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QI Weekly

ACEs Screener
Accountable Care Organizations
ACO Comprehensive Medication Management
Advanced Illness and Frailty
Amerigroup Medication Therapy Management 
AMM and AMR Measures
Annual Wellness Visit
Antidepressant Medication Management
Antidepressant Medication Management 10.11.21
Appointment Call Log
Appointment Flipping
Appropriate Testing for Pharyngitis
Appropriate Treatment for URI and ABB
Asthma Medication
Asthma Medication Ratio
Asthma Medication Ratio 
Avoidable Hospitalizations Measure
Ballad Center for Post Covid Care
Ballad Center for Post Covid Care Referral
BCBS MHP Utilization Metric Changes
BCBS Commercial Reporting-Only Measures
Birth Control Counseling
Birth Control Documentation
Blood Pressure
Blood Pressure Readings Recommendations
BMI
Breast Cancer Screenings
Breast Cancer Screenings
Care of Older Adults
Case Management
CCCM Services
CCCM Services CPT
Cervical Cancer Screening
Chlamydia Screening
Chlamydia Screening
Chlamydia Screening for UPL
Chronic Opioid Users with Decreased Usage
Coding Reminders for 2021
Colorectal Cancer Screening
Controlling Blood Pressure
COPD Documentation and Coding Tips
COVID-19 Workflow
Concurrent Use of Opioids and Benzodiazepines
CSMD Checkbox
Decreasing Inappropriate Utilization
Depression Measures
Depression Measures
Diabetes Care Quality Measures
Diabetes HbA1c
Diabetic Retinal Eye Exam
DMARD Therapy for Rheumatoid Arthritis
DME Cost
Documenting Changes in Patient Status
ED Utilization Data
End of Life Care Training Module
Episodes of Care
Episodes of Care
Entering Immunizations
Fall Risk Screenings
Fentanyl Exposure
Fentanyl Info
Flu Vaccines
Focus Areas for 2022
Follow Up After ED Visit for AOD
Frontier Referral Process
HCC Coding
Health Connect America
Health Connect America Referral Form
Heart Failure and CAD
Hospital Discharge Tips & Tricks
Hospice and Palliative Care
Humana FMC Measure
Humana 2021 New Pharmacy Measures
Humana 2021 Pharmacy Changes
Imaging for Low Back Pain BCBS
Improving Medication Adherence
Influenza Immunizations
Influenza and Pneumonia Immunizations
Informed Consent and Controlled Substance Agreements
Initiation of Opioid Abuse or Dependence Treatment
Kidney Health Evaluation
Managing Strategies for Statin Intolerance
Medical Decision Making - CPT codes
Medication Adherence
Medication Adherence Prescribing Strategy
Medication Reconciliation Post Discharge
Medication Reconciliation Post Discharge
Medication Reconciliation Post Discharge
​Medication Tips & Tricks
MIPS
Morbid Obesity Coding
Naloxone Education
Naloxone Prescribing
Nurse Practitioner Announcement
Nutrition Counseling Referral
Nutrition Sylvan Health Brochure
Obesity and Protein-Calorie Malnutrition
Obesity - Coding
Obesity - HCC Coding
Opioid Policies 
Opioid Risk Tool
Ordering COVID Infusion Therapy
COVID - Community Provider Monoclonal Adult Order
ORT and PEG Screenings
Patient Satisfaction
Patient Centered Care Plans
Patient Experience Surveys
Plan All-Cause Readmissions
Plan All-Cause Readmissions
PCMH Principles
Population Health Team
Pop Health Data Request
Pop Health Data Request Form
Post-Acute Follow Up
Readmissions to Inpatient Hospital Setting
Readmissions to Inpatient Hospital Setting
Remote Patient Monitoring 
Remote Patient Monitoring 
Remote Patient Monitoring Enrollment Notification
RX Renew Tasks
Self Reported Blood Pressure
Signify Health In-Home Assessments
Signing up for TennCare
Statin Therapy for CVD and Diabetes
Statin Use for CVD
Statin Use for Diabetes
Statin Use in Persons with DM 2021
Statin Use in Persons with DM 2021
Sylvan Health Brochure
Sylvan Health Dietary Care Referral Source
Sylvan Health - Ordering Referrals
TennCare Eligibility Reference Guide
TennCare PCP Lock-In Requirements
Tennessee Health Link
Therapeutic Alternatives for BCBS MHP
TN Heart Health Network
TNHHN Brochure
Tobacco Screening
Tobacco Use
Transitional Care Billing
Transitioning HCC Codes
UPL Overview
2022 UPL Overview
UHC MA Pre-Visit Planning
Unite Us Platform
UTI Management
Vascular Disease- Coding Tips
Vascular Disease- HCC Coding
Vascular Disease Part 2- HCC Coding
Humana $35 Copay for Select Insulin
Hypertension- HCC Coding
Hypertension- Coding

Population Health Team

, Why?
  • ​As more of our payer contracts move toward value-based programs, the Population Health team has merged and expanded in order to meet the growing needs. In August 2019, the Family Medicine and MEAC teams were merged to provide a single focus for our value-based programs. 
  • In addition to the centralized team at the Med Tech Parkway Administrative Building, we also have nurses embedded in the primary care clinics who provide face-to-face care. Some of these case managers are members of the Pop Health team, while others are clinic employees, but all work together on the various programs to improve patient care. 
What?
  • Manage 20+ value-based programs, including the UPL, ACO, MIPS, TennCare, PCMH, and all of the payer-specific programs. Meet monthly with payers.
  • Obtain and maintain PCMH certification for our primary care clinics.
  • Work with clinics, staff, residents and faculty to implement new workflows and track progress throughout the year.
  • Utilize case managers to assist clinics with patient outreach, post-discharge calls, and chronic care management. ​
  • Use robust data reporting to guide change management projects throughout the ETSU Health enterprise, and support clinical research requests for residents, physicians, and other researchers.
Who?
  • Monaco Briggs, MBA — Director of Quality Improvement and Operational Optimization
  • Jennifer Logan, BS, MA — Director of Population Health
  • Carolyn Bailey, BS —Population Health Coordinator
  • Morgan Barker, BS — Population Health Program Analyst
  • April Jones, Med Asst — TennCare Data Analyst
  • Tracy Jones, AAS — Lead Data Analyst
  • Yan Yi Lai, BS — Application Analyst
  • Laurel McCarthy, LPN — Health Data Analyst
  • Hannah Vitt, RN, MSN— Data Analyst

  • Betty Dellinger, RN — Case Manager, Centralized
  • Rebecca Duncan, RN — Case Manager, Johnson City Internal Medicine
  • Debra Hollified, LPN — Case Manager, Pediatrics
  • Karen Myers, LPN — Case Manager, Centralized
  • Azlee Sells, RN — Case Manager, Kingsport Internal Medicine
  • Morgan Tipton, BSW, MS-HS — Care Coordinator, OB-GYN and Pediatrics
  • Maggie Holifield, RN — Patient Health Manager, Kingsport Family Medicine
  • Lucinda Treadway, RN — Patient Health Manager, Bristol Family Medicine
  • Millie Wykoff, RN — Patient Health Manager, Johnson City Family Medicine

How to request a report or data?
We have implemented a new workflow for requesting data from our Population Health Data Team. For future data requests, please email meacdatateam@etsu.edu for assistance. Once your email has been received, a member of the team will then reply with a data request application to collect additional information regarding the details of the request. 
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