Alliance for Better Health Proxy Measure Selection

Organization Name *This question is required.

1. Name of organizational contact *This question is required.

2. Email address *This question is required. This question requires a valid email address.

3. Phone number *This question is required.

A requirement of this program is to submit a monthly Medicaid Patient List. Please provide the information below and we will establish a Citrix ShareFile account so that you can transmit data securely to Alliance.

Name of team member responsible for uploading monthly Medicaid Patient Lists *This question is required.

Email Address of above contact responsible for submitting Medicaid Patient List *This question is required. This question requires a valid email address.

Space Cell	Check If Participating
Avoidable Hospital Use	Avoidable Hospital Use: Check If Participating
Preventive Health	Preventive Health: Check If Participating
Asthma	Asthma: Check If Participating
Behavioral Health	Behavioral Health: Check If Participating
Patient Activation Measure (PAM)	Patient Activation Measure (PAM): Check If Participating
Palliative Care (IPOS)	Palliative Care (IPOS): Check If Participating

For the following:

If you have created your own proxy measure(s), please describe by choosing 'I'd like to describe my own proxy measure', and filling in the corresponding fields.

If you have more than one proxy measure, please select, 'I have another proxy measure' at the end of the description, and describe.

Please select at least one proxy measure for the Preventive Health Performance Team.
You may describe your own by selecting 'Other Proxy Measure'

Select measure(s) below :

Engaging New Medicaid Patients
Unmonitored Diabetes
Well Child Visit / Adult Primary Care Visit Rate

Other Proxy Measure

Please use this space to describe the criteria for your own proxy measure(s) - see instructions below

Expectation: What are you expecting to occur?
Example: Readmission rate will decrease as the rate of medication reconciliation rates increase *This question is required.

Metric (A): What are we measuring to monitor success?
Example: Number of readmission's occurring in a measurement period
*This question is required.

Metric (B): What else are we measuring to monitor success? (if anything)
Example: Number of medication reconciliations documented upon discharge

Data Sources: Where is the data you are using to track this coming from? *This question is required.

Workflow Area of Focus: What work flow is going to drive success for this measure?
Example: Medication reconciliation process upon discharge *This question is required.

Please select at least one proxy measure for the Avoidable Hospital Use Performance Team.

Select measure(s) below :

Follow up after Behavioral Health discharge
Potentially Preventable Admissions
Potentially Preventable ED Visits
Potentially Preventable ED Visits - Behavioral Health
Rate of Potentially avoidable Hospital Admissions for Adults
Rate of Potentially avoidable Hospital Admissions for Children

Other Proxy Measure

Please use this space to describe the criteria for your own proxy measure(s) - see instructions below

Expectation: What are you expecting to occur?
Example: Readmission rate will decrease as the rate of medication reconciliation rates increase *This question is required.

Metric (A): What are we measuring to monitor success?
Example: Number of readmission's occurring in a measurement period
*This question is required.

Metric (B): What else are we measuring to monitor success? (if anything)
Example: Number of medication reconciliations documented upon discharge

Data Sources: Where is the data you are using to track this coming from? *This question is required.

Workflow Area of Focus: What work flow is going to drive success for this measure?
Example: Medication reconciliation process upon discharge *This question is required.

Please select at least one proxy measure for the Asthma Performance Team.
You may describe your own by selecting 'Other Proxy Measure'

Select measure(s) below :

Potentially Preventable ED Visits - Asthma

Other Proxy Measure

Please use this space to describe the criteria for your own proxy measure(s) - see instructions below

Expectation: What are you expecting to occur?
Example: Readmission rate will decrease as the rate of medication reconciliation rates increase *This question is required.

Metric (A): What are we measuring to monitor success?
Example: Number of readmission's occurring in a measurement period
*This question is required.

Metric (B): What else are we measuring to monitor success? (if anything)
Example: Number of medication reconciliations documented upon discharge

Data Sources: Where is the data you are using to track this coming from? *This question is required.

Workflow Area of Focus: What work flow is going to drive success for this measure?
Example: Medication reconciliation process upon discharge *This question is required.

Please select at least one proxy measure for the Behavioral Health Performance Team.
You may describe your own by selecting 'Other Proxy Measure'

Select measure(s) below :

Follow up after Behavioral Health discharge
Health Home Enrollment - Behavioral Health
Potentially Preventable ED Visits - Behavioral Health

Other Proxy Measure

Please use this space to describe the criteria for your own proxy measure(s) - see instructions below

Expectation: What are you expecting to occur?
Example: Readmission rate will decrease as the rate of medication reconciliation rates increase *This question is required.

Metric (A): What are we measuring to monitor success?
Example: Number of readmission's occurring in a measurement period
*This question is required.

Metric (B): What else are we measuring to monitor success? (if anything)
Example: Number of medication reconciliations documented upon discharge

Data Sources: Where is the data you are using to track this coming from? *This question is required.

Workflow Area of Focus: What work flow is going to drive success for this measure?
Example: Medication reconciliation process upon discharge *This question is required.

We are in the process of developing measures for the Patient Activation Measure (PAM) Performance Team; however, you may describe your own by selecting 'Other Proxy Measure'

Select measure(s) below :

N/A

Other Proxy Measure

Please use this space to describe the criteria for your own proxy measure(s) - see instructions below

Expectation: What are you expecting to occur?
Example: Readmission rate will decrease as the rate of medication reconciliation rates increase *This question is required.

Metric (A): What are we measuring to monitor success?
Example: Number of readmission's occurring in a measurement period
*This question is required.

Metric (B): What else are we measuring to monitor success? (if anything)
Example: Number of medication reconciliations documented upon discharge

Data Sources: Where is the data you are using to track this coming from? *This question is required.

Workflow Area of Focus: What work flow is going to drive success for this measure?
Example: Medication reconciliation process upon discharge *This question is required.

Please select at least one proxy measure for the Palliative Care (IPOS) Performance Team.
You may describe your own by selecting 'Other Proxy Measure'

Select measure(s) below :

Intervention Rate - Advance directives
Intervention Rate - Depression
Intervention Rate - Symptoms
Intervention Rate - Those not at peace