1. RHP Plan Update Provider Template
February 28, 2018

2. Setting Up Your Category A
Core Activities and Drivers

3. CORE ACTIVITY SELECTION
Access to Primary Care Services
Access to Specialty Care Services
Availability of Appropriate Levels of Behavioral Health Care Services
Chronic Care Management
Expansion of Patient Care Navigation and Transition Services
Expansion or Enhancement of Oral Health Services
Maternal and Infant Health Care
Palliative Care
Patient Centered Medical Home
Prevention and Wellness
Substance Use Disorder

5. Core Activity
Activity implemented by the provider to achieve its Category C Measure Goals.
NEW activity
Activity from a previous DSRIP Project
ALL activities must be tied to at least ONE Measure Bundle
Follow “AIM-DRIVER” model
Driver Diagram

6. Driver Diagram
depicts the relationship between the aim, the primary drivers that contribute directly to achieving the aim, and the secondary drivers that are necessary to achieve the primary drivers

7. Driver Diagram - EXAMPLE
CATEGORY C METRIC

8. Driver Diagram - EXAMPLE
BRAINSTORM - list all system elements, activities, drivers
Focus on Patients with high likelihood of readmission
Timely, effective Communications among all Care Team Members (pre and post discharge)
Follow-Up Calls
Rigorous Medication Review before Discharge
Home Tele-Monitoring
Schedule PCP Follow-Up Appointment before Discharge
Multi-Disciplinary Home Visits
Confirm that Patients Understand what they need to know and do
Provide Patient with a Transition Coach (RN)
ProActive Counseling and Care Planning for End-of-Life Patients

9. Driver Diagram - EXAMPLE
GROUP under high-level headers that summarize the groups
3 to 5 MAX
IMPROVE DISCHARGE PROCESS
PROVIDE EARLY POST-DISCHARGE SERVICES
PATIENT ENGAGEMENT & EDUCATION for SELF-MANAGEMENT
Schedule PCP Follow-Up Appointment before Discharge
Home Tele-Monitoring
Confirm that Patients Understand what they need to know and do
Provide Patient with a Transition Coach (RN)
Rigorous Medication Review before Discharge
ProActive Counseling and Care Planning for End-of-Life Patients
Multi-Disciplinary Home Visits
Timely, effective Communications among all Care Team Members (pre and post discharge)
Follow-Up Calls
Focus on Patients with high likelihood of readmission

10. Driver Diagram - EXAMPLE

11. Template

12. Template

13. Template
All selected Measure Bundles or measures must be associated with a Core Activity otherwise an error message will appear at the bottom of Section 2 to indicate which Measure Bundles or measures are not associated with a Core Activity.

14. Template

15. QUESTIONS