Fillable 2278 Risk Stratification Guide For High Risk Patients (HealthInsight)

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2278 Risk Stratification Guide For High Risk Patients (HealthInsight)

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MANAGEMENT OF HIGH-RISK
PATIENTS:
NEW TOOLS IN INDIAN HEALTH SERVICE
INFORMATION SYSTEMS
Version 1.0
May 2020
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Contents
1.0 Introduction ................................................................................................................................3
2.0 Risk Stratification: Identifying High-Risk Patients ..........................................................................3
2.1 Two Step Method of Risk Stratification ........................................................................................... 3
2.1.1 Step 1: Identify Patients with Multiple Comorbidities (Diagnostic Tags) .............................. 4
2.1.2 Step 2: Provider Review ......................................................................................................... 6
2.2 Helpful Screening Tools ................................................................................................................... 7
2.3 Creating Risk Stratification Tools in iCare ........................................................................................ 7
2.4 Entering Risk Stratification Scores into iCare ................................................................................. 10
2.5 Putting it all Together: Risk Stratifying the Entire Patient Population .......................................... 13
2.6 Entering a Batch of Historical Risk Scores ...................................................................................... 14
3.0 New Assessment Tools ............................................................................................................... 16
3.1 Patient Activation Measurement (PAM)........................................................................................ 16
3.1.1 Entering Patient Activation Measure (PAM) into iCare ....................................................... 17
3.2 EuroQol 5 D Health Assessment Survey ........................................................................................ 17
3.2.1 Part 1: EuroQol Visual Analog Scale (EQVAS) ....................................................................... 18
3.2.2 Part 2: EuroQol 5 Dimension Descriptive System ................................................................ 18
3.2.3 Entering EuroQol Scores into iCare: ..................................................................................... 20
4.0 Graphing Risk, EuroQol, and PAM Scores .................................................................................... 21
5.0 Native American Specific Risk Stratification Model-Under Development ..................................... 22
6.0 Preliminary Outcome Data ......................................................................................................... 23
7.0 Risk Stratification, PAM, EuroQol Report (iCare) ......................................................................... 23
8.0 Appendices ................................................................................................................................ 26
8.1 Appendix A: Assigning Permissions to Enter Risk Scores ............................................................... 26
8.2 Appendix B: Error When Saving Erroneous Measurement............................................................ 27
8.3 Appendix C: Other Screening Tools ............................................................................................... 29
8.3.1 Northern Arizona Healthcare Risk Screening Tool ............................................................... 29
8.3.2 L
ACE Index Tool .................................................................................................................... 32
8.3.3 Hospital Risk Assessment Tool ............................................................................................. 33
8.4 Appendix D: Health Technician/Health Coach-Orientation/Competency Checklist .................... 34
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1.0 Introduction
This guide provides an overview of the technical tools available in the Indian Health Service (IHS)
information systems for the management of high-risk patients. Demonstration of the concepts
presented in this guide can be viewed in the accompanying PowerPoint presentation. The
information in this guide assumes the reader has a basic understanding of the fundamentals of
iCare. For additional information, please consult the iCare User Manual
.
Risk stratification enables practices to identify the right level of care and services for distinct
subgroups of patients. It considers objective and subjective data for identifying the level or risk
to patients, then uses this information to direct care and improve overall health outcomes.
Population health management requires practices to consider patients as both individuals and
as members of a larger community or population. The use of risk stratification identifies patients
with higher potential rates of health care utilization and increased financial liability. A patient's
risk category is the first step in planning, developing and implementing a personalized care plan.
The potential benefits of risk stratification for population health management have been
incorporated into programs such as the Comprehensive Primary Care (CPC) initiative, which
requires participating practices to perform a two-step risk stratification of their empaneled
populations. Some state-led and funded programs have also emphasized the importance of
targeting resources toward complex patient groups to better address their needs, lower costs,
and improve health outcomes
.
2.0 Risk Stratification: Identifying High-Risk Patients
2.1 Two-Step Method of Risk Stratification
Risk stratification provides a systematic way to identify and predict patients who are high
risk or likely to be at high risk to target care management resources and prevent worse
outcomes. There is interest in risk stratification within IHS, but the guidelines and best
practices are still under development. Methodologies may vary between across sites,
provider specialties and patient populations.
This guide features technical tools used to identify and manage high-risk patients at Chinle
Hospital and Northern Cheyenne/Lame Deer. Both facilities used a two-step process to
identify patients with multiple comorbidities, factoring in social determinants of health to
cull out the patients who have the most potential to benefit from intensive care
management. Both sites use iCare to stratify because iCare is available, intuitive,
affordable and totally integrated with cradle-to-grave historical patient data.
Risk stratification is a two-step process of evaluation, combining objective and subjective
data to assign risk levels:
1. Objective: The first step uses iCare (or any data algorithm) to identify patients who
have multiple comorbidities (diagnostic tags).
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2. Subjective: The second step is to review and refine the list using clinical intuition to
identify the patients that would benefit from targeted and intensive care
management.
2.1.1 Step 1: Identify Patients with Multiple Comorbidities (Diagnostic
Tags)
This example demonstrates how to use iCare to risk stratify a provider’s panel of
patients. Repeat this process for each provider panel until the entire patient
population has been stratified.
NOTE: Patients must have been previously assigned (empaneled) to a primary care
provider within the information system. Refer to Section 3.1.6 of the iCare Patient
Record User Manual for instructions to designate primary care providers
.
Follow these steps to create a new panel of patients assigned to a designated
primary care provider (DPCP):
Log in to iCare and select New to create a new panel.
1. Enter the panel name and a brief description.
2. Select Patients Assigned To.
3. Select Providers and Edit. Highlight the Provider name and click Add to move
it to the right column and choose OK to accept.
4. Check DPCP.
1. Click on the Auto Repopulate Options tab and check the box Auto Repopulate.
Check During Nightly Job. This will ensure that any newly empaneled patients
will be added to this panel.
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2. Click OK to exit and answer Yes when prompted to continue to repopulate the
panel.
Tip: Quickly Find Patients with Multiple Comorbidities
Follow these steps to quickly identify patients who have the most comorbidities
by applying a custom filter to the Diagnostic Tags column:
1. Click on the filter icon.
2. Choose Custom.
3. Use Matches Regular Expression. Set the condition to
(.*;){3}.
This will display any patients with more than three diagnostic tags. Choose the
number that is appropriate for your list.
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Double-click on the blue filter and select (All) to remove the filter and display all
patients on the panel.
2.1.2 Step 2: Provider Review
During the second step, the care team combines objective data from step one
with subjective information to score the patient’s risk. The highest risk patients
are those who have the potential for worse outcomes or adverse events.
Sometimes risk may be obvious, while other times it may come down to clinical
intuition. Social determinants of health such as poor family support, no running
water, language and literacy barriers, transportation issues, utility issues and
increased utilization may place a patient in a higher risk category and must be
factored into the scoring decision. Northern Cheyenne/Lame Deer chose to use a
three-tiered scoring system:
Low Risk = 1 Medium Risk = 2 High Risk = 3
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2.2 Helpful Screening Tools
Risk assessment screening tools can be helpful to establish consistency among providers
when scoring patient risk. Here are a few examples:
American Academy of Family Practice (AAFP) Risk Stratification Rubric
The AAFP risk stratification rubric is an excellent resource to guide the care team through
the process of risk stratification. The rubric uses a six levels of health risk. Warm Springs
stratified their entire patient population using the AAFP rubric for guidance. The tool is
available at no cost to AAFP members and can be obtained through their website:
https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric
Northern Arizona Healthcare Risk Screening Tool
The Northern Arizona Healthcare (NAH) risk screening tool is used at Chinle as a secondary
risk screening tool for patients that are referred to the Baa Hozho intensive care
management program. The NAH tool was adopted in an effort to provide some degree of
consistency among clinical staff when stratifying patients. Highest scoring patients are
offered participation in the program. Their scores are entered into the iCare measurement
RISK STRATIFICATION –NAH using the steps outlined in this manual. The NAH tool has not
been validated.
2.3 Creating Risk Stratification Tools in iCare
There are many different ways a facility can risk stratify their patient population. For those
who choose to use an evidence-based tool, such as the LACE tool, we will provide basic
steps on how to create a risk stratification tool within iCare.
Disclaimer: Please note that facilities do not need to use the LACE tool and there is more
than one way for facilities to put risk stratification tools into iCare. This information should
be used as an example.
This example shows how to create a template to assess the patient’s risk stratification.
The facility’s clinical application coordinator (CAC) should follow these instructions to
create the template and share for staff to use.
Step 1: Open the Template Editor in iCare.
Step 2: Select the folder this template will reside in. Use one of the Shared Template
folders for staff to have access to it.
Step 3: Select New Template and fill in the Template Properties, including Name and
Template Type.
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Step 4: In the text box section, type in the risk tool questions to be answered by staff. To
allow for limited answers, radio buttons can be used.
Step 5: Select Tools and from the dropdown menu, then select Edit Template Fields to
add radio buttons and other features to the templates. Do this for each row. As
you can see in the example, each row has a template field.
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Step 6: After opening the Template Field Editor, select New.
Step 7: Fill in the details needed and have responses match the tool referenced.
Step 8: Click Apply.
Step 9: Complete all of the details to match the risk stratification tool and click OK.
6
7
8
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From here staff can either create a quick note or add this to an existing template. Once
the risk score is identified, it is important that staff view the next section to learn how to
enter risk stratification scores into iCare.
2.4 Entering Risk Stratification Scores into iCare
Authorized users may enter risk stratification scores directly into the patient record using
iCare. Consult Appendix A if you receive an insufficient access rights message.
iCare will accept scores between 1 and 100.
1. Open the panel and select the Patient List tab.
2. Double-click on the patient name.
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3. Navigate to PCC tab:
4. On the Type: dropdown menu, select Measurement.
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5. Select Add Event. Consult Appendix A if you receive an insufficient access rights.
message.
6. Enter Date and Hospital Location.
7. Select RISK STRATIFICATION SCORE and enter the risk stratification score in the Value
field.
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8. Click on Add and Save to PCC. Answer Yes when prompted to Add to the Pending
Events list.
9. A chart review visit note may be added if appropriate. Choose Cancel if you do not
wish to add a chart review visit and exit.
If you receive an error message UNABLE TO SAVE THE RECORD SUCCESSFULLY TO RPMS, refer
to Appendix B. When the scores are entered outside of the recommended numeric range or
format, you will receive an error message when trying to save the record to PCC. Click OK
twice to exit out of the error and follow the steps in Appendix B to remove the entries.
2.5 Putting It All Together: Risk Stratifying the Entire Patient
Population
This section describes how Northern Cheyenne/Lame Deer stratified their entire patient
population into low, moderate and high-risk panels.
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1. Create a new panel for each designated primary care provider. Name it “Your Provider
Name – Moderate Risk Patients.” Initially all patients will be placed in this moderate
risk panel. Set this panel to auto-repopulate, so that any patients newly assigned to a
provider will automatically land in the moderate panel. This list should be reviewed on
an ongoing basis and this process repeated so that any recently assigned patients can
be stratified.
2. Click or double-click on the Diagnostic tag (ACTIVE DX TAG) column header to sort the
column until the patients with no diagnostic tags display on top of the column.
Transfer patients with either no diagnostic tags, or a low-risk diagnostic tag into “low
risk panel” by highlighting these patients, right click, and select CUT Patients.
Create a New Panel. Name it “Your Provider Name – Low Risk Patients.” Right-click
and paste the patients from the previous step into this low-risk panel.
3. Patients with multiple diagnostic tags can be easily identified by following the steps
outlined previously in the section,
Tip: Quickly Find Patients with Multiple
Comorbidities. Transfer patients with multiple diagnostic tags into a “high-risk” panel
by highlighting these patients, right-click and select CUT Patients.
Create a New Panel. Name it “Your Provider Name – High-Risk Patients.” Right-click
and paste the patients from the previous step into this high-risk panel.
This panel should undergo a secondary provider review process as outlined in the
previous section, Step 2: Provider Review
of this guide. This is your target population
and would benefit most from longitudinal care resources. Transfer the highest risk
patients into the final panel, Provider Name – Care Management Program.
4. Repeat these steps for all providers.
5. Panels are to be reviewed and updated on a regular basis.
2.6 Entering a Batch of Historical Risk Scores
Risk scores may be entered individually through iCare as described in the previous section
of this manual: Entering Risk Stratification Scores into iCare
. If you have stratified the
entire patient population, it may be quicker to enter the data through the backdoor in
RPMS. A batch of historical data may be retroactively entered into RPMS through PCC
Data Entry menus by authorized PCC data entry staff.
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3.0 New Assessment Tools
While risk stratification plays an important part in identifying high-risk patients based on clinical
factors, it should be supplemented with tools that can identify less activated patients who may
require more intensive care management resources.
Chinle has evaluated the incorporation of the patient activation measure (PAM) and EuroQol
tools to supplement their intensive care management program. Both of these tools can be used
to tailor individual support, education and care planning to help improve self-management
abilities and prevent worse outcomes.
3.1 Patient Activation Measurement
PAM is used throughout the health care industry to determine the level at which a patient
is activated in their care. PAM scores can provide valuable insight in high-risk patients that
may ultimately contribute toward avoidable utilization and better health outcomes. PAM
scores will help find less activated patients who may require intensive care management
resources.
PAM is a proprietary calculator that assesses a patients knowledge, skills and confidence
in managing the own health care. Patient responses to a 10- to 13-question survey are
converted into four levels of activation:
Level 1: Disengaged, overwhelmed
Level 2: Becoming aware but still struggling
Level 3: Taking action
Level 4: Maintaining behaviors and pushing further
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3.1.1 Entering Patient Activation Measure into iCare
1. Licensed users may administer the PAM survey and calculate the results
online using the proprietary calculator to generate the patient activation
measure score: https://www.insigniahealth.com/products/pam-survey
.
2. Refer to the section entitled, Entering Risk Stratification Scores into iCare.
Follow steps 1 through 5.
3. From the Measurement dropdown menu, select PATIENT ACTIVATION LEVEL
and enter the score into the Value field. Do not choose PATIENT ACTIVATION
SCORE: this is a placeholder for future integration with the PAM calculator
and should not be used for direct data entry.
4. Click Add and Save to PCC. Answer Yes when prompted to Add to the Pending
Events list.
3.2 EuroQol-5D Health Assessment Survey
EuroQol-5D is a standardized tool that provides a simple, generic measure of the patient’s
perception of their own health status.
Sites must purchase a license from Insignia Health to uses the proprietary
calculator. The Improving Patient Care program is in the process of obtaining
national licensure. Additional information is available on the Insignia website
:
https://www.insigniahealth.com/products/pam-survey
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EuroQol-5D can provide valuable insight into high-risk patients by identifying problem
areas of the patient’s life that are most impactable by tailored care plans. It is a validated
instrument that can also be used to monitor performance as a health care provider and
the population’s health over time.
EuroQol-5D is a two-part survey designed for self-completion by respondents and is
available in both paper and digital formats. It is provided free to noncommercial entities
after they register to use it online: https://euroqol.org/eq-5d-registration-form/
.
3.2.1 Part 1: EuroQol Visual Analog Scale (EQ VAS)
EuroQol Visual Analog Scale provides a rating of the patient’s overall health status
TODAY.
This tool records the patient’s self-rated health on a vertical visual analog scale,
where the endpoints are labeled, “The best health you can imagine” and “The
worst health you can imagine.”
This score can be used as a quantitative measure of health outcome that reflect
the patient’s own judgement.
3.2.2 Part 2: EuroQol-5D Descriptive System
The EuroQol-5D instrument is a descriptive system comprising five dimensions:
1. Mobility
2. Self-care
3. Usual Activities
4. Pain/Discomfort
5. Anxiety/Depression
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Each dimension has five levels:
1. No problems
2. Slight problems
3. Moderate problems
4. Severe problems
5. Extreme problems
The patient is asked to indicate their health status by checking the box next to the
most appropriate statement in each of the five dimensions. This decision results in
a one-digit number that expresses the level selected for that dimension. The digits
for the five dimensions can be combined into a five-digit number that describes
the patient’s health state.
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3.2.3 Entering EuroQol Scores into iCare:
Step 1: Refer to the section Entering Risk Stratification Scores into iCare. Follow
steps 1-5.
Step 2: From the Measurement dropdown menu, select EUROQOL 5 DIMENSION
5 LEVEL or EUROQOL VISUAL ANALOG SCALE and enter the score into the
Value field.
Recommended format:
EuroQol 5 Dimension 5 Level values must be a numeric response between
1 and 5:
1 = No problem
2 = Slight problem
3 = Moderate problem
4 = Severe problem
5 = Extreme problem
1st digit: Mobility
2nd digit: Self-care
3rd digit: Usual Activities
4th digit: Pain/Discomfort
5th digit: Anxiety/Depression
EuroQol VISUAL ANALOG SCALE values must be a numeric response
between 0 and 100:
0 = The worst health you could imagine
100 = The best health you could imagine
Step 3: Click on Add and Save to PCC. Answer Yes when prompted to Add to the
Pending Events list.
Step 4: A chart review visit note may be added if appropriate. Choose CANCEL if
you do not wish to add a chart review visit and exit.
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4.0 Graphing Risk, EuroQol, and PAM Scores
Individual patient scores may be trended using the graphing tool in iCare. The graphs may be
used as a focal point during the visit to discuss and identify problem areas and health
improvement opportunities.
Step 1: Refer to the section entitled Entering Risk Stratification Scores into iCare
. Follow steps 1
through 4.
Step 2: In the Type: drop down menu, select Measurement. In the Last: dropdown menu, select
the desired timeframe.
Step 3: Select Graph It!
Step 4: Under Chart options, select the measurement type and time interval.
If you receive the error message UNABLE TO SAVE THE RECORD SUCCESSFULLY TO
RPMS, refer to Appendix B. When the scores are entered outside of the
recommended numeric range or format, you will receive an error message when
trying to save the record to PCC. Click OK twice to exit the error and follow the
steps in Appendix B to remove the entries.
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5.0 Native American-Specific Risk Stratification Model:
Under Development
As a participant in the CDC’s Population Health Training in Place Program (CDC−PHTIPP), Chinle
is developing and testing a Native American-specific risk stratification model. This model will be
tailored to the Chinle Service Unit population, incorporating data from RPMS and the Arizona
Healthcare Cost Containment System fee-for-service databases.
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Variables will include sociodemographic variables (age, sex, insurance data, employment data),
geographical data (chapters/community of residence, distance from health care center, distance
from paved road), clinical data (diagnosis, body mass index, hemoglobin A1c, blood pressure,
creatinine clearance).
Timeline:
• Development 2020
• Testing and anticipated testing of reliability and predictability of the model through
January 2121
• Evaluate testing model to extend to data from other service units in Navajo Nation
6.0 Preliminary Outcome Data
Preliminary data from Chinle demonstrates a correlation between risk and patients’ self-
perception of their health:
1. Baseline BMI negatively correlates with patients’ perception of their own health status
(EuroQol-VAS).
2. Patients with higher risk scores had poorer baseline perception of their own health status
(EuroQol-VAS).
3. Patients with fewer comorbidities show a greater improvement with patients’ perception of
their own health status between the first and second surveys.
7.0 Risk Stratification, PAM, EuroQol Report (iCare)
Follow these instructions to generate a list of patients who have existing risk stratification, PAM
or EuroQol scores:
Step 1: Click New Panel
Step 2: Choose Ad Hoc Search
Step 3: Choose PCC
Step 4: Choose Measurements
Step 5: Set the appropriate timeframe. In this example, we chose to display all scores by
selecting By Timeframe and choosing Ever from the dropdown list.
Step 6: To generate a list of patients with existing RISK STRATIFICATION scores, choose Edit and
select the RISK STRATIFICATION SCORE, Click on Add and OK. Click on OK at the bottom
of the screen.
• To generate a list of patients with existing EUROQOL 5 LEVEL or EUROQOL VISUAL
ANALOG SCALE choose Edit and select the desired measurement, Click on Add and
OK. Click on OK at the bottom of the screen.
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• To generate a list of patients with existing PATIENT ACTIVATION MEASURMENT,
choose Edit and select PATIENT ACTIVATION PAMC, click on Add and select OK. Click
on OK at the bottom of the screen.
Step 7: When prompted to set the panel to Auto Repopulate, select Yes. This will allow iCare to
automatically update your panel with newly recorded scores.
Step 8: Choose OK to populate the panel in the background.
Step 9: Double-click on the panel name to open.
Step 10: Navigate to the Definition Details tab to see the report.
Step 11: Click on the Patient column to sort by patient.
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The information on this screen can be customized by adjusting the layout. Choose the
Layout button.
New columns are listed under Available Items. Double-click on an item to add it.
Existing columns are listed under Display Columns. Double-click on an item to remove it
from this report.
The order under Display Columns may be adjusted by dragging the item up or down.
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8.0 Appendices
8.1 Appendix A: Assigning Permissions to Enter Risk Scores
The following message displays when the user does not have the appropriate security keys
to enter risk scores into iCare:
The iCare package manager, Clinical Applications Coordinator or site manager may assign
access by granting the BQIZCMED key by following the steps outlined below. Access to the
iCare Editor will enable editing for PCC Historical Data Entry, Care Management, Family
History and Reproductive Data, Designated Specialty Provider, Problem List Management
and CMET.
Step 1: From Panel View select Tools.
Select iCare Package Manager, iCare User Access Management.
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Check the Editor box for the appropriate user and choose OK to save changes.
8.2 Appendix B: Error When Saving Erroneous Measurement
If scores are entered outside of the recommended numeric range or format, you will
receive an error message when trying to save the record to PCC/RPMS. Click OK twice to
exit and follow these steps to remove the entry.
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Highlight the erroneous entry and select Remove. Click Yes to confirm.
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8.3 Appendix C: Other Screening Tools
8.3.1 Northern Arizona Healthcare Risk Screening Tool
The Northern Arizona Healthcare (NAH) Risk Screening Tool is used at Chinle as a
secondary risk screening tool for patients who are referred to the Baa Hozho intensive
care management program. This risk screening tool was adopted in an effort to provide
some degree of consistency among clinical staff when stratifying patients. Highest
scoring patients are offered participation in the program. Their scores are entered into
the iCare measurement RISK STRATIFICATION – NAH using the steps outlined in this
manual. The NAH tool has not been validated.
Patient Name__________________________________________________________________________________
DOB___________________________ MRN#___________________________ Date__________________________
TOTAL
SCORE
0
Financially solvent
1
No expendable resources/underinsured
1
2
2
Low income
1
2
1=Public Assistance
Dependent; 2=No Public
Assistance
Educational Level (Poor Health Literacy)
TOTAL
SCORE
0
High school graduate or above
1
2
1
Some high school or GED
1
2
2
<8th grade
1
2
Cognitive Functioning
0=No Impairment; 1=Minimal
to Moderate Impairment;
2=Severe Impairment
Medications and Medical Health (Polypharmacy/Problem Medications and Problem Diagnoses)
TOTAL
SCORE
0
No medication assistance needed or 0-2 meds
1
Some medication assistance needed or 3-5 meds
2
Extensive medication assistance needed or >5 meds
Add 1 point for each chronic disease
___Heart disease
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___Hypertension
___Pneumonia
___TKA/THA (post-discharge)
___CABG (post-discharge)
___Diabetes
___Dementia
___Lung disease
___Current tobacco use
___Chronic pain
___Congestive heart failure
___Kidney disease
___Cancer
___Obesity
___Stroke
___Palliative patient
___ED visits (≥5 in last 6 months)
___Readmission within 14 days (2 pts)
___Readmission within 30 days (1pt)
___Other: __________________
___Other: __________________
Add 1 point for each category of medication
___ Anticoagulants
___ Insulin
TOTAL
SCORE
0
No mental health history
1
Past mental health history
2
Current mental health and/or current ETOH/drug abuse
history
1
2
1=With Treatment; 2=No
Treatment
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Adherence Potential
TOTAL
SCORE
0
Full cooperation
1
Limited cooperation (provide health engagement survey)
2
Uncooperative (provide health engagement survey)
***Psychosocial Stressors
TOTAL
SCORE
___Personal injury/illness
___Change in habits
___Children stressors
___Parent stressors
___Partner stressors
___Financial issues
___Language barrier
___Insurance issues
___Death of family/friend
___Work/school
___Lives remote
___Housing stressors
___Legal issues
___Childcare
___Loss of faith
___Relating to God
___Transportation issues
___Solitary living arrangement
___Homelessness
___No running water
___No electricity
___Other: __________________
___Other: __________________
Add the above and circle final Psych/Soc below:
SIGNIFICANCE:
0
0-1
1
2
1
2-3
1
2
2
4-5
1
2
3
>5
1
2
1= Low Risk; 2=High Risk
Support (Physical Limitations)
TOTAL
SCORE
0
No assistance needed
1
Some degree of assistance needed
1
2
2
Extensive assistance needed
1
2
1=Limited Support; 2=No
Support or Lives Alone
FINAL SCORE
LOW
0-15
MEDIUM
16-20
HIGH
≥21
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8.3.2 LACE Index Tool
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8.3.3 Hospital Risk Assessment Tool
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8.4 Appendix D: Health Technician/Health Coach Orientation/
Competency Checklist
Name: ________________________________
Date: _________________________________
Check In with Supervisor
☐ ITAC Authorization
☐ Mandatories
☐ New Employee Checklist
Security Badge
☐ PIV Card
☐ Employee Badge
☐ Emergency Code Orientation
ISSA Mandatory Training
☐ HIPAA Medical Records
☐ Provider Code for Computer Access
Tour Facility
☐ Organizational Chart
☐ Maintenance for Key Request
☐ Drivers Overview
Computer Access
☐ Main Login
☐ Copier/Scanner
☐ Scanning into Patient Record
☐ Outlook Orientation
☐ EHR/HIE
☐ RPMS
☐ iCare
☐ Practice Management Suite/Appointments
☐ Health Stream/HHS
☐ Outside Stakeholder Access:
• FMC
• San Juan
• Banner
healthinsight.org/path
Page 35
Position: ______________________________
Supervisor: ____________________________
Patient Education
☐ KRAMES on Demand
☐ Public Share Education
GPRAMA/Improving Patient Care
☐ Quarterly Measures
☐ Surveys
☐ Performance Improvement Worksheet
☐ Word Load Reports
☐ iCare Reports
Collaboration with Team Members
☐ Native Medicine, behavioral Health Techs, PHNs, Nutrition, Pharmacy, etc.
Pre-Planning
☐ Daily iCare Worksheet
Charting and Care Plan Documentation
☐ Template to Chart
☐ Shadowing
Resources/Toolkit
☐ Phone Use Including:
• Forwarding Calls
• Answering Messages
• Documenting Messages in EHR
• Create Messages for Absence
☐ Contact List for Staff
☐ Resource List for Patients
☐ Packets for New Enrollees
☐ Brochures
☐ Patient Membership Card
☐ Huddle Flowsheet
healthinsight.org/path
Page 36
Health Tech Competencies:
☐ Intensive Health Coach Training
☐ Customer Service Skills
• Patient Advocacy/Patient Centeredness
• Motivational Interviewing
☐ Self-management support
• Brief-Action Planning
• Goal Setting/SMART Goals
• Teach-back
• Ask-Tell-Ask
☐ Referral, Consults, Process and Follow Up
• Scanning Results into Patient Record
• Appointment Verification and Follow Up
☐ Risk Assessment Forms
• FMC Assessment
• Patient Activation Measure
• EuroQol
☐ iCare
• Daily Appointment List Generation
• Update Team List
☐ EHR
• Consult Updates
• EHR with Templates
• Goals in EHR
• Care Plan
• Notification
This material was prepared by Comagine Health, the Medicare Quality Innovation Network – Quality Improvement Organization for Idaho,
Nevada, New Mexico, Oregon, Utah and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the
U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-AIAN-20-20
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2278 Risk Stratification Guide For High Risk Patients (HealthInsight)

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Completed 8 February 2021

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