1. Camden Coalition of
Camden Coalition of
Healthcare Providers
Healthcare Providers
Data Collection
Basics of Capturing Care
Management Process and
Outcomes Data
www.camdenhealth.org
2. Evolution of Program Data Thinking
1. Data is an asset to your programs
2. Start thinking about data early
3. Information Technology plays an important
role in data collection
4. Check data quality
5. Activate you data
6. Think about, talk about, debate the
“activated” data
7. Do something with findings (share your
successes, fine tune the program, gather new
data)
8. An iterative process
3. CCHP CMMI Program Goals
(aka Outcomes)
• Stabilize
• Coordinate
• Improve Health
• Reduce cost
CCHP measures these goals (Outcomes)and steps in to process
towards achieving these goals (Process Measures)
4. Tenets of Good Care (and the role of data)
• It takes a team
• Enroll based on specific triage data r/t preventable readmissions
• Engage patient at hospital
• Build/maintain rapport with patients/families
• Assess medical/social complexity
• Provide immediate post d/c(<72hours) in-person intake
assessment
• Accompany to PCP < 7 days post d/c
• Build the relationship between patient/family and PCP/specialists
• Individualized care plan with specific graduation timeline
• Collect information at each step to evaluate/improve program
• Helping patients help themselves to find long-term sustainable
resources
5. CCHP CMMI Data collection touch points
• Real Time Data to Identify Currently Hospitalized “High Utilizer”
– Camden HIE data
• Triage
– CCHP Triage tool
• Pre-enrollment
– CCHP Risk Stratification tool
• Intake
– CCHP Intake Form
– Client Perceptions of Coordination Questionnaire (CPCQ) (Coordinate)
– Healthy Days Survey
• Care Provided
– CCHP Client Track Form (Staff time activities for each patient)
• Home visit measures
– Care Plan Progress
– Healthy Days Survey (Improve Health)
– 30 day readmissions (Stabilize)
• Status
– Graduated/lost to follow-up/moved/deceased
• Graduation
– Client Perceptions of Coordination Questionnaire (CPCQ) (Coordinate)
• Post-graduation follow-up
– Healthy Days Survey (Improve Health)
• Six month and one year post enrollment
– Compare pre and post cost per month (Reduce Costs)
Process Measure
Outcome
6. Care Management Intervention – Data Collection Timeline
Camden Coalition’s CMMI Data Collection Plan
CLIENT
PRE- TRACKING HOME VISIT
TRIAGE ENROLLMENT ENROLLMENT
Ongoing
Past Utilization Risk Stratification Enrollment Intake Re-administer Risk
Data for Risk Tool CPCQ Tool & Healthy
Staff time/activities
Tool Collected Bedside Intake Healthy Days Days
for each patient
HOSPITAL 30 DAY
DISCHARGE DECISION
(DAY ZERO) POINT
CLIENT
TRACKING
HOME VISIT 6 MONTH POST-DISCHARGE (DAY 0) Graduate?
Ongoing Re-administer
Re-administer Risk Re-administer Risk Tool and Health Days CPCQ
Staff time/activities Tool & Healthy During Follow-up Phone Call
for each patient Days
60 DAY Graduate?
DECISION Re-administer
POINT CPCQ
