January 2017 CTC-RI Expansion: 2017-2019Adult PracticeMilestones Summary(updated 12.19.2017)

Start Up (MP 1)
1/1/17-12/31/17 / Measurement Period 2 (MP 2)
1/1/18-12/31/18 / Measurement Period 3 (MP 3) 1/1/19-12/31/2019 / Notes
Meets with Practice Facilitator 1-2 x per month / January 2017-December2017 / January 2018-December 2018 / January 2019-December 2019 / N/A
*Attends 50% of learning network meetings. / January 2017-December 2017 / January 2018-December 2018 / January 2019-December 2019 / N/A
Submit clinical quality data as defined in Performance Incentives Exhibit 3 / N/A / January 30, 2018 / January 30, 2019 / Submit to:
CTC Portal
Submit reports on high risk patients, as defined by CTC, to Health Plans and CTC and achieves 40% engagement rate. / N/A / January 30, 2018 / January 30, 2019 / Submit to:

Report level(s) of engagement of high risk patients as defined by CTC. / N/A / January 31, 2018 / N/A / Submit to:

Reports to CTC Quarterly Provider Panel Report indicating open/closed panel status and 3rd next available appointment / N/A / February 15, 2018 / February 15, 2019 / Submit to:

Submits a quality improvement activity for improving a performance measure (Quality/customer experience/utilization) / N/A / March 30, 2018 / N/A / Submit to:

Submit to CTC screenshot demonstrating patient access to a secure web portal, enabling secure messaging, appointment requests, referrals, and prescription refills / N/A / March 30, 2018 / N/A / Submit to:

Submit reports on high risk patients, as defined by CTC, to Health Plans and CTC and achieves 40% engagement rate. / N/A / April 30, 2018 / April 30, 2019 / Submit to:

Reports to CTC Quarterly Provider Panel Report indicating open/closed panel status and 3rd next available appointment / N/A / May 15, 2018 / May 15, 2019 / Submit to:

Submits report that demonstrates 75% high risk patients with ED visits receive a follow up interaction including medication reconciliation within 1 week of discharge 6 month. / N/A / N/A / June 30, 2019 / Submit to:

Submit 2 additional compacts as defined by OHIC cost management strategies / N/A / N/A / June 30, 2019 / Submit to:

Submit schedule demonstrating that practice has expanded office hours as defined by OHIC cost management strategies / N/A / June 30, 2018 / N/A / Submit to:

Submit clinical quality data as defined in Performance Incentives Exhibit 3 / July 15, 2017 / July 15, 2018 / July 15, 2019 / Submit to:
CTC Portal
Submits Transition of Care Policy and Procedure / August 31, 2017 / N/A / N/A / Submit to:

Reports to CTC Quarterly Provider Panel Report indicating open/closed panel status and 3rd next available appointment / August 15, 2017 / August 15, 2018 / August 15, 2019 / Submit to:

Achieves NCQA PCMH recognition / N/A / N/A / September 30, 2019 / Submit to:

Hire 1.0 Nurse Care Manager (NCM) Care Coordinator for every 3,000 attributed patients ($2.50 pmpm) / September 30, 2017 / Maintain staffing / Maintain staffing / Submit to:

Submits report that demonstrates 75% of high risk patients who were hospitalized receive a follow up interaction including medical reconciliation within 2 business days / N/A / September 30, 2018 / N/A / Submit to:

Submit to OHIC quality measure information / October 30, 2017 / October 30, 2018 / October 30, 2019 / Submit to:
OHIC Website
Submit clinical quality data as defined in Performance Incentives Exhibit 3 / October 30, 2017 / October 30, 2018 / October 30, 2019 / Submit to:
CTC Portal
Submits to OHIC cost management strategy attestation / October 15, 2017 / October 30, 2018 / October 30, 2019
(and demonstrates achievement 80% of cost management strategy elements) / Submit to:
OHIC Website
Submit reports on high risk patients, as defined by CTC, to Health Plans and CTC and achieves 40% engagement rate. / N/A / April 15, 2018 Baseline
Achieves 40% July 15, 2018 / October 15, 2019 / Submit to:

Submits budget and staffing plan and use of funds to support care delivery model to CTC / October 30, 2017 / N/A / N/A / Submit to:

Reports to CTC Quarterly Provider Panel Report indicating open/closed panel status and 3rd next available appointment / November 15, 2017 / November 15, 2018 / November 15, 2019 / Submit to:

Develop high risk registry and reportable fields for care management. Confirm completion with CTC. / December 31, 2017 / Maintain system / Maintain system / Submit to:

NCM/CC completes standardized learning program as defined by CTC-RI. / N/A / Program starts
February 2018 / N/A / Submit to:

Submit before and after hours protocol as defined by CTC / September 30, 2017 / N/A / N/A / Submit to:

Identifies high volume specialists serving patient population and submits 2 compacts: high volume specialist and behavioral health / September 30, 2017 / N/A / N/A / Submit to:

Submit NCQA PCMH work plan to CTC / September 30, 2017 / N/A / N/A / Submit to:

Submits NCQA PCMH recognition application. / N/A / N/A / March 31. 2019 / Submit to:

Submit patient panel for CAHPS survey to approved data vendor (or “How’s your health” option TBD) / October 2017 / TBD / TBD / Submit to:

Submits report that demonstrates 75% of high risk patients who were hospitalized receive a follow up interaction including medical reconciliation within 2 business days / N/A / December 30, 2018 / N/A / Submit to:

Other Requirements
*Learning Networks:
Orientation
Breakfast of Champion Events
Annual Learning Collaborative / May 9, 2017
September 8, 2017;
November 7, 2017 / February 9, 2018;
May 11, 2018 and
August 10, 2018
Date TBD / Dates TBD
Date TBD