Measurements	Target Goal	Status	Desired Trend	Contributor	January 2017	February 2017	March 2017	April 2017	May 2017	June 2017	July 2017	August 2017	September 2017	October 2017	November 2017	December 2017	January 2018	February 2018	March 2018	April 2018	May 2018	June 2018	July 2018	August 2018	September 2018	October 2018	November 2018	December 2018	January 2019	February 2019	March 2019	April 2019	May 2019	June 2019	July 2019	August 2019	September 2019	October 2019	November 2019	December 2019	January 2020	February 2020	March 2020	April 2020	May 2020	June 2020	July 2020	August 2020	September 2020	October 2020	November 2020	December 2020	January 2021	February 2021	March 2021	April 2021	May 2021	June 2021	July 2021	August 2021	September 2021	October 2021	November 2021	December 2021	January 2022	February 2022	March 2022	April 2022	May 2022	June 2022	July 2022	August 2022	September 2022	October 2022	November 2022	December 2022	January 2023	February 2023	March 2023	April 2023	May 2023	June 2023	July 2023	August 2023	September 2023	October 2023	November 2023	December 2023	January 2024	February 2024	March 2024	April 2024	May 2024	June 2024	July 2024	August 2024	September 2024	October 2024	November 2024	December 2024
# of Waiver/CFC Assessments Completed (New & Redets.)	14	Active	Increase	Elaine	12	17	18	19	21	21	15	13	13	19	14	8	18	18	15	21	24	17	16	20	17	23	14	0.09	18	19	15	14	22	9	21	17	14	25	21	14	17	19	17	17	10	14	15	17	23	15	18	13	18	17	19	13	15	15	18	15	17	14	13	10	14	8	20	11	17	13	13	25	21	14	11	14	11	14	22	16	20	25	12	8	12	9	22	13	16	10	11	19	18	20	11	14	15	14	17
Waiver/CFC Nurse Monitoring UNITS Completed and billed	400	Active	Increase	Elaine	780	816	842	706	805	515	537	549	443	489	386	565	485	225	306	372	570	604	592	475	478	572	475	648	500	464	338	416	322	392	247	405	443	398	355	445	495	478	381	550	542	518	534	517	511	417	514	512	350	401	439	562.99	423	408	444	531	447	323	460	417	403	356	344	370	315	237	402	327	320	362	307	278	405	267	394	315	257	296	354	455	257	206	371	352	263	218	289	237	308	168	353	311	231	269	268
Percentage of Waiver/CFC Assessments completed by requested due date (Referral Log Clinic Analysis Report in PatTrac)	70	Active		Elaine																																					48	26	11	40	25	33	15		35	47	67	67	70	92	82	69	81	57	53	58	41	40	80	80	62	67	73	50	60	61	22	25	52	52	56	57	78	71	60	76	61	74	92	90	96	74	81	72	88	80	69	67	68	71	80	78	79	84	73
Total Number of Nurse Monitoring VISITS Completed in the month	30	Active																																																						39	32	31	34	35	34	24	37	34	35	29	33	31	27	23	39	33	29	33	31	24	32	27	39	29	22	29	31	38	23	17	33	38	25	20	32	26	29	17	36	29	20	23	24
Number of Patients receiving C.F.C. /C.O.W. services on the last day of the month.	150	Active																																																						167	171	173	173	175	176	181	185	180	184	189	192	192	200	182	206	181	192	206	218	246	255	285	297	309	330	333	349	355	350	358	363	361	365	379	384	379	394	400	401	425	432	457	477

Data Narrative

• Measure 1: The number of Assessments completed. The assessment that AERS completes is called an InteRAI. It is a thorough collaborative diagnostic tool that is used to improve the quality of life of vulnerable persons through a seamless comprehensive assessment. The assessment captures the patient’s mental and physical health conditions, the medicines they take, and how well they function with ADL’s and IADL’s.  It also looks at patient’s need for housing, medical equipment, transportation.  The ultimate goal is to connect the patient with resources that will allow them to stay in their own home longer, living independently for as long as possible and also to reduce nursing facility and hospital admissions in the community.  In addition, it is used to approve someone for assistance in the home under the Medicaid Community First Choice or Community Option’s Waiver.  We list this measure as a goal, as it is the goal of AERS to assist as many individuals as possible to be able to stay in their homes or the community with any assistance that may be available and that they qualify for. We based this goal on how many assessments have been completed in the last two fiscal years, and comparing staffing then to what we have now.
• Measure 2: The number of Nurse Monitoring Units that are completed. Nurse Monitoring is also an integral part of AERS’ duties to patients who are currently receiving services under the Community First Choice or Community Options Waiver Programs.  AERS nurses have been tasked by the state to oversee the care that patients are receiving under these programs, to be sure their needs are being met and the services that were written into the Plan of Service are being carried out.  Billing, reimbursement and tracking is done by the amount of time that is required to carry out these duties for each client.  It is calculated and paid in “units”, with time of greater than or equal to 8 minutes, but less than 23 minutes equaling one unit.  Two units is equal to a time of greater than or equal to 23 minutes, but less than 38 minutes, and it continues to go up from there.  Therefore, we chose to report units so that the work done reflects patients are being monitored on a consistent basis, and that monitoring is helping them access medical care and stay in their home. We based this goal on how many assessments have been completed in the last two fiscal years, and comparing staffing then to what we have now.

• Measure 3: The percentage of InteRAI assessments that were referred to us monthly will be completed by the due date. This measure was chosen as it is the goal of AERS to complete assessments in the timeliest way possible in order to assist patients in getting some help as quickly as possible and ultimately reduce nursing facility and hospital admissions.  We are given a time frame by the state for the InteRAI to be completed within 15 business days from the date of the referral.  Sometimes, getting that accomplished is out of our control due to waiting on medical records to be received from the medical provider, not being able to get in contact with the patient to schedule their appointment, or a shortage of AERS staff.  Our goal is to get those completed by the due date at least 70% of the time, while maintaining sufficient staff. We based this goal on the percentage of assessments completed on time in the last two fiscal years when we were fully staffed with nurses. All assessments must be referred for completion to the AERS division of the health department, as mandated by the state. We realized that we were measuring 15 working days, but PatTrac only measures calendar days, so we changed our report in PatTrac to 21 calendar days, thereby more accurately reflecting 15 working days.  This was done late in the year, so we want to give several months to see if this change made a difference.
• Measure 4: The number of Nurse Monitoring Visits completed - This measure was chosen because it is easier to compare number of visits, as opposed to # of units billed.
• Measure 5: The number of clients being served on the program. This measure was chosen because we want to accurately reflect how many clients are being served by  these programs and show that the number of patients being served and the services they are receiving correlate to obtain the goals. We based this goal on the average number of patients that are in this program monthly.

Presently, the state mandates that the AERS division at the local health department is the only entity responsible for the initial and redetermination evaluations.  Therefore, all referrals for this program (most of which originate from MAP) must come to the health department AERS division. The data reported above is collected from the following sources: # of  assessments completed - obtained from a list maintained by the office administrator and reviewed with nursing staff # of Nurse Monitoring Units completed and billed in a month - Obtained from a report in LTSS, under Activity & Billing Reports, entitled SPA-NM Activity Report. Units are calculated based on how many minutes each activity required. % of Assessments completed by the due date -  a report in PatTrac , located under Clinic Reports, and titled Referral Log Clinic Analysis. # of Nurse Monitoring Visits completed in a month - obtained from the nurses, self-reporting # of patients receiving services in the current month - obtained from a report in PatTrac titled AERS Caseload by Program and Service Area.      

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