PPC-3 Care Management

Element D Care Management for Important Conditions

Data Points

6.  Reviewing self-monitoring results and incorporating them into the medical record at each visit.
7.  Assessing barriers when patients have not met treatment goals.
8.  Assessing barriers when patients have not filled, refilled or taken prescribed medications.
9.  Following up when patient have not kept important appointments
10. Reviewing longitudinal representation of patient’s historical or targeted clinical measurements.

While SETMA is not reporting results for these data points in this application, we do the following:

• We do review self-monitoring results for blood sugar and blood pressures. However we do not capture that in structured fields.  We may do that some day but as of now we do not have data to report.
• We assess financial, social and physician barriers for our patient who  are not to goal and who do not get their medications particularly follow-up clinic and hospital discharge visits.  While we have structured fields for these data we have not captured it at present.
• We do follow-up patients who miss important appointments but we do not have structured data fields which allow us to audit this function.
• We are able to and do review any and all data over time, longitudinally on any given patient. In the future, we will be able to report on this but at present our data is skimpy.