Ambulatory Care Sensitive Admissions Tip Sheet

Incentives will be paid on an annual basis, following the end of Quarter 4. For additional information refer to the CBI Technical Specifications.

The list of ambulatory care sensitive conditions listed below is derived from the Prevention Quality Indicators (PQI) and the Pediatric Quality Indicators (PDI) criteria released by the Agency for Health Care Research and Quality (AHRQ). Note: the list below contains the AHRQ code sets used to calculate the measure:

• Asthma in younger adults.
• Community acquired pneumonia.
• COPD/Asthma in older adults (> 40 years old).
• Diabetes long-term complications.
• Diabetes short-term complications.
• Heart failure.
• Hypertension.
• Lower extremity amputation w diabetes.
• Pediatric asthma.
• Pediatric gastroenteritis.
• Pediatric short-term diabetes.
• Pediatric urinary tract infection.
• Uncontrolled diabetes.
• Urinary tract infection.

Educate All Members To:

• Utilize Alliance health education and chronic disease self-management programs to help members achieve healthier outcomes:
  • Healthy Breathing for Life Program (Asthma).
  • Healthier Living Program (Chronic Health Conditions).
  • Live Better with Diabetes (Diabetes) and Diabetes Prevention (Prediabetes).
  • Wellness that Works (Adult (ages 18 and older; Weight Management).
  • Healthy Weight for Life (Pediatric (ages 2-18; Weight Management).
  • Healthy Moms and Healthy Babies (Perinatal and Postpartum).
  • Tobacco Cessation Support.
• Understand and manage their current conditions through health education resources like:
  • The American College of Physicians (ACP) Health Tips:
    • Asthma.
    • Asthma Action Plan (printer and electronic versions).
    • Hypertension.
    • Low Back Pain.
  • American Lung Association My COPD Action Plan in English and Spanish
  • CDC’s Managing Diabetes Steps to Health You stay Healthy with Diabetes
• Utilize Ask Me 3® during visits to encourage members to ask three specific questions of their providers to better understand their health conditions, and what they need to do to stay healthy.
  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?²
• Discover the four ways to Get Ahead of Sepsis.
• Use the Alliance’s Nurse Advice Line – available to all Alliance members 24 hours a day, 7 days a week, 365 days a year.
• Call their PCP office for a follow-up appointment after their hospital discharge.
• Utilize the Alliance’s free interpreting services for telephonic and face-to-face visits.
  • Face-to-face interpreters can be requested to be at the appointment with the member.
  • Telephonic interpreting services are available to assist in scheduling members.
  • Members can call the Alliance Health Education Line at 800-700-3874, ext. 5580.
  • For the Hearing or Speech Assistance Line, call 800-735-2929 (TTY: Dial 711).
• Utilize the Alliance’s Transportation Services by contacting a coordinator at 800-700-3874, ext. 5577. This service is not covered for non-medical locations or for appointments that are not medically necessary.

Assign Clinic Staff To:

• Identify patients at high risk for hospitalizations to provide:
• Regular medication review (what medication is taken and how?).
• Regular monitoring of symptoms and treatment adherence in high risk patients.
• Self-management training of members and caregivers (help members identify when to manage acute deterioration or when to seek timely care from their PCP)[1]; or
• Refer Alliance Members using the Health Programs Referral Form for disease management and health education programs. For any questions, please call the Alliance Health Education Line at (800) 700-3874 ext. 5580.
  • Refer Alliance Members to Care Management Services, including Complex Case Management and Care Coordination, by calling Case Management at (800) 700-3874 ext. 5512.
  • Refer Alliance members to Enhanced Care Management (ECM) Services and Community Supports through the Alliance Provider Portal, online referral on our website, or by phone at 831-430-5512.
  • Refer Alliance Members to behavioral health services through Carelon Behavioral Health Primary Care Provider Referral Form. 

• Orient all new members on what your office hours are, how to reach you after hours, and what kinds of conditions you will see urgently. Heart Failure, COPD/Asthma in older adults, bacterial pneumonia and urinary tract infections continued to be top diagnosis for ambulatory care sensitive conditions.
• Monitor the Provider Portal Linked Members Inpatient Admissions report as a tool for tracking linked members who are admitted to the hospital or have been discharged based on eCensus data.
• Contact and schedule members that have been discharged from the hospital to see their PCP within 14 days.
• Review discharge instructions to ensure members understand their post care and have assistance at home during their recovery time.
• Route after hours calls for Alliance members to the Alliance’s Nurse Advice Line: 1 (844) 971-8907.
• Refer patients that have transportation challenges to the Alliance’s Transportation Coordinator at 1-800-700-3874 ext. 5577; this service is not covered for non-medical locations or appointments that are not medically necessary

1 Freund T, Campbell SM, Geissler S, et al. Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions. Ann Fam Med. 2013;11(4):363-370. doi:10.1370/afm.1498