In order to support the health centers’ work on the new CHCN risk measurements, we are able to produce three reports: Members with no PCP visit, ER frequent flyers, and Members with IP admissions.

1. Quarterly “Members with no PCP visit”, we are able to produce detailed quarterly outreach reports of members fitting this criterion. The report is in excel format that lends itself to sorting on any field to slice the data as desired (e.g., age, patient address, other services accessed, etc.)  These reports are time sensitive as they draw from the most recent encounter data received by CHCN from the health centers in an effort to give the most accurate, actionable information. The reports are released on the 1^st Monday of May, Aug., Nov., and Feb.
2. Monthly “ER frequent flyer”, CHCN is able to produce monthly reports of members having five or more ER visits during one year. The reports include information about PCP visits the members had in the meantime. The reports are ready on the 1^st of each month for the prior month, or the following Monday if the 1^st falls on a weekend.
3. Weekly “Members with IP admission”, CHCN produces weekly report of members having in-patient admissions during the prior week. The reports are ready every Monday, or Tuesday if Monday is a holiday.

We have received feedback from some of the health centers that they are having quality improvement and panel management staff follow-up with these patients to reengage them in their medical home.