Care Coordination Measurement Pilot Q&A
Q: What measures are being piloted?
There are two care coordination measures being piloted by MNCM and the MN Department of Health, 1)
Advanced Care Planning and 2) Follow-up After Hospital Discharge. Please email [email protected] if
you need a copy of the specifications for each measure.
Q: Do I need to participate in the pilots for both measures, or can my clinic just
participate in one pilot?
Participation in pilot testing of measures is voluntary and groups can decide to participate in testing only
one measure or can participate in testing both measures. MNCM and MDH greatly appreciates the time
and effort of the health care homes clinics that contribute towards the testing of the new care coordination
measures and welcomes continuous feedback during the pilot testing process.
Q: When do I need to let MNCM know of our clinic’s plan for participation?
Please let MNCM know no later than Friday May 10th of your intent to participate in pilot testing, indicating
which measures and which clinics you would like to participate in the pilot testing.
Q: What are the data collection and data submission periods for each measure?
There are different timeframes for the two measures, the Follow-up measure begins June 1st and has a
longer data collection period compared to the Advanced Care Plan measure. The longer data collection
period is needed to achieve a higher number of patients in the denominator for the Follow-up measure.
Data Collection Dates of Service for Pilot
Data Submission Period
Measure #1 Advanced Care
Planning
7/1/13 – 9/30/13
10/14/13 – 11/22/13
Measure #2 Follow-up After
Hospital Discharge
6/1/13 – 11/30/13
12/11/13- 1/24/14
Q: What is expected of my clinic or medical group?
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Review detailed measure and field specifications. Think about how your clinic would collect fields
needed for measure calculation.
Ask questions, participate in email exchanges (list serv) with MNCM staff and other pilot participants
Provide feedback, survey questions about time and resources needed for data collection and overall
feasibility.
Participate in conference calls for working through measure specification details or other questions
Submit patient level data for measure calculation.
Q: How do I know if we are ready to participate?
We recommend a thorough review of the measure specifications and individual fields that are included in
the submission. Think about how you would collect this information, either extracting from your EMR or
abstracting from the medical record. What capabilities does your EMR currently have for populating the
data elements that are asked for? What is in structured data and what could be planned for future EMR
modification to include as structured data? What processes or work flow changes would need to be made?
Things don’t need to be perfectly in place to participate in the pilot; one of the reasons why we are piloting
is to determine feasibility of collecting this information. Another thing to consider for pilot participation is
to determine the volume of elderly patients seen at your clinic each month. The Care Coordination
measures will typically apply to patients over the age of 65 years of age OR patients with certain chronic
conditions.
Q: What resources are available to support my clinic/medical group?
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Detailed measurement and field specifications; data collection guide
Financial assistance for technical support through MDH grants
Informational meeting to review measure and field specifications and answer questions
Direct email or phone access to MNCM staff facilitating the pilot testing
Collette Pitzen
Measure Development
[email protected] 612-454-4815
Alison Helm
Measure Implementation
[email protected]
612-454-4824
Nathan Hunkins
Program Management
[email protected] 612-454-4821
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Email “list serve” for pilot participants and other interested medical groups preparing for
measurement; provides ability for ongoing Q&A