2019 quality program work plan - ucare*monitoring of previously identified issues in 2018 2019...
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03/20/19: Approved by the Quality Improvement Committee03/28/19: Approved by the Quality Improvement Advisory and Credentialing Committee04/10/19: Approved by the Board of Directors
2019 Quality Program Work Plan
UCare – 500 Stinson Boulevard NE – Minneapolis, MN 55413 – www.ucare.org
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 1
UCare Focus Area
Admin Administrative
MemX Member Experience
QCC Quality of Clinical Care
QS Quality of Service
SCC Safety of Clinical Care
Products
EC EssentiaCare
MNC MinnesotaCare
MSC+ Minnesota Senior Care Plus
MSHO Minnesota Senior Health Options
PMAP Families and Children Prepaid
Medical Assistance Plans
IFP Individual and Family Plans
UCT UCare Connect (Special Needs Basic
Care)
UCT-M UCare Connect + Medicare (HMO
SNP)
UMP UCare Medicare Plans
FV/NM UCare Medicare with Fairview and
North Memorial
Committees
CR Credentialing Committee
MMC Medical Management Committee
QMIC Quality Measures Improvement Committee
QIC Quality Improvement Committee
QIACC Quality Improvement Advisory and Credentialing Committee
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Admin 2018 Annual
Program
Evaluation
(on 2018 QI
Activities)
All Products Evaluate the
effectiveness of the
Quality Program to
include monitoring
activities and clinical,
operational, and
satisfaction
initiatives.
*
Complete Annual
Program
Evaluation.
Annual evaluation
report submission
to DHS.
NCQA QI
1B, Minn.
Rules
4685.1110,
sub 8
Minn. Rules
4685.1115
Minn. Rules
4685.1120
2018 Program
Evaluation
VP,
Quality
Mar Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 2
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Admin 2019 Annual
Quality Work
Plan
All Products Define quality related
planning and
monitoring of
activities as well as
clinical and
operational
improvement for the
coming year.*
Completion of
2019 Work Plan for
all products based
on regulatory
requirements and
findings from
previous QI
Program
Evaluation. Annual
Quality Work plan
submission to
DHS.
NCQA QI
1A, Minn.
Rules
4685.1115
Minn. Rules
4685.1130
Minn. Rules
4685.1125,
sub 2
2019 Work
Plan
VP,
Quality
Mar Mar
Admin 2019 Quality
Program
Description
All Products Annual review of
Quality Program and
structure.
Complete Quality
Program
description.
Program structure
changes made as
indicated.
Send to MDH
Annually or with
any changes.
NCQA QI
1A, Minn.
Rules
4685.1110,
sub 1-13
Minn. Rules
4685.1115,
Minn. Rules
4685.1130,
sub1
2019 Program
Description
VP,
Quality
Mar Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 3
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QS Access and
Availability
Monitoring
All Products Ensure providers are
meeting regulatory
and UCare access
standards.*
Ensure network is
adequate to meet
members' needs.*
Improve the
network
appointment
availability
assessment process.
Seek additional
behavioral health
and high-use
specialty
contracting
opportunities,
focusing on rural
areas.
Applicable member
satisfaction surveys
(e.g. CAHPS)
Quarterly forums
with member-
facing staff.
NCQA NET 1
and NET 2
42 CFR §§
438.206 and
438.207
MN Statues
Sections 62
D.124 and 62
Q.55
Minn. Rules
4685.1010
Access and
Availability
Report
VP, PRC Jul
SCC Adverse
Actions Bi-
Annual
Report
All Products Ongoing monitoring
of practitioner
sanctions, complaints,
and quality issues
between
Recredentialing
cycles, and take
appropriate action
against practitioners
when occurrences of
poor quality are
identified.*
Identify and when
appropriate, act on
important quality
and safety issues in
a timely manner
during the interval
between formal
credentialing.
Monitor
practitioner-
specific complaints
and adverse events.
Report findings
semi-annually.
NCQA CR 5
A
Adverse
Actions Report
VP,
Quality
Feb
Aug
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 4
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Admin Annual Non-
Discriminatio
n Report
All Products Identify and track
incidences of
discrimination in the
Credentialing
process.*
Complete audits of
credentialing files
to monitor the
Credentialing and
Recredentialing
process to prevent
and/or identify any
discriminatory
practices.
Complete audits of
practitioner
complaints for
evidence of alleged
discrimination.
NCQA CR 1 Annual Non-
Discrimination
Report
VP,
Quality
Oct
Admin Annual
Review of
Criteria for
Credentialing
File Review
Grid
All Products Annual review of
Credentialing File
Review Grid.
Review and update
Criteria for
Credentialing File
Review Grid
NCQA CR 1 Criteria for
Credentialing
File Review
Grid
VP,
Quality
Mar
QCC Annual
Review of
UM Criteria
All Products Annual review of UM
written criteria based
on sound clinical
evidence to make
utilization decisions,
and specify
procedures for
appropriately
applying the criteria.
Review and apply
objective and
evidence-based
criteria, and take
individual
circumstances and
the local delivery
system into account
when determining
the medical
appropriateness of
health care
services.
NCQA UM 2
DHS Contract
UM Criteria VP/CNO Nov Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 5
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Annual
Utilization
Management
Evaluation
All Products Complete an annual
evaluation of the UM
program to determine
if the program
remains current and
appropriate.*
Evaluate the UM
program structure,
scope, processes,
and information
sources used to
determine benefit
coverage and
medical necessity.
Evaluate the level
of involvement of
the senior-level
physician and
designated
behavioral
healthcare
practitioner in the
UM program.
Identify relevant
measures and
analyze results to
identify
opportunities for
improvement.
NCQA UM 1 Annual
Utilization
Management
Evaluation
VP/CNO Mar
Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 6
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QS Assessment
of Network
Adequacy and
Marketplace
Network
Transparency
and
Experience
All Products Monitor access to
healthcare services
and take action to
improve it through
member surveys,
Grievances and
Appeals, and out-of-
Network requests.*
Inform members of
the criteria used to
select hospitals and
practitioners for
participation in plan
networks, and
monitor member
experience with plan
services.*
Review member
satisfaction surveys
(CAHPS, QHP, and
ECHO.)
Seek additional
Primary Care,
Specialty, and
Behavioral
Healthcare provider
contract
opportunities.
Monitor trends in
member
Grievances and
Appeals, and out-
of-network
requests.
Provide members
information to
assist in selecting a
plan and monitor
member experience
to identify
opportunities for
improving plan
offerings.
NCQA NET
3 and NET 4
Assessment of
Network
Adequacy
Report and
Marketplace
Transparency
and
Experience
Report
VP, PRC Jul
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 7
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QS Assessment
of Provider
Directory
Accuracy
All Products Evaluate and identify
opportunities to
improve the accuracy,
and take action to
improve the accuracy
of the information in
the physician
directories.*
Conduct data
validation to
determine accuracy
of the physician
directory.
Identify and act on
opportunities for
improvement.
Implement the new
online solution
(DXT) where
providers can login
securely to a site to
review and update
the practitioner and
site records.
Conducting calls to
verify accuracy of
provider
information.
NET 6 C and
D
42 CFR §§
438.206 and
438.207
MN Statues
Sections 62
D.124 and 62
Q.55
Minn. Rules
4685.1010
Physician and
Hospital
Directories
VP, PRC Jul
Mem
X
CAHPS and
ESS Report
All Products Provide comparative
information on
performance of
Managed Care
organizations and
help identify areas of
improvement.
Achieve a rating at or
above the national
average for CAHPS
(UMP and MSHO)
and ESS.
Achieve a rating at or
above the MN
average for CAHPS
(MHCP).
Focus Areas (below
national/state
average):
Measure
satisfaction of
services with
CAHPS questions
in comparison with
other MCO plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Identify
Opportunities for
Improvement.
-Customer
Service training.
42 CFR §§
422.152 and
422.516
CAHPS and
ESS Survey
Results
VP,
Quality
Nov Nov Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 8
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
UMP
-Rating of Drug Plan
8.40*
MSHO
-Rating of Health
Plan 8.60*
-Getting Needed Care
3.42*
-Customer Service
3.63*
-Getting Needed
Prescription Drugs
3.67*
Connect+Medicare
-Rating of Health
Care Quality 8.4
-Rating of Health
Plan 8.6
-Getting Needed Care
3.46
-Customer Service
3.69
-Getting Needed
Prescription Drugs
3.67
IFP
-Rating of Health
Plan 6.92*
-Access to
Information 2.05*
-Annual Flu Vaccine
1.79
PMAP
-Rating of Personal
Doctor 70%
-Rating of Specialist
75%
-Getting Care
Quickly 56%
-Member
education
materials.
-Provider
education
(example: PCP,
ADC.)
-Off cycle
CAHPS survey.
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 9
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
-How Well Doctors
Communicate 81%
-Customer Service
67%*
MnCare
-Customer Service
63%*
MSC+
-Rating of All Health
Care 51%*
-Rating of Personal
Doctor 61%
-Rating of Specialist
64%
-Rating of Health
Plan 53%*
-Getting Needed Care
45%*
-Getting Care
Quickly 44%*
-How Well Doctors
Communicate 69%
-Customer Service
47%*
Connect
-Rating of All Health
Care 49%*
-Rating of Personal
Doctor 71%
-Rating of Health
Plan 60%*
-Getting Needed Care
53%*
-Getting Care
Quickly 58%*
-How Well Doctors
Communicate 70%
-Customer Service
68%*
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 10
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC CCM
Program
Evaluation
All Products Help members regain
optimum health or
improve functional
capability, in the right
setting and in a cost-
effective manner.*
Coordinate services
for the highest risk
members with
complex conditions
and help them access
needed resources.*
Identify relevant
process or
outcome, measure
and analyze results,
and identify
opportunities for
improvement.
Integrate Complex
Case Management
strategy (PHM 5)
with the Population
Health
Management
Strategy (PHM 1
and 2).
Identify and inform
eligible members of
the CCM program.
NCQA PHM
1, 2, 5, and 6
A and B
CCM Program
Evaluation
VP/CNO May
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 11
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Mem
X
CCM
Satisfaction
Report
All Products Evaluate CCM
experience through
member feedback to
improve the CCM
program.*
Obtain feedback
from members for
the following using
a satisfaction
survey:
-Information
about the overall
program.
-The program
staff.
-Usefulness of
the information
disseminated.
-Members'
ability to adhere to
recommendations.
-Percentage of
members indicating
that the program
helped them
achieve health
goals.
NCQA PHM
5 F
CCM
Satisfaction
Report
VP/CNO May
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 12
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Chronic Care
Improvement
Program
(CCIP)
UMP
MSHO
UCT-M
Reduce inpatient
admissions per 1000
rates by 1% each
year.
Reduce emergency
department visits per
1000 rates by 1%
each year.
Quarterly mailing
to members with 2-
6 chronic
conditions. Each
mailing includes a
quarterly focus,
healthy recipe,
health tips and
resources (all
related to the
quarterly focus
topic). Quarterly
focus topics include
nutrition,
preventive services,
physical activity
and stress
management. An
annual member
satisfaction survey
will also be sent to
participating
members.
43 CFR §§
422.152
CCIP Report VP/CNO Oct Nov
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 13
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
SCC Clinical
Practice
Guidelines
All Products Ensure that
guidelines are
adopted, approved,
reviewed and
monitored by
QIACC.
Existing guidelines
are reviewed and
updated every two
years.
Distribute to
providers and
members according
to State and Federal
standards.
42 CFR §§
438.236
Obesity
Heart Failure
Preventive
Adults
Preventive
Child and
Adol
BH (review
due summer
2020):
Assess and
Treatment of
Child and
Adol
w/AD/AH
Disorder
Assess and
Treatment of
Child and
Adol
w/Depressive
Disorders
Treatment of
patients
w/Major
Depressive
Disorder
Treatment of
patients
w/Schizophren
ia
Treatment of
Patients
w/Substance
Use Disorders
(SUD)
VP/CNO Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 14
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Mem
X
Complaint
Trend Report
All Products Support member by
resolving issues of
dissatisfaction with
UCare.
Standard for meeting
timelines: 95%.*
External report
requirements are met
100% of the time.*
Track complaints,
assess trends, and
establish that
corrective action is
implemented and
effective in
improving the
identified
problems.
Serve as member
advocates by
processing
concerns in a
timely manner.
Provide internal
training on appeal
and grievances
trends.
Minn. Rules
4685.1110,
sub 9
A&G Trend
Report
VP,
Quality
Mar
May
Sep
Nov
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 15
QCC Continuity
and
Coordination
between
behavioral
care and
medical care
All Products Collaborate with
behavioral healthcare
practitioners to
monitor and improve
coordination between
medical care and
behavioral
healthcare.*
Collect and analyze
data to identify
opportunities for
improvement of
coordination
between behavioral
and medical care in
the following areas:
-Exchange of
information.
-Appropriate
diagnosis,
treatment and
referral of
behavioral
disorders
commonly seen in
Primary Care.
-Appropriate use of
psychotropic
medications.
-Management of
treatment access
and follow-up for
members with
coexisting medical
and behavioral
disorders.
-Primary to
secondary
preventive
behavioral
healthcare program
implementation.
-Special needs of
members with
severe and
persistent mental
illness.
Based on the
analysis and
identification of
NCQA QI 6
42 CFR §§
438.208
Continuity and
Coordination
between
behavioral
care and
medical care
AVP, BH Mar Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 16
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
opportunities for
improvement of
coordination
between behavioral
and medical care,
select 2
opportunities and
take action to
address both
opportunities.
QCC Continuity
and
coordination
of Medical
Care
All Products Monitor and take
action as necessary to
improve continuity
and coordination of
care across the health
care network.*
Collect and analyze
data to identify
opportunities for
improvement of
coordination of
medical care by:
-collecting data on
member movement
between
practitioners and
across settings.
-Conducting
quantitative and
causal analysis of
data to identify
improvement
opportunities.
-Identify and select
4 opportunities for
improvement.
-Act on 3 of those 4
identified
opportunities for
improvement
(continued work on
eye exam, MRP,
CBP).
NCQA QI 5
42 CFR §§
438.208
Continuity and
coordination
of Medical
Care
VP,
Quality
Aug Sept Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 17
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Admin Culturally and
Linguistically
Appropriate
Services
(CLAS)
All Products To advance health
equity, improve
quality, and help
eliminate health care
disparities by
implementing
culturally and
linguistically
appropriate services.
Identify activities
for each of the 15
CLAS standards.
Implement
diversity initiatives
and cultural
competency
initiatives for
members and
providers.
Develop, assure,
implement and
evaluate health care
initiatives aimed at
reducing the
disparities in health
status among
targeted UCare
populations.
Maintain,
disseminate, and
annual review the
Limited English
Proficiencies (LEP)
plan.
DHS CLAS
Standards
Work Plan
SVP,
Public
Affairs
and Chief
Marketing
Officer
May
Admin Delegation
Oversight
Regulatory
All Products Perform oversight of
delegated facilities
and responsibilities in
accordance with
regulatory and
contractual delegation
agreements.
Determine and follow
up on opportunities
for improvement.*
Annual audit of
delegated entities.
Annual schedule
submitted to the
State identifying
delegated
functions.
Develop Corrective
Action Plans
(CAPs) based on
audit findings.
Provide member
and clinical data, as
applicable.
NCQA CR
8/MEM
5/PHM 7/QI
7/ UM
12/NET 7
Compliance -
Delegation
Audit
Findings-Sep
Credentialing-
Jan/Jul (Cred
Committee)
VP,
Complian
ce
Jan
Jul
Nov
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 18
QCC DHS
Withholds
PMAP
MNC
MSC+
UCT
UCT-M
MSHO
1. Dental Service
(PMAP, MNC)*
-Age 1-20 - increase
by 10% over 3 yrs.
-Age 21-64 - increase
by 10% over 3 yrs.
-Provider Network
Equity - 90% over 3
yrs.
-Provider Network
Service - TB
2. Repeat
Deficiencies - 0
deficiencies (All)*
3. ED Utilization -
25% reduction, over
3 yrs. (PMAP,
MNC)*
4. Hospital
Admission Rate -
25% reduction, over
3 yrs. (PMAP,
MNC)*
5. 30 Day
Readmission - 25%
reduction, over 3 yrs.
(PMAP, MNC)*
6. Accessibility
Requirements -
complete survey once
a year (UCT, UCT-
M)*
7. Regional
Stakeholder Group -
Attend meetings
(UCT, UCT-M,
MSHO, MSC+)*
8. Annual Dental
Visit, age 19-64 -
10% increase, over 3
years (UCT, UCT-
M)*
Provide telephonic
outreach to
members who have
a gap in care for a
dental visit.
Provide outreach
education to
members who have
had a non-traumatic
ED visit.
Partner with Delta
Dental on
providing
additional outreach
services to
members.
Attend regional
stakeholder
meetings as
scheduled.
Provider education
(tool kit, Webinars,
and resources).
Member education
(IVR calls,
mailings).
Mobile Dental
Clinic.
DHS Contract Bi-annual
Updates
VP,
Quality
VP/CNO
VP, GR
May
Sep
Dec
July
Sep
June
Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 19
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
9. Annual Dental
Visit, age 65+ - 10%
increase, over 3 years
(MSHO, MSC+)*
10. Care Plan Audit -
85% timely
completion (MSHO,
MSC+)*
11. Health Risk
Screening -
completed within 75
days of a member
enrolled for 60 days
(MSHO, MSC+)*
QCC DM Annual
Report
All Products Help members regain
optimum health or
improve functional
capability, in the right
setting and in a cost-
effective manner.*
Provide Disease
Management health
coaching for
members, and help
them access needed
resources.*
Improve DM
program.*
Identify relevant
process or
outcome, measure
and analyze results
and identify
opportunities for
improvement.
Integrate the
Disease
Management
strategy with the
Population Health
Management
Strategy (PHM 1
and 2).
Identify and inform
eligible members of
the DM program.
NCQA PHM
6
DHS Contract
DM
Satisfaction
Report and
Annual
Evaluation
VP/CNO Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 20
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
SCC Health
Outcomes
Survey (HOS)
UMP
MSHO
UCT-M
Assess and monitor
physical and mental
health functional
status of Medicare
members.*
Data used to improve
functional outcomes
as indicated by
survey results, as a
measurement tool,
and as a comparative
indicator of member
health.*
Do a two year
cohort study on a
sample of
members. Review
questions that
pertain to physical
and mental health
outcomes.
Compare the results
to the previous
surveys, and to the
State and National
results.
Provider Education
Member education
42 CFR §§
422.152 and
422.516
HOS Survey
Results
VP,
Quality
Nov
Dec
QCC Healthcare
Effectiveness
Data
Information
Set (HEDIS)
UMP
MSHO
UCT-M
Achieve 5 Star
ratings for UMP.
Achieve 4 Star
ratings or above for
MSHO and UCT-M
(too new to identify
measures).
Address issues
identified in 2018
Annual Evaluation.
Focus Areas:
UMP
-Breast Cancer
Screening 78.43%*
-Colorectal Cancer
Screen 79.81%*
-Diabetes Control <8
80.54%*
-Diabetes Eye
82.24%*
-Diabetes
Nephropathy
97.08%*
Monitor
effectiveness of
care,
access/availability,
of care, and use of
services.
Data used for
program planning
to compare UCare
performance to
other health plans,
as an indicator of
under/over
utilization, and for
improvement.
Compare findings
to previous years
and other health
plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
42 CFR §§
422.152 and
422.516
HEDIS Survey
Results
VP,
Quality
Jul
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 21
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
-Controlling High
Blood Pressure
78.35%*
- DMARD Use for
RA 84.50%*
-Osteoporosis
Management
19.89%*
MSHO
-Breast Cancer
Screening 62.89%*
-COA ADV 87.35%*
-COA FSA 90.27%*
-COA Pain 95.38%*
-COA Rx Review
86.86%*
-Colorectal Cancer
Screen 63.50%*
-Diabetes Control <8
66.67%*
-Diabetes Eye
80.78%*
-Diabetes
Nephropathy
91.00%*
-Controlling High
Blood Pressure
71.05%*
- DMARD Use for
RA 70.97%*
-Osteoporosis
Management
10.71%*
identified in the
annual evaluation.
Explore a member
engagement
solution.
Member outreach
(e.g. IVR,
telephonic,
mailings, etc.).
Provider outreach
to focus on Star
measures (e.g.
action lists,
education on
measures, etc.)
QCC Healthcare
Effectiveness
Data
Information
Set (HEDIS)
IFP Achieve 4 Star rating
or above for QRS
measures.
Monitor effectiveness
of care,
access/availability, of
Monitor
effectiveness of
care,
access/availability,
of care, and use of
services.
42 CFR §§
422.152 and
422.516
HEDIS Survey
Results
VP,
Quality
Jul
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 22
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
care, and use of
services. Data used
for program planning
to compare UCare
performance to other
health plans, as an
indicator of
under/over
utilization, and for
improvement.
Address issues
identified in 2018
Annual Evaluation.
Focus Areas:
IFP
-Annual Dental
31.35%
-Antidepressant Med
Mgmt. 66.23%
-Breast Cancer
Screening 70.21%*
-Cervical Cancer
Screening 53.77%*
-Chlamydia
Screening 41.99%*
-Colorectal Cancer
Screen 62.77%*
-Diabetes Control <8
64.85%
-Diabetes Eye
75.00%
-Diabetes
Nephropathy 92.10%
-Controlling High
Blood Pressure
75.51%
-Follow up After MH
Hosp 54.17%*
-Prenatal 8.50%*
Data used for
program planning
to compare UCare
performance to
other health plans,
as an indicator of
under/over
utilization, and for
improvement.
Compare findings
to previous years
and other health
plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Compare findings
to previous years
and other health
plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Member outreach
(e.g. IVR,
telephonic,
mailings, etc.).
Explore internal
and external
partnerships to
focus on measures.
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 23
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
-Postpartum 83.93%*
-Weight Assess
Nutrition 54.98%*
-Weight Assess
Physical 58.88%*
-Well Child W34
69.91%*
-Well Child 6x15
72.00%*
QCC Healthcare
Effectiveness
Data
Information
Set (HEDIS)
PMAP
MNC
MSC+
UCT
Achieve the 75th
NCQA percentile or
above.
Address issues
identified in 2018
Annual Evaluation.
Focus Areas:
PMAP
-Adolescent Well
Care 36.98%
-Antidepressant Med
Mgmt. 34.97%
-Asthma Med Mgmt.
34.97%
-Breast Cancer
Screening 59.89%
-Cervical Cancer
Screening 57.18%
-Child BMI and
Nutrition 71.05%
-Child BMI and
Physical 67.64%
-Child Immunization
Combo 75.59%
-Children's Access
PCP 86.27%
-Chlamydia
Screening 49.600%
Monitor
effectiveness of
care,
access/availability,
of care, and use of
services.
Data used for
program planning
to compare UCare
performance to
other health plans,
as an indicator of
under/over
utilization, and for
improvement.
Compare findings
to previous years
and other health
plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Compare findings
to previous years
and other health
plans.
42 CFR §§
422.152 and
422.516
HEDIS Survey
Results
VP,
Quality
Jul
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 24
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
-Follow Up After
Hospitalization
79.31%
-Prenatal 63.89%
-Postpartum 60.07%
-Well Visits 15
months 50.00%
-Well Visits Ages 36
69.34%
MnCare
-Adolescent Well
Care 26.83%
-Cervical Cancer
Screening 57.39%
-Breast Cancer
Screening 71.76%
-Cervical Cancer
Screening 57.39%
-Chlamydia
Screening 65.22%
SNBC
-Antidepressant Med
Mgmt. 32.87%
-Breast Cancer
Screening 61.51%
-Cervical Cancer
Screening 54.50%
-Chlamydia
Screening 51.91%
MSC+
-Antidepressant Med
Mgmt. 29.17%
-Breast Cancer
Screening 42.02%
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Compare findings
to previous years
and other health
plans.
Analyze the results
against
benchmarks. Work
on areas below the
threshold and as
identified in the
annual evaluation.
Explore a member
engagement
solution.
Member outreach
(e.g. IVR,
telephonic,
mailings, etc.).
QCC Integrated
Complex
Case
Management
PMAP
MNC
Address the needs of
members with co-
occurring behavioral
and physical health
conditions.
Identify members
who are diagnosed
with a mental
health disorder and
PHM 1 A Report AVP, BH Jul Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 25
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
have a chronic
medical condition.
Promote proper
management of
mental and medical
conditions.
Identify Barriers.
Educate members
on conditions and
risks.
QCC Inter-Rater
Reliability
(IRR) Report
All Products Ensure uniform
application of
objective measurable
criteria for utilization
decisions.*
Percent of inter-rate
reliability.
Update InterQual
medical criteria.
Continue the
testing process.
NCQA UM 2
C
Inter-Rater
reliability
audit results
VP/CNO Dec
QCC LTSS MSHO
MSC+
UCT
UCT-M
Create a system to
implement effective
services that produces
positive outcomes
through
accountability,
continuous
improvement,
cultural
responsiveness, and
partnership.
Assess quality and
appropriateness of
care furnished to
Enrollees using LTSS
services covered
under the contract.
Identify a strategic
direction of
services and
supports.
Identify
performance
measures related to
long term services
and supports.
Monitor and
evaluate the quality
of home and
community based
services provided
members.
DHS Contract Audit Results
Report
VP/CNO Oct Nov Dec
QCC Medical
Record
Standards
All Products Monitor quality of
PCC medical records
for compliance with
UCare standards.*
Address issues
PCC and providers
will be evaluated
for compliance
with UCare
Medical Record
Standards.
Minn. Rules,
part
4685.1110,
subpart 13
NCQA CR 5
DHS contract
Medical
Record Audits
Audit Results
VP, PRC
and VP,
Quality
Sep Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 26
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
identified in 2018
Annual Evaluation.*
Provider Outreach
and Education.
QCC Medication
Assisted
Therapy
Program
PMAP
MNC
Implement a
continuous quality
improvement
program for members
accessing medication
assisted therapies.
Identify members
who are new to
UCare or are new
to taking
methadone.
Promote access to
methadone through
outreach.
Identify Barriers to
treatment.
Educate members
on risks.
N/A Report AVP, BH Jul Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 27
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Mem
X
Member
Satisfaction
Analysis
UMP
IFP
PMAP
MNC
Implement
mechanisms to assess
and improve member
experience and
satisfaction.*
Annually monitor
and evaluate
member experience
with services and
identify areas of
potential
improvement by
reviewing
grievances and
appeals and
CAHPS, ESS, and
ECHO data.
Identify
Opportunities for
Improvement.
-Customer
Service training.
-Member
education
materials.
-Provider
education
(example: PCP,
ADC.)
-Off cycle
CAHPS survey.
NCQA QI 4
C-F
Member
Satisfaction
Report
Dir. QM
Dec
QCC MOC Annual
Evaluation
MSHO
UCT-M
Improve the SNPs
ability to deliver high
-quality health care
services and benefits
to its SNP
beneficiaries.*
Conduct an annual
analysis of select
measures related to
the MOC and
identify
opportunities for
improvement.
NCQA MOC
4
MOC Annual
Evaluation
VP/CNO Mar Mar
Admin NCQA
Accreditation
Updates
UMP
IFP
PMAP
MNC
Complete all annual
requirements for
NCQA Accreditation.
Manage document
review and P&P
updates throughout
the organization.
NCQA Bi-annual
Updates
VP,
Quality
May
Nov
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 28
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Mem
X
New Member
Feedback
Report
UMP
IFP
PMAP
MNC
Assess understanding
of policies and
procedures and
marketing materials.*
Complete
assessment of new
members.
Identify
opportunities for
improvement of
policies and
procedures, and
marketing materials
provided to new
members.
NCQA RR 4
C
New Member
Feedback
Report
AVP,
Business
Developm
ent
May
QCC Over/Under
Utilization
All Products Improve utilization of
appropriate medical
care to contain the
cost of medical
services for
members.*
Monitor both over
and
underutilization of
medical resources.
DHS Contract Over and
Under
Utilization
Report
VP/CNO Feb
May
Sep
Nov
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 29
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC 2018-2020
Performance
and Quality
Improvement
Projects (PIP
and QIP)
Opioid
Dependency
PMAP
MNC
UCT
UCT-M
MSC+
MSHO
Goal is to decrease
the rate/number of
members that are new
chronic users of
opioid pain relievers.
Collaborative
interventions:
Implement training
opportunities on
opioid prescribing
guidelines,
alternative
therapies, and
resources, etc.;
provider toolkit,
implement the
prescription
guidelines from the
UPPW, and Care
Coordination
training.
UCare specific
interventions:
monitor provider
prescribing trends,
provide education
to members, and
distribute Deterra
bags.
DHS
Contract,
Minn. Rules,
4685.1125
PIP and QIP
Report
VP,
Quality
Sep Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 30
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Population
Health
Management
PMAP
MNC
UCT
UCT-M
MSC+
MSHO
UMP
Annually conduct a
comprehensive
analysis inclusive of
clinical,
cost/utilization and
experience measures
to evaluate the
effectiveness of the
PHM programs and
the overall impact of
the PHM strategy.
Design and launch
Population Health
Management
(PHM)
framework/strategy
.
Annually assess
and review the
characteristics and
needs of members
by product,
including Social
Determinants of
Health,
subpopulations,
child/adol, member
disabilities, and
SPMI.
Launch a minimum
of two
programs/activities
in the following
areas: Keeping
Members Healthy;
Managing
Members with
Emerging Risk;
Outcomes Across
Settings and Patient
Safety; Managing
Multiple Chronic
Conditions.
NCQA PHM
1 A, 2, & 6
Population
Health
Management
Strategy
Population
Health
Assessment
Population
Health
Management
Impact
VP/CNO May June
QCC Prior
Authorization
(PA)
All Products Ensure UCare's prior
authorization
processes meet the
needs of members
and providers.*
Review PA
requirements and
update as needed.
DHS Contract CLS/BH
Authorization
and
Notification
Grid.
VP/CNO Sep Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 31
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Quality and
Accuracy of
Information -
Pharmacy
All Products Provide members
information to
understand and use
the pharmacy
benefit.*
Ensure the quality
and accuracy of
pharmacy benefit
information.*
Collect and analyze
the quality and
accuracy of
pharmacy benefit
information
provided via the
website and
telephone, and
identify and act on
opportunities for
improvement.
NCQA MEM
2 C
Pharmacy
Benefit
Information
VP,
Quality
May
QCC Quality and
Accuracy of
Information –
Customer
Services
All Products Provide members
information to
understand and use
the health plan
benefits.*
Ensure the quality
and accuracy of
health plan
information.*
Collect and analyze
the quality and
accuracy of health
plan services
information
provided via the
website, phone and
email response and
identify and act on
opportunities for
improvement.
NCQA MEM
3 C and D
Quality and
Accuracy on
Personalized
Information on
Health Plan
Services
Dir. of CS May
QCC 2017-2019
Quality
Improvement
Strategy
(QIS)
IFP Focused studies
conducted to improve
cervical cancer
screening rates. Goal
is to increase the
screening rate by 10
percentage points to
61.56%.*
UCare specific
interventions:
monitor provider
prescribing trends,
provide education
to members, and
distribute Deterra
bags.
ACA, section
1311(g) (1)
(45 CFR
156.200 (b))
QIS Report VP,
Quality
Sep Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 32
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Quality of
Care Reviews
All Products Complete quality
reviews/investigation
s in a timely manner
to ensure a safe and
quality provider
network.*
90% of Quality Care
cases closed within
90 days of receipt.*
Percent of cases
closed that meet
resolution timeline.
Quarterly trend
reports by volume,
issues, severity, and
outcome.
Provide education
and monitor
providers included
in substantiated
cases.
Refer to peer
review as required.
Provide cross-
departmental
education regarding
Quality of Care
concerns.
DHS Contract QOC Trend
Report
VP/CNO Mar
May
Sep
Nov
Admin Regulatory
Oversight
All Products Ensure results from
the CMS Audit,
MDH Quality
Assurance
Examination and the
TCA audit reports are
reviewed and acted
upon.
Identify number of
deficiencies and
mandatory
improvements in
audit reports.
Discuss mandatory
improvements with
appropriate
VP/Directors and
receive written
confirmation from
VP's of next steps.
CAPs relating to
the audit
deficiencies are
complete or in
process.
Respond to EQRO
requests.
DHS Contract ATR report
CMS Audit,
MDH QA and
TCA
VP, GR
and
VP,
Complian
ce
Jul
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 33
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC SNBC Dental
Project
UCT
UCT-M
Goal is to increase
annual dental visits
for SNBC members
and decrease the
number of ER visits
for non-traumatic
dental visits.*
Member
Engagement
Specialist to
provide telephonic
outreach to increase
annual dental visit
and to decrease ER
utilization for
dental visits.
Collaboration with
DHS and DCT
clinic.
Identify mentoring
opportunities to
mentor dental
providers in the
community on
serving the special
needs population
including a
provider tool kit.
Provide education
to dental providers
on working with
the special needs
population.
Update MCO101
Dental Information
Grid.
Mobile Dental
Clinic
DHS Contract Dental Report VP,
Quality
Sep Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 34
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
SCC Special
Health Needs
(SHCN)
Regulatory
PMAP
MNC
UCT
MSC+
MSHO
UCT-M
Ensure the effective
mechanisms are in
place to:
-Identify adult and
pediatric members
with SHCN.*
- Assess members
identified, offer care
management and
monitor the member's
plan of care.*
Monthly tracking
of select utilization
indicators per
contract.
Monitor
clinical/utilization
triggers.
Continue ER
avoidance program.
Continue to offer
case management
for high risk OB
cases.
Written description
of SHCN Plan.
Complete annual
and quarterly
reports.
DHS Contract Screenings
Referrals for
Services
Claims Data
CCMS Data
VP/CNO Mar
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 35
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
Admin Stars Report UMP
MSHO
UCT-M
Complete quality
improvement
activities based on
Stars ratings with an
emphasis on MSHO.
Achieve a rating of 5
Stars for UMP and 4
Stars for MSHO.
Focus Areas (below
the MA-PD
Average): Achieve a
rating at or above the
MA-PD Average
UMP
-Med Adherence for
Cholesterol 88%
-Med Adherence for
Hypertension 89%
-Med Adherence for
Oral Diabetes 88%
MSHO
-Med Adherence for
Cholesterol 82%
-Med Adherence for
Hypertension 84%
-Med Adherence for
Oral Diabetes 82%
Connect + Medicare
-Med Adherence for
Cholesterol 80%
-Med Adherence for
Hypertension 76%
-Med Adherence for
Oral Diabetes 76%
Develop and
implement
interventions based
on overall Stars
ratings.
Provide activity
reports to QIC and
QIACC.
Analyze the results
against
benchmarks.
Work on areas
below the threshold
and as identified in
the annual
evaluation.
N/A Strategic Plan
Stars Update
VP,
Quality
Mar
Nov
Dec
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 36
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QS Web-based
Physician and
Hospital
Directory
Usability
Testing
All Products Evaluate new
member and
prospective member
understanding and
usefulness of the
web-based physician
and hospital
directories.
Conduct web-based
physician and
hospital directories
testing of the
following:
-Font Size.
-Reading Level.
-Intuitive content
organization.
-Ease of
Navigation.
-Ensure directories
are available in
additional
languages as
appropriate to
membership.
NCQA NET 6
K
Provider
Search Testing
Report
VP, PRC Nov
QS UM
Satisfaction
Report
All Products Evaluate member
experience with the
UM process.*
Collect and analyze
member and
practitioner
experience data to
identify
improvement
opportunities.
Take action on
opportunities for
improvement.
NCQA QI 4
G
DHS Contract
UM
Satisfaction
Report
VP/CNO Sep Sep
*Monitoring of previously identified issues in 2018
2019 Quality Program Work Plan 37
Focus
Area
Activity Products Yearly Objective Planned Activities Regulatory
Requirement
Report Owner CR MMC QMIC QIC QIACC
QCC Utilization
Management
Plan
All Products Annually ensure UM
program is well
structured and makes
utilization decisions
affecting the health of
members in a fair,
impartial, and
consistent manner.
Annually ensure the
UM program has
clearly defined
structures and
processes, and
assigns responsibility
to appropriate
individuals.
Review UM plan
and ensure it
includes the
following:
-A written
description of the
program structure.
-The behavioral
healthcare aspects
of the program.
-Involvement of a
designated senior-
level physician in
UM program
implementation.
-Involvement of a
designated
behavioral
healthcare
practitioner in the
behavioral
healthcare aspects
of the UM
program.
-The program
scope and process
used to determine
benefit coverage
and medical
necessity.
-Information
sources used to
determine benefit
coverage and
medical necessity.
NCQA UM 1
A
DHS Contract
Utilization
Management
Plan
VP/CNO Feb