Milestones and Indicators of Progress: A Reference for Patient


Milestones and Indicators of Progress: A Reference for Patient-Centered Primary Care Participating Practices

How to Use This Guide The following Program Milestones and Indicators of Progress are drawn from industry best practices and our current understanding of determinants for practice success in medical home transformation. They are intended as guidelines to inform interpretation of primary care practice progression through the program. Suggested practice activities are sequenced over the first 15 months of program participation. These are meant as a reference to help you judge your progress and anticipate future steps.

Milestones and Indicators Timeline Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

Transformation Core Elements Survey and system access registration completed. Practice Leadership Engagement in Transformation

Representatives from the practice are attending Learning Collaboratives. Training needs for all job roles identified.

Process and resources in place to address change management/resistance.

Vision and mission statements established.

Job descriptions and roles identified.

Team-Based Care Delivery

Planned care visits embedded and standard for high risk patients.

Planned care visit workflows embedded and standard for registry-identified population.

Quality Improvement Team

Completed initial assessment.

Completed follow-up assessments.

Use of Provider Toolkit

Representatives from the practice using provider toolkit resources.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

1. Establish Internal Infrastructure to coordinate care.1 Care Coordination

Overall workflows for coordinating care established and implemented. Example: Lab tracking process. Practice Care Coordinator identified.

Practice Care Coordinator training needs addressed. Outreach to and intervene with high-risk patients and recent admissions (use of Hot Spotter report).

Care Coordinator outreach to high-risk patients

Outreach to and intervene with patients who have missed appointments.

Outreach to and intervene with patients who have been referred to specialists.

Outreach to and intervene with evaluating population for high-risk patients, not relying solely on reports.

Outreach to patients with gaps in care to facilitate appointments. Practice AdvisorSM (if applicable)

“Work as a Team” Practice AdvisorSM module and Biopsy are complete.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

2. Establish process to review and use reports and MMH+ for population health management and high-risk patient stratification. Successful use of Availity and reports

Successful use of MMH+ Team comfort with attribution methodology

Use of data elements in reports for population management

Registration complete.

Workflows are embedded in practice to allow for the best use of report data for all patients.

Registration complete.

Workflows are embedded in practice for the best use of data from MMH+ for all patients.

Tests workflow and process interventions based on data review to improve quality of care.

Using attribution for patient empanelment.

Developed and implemented workflow to use reports to identify high-risk patients, care gaps, and target care planning.

Workflows for identification of high risk patients, care gaps, and targeted care planning are embedded in practice.

Workflow expanded to include application of risk stratification method across the practice’s patient population to begin care plan targeting. Beginning use of methodology that can be generalized across the population. Process in place to review reports during leadership meetings and/or Quality Improvement team meetings. Uses reports to review Cost of Care implications.

Practice AdvisorSM (if applicable)

Completed “Manage Populations” module and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

3. Establish sustainable process for shared care planning, including self-care management support/goal setting/action planning. Routine for care plan development

Routine process for incorporating selfmanagement support

Demonstrated ability to create care plans using concepts from the Care Plan Playbook. Workflow for care planning process established and implemented. Provision of self-management support and educational resources to patients. Care plan goals and interventions are patient-centric.

Implementation of care plans and evaluation of progress toward goals

Comprehensive Assessment

Care Plans demonstrate evaluation of progression toward goals. Care Plan targeting process identifies barriers to goals. Practice demonstrates ability to perform annual assessment on high- risk patients incorporating these components: Clinical history/problem list; medication review; functional status related to ADL; mental health status including: psychosocial factors, cognitive functions, visual and hearing need, nutritional need, cultural and linguistic need, transportation need, home environment, caregiver resource and life planning.

Proactive creation of care plans across the practice population

Practice is developing and implementing standardized workflow to support comprehensive assessment (inserted into EMR).

Practice is assessing expanding into populations beyond high-risk patients.

Practice is working to get comprehensive assessment workflow fully embedded into processes.

Demonstrating signs of proactive care plan targeting. Using patient experience survey.

Improved patient experience scores specific to shared care planning and selfmanagement support

Workflow in place to create, administer, gather data of the patient experience survey.

Gathered data to analyze. Performing quality improvement based on analysis of survey data.

Risk scores for patient population trending toward reduction.

Improved “Hot Spotter” report Practice AdvisorSM (if applicable)

Care plans demonstrate evidence of progression toward self-management support.

Trend reflecting reduction in unnecessary readmissions. Completed Practice AdvisorSM “Coordinate Care” module and Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

4. Establish and maintain Population Health Registry and reports for patient outreach, closing gaps in care, and managing prevention and chronic disease needs of patients.

Defined and identified registry functionality

Use of a population health registry

Use of a patient registry for identification of patients with chronic conditions

Defined and began to implement registry method, needs and functionality.

Patient population registry in place.

Registry demonstrates identified populations, exception lists, embedded evidence- based guidelines, reminders and monitoring capabilities of patients and practice. Demonstrated use of resources for high-risk patient stratification. Demonstrated use of resources for population health management.

Established and implemented a process using registry data to identify and reach out to patients with chronic conditions, conduct pre-visit planning, and close care gaps.

Improved chronic disease clinical outcome measures Practice AdvisorSM (if applicable)

Identified current registry resources/gaps, including both prevention and chronic disease gaps.

Improved trends for chronic disease clinical outcome measures. Completed Practice AdvisorSM “Use of Technology I” module and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

5.  Maximize e-health record and/or available health information technology for evidence-based care delivery and relevant Clinical Decision Support. Use of evidencebased resources in determining interventions for patients

Using web resources such as WebMD, National Diabetic Association, National Heart Association, NIH, Mayo Clinic, etc. to determine and implement interventions for self-care management and prevention.

Use of an EHR to facilitate coordination of care and exchange of information

Exchange of information between health plan and practice to decrease gaps in care. If technology is not yet developed to exchange information, contingency workflow established.

Practice AdvisorSM (if applicable)

Maximizing use of alerts in MMH+.

Regularly using patient registry with embedded evidence-based guidelines which prompt point of care flags. Maximizing use of EHR clinical decision support, including pharmacy, lab, and allergy alerts (if using an EHR). Exchange of information with medical neighborhood and community (when applicable); coordinates care and ensures continuity of care.

Completed Practice AdvisorSM “Use of Technology II” module and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

6. Transition to a culture of patient-centered care.

Patient input inclusion in care plan goal and intervention development

A holistic approach to patient-centered care

Gathering of patient experience data

Patients are active participants in creating and implementing care plan goals. Care plan documentation supports shared decision making. Regularly using engagement strategies, including motivational interviewing.

Incorporating use of engagement strategies (Motivational interviewing) into interactions with patients.

Regular use of engagement strategies, for example motivational interviewing.

Practice begins to holistically evaluate patients for potential strengths and barriers to goals and interventions, not just looking at the medical condition but at every aspect of a patient‘s mind and body, including social/family support networks.

Processes in place to address barriers/limitations such as environmental/financial/lack of access etc.

Practice is aware of impact of culture and linguistic preferences and or limitations in the care planning process.

Practice has embedded assessment process to evaluate patients holistically.

Regular, established process for gathering patient-experience data.

Patient inclusion on the Quality Improvement team Practice Advisor (if applicable)


Regular, established process for using patient-experience data in Quality Improvement and in Transformation Team activity. Starting to invite patients to Quality Improvement team meetings.

Completed Practice AdvisorSM “Deliver Patient-Centered Care” module and Practice Biopsy.

Completed Practice AdvisorSM “Engage Patients” module and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

7. Provision of enhanced access for patients.

24/7 service availability for patients

Established workflows addressing appointment types and standing orders to streamline care. Documented process in place for staff to follow for all scheduling and clinical advice.

Round-the-clock data availability

Established system for accommodating same day appointments. Clinical staff or an acceptable alternative are made available to patients at all hours.

Recognizes that MMH+ provides 24/7 access to patient longitudinal data; incorporates this in after-hours coverage arrangements.

Morning/ evening appointments and/or weekend options available based on patient and family needs.

Capacity to provide alternative forms of communication such as email or texting if available. Established goal response times. Monitoring the response times against practice standard.

Arrangements made for 24/7 electronic access to personal health information, including after-hours personnel or on-call providers. Established a process for recording which provider the patient sees during the visit.

Percentage of patient visits with the patient’s chosen Primary Care Provider

Established a process for soliciting and documenting the patient choice of primary provider within practice.

Practice AdvisorSM (if applicable)

Completed Practice AdvisorSM “Communicate with Patients” module and Practice Biopsy.

Established a process for determining the percentage of visits that occur with the chosen primary provider.

Completed Practice AdvisorSM “Enhance Patient Access” modules and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch - (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

8. Establish external processes/infrastructure to achieve coordination of care With The Medical Neighborhood And Community. Referrals to [Legal Entity]based and community- based programs

Using [Legal Entity] programs and staff to assist with care plan interventions and planning. Accessing community resources and programs such as support groups, church-based care programs, caregivers, financial aid, etc.

Established process for unnecessary readmission prevention strategies

Care Plan processes include strategies to reduce unnecessary readmissions: D/C Instructions, Monitoring and F/U post DC, medication support, Red flags/Self Management Support, and communication with providers (PHR).

Established process for regular lab tracking

Developed process flow for monitoring status of labs, tracking what was ordered, whether the patient has been notified and what is still pending.

Developed process for incorporating lab data into treatment plan consistently. Written process for reviewing and reconciling medications is embedded in the practice.

Established process for regular medication reconciliation Established care compacts with key specialists

Developing a process for reviewing medications during care transitions (Hospital Discharge, ER Visit). Developing a process for full review of medication list: reconciliation of changes, knowledge, barriers to adherence, side effects, interactions, compliance. Identified key specialists in medical neighborhood.

Communication/ collaboration with medical neighborhood, including skilled nursing facility and inpatient facilities

Reaching out to patients who have been referred to specialists to maintain relationship and update status.

Communication and collaboration with community resources

Begin to make referrals to community resources and develop process flow for outreaching to patients to maintain relationship and updated status.

Practice AdvisorSM (if applicable)

Practice has an embedded process for providing information about new prescriptions, and for assessing patient/family understanding of medications, including barriers to adherence. Documentation of patient medications includes over-the-counter medications, herbal therapies, and supplements are done at each visit. Established relationships with the identified specialists through collaborative agreements.

Developing a process flow for monitoring status of referrals, tracking whether the patient saw the specialist; what the specialist recommended; and whether the patient made follow-up appointments.

Processes and workflows for monitoring /tracking referrals to specialist are embedded in the practice.

Developing a process flow for monitoring and determining when patients have stabilized and can return to the patient’s medical home as the main source of care. Develop process for monitoring and tracking of referrals to community resources.

Embedded process flow for monitoring status of referrals to community resource, including whether the community organization contacted the patient, whether the patient meets the criteria for the program/support and whether the patient is participating with the community resource/program with follow through or meeting obligations. Completed Practice AdvisorSM “Facilitate Transitions I/II” modules and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

9. Achieve improved clinical and utilization/affordability outcomes. Use of data to monitor quality improvement and cost savings

Evidence of utilizing in-network resources that provide cost savings, such as freestanding labs and radiology resources. Using program-specific tools and resources to make informed referrals to providers/specialists.

Demonstrated knowledge and use of clinical and utilization data to implement quality improvement activities.

Familiarity with clinical and utilization metrics

Quality Improvement/ Transformation Team

Practice AdvisorSM (if applicable)

Evidence of decreased utilization, ER visits and hospitalization.

Uses Quality Improvement tools such as Plan-Do-StudyAct cycles (PDSA) to monitor and adjust processes as necessary.

Uses patient and staff satisfaction surveys to monitor quality. Completed Practice AdvisorSM “Improve Quality” module and Practice Biopsy.


Milestones and Indicators of Progress Time Frame Pre-Launch

Program Launch (Months 1-3)

Months 4-6

Months 7-9

Months 10-15

10. Achieve Level III NCQA PCMH Recognition 2 Continuous process improvement tools system

Uses QUALITY IMPROVEMENT tools such as PDSA to monitor and adjust processes as necessary.

Monitoring system for transformation goals

Tracking progress on above milestones and indicators for success. Staff attended learning collaboratives to support elements of NCQA recognition.

Work to achieve Level III NCQA PCMH recognition

Practice AdvisorSM (if applicable)

Researched, understands, and implemented the standards to achieve recognition.

Completed and submitted recognition application.

Completed Practice AdvisorSM “NCQA Quick Start” module and Biopsy.

Footnotes 1 T his milestone is met when a practice systematically uses care coordination to accomplish report review, risk stratification, shared care planning and registry management as outlined in Milestones 2, 3, and 4. 2 NCQA Recognition is strongly encouraged, but not required.

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.



Milestones and Indicators of Progress: A Reference for Patient

Milestones and Indicators of Progress: A Reference for Patient-Centered Primary Care Participating Practices How to Use This Guide The following Prog...

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