Q150_Health_System_Area_Assessment_Report_06.22.15.pdf

DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

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Page of Pages

Health System Area Assessment

PSA: XXXX; MTF DMIS: XXXX

Market Director: Xxxxxx

As of MM/DD/YYYY

Health System Manager –

Contract Office Name XXXX Post/Base – Xxxx Clinic/Hosp/Med Ctr

Health Systems Consultant

Population Assessment

TRICARE Eligible Penetration

Total Population (http://quickfacts.census.gov/qfd/states/22000.html)

XXXXXXXX

TRICARE Eligible

XXXX

Percentage of Total Population X.X%

Total Spend CY XXXX

Total AD ADD NAD/NADD

$XX,XXX,XXX $X,XXX,XXX $X,XXX,XXX $XX,XXX,XXX

Eligibles By Beneficiary Category / Age

Ben CAT 0‐17 18‐39 40‐49 50‐64 65+ Total

AD XX XX XX XX XX XX

ADD XX XX XX XX XX XX

NAD XX XX XX XX XX XX

NADD XX XX XX XX XX XX

Total XX XX XX XX XX XX

By Enrollment Category/Gender/Age

Enrollment Gender 0‐17 18‐39 40‐49 50‐64 65+ TOTAL

MTF Prime Total XX XX XX XX XX XX

MTF Prime M XX XX XX XX XX XX

MTF Prime F XX XX XX XX XX XX

Civilian Prime Total XX XX XX XX XX XX

Civilian Prime M XX XX XX XX XX XX

Civilian Prime F XX XX XX XX XX XX

NonPrime (Standard) Total XX XX XX XX XX XX

NonPrime (Standard)

M XX XX XX XX XX XX

NonPrime (Standard)

F XX XX XX XX XX XX

TRICARE Prime Remote (TPR) Total XX XX XX XX XX XX

TPR M XX XX XX XX XX XX

TPR F XX XX XX XX XX XX

TRICARE Reserve Select (TRS) Total XX XX XX XX XX XX

TRS M XX XX XX XX XX XX

TRS F XX XX XX XX XX XX

TRICARE Retired Reserve (TRR) Total XX XX XX XX XX XX

TRR M XX XX XX XX XX XX

TRR F XX XX XX XX XX XX

GRAND TOTAL XX XX XX XX XX XX

Network

Network Penetration

Licensed Physicians X,XXX

TRICARE Network Physicians X,XXX

Percentage of TRICARE Network XX%

Network Primary Care (PCMs) (within 40 miles of MTF)

Primary Care Managers (PCMs) Target: XXX

Family Practice – XXX; General Practice – X; Internal Medicine – XX; Pediatrics – XX;

Nurse Practitioners ‐X;

Total contracted – XXX

PCMs accepting new patients Family Practice – XX; General Practice – X; Internal Medicine –XX; Pediatrics – XX;

Nurse Practitioners – X;

Total contracted– XXX

Specialists (within 40 miles of MTF)

Medical Target: XXX

Total contracted ‐ XXX

Surgical Target: XX

Total contracted – XXX (Includes OB/GYN & Ortho) OB/GYN: total contracted ‐ XX (Targeted ‐ XX); Orthopedics: total contracted ‐ XX (Targeted ‐XX)

Behavioral Health Target: XX

Total contracted – XXX MDs – XX, Child MDs ‐ X; ARNPs/RNCs ‐ X; PHDS – XX; Master Level – XX

Facilities (within 40 miles of MTF)

Facilities – Medical/Surgical

Xxxxx Hospital System o Xxxxxx Hospital Main & Xxxxxxx Hospital for Women and Children – X min from MTF

XXX bed short term acute care, including XXX special care beds Neonatal, Pediatric, and Adult ICU’s 24/7 Emergency Services ‐ Designated Pediatric ER Level 1 Trauma Center Home to MedFlight Air Ambulance Comprehensive orthopedic services available OB services available ; average 4X,XXX births/year according to American

Hospital Association (AHA) Data report Nursery – XX bassinets, currently using XX Labor Delivery Recovery Postpartum (LDRPs) ‐ XX rooms OR Suites – XX

Xxxxxx Medical Center ‐ XX minutes from MTF o XXX bed short term acute care, including XX special care beds, to include neonatal ICU o 24/7 Emergency Services (Level III) o Comprehensive orthopedic services available o OB services available; average XXX births/year according to American Hospital

Association (AHA) Data report o Nursery – XX bassinets, currently using XX o Labor Delivery Recovery Postpartum (LDRPs) ‐ X L&D rooms / X LDRP rooms o OR Suites ‐ XX suites

Facilities – Behavioral Health Total contracted – X (can accommodate children, adolescents, adults and geriatrics)

Xxxxxx General Hospital o Inpatient Psychiatric – Children, Adolescents, Adult and Geriatric

Xxxxxx Health Services o PHP Substance Abuse Half Day‐Adolescents and Adults

Xxxxxx Medical Center o Inpatient Psychiatric – Adults o Inpatient Detoxification – Adults o PHP Psychiatric Full Day‐ Adults o Emergency Room‐ Adults o XX Observation ‐Adults

Trauma Centers Xxxxxx Hospital – Level I Trauma Center

Urgent Care Centers Xxxxxx Walk‐In Family Care, (Address)

Quick Care Urgent ‐ (Address)

Urgent Care Center LLC, (Address)

Ground Ambulance Provider Xxxxx EMS – (City/State)

Mammography Provider

Free Standing ASC Xxxxx Surgery Center LLC – (Address)

Telemedicine Originating Sites

Capacity of Network

Access to Care (List those specialties with greater than 25% of the referrals going greater than 60 minutes)

Access to Care (greater than 28 days)

(Specialty) (Mitigation strategies)

Network Limitations (Existing or Expected) (PSA peculiarities)

(Specialty) (Where care is rendered/Mitigation strategies)

Community Shortfalls

Primary Care

(Specialty) (Where care is rendered/Mitigation strategies)

Medical/Surgical

(Specialty) (Where care is rendered/Mitigation strategies)

Behavioral Health

(Specialty) (Where care is rendered/Mitigation strategies)

Beneficiary Satisfaction

TROSS Benchmark Score Delta

Satisfaction with Healthcare (CAHPS) XX% XX% X%

Satisfaction with Provider (CAHPS) XX% XX% X% XX% XX% XX%

Access to Care XX% XX% X% XX% XX% XX%

Doctors Communicate XX% XX% X% XX% XX% XX%

Office Staff XX% XX% X% XX% XX% XX%

Satisfaction with Healthcare (BSC) XX% XX% X% XX% XX% XX%

Satisfaction with Provider (BSC) XX% XX% X% XX% XX% XX%

TRISS Benchmark Score Delta

Huntsville Hospital‐ Overall Hospital Rating

XX% XX% X%

XX% XX%

XX%

Recommend the Hospital XX% XX% X%

XX% XX% XX%

Discharge Information XX% XX% X%

Communication with Doctors XX% XX% X%

Communication with Nurses XX% XX% X%

Cleanliness of Hospital Environment XX% XX% X%

Pain Management XX% XX% X%

Communication about Medicines XX% XX% X%

Quietness of Hospital Environment XX% XX% X%

Responsiveness of Hospital Staff XX% XX% X%

Care Transition XX% XX% X%

Other Factors to Consider/Barriers

Military Treatment Facility

MTF Leadership

Commander – Deputy Commander Clinical Services – Deputy Commander Nursing – Deputy Commander Administration – Contract Liaison –

MTF capabilities (i.e. clinic only; bedded facility with XX beds, etc.)

Recapture Initiative Goal

External Resource Sharing Agreements (ERSA)

Clinical Support Agreements (CSA)

Map of Plan Area