Ursa Health Population Health Foundations Module

Overview

The Ursa Health Population Health Foundations (PHF) module establishes a solid foundation for population health programs with performance measures covering essential concepts related to utilization and financial performance, as well as data marts with key patient features and risk factors, such as socioeconomic deprivation, chronic disease burden, primary care provider attribution, and plan membership status.

The assets in this module build on the many useful concepts implemented in the Ursa Health Core Data Model, integrating claims, billing, and EMR encounter data, when available, to present a robust picture of each patient. The module also includes a number of pre-loaded groupers that allow financial outcomes to be split by care setting, service type, encounter type, and other dimensions. The results are dynamic, reflecting changes to a patient’s status longitudinally, allowing tracking of performance over time. This module represents 50+ frequently used measures for population health analytics. Concepts introduced in URSA-PHF will carry forward into analytic modules beyond URSA-PHF.

Assets in this module are identified by the namespace URSA-PHF.

Reports

• URSA-PHF | Summary Dashboard
• URSA-PHF | Basics
• URSA-PHF | Hospital Utilization Metrics
• URSA-PHF | Hospital Inpatient Readmission Metrics
• URSA-PHF | Clinician & Primary Care Visit Metrics
• URSA-PHF | Surgical Encounter Metrics

Release Notes

• Ursa Health Population Health Foundations Release Notes

Measures

• URSA-PHF-R01: Patients with Active Membership
• URSA-PHF-R02: Hospital IP & ED High Utilizers
• URSA-PHF-R03: Registry of all URSA-CORE Encounters
• URSA-PHF-R04: Registry of Hospital Inpatient Encounters
• URSA-PHF-R05: Registry of Hospital Observation Stay Encounters
• URSA-PHF-R06: Registry of Emergency Department Encounters
• URSA-PHF-R07: Registry of URSA-CORE Surgical Encounters
• URSA-PHF-R08: Registry of SNF Encounters
• URSA-PHF-R10: Registry of Claims
• URSA-PHF-R11: Registry of Clinician Office Visits
• URSA-PHF-R12: Registry of Primary Care Office Visits
• URSA-PHF-001: PMPM Plan Spending
• URSA-PHF-001b: Simplified PMPM Plan Spending
• URSA-PHF-002: Hospital Inpatient Admission PMPM Plan Spending
• URSA-PHF-003: ED Visits without Admission PMPM Plan Spending
• URSA-PHF-004: Clinician Office Visit PMPM Plan Spending
• URSA-PHF-004b: Primary Care Office Visit PMPM Plan Spending
• URSA-PHF-005: Hospital Observation Encounter PMPM Plan Spending
• URSA-PHF-006: Surgery Encounter PMPM Plan Spending
• URSA-PHF-006b: ASC Encounter PMPM Plan Spending
• URSA-PHF-007: SNF Stay PMPM Plan Spending
• URSA-PHF-009: URSA-CORE Encounter PMPM Plan Spending
• URSA-PHF-009b: Hospital Encounter PMPM Plan Spending
• URSA-PHF-010: PMPM Patient Spending
• URSA-PHF-011: Spending per URSA-CORE Encounter
• URSA-PHF-013: Plan Paid Per Clinician Office Visit
• URSA-PHF-020: Inpatient LOS in Midnights per 1000 Member-Years
• URSA-PHF-020b: Inpatient LOS in Midnights per 1000 Member-Years
• URSA-PHF-021: Admits per 1000 Member-Years
• URSA-PHF-022: ED Visits per 1000 Member-Years
• URSA-PHF-023: Clinician Office Visits per 1000 Patient-Years
• URSA-PHF-023b: Primary Care Office Visits per 1000 Patient-Years
• URSA-PHF-024: Observation Encounters per 1000 Patient-Years
• URSA-PHF-025: Surgery Encounters per 1000 Patient-Years
• URSA-PHF-026: Hospital Encounters per 1000 Member-Years
• URSA-PHF-027: SNF Stays per 1000 Member-Years
• URSA-PHF-028: SNF LOS in Midnights per 1000 Member-Years
• URSA-PHF-028b: SNF LOS in Days per 1000 Member-Years
• URSA-PHF-029: URSA-CORE Encounters per 1000 Member-Years
• URSA-PHF-030: 30-Day All-Cause Readmissions
• URSA-PHF-030b: 7-Day All-Cause Readmissions
• URSA-PHF-030c: 90-Day All-Cause Readmissions
• URSA-PHF-031: Subsequent Hospital IP Admits within 1 Year
• URSA-PHF-032: Observation to Hospital IP Conversion Rate
• URSA-PHF-033: Emergency Dept. to Hospital IP Conversion Rate
• URSA-PHF-034: Patients with PCP Visit Last 12 Months
• URSA-PHF-035: Patients with AWV Last 12 Months
• URSA-PHF-036: Post-Inpatient Primary Care Visit within 7 Days
• URSA-PHF-036b: Post-Inpatient Office Visit within 7 Days
• URSA-PHF-040: Post-Op 90 Day Episode Plan Spending
• URSA-PHF-041: Post-Op 180 Day Episode Plan Spending
• URSA-PHF-042: Pre-Op 180 Day Episode Plan Spending
• URSA-PHF-043: 90-Day Post-Op All-Cause Hospital IP Admission
• URSA-PHF-044: 30-Day Post-Op All-Cause Hospital IP Admission
• URSA-PHF-045: Post-Op Clinician Office Visit within 14 Days
• URSA-PHF-046: Percent of Surgery Encounters Discharged Home
• URSA-PHF-047: Surgery Discharges with SNF Stay within 7 Days
• URSA-PHF-050: SNF Encounter Average LOS in Calendar Days
• URSA-PHF-051: SNF Encounter Plan Paid per Day
• URSA-PHF-052: SNF Encounter Average Plan Paid
• URSA-PHF-060: Observation Discharge 60-Day Return to Inpatient
• URSA-PHF-061: Observation Discharge 60-Day IP Plan Spending
• URSA-PHF-901: Patients with Active Membership (Reduced Fields)
• URSA-PHF-902: Registry of Claim Financials (Reduced Fields)
• URSA-PHF-903: PMPM Plan Spending (Reduced Fields)