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www.ahrq.gov/sops/surveys/medical-office/supplemental-items/index.html
May 01, 2021 - Items for Medical Office SOPS
All SOPS ® surveys are composed of standardized questions—referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
March 01, 2023 - order set in such a way that all patients
with a qualifying diagnosis and/or procedure for CR are referred … ALL patients with an agreed-upon set of codes should be automatically
referred/opted in. … And ONLY patients with the agreed-upon set of codes should be
referred/opted in. … You will need to decide whether any such patients
should be referred or whether they should be flagged … The wrong patients are
getting referred.
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-ex517.html
March 01, 2013 - This measure calculated the proportion of all patients with risk factors referred for intensive counseling … behavior and engaged to address the unhealthy behavior (A1-A3)
Numerator:
Number of patients referred
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra-16-p001-3-ef.pdf
April 01, 2016 - Patients who were referred for follow-up
services but did not continue care in
the medical home where … families do not follow through with referrals, and
families often do not understand where they are being referred … more
children are being identified and linked to services as feedback on eligibility status of the referred … Children should also be referred to community-based family support services such as respite care,
parent-to-parent
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-implementation-guide.pdf
March 01, 2023 - actionable, step-by-step guidance for
redesigning processes to enhance care coordination for patients referred … Patients referred to CR come from diverse backgrounds and face a wide variety of challenges
that can … Working with the providers to understand opt-outs and ease concerns to ensure
eligible patients are referred … Follow up with patients who were referred but failed to enroll --
or who enrolled but never attended … These environmental
factors are referred to as SDOH.
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter1.html
December 01, 2017 - Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure project, also referred … , IHS is incorporating patient-centered, medical home concepts throughout its system, using a model referred
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-14.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … Medicine
Denominator:
Clinicians in the area who have at least six dementia patients and who referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-slides.pdf
October 28, 2021 - Automatic
referral (AR) of
eligible patient
to CR
• AR + ordering
clinician
conversation
with referred … of CR
Automatic referral alone enrollment &
participation
Care coordination is needed to get referred … processes and
activities designed and systematically
executed to help ensure eligible
patients get referred … patients
Short length of stay: hours -> a few
days
Helps ensure clinician conversations
about CR w/ referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
February 09, 2022 - - Which patients currently
referred?
- Are some dx missing? … - Who decides which
patients are referred? … Surgeon
A Program’s Call to Action
Per AACVPR Registry:
Of eligible MI, PCI, and CABG patients
referred … Per Advisory Board:
Just over half of eligible MI, PCI, and
CABG patients are referred to cardiac
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-8-slides.pdf
November 18, 2021 - processes and
activities designed and systematically
executed to help ensure eligible
patients get referred … productive use
29
Workflow Processes to Support Referrals to Phase II
GOAL: Eligible patients are referred … letter
Referring eligible patients to CR (automatic referral)
Informing external CR programs about referred … completion by underrepresented
patient groups – CR program overall
Percent of eligible patients referred
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-implementation-guide.pdf
June 02, 2025 - • Training for CR staff coordinating the care of patients who have been referred on how to
use … Staff will need to know how to obtain information about each
patient who has been referred, including … service
# Of referred clients seen at referring service
# Of clients referred from initiating … o Institutional loss of patients referred to CR is revenue leakage. … The wrong
patients are
getting referred.
• ICD-10 codes used to build order set?
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6e.pdf
July 07, 2017 - “Patients are often informed
that they will be ‘referred’
but have little or no influence
on the process … or knowledge
about who they will be
referred to or how long the
expected wait will be.” … guidelines is to identify which clinical conditions the PCPs should manage
themselves and which should be referred … them are more obvious: more effective care for
patients, higher relative value units (RVUs), and more referred
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlasapd4.html
March 01, 2013 - After you referred your patients and family caregivers to the ASCP, did you receive a treatment plan … (Circle your answer)
Yes, for all patients (even if only one patient referred).
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www.ahrq.gov/sops/surveys/supplemental-items.html
February 01, 2025 - The AHRQ Surveys on Patient Safety Culture® (SOPS®) surveys are composed of standardized questions—referred
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www.ahrq.gov/cahps/surveys-guidance/hospital/index.html
November 01, 2023 - CAHPS Hospital Survey
The CAHPS Hospital Survey (often referred to as HCAHPS or Hospital CAHPS
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/user-guide.pdf
June 02, 2025 - describes the aims and proven benefits of
effective CC; provides guidance on improving CC processes for referred … after reviewing your data, you find your program has processes in place
to ensure CR enrollment of all referred … patients, but not all eligible patients are being
referred or referrals are being inequitably made across
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-15.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … Medicine
Denominator:
Clinicians in the area who have at least six dementia patients and who referred
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-16.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … Medicine
Denominator:
Clinicians in the area who have at least six dementia patients and who referred
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-12.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … Medicine
Denominator:
Clinicians in the area who have at least six dementia patients and who referred
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-apptabA-3.html
October 01, 2013 - Measure 14: Patients referred to a community health educator referral liaison (CHERL)
A-18. … discussion of treatment plan with patients or family caregivers (ASCP Physician Survey)
14
Patients referred