Masters 1 and 2

Masters Level 1

Masters 1 practices will focus on care management of high risk patients and coordination of care across the medical neighborhood.  This body of work includes empanelment, identification of high risk patient populations and embedding processes for care management.  Work is completed on care coordination as it relates to the medical neighborhood to include avoidance of unnecessary hospital and ED visits and timely follow-up after discharge. 

Program Objectives:

  1. Provide care management for high risk patients
  2. Demonstrate active engagement and care coordination across the medical neighborhood

Practice Deliverables:

  1. Written process for empanelment of all active patients
  2. Written process for risk stratification of all RMHP patients
  3. Written process for care management including the use of a complete needs assessment of high risk patients, and patient-specific care plans
  4. Examples of your completed high risk patient care plans and assessments
  5. Written process for care coordination across the medical neighborhood addressing:
    1. ED visits
    2. Hospital discharges
  6. Quarterly narrative reports for the purpose of sharing progress, best practices, and challenges, as well as assessment of progress towards reducing risk and lowering costs utilizing reports generated monthly to practices
  7. Quarterly submission of quality measures to RMHP for entire patient population
  8. Participation in at least 2 Learning Collaboratives

Masters 1 Portal ›

Masters Level 2

Master 2 practices will expand their focus on care management of high risk patients and care coordination across the medical neighborhood and they bring the patient experience into their QI processes through the use of shared decision making, the incorporation of surveys or patient family advisory councils (PFACs), and through the use of the Patient Activation Measure (PAM).

Program Objectives: 

  1. Provide care management for high risk patients including implementation of the Patient Activation Measure and Coaching for Activation tool
  2. Demonstrate active engagement and care coordination across the neighborhood
  3. Assess and Improve patient experience of care
    1. Patient Surveys OR Patient Family Advisory Council (PFAC)
  4. Shared Decision Making

Practice Deliverables:

  1. Ongoing implementation of empanelment and risk stratification process for care coordination and care management of high risk patients including the use of a complete patient needs assessment and patient specific care plans (update written process)
  2. Examples of care plans and completed total needs assessments
  3. Update written process for care coordination across the medical neighborhood focusing on:
    1. ED visits
    2. Hospital discharges
  4. For the selected item:
    1. Written process to survey patients, copy of survey, and findings and changes addressed
    2. Written process for implementing PFAC, and meeting agendas and minutes
    3. Written process of shared-decision making and implementation of the use of a shared-decision making tool
  5. Quarterly narrative reports for the purpose of sharing progress, best practices and challenges, as well as assessment of progress towards reducing risk and lowering costs utilizing reports generated monthly to practices
  6. Quarterly submission of quality measures (see attached) to RMHP for entire patient population
  7. Participation in at least 2 Learning Collaboratives

Masters 2 Portal ›