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Announcing LHP’s 2023 Clinical Integration program

We are pleased to announce the 2023 clinical integration program to the network. You can view a summary of all 2023 performance measures, membership requirements, and access standards on the LHP team site.

Our clinical integration program will remain mostly the same in 2023 with a few new measures and updates to existing measures to ensure we’re measuring and improving what matters to patients, our network of providers, and to insurance payors.

Update or change

Measure Name



Provider-level measures for adult primary care

Medication reconciliation post-discharge

Medications are often changed while a patient is hospitalized. Continuity between inpatient and on-going care is essential.

Advance care planning

To ensure patient’s wishes regarding medical treatment are established as much as possible prior to incapacity.


Practice attestation measure for adult primary care practices

Proficiency in Medicare Star measures and workflows

Since clinics within LHP follow workflows for monitoring outcomes for their Medicare Advantage populations and reporting (like completing fall risk assessments, medication adherence, and follow-up after ED visits) that is specific to their operations and EMR systems, practices will provide information about how they monitor patient discharges, how they follow-up with patients, and how they document in their EMR that these processes took place.


Network measure for OB/GYN providers

Syphilis screening during pregnancy

Syphilis infection rate is an epidemic in our region and it is recommended that pregnant women be tested for syphilis three times, representing more frequent testing than is done in areas where syphilis is not epidemic.


Refining utilization measure definitions; applicable to all specialties

Ambulatory care sensitive admissions per 1,000

Replaces the current ‘Admissions per 1,000’ measure to identify inappropriate hospital admissions based upon evidence-based guidelines to free up capacity for appropriate admissions and improve revenue and quality.

Avoidable ED visits per 1,000

Replaces the current ‘ED visits per 1,000’ measure to identify visits for non-urgent care and conditions that could have been treated in a primary care setting.


Network measure for surgical and gynecology specialties

Surgical Site Infections (SSIs)

Overall performance will still be monitored as part of the hospital pool but is being retired at the LHP network level since we have performed well historically and the denominator size for LHP patients is small.