Demonstrating value of intervention 

A program supervisor would like to evaluate a cohort’s cost and utilization before and after the start of a program intervention to evaluate its efficacy.

  1. Log into CRISP Reporting Services (CRS). 
  2. Access Panels card 
  3. Access Pre/Post Report 
  4. Submit a distinct panel of patients for which data is requested or choose to run pre-post analysis for a previously uploaded panel – Must include date of initial intervention, as defined by the practice
      Intervention may be enrollment into a specific program, date of starting a specific
         medication regimen, etc. 
  5. The report output is hospital utilization information for up to 12 months pre/12 months post intervention date. 
  6. This data is often used to inform changes to your program or compare costs by hospital to drive partnerships in care, with a goal of decreasing overall utilization.

Identifying high and rising risk patients

A practice administrator would like to identify high and rising risk patients, and provide patients with adequate support, education, appointments, and services to prevent a decline in health.

  1. Log into CRISP Reporting Service portal.
  2. Access Panels card, which are based on ENS panels submitted for the CRISP Encounter Notification Service. 
  3. Access Panels for Practices Reports.
    a.   You may have access to different metrics based on casemix data, at a summary
          or patient level. 
  4. To learn more about general trends:
    a.   Panel utilization
    b.   Bedded care
    c.   Hospital utilization
    d.   Chronic conditions
    e.   This data is often used as a part of larger quality management, population health,
          and patient or provider education strategies. 
  5. To learn more about patients:
    a.   Unique patient
    b.   This data is often used to identify patient needing enhanced or higher level
          services. 

Care Coordination During Inpatient or Sub-Acute Encounter

Practice staff wants to help coordinate care while their patient is hospitalized or at a sub-acute treatment facility. This could include providing support or information to hospital/facility staff, and potentially avoiding hospital admission or reducing length of stay. 

  1. Submit panel to CRISP in one of the following ways:
    a.   Self-service panel loader.
    b.   Manual submission on a bi-weekly basis (via secure e-mail or sFTP).
    c.   Auto-subscribe via ADT integration.
  2. Receive Alerts via CRISP Encounter Notification Service (CRISP Direct, ENS PROMPT, Census View, DocHalo, etc.) for the following encounters:
    a.   ED admissions and discharges.
    b.   Inpatient admissions and discharges.
    c.   Skilled nursing facility admissions and discharges.  
  3. Review encounters daily, or more than once a day.
    a.   Identify the patient as complex using clinical judgement or past hospitalizations
          and ED visits listed with notification. 
  4. High Risk Encounters: Contact the treatment facility to speak with the Care Team regarding the patient’s condition and provide pertinent clinical information and prevent an avoidable admission.
  5. When patient is discharged, refer to workflow for Transitional Care Management.

Transitional care management (post-discharge)

Practice staff can identify patients who have been discharged from hospital-based care. The physician can support her patients’ safe transitions from inpatient hospital settings. 

  1. Submit panel to CRISP in one of the following ways :
    a.   Self-service panel loader.
    b.   Manual submission on a bi-weekly basis (via secure e-mailor sFTP).
    c.   Auto-subscribe via ADT integration. 
  2. Receive Alerts via CRISP Encounter Notification Service for the following encounters :
    a.   ED admissions and discharges.
    b.   Inpatient admissions and discharges.
    c.   Skilled nursing facility admissions and discharges.  
  3. Review encounters daily, or more than once a day. 
  4. When a patient is discharged from the ED: Call patient to check on status, do medication reconciliation, understand discharge instructions, and assist as necessary. 
  5. When a patient is discharged from an Inpatient Stay: Call patient to check on status, do medication reconciliation, understand discharge instructions, and assist as necessary. Also, schedule an appointment within 7 days of discharge in accordance with Transitional Care Management billing guidelines.
    a.   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
          MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-
          Fact-Sheet-ICN908628.pdf
     
  6. Prior to transitional care face-to-face appointment, refer to workflow for Pre-Visit Planning and Patient History.

Addressing potential gaps in patient care 

A provider is responsible for ensuring that a patient completes preventive health screenings, and may need documentation of these screenings for quality measurements (ex. MIPS, HEDIS). They need to distinguish between patients who are out of compliance and those who may have completed screenings for which the provider has not received results. 

  1. Compile a list of patients who are out of compliance with a preventive health measure, such as a mammogram.  
  2. Log into Unified Landing Page and Search for Patient.
    a.   Required search fields are First Name, Last Name, and DOB. 
  3. Check CRISP Query Portal for relevant results. 
  4. Document or import relevant information into your native Electronic Medical Record (EMR).
  5. Review results and call with any follow up instructions. 
  6. If the result is not available in CRISP, follow up with the patient to ask if they completed the procedure. If not, place a requisition for the patient to complete.

Test Follow Up

A provider has ordered a test or procedure and would like to follow up on its results.

  1. Set a reminder after the order is placed. 
  2. Log into Unified Landing Page and Search for Patient
    a.   Required search fields are First Name, Last Name, and DOB. 
  3. Check CRISP Query Portal for Labs and Radiology results. 
  4. Document or import relevant information into your native Electronic Medical Record (EMR).
  5. Review results and call with any follow up instructions.
  6. If results are not available in CRISP, follow up with patient. 

Pre-visit planning

In an outpatient setting, a staff member or clinician is preparing for a patient encounter, and trying to understand the patient’s complex medical history and recent tests and procedures.

  1. Log into Unified Landing Page and Search for Patient.
    a.   Required search fields are First Name, Last Name, and DOB.
  2. Check Snapshot for Prior Encounters, Care Alerts, and Care Team.
  3. Check CRISP Query Portal for Labs, Radiology, Discharge Summaries, etc.
  4. Document or import relevant information into your native Electronic Medical Record (EMR).
  5. Review data obtained from CRISP and incorporate into your clinical decision making process, where appropriate.