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Clinical Care Model Glossary

Terms may be classified into any of these domains: Administration, Clinical Care, Customer Experience, Evidence Based

Medicine, General Healthcare, Governance, Government Programs, Financial, Informatics and Technology, Medical

Organizations and Partners, Population and Community Health, and/or Quality and Risk.

Term Domain Definition

AANM Medical Organizations and Partners

Anesthesia Associates of New Mexico (more info)

ABIM Medical Organizations and Partners

American Board of Internal Medicine (more info)

access General Healthcare

The timely use of personal health services to achieve the best possible outcome. Key components of access:

• Gaining entry into the health care system.

• Getting access to sites of care where patients can receive needed services.

• Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust. (source)

Accountable Healthcare Organization (ACO)

Financial A groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. (source)

advance healthcare directive

General Healthcare

Advance healthcare directives (sometimes called just “advance directives”) are instructions that state a patient’s healthcare choices. Most advance directives contain two important parts:

1. Identification of a “healthcare decision maker” who is entrusted to make healthcare decisions for a patient when the patient is not able to voice his or her wishes; and

2. An explanation of what medical treatment the patient’s want or do not want, if he/she becomes seriously ill and unable to make or communicate healthcare choices.

Under New Mexico law, the instructions may be either oral or written. Oral instructions must be made by personally informing a healthcare provider. Written instructions are known by different names, including: Living Will, healthcare directive, advance healthcare directive, DNR, Medical Power of Attorney, and Durable Power of Attorney.

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Term Domain Definition

advance healthcare planning (ACP)

General Healthcare

ACP is a communication process to help an individual understand his/her goals related to future healthcare decisions. Effective ACP results in a written advance directive that accurately describes the individual’s wishes. Advance healthcare planning is appropriate for adults at all stages of life, and can reduce stress or anxiety for the patient and family.

advanced illness General Healthcare

The Coalition to Transform Advanced Care (CTAC) defines advanced illness as “occurring when one or more conditions become serious enough that general health and functioning decline and treatments begin to lose their impact. This is a process that continues to the end of life.” Examples of diagnoses that qualify as advanced illness include heart failure, COPD, end stage renal disease, and metastatic cancer.

Advanced Practice Clinician (APC)

General Healthcare

A licensed, independent practitioner who practices autonomously or in association with a physician to assess, diagnose, treat and manage the patient’s health problems and needs. Examples of APCs include certified registered nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, behavioral health clinicians, and pharmacist clinicians. (formerly called “mid-levels”)

Affordable Care Act (ACA)

Government Programs

The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or, colloquially, ObamaCare, is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act amendment, it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965. Under the act, hospitals and primary physicians would transform their practices financially, technologically and clinically to drive better health outcomes, lower costs and improve their methods of distribution and accessibility. (source)

Agency for Healthcare Research and Quality (AHRQ)

Government Programs

A government office created to produce evidence that makes health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. (source)

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Term Domain Definition

Alzheimer disease (AD) Clinical Care The most common cause of dementia among people age 65 and older, AD is

an age-related, non-reversible brain disorder that develops over a period of

years. Initially, people experience memory loss and confusion, which may

be mistaken for the kinds of memory changes that are sometimes

associated with normal aging. However, the symptoms of AD gradually lead

to behavior and personality changes, a decline in cognitive abilities such as

decision-making and language skills, and problems recognizing family and

friends. AD ultimately leads to a severe loss of mental function.

There are three major hallmarks in the brain that are associated with the

disease processes of AD:

• Amyloid plaques, which are made up of fragments of a protein called beta-amyloid peptide mixed with a collection of additional proteins, remnants of neurons, and bits and pieces of other nerve cells.

• Neurofibrillary tangles (NFTs), found inside neurons, are abnormal collections of a protein called tau. Normal tau is required for healthy neurons. However, in AD, tau clumps together. As a result, neurons fail to function normally and eventually die.

• Loss of connections between neurons responsible for memory and learning. Neurons can't survive when they lose their connections to other neurons. As neurons die throughout the brain, the affected regions begin to atrophy, or shrink. By the final stage of AD, damage is widespread and brain tissue has shrunk significantly. (source)

Presently there are no medicines that can slow the progression of AD. However, four FDA-approved medications are used to treat AD symptoms. These drugs help individuals carry out the activities of daily living by maintaining thinking, memory, or speaking skills. Medication therapy can also help with some of the behavioral and personality changes associated with AD.

ASO Financial An ASO (Administrative Services Only) is an arrangement in which an organization funds its own employee benefit plan such as a pension plan or health insurance program but hires an outside firm to perform specific administrative services. (source)

asymptomatic bacteriuria

Clinical Care As defined by the Infectious Diseases Society of America (IDSA) guidelines: in women, two consecutive clean-catch voided urine specimens with isolation of the same organism in quantitative counts of ≥10,000 cfu/mL; in men, a single clean-catch voided urine specimen with isolation of a single organism in quantitative counts of ≥10,000 cfu/mL; in the absence of symptoms.

at risk Financial A payment model in which a payor or group of providers receive a fixed payment per member per month to provide all covered services to some defined population. Providers assume utilization and actuarial risks along with the risks assumed under other reimbursement method. Payors and/or physician payments may also be held “at risk” if certain contractual goals are not met, such as hospitalization rates exceeding agreed upon thresholds. The sharing of risk is often employed as a utilization control mechanism. (source)

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Term Domain Definition

Atrial fibrillation (AFib or AF)

Clinical Care AFib is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. About 15–20 percent of people who have strokes have this heart arrhythmia. An estimated 2.7 million Americans are living with AF.

bacteriuria Clinical Care The isolation of a specified quantitative count of bacteria in the urine. This may be symptomatic or asymptomatic of a urinary tract infection. (source)

Bariatric Surgery Clinical Care Bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold (gastric restriction), or by a combination of both gastric restriction and restricting the absorption of food (malabsorption). Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery). The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch.

behavioral activation Clinical Care A behavioral therapy that uses the strategy of increasing the patient’s daily involvement in pleasant, meaningful activities. This simple, inexpensive therapy may be equally as effective at treating depression as cognitive behavioral therapy. (source)

Behavioral Health Clinician (BHC)

Clinical Care A professional in the behavioral aspects of health. A BHC can help a patient with habits, behaviors, stress, or emotional concerns that get in the way of daily life and/or overall health. The BHC works with the patient’s Primary Care Provider to provide a holistic approach to becoming healthier and improving quality of life. The BHC also provides brief intervention for patients who need it. The BHC may also refer the patient to specialty behavioral health services. The BHC will documents any assessments and recommendations in the patient’s medical record; a separate mental health record is not created.

Benzodiazepines Clinical Care Drugs in this group act as gamma-aminobutyric acid (GABA) receptor agonists that have hypnotic, anxiolytic, muscle relaxant, and anticonvulsant properties.

Benzodiazepines are commonly divided into three groups according to how quickly they are eliminated from the body: 1) Short-acting (half-life less than 12 hours), such as midazolam and triazolam (Halcion); 2) Intermediate-acting (half-life between 12 and 24 hours), such as alprazolam (Xanax), lorazepam (Ativan), and temazepam (Restoril); 3) Long-acting (half-life greater than 24 hours), such as diazepam (Valium), clonazepam (Klonopin), clorazepate (Tranxene), chlordiazepoxide (Librax), and flurazepam (Dalmane).

Both benzodiazepines and Z-drugs (BZRAs) (source) are considered a “high-risk medication in the elderly” and are listed on the American Geriatrics Society Beers Criteria list.

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Term Domain Definition

blood pressure Clinical Care Blood pressure (BP) is typically recorded as two numbers, written as a ratio:

1. Systolic: The top number, which is also the higher of the two numbers, measures the pressure in the arteries when the heart beats (when the heart muscle contracts).

2. Diastolic: The bottom number, which is also the lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood).

“Controlled” BP is defined based on the age category and risk factors, according to JNC 8 guidelines: For patients 18‐59yoa, the goal is <140/90; for patients 60‐85yoa, the goal is <150/90; and for patients with diabetes, the goal is <140/90, regardless of age.

bridging Clinical Care Bridging anticoagulation refers to the administering of a short-acting anticoagulant, like enoxaparin (Lovenox®), during a period when warfarin (Coumadin®) therapy is initiated or interrupted (and its anticoagulant effect is outside a therapeutic range). Bridging is an option when a patient requires warfarin to be stopped because of an upcoming surgery/procedure. Bridging aims to reduce the patient’s risk for developing blood clots, such as stroke, but may also increase the patient’s risk for developing potentially serious bleeding complications after surgery. Bridging involves care by the PMG anticoagulation clinic before the procedure, care by the proceduralist peri-procedurally, and then care by the anticoagulation clinic post procedure.

brief intervention Clinical Care Typically, the BHC will suggest a solution-focused, action-oriented plan of care that can be accomplished in anywhere from 1 to 6 appointments.

bundle Clinical Care A series of interventions related to clinical care, that, when implemented together will achieve significantly better outcomes than when implemented individually. When a clinical bundle is approved related to clinical care, this constitutes a protocol.

C4 (Clinical Coordination and Communication Committee)

Governance Clinical governance body responsible for coordinating and communicating clinical change requests within the clinical governance structure.

capitation Financial A flat periodic payment per enrollee to a healthcare provider; this payment is the sole reimbursement for providing services to a defined population. “Capitation” is derived from the term “per capita,” which means per person. Generally, capitation payments are expressed as some dollar amount per member per month (PMPM). Capitated payments may be adjusted for age and gender, but no other adjustments typically are made. Under capitation, fixed payments are made to providers regardless of the volume of services rendered, so risk sharing occurs among Providers, insurers, and purchasers. Under capitation, profitability depends on cost control – to work “smarter” with lower volume and cost-effective treatment plans. (source)

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Term Domain Definition

care coordination General Healthcare

Care coordination is a broad, complex process, involving collaboration among the patient, Providers, and health plan administrators, to determine the most appropriate plan of care for a patient. Typically, this encompasses an assessment of a patient’s needs, development and implementation of a plan of care, and evaluation of the care plan. Care coordination involves but is not limited to the following: planning treatment strategies; facilitating access to services; coordinating visits with specialists; organizing care to avoid duplication of diagnostic tests and services; monitoring outcomes and resource use; sharing information among healthcare professionals and family; actively managing transition of care such as hospital discharge; training caregivers; and ongoing reassessment and refinement of the care plan. Care coordination is member-centered, consumer-directed and family-focused, culturally competent, and strengths-based, and identifies medical and behavioral health needs.

Care Coordinator General Healthcare

“Care Coordinator” is an encompassing title that recognizes the Nurse Navigator, Care Manager, Case Manager, Social Worker, Behavioral Health Care Coordinator, or other licensed professional who works directly with the patient and family caregiver(s) to improve the quality of care and to reduce cost. All of these workers may serve as a patient’s Care Coordinator at some point in the continuum of care. As member of the multidisciplinary care team, the Care Coordinator:

• Facilitates timely access to appropriate care

• Ascertains the patient’s needs, via Health Risk Assessment and/or Comprehensive Needs Assessment

• Creates a care plan and promotes adherence to it, developed collaboratively with the patient and the Provider(s)

• Provides medication reconciliation

• Assists the patient’s comprehension through culturally and linguistically appropriate education

• Develops the patients’ ability for self-management and shared decision-making

• Promotes the utilization of preventative care

• Augments the continuity of care by managing relationships with tertiary care providers, transitions of care, and referrals

• Connects patients to relevant community resources

A Complex Care Coordinator works with chronically ill or high-risk patients: identifying them, tracking them over time, and aiming to keep them out of the hospital. Oftentimes, this involves triaging patients to lower-acuity settings that are appropriate to their needs.

care pathway Clinical Care A treatment regimen, agreed upon by consensus that includes all the elements of care, regardless of the effect on patient outcomes. It is a broader look at care and may include tests and X-rays that do not directly influence patient recovery.

care plan Population and Community Health

A documented plan developed between the Care Coordinator, the patient/member and other pertinent members of the care team to assist the patient/member to manage their condition, maintain or improve their health status, maintain a safe environment, coordinate treatments, services and care, and to help the patient/member to achieve individual goals, objectives, and desired health, functional, and quality of life outcomes.

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Term Domain Definition

Case Manager General Healthcare

Case Managers assist patients by providing support advocacy, adherence assessment, motivational intervention, resource coordination, patient self-management coaching, and care planning. Case Managers ensure that information related to the patient’s current symptoms, medication list, advanced directives, adherence assessment, literacy, knowledge/comprehension, motivation, readiness to change, functional limitations, cognitive ability, coping ability, informal caregiver information, and professional caregiver contacts are stipulated in an accessible record. Case Managers working collaboratively with emergency department physicians, residents, hospitalists, community practitioners, managed care administrators, health plans, pharmacists, and employers have the opportunity to coordinate care by overseeing the transfer of information through any transitions. Case Managers utilize the Standards of Practice for Case Management from the Case Management Society of America, as well as base their practice within the Self-care Deficit Theory of Dorothea Orem. Within Presbyterian, PHP Case Managers, PMG Case Managers, and Home Health Case Managers may provide distinct services for specific populations of patients.

CCIT (Clinical Content Informatics Team)

Governance Clinical governance body responsible for coordinating and communicating clinical change requests within the clinical governance structure.

CDS (Central Delivery System)

Governance All PHS care delivery services provided within New Mexico’s central 4-county area (Bernalillo, Sandoval, Torrence, and Valencia counties).

Center for Medicare and Medicaid Services (CMS)

Government Programs

A government agency part of the Department of Health and Human Services (HHS) that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace. (source)

Center of Excellence General Healthcare

A Center of Excellence (COE) is a Service Line or Department that has achieved external validation of excellence in clinical outcomes, experience and cost. (source)

CGCAHPS Government Programs

The Clinician and Group Surveys Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) assess patients’ experiences with health care providers and staff in doctors’ offices. CMS requires CGCAHPS data collection for medical practices with over 100 eligible professionals under one tax identification number who are submitting PQRS through the GPRO web interface and will start mandatory participation for groups with 100 or more eligible professionals in 2015. Both Pioneer ACOs and Medicare Shared Savings Program ACOs are required to participate in annual CGCAHPS data collection as part of the ACO CAHPS program. (source)

Children’s Health Insurance Program (CHIP)

Government Programs

CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers parents and pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program. (source)

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Term Domain Definition

Chronic Obstructive Pulmonary Disease (COPD)

Clinical Care COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that characterizes COPD is caused by a mixture of small airways disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person. Chronic inflammation causes structural changes, small airways narrowing, and destruction of lung parenchyma. A loss of small airways may contribute to airflow imitation and mucociliary dysfunction, a characteristic feature of the disease. Subtypes of COPD are emphysema, chronic bronchitis, and chronic obstructive asthma. (source)

chronic pain Clinical Care Pain that typically lasts >3 months or past the time of normal tissue healing. Chronic pain consists of both persistent pain, which is pain that is continuous throughout the day, and breakthrough pain (BTP), which involves transitory flares of moderate-to-severe pain in a person whose persistent pain is otherwise controlled.

Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause. Estimates of the prevalence of chronic pain vary; an estimated 14.6% of U.S. adults have current widespread or localized pain lasting at least 3 months. Chronic pain is often due to musculoskeletal pain conditions (e.g., arthritis, rheumatism, chronic back or neck problems, and frequent severe headaches). (source CDC) It can be complicated by psychological comorbidities and a range of contributing factors, and can have a range of effects on daily functioning.

Clinical Content Informatics Team (CCIT)

Informatics and Technology

A broadly multidisciplinary team selected to review evidence, recommend order set changes, and serve as the key guiding body for inpatient order sets.

clinical documentation

General Healthcare

The Provider’s “recording” of any and all events related to a patient’s particular episode of care regardless of the setting (e.g., inpatient or outpatient)

clinical informatics Informatics and Technology

The application of informatics and information technology to deliver healthcare services. Clinical informatics includes a wide range of topics ranging from clinical decision support to visual images (e.g. radiological, pathological, dermatological, ophthalmological, etc); from clinical documentation to provider order entry systems; and from system design to system implementation and adoption issues.(source)

Clinician General Healthcare

Clinical health care workers, including physicians, APCs, and nurses.

Clostridium difficile (C. diff)

Clinical Care C. diff is a spore-forming, toxin-producing, gram-positive anaerobic bacterium that colonizes the human intestinal tract after the normal gut flora has been altered by antibiotic therapy; it is the causative organism of antibiotic-associated pseudomembranous colitis. Diarrhea and fever are the most common symptoms of Clostridium difficile infection (CDI). CDI is one of the most common hospital-acquired (nosocomial) infections and is an increasingly frequent cause of morbidity and mortality among older adult hospitalized patients. Overuse of antibiotics is the most important risk for getting a C. diff infection. (source, source)

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Term Domain Definition

CMI (Case Mix Index) Financial A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. (source)

Code Lavender Clinical Care A crisis intervention strategy designed to provide emotional, spiritual, and/or physical support to health care workers during times of high stress or loss while on the job. At Presbyterian, Code Lavender responses are coordinated through the Employee Assistance Program.

coding

Administration The translation of the “clinical language” of diagnoses and procedures into alphanumeric codes (e.g., ICD-10-CM/PCS), creating a common “language” for healthcare services that is used for multiple purposes. (e.g., clinical, analytics, and billing)

cognitive-behavioral therapy (CBT)

Clinical Care CBT is a therapy modality that is used widely in the treatment of substance use disorders. Derived from both behavioral and cognitive theories, it focuses on learning and practicing a variety of coping skills. CBT tries to change what the client both does and thinks, to help the client identify self-defeating, negative thoughts and behaviors which may often drive addiction. CBT for SUDs focuses on relapse prevention, including: 1) Individualized training in recognizing and coping with cravings, managing thoughts about substance use, problem solving, planning for emergencies, recognizing seemingly irrelevant decisions, and using refusal skills; 2) An examination of the client's cognitive processes related to substance use; 3) The identification and debriefing of past and future high-risk situations; 4) The encouragement and review of extra-session implementation of skills; and 5) Practice of skills within sessions. (source)

Cognitive behavioral therapy (CBT) is a form of psychotherapy that treats problems and boosts happiness by modifying dysfunctional emotions, behaviors, and thoughts. CBT focuses on solutions, encouraging patients to challenge distorted cognitions, and change destructive patterns of behavior. (source) CBT can address psychosocial contributors to pain and improve function. (source)

Coleman Model Clinical Care Developed by Eric Coleman, MD, MPH, a member of the NTOCC advisory task force, the Care Transitions Intervention (CTI) is a transitions self-management model that encourages patients and caregivers assert a more active role during this vulnerable time. CTI not only prepares patients and caregivers for the immediate transitions but also simultaneously prepares them for future transitions. The intervention is low-cost, low intensity and yet as been shown to produce a sustained effect, reducing hospital readmissions.

colonoscopy Clinical Care A colorectal cancer screening or diagnostic test in which a long, 10 mm, flexible, lighted tube is inserted into the rectum. Polyps or cancer can be detected inside the rectum and the entire colon. During the test, the Physician can detect and remove most polyps and some cancers. Colonoscopy also is used as a follow-up test to any other screening test that results positively.

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Term Domain Definition

Community Health Population and Community Health

The health outcomes of a group of individuals, including the distribution of such outcomes within the group. While populations are united by shared characteristics such as health outcomes, patterns of health determinants or geography, communities are defined by geographic area alone. For the definition purposes required by the IRS and the ACA Presbyterian has defined “communities” as a geographic area alone, counties where there are PHS hospitals. (source)

Community Health Needs Assessments and Plans

Government Programs

On March 23, 2010 the Patient Protection and Affordable Care Act was signed into law. One section of the act delineates additional requirements imposed on charitable hospitals. The section amends the Internal Revenue Code to require that hospitals claiming tax-exempt status conduct a community health needs assessment every three years and develop a strategy to address the needs identified. Presbyterian’s needs assessments and plans by county can be found on phs.org/community. (source)

community reinforcement approach (CRA)

clinical care Based on the principles of operant learning, CRA is a therapy modality used in the treatment of substance use disorders, the goal of which is to increase the likelihood of continued abstinence from alcohol or drugs by reorganizing the client's environment. Specifically, CRA attempts to weaken the influence of reinforcement received by substance use by increasing the availability and frequency of reinforcement derived from alternative activities, particularly those vocational, family, social, and recreational activities that are incompatible with substance use, which are referred to as prosocial activities. These alternative interpersonal and social sources of reinforcement are available when the person is not intoxicated, but unavailable if the person drinks or uses. CRA also incorporates motivational interviewing and CBT relapse prevention. The CRA model has been modified into the Community Reinforcement and Family Training procedure (CRAFT), in which the client's significant other and family members receive training in behavior modification and enhancing motivation. CRAFT seeks to reduce or stop substance use by working through non-using family and friends. (source)

Complete Care Population and Community Health

Presbyterian’s population management program for individuals with advanced illness. Specifically, this program is a voluntary, comprehensive, team-based, home service model for Presbyterian Senior Care (HMO) members.

Comprehensive Care for Joint Replacement (CJR)

Government Programs

A CMS model intended to test bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. (source)

Consult Liaison (CL) Clinical Care Licensed Therapist in the Emergency Department responsible for assessing a patient’s need for behavioral health services

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Term Domain Definition

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Government Programs

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a multi-year initiative of the Agency for Healthcare Research and Quality (AHRQ) to support and promote the assessment of consumers’ experiences with health care. The goals of the CAHPS program are twofold:

• Develop standardized patient questionnaires that can be used to compare results across sponsors and over time.

• Generate tools and resources that sponsors can use to produce understandable and usable comparative information for both consumers and health care providers

The CAHPS Health Plan Survey is a tool for collecting standardized information on enrollees’ experiences with health plans and their services. (source)

Continuity of Care Document (CCD)

Informatics and Technology

An XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. (source)

controlled medication agreement

Clinical Care This written agreement, signed by the patient, outlines the patient’s responsibilities when taking a prescribed controlled substance for pain therapy.

controlled substance care plan (CSCP)

Clinical Care The CSCP is a tool within the Epic environment, a central place to document prescribed controlled substances; it conveys the patient’s history to providers across the system. Add code CSCP to the problem list.

Cost Leadership

Administration A primary objective of “The Triple Aim” (a widely accepted model advocated by the Institute of Healthcare Improvement), Cost Leadership includes Presbyterian’s efforts to lower the cost of healthcare delivery by redesigning care models, maximizing process efficiency, and eliminating waste.

Creutzfeldt-Jakob disease (CJD)

Clinical Care CJD is a rare, degenerative, fatal brain disorder. Symptoms of CJD include problems with muscular coordination, personality changes including progressive and severe mental impairment, impaired vision that may lead to blindness, and involuntary muscle jerks called myoclonus. People eventually lose the ability to move and speak and enter a coma. The first concern is to rule out treatable forms of dementia such as encephalitis or chronic meningitis. The only way to confirm a diagnosis of CJD is by brain biopsy or autopsy. Typically, onset of symptoms occurs at about age 60. Presently, there is no cure or treatments to control CJD, although studies of a variety of drugs to alleviate symptoms are now in progress. (source)

CT colonography Clinical Care Computed tomography (CT) colonography, also called a virtual colonoscopy, is a colorectal cancer screening test that scans the colon and rectum to produce detailed cross-sectional images so the Physician can detect for polyps or cancer. Air is pumped into the rectum and colon, and then a CT scanner is used to take X-ray images of the colon.

Customer Experience Customer Experience

The perceived sum of ALL interactions, both positive and negative, that a customer encounters both directly and indirectly, over time. The Customer Experience forms the basis of the story they tell about us.

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Term Domain Definition

DASH Clinical Care The DASH (Dietary Approaches to Stop Hypertension) eating plan, promoted by the National Institutes of Health, has been proven to lower high blood pressure, especially when combined with salt restriction. This plan recommends:

• Eating vegetables, fruits, and whole grains

• Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils

• Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils

• Limiting sugar-sweetened beverages and sweets (source)

D-dimer Clinical Care A blood test that measures a substance in the blood that is released when a clot breaks up. If the D-dimer test is negative, it means that the patient probably does not have a blood clot.

deference to expertise General Healthcare

A universal understanding that leaders and supervisors must be willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face. This is a must for a high reliability organization. (source)

Delegated Utilization Management (UM)

Population and Community Health

The clearly defined and documented delegation of insurance coverage approval or denial decisions to a third party. (source)

delirium Clinical Care Delirium is usually acute or subacute in onset and is associated with a clouding of the sensorium; patients have fluctuations in their level of consciousness and have difficulty maintaining attention and concentration. Delirium and dementia can overlap, making the distinction difficult and sometimes impossible.

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Term Domain Definition

dementia Clinical Care Major neurocognitive disorder. The Diagnostic and Statistical Manual of

Mental Disorders Fifth Edition (DSM-5™) defines clinical criteria for major

neurocognitive disorder:

• Evidence from the history and clinical assessment indicates significant cognitive impairment in at least one of these six cognitive domains: learning and memory; language; executive function; complex attention; perceptual-motor function; and/or social cognition.

• The impairment must be acquired and represent a significant decline from a previous level of functioning.

• The cognitive deficits must interfere with independence in everyday activities.

• In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of insidious onset and are progressive, based on evidence from the history or serial mental-status examinations.

• The disturbances are not occurring exclusively during the course of delirium.

• The disturbances are not better accounted for by another mental disorder (e.g., major depressive disorder, schizophrenia).

While dementia is more common as people grow older (up to half of all

people age 85 or older may have some form of dementia), it is not a normal

part of aging. Many people live into their 90s and beyond without any signs

of dementia. One type of dementia, frontotemporal disorders, is more

common in middle-aged than older adults. Alzheimer disease (AD) is the

most common form of dementia in the elderly.

Dementia “secondary to general medical condition” are cognitive or behavioral symptoms that can be resolved once the primary medically-related etiology is treated; treatment can result in improvement in cognitive functioning.

dementia with Lewy bodies (DLB)

Clinical Care DLB is one of the most common types of progressive dementia. The central features of DLB include progressive cognitive decline, “fluctuations” in alertness and attention, visual, long-lasting hallucinations, and parkinsonian motor symptoms, such as slowness of movement, difficulty walking, or rigidity. People may also suffer from depression. The symptoms of DLB are caused by the build-up of Lewy bodies – accumulated bits of alpha-synuclein protein -- inside the nuclei of neurons in areas of the brain that control particular aspects of memory and motor control. The similarity of symptoms between DLB and Parkinson disease, and between DLB and Alzheimer’s disease, can often make it difficult for a doctor to make a definitive diagnosis. In addition, Lewy bodies are often also found in the brains of people with Parkinson's and Alzheimer’s diseases. These findings suggest that either DLB is related to these other causes of dementia or that an individual can have both diseases at the same time. Presently, there is no cure for DLB. Treatments aim to control the cognitive, psychiatric, and motor symptoms of the disorder. (source)

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Term Domain Definition

depression Clinical Care Depression (major depressive disorder; clinical depression) is a common but serious mood disorder. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5™) refers to major depressive disorder as the classic condition in depressive disorders, characterized by episodes of at least 2 weeks duration, including changes in affect and cognition. Single episodes are possible, although in most cases, the disorder is a recurrent one. (source, source)

direct oral anticoagulants (DOACs)

Clinical Care DOACs are oral medications that inhibit a specific enzyme in the coagulation cascade. DOACs are associated with a low overall risk of major bleeding. Routine coagulation tests cannot be used to determine the degree of anticoagulation, making it more challenging to determine when the anticoagulant effect has resolved.

The medication that is covered by PHP is rivaroxaban (Xarelto). Other DOACs appearing in the discharge orders may be: 1.) apixaban (Eliquis); 2.) dabigatran (Pradaxa); 3.) edoxaban (Savaysa); or 4) betrixaban (Bevyxxa).

Doppler Clinical Care Doppler ultrasound is an imaging technology used to detect abnormalities of blood flow. Sound waves are bounced off the blood within a vein. Flowing blood changes the sound waves by the “Doppler effect.” The ultrasound machine can detect these changes and determine whether blood within a vein is flowing normally. Absence of blood flow would confirm the diagnosis of DVT.

downside risk Financial An estimation of a security’s potential to suffer a decline in value if the market conditions change, or the amount of loss that could be sustained as a result of the decline. Downside risk explains a “worst case” scenario for an investment, or how much the investor stands to lose. (source)

EIA Clinical Care enzyme immunoassay

electronic health record (EHR)

Informatics and Technology

A digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. (source)

Employee Assistance Program (EAP)

Administration To help employees cope with personal and work-related challenges and stress that may be affecting the employee’s wellbeing, including our ability to function at home and on the job, Presbyterian offers access to an Employee Assistance Program. EAP services are provided by The Solutions Group; free to employees and their immediate household members. To access, call (505) 254-3555 in Albuquerque, or (866) 254-3555 statewide, 24 hours a day, 7 days a week.

EMTALA Government Programs

The Emergency Medical Treatment and Labor Act of 1986 ensures public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-Participating hospitals that offer emergency services to provide a medical screening exam when a request is made for examination or treatment for an emergency medical condition, including active labor, regardless of an individual’s ability to pay (cms.gov).

engagement Clinical Care In treating substance use disorders (SUD), engagement is defined as initiation of intensive treatment as soon as possible after receiving a diagnosis.

Epic Informatics and Technology

PHS’ Electronic Health Record for hospital, clinic, and home- based care; used for order management, patient care documentation, communication and collaboration between members of a patient’s care team, and reporting.

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Term Domain Definition

episode of care General Healthcare

All services provided to a patient for a medical problem within a specific period of time across a continuum of care in an integrated system. (source)

Evidence Based Medicine (EBM)

Evidence Based Medicine

The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (source)

evidence-based care Evidence Based Medicine

(Evidence-based Medicine) The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Evidence-Based Care Design (EBCD)

Evidence Based Medicine

A formal, evidence-driven, cross-disciplinary method for clinical workflow development, redesign, or augmentation.

evidence-based practice Evidence Based Medicine

The use of the best scientific evidence integrated with clinical experience and incorporating patient values and preferences in the practice of professional patient care. (source)

extended-release / long-acting (ER/LA) opioids

Clinical Care ER/LA opioids include methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine.

Evidence shows that there is a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids. (source CDC)

fee-for-service Financial Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it can create a financial incentive to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. (source)

FIT

Clinical Care Fecal immunochemical test; an at-home colorectal cancer screening test that uses antibodies to detect hemoglobin in the stool. FIT is more specific than guaiac-based testing (gFOBT) because FITs returns positive results only when globins are present — FITs don't react with foods that have peroxidase activity and aren't positive in patients with upper gastrointestinal (UGI) bleeding, because globin from UGI bleeds is digested. Therefore, patients do not need to alter their diet prior to testing, and a single fecal sample usually is sufficient.

FIT-DNA Clinical Care Also referred to as the stool DNA test, this at-home colorectal cancer screening test combines the FIT with a test that detects altered DNA in the stool. The patient must collect an entire bowel movement and send it to a lab to be checked for cancer cells.

flexible sigmoidoscopy Clinical Care A colorectal cancer screening test in which a short, flexible, lighted tube is inserted into the rectum. Polyps or cancer can be detected inside the rectum and lower third of the colon.

foundational competencies

General Healthcare

The knowledge, critical thinking and skills needed to perform essential care and team coordination functions including: knowledge of roles, interprofessional communication techniques, team based problem-solving, and relationship-based teamwork. (source)

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Term Domain Definition

frontotemporal disorders

Clinical Care Frontotemporal disorders are the result of damage to neurons the frontal and temporal lobes. As neurons die in the frontal and temporal regions, these lobes atrophy. Gradually, this damage causes difficulties in thinking and behaviors normally controlled by these parts of the brain. Symptoms include unusual behaviors, emotional problems, trouble communicating, difficulty with work, or difficulty with walking. Frontotemporal disorders are forms of dementia caused by a family of brain diseases known as frontotemporal lobar degeneration (FTLD). FTLD may cause up to 10 percent of all cases of dementia and is the second most common cause of dementia, after Alzheimer disease, in people younger than age 65. Roughly 60 percent of people with FTLD are 45 to 64 years old. Presently, no cure or treatments are available to slow or stop the progression of frontotemporal disorders. (source)

gap in care Population and Community Health

“Gap in care” (or “care gap”) is a term used widely throughout patient health analytics to recognize a disparity between health care needs or recommended best practices and the services that have actually been provided. Gaps in care may be those outstanding office visits, lab tests, procedures, and pharmaceuticals that a patient needs, but have not yet received, usually because there are obstacles. A successful Population Health program gives real-time insights to both clinicians and administrators, allowing them to identify and address gaps in care within the patient population. According to CMS: “There is a need for all providers to work actively to continuously monitor and address disparities, and to be accountable for reducing gaps in care and outcomes. All CMS beneficiaries must have access to and receive person-centered, equitable, effective, safe, timely, and efficient care and services.” (source)

gFOBT Clinical Care Guaiac-based fecal occult blood test; an at-home colorectal cancer screening test that uses the chemical guaiac to detect blood from any source in the stool.

GPRO web interface Government Programs

Report submission mechanism for groups who have registered with the Centers for Medicare & Medicaid Services (CMS) to report Physician Quality Reporting System (PQRS) measures. (source)

guideline General Healthcare

Recommended instructions and/or suggestions for completing a process or form. Clinical Practice Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. (source)

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

Government Programs

The CAHPS Hospital Survey, sometimes known as HCAHPS or Hospital CAHPS, is a standardized 32-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. HCAHPS was the first common metric and national standard for collecting and publicly reporting information about patient experience of care. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally. (source)

Health Information Exchange (HIE)

Informatics and Technology

A technology and programmatic solution that allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically, even between healthcare companies. HIEs are designed to improve the speed, quality, safety and cost of patient care. (source)

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Term Domain Definition

Health Insurance Marketplace

Financial A resource where individuals, families, and small businesses can: learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). The Marketplace encourages competition among private health plans, and is accessible through websites, call centers, and in-person assistance. In some states, the Marketplace is run by the state. In others it is run by the federal government. (source)

health literacy General Healthcare

The degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. (source)

Health Maintenance Organization (HMO)

Financial An organization that provides health coverage with providers under contract. A Health Maintenance Organization (HMO) differs from traditional health insurance by the contracts it has with its providers. These contracts allow for premiums to be lower, because the health providers has the advantage of having patients directed to them; but these contracts also add additional restrictions to the HMO’s members. (source)

health numeracy General Healthcare

The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions. (source)

Health Outcomes Survey (HOS)

Government Programs

The Medicare Health Outcomes Survey (HOS) was designed to gather valid, reliable, and clinically meaningful health status data in the Medicare Advantage (MA) program for use in quality improvement activities, pay for performance, program oversight, public reporting, and improving health. All managed care organizations with Medicare contracts must participate. The HOS is administered annually to a random sample of Medicare beneficiaries drawn from each participating MA plan and surveyed in the spring (i.e., a baseline survey is administered to a new cohort, or group, each year). Two years later, these same respondents are surveyed again (i.e., follow up measurement). The survey asks the member how they have been feeling, both physically and mentally, during the four weeks prior to the survey.

The Medicare HOS 3.0 questionnaire consists of the following major components: the VR-12 (a generic patient reported outcome measure used to measure health related quality of life); questions to gather information for case-mix and risk-adjustment; questions to collect results for four HEDIS® Effectiveness of Care measures; updated questions on race, ethnicity, sex, primary language, and disability status as part of Section 4302 of the Affordable Care Act; and additional health questions, including new and revised questions. (source; source)

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Term Domain Definition

Health Risk Assessment (HRA)

General Healthcare

A systematic approach to collecting information from individuals that identifies health risk factors, provides individualized feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease. A typical HRA instrument obtains information on demographic characteristics (e.g., sex, age), lifestyle (e.g., smoking, exercise, alcohol consumption, diet), personal medical history, and family medical history. In some cases, physiological data (e.g., height, weight, blood pressure, cholesterol levels) are also obtained. (source)

Health Service Aid Clinical Care (also: Home Health Aid) An employee trained to provide part time or intermittent services to help patients with their daily living activities.

healthcare decision General Healthcare

A decision made by an individual (or the individual’s designated decision maker) regarding:

• Selection and discharge of healthcare Providers and institutions;

• Approval or disapproval of diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate (DNR);

• Directions relating to life-sustaining treatment, including withholding or withdrawing life-sustaining treatment and the termination of life support; and

• Directions to provide withhold or withdraw nutrition and hydration and all other forms of healthcare.

Healthcare Decision Maker

General Healthcare

A healthcare decision maker is a person or persons selected by an individual to make medical decisions for that individual, if the individual cannot make his/her own decisions. The decision maker is entrusted to make decisions that are consistent with the individual’s known wishes. Ideally, the decision maker is 18 years of age or older, willing and able to serve in this role, will support the wishes of the individual, and lives in the area. The designated decision maker may or may not be a family member.

HEAT Customer Experience

A widely accepted customer service method for dealing with dissatisfied customers. It provides an opportunity to address the patient/member’s personal needs (feelings) as well as his/her practical needs (facts). Four steps in the HEAT model are to: Hear them out, Empathize, Apologize, and Take responsibility for the action.

HEDIS Government Programs

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. (source)

Hierarchical Condition Categories (HCC)

Financial Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated in 1997 by the Centers for Medicare and Medicaid Services (CMS). Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details. The individual’s health conditions are identified via International Classification of Diseases – 10 (ICD –10) diagnoses that are submitted by providers on incoming claims. CMS requires documentation in the person’s medical record by a qualified health care provider to support the submitted diagnosis. Documentation must support the presence of the condition and indicate the provider’s assessment and plan for management of the condition. This must occur at least once each calendar year in order for CMS to recognize the individual continues to have the condition. (source)

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Term Domain Definition

high reliability General Healthcare

The measurable capability of a process, procedure or health service to perform its intended function in the required time under commonly occurring conditions.

Highly Reliable Organization (HRO)

General Healthcare

An organization with systems in place that is exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors. A High Reliability Organization is one that is able to conduct:

• Relatively error free operations

• Over a relatively long period of time

• Making consistently good decisions

• Meeting expectations of performance/outcomes/results – from the perspective of the customer

• Operations that are agile and able to respond to unexpected events or developments without sacrificing outcomes

• Work with high quality and reliably operating systems to achieve customer, stakeholder and organizational goals. (source 1, source 2)

HL7 Informatics and Technology

(Health Level 7) A set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is “layer 7″ in the OSI model. (source)

Home Health Care Clinical Care A wide range of health care services that can be given in your home for an illness or injury. Home health care is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility. Examples of skilled home health services include:

Wound care for pressure sores or a surgical wound

Patient and caregiver education

Intravenous or nutrition therapy

Injections

Monitoring serious illness and unstable health status

Hospice Care Clinical Care Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure. The goal is to enable patients to be comfortable and free of pain, so that they live each day as fully as possible.

hypertension Clinical Care Hypertension (high blood pressure) is clinically defined as blood pressure above 140/90. The more forcefully that blood pumps, the more the arteries stretch to allow blood to easily flow. If blood pressure remains high, over time the tissue that makes up the walls of arteries gets stretched and damaged. A person with hypertension may not feel that anything is wrong, but high blood pressure can cause permanent damage, often leading to heart attack and heart failure, stroke, kidney failure, blindness, and other health consequences.

ICD-10 Financial The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is a revision of the ICD-9-CM system which physicians and other providers currently use to code all diagnoses, symptoms, and procedures recorded in hospitals and physician practices. (source)

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Term Domain Definition

illicit drugs clinical care Illicit drugs include marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, and others as well as prescription-type drugs used non-medically, as defined in SAMHSA’s National Survey on Drug Use and Health (NSDUH).

inferior vena cava filter (IVC)

Clinical Care An inferior vena cava (IVC) filter is a device that blocks the circulation of clots in the venous bloodstream. It is placed in the inferior vena cava (the large vein leading from the lower body to the heart) with a catheter that is inserted into a vein in the neck or groin and threaded through the blood vessels.

An IVC filter is often recommended in patients with DVT or PE who cannot use anticoagulants because of recent surgery, a stroke caused by bleeding, or significant bleeding in another area of the body. However, IVC filters can be used along with other therapies such as anticoagulation, thrombolysis, or embolectomy when these are appropriate. An IVC filter is also recommended in some patients who develop recurrent PE despite anticoagulation. It may also be recommended for patients whose condition makes them susceptible to life-threatening complications if another PE were to occur. (source)

Informatics Informatics and Technology

The study and application of information technology to the arts, science and professions, and to its use in organizations and society at large. (source)

Inpatient Rehabilitation Facility (IRF)

Clinical Care A facility or hospital devoted to the rehabilitation of patients with various neurological, musculo-skeletal, orthopedic and other medical conditions following stabilization of their acute medical issues.

insomnia Clinical Care Insomnia is present when all three of the following criteria are met: 1) A complaint of difficulty initiating sleep, difficulty maintaining sleep, or waking up too early. In children or individuals with dementia, the sleep disturbance may manifest as resistance to going to bed at the appropriate time or difficulty in sleeping without caregiver assistance; 2) The above sleep difficulty occurs despite adequate opportunity and circumstances for sleep; and 3) The impaired sleep produces deficits in daytime function. (source)

Intensive Outpatient Program for Substance Abuse (IOP)

Clinical Care The Intensive Outpatient Program helps adults 18 years and older struggling with chemical dependency, including alcohol, opiates, heroin, prescription drugs, marijuana, stimulants/amphetamines, hallucinogens, and inhalants, through an eight-week, 24-session program. An Aftercare Support Group is also available for those who have completed the program.

Licensed addiction therapists conduct these sessions, offering the client/patient the chance to explore the biological and emotional dimensions of addiction, and to learn new coping skills for sobriety. Suboxone therapy for opioid dependency and other craving treatments for alcohol dependence are available to those enrolled in the program.

PHS IOP is located in the Presbyterian Medical Group Child and Adolescent Behavioral Health Clinic

at Presbyterian Kaseman Hospital campus.

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Term Domain Definition

interdisciplinary General Healthcare

A group of professionals from several disciplines working collaboratively in the same setting toward a common goal. Each team member may conduct separate assessments, but the information/data is shared among all members of the team. Problems are solved in a systematic way, typically during team meetings. This term may be used interchangeably with “interprofessional team”: interdisciplinary is frequently used to describe an educational process, whereas interprofessional care is used to describe clinical practice.

International Normalized Ratio (INR)

Clinical Care This laboratory test is used to determine the degree to which the patient's coagulation has been successfully suppressed by the vitamin K antagonist (VKA). For most patients, the goal is to keep the INR between 2 and 3.

interprofessional General Healthcare

The process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population. It involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation. Interprofessionality requires a paradigm shift, since interprofessional practice has unique characteristics in terms of values, codes of conduct, and ways of working. (source)

IRB (Institutional Review Board)

Governance A committee established to review and approve clinical research involving human subjects. The purpose of the IRB is to ensure that all human subject research be conducted in accordance with all federal, institutional, and ethical guidelines. (source)

Just Do It (JDI) Evidence Based Medicine

A project with a known solution that should just be implemented; additional six sigma processes or analysis is unnecessary.

LACE Score Clinical Care Derived in 2010 by a group of clinicians in Ontario, Canada, the LACE index is an objective measure used widely to predict the risk of unplanned readmission or death within 30 days after hospital discharge in both medical and surgical patients. It includes the length of hospitalization stay (“L”), acuity of the admission (“A”), comorbidities of patients (“C”), and emergency department use of patients (“E”). Studies of the LACE index have shown that a higher LACE score predicts a higher probability of patient readmissions; the scale is 0 to 19.

Lean Six Sigma

Quality and Risk Lean Six Sigma is a fact-based, data-driven methodology of improvement that values defect prevention over defect detection. It drives customer satisfaction and bottom-line results by reducing variation, waste, and cycle time, while prompting the use of work standardization and flow, thereby creating a competitive advantage. It applies where variation and waste exist, and every employee should be involved. (American Society for Quality)

low-molecular-weight heparin (LMHW)

Clinical Care LMWH is a class of medication (including enoxaparin, dalteparin) used as an anticoagulant in diseases that feature thrombosis, as well as for prophylaxis in situations that lead to a high risk of thrombosis. Because it can be taken subcutaneously and does not require aPTT or INR monitoring, LMWH permits outpatient treatment of conditions such as deep vein thrombosis (DVT) or pulmonary embolism (PE). Because LMWH has more predictable pharmacokinetics and anticoagulant effect, LMWH is recommended over unfractionated heparin (UFH) for patients with massive pulmonary embolism and for initial treatment of deep vein thrombosis.

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Term Domain Definition

major depressive episode (MDE)

Clinical Care A condition defined as a period of at least two weeks, during which there is either depressed mood or the loss of interest or pleasure in nearly all activities and in which the patient experiences at least four additional symptoms, including: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death, or suicidal ideation, plans or attempts. (source)

Meaningful Use Government Programs

Meaningful use is a staged set of Electronic Health Record (EHR) objectives that eligible professionals (EPs) and hospitals must achieve to qualify for CMS EHR Incentive Programs. CMS defines meaningful use as using certified electronic health record (EHR) technology to:

• Improve quality, safety, efficiency, and reduce health disparities

• Engage patients and family

• Improve care coordination, and population and public health

• Maintain privacy and security of patient health information (source)

means Clinical Care (suicide risk) The instrument or object used to carry out a self-destructive act (e.g., chemicals, medications, illicit drugs, guns, knives, etc.).

MEAT criteria Financial Providers documentation showing evidence that patient conditions are monitored, evaluated, assessed/addressed, and treated.

Medicaid Government Programs

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. (source)

medical detoxification clinical care Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug or alcohol use. However, medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug or alcohol use. Although detoxification alone is rarely sufficient to help people achieve long-term abstinence, for some individuals it is a necessary precursor to effective drug and alcohol addiction treatment. (source)

Medical Home General Healthcare

The patient’s established, long-term relationship with a provider, usually a Primary Care Provider (PCP), which focuses on their total health, including prevention and wellness.

Medical Orders for Scope of Treatment (MOST)

General Healthcare

A standardized form, identified as a national best practice standard to document goals for care conversations, it is completed by the provider and serves as a medical order that is transferable across care settings. (source)

Medicare Government Programs

Medicare is a federally managed health insurance program for:

1. people age 65 or older, 2. people under age 65 with certain disabilities, and 3. people of all ages with End-Stage Renal Disease (permanent kidney

failure requiring dialysis or a kidney transplant).

Medicare services are divided into 4 parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (outpatient Prescription Drug insurance). (source)

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Term Domain Definition

Medicare Advantage Plans

Government Programs

A type of Medicare health plan offered by a private company that contracts with Medicare to provide patients with Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

The Medicare Advantage Plans (offered as Medicare Part C) take the place of a member’s original Medicare program benefits. These plans provide the member with the basic benefits plus additional benefits that are not typically covered, paying for such expenses as coinsurance and copayment requirements, any deductibles payable under Parts A and B, and other out-of-pocket costs. Presbyterian Health Plan offers two Medicare Advantage plans: Presbyterian Senior Care, a Health Maintenance Organization (HMO), and Presbyterian Medicare Preferred Provider Organization (PPO). The HMO plan is limited in availability only to residents of Bernalillo, Cibola, Rio Arriba, Sandoval, Santa Fe, Socorro, Torrance, and Valencia counties.

Most Medicare Advantage Plans offer prescription drug coverage. (source)

Medicare Part A Government Programs

Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. (source)

Medicare Part B Government Programs

Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. (source)

Medicare Part C Government Programs

Medicare Part C is not a separate Medicare benefit; it is the part of Medicare policy that allows private health insurance companies to provide Medicare benefits. These Medicare private health plans, such as HMOs and PPOs, are known as Medicare Advantage plans. (source)

Medicare Part D Government Programs

Medicare Part D (outpatient Prescription Drug Insurance) is the part of Medicare that provides outpatient prescription drug coverage. Part D is provided only through private insurance companies that have contracts with the government—it is never provided directly by the government (as Part A and Part B are). (source)

Medicare Shared Savings Program

Government Programs

The Medicare Shared Savings Program (Shared Savings Program) was established by section 3022 of the Affordable Care Act. The Shared Savings Program will reward Accountable Care Organization (ACOs) that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an ACO. Participation in an ACO is purely voluntary. (source)

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Term Domain Definition

Medicare Star Government Programs

Developed by the Center for Medicare and Medicaid Services (CMS), the Star Rating System (also called “MA Star”) measures how well Medicare Advantage (MA) and its prescription drug plans perform for consumers. MA Star ratings serve several purposes: to measure quality in Medicare Advantage and Prescription Drug Plans, to assist beneficiaries in finding the best plan for them, and to award MA quality bonus payments. In addition, CMS has extended Star Ratings to hospitals, nursing homes, and dialysis facilities, to support improvement of the quality of care provided by those facilities. CMS rates MA contracts based on a range of as many as 44 unique quality and performance measures, with data gathered from a variety of data sources, including standard HEDIS, CAHPS, and HOS measures. Altogether, the weighted measures are used to calculate a relative quality score using a 5-star rating system, with 5 being the highest and 1 being the lowest score.

medication reconciliation

General Healthcare

Whenever new therapy is ordered or new information becomes available, the patient’s medication regimen may be evaluated, with the goal of reducing potential harm related to medication utilization. This comparison addresses duplications, omissions, and interactions. This process may occur at any time during the patient’s care, including transitions when new medications are ordered and when existing orders are rewritten or adjusted.

methods Clinical Care (suicide risk) Actions or techniques that result in an individual inflicting self-directed injurious behavior (e.g., overdose).

Midas Informatics and Technology

Software system used for delivery system data capture, focus studies, quality reporting, and utilization review. (source)

mild cognitive impairment (MCI)

Clinical Care Mild neurocognitive disorder. MCI is a syndrome between the cognitive changes of aging and dementia, also known as "cognitive impairment, no dementia" or CIND. Typically, MCI presents as memory difficulty and objective memory impairment, yet the patient can function in daily life. There are clinical subtypes of MCI that may have value in predicting conversion to a specific type of dementia. Not everyone with MCI will develop Alzheimer’s disease. (source)

minimally disruptive healthcare

General Healthcare

Health care delivery designed to reduce the treatment burden on patients while pursuing patient goals. (source)

misuse General Healthcare

Another way of describing medical errors. Misuse occurs when a patient doesn’t fully benefit from a treatment because of a preventable problem or when a patient is harmed by a treatment. (source)

morphine milligram equivalents (MME)

Clinical Care Established by the CDC, a value assigned to a dose of opioid medicine to represent its relative potency.

The MME of a dose of an opioid is determined by multiplying it by its equivalency factor. The Centers for Medicare & Medicaid Services (CMS) have published a table of MME conversion factors. MME is equal to morphine equivalent dose (MED) in milligrams, a term used by CMS. Morphine equivalent dosing determines a patient’s cumulative intake of all drugs in the opioid class over 24 hours in an effort to help reduce the likelihood of overdose.

MSE Informatics and Technology

Medical Screening Exam – an ED tool within Epic for determining patient acuity.

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Term Domain Definition

multidisciplinary team General Healthcare

A multidisciplinary team is composed of members from more than one discipline so that the team can offer the patient a greater breadth of services. Team members work independently and interact formally. Appropriate experts from different professions handle different aspects of a patient’s care independently. Each provider is responsible only for his or her own area. A project coordinator or team leader may mold these parallel care pathways to culminate the process.

MyChart Informatics and Technology

Presbyterian’s patient portal designed to connect patients with their care team through the Epic EHR. MyChart provides patients the ability to schedule appointments, message their care team, review clinical results, and more. (source)

NMOA Medical Organizations and Partners

New Mexico Orthopaedics (more info)

normal pressure hydrocephalus (NPH)

Clinical Care NPH is an abnormal buildup of cerebrospinal fluid (CSF) in the brain's ventricles, or cavities. It occurs if the normal flow of CSF throughout the brain and spinal cord is blocked in some way. This causes the ventricles to enlarge, putting pressure on the brain. Common in the elderly, it may result from a subarachnoid hemorrhage, head trauma, infection, tumor, or complications of surgery, but NPH may develop even when none of these factors are present. Symptoms of NPH include progressive mental impairment and dementia, problems with walking, and impaired bladder control. The person also may have a general slowing of movements. Because these symptoms are similar to those of other causes such as Alzheimer disease, Parkinson disease, and Creutzfeldt-Jakob disease, the disorder is often misdiagnosed. (source)

OPLT (One Presbyterian Leadership Team)

Governance One Presbyterian Leadership Team (OPLT) serves as the senior most executive body within Presbyterian Healthcare Services (PHS). OPLT assures organizational performance and the creation and deployment of Presbyterian’s strategy. OPLT is responsible for strategic planning and execution and management of organizational performance, including scorecards.

order set Informatics and Technology

A standardized list of orders that help direct care for a specific diagnosis or population. These orders have been carefully developed by a team of clinicians who consult local consensus and/or medical literature for evidence-based best practices. Order sets themselves do not constitute a guideline or protocol, but are a tool to help deliver elements of care. (source)

overuse General Healthcare

When a drug or treatment is given without medical justification or strong scientific evidence. Overuse includes failing to follow effective options that cost less or cause fewer side effects. For example, antibiotics are prescribed for children’s ear infections 80 percent of the time, despite the finding that these infections usually resolve within three days without antibiotics. (source)

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Term Domain Definition

PAC (Physician Accountability Council)

Governance Physician-led committee that provides leadership and oversight of clinical practice changes and requests that are made by PMG, provider groups, and other external provider groups. The PAC represents and leads the interface of enterprise-wide clinical initiatives with PMG that include Population Health, PHP, and others, as necessary. The mission of the PAC is to 1) enable physicians and APCs to direct initiatives by providing strategic and operational input, 2) advance and promote accountability, and 3) govern the approach to making decisions and changes that impact value-based care delivery for patients and members. The PAC reports to the PCLT.

Palliative Care Clinical Care Specialized medical care for people with serious illnesses; this type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis. This care can be provided concurrently with curative and intensive medical regimens.

Parkinson disease (PD) Clinical Care PD belongs to a group of conditions called motor system disorders, which

are the result of the loss of dopamine-producing brain cells. The four

primary symptoms of PD are tremor, or trembling in hands, arms, legs, jaw,

and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or

slowness of movement; and postural instability, or impaired balance and

coordination. As these symptoms become more pronounced, patients may

have difficulty walking, talking, or completing other simple tasks. Other

symptoms may include depression; difficulty in swallowing, chewing, and

speaking; urinary problems or constipation; skin problems; and sleep

disruptions. Cognitive symptoms of dementia and changes in mood and

behavior may arise. PD usually affects people over the age of 60. Presently

there is no cure for PD, but a variety of medications provide dramatic relief

from the symptoms.

Not all people with PD develop dementia, and it is difficult to predict who will. Being diagnosed with PD late in life is a risk factor for Parkinson disease dementia. (source, source)

PASS Governance Pre-Anesthesia and Surgical Screening (source)

patient activation Customer Experience

Understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role. (source)

Patient Activation Measure

Customer Experience

The Patient Activation Measure® (PAM®) assessment gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare. The PAM assessment segments consumers into one of four progressively higher activation levels. Each level addresses a broad array of self-care behaviors and offers deep insight into the characteristics that drive health activation. A PAM score can also predict healthcare outcomes including medication adherence, ER utilization and hospitalization. The Patient Activation Measure is a valid, highly reliable, unidimensional, probabilistic Guttman-like scale that reflects a developmental model of activation. Activation appears to involve four stages:

1. believing the patient role is important, 2. having the confidence and knowledge necessary to take action, 3. actually taking action to maintain and improve one’s health, and 4. staying the course even under stress. (source 1, source 2)

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Term Domain Definition

patient decision aids Customer Experience

Interventions such as books, videos, leaflets, DVDs, websites and other interactive media that are designed to provide the best evidence available about the risk and benefits of different medical treatment options. These aids are intended to help patients make informed decisions in consultation with their physician. (source)

patient education Customer Experience

Health information and instruction to help patients learn about specific or general medical topics. Topics include the need for preventive services, the adoption of healthy lifestyles, the correct use of medications, and the care of diseases or injuries at home. (source)

patient engagement Customer Experience

Actions that people take for their health and to benefit from care. (source)

Patient Experience Customer Experience

The sum of all interactions, shaped by the organization’s culture, that influence patient perceptions across the continuum of care. (source)

Patient-Centered Medical Home (PCMH)

General Healthcare

A way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care. (source)

Patient-Centered Medical Neighborhood (PCMN)

General Healthcare

A PCMH and the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations and State and local public health agencies. (source)

PCLT (Presbyterian Clinical Leadership Team)

Governance Executive governance body designed to lead the transformation of PHS’ Care Model to advance achievement of the Triple Aim for Presbyterian’s customers. This team is comprised of clinical leaders across the system and has a direct connection to the OPLT. The PCLT is responsible for 1) creating a framework for and driving strategic transformation of PHS’ Care Model, 2) setting enterprise clinical priorities at a system level for key practice and evidence based care design (EBCD) decisions, and 3) serving as a key influencer of care across the state.

PCR Clinical Care polymerase chain reaction

PDS (Presbyterian Delivery System)

Governance Presbyterian’s care delivery division, which encompasses all pre-hospital, emergency, primary, specialty, inpatient, and post-acute care provided by Presbyterian employees.

PDS Hospital Care Management

Clinical Care A care team consisting of a triad of Care Manager, Clinical Social Worker, and Health Service Aid. This team is accountable for planning and ensuring effective transition of care from the hospital to the next setting of care. Traditional hospital utilization management is organized through these services as well. This team is integrated with the hospital care teams and uses Epic.

PDSA Cycle Evidence Based Medicine

The Plan-Do-Study-Act Cycle (PDSA) is a four-step process for implementing change, problem solving, and continuous improvement. First, develop a plan to test the change (Plan); then carry out the test or pilot (Do); next, observe and learn from the consequences (Study); and finally, determine what modifications should be made to the test (Act). Implement the change on a broader scale. Continue to monitor the change, and iterate as necessary by repeating the cycle. Also known as Plan-Do-Check-Act, Deming Wheel, Deming Cycle, or Shewhart Cycle. (source; source)

PEL Informatics and Technology

(Presbyterian Electronic Library) Presbyterian’s enterprise documentation management system (source)

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Term Domain Definition

People Subcommittee Governance The People Subcommittee of OPLT devotes the leadership attention required by the Creating the Best Place to Work strategic initiative. Primary accountabilities for the People Subcommittee include:

• Create value from PHS’ integrated strategy.

• Build a shared leadership view of People with respect to the PHS Annual Rhythm.

• Align the work of the People Subcommittee with the Egg.

• Guide PHS to the right short- and longer-term specifications, plans, and resource requirements with respect to People to achieve the PHS strategy.

• Identify and prioritize issues related to Presbyterian’s workforce.

• Incorporate the Employee Voice into discussions and decision-making.

• Actively integrate the work of the People Subcommittee with other operational teams and committees and vice versa to ensure active and agile communication and coordinated action throughout PHS.

percent time in therapeutic INR range (TTR)

Clinical Care TTR is a way of summarizing INR control over time; the mean therapeutic INR range. It is a widely cited measure of the quality of warfarin therapy.

pharmacist clinician (PhC)

General Healthcare

Pharmacist Clinicians (PhCs) are advanced practice pharmacists with prescriptive authority granted by the New Mexico Board of Pharmacy and New Mexico Medical Board. Pharmacist Clinicians have provided disease management services within PMG for a number of years which allows the PhCs to practice at the top of their licensure within the Patient Centered Medical Home and some specialty clinics.

Currently, PhCs practice in the ambulatory setting providing direct patient care services for chronic diseases and medication management. Given the comprehensive care, with prescriptive authority, the PhC practice model has evolved quickly into that of an advanced practice clinician (APC). This has been recognized by PMG leadership along with medical staff affairs (MSA) resulting in approval by MSA to include PhCs into the credentialing and privileging process. Additionally, PhCs actively participate in APC focus groups, APC council, provider experience subcommittee, and PMG Executive Council.

Presbyterian supports a model which successfully utilizes PhCs as health care providers and recognizes them as essential members of the health care team. No longer are the days when pharmacists only provide information and education about medications. Rather, PhCs provide expertise and health care in a variety of ways, from primary prevention to comprehensive medication management. Furthermore, PhCs are increasingly requested by various teams and clinics to improve clinical outcomes and access to care.

phlegmasia cerulea dolens (PCD)

Clinical Care An uncommon form of massive proximal (iliofemoral) DVT. For this condition, more aggressive management, usually thrombolysis and/or thrombectomy, may be considered.

PHP (Presbyterian Health Plan)

Governance Presbyterian’s healthcare financing division; PHP offers individual, family, employer-funded, Medicare Advantage, and Centennial Care (Medicaid) plans. (source)

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Term Domain Definition

PHP Case Managers Clinical Care Nurses dedicated to the health care management of complex PHP members identified through risk stratification as needing these services. They will manage day to day case management activities, patient status monitoring, and identification of care gaps and service needs. PHP case managers focus on the Centennial Care population as well as PHP commercial and Medicare patients not accessing PMG for services. Additionally they are accountable for PHP commercial ASO and Medicare PPO members accessing PMG for services as they are not PHP HMO Capitated. This current delegation agreement between PHP and PMG for Case Management represents an opportunity to clarify roles and responsibilities.

PHQ-9 Clinical Care Patient Health Questionnaire (PHQ); a screening tool that measures depression symptoms, containing nine items each of which is scored 0 to 3, resulting in a severity score of 0 to 27. Along with other elements of patient assessment, the PHQ-9 can help evaluate and diagnose a major depressive episode. It also screens for suicidal tendencies, impairment, and chronic depression. Adolescent and pediatric versions are available.

PI (Principle Investigator)

Governance The individual who is responsible and accountable for conducting a clinical trial. The PI assumes full responsibility for the treatment and evaluation of human subjects, and for the integrity of the research data and results. (source)

PILT (Presbyterian Integration Leadership Team)

Governance The Presbyterian Integration Leadership Team serves as the executive body that champions and demonstrates the commitment to system integration among Presbyterian Health Plan (PHP) and Presbyterian Delivery System (PDS) operations. The integration team will guide performance improvement and monitor outcomes and experience for PHS customers who are both patients and members (the “Integrated Populations”). In 2016, the Presbyterian Integration Leadership Team will serve as the accountable body for achieving two Strategic Initiative work-streams: Preventing Illness and Addressing Care Gaps for Success in Medicare Advantage and Expanding PMG Primary Care Access to Serve Patients. The team also serves to monitor and improve the efficiency, effectiveness and experience of functions performed among PHP, PDS and Integrated Care Solutions (ICS).

Pioneer ACO Model Government Programs

The Pioneer ACO Model was a 3-year (2012-2015) program designed for health care organizations and providers that were already experienced in coordinating care for patients across care settings. It was designed to allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program. The program was designed to work in coordination with private payers by aligning provider incentives, which would improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients. (source)

Note: PHS participated in the Pioneer ACO model in 2012, but left in 2013.

plan survey Customer Experience

A tool for collecting standardized information on enrollees’ experiences with health plans and their services. Since its launch in 1997, this survey has become the national standard for measuring and reporting on the experiences of consumers with their health plans. A version of this survey is conducted in almost every State in the U.S. (source)

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Term Domain Definition

PMG (Presbyterian Medical Group)

Governance Presbyterian’s Primary Care and outpatient Specialty Care division (source)

PMG Care Manager Clinical Care A Nurse who provides outreach services for chronic disease, wellness, and HEDIS care gap closures. They work within the integrated EHR (Epic) to manage registries, order necessary tests, studies, and referrals, and coordinate with the care team. They also assist in gap closure initiatives and may use lists provided by payors.

PMG Case Manager Clinical Care A Nurse or a Social worker dedicated to the healthcare management of high-risk patients. They specifically serve the population of patients where PDS has contractually accepted financial risk. They manage day to day case management activities, monitor patient status, and identify care gaps and services needed. They use Epic to communicate with care teams, coordinate care, make referrals, and address care gaps. They use a unified set of processes and programs for at-risk patients including those who are not members of Presbyterian Health Plan (PHP).

PMG Providers and Clinic Staff

Clinical Care Clinicians who manage daily care for patients. Workflows and tools are designed to assist in recognizing patients’ needs and addressing these at each point of contact to proactively minimize future gaps in care. These teams work exclusively in Epic. These teams benefit from discrete lists of risk stratified patients provided by the Case Manager. The teams will benefit further in the future when the Identify risk stratified registries are capable of import into Epic.

Population Health Population and Community Health

The identification and improvement of health outcomes of a group of individuals, including the distribution of such outcomes within the group. (source)

Population Health Management

Population and Community Health

Monitoring and improving PHS sub-populations’ health using defined quality measures and targets.

Population Medicine Population and Community Health

The specific activities of the medical care system that, by themselves or in collaboration with partners, promote population health beyond the goals of care of the individuals treated.

Post-acute Admission Clinical Care Admission to a post-acute care setting, such as a skilled nursing facility, inpatient rehabilitation hospital, long term care facility/ nursing home, or home healthcare services.

PPI Clinical Care Proton pump inhibitor; a class of drugs that reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid.

PPO (Preferred Provider Organization)

Financial In comparison to an HMO, a PPO is a type of health insurance arrangement that allows plan participants relative freedom to choose the doctors and hospitals they want to visit. Obtaining services from doctors within the health insurance plan’s network, called “preferred providers”, results in lower fees for policyholders; however, out-of-network doctors are still covered. Coverage under a preferred provider organization (PPO) requires ongoing payment of premiums by policyholders to the insurance company. (source)

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Term Domain Definition

PQRS (Physician Quality Reporting System)

Government Programs

The Physician Quality Reporting System (PQRS) is a CMS quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare. PQRS gives participating EPs and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time. By reporting on PQRS quality measures, individual EPs and group practices can also quantify how often they are meeting a particular quality metric. Beginning in 2015, the program began applying a negative payment adjustment to individual EPs and PQRS group practices who did not satisfactorily report data on quality measures for Medicare Part B Physician Fee Schedule (MPFS) covered professional services in 2013. Those who reported satisfactorily for the 2015 program year will avoid the 2017 PQRS negative payment adjustment. PQRS was formerly known as the Physician Quality Reporting Initiative (PQRI). (source)

preventable harm General Healthcare

Presence of physical, psychological or financial harm caused to patients by healthcare that is both identifiable and modifiable. (source)

proactive care Population and Community Health

A multi-pronged approach to help patients close gaps in care. Program improves performance on quality measures through the timely identification and closure of gaps. Patient engagement includes Care Advisor outreach, population health manager support of physician offices, and digital and print communications. (source)

process owner Evidence Based Medicine

The manager with responsibility and authority to manage a process being improved. Ideally, the process owner has operational responsibility and authority across all of the sub-process elements. In a cross-functional process, the process owner works closely with the operational manager(s) to ensure the process measures stay within specified performance limits. The process owner is responsible for the creation, update and approval of documents (procedures, protocols, standard work) to support the process.

protective factors Clinical Care (suicide risk) Factors that make it less likely that individuals will develop or engage in a suicidal behavior. Protective factors may encompass biological, psychological, or social factors in the individual, family, and environment.

protocol General Healthcare

A code of correct conduct or a plan for course of medical treatment or procedure. (source)

Provider General Healthcare

psychotherapy Clinical Care Psychotherapy encompasses a variety of therapeutic approaches — such as cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and short-term dynamic therapies. It treats depression by helping the patient identify, address, and solve life problems that contribute to their depression. It can also help the patient identify and improve negative or distorted thinking patterns and explore other learned thoughts and behaviors that create problems and contribute to depression.

Pulmonary Rehabilitation (PR)

Clinical Care Pulmonary Rehabilitation is a program of exercise, education, and support designed to control and alleviate symptoms, optimize functional capacity, and enhance quality of life for people with chronic pulmonary disease. At PHS, a patient may be referred by any provider for PR, offered at the Healthplex in Albuquerque, NM.

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Term Domain Definition

pyuria Clinical Care Pyuria is defined as the presence of 10 or more white cells per cubic millimeter in a urine specimen, 3 or more white cells per high-power field of unspun urine, a positive result on Gram’s staining of an unspun urine specimen, or a urinary dipstick test that is positive for leukocyte esterase. (source) The increased number of leukocytes is evidence of an inflammatory response in the urinary tract. (source)

query General Healthcare

A question posed to a Provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.

rating levels General Healthcare

Beginner: Able to demonstrate basic acceptable performance but lacks experience

Competent: Have the basic skills and ability to meet standards. Able to see aspects of performance yet may not be able to see the whole. Able to identify gaps in performance and apply mitigating plans.

Proficient: Well advanced in skills and ability. Perceives situations as a whole rather than aspects. Able to proactively identify gaps in performance and develop and apply process changes. Able to identify means to accelerate performance. (source)

RDS Governance Regional Delivery System (retired); Regional facilities are now referred to as part of the Presbyterian Delivery System (PDS) or by their unique facility name(s).

readmission General Healthcare

Generally speaking, a hospital readmission occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this time period is defined as 30 days, and includes hospital readmissions to any hospital, not just the hospital at which the patient was originally hospitalized. Medicare uses an “all-cause” definition of readmission, meaning that hospital stays within 30 days of a discharge from an initial hospitalization are considered readmissions, regardless of the reason for the readmission; admissions for planned procedures that are not accompanied by an acute diagnosis do not count as readmissions in the measure outcome.

reluctance to simplify General Healthcare

An understanding that while simple processes are good, simplistic explanations for why things work or fail are risky. This requires avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) and reviewing processes and systems to understand the true reasons patients are placed at risk. (source)

resilience General Healthcare

The condition where leaders and staff are trained and prepared to know how to respond when system failures do occur. This includes assessing for containment strategies, attending to the needs of the patient, family and the staff, as well as ensuring that proper reporting takes place in a timely manner. (source)

Risk Adjusted Mortality Index

Quality and Risk The Commission on Professional and Hospital Activities (CPHA) developed the Risk-Adjusted Mortality Index (RAMI) with funding from CMS, a method for comparing hospital death rates using existing abstract or billing data. (source) The method is comprehensive insofar as it includes all payers and all types of cases except neonates. RAMI was designed to differentiate among admissions on the basis of the patient characteristics that increase or reduce the risk of dying in the hospital. Using a large national data base, risk factors were determined empirically within each of 310 clusters based on diagnosis-related groups (DRGs). (source)

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Term Domain Definition

Risk Adjusted Mortality Rate

Quality and Risk A mortality rate that is adjusted for predicted risk of death. It is usually utilized to observe and/or compare performance, and uses data that incorporate acuity and observed vs expected mortality. (source)

Risk Adjustment Factor (RAF)

Financial A Medicare payment adjustment through which CMS pays plans for the risk of the beneficiaries they enroll, instead of using an average rate for all Medicare/Medicare Advantage beneficiaries. By doing so, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs and use standardized bids as base payments to plans. (source)

risk factors Clinical Care (suicide risk) Factors that make it more likely that individuals will develop or engage in a suicidal behavior. Risk factors may encompass biological, psychological, or social factors in the individual, family, or environment.

Risk of Mortality (ROM) Measure

Quality and Risk A physiological based system that calculates a patient’s short term risk of mortality and morbidity based on a formal algorithm that incorporates clinical variables collected in-hospital over a period of time or at a specific point in a patient’s care. Examples include the Modified Early Warning System (MEWS), PRISM, and the Society of Thoracic Surgeons Risk calculator.

risk stratification Population and Community Health

An intentional, proactive, and statistical approach for identifying and predicting which patients are at high risk—or likely to be at high risk—and prioritizing the management of their care in order to prevent worse outcomes. (source)

safety plan Clinical Care (suicide risk) Written list of warning signs, coping responses, and support sources that an individual may use to avert or manage thoughts, feelings, impulses, or behaviors related to suicide.

SBAR General Healthcare

Summary document used to identify and document the: 1) overall summary of the situation; 2) background of the issue; 3) assessment of the solutions; and, 4) recommendation to resolve.

Secondary Diagnosis General Healthcare

All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.

self-directed violence (or self-harm)

Clinical Care Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Self-directed violence can be categorized as non-suicidal or suicidal.

Service Line Governance Note: the Service Line model is no longer used within PHS. A Service Line is a collection of services that a patient may require during treatment for an episode or condition. Each Service Line is organized around a patient diagnosis to provide coordination of care and accessibility of information over time, regardless of where the care is provided or who provides it. Each Service Line is led by a “Leadership Dyad,” a co-accountable physician and administrative leader responsible for all aspects of the Service Line. Presbyterian has 10 clinical service lines: Adult Medical Specialty, Behavioral, Cancer, Children’s, Heart and Vascular, Home and Transition Services, Primary Care, Surgery, Urgent and Emergent Services, and Women’s. (source)

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Term Domain Definition

shared decision making (SDM)

Customer Experience

A collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. SDM honors both the provider’s expert knowledge and the patient’s right to be fully informed of all care options and the potential harms and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing providers to feel confident in the care they prescribe. (source)

Skilled Nursing Facility (SNF)

Clinical Care A nursing facility that provides 24-hour non-acute nursing, medical, and rehabilitative care. SNFs are recognized by Medicare and Medicaid as meeting long term health care needs for individuals who have the potential to function independently after a limited period of care, as compared to the residential nature of a long-term care facilities or nursing homes. Most patients are admitted to a SNF facility after a hospital discharge to facilitate access to intensive rehabilitation services and/or ease their transition home. Presbyterian Kaseman Hospital has 2 inpatient SNF units.

smart set Informatics and Technology

Epic-specific terminology for order sets used in the outpatient setting/ the Epic ambulatory software module.

SmartExam™

Informatics and Technology

An online healthcare service. SmartExam is a care automation technology that allows the patient to submit a clinical history for the list of common, minor conditions supported within a defined service menu. Based on the information collected by SmartExam and their own clinical judgment, a PMG Provider may determine a diagnosis and treatment plan.

Stages of Change clinical care A series of phases that people move through when modifying their behavior, the Stages of Change (precontemplation, contemplation, preparation, action, maintenance, and relapse) are described in the Transtheoretical Model (Prochaska & DiClemente), a comprehensive, integrative, biopsychosocial model to conceptualize the process of intentional behavior change. For each stage, specific intervention strategies are most effective at advancing the person to the next stage and ultimately to a changed behavior. (source, source)

strata clinical care To facilitate care coordination, Presbyterian’s Integrated Care Solutions team has objectively stratified LACE scores into four risk profiles, low (1) to high (4); PHS patients are offered post-discharge interventions based upon the stratum in which they are classified. For example, patients assigned to stratum 4 have the highest LACE scores (from 12 to 19) and the highest (≥97%) probability of readmission. These patients would be provided the most intensive interventions, such as in-home care within 24 hours plus Case Management services. Patients assigned to stratum 3 (LACE 9 to 11) have a fairly high probability of readmission (88%-96%), and would be eligible for high-level interventions, such as Case Management services. The most appropriate intervention for patients in stratum 2 (LACE 6 to 8) may be supported self-care. The stratum 1 (LACE 0-5) patients are generally low-risk, healthy patients who may need the least amount of post-discharge care.

substance use disorder (SUD)

clinical care Substance use disorder describes a problematic pattern of using alcohol or another substance (legal and/or illegal drugs) that results in impairment in daily life or noticeable distress. The term encompasses a range of severity levels, from problem use/misuse to dependence and addiction. The diagnosis is based on fulfilling diagnostic criteria as defined by the Diagnostic and Statistical Manual, 5th edition (DSM-5).

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Term Domain Definition

suicidal behavior Clinical Care Acts and/or preparation toward making a suicide attempt or toward a death by suicide.

suicidal ideation Clinical Care Thoughts of engaging in suicidal behaviors; contemplating ending one’s own life. These thoughts may arise in people who feel completely hopeless or believe they can no longer cope with their life situation. Suicidal ideation can vary greatly from fleeting thoughts to preoccupation to detailed planning. (source)

suicidal intent Clinical Care Evidence (explicit and/or implicit) that at the time of injury the individual intended to kill him or herself or wished to die and that the individual understood the probable consequences of his or her actions

suicidal plan Clinical Care A thought regarding a self-initiated action that facilitates self-harm behavior or a suicide attempt, often including an organized manner of engaging in suicidal behavior such as a description of a time frame and method.

suicide Clinical Care Death caused by self-directed injurious behavior with any intent to die as a result of the behavior.

suicide attempt Clinical Care A non-fatal, self-directed, potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury.

suicide risk assessment Clinical Care The purpose of a suicide risk assessment in a healthcare setting is to manage the patient safely to the appropriate level of care. Clinicians may evaluate risk factors and protective factors with a focus on identifying modifiable targets for intervention. Clinicians may be concerned that asking about suicide will instigate suicidal thoughts or actions, but no data support this assumption. Instead, a patient may appreciate the opportunity to discuss suicidal thoughts. Sometimes the only clue a patient gives to being suicidal is expressed to a clinician during an office visit. (source) Evidence-based tools exist to prompt the patient to verbalize these issues.

PHS patients may be screened initially when asked question number nine from the Patient Health Questionnaire Nine Item (PHQ-9) – “Over the last two weeks, how often have you been bothered by thoughts you would be better off dead or of hurting yourself in some way?” Patients who screen positive are subsequently assessed using six questions from the Columbia-Suicide Severity Rating Scale (C-SSRS) that can evaluate the suicide risk as minimal, moderate, and high.

summit Evidence Based Medicine

Education event designed to establish a shared knowledge base and create buy-in with key stakeholders.

surgical site infection (SSI)

Quality and Risk A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. (source)

syncope Clinical Care Syncope is an abrupt, transient loss of consciousness, associated with loss of postural tone, with spontaneous return to baseline neurologic function requiring no resuscitative efforts; caused by cerebral hypoperfusion. (source)

Synergy Model General Healthcare

A care model that describes nursing practice on the basis and needs of patients’ characteristics. Patient characteristics drive nurses’ competencies and when patients’ characteristics and nurses’ competencies match and synergize, outcomes for the patients are optimal. (source)

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Term Domain Definition

Team Care General Healthcare

The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable. (source)

telehealth Informatics and Technology

The use of electronic information and telecommunication technologies to support long distance clinical health care, patient/ member and professional health-related education, public health services, and health administration. Telehealth refers to a scope of remote healthcare services broader than telemedicine and can include non‐clinical services. (source)

telemedicine Informatics and Technology

The use of electronic information and telecommunication technologies to improve a patient/ member’s health by permitting two‐way, real time, interactive communication between the patient/ member and the practitioner. Telemedicine refers specifically to remote clinical services. At PHS, this definition has been further expanded, for operational purposes, by including technology-enabled provider-to-provider interactions that extend scarce provider resources. Telemedicine in a subset of telehealth. (source)

thromboembolism Clinical Care Formation in a blood vessel of a clot (thrombus) that breaks loose and is carried by the blood stream to obstruct another vessel. The clot may plug a vessel in the lungs (pulmonary embolism), brain (stroke), gastrointestinal tract, kidneys, or leg. Thromboembolism is a significant cause of morbidity and mortality, especially in adults. Treatment may involve anticoagulants, aspirin, or thrombolytics.

total joint replacement (TJR)

Clinical Care A surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint.

total population health Population and Community Health

Refers to all the residents of a geopolitical area, within which a variety of sub-populations can be defined. Sub-populations can be defined in a variety of ways, including by income, race/ethnicity, disease burden, or those served by a particular health system or in a particular workforce. Populations served by a Triple Aim initiative might be either a total population or a sub-population defined in this way; in either case, it is essential to specify the population. (source)

transition of care General Healthcare

A transition of care, sometimes called a “hand-off”, occurs any time a patient leaves one care setting (i.e. hospital, skilled nursing facility, assisted living facility, primary care physician care, home health care, or specialist care) and moves to another setting or back to the patient’s home. This transition often involves several people, including the patient, family or other caregivers, nurses, social worker, case manager, pharmacist, physician, and other Providers. Transitions of care affect not only the patient but the health care professionals as well. (source)

Transition of Care Documentation

Informatics and Technology

A summary of patient care designed to be sent between providers when a patient is moved / referred from one setting of care (hospital, ambulatory primary care practice, SNF, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. Required by CMS under Meaningful Use.

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Term Domain Definition

Triple Aim General Healthcare

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which they call the “Triple Aim”:

1. Improving the patient experience of care (including quality and satisfaction);

2. Improving the health of populations; and 3. Reducing the per capita cost of health care (source)

underuse General Healthcare

When doctors or hospitals neglect to give patients medically necessary care or to follow proven health care practices – such as giving beta-blocking drugs to people who have heart attacks. (source)

upside risk Financial The uncertain possibility of gain. (source)

Utilization Management Population and Community Health

Health Plan: Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. (source)

utilization review (UR) Population and Community Health

Delivery System: A critical evaluation (as by a physician or nurse) of health-care services provided to patients that is made especially for the purpose of controlling costs and monitoring quality of care. (source)

value equation General Healthcare

Value = quality/cost (source)

value-based initiative

Population and Community Health

Through the use of data and analytics, this kind of program identifies cost and utilization reduction opportunities to both lower the total cost of care and improve the quality of care. These initiatives focus on trends, delivery system services, and improvement in population health metrics.

value-based purchasing (VBP)

Quality and Risk VBP programs are positioned as reward and incentive payment programs that pay for quality performance related to the patient and members experience. Under federal program rules, base payments are reduced and funds are redirected to make value-based incentive payments to hospitals and health plans that meet designated performance standards. For all programs the percent of payment directed to the VBP program increases year over year. CMS bases hospital performance on an approved set of measures and dimensions, grouped into specific quality domains. There are four domains:

1. Clinical Process of Care Domain 2. Patient Experience of Care Domain 3. Outcome Domain 4. Efficiency Domain

(source)

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Term Domain Definition

vascular dementia (VaD) Clinical Care VaD is a heterogeneous syndrome in which the underlying cause is

cerebrovascular disease in some form, and its ultimate manifestation is

dementia. It is the second most common form of dementia after Alzheimer

disease (AD), and it makes up 10-20% of cases in North America and

Europe. The presentation of cognitive impairment in VaD may be quite

distinct from AD, especially early in the disease course, with prominent

deficits in executive dysfunction causing significant disability, even while

memory impairment is quite mild and before the patient reaches criteria for

dementia.

The National Institute of Neurological Disorders promulgates the use of "vascular cognitive impairment" (VCI) as "cognitive impairment that is caused by or associated with vascular factors". Cognitive deficits associated with vascular disease that don't meet criteria for dementia are labelled "vascular cognitive impairment, no dementia" (vCIND). This is somewhat analogous to mild cognitive impairment (MCI). (source)

VAT (Value Assessment Team)

Governance Presbyterian committees focused on securing lowest prices and contracting rates for clinical supplies and services.

venous thromboembolism (VTE)

Clinical Care VTE is the formation of blood clots in the vein. When a clot forms in a deep vein, usually in the leg, it is called a deep vein thrombosis (DVT). If that clot breaks loose and travels to the lungs, it is called a pulmonary embolism (PE). DVT and PE are two manifestations of VTE.

warfarin Clinical Care A widely-used synthetic anticoagulant, warfarin inhibits the hepatic synthesis of vitamin K-dependent clotting factors (Factors II, VII, IX and X) and the natural anticoagulant proteins C and S. Warfarin acts to inhibit the reduction of oxidized vitamin K, resulting in a depletion of active vitamin K that is required for carboxylation of the clotting factors. Although therapeutic doses of warfarin only inhibit up to 50% of clotting factor synthesis, it is enough to weaken the biologic activity of the clotting factors and produce a therapeutic anticoagulant effect.

The PT test (Prothrombin Time) can be used to monitor patients being treated with warfarin. Brand names include: Athrombin-K, Compound 42, Co-Rax, Coumadin, Panwarfin, Rodex, and WARF Compound 42. It is also used as a rodenticide, causing fatal hemorrhaging in any mammal consuming a sufficient dose. (source, source, source)

Wells Score Clinical Care An evidence-based clinical probability assessment to determine the likelihood of VTE. Based on the Wells criteria for DVT, patients can be classified “DVT likely” (Wells Score ≥2.0) and “DVT unlikely” (<2.0). Scores ≥3.0 qualify patient as “High Probability” for DVT. Likewise, patients can be classified “PE likely” (>4.0) and “PE unlikely” (≤4.0). Scores >6.0 qualify patient as “High Probability” for PE. The physician can then choose what further testing is required for diagnosing DVT or PE. (source DVT, source PE)

The scoring model was developed by Phil Wells, MD, MSc, a professor and chief of the Department of Medicine at The University of Ottawa, who researches thromboembolism, thrombophilia and long term bleeding risk in patients on anticoagulants.

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Term Domain Definition

XML Informatics and Technology

(Extensible Markup Language) A markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable. It is defined by the W3C’s XML 1.0 Specification and by several other related specifications, all of which are free open standards. (source)

Z-drugs Clinical Care Like benzodiazepines, drugs in this group act as GABA receptor agonists. Because they have a different structure than benzodiazepines, they produce fewer anxiolytic and anticonvulsant effects. Specific for the treatment of insomnia, Z-drugs have not been shown to be any safer than benzodiazepines.

Examples include zolpidem (Ambien) and eszopiclone (Lunesta).

Zynx Informatics and Technology

Evidence assessment and review process management tool. (source)