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Project Goals

Qualis Health's Cardiac LAN is focused on important goals:

Improving preventive cardiac care

Coronary disease is the greatest single cause of morbidity and mortality in the U.S.

Using cardiac population health as the focus of our program represents a high-leverage opportunity to improve the health of a large number of Idaho and Washington’s Medicare beneficiaries while putting systems in place that will serve everyone—patients and providers alike.

Integrating EHR meaningful use, primary care redesign, and accountable care into a focused improvement effort

Practices often feel stretched to provide resources for multiple improvement efforts. This program is designed to build on existing efforts, meeting a single important clinical goal.

Building Physician Quality Reporting System (PQRS) reports directly from EHR data

EHR-built reports provide quality data for improvement efforts, position organizations to participate in accountability programs, and provide a 0.5% incentive from Medicare. Practices that report to PQRS will also avoid the 1.5% Medicare payment adjustment starting in 2015.

Using the EHR as a quality improvement tool

Identifying patients that are lost to follow up, have gaps in care, or have poorly controlled risk factors is important for accountability and financial sustainability. Addressing these gaps is the critical next step in care improvement.

Redesigning clinical workflows

Workflow improvement is the key to providing efficient, cost-effective, and quality care.

Applying proven primary care change concepts toward cardiac population health outcomes

Primary care redesign provides the foundation for real and measurable clinical improvement.

Starter Resources

Patient empanelment is not only a crucial first step in becoming a patient-centered medical home, but it is also a high-leverage activity for practices wanting to improve the health of defined patient populations—and make full use of their EHR reporting capabilities.

Cardiac LAN members will learn about patient empanelment through several of our training sessions.

The following resources are also available to the general public, courtesy of the Safety Net Medical Home Initiative:

Empanelment Guide, Part 1: Establishing Patient-Provider Relationships

Empanelment Guide, Part 2: Assigning and Managing Patient Panels in a Patient-Centered Medical Home

Implementation Guide: Clinical Standards for Empanelment

Implementation Guide: Provider Staffing and Scheduling Policy

Implementation Guide: Empanelment Scripting for Appointment Scheduling