1. Reducing Unnecessary Testing & Hospitalizations

2. Milestone 2
Practice has reduced unnecessary tests, as defined by the practice.
Practice has not reduced unnecessary tests or does not have baseline data on this measure.
Practice has identified the tests it will focus on for reduction and the corresponding metrics it will monitor and manage.
Practice has established a baseline, is regularly monitoring its identified metrics, but improvement has not yet been demonstrated.
Practice has demonstrated improvement in reducing unnecessary tests.

3. Milestone 2
Inspired by “Choosing Wisely” campaign by ABIM and Consumer Reports.
In the spirit of the milestone, this really includes diagnostics (studies/test) and treatments (meds/procedures).
As a PTN, we will accept either/both
Must be able to demonstrate improvement, no requirement for sustained 12 months
May or may not overlap with utilization incentive metrics

4. Milestone 2- Reducing Unnecessary Testing
Northcrest
We have chosen to work on reducing imaging for low back pain with no red flags. We have created a practice wide policy and have communicated to all providers and clinicians the following information:
If the patient has been diagnosed with uncomplicated low back pain you should wait 28 days from the time of diagnosis before obtaining imaging studies.
You should immediately order imaging studies if your patient has “red flag” conditions; including Cancer, Infection, Recent Trauma, IV Drug Abuse, Neurologic Impairment, Loss of Bodily Function, Loss of Feeling or Strength in Legs or Buttocks.
Educate your patients on the rationale for not obtaining an initial imaging study and caution them about receiving imaging studies in other settings unless symptoms change.
Takeaways
Receiving the patients information from inpatient and ER stays greatly reducing duplicate testing. The Providers review those notes prior to the visit for transition of care.

5. Milestone 2- Reducing Unnecessary Testing
Core Heart Medical Center
We are a single MD cardiology practice. We average office visits/day, testing procedures/day, and have approximately 5,000 active patients.
We follow strict guidelines for our testing based on evidence-based best practices (American College of Cardiology recommendations, Choosing Wisely guidelines, etc.), payer requirements, and clinical conditions of the patient. For example, we follow the Medicare guidelines for EKGs. Also, if patients are capable of undergoing a full stress test using only a treadmill, we will not administer any medications. If the patient can’t, then we would perform nuclear imaging. CTAs are not performed unless necessary for correlation. We use evidence-based preferred order sets and templates in our EHR.
We use shared decision making and decision aids with our patients. We utilize these to operate as a value-driven, evidence-based practice, as well as to incorporate patient values and preferences.

6. Core Heart- example of EKG Guidelines

7. Practice has reduced unnecessary hospitalizations.
Milestone 3
Practice has reduced unnecessary hospitalizations.
Practice has not reduced unnecessary hospitalizations or does not have baseline data on this measure.
Practice has established a baseline but does not yet have a process to reduce unnecessary hospitalizations.
Practice has established a baseline and is piloting a process to reduce unnecessary hospitalizations.
Practice has implemented and documented a tested process and has demonstrated a reduction in unnecessary hospitalizations from its baseline.

8. Milestone 3
Significant opportunities to reduce cost, improve experience, and advance safety.
May or may not overlap with utilization incentive metrics.
As a PTN, we will consider any relevant reduction in high-cost hospital/facility utilization, including ED visits, condition specific readmissions, unplanned admissions
Must be able to demonstrate improvement, but no requirement for sustained 12 months

9. Milestone 3- Reducing Unnecessary Hospitalizations
Northcrest
In an effort to reduce hospital readmission and unnecessary ED use, each morning a report is pulled of all Northcrest patients that presented to ER or that were admitted to hospital. This report is shared with the responsible care teams, and patients are called and follow up appointments are scheduled. At follow up appointment, patients are educated about appropriate ED use (when necessary).
For chronically ill patients, we have implemented a chronic care management program for CAD, chronic kidney disease and diabetes. A report is generated each month of all patients in need of testing related to their chronic illness, and these patients are also followed closely to ensure they are coming in for scheduled appointments, including annual exams. As needed, patients may also be referred to other programs that support managing chronic illness.
In 2016 we had 127 days without a readmit, and in 2017 we had 238 days without a readmit.

10. Milestone 3- Reducing Unnecessary Hospitalizations
BMG
We have been monitoring unnecessary hospitalizations as defined by patients who have been seen in clinic recently but were admitted to hospital afterwards. Implementation of Transitional Care Management Team (TCM) processes has shown improvement in unnecessary hospitalizations.
The TCM team follows up with patients who were discharged and assists with necessary services to avoid return to ER/hospitalizations. Additional access to urgent care, appointments and provider services have helped to reduce unnecessary hospitalizations.