Ambulatory Care Sensitive Admissions Tip Sheet

Incentives are paid to the linked primary care provider (PCP) on an annual basis, following the end of quarter four. For additional information, refer to the CBI Technical Specifications.

• Administrative members at the end of the measurement period.
• Dual coverage members.
• California Children’s Services (CCS) members.
• Condition-specific as outlined by the AHRQ.

The ambulatory care sensitive conditions listed below are derived from the Prevention Quality Indicators in Inpatient Settings Measures (PQIs) and the Pediatric Quality Indicator Measures (PDIs) criteria released by the Agency for Health Care Research and Quality (AHRQ). The list of diagnoses for the measure include:

• 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 with diabetes.
• Pediatric asthma.
• Pediatric gastroenteritis.
• Pediatric short-term diabetes.
• Pediatric urinary tract infection.
• Uncontrolled diabetes.
• Urinary tract infection.

Data for this measure is collected using claims.

• Educate all members to:
  • Use Alliance health education and chronic disease self-management programs
    to help them achieve healthier outcomes:
    • Healthy Breathing for Life Program – Asthma
    • Healthier Living Program (HLP) workshops – Chronic Conditions.
    • Live Better with Diabetes program – Diabetes/Prediabetes.
    • Weight Watchers program – Adult Weight Management.
    • Healthy Weight for Life (HWL) program workshops – Children ages two to 18
    • Healthy Moms and Healthy Babies (HMHB) program – Early prenatal and postpartum care
    • Tobacco Cessation Support Program (TCSP) – Quitting Tobacco.
  • Understand and manage their conditions through health education resources.
    • Asthma Action Plans – Regional Asthma Management & Prevention (RAMP).
    • My COPD Action Plan – American Lung Association:
      • English
      • Spanish
    • Steps to Help You Stay Healthy with Diabetes – CDC.
  • Use Ask Me 3: Good Questions for Your Good Health during visits to encourage them to ask three specific questions to better understand their health conditions and what they need to do to stay healthy:
    • What is my main problem?
    • What do I need to do?
    • Why is it important for me to do this?
  • Discover how to Get Ahead of Sepsis.
• Assign clinical staff to:
  • Identify members at high risk for hospitalization and provide:
    • Regular medication reviews (what medication is taken and how?).
    • Regular monitoring of symptoms and treatment adherence in high-risk patients.
    • Self-management training and caregivers to help identify when to manage acute deterioration or when to seek timely care from the PCP.
    • Assistance 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.

• Provide members information on your office hours, how to reach you after hours, and what conditions you will see urgently.
  • Heart failure, COPD/asthma in older adults, bacterial pneumonia and urinary tract infections continue to be the top diagnoses for ambulatory care sensitive conditions.
• Monitor the Provider Portal Linked Members Inpatient Admissions report to track linked members who are admitted to the hospital or were discharged based on eCensus data.
• Contact and schedule members that were 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.

• Alliance Cultural and Linguistic Services are available to network providers.
  • Language Assistance Services – request materials at 800-700-3874, ext. 5504.
  • Telephonic Interpreter Services – available to assist in scheduling members.
  • Face-to-Face Interpreter Services – can be requested for the appointment with the member.
  • For information about the Cultural and Linguistic Services Program, call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].
• Alliance Enhanced Care Management (ECM) and Community Supports.
  • Refer Alliance members through the Alliance Provider Portal, email [email protected], mail or fax, or by phone at 831-430-5512.
• For Complex Care Management and Care Coordination, call the Care Management team at 800-700-3874 (TTY: Dial 711).
• Alliance Nurse Advice Line to talk to a nurse.
  • 844-971-8907 (TTY: Dial 711).
  • Educate all members to use the Alliance Nurse Advice Line that is available to all Alliance members 24 hours a day, 7 days a week to discuss health concerns to avoid hospital readmissions and preventable emergency visits.
  • Add to your phone-tree and route after-hours calls from Alliance members.

• Alliance Transportation Services for patients with transportation challenges.
  • Non-emergency medical transportation (NEMT), call 800-700-3874, ext. 5640
    (TTY: Dial 711).
  • Non-medical transportation (NMT), call 800-700-3874, ext. 5577 (TTY: Dial 711).
• Carelon Behavioral Health Primary Care Provider (PCP) Referral Form.
• Carelon Care Management Referral Form.
• Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions.