHCS utilizes State Mental Health Facilities to provide inpatient psychiatric care to those clients requiring a higher level of care. We received discharge paperwork indicating the admission and discharge dates. CHCS is responsible for the follow-up services for individuals who are discharged from these beds.  Data is secured through the sate data base: CARE system. "]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","GRMC is licensed for 125 acute care beds providing services to inpatients and inpatient observation patients.  We provide inpatient services to all ages from newborn deliveries, maternity care, pediatric and adult Med/Surg, intensive care, and inpatient rehab.  We also provide inpatient palliative care services.   "]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","GRMC has a Level 4 Emergency Department with 25 rooms, all of which are private.  We have three rooms designated for cardiac, respiratory and critical-care patients and two rooms designated for SANE patients.      "]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","GRMC owns and operates one outpatient clinic, which serves Guadalupe County residents.  This clinic is our Guadalupe Clinic for Chronic Disease.  The Guadalupe Clinic provides primary care access to adult patients, 18 years and older, who are unfunded or unable to afford primary care that have one or more chronic illnesses. Specific illnesses that are managed at the clinic include: asthma, congestive heart failure, COPD, diabetes, hypertension and seizures.  "]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Our maternal department is referred to as the Birthing Center.  GRMC's Birthing Center provides comprehensive inpatient maternity care services that span the antepartum, intrapartum, and postpartum periods.  Additional support offered postpartum includes lactation support, breastfeeding supplies, neonatology, and daily Mommy & Me time on a secured unit with all private rooms."]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Contracted Specialty Clinics","Optional","Y","Our Maternal Fetal Monitoring (MFM) clinic is an outpatient clinic offering ultrasound testing, Amniocentesis, counseling, co-management of medical conditions such as Diabetes, Hypertension, Thyroid Disease, and Kidney Disease.  We have a perinatal coordinator at University Hospital who coordinates any referrals to specialists in San Antonio.  She also plans delivery in San Antonio should that be warranted.  We have four MFM physicians and two fellows who come on Wednesdays to see patients.  We have about 42 visits per month on average."]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Other - Outpatient services such as Cardiac Rehab","Optional","Y","Our medically supervised Cardiac Rehab exercise program is designed to improve both health and quality of life.  The team consists of a registered nurse and respiratory therapists certified in ACLS.  Exercise is tailored to the patient's physical abilities and needs.  Patients learn about heart disease, the risk factors, stress management, diet and nutrition, and many other topics designed to help patients successfully improve and manage their health.  Vital Steps is also available to individuals with health concerns who want help starting an exercise program."]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Other - Palliative Care","Optional","Y","Along with inpatient palliative care services, GRMC offers these services to patients on an outpatient basis as well.  Our program is designed to improve the quality of life for patients and their families facing the problems associated with serious or life-threatening illness. The goal is to prevent and relieve suffering by early identification and treatment of pain and other physical symptoms. Patients are seen by our palliative care physician, chaplain, and licensed social workers to assist with needs of the patient/family/caregiver(s)."]
["138411709.7.1",6,"138411709","Guadalupe County Hospital Board dba Guadalupe Regi","Hospital","Non‐State Owned Public","Other - Outpatient Rehab","Optional","Y","GRMC offers comprehensive outpatient rehabilitation center and therapy services.  Our experienced and licensed staff helps to improve function and reduce pain by developing a personalized rehab plan that best suits each individual and focuses on managing each patient's condition."]
["159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services (Baptist Medical Center, Mission Trail Baptist Hospital, St. Luke's Baptist Hospital, Northeast Baptist Hospital, and North Central Baptist Hospital)."]
["159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private","Emergency Department","Required","Y","All urgent services to which a patient may be admitted to the hospital for emergency medical or surgical care treated and discharged from the ED, including diagnostic and laboratory services within Baptist Medical Center, Mission Trail Baptist Hospital, St. Luke's Baptist Hospital, Northeast Baptist Hospital, and North Central Baptist Hospital."]
["159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Baptist Health System owns and operates 15 Healthlink Outpatient Rehab Centers across San Antonio and New Braunfels. These centers provide various services including physical therapy, sports rehab, cardiac rehab, amputee care and rehab, dysphagia and voice therapy, vestibular/balance therapy, aquatic therapy, neurological rehab, and kinesiotaping. "]
["159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private","Maternal Department","Required","Y","Four of the five BHS acute care hospitals (Baptist Medical Center, St. Luke's Baptist, North Central Baptist, and Northeast Baptist) provide maternal services including the delivery of babies and care during childbirth, couplet care and postpartum support."]
["159156201.7.1",6,"159156201","Baptist Medical Center (VHS San Antonio Partners)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Medina Regional Hospital provides acute care and swingbed services for pediatric, adult and geriatric populations.  The hospital provides inpatient medical, surgical, diagnostic, and procedural services to include: anesthesia, nursing, surgical, imaging, obstetrics/gynecology, emergency, rehabilitation (inpatient and outpatient including Physical therapy, Occupational Therapy, and Speech Therapy), cardiopulmonary, case management/social support services, clinical laboratory (with a contracted offsite pathology center available), nutrition, and general medicine."]
["212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The provider has contracted with Victoria Emergency Associates to service the ED with an in house physician 24/7.  Imaging is available adjacent to the Emergency department (ED).This is a level 4 trauma center.  The provider utilizes a stroke robot for tele-medicine on any potential stroke patients.  In 2017 there were approximately 11,000 encounters in the ED.  "]
["212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Medina Regional Healthcare system is comprised of the hospital and its 3 Rural Health Clinics.  One of the rural health clinics is attached to the hospital in Hondo, and the other two are located in Castroville and Devine to service other towns in the county.  There is one full-time general surgeon, one physician that provides Obstetrics & Gynecology services.  The provider has three Family Practice & Obstetrics physicians, two Family Practice physicians, 1 Nurse Practitioners, and 2 Physician's Assistants.    There were approximately 56,000 clinic visits in the last fiscal year.  "]
["212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","MRH offers maternal services with one operating suite, four Labor/delivery/recovery/postpartum rooms and one newborn bed.  The provider recently went through the process of neonatal designation, and will be working towards maternal designation as well.   This department delivered 158 newborns in 2017."]
["212140201.7.1",6,"212140201","Medina County Hospital District dba Medina Regiona","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["217884001.7.1",6,"217884001","Dimmit County Memorial Hospital","Hospital","Private","Inpatient Services","Required","Y","DRH provides Inpatient services.  Inpatient services include Med/Surgical unit, outpatients, Swing-bed patients, post-partum patients.  We also see pediatrics patients.  DRH just became a Critical Care Access hospital with 15 in-patient beds and 10 Swing-Bed concept beds to give us a total of 25 beds and of those 15 inpatient beds to include 2 rooms that are critical care rooms."]
["217884001.7.1",6,"217884001","Dimmit County Memorial Hospital","Hospital","Private","Emergency Department","Required","Y","DRH provides Emergency services.  It has 2 Trauma rooms and 4 other rooms equipped with cardiac monitors in all rooms.  It has the capacity to see urgent and non-urgent cases.  Patients that need higher level of care are transferred to San Antonio’s hospitals.  We have a telemedicine stroke connected to Methodist Hospital and soon will open a telemedicine ER.  We have 24 hr. physician coverage."]
["217884001.7.1",6,"217884001","Dimmit County Memorial Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","DRH provides outpatient services that consists of outpatient laboratory workup, radiology exams, CT’s, MRI, outpatient surgeries, antibiotic outpatient regimen and OB services like non-stress testing and also antibiotic regimen for the OB Physician."]
["217884001.7.1",6,"217884001","Dimmit County Memorial Hospital","Hospital","Private","Maternal Department","Required","Y","DRH provides maternity services.  It has 3 acute beds for maternal use.  We also provide C-Sections in the adjacent OR suite.  We have a Level 1 Nursery."]
["217884001.7.1",6,"217884001","Dimmit County Memorial Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The provider delivers MH and IDD services to individuals in their home setting.  This excludes Crisis Residential Services, Psychiatry, Counseling and Day Habilitation services."]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The provider delivers MH and IDD services to individuals in office/clinic setting.  This excludes Crisis Residential Services, Respite and Day Habilitation."]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","The provider utilizes State Mental Health Facilities to provide inpatient psychiatric care to those clients from our service area requiring a higher level of care.  Data is secured through the state data base.  We receive discharge paperwork indicating the admission and discharge dates."]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community","Optional","Y","The provider delivers services to individuals in their communities."]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Day Habilitation","Optional","Y","The provider delivers services to individuals attending day programming services."]
["121990904.7.1",6,"121990904","Camino Real Community Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Crisis Residential Facility","Optional","Y","The provider operates two 24/7 Crisis Residential facilities."]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including intensive care"]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Emergency Department","Required","Y","All services which may be provided to a patient in the emergency department"]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient clinics operating under the performing provider's hospital designation"]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Maternal Department","Required","N",""]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Contracted Specialty Clinics","Optional","Y","Performing Provider is including contracted specialty clinics operated by Ascension Medical Group that support the management of care reflected in the Category C Measure Bundles selected and provide services to the MLIU population."]
["137265806.7.1",7,"137265806","Seton Family of Hospitals Dell Seton Med Ctr @UT","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Performing Provider is including contracted primary care clinics operated by Ascension Medical Group that support the management of care reflected in the Category C Measure Bundles selected and provide services to the MLIU population."]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Primary Care Clinics","Required","N",""]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Specialty Care Clinics","Required","N",""]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Hospital","Required","N",""]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Contracted Primary Care Clinics","Optional","Y","This component will include the Medical Access Program (MAP) enrollees who seek medical and dental care at CommUnityCare and Lone Star Circle of Care clinics as approved by HHSC (per Natasha Boston via email on 3/12/2018)."]
["307459301.7.1",7,"307459301","Community Care Collaborative","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Contracted Palliative Care Programs","Optional","Y","This system component includes the Medical Access Program enrollees who seek palliative care at Hospice Austin, a contracted entity, as approved by HHSC (per Natasha Boston via email on 3/12/2018).","Y","2020-08-11"]
["344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Clinics at APH are limited to three locations: RBJ STD Clinic, RBJ TB clinic, and Refugee clinic. These clinics are staffed with physicians and nurse practitioners and have their own labs. "]
["344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","APH's immunizations program is a balance of brick and mortar immunizations sites and outreach to health fairs, partner organizations, and community events. Adult Immunizations and flu outreach is implemented at various community locations, non-traditional settings reaching at-risk populations, and at locations throughout the county. "]
["344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Many of APH's programs blend traditional service provision with mobile outreach. Aside from the locations already mentioned under Immunizations Locations. Additionally, our Neighborhood Center Nurses participate in some mobile outreach to community events and partners. Lastly, our Diabetes Empowerment Education Program (DEEP) implements DEEP curriculum at community locations providing free nutrition education classes and diabetes prevention and self-management classes. "]
["344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public","Other - Neighborhood Center Nurses","Optional","Y","Neighborhood Center Nurses provide health navigation, follow-up, and engagement to clients in need of partnering with their medical homes to impact health outcomes. If clients do not have a medical home, neighborhood center nurses will work with clients to establish a medical home. "]
["344398801.7.1",7,"344398801","City of Austin","Local Health Department (LHD)","Non‐State Owned Public","Other - Mom's Place","Optional","Y","Mom's Place is a specialty care location within APH's WIC program that provides more case management-style services to WIC mom's and families. "]
["133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","N",""]
["133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Will include all individuals who receive face to face or telehealth services in office/clinic-based settings in the system of care."]
["133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community Based","Optional","Y","Integral Care does have specific clinics set up in the community-based locations, however, we provide services beyond the four walls of traditional clinic confines.  This expands the system to include all individuals who receive Integral Care face to face or telehealth services in community-based settings.  This can also include services within the home but not under a separate services licensure."]
["133542405.7.1",7,"133542405","Austin Travis County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Inpatient Beds","Optional","Y","Inpatient beds authorized by Integral Care’s Utilization Management department. These include Integral Care’s allotment of state mental health facility beds (civil commitments), TX HHSC granted funded private psychiatric beds and contracted beds through our local partner. "]
["121789503.7.1",7,"121789503","Central Texas Medical Center","Hospital","Private","Inpatient Services","Required","Y","All patients admitted as inpatient, observation, or outpatient in a bed (excluding women's services unit) for general medical or surgical care."]
["121789503.7.1",7,"121789503","Central Texas Medical Center","Hospital","Private","Emergency Department","Required","Y","All patients treated and discharged from the emergency department. (not admitted to the hospital for further care) "]
["121789503.7.1",7,"121789503","Central Texas Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All patients receiving primary and/or specialty care at Live Oak Health Partner clinics."]
["121789503.7.1",7,"121789503","Central Texas Medical Center","Hospital","Private","Maternal Department","Required","Y","All patients admitted as inpatient, observation, or outpatient in a bed for care in the women's services unit."]
["121789503.7.1",7,"121789503","Central Texas Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general or surgical care, including intensive care "]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Emergency Department","Required","Y","All services which may be provided to a patient in the emergency department"]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient clinics operating under the performing provider's hospital designation"]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Maternal Department","Required","N",""]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["186599001.7.1",7,"186599001","Seton Healthcare dba Dell Children's Medical Cente","Hospital","Private","Contracted Specialty Clinics","Optional","Y","Performing Provider is including contracted specialty clinics operated by Dell Children's Medical Group that support the management of care in the Category C Measure Bundles selected and provide services to the MLIU population."]
["112717702.7.1",7,"112717702","St David's Hlthcare Partnership dba South Austin M","Hospital","Private","Inpatient Services","Required","Y","St. David's South Austin Medical Center is an acute care hospital will a full inpatient services. St. David's South Austin Medical Center has 304 licensed beds and includes both medical/surgical units, intensive care units and trauma services. "]
["112717702.7.1",7,"112717702","St David's Hlthcare Partnership dba South Austin M","Hospital","Private","Emergency Department","Required","Y","St. David's South Austin Medical Center operates 3 emergency departments. 1 located within the main campus and 2 free standing emergency departments located in Bastrop and Bee Caves."]
["112717702.7.1",7,"112717702","St David's Hlthcare Partnership dba South Austin M","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["112717702.7.1",7,"112717702","St David's Hlthcare Partnership dba South Austin M","Hospital","Private","Maternal Department","Required","Y","St. David's South Austin Medical Center operates a full service maternal department, new born nursery and neonatal intensive care unit."]
["112717702.7.1",7,"112717702","St David's Hlthcare Partnership dba South Austin M","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Inpatient Services","Required","Y","All services in all units [excluding the women's maternity unit] to which a patient may be admitted to the hospital (i.e. Round Rock Medical Center) for general medical or surgical care, including diagnostic and therapeutic services."]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Emergency Department","Required","Y","All services in the emergency department to which a patient may be treated for emergency type conditions, including Level II trauma-related injuries"]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Maternal Department","Required","Y","All services in the women's maternity unit to which a patient may be admitted to the hospital for services related to childbirth"]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","All services in the Cedar Park Free Standing Emergency Center and Leander Free Standing Emergency Center to which a patient may be treated for urgent and emergent medical conditions"]
["020957901.7.1",8,"020957901","St David's Hlthcare Partnership dba Round Rock Med","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Beginning in DY7, RRMC will continue its existing collaboration with local clinics to provide primary care services, specifically targeting on services intended to improve outcomes for patients with diabetes, to uninsured Williamson County patients.  These clinics are: (1) Lone Star Circle of Care, (2) Samaritan Health Ministries, and (3) Sacred Heart Community Clinic."]
["081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Central Counties Services provides home-based services within all three departments of the organization, to include Behavioral Health, Intellectual and Developmental Disabilities, and Early Childhood Intervention.  These services include case management, assessment, skills training, nursing, community support, specialized therapies, and referral.  Home-based services are provided in all five counties of service, Bell, Milam, Lampasas, Coryell, and Hamilton Counties.  Services are provided in all service packages, to include crisis intervention."]
["081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Central Counties Services provides clinical services in Temple, Killeen, Cameron, Rockdale, Gatesville, Hamilton, and Lampasas within Bell, Milam, Lampasas, Coryell, and Hamilton Counties.  These services include case management, skills training, crisis, referral, group/individual counseling, application assistance with Medicaid and Social Security, respite, nursing, medication management, telehealth, assessment and education of chronic health symptoms, and behavioral health psychiatric services"]
["081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","Central Counties Services has received a grant of $204,400 to purchase inpatient bed days for individuals in crisis.  CCS has contracted with Metroplex Hospital in Killeen, TX and Cedar Crest Hospital in Belton, TX to perform these tasks.  CCS staff provides referral for placement into the inpatient bed and then provides services at discharge to ensure that the crisis has been appropriate addressed.  The data for this inclusion will come from the CARE system."]
["081771001.7.1",8,"081771001","Central Counties Center for MHMR Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Central Counties Services is designated as the Local Mental Health Authority (LMHA) and has the ability to refer individuals into State-Funded Community Hospitals.  Austin State Hospital is the designated state hospital for Central Counties Services' catchment area.  Individuals placed into the state hospitals that reside in the Central Counties Services catchment area are provided services post discharge once they have returned to the service area.  The data for this inclusion will come from the CARE system."]
["088334001.7.1",8,"088334001","Bell County Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y"," The Bell County Public Health District (BCPHD) provides services to the men and women in Bell County and the surrounding areas. The BCPHD Medical and Nursing division operates out of two clinics, one in Temple and the other in Killeen. Under the direction of the Local Health Authority, BCPHD provides the following services in both clinics: pre-conception counseling, family planning, pregnancy testing and counseling, sexually transmitted diseases (STD) testing and treatment, immunization administration and tuberculosis (TB) testing and treatment. Total number of unduplicated clients for Patient Population by Provider (PPP) was arrived at by adding the number of clients seen for family planning, STD, immunizations and tuberculosis at both clinics during the requested demonstration years. The lists of clients were carefully scrutinized to remove any clients that were seen for multiple services. Payor source, income, and family size information is collected on each family planning and STD client for state and federal family planning grants. This enables the Heath District to be able to calculate the Medicaid, low income and uninsured population (MLIU) that visits our clinics for these services. For immunization services, an attestation form is completed for each client, stating that these clients are uninsured. The tuberculosis program is fully funded by state and federal grants and does not consider the patient's insurance status when seeking treatment; therefore, these clients were not asked. The TB clients are counted in the Total PPP number, but not in the number for MLIU because the payor source is not collected for these clients."]
["088334001.7.1",8,"088334001","Bell County Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","N",""]
["094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private","Inpatient Services","Required","Y","Metroplex Hospital is a community hospital providing inpatient services which includes surgical, cardiac, maternal health, behavioral and Etc."]
["094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private","Emergency Department","Required","Y","Our ED had a volume of 43,325 in 2017, Admissions of 6,503 and a newborn count of 1215. Women less than 20 weeks pregnant are seen and treated in the ED."]
["094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Here at metroplex we offer a variety of services that take place in outpatient clinics such as Rehab, wound care, hbo, open MRI, Home Health."]
["094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private","Maternal Department","Required","Y","The Maternal Service Departments are subject to new born births in labor and delivery. Criteria for this requires a minimum of 20 weeks pregnant and/or your OBGYN is present in this department. Women less then 20 weeks are seen and treated in the ED. "]
["094119702.7.1",8,"094119702","Metroplex Health System","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including intensive care"]
["094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private","Emergency Department","Required","Y","All services which may be provided to a patient in the emergency department "]
["094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient clinics operating under the performing provider's hospital designation as reported for regulatory monitoring"]
["094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private","Maternal Department","Required","N",""]
["094151004.7.1",8,"094151004","Seton Highland Lakes","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Will include all individuals who receive services in home based settings in the system of care. These services are provided either face to face or through telehealth/telemedicine systems including individuals with diagnoses of Mental Health, Substance Use, Intellectual and Developmental Disabilities, Developmental Delay, Autism, and shared patients with our primary care partners."]
["126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Will include all individuals who receive services in office/clinic-based settings in the system of care. These services are provided either face to face or through telehealth/telemedicine systems including individuals with diagnoses of Mental Health, Substance Use, Intellectual and Developmental Disabilities, Developmental Delay, Autism, and shared patients with our primary care partners."]
["126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Individuals who are discharged from the state hospitals that BTCS is responsible for the follow-up services, will be included in the system of care.  The data for this inclusion will come from the CARE system."]
["126844305.7.1",8,"126844305","Bluebonnet Trails Community MHMR Center dba Bluebo","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community Based","Optional","Y","BTCS does not have specific clinics set up in the community-based locations, however we provide services beyond the four walls of traditional clinic confines.  This expands the system to include all individuals who receive BTCS services in the following community-based settings: Day Program, Emergency Room, General Medical Hospital, Institute for Mental Disease (IMD), Chemical Dependency Clinic, Private HCS/ICF home, School, and other (any additional location in the individuals’ community in which services are provided) in the system of care. These services are provided either face to face or through telehealth/telemedicine systems including individuals with diagnoses of Mental Health, Substance Use, Intellectual and Developmental Disabilities, Developmental Delay, Autism, and shared patients with our primary care partners."]
["126936702.7.1",8,"126936702","Williamson County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","We have four public health center (PHC) clinics in the County: Cedar Park PHC, Georgetown PHC, Round Rock PHC, and Taylor PHC. The core clinical health services provided include immunizations for children and adults, screening and counseling for tobacco cessation, screening and treatment of tuberculosis (TB), and testing, treatment, and counseling for Sexually Transmitted Infections (STIs)."]
["126936702.7.1",8,"126936702","Williamson County & Cities Health District","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","N",""]
["137249208.7.1",8,"137249208","Scott & White Memorial Hospital c/o State Comp Dep","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “INPATIENT”, “ADMIT”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["137249208.7.1",8,"137249208","Scott & White Memorial Hospital c/o State Comp Dep","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["137249208.7.1",8,"137249208","Scott & White Memorial Hospital c/o State Comp Dep","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["137249208.7.1",8,"137249208","Scott & White Memorial Hospital c/o State Comp Dep","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["137249208.7.1",8,"137249208","Scott & White Memorial Hospital c/o State Comp Dep","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Inpatient Services","Required","Y","All services provided in all departments to which a patient may be admitted to the hospital of Cedar Park Regional Medical Center (\"CPRMC\") for general medical or surgical care."]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Emergency Department","Required","Y","The department of CPRMC specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance."]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","CPRMC's clinic providing imaging and related lab services, including bone densitometry, CT, MRI, PET/CT,\n3D mammography, sereotactic biopsy, and ultrasound."]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Maternal Department","Required","Y","The department of CPRMC specializing in providing antenatal care, care during childbirth, and postnatal support."]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","CPRMC's freestanding Emergency Department located in Leander, Texas (Cedar Park Emergency Center - Leander)"]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Contracted Specialty Clinics","Optional","Y","The following specialty clinics contracted with CPRMC:  (1) Cedar Park Neurology and Sleep Medicine; (2) Cedar Park OB/GYN Associates; (3) Cedar Park Regional Medical Center Occupational Medicine Clinic.  "]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","The clinics or offices of the following physician providers, which are contracted with the performing provider:  (1) Cedar Park Physician Associates - Anderson Mill; (2) Cedar Park Physician Associates - Cypress Creek; (2) Cedar Park Physician Associates - Lago Vista; (4) Cedar Park Physician Associates - Avery Ranch; (5) Family First Healthcare - Leander; (6) Liberty Hill Physician Associates."]
["192622201.7.1",8,"192622201","Cedar Park Health System, LP dba Cedar Park Region","Hospital","Private","Contracted Palliative Care Programs","Optional","Y","CPRMC's palliative care program is provided by Austin Geriatric Specialist, PA.  They have 2 physicians who are on staff at CPRMC."]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “Inpatient”, “Admit”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N"]
["220798701.7.1",8,"220798701","Scott & White Hospital - Llano","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","Through an established service-level contract agreement; three outpatient clinics (BSW Llano, BSW San Saba, and BSW Johnson City) system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R. as 'OUTPATIENT', 'AMBULATORY', 'HOSPITAL OUTPATIENT SURGERY' and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to the outpatient visits in the hospital setting. All clinics considered Contracted are ones in accordance with Category B specifications of inclusion and exclusion criteria and have an established agreement for services between the clincs and Baylor Scott & White Medical Center Marble Falls, owner of the clinic facilities as listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes owned and operated facilities. "]
["312239201.7.1",8,"312239201","HH Killeen Hlth Sytm LLC dba Seton Med Ctr Harker","Hospital","Private","Inpatient Services","Required","Y","Inpatient services consist of a ten bed intensive care unit, a fifty five bed medical/surgical floor and an eighteen bed women's center. "]
["312239201.7.1",8,"312239201","HH Killeen Hlth Sytm LLC dba Seton Med Ctr Harker","Hospital","Private","Emergency Department","Required","Y","The emergency department consists of seventeen treatment rooms including two trauma rooms and one psychiatric room. "]
["312239201.7.1",8,"312239201","HH Killeen Hlth Sytm LLC dba Seton Med Ctr Harker","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Outpatient imaging, laboratory and respiratory departments are located within the hospital building. Outpatient physical therapy is located within the local YMCA wellness center, and cardiac rehab and the sleep lab are located within the medical office building located on the hospital campus. "]
["312239201.7.1",8,"312239201","HH Killeen Hlth Sytm LLC dba Seton Med Ctr Harker","Hospital","Private","Maternal Department","Required","Y","Eighteen bed women's center including eight LDRP suites and ten antepartum/postpartum rooms. "]
["312239201.7.1",8,"312239201","HH Killeen Hlth Sytm LLC dba Seton Med Ctr Harker","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “Inpatient”, “Admit”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["353712801.7.1",8,"353712801","Scott & White Hospital - Marble Falls","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","We are including primary clinics on our main campus. In the   primary care clinics,  the majority of the general dentistry treatment is provided by third and fourth year dental students under the supervision of faculty. "]
["009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","We are including the specialty care clinics that are owned and operated by TAMCOD on our main campus. In these specialty care clinics, the majority of the advanced specialty care treatment is provided by residents under the supervision of faculty from various specialties such as endodontics, periodontics, prosthodontics, pediatrics,  and oral surgery. "]
["009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["009784201.7.1",9,"009784201","TAMUS Health Science Center dba Baylor College of","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Community-based Programs","Optional","Y","The community clinics are co-located with organizations with complementary services. These community clinics include: the Juvenile Detention Center, North Dallas Shared Ministries, and the Agape Clinic. We provide dental care at these community-based organizations and coordinate medical and behavioral health services with other providers. "]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care"]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal care for delivery, antenatal acute care as needed, and gynecological acute care."]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020908201.7.1",9,"020908201","Presbyterian Hospital Of Dallas (TX Health Resourc","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","THD has an established relationship with Healing Hands Ministries and contracts with them to provide a Medical Home to the underserved."]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Inpatient Services","Required","Y","Medical City Dallas is a 796 bed acute care hospital in north Dallas. 156 beds are dedicated to pediatric care. Our services include adult oncology/hemotology , neurosurgery, orthopedics, transplants and cardiology. For pediatrics, we have a level IV NICU and provide services for pediatric oncology, congenital heart, craniofacial , orthopedics and neurosurgery."]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Emergency Department","Required","Y","Medical City Dallas operated 3 emergency rooms. 2 emergency rooms are located on the main hospital campus, one for adult care and one dedicated to pediatric care. A third freestanding emergency room is located 6 miles from hospital main campus in Dallas"]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Maternal Department","Required","Y","Medical City Dallas operates  24 bed L&D with 56 post partum beds. We deliver over 3500 babies each year and over 770 NICU babies."]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We are partnering with a local non-profit pediatric clinic that provides pediatric services to Medicaid and low income childrens. PediPlace is a 501c3 clinic that was also a partner with Medical City Dallas in DSRIP DY2-DY6 in opening a second site in north Dallas. "]
["020943901.7.1",9,"020943901","Columbia Hosp at Med City Dallas Subsid dba Medica","Hospital","Private","Other - Medical City Green Oaks Hospital","Optional","Y","Medical City Green Oaks Hospital (Green Oaks) is a 124 bed psychiatric provider adjacent to the Medical City Dallas campus.  Green Oaks partnered with Medical City Dallas in DY2 thru DY6 to provide DSRIP projects for behavioral health services. We will continue this partnership in DY7 and DY8 for Behavioral health improvements."]
["020967801.7.1",9,"020967801","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["020967801.7.1",9,"020967801","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care"]
["020967801.7.1",9,"020967801","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THDN operates the Caring Clinic, a diabetes management program."]
["020967801.7.1",9,"020967801","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal care for delivery, antenatal acute care as needed, and gynecological acute care."]
["020967801.7.1",9,"020967801","Texas Health Presbyterian Hospital Denton Presbyte","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020979302.7.1",9,"020979302","Columbia Medical Center of Las Colinas Inc dba Las","Hospital","Private","Inpatient Services","Required","Y","We operate 100 bed acute care hospital including ICU, med- surgical/step down, bariatric and OB/GYN services. Las Colinas also operates outpatient services through provider-based outpatient departments of the hospital."]
["020979302.7.1",9,"020979302","Columbia Medical Center of Las Colinas Inc dba Las","Hospital","Private","Emergency Department","Required","Y","We operate 1 Emergency room departments on the main hospital campus that sees over 30,000 visits each year."]
["020979302.7.1",9,"020979302","Columbia Medical Center of Las Colinas Inc dba Las","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020979302.7.1",9,"020979302","Columbia Medical Center of Las Colinas Inc dba Las","Hospital","Private","Maternal Department","Required","Y","We operate a maternal services department that delivers over 1800 babies each year and sees over 250 NICU babies"]
["020979302.7.1",9,"020979302","Columbia Medical Center of Las Colinas Inc dba Las","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THK will be operating the Health, Education and Lifestyles Program, a chronic disease management clinic."]
["094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private","Maternal Department","Required","N",""]
["094140302.7.1",9,"094140302","Texas Health Presbyterian Hospital Kaufman dba Pre","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private","Inpatient Services","Required","Y","We operate 100 bed acute care hospital including ICU, med- surgical/step down, bariatric and OB/GYN services"]
["094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private","Emergency Department","Required","Y","We operate 2 Emergency room departments. One emergency department is on the main hospital campus  and other in adjoining  local  community of Flower Mound .  Combined they see over 440,000 visits each year."]
["094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The hospital operates a Senior primary care clinic for Medicare beneficiaries."]
["094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private","Maternal Department","Required","Y","We operate a maternal services department that delivers over 1400 babies each year and sees over 220 NICU babies"]
["094192402.7.1",9,"094192402","Columbia Medical Center of Lewisville dba Medical","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["111905902.7.1",9,"111905902","Columbia Medical Center of Denton dba Denton Regio","Hospital","Private","Inpatient Services","Required","Y","We operate 208 bed acute hospital with ICU, med- surgical/step down, rehabilitation, neurosurgery and cardiology. Denton Regional also operates outpatient services through provider-based outpatient departments of the hospital."]
["111905902.7.1",9,"111905902","Columbia Medical Center of Denton dba Denton Regio","Hospital","Private","Emergency Department","Required","Y","We operate 1 Emergency room department located on the main hospital campus and we are a designated Level II Trauma center."]
["111905902.7.1",9,"111905902","Columbia Medical Center of Denton dba Denton Regio","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["111905902.7.1",9,"111905902","Columbia Medical Center of Denton dba Denton Regio","Hospital","Private","Maternal Department","Required","N",""]
["111905902.7.1",9,"111905902","Columbia Medical Center of Denton dba Denton Regio","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121758005.7.1",9,"121758005","Dallas County","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","This component of Dallas County LHD system consists of three Dallas County Health and Human Services (DCHHS) clinics which are the DCHHS STD/HIV Clinic, DCHHS TB Elimination Clinic and DCHHS Refugee Clinic. \n\nDCHHS STD Clinic: Located at DCHHS main facility in Dallas, the DCHHS STD/HIV clinic offers diagnosis and treatment for sexually transmitted diseases (STDs).  The clinic offers testing for Gonorrhea, Chlamydia, Syphilis, HIV, Herpetic lesions, Trichomonas, Chancroid with symptoms and Yeast. In addition to on-site treatments for clients diagnosed with STD infection, preventive treatment is also provided for clients exposed to STDs.  Moreover, through its HIV Early Intervention Program (EI), the STD Clinic provides a number of services to people who are newly diagnosed with HIV and to people who have been living with HIV but have not yet been in care. These services include: complete evaluation of health status, immunizations, STD testing, TB testing, counseling and linkage to care. In 2017 almost 8,000 clients were served by the STD/HIV clinic with more than 10,400 visits.\n\nDCHHS TB Elimination Clinic: Located at DCHHS main facility in Dallas, the DCHHS TB Elimination Clinic aims to prevent, control and ultimately eliminate TB among the people of Dallas County.  To do this, the clinic provides a wide variety of services including: complete evaluation and treatment of patients with TB infection/disease, TB screening and latent TB treatment, case management and on-site or off-site directly observed therapy (DOT), directly observed preventive therapy (DOPT) to school children, counseling and outreach as well as education, court-ordered quarantine of non-compliant patients, and other services. In 2017, there were 16,928 visits by more than 8,000 clients at the TB Elimination Clinic. In addition, clinic staff conducts continuous disease surveillance and contact investigation to stem the spread of TB and minimize possibility of an outbreak.\n\nDCHHS Refugee Clinic: The DCHHS Refugee clinic aims to prevent disease transmission and outbreak through early detection of diseases and referral. Located in North Dallas, the Clinic provides a wide variety of services for refugees and referrals to primary care providers. Some of the services include: physical examination, TB screening, hepatitis diseases screening, STD/HIV screening, lead screening, immunizations, pregnancy test, counseling and education, and other. Individuals who are diagnosed with TB infection will be transferred to the DCHHS TB Elimination clinic for treatment and follow-up. In 2017, there were more than 7,000 visits by 1,821 clients at the Refugee clinic.\n\n\n"]
["121758005.7.1",9,"121758005","Dallas County","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","This component of Dallas County LHD system includes DCHHS Immunization and Well Child Clinics. \n\nDallas County Health and Human Services (DCHHS) provides immunization services to protect Dallas County community from vaccine-preventable diseases. DCHHS operates one adult and six child immunization clinics at different locations in Dallas and other cities in the County. Four of the child immunization clinics also double as well-child clinics. In addition, DCHHS at its main facility operates a special clinic dedicated to influenza vaccination and an adult safety net clinic for administering various vaccines to indigent individuals. \n\nThe adult immunization clinic at DCHHS main facility offers vaccinations to adults for routine immunization and foreign travel. The clinic also provides information on CDC recommended vaccines to travelers and issues international travel immunization cards. Similarly, DCHHS children immunization clinics provide routine vaccines for children primarily through the Texas Vaccine for Children Program (TVFC). Moreover, through the Well-Child (THSteps) program, some of the clinics provide free medical checkups for children birth through age 20 in keeping with schedules recommended by the American Academy of Pediatrics. More than 40,000 children and adults are served by the DCHHS immunization clinics every year.\n\n\n\n"]
["121758005.7.1",9,"121758005","Dallas County","Local Health Department (LHD)","Non‐State Owned Public","Other - Jail","Optional","Y","The Dallas County Jail is a key entry point for individuals with behavioral health needs who are involved in the criminal justice system. There is currently a large amount of individuals that enter the criminal justice system and the Dallas County jail who have an active behavioral health need. A key aspect of our core activities involves identifying those with behavioral health needs who enter the jail, providing triage, face-to-face assessment, and linkage to services in the community to individuals seeking and agreeing to those services."]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as 'INSTITUTIONAL', 'RECURRING', 'INPATIENT', 'SURGERY ADMIT', and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY' and receive services and care that do not require patients to be admitted."]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘OBSERVATION-OP’, and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as 'NICU', 'POST PARTUM', 'L&D', 'NURSERY', 'NEWBORN NURSERY',  and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121776204.7.1",9,"121776204","Baylor Medical Center At Irving","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We will be including charity clinics that are part of our 501a physician group that are not on the Schedule H of the 990. These clinics are PCMH primary care clinics providing care to predominantly low income uninsured patients."]
["121988304.7.1",9,"121988304","Lakes Regional MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Lakes Regional Community Center, provides community based services for individuals with mental illness, developmental disabilities, substance use and co-occurring disorders. We provide rehabilitative, habilitation and other therapy services in an individuals home when appropriate based on a person centered treatment or habilitation plan. "]
["121988304.7.1",9,"121988304","Lakes Regional MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Lakes Regional provides Mental Health (MH), Substance Use Disorder (SUD) and Intellectual and Developmental Disabilities (IDD) services within a region of 15 counties in north Texas. Our numerous locations consist of outpatient clinics, day habilitation programs, crisis respite facilities, and substance use disorder program sites."]
["121988304.7.1",9,"121988304","Lakes Regional MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Individuals who are discharged from the state hospitals for whom Lakes Regional is responsible for follow-up care will be included. "]
["126679303.7.1",9,"126679303","Methodist Hosp of Dallas Methodist Charlton Med Ct","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["126679303.7.1",9,"126679303","Methodist Hosp of Dallas Methodist Charlton Med Ct","Hospital","Private","Emergency Department","Required","Y","All services administered in the Methodist Charlton Medical Center Emergency Department."]
["126679303.7.1",9,"126679303","Methodist Hosp of Dallas Methodist Charlton Med Ct","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services and patient visits within the Methodist Charlton Medical Center outpatient clinics."]
["126679303.7.1",9,"126679303","Methodist Hosp of Dallas Methodist Charlton Med Ct","Hospital","Private","Maternal Department","Required","Y","All services administered within the MCMC Maternity Department."]
["126679303.7.1",9,"126679303","Methodist Hosp of Dallas Methodist Charlton Med Ct","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","UT Southwestern Medical Center primary care physicians strive to help patients maintain optimal health and well-being throughout their lives. UT Southwestern Medical Center is dedicated to treating patients with attentive and compassionate care in the following primary care services:\n\nFamily Medicine: Provides comprehensive care including preventive care and disease maintenance for the whole family, from newborns to seniors\n\nGeneral Internal Medicine: Specializes in maintaining long-term adult wellness, including the prevention and treatment of common disorders such as diabetes, high blood pressure, high cholesterol, heart disease, obesity and osteoporosis. Coordinates care with other specialists\n\nGeriatrics: Focuses on comprehensive health care for seniors \n\nUT Southwestern Medical Center provides primary care services at the following locations: Aston Ambulatory Care Center, UTSW Professional Office Buildings I and II, UTSW Outpatient Professional Building, UTSW Clinical Center at Richardson/Plano, UTSW Clinical Center at Park Cities, UTSW Clinical Center at Las Colinas, Paul M Bass Center (Atrium and Towers 1 and 2), Lewisville Main Professional Building, Health Professions Center, UTSW MFM Clinic at Legacy, Seay Building, UTSW Student Support Services, The UT Southwestern Family Medicine at Texas Health Dallas, UTSW Family Medicine Clinic, Moncrief Cancer Institute, Monty and Tex Moncrief Medical Center at Fort Worth.\n\n"]
["126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","UT Southwestern has one of the largest academic physician practices in the nation and is a major referral center for patients with the most complex conditions. UT Southwestern’s commitment to primary care is enhanced by the comprehensive specialties offered by the organization. On an annual basis, UT Southwestern clinicians provide care to patients within a wide variety of specialty services. \n\nUT Southwestern Medical Center provides specialty care services at the following locations: Aston Ambulatory Care Center, UTSW Professional Office Buildings I and II, UTSW Outpatient Professional Building, UTSW Clinical Center at Richardson/Plano, UTSW Clinical Center at Park Cities, UTSW Clinical Center at Las Colinas, Paul M Bass Center (Atrium and Towers 1 and 2), Lewisville Main Professional Building, Health Professions Center, UTSW MFM Clinic at Legacy, Seay Building, Sprague Clinical Building, UTSW Student Support Services, The UT Southwestern Family Medicine at Texas Health Dallas, UTSW Family Medicine Clinic, Moncrief Cancer Institute, Monty and Tex Moncrief Medical Center at Fort Worth. \n"]
["126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","Y","UT Southwestern owns and operates William P. Clements Jr. University Hospital and Zale Lipshy Pavilion. \n\nFor the purposes of DSRIP reporting, the scope of measurement may include all services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic procedures.\n"]
["126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["126686802.7.1",9,"126686802","UT Southwestern Medical Center at Dallas","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Contracted Primary Care Clinics","Optional","Y","UT Southwestern Medical Center (UTSW) has collaborated with North Dallas Shared Ministries Clinic (NDSM) for the past several years and would like to include the associated medical interventions as a component of the system. NDSM is a charity wellness clinic providing primary care to the uninsured Dallas-area population. Additionally, UTSW would like to include a partnership with Woven Health Clinic and associated interventions as a system component.  Woven Health Clinic is a charitable clinic that provides primary health care services and is a medical home for people who live in Addison, Carrollton, Coppell, and Farmers Branch, Dallas and surrounding areas that cannot afford healthcare. Woven Health Clinic collaborated with UTSW during the first several demonstration years and will continue to partner with UTSW in demonstration years seven and eight. UT Southwestern looks forward to continuing to work with both clinics to enhance patient care."]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Parkland operates 774-adult bed and 96-neonatal bed acute care hospital, and the only American College of Surgeons certified burn center in the region.  "]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Parkland Hospital is a Level 1 Trauma Center, with ED utilization impacting the system with over 200,000 visits per year of which approximately 80% are Medicaid or indigent.  The Parkland Emergency Room (ER) provides full-service emergency care 24 hours a day, seven days a week.  Our highly trained emergency medical staff includes Board-certified physicians, medical residents, mid-level providers and registered nurses."]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Parkland Health and Hospital Systems operates over 90 specialty care clinics, 20 community-based clinics, including primary care and women's clinics, and 12 school-based clinics that offer affordable, comprehensive, and conveniently located medical care throughout Dallas neighborhoods. The community clinic program is designated by the National Committee for Quality Assurance as a Physician Practice Connections - Patient-Centered Medical Home."]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Parkland Health and Hospital Systems offer a range of women’s health services, from basic gynecology check-ups and routine prenatal care to high-risk pregnancy care and complex surgeries.  Parkland’s Dallas Healthy Start program seeks to reduce infant deaths, pre-term and low-weight births. The program offers services in seven ZIP codes that have the highest rates of infant deaths in Dallas County."]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Parkland Hospital owns and operates an urgent care emergency services center located on the main campus that provides care by physicians, physician assistants and nurse practitioners who are highly qualified to treat acute illnesses and injuries."]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","School-based Clinics","Optional","Y","Parkland owns and operates 12 School-Based Care Clinics that offer affordable, comprehensive, and conveniently located medical care throughout Dallas neighborhoods. "]
["127295703.7.1",9,"127295703","Dallas County Hospital District dba Parkland Healt","Hospital","Non‐State Owned Public","Other - Homeless Outreach Medical Services","Optional","Y","Provide health care to homeless pediatric and adult individuals in Dallas County. "]
["135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private","Emergency Department","Required","Y","All services administered in the Methodist Dallas Medical Center Emergency Department."]
["135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services and patient visits within the Methodist Dallas Medical Center outpatient clinics."]
["135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private","Maternal Department","Required","Y","All services administered within the MDMC Maternity Department."]
["135032405.7.1",9,"135032405","Methodist Hosp of Dallas Methodist Dallas Med Ctr","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["135234606.7.1",9,"135234606","Denton County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Individuals are receive case management, skills training, home based nursing or other services at their home are considered clients of MHMR and count in the system definition. "]
["135234606.7.1",9,"135234606","Denton County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All individuals who come in for clinic appointments with prescribers and case managers are included in the system definition."]
["135234606.7.1",9,"135234606","Denton County MHMR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Individuals who are discharged from the state hospitals for whom Denton County MHMR is responsible for follow-up care will be included. "]
["136360803.7.1",9,"136360803","Denton County dba Denton County Health Department","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Outpatient primary acute care for men, women and children. All medical services including prenatal care through 36 weeks, general medical care, minor diagnostic and therapeutic services, diabetic education and self management."]
["136360803.7.1",9,"136360803","Denton County dba Denton County Health Department","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Immunizations are provided by the Vaccines for Childrens and Adult Safety Net programs. Vaccines are available at both locations "]
["137252607.7.1",9,"137252607","Metrocare Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The Metrocare System is defined as all individuals who have received at least a face to face service in either homes, nursing homes, or community as provided by direct employee of Metrocare Services within the measurement period. Thus the system will exclude an services provided by contracted employees and/or outside entities. "]
["137252607.7.1",9,"137252607","Metrocare Services","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The Metrocare System is defined as all individuals who have received at least a face to face service in our clinics and/or other field based services as provided by direct employee of Metrocare Services within the measurement period. Thus the system will exclude an services provided by contracted employees and/or outside entities. "]
["138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Care for patients admitted to the hospitals in our system as Inpatients."]
["138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department, and Care Transition coordination to Home, Ambulatory, Observation or Inpatient care. "]
["138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Primary Care Clinics plus Medical, Surgical, Behavioral Health, Pulmonology, Endocrinology, Orthopedics, Otolaryngology, Dermatology, Genetics, Cardiology, Hematology/Oncology, Neurology, Nephrology, Gastroenterology, Pain Management, Palliative Care, Infectious Diseases, Ophthalmology, Dental and other Specialty Care Clinics."]
["138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private","Maternal Department","Required","N",""]
["138910807.7.1",9,"138910807","Children's Medical Center of Dallas","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as 'INSTITUTIONAL', 'RECURRING', 'INPATIENT', 'DAY SURGERY', or 'OBSERVATION' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY' and receive services and care that do not require patients to be admitted."]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘OBSERVATION-OP’, and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as 'NICU', 'POST PARTUM', 'L&D', 'NURSERY', 'NEWBORN NURSERY',  and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["139485012.7.1",9,"139485012","Baylor University Medical Center","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We will be including charity clinics that are part of our 501a physician group that are not on the Schedule H of the 990. These clinics are PCMH primary care clinics providing care to predominantly low income uninsured patients."]
["209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private","Emergency Department","Required","Y","All services administered in the Methodist Richardson Medical Center Emergency Department."]
["209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services and patient visits within the Methodist Richardson Medical Center outpatient clinics."]
["209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private","Maternal Department","Required","Y","All services administered within the MRMC Maternity Department."]
["209345201.7.1",9,"209345201","Methodist Hosp of Dallas dba Methodist Richardson","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["364710901.7.1",9,"364710901","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private","Inpatient Services","Required","Y","Hospital is licensed for 218 IP acute care beds."]
["364710901.7.1",9,"364710901","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private","Emergency Department","Required","Y","Hospital operated a 18 room ER and sees nearly 40,000 visits per year."]
["364710901.7.1",9,"364710901","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","In addition to inpatient and ER services hospital operates two outpatient specialty clinics."]
["364710901.7.1",9,"364710901","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private","Maternal Department","Required","Y","Hospital has a maternity department that performed over 1400 deliveries in 2017"]
["364710901.7.1",9,"364710901","Tenet Hosp Ltd dba Doctors Hosp at White Rock","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private","Inpatient Services","Required","N","We have  320 beds including ICU,Cardiac care, oncology and neurosurgery. Medical Center Arlington also provides outpatient services as part of hospital based departments. "]
["020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private","Emergency Department","Required","Y","We have 2 Emergency departments. One located on main campus and 2nd ER in adjacent town of Grand Prairie TX"]
["020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private","Maternal Department","Required","Y","We have 3 floors dedicated to Maternal care including a Level 3 NICU. We deliver over  4,000 babies each year."]
["020950401.7.1",10,"020950401","Columbia Medical Ctr of Arlington dba Med Ctr Arli","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private","Inpatient Services","Required","Y","Inpatient hospital setting providing inpatient services, surgical services, Emergency care and full neonatal and pediatric intensive care services"]
["021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private","Emergency Department","Required","Y","Emergency department setting"]
["021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Clinics owned and operated around the Tarrant County."]
["021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private","Maternal Department","Required","N",""]
["021184901.7.1",10,"021184901","Cook-Fort Worth Children's Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Urgent care clinics owned and operated around Tarrant County."]
["081599501.7.1",10,"081599501","MHMR of Tarrant County","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All services across MHMR divisions provided to individuals in their home.  Services are provided in the following areas: Mental health, Intellectual & developmental disabilities, Substance use, Early childhood intervention , Homelessness, and Veterans."]
["081599501.7.1",10,"081599501","MHMR of Tarrant County","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All services across MHMR divisions provided at residential and outpatient office/clinic locations in Tarrant County.  Services are provided in the following areas: Mental health, Intellectual & developmental disabilities, Substance use, Early childhood intervention , Homelessness, and Veterans. \n"]
["094105602.7.1",10,"094105602","Columbia North Hills Hospital dba North Hills Hosp","Hospital","Private","Inpatient Services","Required","Y","We operate 320 bed including ICU, med- surgical/step down, rehabilitation, neurosurgery and transplant. North Hills Hospital also provides outpatient services as part of hospital based departments."]
["094105602.7.1",10,"094105602","Columbia North Hills Hospital dba North Hills Hosp","Hospital","Private","Emergency Department","Required","Y","We operate 2 Emergency room departments. 1 ER is located on our main campus in Fort Worth and our 2nd ER is on Burleson Texas"]
["094105602.7.1",10,"094105602","Columbia North Hills Hospital dba North Hills Hosp","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","we operate a Senior Clinic for Medicare patients to provide primary care services"]
["094105602.7.1",10,"094105602","Columbia North Hills Hospital dba North Hills Hosp","Hospital","Private","Maternal Department","Required","N",""]
["094105602.7.1",10,"094105602","Columbia North Hills Hospital dba North Hills Hosp","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["094193202.7.1",10,"094193202","Columbia Plaza Medical Center of Fort Worth dba Pl","Hospital","Private","Inpatient Services","Required","Y","We operate 320 bed including ICU, med- surgical/step down, rehabilitation, neurosurgery and transplant. Plaza Medical Center also provides outpatient services as part of hospital based departments."]
["094193202.7.1",10,"094193202","Columbia Plaza Medical Center of Fort Worth dba Pl","Hospital","Private","Emergency Department","Required","Y","We operate 2 Emergency room departments. 1 ER is located on our main campus in Fort Worth and our 2nd ER is on Burleson Texas"]
["094193202.7.1",10,"094193202","Columbia Plaza Medical Center of Fort Worth dba Pl","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["094193202.7.1",10,"094193202","Columbia Plaza Medical Center of Fort Worth dba Pl","Hospital","Private","Maternal Department","Required","N",""]
["094193202.7.1",10,"094193202","Columbia Plaza Medical Center of Fort Worth dba Pl","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients."]
["112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care."]
["112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THFW operates the Senior Clinic."]
["112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal care for delivery, antenatal acute care as needed, and gynecological acute care."]
["112677302.7.1",10,"112677302","Harris Methodist Fort Worth Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THSW will be operating the Health, Education and Lifestyles program, a chronic disease management clinic."]
["120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private","Maternal Department","Required","Y","Women's Health and obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed and gynecological acute care."]
["120726804.7.1",10,"120726804","Harris Methodist Southwest Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THS will be operating the Health, Education and Lifestyles Program, a chronic disease management clinic."]
["121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private","Maternal Department","Required","Y","Women's Health and obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed and gynecological acute care."]
["121794503.7.1",10,"121794503","Texas Health Harris Mehodist Hospital Stephenville","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["121822403.7.1",10,"121822403","PRHC-Ennis, L.P. dba Ennis Regional Medical Center","Hospital","Private","Inpatient Services","Required","Y","Ennis Regional Medical Center (ERMC) is licensed for 60 beds with a 54 bed medical surgical unit with Telemetry capabilities and a 6 bed Intensive care unit. "]
["121822403.7.1",10,"121822403","PRHC-Ennis, L.P. dba Ennis Regional Medical Center","Hospital","Private","Emergency Department","Required","Y","ERMC's emergency department has 7 treatment rooms and 2 trauma bays. We have seen a 5 year average of 16,560 patients. We are designated Level IV trauma center since 2007. Accredited Chest Pain Center since 2016"]
["121822403.7.1",10,"121822403","PRHC-Ennis, L.P. dba Ennis Regional Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","ERMC's outpatient services are housed in our facility. We provide outpatient services for Laborory, Imaging, Physical Therapy, Occupational Therapy, Speech Therapy, and Cardiac Rehab. We also have outpatient surgery."]
["121822403.7.1",10,"121822403","PRHC-Ennis, L.P. dba Ennis Regional Medical Center","Hospital","Private","Maternal Department","Required","N",""]
["121822403.7.1",10,"121822403","PRHC-Ennis, L.P. dba Ennis Regional Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N"]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All units and departments providing Medical, Surgical, Obstetrical, and Behavioral Health Acute Care for patients admitted to the hospital as Inpatients."]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Medical, Surgical, Obstetrical, and Behavioral Health Emergent Care within our Emergency Department, Behavioral Emergency Department, and OB Triage with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care."]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Primary Care PCMH Clinics plus Medical, Surgical, Obstetrical, and Behavioral Health Specialty Care Clinics."]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed, and gynecological acute care. Ambulatory Women's Health Clinics that provide obstetrical and gynecological outpatient care and cancer screenings."]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Medical Urgent Care with Care Transition coordination back to Home or Ambulatory Care."]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","School-based Clinics","Optional","Y","Owned and operated School Based Primary Care Clinics"]
["126675104.7.1",10,"126675104","Tarrant County Hospital District dba JPS Health Ne","Hospital","Non‐State Owned Public","Other - Acute Palliative Care Program","Optional","Y","Acute Palliative Care Program offered to inpatients and their families who are referred to, evaluated for, and enrolled in the program."]
["127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care"]
["127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THAZ operates the Health, Education and Lifestyles program, a chronic disease management clinic"]
["127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private","Maternal Department","Required","N",""]
["127304703.7.1",10,"127304703","Harris Methodist Northwest Hosp (Azle)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient Services consists of all healthcare services provided to any patient admitted into the Wise Health System Hospital in Decatur or Fort Worth facilities.  A new facility will be opening in Argyle to provide some inpatient services.  The expected opening date is July of 2018."]
["130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Wise Health System Emergency Department in Decatur and Fort Worth serves all patients with emergency care needs seen in the Emergency Department. There will also be an emergency department providing services with the opening of the Argyle facility."]
["130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Wise Health System operates a number of imaging, physical therapy, and pain management clinics across our region.  It is likely we will add additional locations throughout the demonstration years."]
["130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Maternity Department is a business component of Wise Health System Hospital. It is a comprehensive labor and delivery department."]
["130606006.7.1",10,"130606006","Decatur Community Hospital (Wise Reg Health Systm)","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care"]
["130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THAM operates the Diabetes and Heart Disease Clinics."]
["130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal care for delivery, antenatal acute care as needed, and gynecological acute care."]
["130614405.7.1",10,"130614405","Texas Health Arlington Memorial Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["130724106.7.1",10,"130724106","Pecan Valley MHMR Region dba Pecan Valley Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All services rendered under the Texas Resilience and Recovery (TRR) model, as outlined in the 2017 TRR Utilization Management (UM) Guidelines for both adult and child/adolescent services."]
["130724106.7.1",10,"130724106","Pecan Valley MHMR Region dba Pecan Valley Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All services rendered under the Texas Resilience and Recovery (TRR) model, as outlined in the 2017 TRR Utilization Management (UM) Guidelines for both adult and child/adolescent services."]
["130724106.7.1",10,"130724106","Pecan Valley MHMR Region dba Pecan Valley Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","Individuals admitted to and discharged from contracted beds at Red River Hospital with a principal diagnosis of mental illness."]
["131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients."]
["131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department with Care Transition decision-making and coordination to Home, Ambulatory, Observation or Inpatient care."]
["131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THC operates the Transitional Care Clinic."]
["131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private","Maternal Department","Required","Y","Women's Health and Obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed, and gynecological acute care. "]
["131036903.7.1",10,"131036903","Texas Health Harris Methodist Hospital Cleburne","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “Inpatient”, “Admit”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["135036506.7.1",10,"135036506","Baylor All Saints Medical Center","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We will be including charity clinics that are part of our 501a physician group that are not on the Schedule H of the 990. These clinics are PCMH primary care clinics providing care to predominantly low income uninsured patients."]
["136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THHEB will be operating the Health, Education and Lifestyles program, a chronic disease management clinic"]
["136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private","Maternal Department","Required","Y","Women's Health and obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed and gynecological acute care."]
["136326908.7.1",10,"136326908","Texas Health Harris Methodist HEB","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","For this Required System Component, the UNTHSC system definition includes patients receiving services in the Family Medicine, Geriatric Medicine, and Pediatric Medicine clinics located in the UNTHSC Health Pavilion building at 855 Montgomery Street in Fort Worth, TX.  Additionally, this system definition includes patients receiving services in the Family Medicine clinic located in the UNTHSC Seminary Clinic building at 1305 East Seminary Drive in Fort Worth, TX."]
["138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","For this Required System Component, the UNTHSC system definition includes patients receiving services in the Cardiology, Dermatology, Gastroenterology, Musculoskeletal Medicine, Allergy and Surgical clinics located in the UNTHSC Health Pavilion building at 855 Montgomery Street in Fort Worth, TX."]
["138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["138980111.7.1",10,"138980111","UNTHSC at Fort Worth","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private","Emergency Department","Required","Y","All services administered in the Methodist Mansfield Medical Center Emergency Department."]
["186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services and patient visits in the Methodist Mansifield Medical Center's Outpatient Clinics."]
["186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private","Maternal Department","Required","Y","All services administered within the MMMC Maternity Department."]
["186221101.7.1",10,"186221101","Methodist Mansfield Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["206106101.7.1",10,"206106101","Wise Clinical Care Associates","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Wise Health Clinics include several primary care clinics with care providers administering primary care located in Wise County."]
["206106101.7.1",10,"206106101","Wise Clinical Care Associates","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","Wise Health Clinics include an array of specialty care clinics including orthopedics, bariatrics, pain management with care providers administering in and around Wise County."]
["206106101.7.1",10,"206106101","Wise Clinical Care Associates","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Hospital","Required","N",""]
["206106101.7.1",10,"206106101","Wise Clinical Care Associates","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","The Medical Acute Care department that serves patients who are admitted as inpatients."]
["216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department patients who are served in our Emergency Room and then either admitted as an impatient, transferred to another facility or are discharged in some capacity to their home, with the sheriff's office, or to the nursing home/rehabilitation center."]
["216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The primary care clinic that is attached to the hospital."]
["216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["216719901.7.1",10,"216719901","Glen Rose Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THH will be operating the Health, Education and Lifestyles program, a chronic disease management clinic"]
["314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private","Maternal Department","Required","Y","Women's Health and obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed and gynecological acute care."]
["314080801.7.1",10,"314080801","Texas Health Huguley INC   dba Huguley Memorial Me","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private","Inpatient Services","Required","Y","All units and departments providing Medical and Surgical Acute Care for patients admitted to the hospital as Inpatients"]
["316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private","Emergency Department","Required","Y","Medical and Surgical Care within our Emergency Department. "]
["316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","THAL will be operating the Health, Education and Lifestyles program, a chronic disease management clinic"]
["316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private","Maternal Department","Required","Y","Women's Health and obstetrical hospital departments for perinatal hospital care for delivery, antenatal acute care as needed and gynecological acute care."]
["316296801.7.1",10,"316296801","Texas Health Harris Methodist Hospital Alliance","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["083149703.7.1",10,"083149703","Tarrant County","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Tarrant County Public Health has 4 specialty clinics: Adult Health Services performed at 2 locations main and Arlington (testing for HIV, sexually transmitted diseases), Breast and Cervical Cancer Control (breast exams and Pap smears), Preventive Medicine Clinic (HIV services and treatment), and Tuberculosis Elimination Clinic (TB outreach and refugee screening) included within our system."]
["083149703.7.1",10,"083149703","Tarrant County","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Tarrant County Public Health has 8 immunization locations including 6 outlying centers and 2 Travel Health Services locations that are included within our system."]
["133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All behavioral health services for children and adults."]
["133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All behavioral health services for children and adults, including the Contracted Inpatient Beds and State Mental Health Facility"]
["133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","All behavioral health services for children and adults, including the Contracted Inpatient Beds and State Mental Health Facility"]
["133338707.7.1",11,"133338707","Abilene Regional MHMR dba Hardwick Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","All behavioral health services for children and adults, including the Contracted Inpatient Beds and State Mental Health Facility"]
["094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","N"]
["094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","N"]
["094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","N","Hamlin Medical Clinic is a Rural Health Clinic owned and operated by Hamlin Memorial Hospital. Visits include clinic visits, nursing home visits, and house calls."]
["094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["094131202.7.1",11,"094131202","Hamlin Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094131202.7.1",12,"094131203","Hamlin Memorial Hospital","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Our hospital closed on July 31, 2019. We no longer have an ER or Inpatient department to report on. We only have 2 providers who provide services in a stand alone primary care clinic. "]
["094131202.7.1",13,"094131204","Hamlin Memorial Hospital","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Specialty Care Clinics","Required","N"]
["094131202.7.1",14,"094131205","Hamlin Memorial Hospital","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Hospital","Required","N"]
["094131202.7.1",15,"094131206","Hamlin Memorial Hospital","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N"]
["112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient services allows us to provide services to our acute care patients that require more care and that are unable to be discharged home at the time services are rendered. "]
["112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency services allow us to care for patients that have medical emergencies. With this service we are able to evaluate and treat patients according to their needs. "]
["112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have 2 operating Rural Health Clinics within our county. "]
["112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["112692202.7.1",11,"112692202","Fisher County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","all services for all inpatients and outpatients admitted to the hospital for medical care"]
["112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","all services for all emergency room patients admitted to the hospital emergency room for medical care"]
["112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","all physician services for all patients presenting to our walk in clinic and primary care clinic for medical care"]
["112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["112702904.7.1",11,"112702904","Haskell Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","The Hospital consists of a Medical/Surgical Unit, an ICU Unit, an OB Unit, and offers the following ancially services to its inpatients and/or outpatients: Surgery, Pharmacy, Laboratory, Radiology, Cardiopulmonary, Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehab, Sleep Studies"]
["133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department is a Level IV certified Trauma Unit.  Its location is right of off Interstate 20 and typically sees a high volume of non local individuals, and a high volume of MVAs.  Annual volume averages 12,000 visits."]
["133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Hospital owns a Rural Health Clinic, an Orthopedic Surgeon practice, a Family Practice/Obstetrics practice,  an Internal Medicine practice, and Family Practice "]
["133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Hospital has 3 FP/OB doctors who deliver babies.  Births are currently 230 per year, and the Hospital is working to increase the birth rate."]
["133244705.7.1",11,"133244705","Rolling Plains Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133339505.7.1",11,"133339505","Central Texas MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","As a community mental health center, also referred to as Local Mental Health Authorities (LMHAs) we provide services to a specific geographic area.  Our area includes Brown, Coleman, Comanche, Eastland, Mills, San Saba and McCulloch counties.  We offer services in the consumers home as well as anywhere in the community.  Eligible populations may receive a myriad of services, from adult/child behavioral health, veteran services, substance abuse services, peer support, autism and services for those with intellectual and developmental delays.  "]
["133339505.7.1",11,"133339505","Central Texas MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","As a community mental health center, also referred to as Local Mental Health Authorities (LMHAs) we provide services to a specific geographic area.  Our area includes Brown, Coleman, Comanche, Eastland, Mills, San Saba and McCulloch counties.  We have an office located in each of these counties where consumers are able to receive services.  Eligible populations may receive a myriad of services, from adult/child behavioral health, veteran services, substance abuse services, peer support, autism and services for those with intellectual and developmental delays."]
["133339505.7.1",11,"133339505","Central Texas MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","Individuals who are discharged from the state hospitals, that Center for Life Resources is responsible for the follow up services, will be included in the system of care.  The data for this inclusion will come from the CARE system. "]
["133339505.7.1",11,"133339505","Central Texas MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Community Based Services","Optional","Y","We are able to offer our services in the home, clinic/office, and out in the community.  We are able to provide many of the same services in each of these settings."]
["136325111.7.1",11,"136325111","Mitchell County Hospital District dba Mitchell Cou","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care including diagnostic and therapeutic services"]
["136325111.7.1",11,"136325111","Mitchell County Hospital District dba Mitchell Cou","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","All services to which a patient may be seen in the emergency department for emergent care"]
["136325111.7.1",11,"136325111","Mitchell County Hospital District dba Mitchell Cou","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","All services to which a patient may be seen in the clinic for wellness, vaccinations, and diagnosis of other ailments"]
["136325111.7.1",11,"136325111","Mitchell County Hospital District dba Mitchell Cou","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["136325111.7.1",11,"136325111","Mitchell County Hospital District dba Mitchell Cou","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private","Inpatient Services","Required","Y","Inpatient Services include all services in all units to which a patient may be admitted to the hospital for general medical or surgical care, critical care, including outpatient services such as diagnostic and therapeutic services. Hendrick Medical Center has 564 licensed beds, 16 operating suites.  HMC has a 31 bed Comprehensive Inpatient Rehabilitation Unit (CIRU) that also serves Abilene and the surrounding communities. "]
["138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private","Emergency Department","Required","Y","Hendrick Medical Center has a Level III Trauma Center on campus and also an off campus free-standing Emergency Department. HMC averages about 4,700 ED visits per month, and 56,000 in a year."]
["138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Hendrick Medical Center owns and operates Hendrick Provider Network which is made up of primary care and specialty care clinics. Our primary and specialty care clinics serve as outreach clinics in  several surrounding communities including: Breckenridge, Brownwood, Colorado City, Coleman, Comanche, Eastland, Hamlin, Haskell, Stamford, and Sweetwater.  We offer specialty services that include: Cardiology, Rheumatology, Cancer, Internal Medicine, Infectious Disease, Orthopedic, OB, Endocrinology, Gastroenterology, Cardiovascular, and Urology services.  "]
["138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private","Maternal Department","Required","Y","Hendrick Medical Center provides prenatal, perinatal and post-partum care for women, including inpatient and outpatient care. Approximately 1,300 births occur at HMC each year. Hendrick has a Nursery equipped with 30 bassinets and the latest equipment to care for newborns. HMC also has a Level III Neonatal Intensive Care Unit with 25 bassinets to care for low-birth weight, pre-term, and critically ill newborns."]
["138644310.7.1",11,"138644310","Hendrick Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient Services includes all units including Women's Services, 6 bed Intensive Care Unit, Medical/Surgical Unit, and Swing Bed Services. We have some limited specialty providers available for consult including Gastroenterology, Non-interventional Cardiology, Surgical Services, General Surgery, Urology, and Orthopedics."]
["138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","16 bed Emergency Department, Level IV Trauma Center designated. Our ED serves approximately 1600 patients per month or 20,000 per year. "]
["138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have a robust clinic system which includes: Rural Health Clinics in Mineral Wells, Gordon, Santo, and a mobile unit which provides access to care for other underserved areas of the county."]
["138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","We provide Women's Services which accommodates approximately 300 births per year. We have recently received Level 1 designation in our nursery. This service line is currently supported by 2 Obstetricians. "]
["138950412.7.1",11,"138950412","Palo Pinto Co Hosp Dist dba Palo Pinto Gen Hosp","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","We operate an Urgent Care Clinic in Mineral Wells 7 days per week and 12 hours per day. It offers cost effective alternative care to the Emergency Department. "]
["281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private","Emergency Department","Required","Y","All services in all units to which a patient may be admitted to the emergency department for emergent care, including diagnostic and therapeutic services."]
["281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services in all outpatient units and rural health clinic to which a patient may be admitted for outpatient and rural health clinic services, including diagnostic and therapeutic services."]
["281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private","Maternal Department","Required","N",""]
["281406304.7.1",11,"281406304","Comanche County Medical Center Company","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020992601.7.1",11,"020992601","Stonewall Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Stonewall Memorial Hospital is a critical access hospital in Aspermont, TX that is licensed for 20 beds."]
["020992601.7.1",11,"020992601","Stonewall Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The emergency department is located within the main hospital building that provides anytime access to medical care."]
["020992601.7.1",11,"020992601","Stonewall Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The hospital district owns and operates three rural health clinics. The Stonewall Rural Health Clinic is in Aspermont on the main hospital campus. The Kent County Rural Health Clinic is in Jayton. The Spur Rural Health Clinic is located in Dickens County."]
["020992601.7.1",11,"020992601","Stonewall Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["020992601.7.1",11,"020992601","Stonewall Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["126842708.7.1",11,"126842708","Jones County Reg Healthcare Systm Stamford Mem Hos","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Rural health clinic and diagnostic clinic (bills ancillary services such as lab, rad, and PT)"]
["126842708.7.1",11,"126842708","Jones County Reg Healthcare Systm Stamford Mem Hos","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Specialty Care Clinics","Required","N",""]
["126842708.7.1",11,"126842708","Jones County Reg Healthcare Systm Stamford Mem Hos","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public","Owned or Operated Hospital","Required","N",""]
["126842708.7.1",11,"126842708","Jones County Reg Healthcare Systm Stamford Mem Hos","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Non‐State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Eastland Memorial has a 36 bed inpatient acute care unit primarily comprised of medical surgical services with telemetry capability but no ICU beds at this time. Patients may also be admitted to swingbed status. "]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Eastland Memorial has a 7 bed Emergency Room with 1 trauma room. Staffed 24/7, the emergency room is certified as a Level IV trauma center with telemedicine capabilities for Neurology/Stroke evaluations. Housed adjacent to the Emergency Room is a 2 truck EMS department staffed with Paramedics and EMTs as well as a satellite office with an additional 2 trucks within the county also staffed with paramedics and EMTs. "]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Eastland Memorial operates a primary care clinic in Ranger, TX (Eastland County) that is open 5 days a week staffed with a full time nurse practitioner and part time family practice physician. The clinic is currently billing under provider based reimbursement as a department of the hospital but has plans to apply for Rural Health Clinic status in January 2020 as well as add a second full time nurse practitioner in December 2019. Under construction is a 5,000 sq foot Rural Health Clinic in the city of Eastland 1 mile from the hospital that is scheduled to be completed and open in June 2020 with a full time nurse practitioner and part time physician. Eastland Memorial has plans to renovate an existing structure in Rising Star, TX and open a Rural Health Clinic in early 2020 with a part time nurse practitioner and part time Rehab and Therapy Services department. "]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Other - Perioperative Services","Optional","Y","Eastland Memorial has two operating room suites, one Special Procedures suite, and a three bed PACU. Inpatient and outpatient surgeries comprise the service lines of general surgery, orthopedics, plastics, dental, podiatric, ophthalmology, urology and gynecology. General surgery has the capability of performing laparoscopic procedures in addition to the traditional open approach.  "]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Other - Outpatient Services","Optional","Y","Eastland Memorial provides outpatient services in the areas of Rehabilitation, GI Lab, Interventional Radiology, Infusion and Special Procedures, and Diagnostic Laboratory, Radiology, CT, MRI and Ultrasound Services.  The Rehabilitation Services department provides physical, speech, and occupational therapy services as well as wound care and aquatic therapy services.  "]
["137074409.7.1",11,"137074409","Eastland Memorial Hospital","Hospital","Non‐State Owned Public","Other - Outpatient Dialysis Center","Optional","Y","Eastland Memorial assumed ownership and took over management of Eastland Dialysis Center in April 2019 as a department of the hospital. The Dialysis Center is open 3 days a week (MWF) with 12 chairs and currently runs 3 shifts. "]
["337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in Med/Surg."]
["337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","All services provided in the Emergency Department. "]
["337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","All services provided at our Rural Health Clinic, which includes outpatient services. Outpatient services are ordered from our clinic and resulted at the hospital."]
["337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["337991901.7.1",11,"337991901","Stephens Memorial Hospital dba Stephens County Eme","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","All services provided at our Urgent Care Center. "]
["065100201.7.1",12,"065100201","City of Amarillo","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Clinical services provided through the fixed location at public health."]
["065100201.7.1",12,"065100201","City of Amarillo","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Immunization services provided through the fixed location at public health."]
["065100201.7.1",12,"065100201","City of Amarillo","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Mobile immunization clinics and HIV prevention."]
["084563802.7.1",12,"084563802","Texas Tech University Health Sciences Center AMA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Patients with a primary care relationship with TTUHSC Amarillo clinics to include Family Medicine, Internal Medicine and Pediatrics."]
["084563802.7.1",12,"084563802","Texas Tech University Health Sciences Center AMA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","Patients with a specialty care relationship with TTUHSC Amarillo clinics to include OB/GYN, Surgery and Psychiatry. "]
["084563802.7.1",12,"084563802","Texas Tech University Health Sciences Center AMA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["084563802.7.1",12,"084563802","Texas Tech University Health Sciences Center AMA","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","The primary clinics for TTUHSC Lubbock (Texas Tech Physicians of Lubbock) consist primarily of our Departments of Family Medicine, Pediatrics, Internal Medicine, and OB/GYN. These clinics are in the Lubbock area, and service patients throughout West Texas."]
["084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","The specialty clinics for TTUHSC Lubbock (Texas Tech Physicians of Lubbock) consist of several specialty and sub-specialty providers. Our locations are in the Lubbock area, and serve patients from throughout the region working with primary care providers at TTUHSC, UMC-Physicians, Covenant, and UMC Medical Center."]
["084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["084599202.7.1",12,"084599202","Texas Tech University Health Sciences Center Offic","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["084897001.7.1",12,"084897001","Lubbock Regional MHMR Ctr dba StarCare Specialty","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","StarCare Specialty Health System (StarCare) is a community mental health center (CMHC) and as such, the primary home-based services provided are Psychosocial Rehabilitation and Peer Support Services.  Psychosocial Rehabilitation services are defined in the Texas Administrative Code as:  “Social, educational, vocational, behavioral, and cognitive interventions provided by members of a client’s therapeutic team that address deficits in the individual’s ability to develop and maintain social relationships, occupational or educational achievement, independent living skills, and housing, that are a result of a severe and persistent mental illness. This service includes treatment planning to facilitate recovery.”  Peer Support Services are defined in the Texas Administrative Code as:  “Activities provided between and among clients who have common issues and needs that are client-motivated, initiated, and/or managed and promote wellness, recovery, and an independent life in the community.”  Peer Support Services include, but are not limited to, drop in centers, peer counseling, peer support groups and peer led education groups.  This System Component includes all of the adults, youth and adolescents receiving community-based mental health services from StarCare, defined by the Health and Human Services Commission/Department of State Health Services (HHSC/DSHS) as “Service Packages 1, 2, 3 and 4.”   "]
["084897001.7.1",12,"084897001","Lubbock Regional MHMR Ctr dba StarCare Specialty","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","StarCare Specialty Health System (StarCare) is a community mental health center (CMHC) and as such, the primary office/clinic-based services provided are Eligibility Determination, Targeted Case Management and Medication Management.  Eligibility Determination includes face-to-face assessment of a person, by a qualified mental health professional (QMHP) for the purpose determining eligibility for mental health services funded by the Health and Human Services Commission/Department of State Health Services (HHSC/DSHS).  Targeted Case Management is defined by HHSC/DSHS as “Primarily site-based services that assist an adult, child or adolescent, or caregiver in gaining and coordinating access to necessary care and services appropriate to the individual's needs.”  Medication Management is defined by HHSC/DSHS as “A service provided by a physician or other prescribing professional which focuses on the use of medication and the in-depth management of psychopharmacological agents to treat a client's signs and symptoms of mental illness.”  This System Component includes all of the adults, youth and adolescents receiving community-based mental health services from StarCare, defined by the Health and Human Services Commission/Department of State Health Services (HHSC/DSHS) as “Service Packages 1, 2, 3 and 4.”"]
["094117105.7.1",12,"094117105","Hansford  County Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient acute care services. Our inpatient acute care system definition includes all inpatient services consisting of both acute care and swing bed."]
["094117105.7.1",12,"094117105","Hansford  County Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency Department services"]
["094117105.7.1",12,"094117105","Hansford  County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Rural Health Clinic. This system definition includes all outpatient services consisting of rural health clinic, ancillary services, observation and physical therapy."]
["094117105.7.1",12,"094117105","Hansford  County Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["094117105.7.1",12,"094117105","Hansford  County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Moore County Hospital "]
["094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency Department located at Moore County Hospital "]
["094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Moore County Family Health Clinic, Moore County Internal Medicine, Moore County OBGYN, Moore County Ortho, Moore County Podiatry, Moore County Hospice and Moore County Physical Therapy "]
["094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","OB Department Labor & Delivery located at Moore County Hospital. "]
["094129604.7.1",12,"094129604","Moore County Hospital District dba Memorial Hospit","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Lynn County Hospital District opened its doors in 1971 providing acute care to the predominantly low-income and uninsured county.  In March 2004, CMS designated the 24 bed hospital as a Critical Access Hospital specializing in Rehab services.  Swing Bed program offers 24/7 skilled nursing care for illnesses and post-operative care.  Our therapy departments make visits based on patients' needs to provide education and therapy necessary for recovery.  "]
["094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Lynn County Hospital District and the Texas Department of Health (TDH) provides emergency response teams that provide a lifesaving link between ill or injured individuals and medical care in Lynn County."]
["094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Lynn County Hospital District proudly hosts three clinics.  We have the Family Wellness Clinic,  a Specialty Clinic & Walk-In Clinic, and the  O'Donnell Clinic as well.  Our clinics are centrally located in both Tahoka and O'Donnell which are the two largest populated towns in the county.  "]
["094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["094180903.7.1",12,"094180903","Lynn County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Hemphill County Hospital inpatient services is a 26 bed licensed facility. We serve patients classified as acute, observation, swingbed, hospice, and/or respite. "]
["109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Hemphill County Hospital Emergency Department contains four exam rooms. We have a physician or nurse practitioner on call at all times. HCH serves as a Level IV Trauma Center. "]
["109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Hemphill County Hospital operates two rural health clinics. We currently house five providers in these two clinics with the ability to house more providers in the future. Within our hospital setting, we also serve in the outpatient setting of physical therapy and gastrointestinal diagnostic procedures. "]
["109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["109588703.7.1",12,"109588703","Hemphill County Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["112704504.7.1",12,"112704504","Ochiltree General Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","25 bed general acute Critical Access Hospital providing inpatient and outpatient services."]
["112704504.7.1",12,"112704504","Ochiltree General Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department at Ochiltree General Hospital is a state-certified Level IV Trauma Center available to community 24 hours per day, 365 days per year.  It is staffed by  trained emergency physicians and nurses proficient in advanced life support."]
["112704504.7.1",12,"112704504","Ochiltree General Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Provider based Medicare certified Rural Health Clinic. Provider has two clinics open, since the 2nd one opened in July of 2018.  "]
["112704504.7.1",12,"112704504","Ochiltree General Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Women's health and Obstetric Services"]
["112704504.7.1",12,"112704504","Ochiltree General Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["126667806.7.1",12,"126667806","Lockney Gen Hosp Dist (W.J. Mangold Mem Hosp)","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","WJ Mangold Memorial Hospital is a 25 bed critical access hospital which includes inpatient services in that capacity. "]
["126667806.7.1",12,"126667806","Lockney Gen Hosp Dist (W.J. Mangold Mem Hosp)","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","WJ Mangold Memorial Hospital owns an Emergency Department which is staffed with contracted ER physicians. "]
["126667806.7.1",12,"126667806","Lockney Gen Hosp Dist (W.J. Mangold Mem Hosp)","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","WJ Mangold Memorial Hospital has two rural healthcare clinics- one in Briscoe County in Silverton and the other in Lockney, Texas. "]
["126667806.7.1",12,"126667806","Lockney Gen Hosp Dist (W.J. Mangold Mem Hosp)","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["126667806.7.1",12,"126667806","Lockney Gen Hosp Dist (W.J. Mangold Mem Hosp)","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private","Inpatient Services","Required","Y","Collingsworth General Hospital is a Critical Access Hospital licensed for 13 inpatient acute care beds, all of which may be used as Swing  Beds or skilled nursing beds."]
["126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private","Emergency Department","Required","Y","The hospital is designated a Level IV Trauma Center (expires 11/1/2019), providing emergency services for the residents of Collingsworth and surrounding counties."]
["126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Collingsworth General Hospital includes Collingsworth Family Medicine, a Rural Health Clinic."]
["126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private","Maternal Department","Required","N",""]
["126840107.7.1",12,"126840107","Preferred Hosp Leasing, Inc. dba Collingsworth Gen","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Includes related inpatient services for Lamb Healthcare Center, as well as Lab and X-Ray"]
["127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Includes related emergency department services provided at Lamb Healthcare Center"]
["127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Includes patients related to our two association rural health clinics, Olton Rural Health Clinic and Lamb Healthcare Center"]
["127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Includes patients who utilize our OB services within the hospital, these patients would be included as a component of inpatients and/or outpatient clinics"]
["127313803.7.1",12,"127313803","Lamb Healthcare Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private","Inpatient Services","Required","Y","Covenant Children’s Acute Care and Intensive Care Inpatient Services "]
["127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private","Emergency Department","Required","Y","Covenant Children’s Emergency Department, Level 2 Trauma Center and Covenant Children’s OB Emergency Department"]
["127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Covenant Medical Group Pediatrics Primary Care Clinics and Covenant Medical Group Pediatrics Specialty Care Clinics"]
["127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private","Maternal Department","Required","Y","Covenant Children’s Hospital  Women's Services"]
["127319504.7.1",12,"127319504","Methodist Children's Hosp dba Covenant Children's","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["127374005.7.1",12,"127374005","Central Plains Center for Mental Health Mental Ret","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The system is our mental health services.  This population is made up of children ages 3-17 and adults 18 years and older."]
["127374005.7.1",12,"127374005","Central Plains Center for Mental Health Mental Ret","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The system is our mental health services.  This population is made up of children ages 3-17 and adults 18 years and older."]
["127378105.7.1",12,"127378105","Texas Panhandle Mental Health Mental Retardation","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Texas Panhandle Centers’ Home Based Services, provided in the top 21 counties of the Texas Panhandle, include the following: Intake and Assessment,  Case Management and Skills Training Services, Psychosocial Rehab, Occupational  Therapy, Physical Therapy, Speech Therapy, Crisis Services to include the Mobile Crisis Outreach Team (MCOT), Mental Health Jail Docket Diversion, First Episode Psychosis Interventions (FEP), Crisis Stabilization, Assertive Community Treatment (ACT), Supported Housing (SH) Supportive Employment (SE), Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI), Projects for Assistance in Transition from Homelessness (PATH), Psychopharmacological Services, Nursing services, Whole Health Peer Support, Cognitive Behavioral Therapy, Services to At Risk Youth and their Families (STAR), HCS Group Homes, In-Home Respite Services, IDD Specialized Services, Early Childhood Intervention (ECI), IDD Texas Home Living (TxHmL), Youth Empowerment Services (YES), and IDD Service Coordination & Community Supports.  "]
["127378105.7.1",12,"127378105","Texas Panhandle Mental Health Mental Retardation","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The office/clinic component for Texas Panhandle Centers may include the following services:  Screening, Intake, & Assessment, Nursing services, Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI), Psychopharmacological Services, Case Management, Psychosocial Rehab, Care Coordination,  IDD Specialized Services, Day Habilitation, Whole Health Peer Support, Integrated Primary and Behavioral Health Care, Crisis Intervention, Jail Diversion and Mental Health Jail Docket, Telemedicine, IDD Psychology, Individual Cognitive Behavioral Therapies, Group Counseling, and Homeless Services. \nOffice/Clinic Services are provided at the following locations:  Amarillo, Borger, Clarendon, Dumas, Hereford, Pampa and Perryton Centers.\n"]
["127378105.7.1",12,"127378105","Texas Panhandle Mental Health Mental Retardation","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other: Contracted Crisis Respite Services","Optional","Y","The Wood Group provides Crisis Respite Services that are designed to provide 24 hour supervision of a resident for a limited time. The resident stay in the Crisis Respite Bed is determined by the need of the resident and the nature of their crisis. Residents in this program must be able to self-administer medications. All medications are monitored and maintained by trained Crisis Respite Staff."]
["130618504.7.1",12,"130618504","Terry Memorial Hospital District Brownfield Region","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services.  "]
["130618504.7.1",12,"130618504","Terry Memorial Hospital District Brownfield Region","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The ED is designated as a Level IV Trauma Center which is staffed 24 hours a day, seven days a week.  "]
["130618504.7.1",12,"130618504","Terry Memorial Hospital District Brownfield Region","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The rural health clinic is devoted to the diagnosis and care of outpatients.  "]
["130618504.7.1",12,"130618504","Terry Memorial Hospital District Brownfield Region","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","This is a component of the Hospital that provides care for women during pregnancy and childbirth and for newborn infants."]
["130618504.7.1",12,"130618504","Terry Memorial Hospital District Brownfield Region","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["130725806.7.1",12,"130725806","West Texas Centers for MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","West Texas Centers is a community center and serves as the designated local authority for mental health and intellectual and developmental disabilities for the established 23-county catchment area.  Home-based services provided in these counties include crisis intervention, peer support, case management, supported employment,  supported housing and psychiatric rehabilitation. "]
["130725806.7.1",12,"130725806","West Texas Centers for MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","West Texas Centers’ administrative office is located at 319 Runnels St.; Big Spring, TX.  WTC operates 15 mental health centers which are located in Big Spring, Snyder, Sweetwater, Colorado City, Winters, Andrews, Seminole, Denver City, Brownfield, Post, Lamesa, Kermit, Monahans, Pecos and McCamey.  West Texas Centers provides mental health services to include 24-hour crisis intervention, case management, psychiatric evaluation and consultation, medication management, supported housing, and employment and psychiatric rehabilitation. "]
["130725806.7.1",12,"130725806","West Texas Centers for MHMR","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","West Texas Centers contracts with multiple hospitals for inpatient psychiatric services.  A provision of the contractual relationship with the hospitals requires the exchange of clinical information."]
["130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","21 bed unit where medical surgical, L&D, neonatal, pediatric, and hospice services are provided. "]
["130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","8 bay Level IV Trauma Center"]
["130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","2 rural health clinics, physical therapy, occupational therapy, speech therapy, cardiopulmonary rehabilitation, and behavioral health."]
["130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","2 L&D rooms and nursery."]
["130826407.7.1",12,"130826407","Dallam-Hartley Counties Hosp District dba Coon Mem","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133250406.7.1",12,"133250406","Childress County Hospital District dba Childress R","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Childress Regional Medical Center is a 39-bed hospital located in the city of Childress, Texas.  Inpatient services are those services where the physician order indicates an expected length of stay of 2 midnights or more.  Provider will also include all inpatient services in the system definition regardless of length of stay."]
["133250406.7.1",12,"133250406","Childress County Hospital District dba Childress R","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The hospital is designated a Level IV Trauma Center.  Our Emergency Department provides emergency services for the residents of Childress and surrounding counties."]
["133250406.7.1",12,"133250406","Childress County Hospital District dba Childress R","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Childress Regional Medical Center includes Fox Rural Health Clinic, a certified Rural Health Clinic."]
["133250406.7.1",12,"133250406","Childress County Hospital District dba Childress R","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Childress Regional Medical Center includes 6 labor and delivery beds and we deliver approximately 200 babies a year."]
["133250406.7.1",12,"133250406","Childress County Hospital District dba Childress R","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y"," The Inpatient service include Inpatient Medical-Surgical department and the Intensive Care Unit with a total of  31 beds available.  Within our inpatient care, a variety of services are available including medical needs, pre and post surgical needs, as well as swing bed services and at time palliative care. "]
["133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department is located on the campus of DSCHD.  The ED is  a Level IV designated Trauma Facility with the State of Texas."]
["133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Rural Health clinic is located on the campus of DSCHD and provides a variety of healthcare needs to the community members."]
["133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Located on the north end of the physical plant, the Maternal Department provides full range care for birthing options as well as normal newborn nursery services. 303 clients chose delivery services at HRMC for the calendar year of 2017. "]
["133544006.7.1",12,"133544006","Deaf Smith County Hospital District dba Hereford R","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Plains Memorial Hospital provides inpatient services such as swingbed, observation, and medical/surgical care.  "]
["136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Plains Memorial Hospital has accredited Level IV Trauma Center that provides emergency medical care to our community.  "]
["136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Medical Center of Dimmitt provides a continuum of care to pediatric, adult, and geriatric residents.  Welch Rehab is an outpatient therapy clinic that provides physical, occupational, and speech therapy.  Therapist also provide inpatient services to Plains Memorial Hospital.  "]
["136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["136142011.7.1",12,"136142011","Plains Memorial Hospital DSH Acct (Castro County)","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["136330112.7.1",12,"136330112","D. M. Cogdell Memorial Hospital (Scurry County)","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Cogdell Memorial Hospital is a 25 bed Critical Access Hospital."]
["136330112.7.1",12,"136330112","D. M. Cogdell Memorial Hospital (Scurry County)","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Cogdell Memorial Hospital has a 9 bed emergency department which is a level IV Trauma unit."]
["136330112.7.1",12,"136330112","D. M. Cogdell Memorial Hospital (Scurry County)","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","There are 2 clinics which the hospital owns and operates, one Cogdell Family Clinic and the other Cogdell Physician Services which includes the hospital billings for the providers and Cogdell Orthopedic Clinic which has about 40,000 encounters."]
["136330112.7.1",12,"136330112","D. M. Cogdell Memorial Hospital (Scurry County)","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","As part of the IP piece above, Cogdell has a seven bed OB department which handles about 160 deliveries annually."]
["136330112.7.1",12,"136330112","D. M. Cogdell Memorial Hospital (Scurry County)","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Sunrise Canyon Hospital (SRCH) is a 30-bed institution of mental disease (IMD) owned and operated by StarCare Specialty Health System (StarCare) a community mental health center (CMHC)/governmental entity/public provider under Chapter 534 of the Texas Health and Safety Code.  For the purposes of Category B, Sunrise Canyon Hospital defines its “System” as all of the unique (unduplicated) people served for at least one (1) bed day within the baseline and reporting years."]
["136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public","Emergency Department","Required","N",""]
["136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","N",""]
["136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["136492909.7.1",12,"136492909","Lubbock Regional MHMR Center dba Sunrise Canyon Ho","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Yoakum County Hospital is a rural, 24 bed hospital which offers inpatient medical services."]
["137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Yoakum County Hospital offers 24 hour emergency medical services via its level IV trauma emergency department"]
["137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Yoakum County Hospital offers outpatient medical services via its two rural health clinics: West Texas Medical Center in Denver City, Texas and Plains Clinic in Plains, Texas."]
["137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Yoakum County Hospital offers maternal medical services."]
["137227806.7.1",12,"137227806","Yoakum County dba Yoakum County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private","Inpatient Services","Required","Y","This includes all inpatient services of Northwest Texas Hospital including the Pavillion, our mental health hospital.  "]
["137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private","Emergency Department","Required","Y","In September 2019 we added a new Freestanding ED. We now have 2 Free standing ED locations and a main ED. "]
["137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All hospital based outpatient clinics like Physical Therapy, Occupational Therapy, Balance Clinic, etc. are included. This includes an Outpatient Surgery Center. The J.O. Wyatt Outpatient Clinic and two locations of Women's and Children's Clinic are also hospital based outpatient clinics."]
["137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private","Maternal Department","Required","Y","The maternal department of the hospital is included. "]
["137245009.7.1",12,"137245009","UHS @ Amarillo Inc dba Northwest Texas Healthcare","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","One of our two Urgent Care Clinics closed. We now only operate one Urgent Care clinic."]
["137343308.7.1",12,"137343308","Parmer County Community Hospital","Hospital","Private","Inpatient Services","Required","Y","Parmer Medical Center is a Critical Access Hospital licensed for 25 inpatient acute care beds, all of which may be used as Swing  Beds or skilled nursing beds. Patients also benefit from many outpatient services (Radiology, Laboratory, IV Therapy, Physical Therapy)."]
["137343308.7.1",12,"137343308","Parmer County Community Hospital","Hospital","Private","Emergency Department","Required","Y","Parmer Medical Center's Emergency Department is open 24 hours per day, 365 days a year."]
["137343308.7.1",12,"137343308","Parmer County Community Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Parmer Medical Center includes Friona Rural Health Clinic."]
["137343308.7.1",12,"137343308","Parmer County Community Hospital","Hospital","Private","Maternal Department","Required","N",""]
["137343308.7.1",12,"137343308","Parmer County Community Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","This system component includes our, University Medical Center, acute care and ICU IP or OBS services."]
["137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","This system component includes our, University Medical Center, Emergency Department & Level 1 Trauma Center."]
["137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","This system component includes our, University Medical Center Physicians Group, Primary Care (adult & Pedi), specialist, and hybrid clinics."]
["137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","This system component includes our, University Medical Center, IP maternal services."]
["137999206.7.1",12,"137999206","Lubbock County Hospital District dba University Me","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","This system component includes our, University Medical Center Physicians, Urgent Care Clinics. "]
["139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private","Inpatient Services","Required","Y","Covenant Medical Center Acute Care, Intensive Care and Critical Care Inpatient Services, Covenant Medical Center Palliative Care Inpatient Services, Covenant Medical Center-Plaza Behavioral Health Inpatient Services, and Covenant Specialty Hospital LTAC Inpatient services"]
["139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private","Emergency Department","Required","Y","Covenant Medical Center Emergency Department, Level 2 Trauma Center"]
["139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Joe Arrington Cancer Center, Covenant Medical Group Primary Care / Family Practice Clinics, and Covenant Medical Group Specialty Care Clinics, CMC GI Clinic"]
["139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private","Maternal Department","Required","N",""]
["139461107.7.1",12,"139461107","Covenant Health System dba Covenant Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Covenant Medical Group Urgent Care Clinics (4)"]
["189947801.7.1",12,"189947801","Medical Arts Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","We are a rural acute care hospital licensed for 23 beds. We provide medical services to all ages, newborn to geriatrics."]
["189947801.7.1",12,"189947801","Medical Arts Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","We are a Level 4 Trauma Center that provides 24 hour care, 7 days per week. We have lab and radiology support available 24 hours, 7 days per week. We do have an emergency department physician on staff 24 hours per day, 7 days per week, including holidays and weekends. "]
["189947801.7.1",12,"189947801","Medical Arts Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Our rural health clinic in on our hospital campus and currently we have 3 family practice physicians and a mid-level provider.  We are actively searching/recruiting providers, to include mid-levels to staff up our clinic. We provide Healthsteps examinations, DOT physicals, annual wellness exams, immunizations and care for the sick. We perform minor procedures within the scope of each physician provider."]
["189947801.7.1",12,"189947801","Medical Arts Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["189947801.7.1",12,"189947801","Medical Arts Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private","Inpatient Services","Required","Y","We have 15 licensed beds for acute healthcare services, swingbed services and pediatric services; a three bed intensive care services unit, and a 7 bed ob/gyn services unit on an inpatient basis."]
["197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private","Emergency Department","Required","Y","We are a Level IV Trauma designated facility, with a 24 hour per day, seven day a week emergency room operation"]
["197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","We have five clinics in operation which provides a general surgery clinic, an orthopedic specialty clinic, two obstetric and gynecology clinics, and a rural health clinic located in a neighboring town. We also have a rural health clinic located less than two miles from the hospital to try to divert patients from over usage of the ER."]
["197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private","Maternal Department","Required","Y","Our OB/GYN unit consists of 6 labor and delivery and recovery rooms"]
["197063401.7.1",12,"197063401","GPCH LLC dba Golden Plains Community Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private","Inpatient Services","Required","Y","Inpatient services are provided by Pampa Regional Medical Center."]
["308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private","Emergency Department","Required","Y","The emergency department is provided by Pampa Regional Medical Center"]
["308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Outpatient Clinics are part of Pampa Regional Medical Center & Pampa Medical Group."]
["308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private","Maternal Department","Required","Y","Maternal Department is part of Pampa Regional Medical Center."]
["308032701.7.1",12,"308032701","Prime Healthcare Services - Pampa, LLC dba Pampa R","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Urgent Care clinic is part of Pampa Medical Group."]
["316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private","Inpatient Services","Required","Y","We are a 20 bed inpatient facility that is fully staffer and offers acute medical care for patients of all ages. We provide Swing Bed services for patients requiring rehabilitation, IV therapy, or other skilled services. "]
["316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private","Emergency Department","Required","Y","Our Emergency Department is a certified LEVEL IV Trauma Center. We provide emergency services 24 hours a day seven days a week by physicians who are ATLS certified and nurses who are TNCC, ACLS and ENPC certified. "]
["316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","We operate a rural health clinic that serves Swisher and the surrounding counties through: Family Care, EPSDT Physicals, DOT Physicals, School Physicals, Insurance Physicals, Workers Comp, Flu Shots, Wound Care, Pap Smears, Immunizations, Pregnancy Tests, Medicare Exams, and more. We are open Monday through Saturday. "]
["316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private","Maternal Department","Required","N",""]
["316076401.7.1",12,"316076401","Swisher Memorial Healthcare System, dba Swisher Me","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["322879301.7.1",12,"322879301","Baptist St. Anthony's Health System","Hospital","Private","Inpatient Services","Required","Y","Our IP services include visits at BSA Hospital, Panhandle Surgical Hospital and Quail Creek Surgical Hospital."]
["322879301.7.1",12,"322879301","Baptist St. Anthony's Health System","Hospital","Private","Emergency Department","Required","Y","Our Emergency Department is located at BSA Hospital and serves between 55,000 to 65,000 patients annually. "]
["322879301.7.1",12,"322879301","Baptist St. Anthony's Health System","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Outpatient clinic include: BSA Family Medical Center, Amarillo Diagnostic Clinic, Panhandle Ear, Nose and Throat Clinic, and Harrington Cancer Center. "]
["322879301.7.1",12,"322879301","Baptist St. Anthony's Health System","Hospital","Private","Maternal Department","Required","Y","BSA Hospital maintains a Labor and Delivery department for maternal care."]
["322879301.7.1",12,"322879301","Baptist St. Anthony's Health System","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","BSA Health System runs one Urgent Care Clinic. "]
["350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private","Inpatient Services","Required","Y","Muleshoe Area Medical Center is a 25 bed Critical Access Hospital including Inpatient, Outpatient Services (Radiology, Laboratory, IV Therapy, Physical Therapy), and swing bed services."]
["350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private","Emergency Department","Required","Y","The hospital provides emergency services 24 hours a day 7 days a week."]
["350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","As of March 2018, Muleshoe Are Medical Center includes Muleshoe Family Medicine Clinic and Medical Clinic of Muleshoe, Rural Health Clinics."]
["350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private","Maternal Department","Required","N",""]
["350190001.7.1",12,"350190001","Preferred Hospital Leasing Muleshoe Inc","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private","Inpatient Services","Required","Y","Shannon Medical Center is licensed for 441 beds."]
["137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private","Emergency Department","Required","Y","The Shannon Emergency Department is designated a Level III Trauma Facility."]
["137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Shannon Clinic offers access to more than 275 providers in 40 specialties across 19 clinic locations."]
["137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private","Maternal Department","Required","Y","Shannon Medical Center includes a dedicated Women’s & Children’s Hospital which celebrates the birth of more than 1,200 new babies each year and is home to the Children’s Miracle Network for this area. "]
["137226005.7.1",13,"137226005","Shannon Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Shannon Clinic locations include 4 Urgent Care Clinics located throughout San Angelo, TX."]
["121781205.7.1",13,"121781205","L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Lillian M. Hudspeth Memorial Hospital is a licensed 12 bed not for profit Critical Access Hospital located in Sutton County."]
["121781205.7.1",13,"121781205","L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Lillian M Hudspeth Memorial Hospital is a designated Level IV trauma center with a 5 bay ER,  We have Telestroke capabilities with an in-house EMS service."]
["121781205.7.1",13,"121781205","L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have a RHC with MD oversight of 2 mid level providers."]
["121781205.7.1",13,"121781205","L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["121781205.7.1",13,"121781205","L M Hudspeth Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","North Runnels Hospital is a Critical Access Hospital licensed for 25 beds, all of which can be used for Acute Care or Swing beds."]
["020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department is open 24/7 to provide highly qualified medical care for the residents of Winters and the surrounding area."]
["020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","North Runnels Clinic is a Rural Health Clinic."]
["020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["020989201.7.1",13,"020989201","North Runnels Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["022793601.7.1",13,"022793601","City of San Angelo","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","The San Angelo-Tom Green County Health Department is a Local Health Department is a local health department serving the uninsured or Medicaid population of the City of San Angelo and Tom Green County.  We offer 3-day/week STD Clinics, along with daily case management/questions/answers, and scheduling of appointments.  In addition, the health department offers 1-day/week Immunization Clinic.  We provide opportunity for Outreach Clinics as warranted and requested.  "]
["022793601.7.1",13,"022793601","City of San Angelo","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Immunizations are administered at our fixed location, 2030 Pulliam Street, Suite 8, San Angelo, TX 76903.  The health department is a Texas Vaccines for Children provider, and thus, provide vaccinations to children who are non-insured or on Medicaid, only.  In addition, we also provide vaccine to un-insured adults through the Adult Safety Net vaccine program.  "]
["022793601.7.1",13,"022793601","City of San Angelo","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Mobile Outreach Clinics provide an opportunity to serve the citizenry outside a formal office setting, providing accessibility to some who might not come into a formal office setting.  Outreach Clinics are typically held at Angelo State University, Tom Green County Jail, Roy K. Robb Men's Detention and CTWR Women's Detention Centers, and other locations if warranted or requested.  "]
["109483102.7.1",13,"109483102","MHMR Svcs for the Concho Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All services in all units where \"home\" is an allowable service location for an authorized outpatient intervention."]
["109483102.7.1",13,"109483102","MHMR Svcs for the Concho Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All services in all units where \"office/clinic\" is an allowable service location for an authorized outpatient intervention."]
["121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Our facility offers general acute inpatient services for our patients."]
["121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Our facility has an emergency department equipped to meet the needs of our community.  Additionally, we are designated as a level IV trauma facility."]
["121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have a Rural Health Clinic within the hospital. Physician-based outpatient services at the hospital also include Lab, Radiology, and Physical Therapy."]
["121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["121806703.7.1",13,"121806703","Reagan Hosp District dba Reagan Memorial Hosp","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Pecos County Memorial Hospital (PCMH) is an accredited Joint Commission facility. PCMH provides general medical and surgical care for inpatient, outpatient, and emergency room patients, and participates in the Medicare and Medicaid programs. \n"]
["130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Our Emergency room is designated as a level IV certified trauma ER and services are available on a 24-hour per day, seven-day per week basis. "]
["130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The PCMH system has three outpatient clinics:  Family Care Center Clinic:  located in Fort Stockton, Pecos County, Texas, is a designated rural healthcare facility with 3 Family Practice Physicians, 1 part-time General Surgeon, 2 Family Nurse Practitioners, and 2 Family Practice residents provided through a collaboration with Texas Tech University (designating PCMH as a teaching facility); Family Care Center Walk-in Clinic: Also a designated rural healthcare facility with 3 physician assistants and 2 part-time Family Nurse Practitioners that does not house any radiological equipment; Sanderson Rural Health Center Clinic:  located in Sanderson, Terrell County, Texas is also a designated rural healthcare facility with one full-time Family Nurse Practitioner. Physicians who help with the Sanderson Clinic must travel approximately 65 miles one way in order to provide services to patients."]
["130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Our unit is equipped with 3 labor, delivery, and recovery rooms, and a nursery for special care infants."]
["130616909.7.1",13,"130616909","Pecos County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["316360201.7.1",13,"316360201","Coleman County Medical Center","Hospital","Private","Inpatient Services","Required","Y","Coleman County Medical Center is a 25 bed Critical Access Hospital including Inpatient, Outpatient Services (Radiology, Laboratory, IV Therapy, Physical Therapy), and swing bed services."]
["316360201.7.1",13,"316360201","Coleman County Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency room is open 24/7 and staffed with highly-qualified providers and allied staff trained to deliver medical care at all levels. The hospital is designated as a Level IV Trauma Center by the state of Texas (Expires 12/1/2019 )."]
["316360201.7.1",13,"316360201","Coleman County Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Coleman Medical Associates, a Rural Health Clinic, is housed in Coleman County Medical Center and is a recognized Level 2 Patient Centered Medical Home."]
["316360201.7.1",13,"316360201","Coleman County Medical Center","Hospital","Private","Maternal Department","Required","Y","All three physicians with family practices at the Coleman Medical Associates clinic that is part of Coleman County Medical Center practice obstetrics. "]
["316360201.7.1",13,"316360201","Coleman County Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private","Inpatient Services","Required","Y","Schleicher County Medical Center is a 13 bed Critical Access Hospital including Inpatient, Outpatient Services (Radiology, Laboratory, IV Therapy, Physical Therapy), and swing bed services."]
["179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private","Emergency Department","Required","Y","Schleicher County Medical Center is a designated Level IV trauma center (Expires 3/1/2020) that operates 24 hours a day, 7 days a week."]
["179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Schleicher County Medical Center  includes Schleicher County Family Clinic, a Rural Health Clinic."]
["179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private","Maternal Department","Required","N",""]
["179272301.7.1",13,"179272301","Preferred Hosp Leasing Eldorado, Inc. dba Schleich","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private","Inpatient Services","Required","Y","Kimble Hospital is a Critical Access Hospital licensed for 15 inpatient acute care beds, all of which may be used as Swing Beds or skilled nursing beds.  Outpatient Services provided at the facility include; Radiology, Laboratory, IV Therapy, and Physical Therapy."]
["206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private","Emergency Department","Required","Y","The hospital is designated a Level IV Trauma Center (Expires 7/1/2021), providing emergency services for the residents of Kimble and surronding counties."]
["206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Kimble Hospital includes Junction Medical Clinic, a Rural Health Clinic."]
["206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private","Maternal Department","Required","N",""]
["206083201.7.1",13,"206083201","Preferred Hosp Leasing Junction Inc. dba Kimble Ho","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["130089906.7.1",13,"130089906","Ballinger Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Ballinger Memorial Hospital (BMH) is Critical Access Hospital in Runnels County Texas that provides short-term inpatient care for common medical condition for any patient who is formally admitted (or 'hospitalized')  for treatment and/or care and stays for a minimum of one night in the hospital.   BMH generally maintains an annual average length of stay of 96 hours or less for acute care patient in accordance with Critical Access Hospital guidelines. BMH is certified for 25 acute inpatient beds and/or \"Swing Beds” that can be used for either acute care or care that is equivalent to Skilled Nursing Facility (SNF) care. "]
["130089906.7.1",13,"130089906","Ballinger Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Ballinger Memorial Hospital operates a Basic (Level IV) Trauma Facility and provides resuscitation, stabilization, and assessment of injury victims and either provides treatment or arranges for appropriate transfer to a higher level designated trauma facilities. BMH has established relationships with the tertiary trauma facilities to which it routinely transfers.  BMH Emergency Department is staffed by specially trained nurses and board-certified physicians who provide 24-hour care for a broad spectrum of illnesses and injuries. BMH also provides 24 hour EMS (Emergency Medical Services) .\n\n"]
["130089906.7.1",13,"130089906","Ballinger Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Ballinger Hospital Clinic(BMH) is a Rural Health Clinic and outpatient medical clinic owned and operated by BMHD.     BHC provides wellness checkups, scheduled, same-day, and urgent care (walk-in) appointments, chronic and acute illness care and a CLIA certified point-of-care laboratory. Primary care and urgent care services are provided to two local nursing facilities in person or via telemedicine as part of Rural Health Clinic services."]
["130089906.7.1",13,"130089906","Ballinger Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["130089906.7.1",13,"130089906","Ballinger Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["322916301.7.1",13,"322916301","McCulloch County Hospital District dba Heart of Tx","Hospital","Private","Inpatient Services","Required","Y","Our facility offers general acute inpatient services for our patients."]
["322916301.7.1",13,"322916301","McCulloch County Hospital District dba Heart of Tx","Hospital","Private","Emergency Department","Required","Y","Our facility has an emergency department equipped to meet the needs of our community.  Additionally, we are designated as a level IV trauma facility."]
["322916301.7.1",13,"322916301","McCulloch County Hospital District dba Heart of Tx","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","We have a Rural Health Clinic adjacent to the hospital. Physician-based outpatient services at the hospital also include Lab, Radiology, and Physical Therapy."]
["322916301.7.1",13,"322916301","McCulloch County Hospital District dba Heart of Tx","Hospital","Private","Maternal Department","Required","N",""]
["322916301.7.1",13,"322916301","McCulloch County Hospital District dba Heart of Tx","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient services we do cardiac monitoring, administer medications, do wound care, give IV therapy, assist with activities of daily living, perform respiratory therapy, obtain vital signs, do discharge planning, and arrange for home health and/or durable medical equipment on discharge.  "]
["091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","In the Emergency Department we provide emergency and trauma care to the population of the surrounding area. We stabilize patients until they get transferred, discharged or admitted.  "]
["091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","N",""]
["091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["091770005.7.1",13,"091770005","Concho County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Our system will be defined as any patient that we see as the primary care provider in both Midland and Odessa clinics. "]
["081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","We also offer specialty care clinics in Surgery and Psychiatry."]
["081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["081939301.7.1",14,"081939301","Texas Tech University Health Sciences Center Odess","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Reeves County Hospital District has 25 bed inpatient service to handle all inpatient needs, including labor and delivery.  Included in the 25 beds are 2 ICU beds"]
["112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Reeves County Hospital District has a 24/7 Emergency Department staffed by contracted physicians as well as clinical hospital employee staff"]
["112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Reeves County Hospital District has a Rural Health Clinic staffed with thirteen providers."]
["112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Reeves County Hospital District has three Family Practice/OB physicians, as well as one OB/GYN."]
["112684904.7.1",14,"112684904","Reeves County Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["112711003.7.1",14,"112711003","Odessa Regional Medical Center","Hospital","Private","Inpatient Services","Required","Y","All services in all units, excluding women's maternity unit, to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services. Includes pediatric and NICU services."]
["112711003.7.1",14,"112711003","Odessa Regional Medical Center","Hospital","Private","Emergency Department","Required","Y","All emergency services a patient may be given for general medical or traumatic care, including diagnostic services."]
["112711003.7.1",14,"112711003","Odessa Regional Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient clinics that provide primary care services, hospital outpatient services and specialty care services to adult and pediatric populations."]
["112711003.7.1",14,"112711003","Odessa Regional Medical Center","Hospital","Private","Maternal Department","Required","Y","All inpatient women's maternity services provided to include diagnostic, delivery and surgical care."]
["112711003.7.1",14,"112711003","Odessa Regional Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Permian Regional Medical Center is a 34 bed acute care hospital offering all services to which a patient can be admitted for medical or surgical care (except obstetrical services) which is listed below to Andrews county and the surrounding area.  "]
["127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","There is one emergency room that is a level 4 trauma unit serving the emergency services of the surrounding area."]
["127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","There are two rural health care clinics.  Andrews Family Medicine has 15 providers and the Quick Care Clinic has 7 providers serving Andrews County and the surrounding area."]
["127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The hospital has one maternal department serving the obstetrical needs of Andrews and the surrounding area."]
["127298107.7.1",14,"127298107","Permian Regional Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Ector County Hospital District dba Medical Center Health System is a multi-site health system anchored by Medical Center Hospital a 402-bed hospital in Odessa, TX.  "]
["135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Medical Center Hospital offers a 24 hour physician-staffed Emergency Department. As the only Level II Trauma Center in the Permian Basin, Medical Center Hospital is the leading provider of emergency and trauma care in the region."]
["135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","MCH Procare operates the system's outpatient specialty and primary care clinics, and employs both physician and clinic-based providers.  MCH Family Health Clinic, a Federally Qualified Health Center Look-A-Like, provides primary care services in a community healthcare center setting."]
["135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","The Center for Women and Infants at Medical Center Hospital offers the most state-of-the-art maternity center in the region, including a 30-room Level III NICU. The CWI NICU is the regional referral center for neonatal consultation and care of high-risk newborns from throughout the Permian Basin."]
["135235306.7.1",14,"135235306","Ector County Hospital District dba Medical Center","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Medical Center Health System operates three Urgent Care clinics in Ector County serving patients from all across the Permian Basin.  MCH Urgent Care clinics provide an after-hours option for residents seeking care. "]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Midland Memorial Hospital operates all services in all units (except maternal department) to which a patient may be admitted to the hospital for general medical or surgical care, including ancillary services such as diagnostic studies, laboratory services, radiology and therapeutic services."]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Midland Memorial Hospital emergency department operates emergency and urgent care services for unscheduled episodic services to clients who present for immediate medical attention, including diagnostic and therapeutic services."]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Midland Memorial Hospital owns and operates outpatient clinics that provides medical care on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, rehabilitation services, laboratory services,  and therapeutic services."]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Midland Memorial Hospital operates a women's maternity department which specializes in caring for women while they are pregnant and during childbirth as well as post-natal care.                   "]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["136143806.7.1",14,"136143806","Midland County Hospital District dba Midland Memor","Hospital","Non‐State Owned Public","Contracted Primary Care Clinics","Optional","Y","Midland Memorial Hospital is contracted with Midland Community Healthcare Services pediatric clinics for the purpose of DSRIP."]
["138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","PBCC does provide certain services in our clients' homes.  The occurrence of services in our patients homes is determined based on the needs of the individual being served and the program in which the client receives services. "]
["138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","PBCC provides office based services.  Services provided in the office can be delivered to any of our clients/patients in any of our programs.  This is driven largely by the needs of our patients."]
["138364813.7.1",14,"138364813","Permian Basin Community Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Clinic","Optional","Y","PBCC provides clinic using contracted providers in our integrated care and specialty care behavioral health clinics.  These clinics began as DSRIP projects during the initial waiver period and will continue on as core activities during the extension period. "]
["176354201.7.1",14,"176354201","Culberson Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Culberson Hospital is a 14-bed Critical Access Hospital (CAH) including Inpatient, Outpatient Services (Radiology, Laboratory, IV Therapy, Physical Therapy), and swing bed services."]
["176354201.7.1",14,"176354201","Culberson Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Culberson Hospital is a designated Level IV trauma center (Expires 4/1/2020) that operates 24 hours a day, 7 days a week."]
["176354201.7.1",14,"176354201","Culberson Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Culberson Hospital includes Van Horn Rural Health Clinic."]
["176354201.7.1",14,"176354201","Culberson Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["176354201.7.1",14,"176354201","Culberson Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private","Inpatient Services","Required","Y","The inpatient service units includes the below areas at Las Palmas Medical Center and Del Sol Medical center: Neuro/ortho, Medical, Rehab, Tele, ICU and Pediatrics."]
["094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private","Emergency Department","Required","Y","This system component includes emergency departments at Las Palmas and Del Sol and also the Free Standing ED (FSEDs)."]
["094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","This system component includes the following clinics: First Horizon, EL Paso Perinatology,Neurosurgical Specialist of El Paso, Cardiology Care Consultants, East Side Women's, Elite OB, Teen Centers, El Paso Ortho, and Texas Cardiac Arrythmia"]
["094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private","Maternal Department","Required","Y","This system component includes OB, NICU , L & D at Las Palmas and Del Sol. "]
["094109802.7.1",15,"094109802","El Paso Healthcare System Ltd dba Las Palmas Medic","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Includes Las Palmas CareNow Urgent Care-West El Paso"]
["065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","In April 2019, the U.S. Department of Health and Human Services/Office of Population Affairs awarded the CEPDPH a one-year grant to implement a Title X Family Planning Program. The department now provides an array of family planning services overseen by the assistant and medical directors, and a nurse practitioner. Under one comprehensive clinical center, clinicians provide health care for Medicaid recipients, low-income and uninsured patients including physical exams, STD screening and treatment, HIV/HCV testing and referral for treatment, pregnancy testing and counseling, birth control and cervical cancer screening.  The new clinical center is part of the health department’s system definition expanding health services from the former STD clinic reported in the DY7-8 system.  The other component reported under the initial system definition is the HIV prevention program, which changes include omission of HIV/HCV Gilead grant and deletion of HCV outcome measure for local health departments by HHSC's DSRIP Category 3 measure specifications. Thus, reducing workforce for disease surveillance and intervention reported in the initial system, which will limit reporting for DY9-10.  To compensate, all changes to previous system will be strengthen with a unified clinical record system under the new CommUnity Care Center to define the health department’s clinical system as the required component. "]
["065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","The Immunizations Clinics are venues to provide preventive services in the form of immunizations to the El Paso/Hudspeth Community. Any one six months and older is welcomed to come in on a walk-in basis. However, for expedited service, QLESS, an appointment and queue management system, is offered that provides individuals an accessible way to schedule their appointment or call ahead to book by phone. Priority individuals are those who do not have insurance, are low-income, or are Medicaid recipients. The clinics offer a flat fee of $15 to anyone uninsured.  The vaccines are tracked in the Advanced Business Solutions (ABS) electronic health record system. Individuals who are Medicaid, Low-Income or Uninsured can also get services provided at no cost by enrolling in the Medicaid Waiver Program. Health Education Specialists and Disease Intervention Specialists utilize a health referral survey to determine what vaccines a participant is eligible to receive. These vaccines are documented through a voucher system.  The participant is assigned a voucher listing the vaccines. The Immunizations Clinic then takes the voucher and administers the vaccine.  Tracking the voucher is important because it can be determined if the participant has used the referral to be immunized.  The immunization clinic staff is composed of 14 clinicians; one nursing supervisor, four registered nurses, five medical assistants, three patient care technicians, and one clinical assistant. The Delivery System Reform Incentive Payment Program (DSRIP) funds three of the clinicians in order to expand services beyond the fixed site clinics and traditional clinic schedule.  This immunization outreach team immunizes participants in venues outside of the clinic. Outreaches are within different locations where such as health fairs, schools, community centers, Mexican consulate, universities, and housing community complexes, in order to better reach the underserved population with transportation barriers or lack of fixed site clinics. The majority of the clients that the Immunizations clinic serves have Medicaid or are uninsured.  The clinics served over 10,000 clients including those who received the series vaccines in 2017.  The public may obtain a variety of vaccines at the immunizations clinic. These include: Hepatitis B, Rotavirus series, Diphtheria, tetanus and acellular pertussis, Haemophilus influenza type b (Hib), Pneumococcal conjugate (Pcv13), Inactivated poliovirus, Influenza, Measles, Mumps, rubella (MMR) , Varicella, Hepatitis A, Human papillomavirus, and the Meningococcal vaccine. The immunization clinic has three clinic locations to serve the West-Central, Central, and East El Paso regions.  The clinics are strategically located throughout the city to serve the uninsured and underinsured population."]
["065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public","Mobile Outreach","Optional","Y","Mobile Dental Unit: The mobile dental unit is a continuous mode of service delivery to expand dental exams and treatments beyond the fixed-site clinic. Priority population for the mobile dental unit are children and pregnant women ages 21 and younger.  A team composed of two dentists, a dental hygienist, an outreach specialist and a clerical assistant organize and provide dental health services within the mobile dental unit. Mobile dental services include general examinations, diagnostic X-rays, restorative procedures and preventive treatment such as dental cleaning, fluoride application, sealants, oral hygiene instructions and supply of oral hygiene products.  The mobile dental unit is deployed between 20 to 30 times per year to various underserved locations city-wide including Region 15 Head Start locations, elementary schools, WIC clinics, and health fairs. Services are offered to participants at their regional educational facilities for easier access to care and to fill the gap of limited clinics in these areas mostly in the outskirts of the city.\n"]
["065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public","Other - Community Health Outreach","Optional","Y","Health services are also offered throughout various community settings during outreach events in order to expand beyond the health department's fixed site clinics/offices.  This system component is defined as community health outreach for which health education specialists, community health workers, disease intervention specialists, and other trained personnel conduct referral interviews to identify and connect individuals in need of health screenings and/or vaccinations to access these services. Academic partners also collaborate with community health outreach as part of their research integrated in DSRIP projects. Trained personnel conducting research include Master's and Doctoral students from interdisciplinary health science disciplines as well as principal investigators, research assistants, and community health workers.  In addition, health department's clinicians (registered nurse, medical assistant, nurse aides) are deployed once a week to community health outreach events to provide basic health screenings onsite. These health services include blood pressure checks, biometric readings, glucose testing and vaccines. Community health outreach sites include community centers, housing complexes, shelters, colonias, schools, recreation centers and health fairs.  Administrative staff to include a director, program manager, accountant and office manager all assist in the coordination and logistics of all the DSRIP's six projects, contracted services with universities, mobile dental unit, community health ATLAS, and health information exchange.  In addition, a grant writer and quality improvement officer assist with sustainability activities.  Two health education specialist's and information specialist also assist with follow-up and customer service satisfaction for continuum of care."]
["065086301.7.1",15,"065086301","City of El Paso dba City of El Paso Department of","Local Health Department (LHD)","Non‐State Owned Public","Other - Fire Station Clinics","Optional","Y","Fire Department’s Emergency Medical Services (EMS) provides critical vaccinations and select health screenings during scheduled clinic events at neighborhood fire stations and nearby locations.  The target population are residents 18 and older who are Medicaid, Low income, and Uninsured (MLIU).  The fire department hosts clinics usually once a week to provide influenza and pneumonia vaccines. Clinic events include completion of REAL data referral interview, brief health assessment, blood pressure monitoring, glucose check, and fecal occult blood test (FOBT) kits.  All services are free of charge. Follow-up services are also being integrated to provide additional health resources to patients.  Most clinics are hosted in a central location known as the Safety & Health Outreach Center (SHOC) which is an old fire station retrofitted as clinic. Other fire stations located in areas with the most MLIU population also serve as venues once a month. The fire department also participates in health fairs and other large outreach events in order to reach the target population as approved by HHSC in previous DSRIP years."]
["084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","Includes all TTUHSC EP Primary Care clinics providing services directed to primarily address the condition referenced in the selected measure bundles. Prenatal care services are considered primary care services. Most of the prenatal care services are performed by the OB/GYN department. However, Family Medicine department provides prenatal care services on a smaller scale (i.e. first visit, before the patient is referred to OB/GYN)."]
["084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","Includes all TTUHSC EP Specialty Care clinics providing services directed to primarily address the condition referenced in the selected measure bundles. Prenatal care services are considered primary care services. Most of the prenatal care services are performed by the OB/GYN department. However, Family Medicine department provides prenatal care services on a smaller scale (i.e. first visit, before the patient is referred to OB/GYN)."]
["084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["084597603.7.1",15,"084597603","Texas Tech University Health Sciences Center EL Pa","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["127376505.7.1",15,"127376505","El Paso Community MHMR dba Emergence Health Networ","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Home-based services form a large component of services provided by Qualified Mental Health Provider’s (QMHP)/Caseworkers. An individual credentialed to provide QMHP services conducts assessments, treatment planning and follow-up in client homes. Some of the services performed by caseworkers are quantified in the Category B system. Services quantified include only those that are conducted face-to-face such as triage, assessments, and medication management amongst others. Those services were quantified (counted towards) in the MLIU PPP and PPP, as a part of the Category B Patient Universe.  EHN is excluding only those services that are not conducted face-to-face (e.g. over the phone screenings). "]
["127376505.7.1",15,"127376505","El Paso Community MHMR dba Emergence Health Networ","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","EHN Outpatient Clinics and other programs provide clinical behavioral health services in an outpatient (office/clinical) setting.  Services conducted in this setting are quantified in the Category B system.    \n    \n"]
["127376505.7.1",15,"127376505","El Paso Community MHMR dba Emergence Health Networ","Community Mental Health Center (CMHC)","Non‐State Owned Public","State Mental Health Facility","Optional","Y","The source of hospital discharges are from the El Paso Psychiatric Center, which is a State of Texas Hospital Facility. As the local mental health authority, Emergence is tasked with conducting continuity of care for discharges from the El Paso Psychiatric Center. Only those patients discharged from the center and linked to EHN become a part of EHN’s patient universe and included in the Category B system.  "]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Inpatient Services","Required","Y","All adult and pediatric inpatient units (excluding the women’s maternity unit) to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and treatment services."]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Emergency Department","Required","Y","All emergency services departments, both within the main hospital facility and freestanding, that provide emergency care to patients."]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All adult and pediatric outpatient locations within the community that provide treatment and/or diagnosis services to patients on an outpatient basis."]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Maternal Department","Required","Y","All maternal-specific units to which a patient may be admitted to the hospital for maternal care including but not limited to Labor and Delivery services, Post-Partum services, and diagnostic and therapeutic services. "]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["130601104.7.1",15,"130601104","Tenet Hospital Limited dba Providence Memorial Hos","Hospital","Private","Other - Owned and Operated Palliative Care Program","Optional","Y","All owned and operated palliative care services provided by Mariposa Hospice, including inpatient and outpatient services. "]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","UMC provides inpatient services as the county hospital for the El Paso and Hudspedth region."]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","UMC's Emergency Department is a level one trauma center  and provides Emergency services to El Paso and the surrounding rural areas."]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","UMC has 27 outpatient/ primary care clinics, including Employee Clinics, located throughout the El Paso region that provide primary care, lab and pharmacy services. Some facilities have orthopedic rehabilitation services."]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","UMC's inpatient hospital has a Labor and Delivery department and provides maternal services through Texas Tech University Health Sciences Center providers."]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["138951211.7.1",15,"138951211","El Paso Co Hosp Dist - University Medical Center o","Hospital","Non‐State Owned Public","Contracted Palliative Care Programs","Optional","Y","UMC will continue its contract with Hospice of El Paso to provide hospice and palliative care to our patients.  This partnership will continue and expand those DSRIP efforts developed during DY2-6."]
["196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private","Inpatient Services","Required","Y","All adult inpatient units (excluding the women’s maternity unit) to which a patient may be admitted to the hospital for general medical, surgical, or critical care, including diagnostic and treatment services"]
["196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private","Emergency Department","Required","Y","All emergency services within the main hospital facility that provide emergency care to patients. "]
["196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All SPEMC owned or operated adult outpatient locations within the community that provide treatment and/or diagnosis services to patients on an outpatient basis."]
["196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private","Maternal Department","Required","Y","All maternal-specific units to which a patient may be admitted to the hospital for maternal care including but not limited to Labor and Delivery services, Post-Partum services, and diagnostic and therapeutic services for expecting mothers. "]
["196829901.7.1",15,"196829901","Sierra Providence East Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private","Inpatient Services","Required","Y","EPCH has a 26 bed General Acute Medical and Surgical Care Unit; a 22 bed Pediatric ICU; a 50 bed Neonatal Intensive Care Unit, and a 24 bed Hematology/Oncology Unit."]
["291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private","Emergency Department","Required","Y","EPCH has a 10 bed Emergency Department."]
["291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","EPCH's Hematology/Oncology Unit has an Outpatient Infusion Clinic consisting of 8 beds. EPCH also operates an outpatient Medical Child Abuse Resources and Education System (MedCARES Clinic)."]
["291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private","Maternal Department","Required","N",""]
["291854201.7.1",15,"291854201","El Paso Children's Hospital","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["084859002.7.1",16,"084859002","Heart of Texas Region MH & MR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The HOTRMHMR Center's system definition is all adults and youth over the age of 6 that receive services from HOTRMHMR to exclude our contracted services for telepsychiatry in our crisis treatment Center.  We do not have access to the contractor's database or have the ability to pull data from their system.  The primary services provided are on-going supports and services, a needed component in impacting selected metrics. "]
["084859002.7.1",16,"084859002","Heart of Texas Region MH & MR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","The HOTRMHMR Center's system definition is all adults and youth over the age of 6 that receive services from HOTRMHMR to exclude our contracted services for telepsychiatry in our crisis treatment Center.  We do not have access to the contractor's database or have the ability to pull data from their system. The primary services provided are on-going supports and services, a needed component in impacting selected metrics. These office based services involve case management, skills training, psychosocial rehabilitation, nursing supports, psychiatric services, medication management, wellness screenings, assessments and integrated health care. This includes school-based services."]
["084859002.7.1",16,"084859002","Heart of Texas Region MH & MR Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","This includes state funded beds which consists of state hospital and private psychiatric beds. "]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general or surgical care or psychiatric care, including intensive care"]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Emergency Department","Required","Y","All services which may be provided to a patient in the emergency department"]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All outpatient clinics operating under the performing provider's hospital designation"]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Maternal Department","Required","Y","All services which may be provided to a patient in the maternal department"]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["111829102.7.1",16,"111829102","Providence Health Services of Waco  dba Providence","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","The Performing Provider is including contracted primary care clinics that support the management of care in the Category C Measure Bundle selected and provide services to the MLIU population."]
["121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","This system component is a 42 bed acute care facility transitioning to a 25 bed Critical Access Hospital.  Important inpatient services include Radiology and Laboratory Services, general surgery, acute care, and Swing Bed."]
["121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Emergency Department maintains a Level 4 Trauma designation with 24 hour service.  We have an ambulance service."]
["121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Our Hospital Based Outpatient Services include an Orthopedic Clinic led by a practicing board certified orthopedic surgeon and a Special Care clinic staffed with Licensed Mental Health Counselors and a Psychiatrist.  Additional outpatient services include Cardiac and Pulmonary Rehab, Congestive Heart Failure, Diabetes Self-Management and Nutrition Services, Physical and Occupational Therapy, Laboratory and Radiology Services, basic Nuclear Medicine, Wound Care Center, Sleep Medicine, Social Services, and Chronic Care Management.  Telemedicine is an established service set to expand.  Currently telemedicine consults occur at our facilities for psychiatry, hematology and retinal ophthalmology.  Primary Care is delivered through our three Rural Health Clinics located in Hamilton, Goldthwaite, and Hico.  We have a total of 15 primary care providers.\n\n"]
["121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["121792903.7.1",16,"121792903","Hamilton County Hospital District dba Family Pract","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Coryell Memorial Healthcare System operates a 25 bed critical access hospital in Coryell County. It is licensed as a non-taxable county hospital authority."]
["134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Coryell Memorial Healthcare System (CMHS) operates a 6 bed Level IV Trauma Center in Coryell County, adjacent to the critical access hospital.  CMHS also owns a 24 hour ambulance service in Coryell County."]
["134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Coryell Memorial Healthcare System (CMHS) owns an outpatient clinic in Coryell County that includes a hospital based primary care clinic and specialty care services.  CMHS also owns a rural health clinic in Goldthwaite, Texas, in Mills County.  Specialty care services include orthopedic surgery, general surgery, cardiology, pulmonology, podiatry, sleep lab, pain clinic, wound care, nephrology, cardiac rehab, and physical therapy."]
["134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["134772611.7.1",16,"134772611","Coryell County Memorial Hospital Authority dba Cor","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private","Inpatient Services","Required","Y","All services for patients admitted to the  medical/surgical care unit."]
["137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private","Emergency Department","Required","Y","All services that may be provided to all patients that are admitted to the emergency department"]
["137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","All services provided to all patients that are seen in  all outpatient clinics that operate under the performing providers hospital designation"]
["137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private","Maternal Department","Required","Y","All services provided to all patients admitted to the labor, deliver, postpartum, and nursery (LDPN) unit"]
["137075116.7.1",16,"137075116","Goodall-Witcher Healthcare Foundation Administrati","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “Inpatient”, “Admit”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138962907.7.1",16,"138962907","Hillcrest Baptist Medical Center","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We will be including primary care clinics that are part of our 501a physician group that are not on the Schedule H of the 990. These clinics are PCMH primary care clinics providing care to low income uninsured patients."]
["140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Hospital has 20 licensed beds for inpatient and swing bed which includes all services in all units to which a patient may be admitted to the hospital for general medical car, including diagnostic and therapeutic services."]
["140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The emergency department is a level IV trauma 5 bed capacity.  The medical center owns and operates the EMS/911 services for the South Limestone area and also does transfers.  The Emergency room physicians are contracted."]
["140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The medical center owns and operates a rural health clinic as an operating department of the hospital.  The medical center oprates an additional clinic-NON RHC- at another location about a mile from the main campus; started on July 23, 2018.  The medical center will provide outpatient clinic services on or before December 19, 2019 for the town of Kosse; the town had a federal grant that built a clinic and must provide medical services for 10 years per the grant."]
["140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["140714001.7.1",16,"140714001","Limestone Medical Center dba Limestone Medical Cen","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private","Inpatient Services","Required","Y","Conroe Regional Medical Center has designated inpatient services include beds for Medical/Surgical, ICU/CCU, Neonatal ICU, Pediatric and comprehensive medical rehabilitation."]
["020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private","Emergency Department","Required","Y","Conroe Regional Medical Center has a designated Emergency Department on site. "]
["020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private","Maternal Department","Required","Y","Conroe Regional Medical Center provides Obstetrical Care consisting of a birthing center, inpatient antepartum, intra-partum, and/or post partum services, as well as on-site birthing and parenting classes."]
["020841501.7.1",17,"020841501","Conroe Regional Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private","Inpatient Services","Required","Y","The Med's inpatient Services include all inpatient services"]
["020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private","Emergency Department","Required","Y","The Med's Emergency Department includes all services that are provided to ED patients.  "]
["020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","N",""]
["020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private","Maternal Department","Required","N",""]
["020860501.7.1",17,"020860501","College Station Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["081844501.7.1",17,"081844501","Tri-County Behavioral Healthcare","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","The home-based services component provides a range of services to adults with serious mental illness intended to support long term recovery with services to include: Psychosocial Rehabilitation Services, Supported Employment Services, Service Coordination, and short-term respite."]
["081844501.7.1",17,"081844501","Tri-County Behavioral Healthcare","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Outpatient adult and child mental health, IDD, primary care, and substance use disorder services are provided in person or via televideo in our community mental health center clinics. Some specific services include: psychiatric evaluations, medications, case management, counseling, and mental health assessments. Integrated primary care services are available on site. "]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Inpatient Services","Required","Y","CHI St. Joseph Regional Health -all services in all units to which a patient may be admitted to the hospital"]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Emergency Department","Required","Y","All services in the ER to which a patient may have an encounter at Emergency and Trauma Center at Regional Hospital (Bryan)"]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","all services in the owned or operated outpatient clinics that are included in joint commission survey- 21 total clinics"]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Maternal Department","Required","Y","all services in the maternal inpatient department"]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Other - Observation Unit","Optional","Y","All services in the observation unit of the CHI St Joseph Regional Hospital"]
["127267603.7.1",17,"127267603","St. Joseph Regional Health Center","Hospital","Private","Other - Surgical Day Care","Optional","Y","All services in the CHI St. Joseph Regional Hospital in the Surgical Day Care unit"]
["130982504.7.1",17,"130982504","Brazos Co Treasurer (Brazos County Health Departme","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","All clinical services provided by the Brazos County Health Department, including immunizations, TB, and sexually transmitted infections testing and treatment."]
["130982504.7.1",17,"130982504","Brazos Co Treasurer (Brazos County Health Departme","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","All immunization services provided to both children and adults.  "]
["135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “INPATIENT”, “ADMIT”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["135226205.7.1",17,"135226205","Scott & White Hospital Brenham","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Services to individuals in his/her place of residence who have been diagnosed with a mental health or intellectual developmental disability."]
["136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Services provided to an individual in any of the provider's office/clinic locations who have been diagnosed with a mental health or intellectual developmental disability."]
["136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Hospital","Optional","Y","Crisis services provided in an ER or hospital setting."]
["136366507.7.1",17,"136366507","MHMR Authority of Brazos Valley","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - Jail","Optional","Y","services provided to inmates in a jail or juveniles in a detention facility."]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Inpatient Services","Required","Y","CHI St. Luke’s Health – The Woodlands Hospital is a 241 licensed beds acute-care, non-profit, inpatient hospital system that provides a multitude of inpatient services including:\n• Surgery\n• Gastroenterology\n• Cardiology\n• Pulmonology\n• Cosmetic/Reconstructive Surgery \n• Imaging/Lab/Pathology\n• Infectious Diseases\n• Neurology\n• Orthopedic Care\n• Pain Management\n• Interventional Radiology \n• Urology\n• Women's Health\n• Wound Care\n• Maternal Health\n• Newborn and Neonatology\n• Cardiac Catheterization \n• Endoscopy\nCHI St. Luke’s Health – Springwoods Village Hospital\nCHI St. Luke’s Health – Springwoods Village Hospital in North Houston has 4 licensed beds and provides the following inpatient services:\n• Diagnostic imaging (CT, MRI, X-Ray)\n• Peripheral vascular laboratory \n• Four medical-surgical inpatient beds"]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Emergency Department","Required","Y","Business Component of the Organization\n• CHI St. Luke’s Health The Woodlands Emergency Department\n• CHI St. Luke’s Health The Woodlands Obstetric Emergency Department (OBED)\n• CHI. St. Luke’s Health Springwoods Village Emergency Department\n• CHI St. Luke’s Health The Woodlands Community Emergency Center Departments (HOPD): \no Conroe\no Huntsville\no Montgomery\no Spring\n"]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Business Component of the Organization\n• CHI St. Luke's Health - Pediatric Bridge Clinic \n• The Center for Liver Disease satellite clinic \n• Wound Care clinic\n• Performance Medicine provides \no Performance testing and training\no Sports medicine services\no Concussion assessments\no Health and wellness services\no Outpatient therapies/Rehabilitation\n Physical\n Occupational\n Speech \n Cardiac \n Pulmonary \n• Outpatient Sleep Lab Center\n• Outpatient Gamma Knife Center\n• Transitional Care Clinic\n• Dan L Duncan Medical Oncology Clinic\n• Dan L Duncan Radiation Center \n• Center for Infectious Diseases","Y","2020-09-01"]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Maternal Department","Required","Y","Business Component of the Organization\nCHI St Luke's Health - The Woodlands Hospital maternal department provides the following services: \n• Antepartum\n• Labor and delivery\n• Postpartum \n• Well nursery \n• Level II Neonatal Intensive Care Unit (NICU)\n"]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Other - Primary Care Clinic Physicians in The Baylor St. Luke's Medical Group, North Region, The Woodlands","Optional","Y","Baylor St. Luke's Medical Group, North Region, the Woodlands: \n•   Creekside Primary Care Clinic\n•   Magnolia Family Medicine Clinic\n•   Springwoods Village Family Medicine Clinic\n•   Woodlands Primary Care clinic ","Y","2020-09-01"]
["160630301.7.1",17,"160630301","St. Luke's Community Health Srvs (The Woodlands)","Hospital","Private","Other - Specialty Care Clinic Physicians in The Baylor St. Luke's Medical Group, North Region, The Woodlands:","Optional","Y","Specialty Care Clinic Physicians in The Baylor St. Luke's Medical Group, North Region, The Woodlands: \n• Woodlands OB/GYN Clinic not owned or operated by CHI St. Luke's Health - The Woodlands but in The Baylor St. Luke's Medical Group, North Region"]
["189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private","Inpatient Services","Required","Y","Huntsville Memorial Hospital's inpatient services include all medical units, laboratory services, diagnostic imaging departments, inpatient rehabilitation, inpatient pharmacy, and the Heart & Vascular Center. "]
["189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private","Emergency Department","Required","Y","Huntsville Memorial Hospital has an emergency department which will be included in its system definition.  The emergency department is located in the main hospital facility."]
["189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Huntsville Memorial Hospital (HMH) has multiple owned and/or operated outpatient clinics, all of which will be included in its system definition. These outpatient clinics include a primary care clinic [RHC- Huntsville] and specialty care clinics [Orthopedics and Wound Care]. "]
["189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private","Maternal Department","Required","Y","Huntsville Memorial Hospital (HMH) has a perinatal department with birthing suites. This includes a 4 bed Level I special care nursery; we are in the process of obtaining Level II Special Care Nursery Designation with the State of Texas. The perinatal department is part of our required system definition. "]
["189791001.7.1",17,"189791001","Walker County Hosp Corp. dba Huntsville Memorial","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Primary Care Clinics","Required","Y","The Texas A&M Physicians provider system will include the two primary care clinics we own and/or operate; main clinic located in Bryan and satellite clinic in Navasota."]
["198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Specialty Care Clinics","Required","Y","The Texas A&M Physicians provider system will include the two specialty clinics we operate at the Bryan medical clinic; Behavioral Health Practice and Procedures Clinic."]
["198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public","Owned or Operated Hospital","Required","N",""]
["198523601.7.1",17,"198523601","The TX A&M Unv Systm Hlth Science Cent dba Tx A&M","Physician Practice affiliated with an Academic Health Science Center (AHSC)","State Owned Public"," Owned or Operated Urgent Care Clinics","Required","N",""]
["311035501.7.1",17,"311035501","Montgomery County Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","MCPHD provides vaccinations, and the testing and treatment for both sexually transmitted diseases and tuberculosis both in the clinical office setting and in the community through mobile clinics and at home visits. At this time, MCPHD has not expanded services to include physician evaluations nor chronic care management. "]
["311035501.7.1",17,"311035501","Montgomery County Public Health District","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","This service is delivered through the primary location and we do not have satellite clinics or testing locations. "]
["326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as “Inpatient”, “Admit”, 'REHAB INPATIENT', 'SNF INPATIENT', 'SURGERY ADMIT', 'SURGERY ADMIT TO INPATIENT' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as ‘EMERGENCY’ and ’OBSERVATION’ and receive services and care that do not require patients to be admitted."]
["326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as ‘OUTPATIENT’, ‘AMBULATORY’, ‘HOSPITAL OUTPATIENT SURGERY’ and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as ‘NEWBORN’ and ‘L&D ASSESSMENT’, ‘NICU’ and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["326725404.7.1",17,"326725404","Scott & White Hospital College Station","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","This includes crisis assessment and intervention and crisis follow-up and relapse prevention by mobile crisis outreach teams; psychosocial rehabilitation by assertive community treatment teams; psychosocial, skill training, med education, case management, supported housing and employment, engagement & outreach by jail diversion teams and intensive field-based providers, wraparound/intensive case management services for children, YES Waiver services for children/adolescents, crisis transportation, MI PASRR evaluations,  and field-based supported housing and supported employment services."]
["084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","This includes all services provided in our Behavioral Health clinics including screenings, psychiatric diagnostic evaluation, evaluation and management, injection administration, medication monitoring, medication training & support, psychotherapy, crisis intervention, skills training and development, psychosocial rehabilitation, supported housing, supported employment, co-occurring disorders treatment, extended observation, engagement activity, peer support, crisis respite services, safety monitoring, crisis follow-up and relapse prevention, threat assessments, routine case management, intensive case management, parent support groups, family partner supports, family training, family case management, urine drug screenings, CD screenings & assessments, CD education groups, CD group and individual counseling, SBIRT Screening and Intervention, language translation services, outreach, benefit enrollment determination services.  These services are provided by the psychiatrists, nurse practitioners, RNs, LVNs, LPCs, LCSWs, LMFTs, QMHPs (Master and Bachelor level qualified staff), LCDCs, Certified Peer Support, Family Partners, CMAs, and qualified support staff in our clinics."]
["084001901.7.1",18,"084001901","Collin County MHMR dba LifePath Systems","Community Mental Health Center (CMHC)","Non‐State Owned Public","Contracted Inpatient Beds","Optional","Y","We contract with several local community psychiatric inpatient facilities for beds for our indigent individuals receiving crisis services.  These data are included in our electronic health record and will be included in our data going forward.  Services provided at this level of care include 24 hour professional monitoring, supervision, and assistance in an environment designed to provide safety and security during acute psychiatric crisis."]
["084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All service encounters occurring in a home, community-based, non-office/clinic setting.  These encounters may be provided through the mental Health, Substance Use Disorder, or Intellectual & Developmental Disability programs."]
["084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All service encounters occurring at center outpatient offices, clinics, respite units, living facilities, or group homes. These encounters may be provided through the mental Health, Substance Use Disorder, or Intellectual & Developmental Disability programs."]
["084434201.7.1",18,"084434201","MHMR SVCS of Texoma","Community Mental Health Center (CMHC)","Non‐State Owned Public","Other - State-funded Community Hospital","Optional","Y","Individuals who are discharged from the state hospitals for whom TCC is responsible for follow-up services, will be included in the system of care. Data will be acquired from the CARE information system."]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Inpatient Services","Required","Y","The inpatient system component is defined as all services and procedures administered to patients that are required to be admitted into the hospital. Patients have a classification in the E.H.R as 'PEDIATRIC ACUTE', 'HOSPICE', 'INTENSIVE CARE ' 'ISOLATION', 'MEDICAL ACUTE', 'ORTHOPEDIC ACUTE', 'PEDIATRIC ACUTE', 'SURG DIAG OBS BED', 'SURGICAL ACUTE' and receive services and care that require patients to be admitted and have a DRG associated with their visit. "]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Emergency Department","Required","Y","The emergency department system component is defined as all services and procedures administered to patients that are NOT required to be admitted into the hospital. Patients have a classification in the E.H.R as 'EMERGENCY ROOM' and 'MED OBSV PT' and receive services and care that do not require patients to be admitted."]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","The owned or operated outpatient clinics system component is defined as all services and procedures administered to patients that do not require hospital admission or requiring overnight hospitalization. Outpatient entails outpatient, non-admitting departments of the hospital as well as outpatient primary and specialty care clinics. Patients have a classification in the E.H.R as 'DIAG OUTPT', 'OUTPATIENT REHAB', 'OUTPT IN BED-NON OBS' and 'SURG DIAG NBD' and will typically have CPT codes associated with clinic visits and Hospital billing codes attached to outpatient visits in the hospital setting. All Clinics considered Owned and operated are ones in accordance with Category B specifications of inclusion and exclusion criteria and are listed on the BSWH Schedule H of the 990 form submitted to the IRS which constitutes Owned and Operated facilities. "]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Maternal Department","Required","Y","The maternal department system component is defined as all services and procedures administered to patients that require services associated with labor and childbirth. Patients have a classification in the E.H.R as 'GYNECOLOGY ACUTE', 'LABOR & DEL', 'NURSERY ACUTE','NURSERY INTENSIVE' and 'OBSETRICS ACUTE'  and receive services and care that require patients to be admitted and have a DRG associated with their visit."]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["169553801.7.1",18,"169553801","Tenet Frisco Ltd dba Centennial Medical Center","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","We will be including charity clinics that are part of our 501a physician group that are not on the Schedule H of the 990. These clinics are PCMH primary care clinics providing care to predominantly low income uninsured patients."]
["179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Primary Care Clinics","Required","Y","The Health Center of Helping Hands (the Health Center) provides quality, affordable healthcare to those with insurance, without insurance, without a medical home, and to those seeking a low cost alternative to other healthcare system options. Rockwall has no public hospital, and its health department functions are small and limited. The Health Center offers adults and children without a primary care physician, a medical home where they can consistently obtain health services from a caring provider. Primary care is provided for men, women, and children of all ages.  There are no income or residency requirements.  The Health Center's sliding fee scale rates are among the lowest in the area. We offer an income-based sliding scale program for Rockwall County residents that are at or below 200% of the federal Poverty Level. The Health Center is staffed with professionals, including physicians, mid-level providers, medical assistants, and administrative employees. The Health Center uses a chronic disease management model, treating high blood pressure, heart and lung diseases, diabetes, and asthma.  Nurse Practitioners invest a portion of their clinical time educating patients about their conditions and in better self-care strategies.  Rockwall County residents living below 200% of the Federal Poverty Level may qualify for fees based on a sliding scale. Care plans are assessed for every patient and follow-up visits are encouraged.   Children's health is of considerable importance at the Health Center. We provide vaccinations, sports physicals, and well child check-ups at a low cost. Eye exams and dental exams are arranged with partner providers to ensure care regardless of ability to pay. Our qualified medical staff includes Family Nurse Practitioners, medical assistants, lab technicians, and a variety of volunteer physicians in the fields of OB-GYN, Endocrinology, Internal Medicine and Family Practice. Our volunteer physicians generously donate all of their time and expertise to our patients at the health center.  "]
["179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Specialty Care Clinics","Required","N",""]
["179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Hospital","Required","N",""]
["179917301.7.1",18,"179917301","Rockwall County Helping Hands Inc","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private"," Owned or Operated Urgent Care Clinics","Required","N",""]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Inpatient Services","Required","Y","TMC provides inpatient services for residents of Grayson County and surrounding areas."]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Emergency Department","Required","Y","TMC operates a Emergency Department for residents of Grayson County and surrounding areas"]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y"," TMC provides rehabilitation services on an outpatient basis, but a majority of its rehab clients are in an inpatient status, and then may transition to outpatient."]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Maternal Department","Required","Y","TMC operates a Maternal department for residents of Grayson County and surrounding areas."]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["194997601.7.1",18,"194997601","UHS Texoma, Inc. dba Texoma Medical Center","Hospital","Private","Contracted Primary Care Clinics","Optional","Y","TMC is a collaborator with the Grayson County Health Clinic that was created as a non profit taxable corporation in 2013 under the 1115 Waiver and DSRIP programs as the safety net hospital. The  clinic was approved for a 501c3 non profit designation as of 09/30/2016 and is a primary care clinic that is governed by a board of directors.  This entity is not owned or operated by TMC as an entity or department.   Per the clinic by-laws the clinic is under the governorship of a board of directors. GCHC has been the provider of DSRIP covered services under agreement with TMC in cooperation with Grayson County government, and has been the only source of data reported for DSRIP participation since 2012."]
["283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Primary Care Clinics","Required","N",""]
["283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Specialty Care Clinics","Required","Y","Our clinic is an office-based clinic, staffed by nurse practitioners and physicians. Strategically located in Collin County in a location best accessible to the target population, the clinic will provide obstetric and gynecologic care to the MLIU population. Obstetric and gynecologic procedures will be performed at local hospitals which have assisted in and supported our mission and whose administrators share our vision of providing safe, quality, and efficient care to all patients."]
["283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private","Owned or Operated Hospital","Required","N",""]
["283637101.7.1",18,"283637101","Brock Lawson Pierce MD","Physician Practice not affiliated with an Academic Health Science Center (AHSC)","Private"," Owned or Operated Urgent Care Clinics","Required","N",""]
["088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Throckmorton County Memorial Hospital has one inpatient facility located in Throckmorton, TX. The hospital is a 14-bed Critical Access Hospital serving Throckmorton and the surrounding counties. We provide inpatient, observation, and swing bed services within the facility. "]
["088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","We have a 24 hour staffed emergency department within our hospital. "]
["088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have a certified Rural Health Clinic located at the Hospital. It is staffed by 1 physician and NP. "]
["088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["088189803.7.1",19,"088189803","Throckmorton County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Clay County Memorial Hospital is a 25-bed acute care facility providing healthcare services for Clay County, Texas residents. Clay County Memorial Hospital has an inpatient swingbed  program for eligible patients that offers rehabilitation therapy, IV therapy and wound care. "]
["094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Clay County Memorial Hospital Emergency Department provides 24/7 access to trauma and acute care. "]
["094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Clay County Memorial Hospital has two family practice clinics in Henrietta, TX.  They serve all of Clay County and many patients from Archer, Jack and Wichita counties.  "]
["094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["094138703.7.1",19,"094138703","Clay County Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","Y","Clay County Memorial Hospital operates an Urgent Care Clinic seven days a week. The available hours are 8 am to 5 pm. "]
["110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","This includes all patient services dealing with acute care patients."]
["110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","  Our ED covers all emergency cases and prescribed outpatient services such as IV therapy."]
["110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","We have two provider based Rural Health Clinics.  We have one in Olney and one in Archer City, Texas.  Between both clinics we have 4 physicians and 3 nurse practitioners."]
["110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","We have maternal department with Dr. Johnson as the head of the department with an OB suite. "]
["110856504.7.1",19,"110856504","Olney Hamilton Hospital District dba Hamilton Hosp","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Faith Community Hospital is a 17-bed medical facility that provides healthcare services for residents of Jack County, Texas. FCH offers an inpatient swing bed program for eligible patients needing an extended stay for rehabilitation therapy, IV therapy or wound care."]
["119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Faith Community Hospital Emergency Department is a Level IV 24-hour trauma center."]
["119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Faith Community Rural Health Clinic is a rural health clinic with two locations serving the needs of Jack County and surrounding areas.  One location is in Jacksboro, TX.  The second and newest location is in Bowie, TX."]
["119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Faith Community Hospital is designated as a level 1 Newborn Nursery.  FCH’s Labor and Delivery Unit contains 4 Labor, delivery, recovery, postpartum rooms.  We average about 50 births a year with 3 family practice physicians delivering."]
["119874904.7.1",19,"119874904","Jack County Hospital District dba Faith Community","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in all units (excluding the women's maternity unit) to which a patient may be admitted to the hospital as an inpatient for generally medical and/or surgical care, including diagnostic and therapeutic services."]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","all services in the ED to which a patient may be seen in an emergency department setting including diagnostic and therapeutic services.\n\n\n"]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","All clinic services provided in the following clinics, including diagnostic and therapeutic services.  We have one primary care clinic (Cooke County Medical Center), a specialty clinic providing surgery, pain management, primary care and occupational medicine services (NTMC Specialty Clinic), an orthopedic clinic (NTMC Orthopedic Clinic), a surgery clinic (Surgery Specialists of North Texas), and a sleep study clinic (Sleep Wellness Center). We are providing prenatal and postpartum services at Cooke County Medical Center.\n\n"]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","All services in the maternal department of NTMC to which a patient may be admitted to the hospital for maternal care, including diagnostic and therapeutic services."]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["121777003.7.1",19,"121777003","Gainesville Memorial Hospital (North Texas Medical","Hospital","Non‐State Owned Public","Other - Outpatient services of the hospital including;\n• Observation patients\n","Optional","Y","All services that may be provided to observation patients including diagnostic and therapeutic services."]
["127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","NGH provides acute inpatient care. "]
["127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","NGH provides emergency department services. "]
["127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","N",""]
["127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["127310404.7.1",19,"127310404","Nocona Hospital District dba Nocona Gen Hosp","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["127373205.7.1",19,"127373205","Helen Farabee Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","All service encounters occurring in a home, community-based, non-office/clinic setting. These encounters may be provided through the Mental Health, Substance Abuse, Intellectual & Developmental Disability, or Early Childhood Intervention programs."]
["127373205.7.1",19,"127373205","Helen Farabee Centers","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","All service encounters occurring at center outpatient offices, clinics, respite units, living facilities, or group homes. These encounters may be provided through the Mental Health, Substance Abuse, Intellectual & Developmental Disability, or Early Childhood Intervention programs."]
["346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","All services in all units to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services."]
["346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Department operating 24 hours a day specializing in emergency medicine (acute, immediate medical care to patients). This department is responsible for preliminary management and stabilization of patients who present without prior appointment, and with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention."]
["346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Young County Family Clinic - provides outpatient (ambulatory), family-practice services. Generally focused on injury or illness that may not be serious enough to require a visit to the emergency room."]
["346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["346945401.7.1",19,"346945401","Graham Hospital District","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Acute, Observation and Swing bed services at Electra Memorial Hospital"]
["135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","Emergency Department services at Electra Memorial Hospital"]
["135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","Clinic services provided at Electra Medical Clinic, Iowa Park Clinic or outreach clinic locations, including education programs, wellness initiatives, and any other services provided in an effort to coordinate care or encourage behaviors that influence healthy lifestyles."]
["135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","N",""]
["135034009.7.1",19,"135034009","Electra Memorial Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private","Inpatient Services","Required","Y","All inpatient/outpatient & observation services in all units, including inpatient palliative care, to which a patient may be admitted to the hospital for general medical or surgical care, including diagnostic and therapeutic services. Our inpatient/outpatient/observation services include: assessment and treatment of medical condition; coordinating and providing medical care, which may include working with medical and surgical consultants, physical and occupational therapists, discharge planners, dietitians, and clergy; ordering laboratory, X-ray and other diagnostic testing; providing regular care updates; communicating frequently with primary care physicians regarding care and progress; coordinating discharge planning with physicians and hospital staff; and transitioning back to primary care physician following hospitalization."]
["135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private","Emergency Department","Required","Y","The only full service health care system and Level II trauma center in the region, the Bridwell Center for Emergency Care houses two trauma rooms,  43 universal treatment rooms, eight patient evaluation rooms, six rapid treatment rooms and two consultation rooms. The facility also includes a 10-bed clinical (observation) decision unit, disaster preparedness area, expanded ambulance bays, and a new interior walkway from the ER entrance to the Bethania Building. "]
["135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","United Regional Physician Group (URPG) is non-profit multispecialty group.  Specialties including Family Medicine, Bariatric Surgery, Internal Medicine, Rheumatology, Endocrinology, ObGyn, Urology, Sports Medicine, Neurosurgery, and Orthopedic Surgery. In addition, URPG offers acute walk-in care at the CarePlus Clinic. CarePlus is opened seven days a week and offers evening appointments to ensure patients have adequate access to care. \nOther outpatient clinics/services include: Transition Clinic and Heart Failure Clinic."]
["135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private","Maternal Department","Required","Y","We offer personalized care before, during and after pregnancy, with leading-edge technology, antepartum and postpartum rooms, C-Section rooms, and a Level II Nursery. Prenatal and Childbirth Classes are offered for expectant moms, and classes on Infant CPR and Breastfeeding. We also offer a Special Siblings Class, which is designed to help future big sisters and brothers understand more about the birth of their new sibling. The Level II Nursery has advanced equipment to care for complex conditions premature babies often experience including infant CPAP, Giraffe beds, and infant ventilators."]
["135237906.7.1",19,"135237906","United Regional Health Care System","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","N",""]
["138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public","Inpatient Services","Required","Y","Inpatient services include inpatient medical, inpatient surgical, observation stays and swingbed/SNF services provided through Seymour Hospital."]
["138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public","Emergency Department","Required","Y","The Seymour Hospital Emergency Department services are provided 24 hours a day, 365 days per year.  Our existing two bed ER is currently being expanded to include a third bed with projected completion in the Summer of 2018."]
["138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public","Owned or Operated Outpatient Clinics","Required","Y","The Seymour Hospital Rural Health Clinic provides outpatient primary care services to our community."]
["138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public","Maternal Department","Required","Y","Seymour Hospital provides obstetrical services to include labor and delivery.  This population includes both mothers and babies.  We are the only facility that delivers babies in the 150 mile stretch between Wichita Falls and Abilene."]
["138353107.7.1",19,"138353107","Seymour Hospital","Hospital","Non‐State Owned Public","Owned or Operated Urgent Care Clinics","Required","N",""]
["094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private","Inpatient Services","Required","Y","Inpatient services for the hospital include acute care areas: Internal medicine, surgical services, neurology, cardiology, orthopedic, IP rehabilitation, GI, pulmonology."]
["094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private","Emergency Department","Required","Y","This component includes any patients that seek services at our main emergency department located on the hospital campus or any freestanding emergency department that is operated as a unit of the hospital."]
["094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Includes the Mines road Clinic, Mobile Unit and Wound Care Center"]
["094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private","Maternal Department","Required","Y","Labor and delivery, postpartum and NICU"]
["094186602.7.1",20,"094186602","Laredo Reg Med Ctr dba Doctor's Hospital of Laredo","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","N/A"]
["121989102.7.1",20,"121989102","Border Region MHMR Community Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Home-based Services","Required","Y","Border Region Behavioral Health Center provides services to four counties, Webb, Zapata, Jim Hogg and Starr County. Region 20 consists of Webb, Zapata and Jim Hogg, while Starr County is under the area of Region 5. The populations being served for our selected measures are adults over the age of 18. This includes The Adult Behavioral Health Services Unit which provides services to adults 18 years of age or older who suffer from schizophrenia, bipolar disorder, major depressive disorder or any disabling mental disorders which require support and treatment. It also includes individuals in the Intellectual and Developmental Disabilities Program which offers services specifically designed to meet the needs of individuals diagnosed with intellectual/cognitive, pervasive developmental disorder and/or related conditions. For Demonstration Years 7 and 8, five measures were selected; Controlling High Blood Pressure (M1-103), Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (M1-105), Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (M1-115), Diabetes Care: BP Control (M1-207) and Assessment for Substance Abuse Program of Psychiatric Patients (M1-261).                 "]
["121989102.7.1",20,"121989102","Border Region MHMR Community Center","Community Mental Health Center (CMHC)","Non‐State Owned Public","Office/Clinic","Required","Y","Three of the selected measures focus on the integration of primary health care with mental health. The following three measures focus on controlling high blood pressure as well as diabetes. Controlling High Blood Pressure (M1-103) focuses on the percentage of clients ages 18 to 85 with a diagnosis of hypertension and whose blood pressure is adequately controlled (<140/90) during the measurement year. Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (M1-115) focuses on the percentage of patients age 18 to 75 with diabetes who had a hemoglobin A1c > 9.0% during the measurement year. Diabetes Care: BP Control (M1-207) focuses on patients ages 18 to 75 with diabetes (type 1 and type 2) whose most recent blood pressure level taken is <140/90 mm Hg during the measurement year. Border Region clients in Webb County are provided with an on-site Primary Care Clinic under the supervision of Dr. Arturo Garza-Gongora with services provided by Dr. Laura Garza-Gongora and Family Nurse Practitioner Priscilla Salinas-Ramos. The Primary Care Clinic provides treatment for both chronic and acute conditions, as well as providing physical exams, well woman exams, health screenings and preventative care. Aside from on-site health care, individuals also obtain routine laboratories at either Clinical Pathology Laboratories or Lab Corps, with the referral of one of our three providers. PrognoCIS is software used by the Primary Care Clinic in Webb County for documentation and data input. Client’s blood pressure as well as A1c are tracked through PrognoCIS.  In Zapata County, clients are provided with services at Zapata Primary Care Clinic by Nurse Practitioner Mary Plattner. Clients at Zapata Primary Care Clinic are provided with treatment for chronic and acute conditions, as well as physical exams, health screenings and preventative care. In Jim Hogg County, clients are provided health care services, including both chronic and acute care, at Gateway Community Health Center. Clients in Jim Hogg County also have the opportunity of obtaining routine laboratories at Lab Corps, with the referral of Gateway Community Health Center providers.  In Region 5, Starr County, Border Region clients are provided with easily accessible health care services at Family Health Center by Dr. Antonio Falcon, which is located within walking distance from the Border Region office. Dr. Falcon provides services such as preventive care, physical exams, health screenings and provides treatment for both acute and chronic conditions. Along with obtaining medical services from. Falcon, clients also have access to routine lab at Renaissance Laboratories with a referral from Dr. Falcon. \nThe final two measures focus on substance use and mental health. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (M1-105) focuses on the percentage of clients 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Assessment for Substance Abuse Program of Psychiatric Patients (M1-261) focuses on the percentage of individuals who received an assessment for substance abuse problems. In Region 20, individuals are also being provided with the Tobacco Cessation Program. Region 20 is also provided with Alcohol, Tobacco and other Drug (ATOD) Education and with Substance Use Interventions by our Licensed Chemical Dependency Counselors. In Webb County, individuals are also being provided with Outpatient Treatment for Substance Use, along with the ATOD Education and Substance Use Intervention. In Region 5, individuals are also being provided with the Tobacco Cessation Program. Region 5 is also provided with Alcohol, Tobacco and other Drug (ATOD) Education and with Substance Use Interventions by our Licensed Chemical Dependency Counselors. For individuals obtaining Substance Use treatment, Border Region’s Licensed Chemical Dependency Counselors use AccuCare as a system of documentation and inputting data. \nAlong all four counties, there are several software and web-based pages which are used to interchange information. Border Region Behavioral Health Center uses Cerner (ANASAZI) as its primary software. In Cerner information is shared between all four agencies including diagnosis, medication, recovery plans and other important treatment information. Across all four counties, there has been a tremendous increase in the use of telehealth video conference. Scopia is the primary software used across all four counties to transmit information and for video conferencing.  In conjunction with Cerner, Border Region also uses several web-based pages such as Clinical Management for Behavioral Health Services (CMBHS) where the client’s enrollment status, level of care and other demographic information can be verified. CMBHS is also used for the Inpatient Care Waitlist for state psychiatric hospitals. MBOW is another web-based page used to obtain information and status of Border Region metrics. Texas Medicaid and Healthcare Partnership (TMHP) is a web-based site used to verify Medicaid information for clients. TMHP is also the site used for Preadmission Screening and Resident Review (PASRR).  CARE is another web-based system used to obtain demographic information of clients, as well as the system used to transfer date to CMBHS. Web App is a system used in the Adult Behavioral Unit for Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI) clients. Clients under the TCOOMMI program often obtain substance use treatment, as well as health care services from the Primary Care Clinic. \n\n"]
["137917402.7.1",20,"137917402","City of Laredo","Local Health Department (LHD)","Non‐State Owned Public","Clinics","Required","Y","Our system is composed of public health multiple site clinics that offer services in Primary Care, Maternity, Family Planning, Womens Health, Tuberculosis/HIV/AIDS/STD, hepatitis C prevention and treatment, disease control, lab testing, nutrition and health education, environmental health, immunizations, behavioral health and substance use treatment and prevention services  to persons in the County of Webb. In addition we serve as the city registrar for birth and death certificates and serve as the regional public health preparedness lead.  "]
["137917402.7.1",20,"137917402","City of Laredo","Local Health Department (LHD)","Non‐State Owned Public","Immunization Locations","Required","Y","Our Health Department has an Immunization, Disease Control and Public Health Preparedness program that provides preventive care to Webb County along with children that belong to local school districts such as Laredo Independent School District and United Independent School District, the Universities and their employees."]
["162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private","Inpatient Services","Required","Y","Laredo Medical Center has 326 Inpatient Beds that serves different patient populations in areas of Medicine, Women's Services, Cardiology, Oncology, Orthopedics, Wound Care, Bariatrics, Urology."]
["162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private","Emergency Department","Required","Y","Laredo Medical Center is home to a 26,000 square foot emergency department that includes 38 private rooms, a specialized gynecology exam room, in house lab and in house radiology for quicker turnaround times. Our ER maintains a trauma designation of Level III and included in our facility are three trauma rooms. LMC also is an Accredited Chest Pain Center Level IV with PCI to diagnose and care for people with heart attack symptoms. Laredo Medical Center will be adding a 10,000 square feet Freestanding Emergency Room with 7 treatment rooms and 3 triage bays Q2 2020."]
["162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private","Owned or Operated Outpatient Clinics","Required","Y","Laredo Medical Center has several outpatient clinics in the community. Laredo Medical Center North is an Ambulatory Surgery Center that has radiology and lab services available from Monday to Saturday. Laredo Medical Center South provides radiology and lab services to our patients in South Laredo. LMC also has several employed physician clinics in the hospital's medical office building. Laredo Surgical Associates, Laredo Hematology and Oncology Associates, Laredo Urology Associates, Zapata Family Medical Clinic in Zapata, TX, Laredo Neurosurgical Associates, and Primary Care Associates of Laredo."]
["162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private","Maternal Department","Required","Y","Laredo Medical Center has 34 post partum hospital beds, 15 Labor and Delivery Rooms and 2 Operating Rooms exclusively for our Maternity Department. "]
["162033801.7.1",20,"162033801","Laredo Texas Hosp Co dba Laredo Medical Center","Hospital","Private","Owned or Operated Urgent Care Clinics","Required","Y","Laredo Medical Center has two Urgent Care Clinics in the community. Laredo CareClinic is an after hours clinics that provides quality affordable care for the whole family and offers a wide range of services for minor illnesses and injuries with convenient evening and weekend hours, 7 days a week.  Laredo Care Clinic South is located at 4415 US Highway 83, Unit 100 and is open M-F 4 p.m. to 11 p.m. and Saturday and Sunday from 9 a.m. to 9 p.m. Laredo CareClinic North is located on 10201 McPherson Rd, Suite 300 and is open M-F 4 p.m. to 11 p.m. and Saturday and Sunday from 9 a.m. to 9 p.m."]