care providers and quality measures august 11, 2015

Care Providers and Quality MeasuresAugust 11, 2015

Overview

• Annual Quality of Care Performance Measures

• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Requirements

• HEDIS Guidelines

• Documenting Anticipatory Guidelines

• Monitoring and Improving Quality of Care

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Annual Quality of Care Performance MeasuresCare Effectiveness

• Reduce gaps in quality of health care delivery

• Identify barriers to preventive care

Care Access and Availability

• Location of care providers in health plan service area

• Does the network provide multi-lingual care providers

• Are member cultural needs considered when creating the network

Use of Service

• Quality measures indicating how health plans use physician visits, hospital stays and other resources to care for members identified having one of five chronic diseases: cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes, hypertension and asthma.


EPSDT Requirements

Screening requirements include:

• Comprehensive health and development history assessment for physical and mental health, and substance use disorders

• Comprehensive physical examination

• Immunizations, according to the pediatric vaccine schedule established by the Advisory Committee on Immunization Practices

• Laboratory testing, including blood lead screening if appropriate for age and risk factors

• Health education and anticipatory guidance for children and caregivers

Early and Periodic Screening, Diagnostic and Treatment services encompass a wide array of prevention, diagnostic and treatment services for infants, children and adolescents under age 21 who are enrolled in Medicaid and from low-income families.


EPSDT Periodicity Schedule

States must establish a periodicity schedule for each type of EPSDT screening to help ensure patients are receiving the following age-appropriate services: • Medical • Vision • Hearing • Dental

Visit BrightFutures.org to view EPSDT periodicity schedules for pediatric and adolescent members.


http://brightfutures.org/

HEDIS Guidelines: Immunizations/Well Child Visits/Adolescent Well Visits

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Pediatric Wellness Screenings

Well Child 0–15 months of age: • At least six screenings before age 15 months

Well Child Ages 3–6 years: • One visit annually beginning at age 3

Adolescent Well Care: • Percentage of enrolled members ages 12–21 years who had at least one

comprehensive well-care visit with a PCP or an OB/GYN in the measurement year

Child and Adolescent Access to PCPs: • Children 12–24 months and 25 months–6 years who had a visit with a PCP during

the measurement year

• Children ages 7–11 years and adolescents ages 12–19 years who had a visit with a

PCP during the measurement year or the year prior

HEDIS Guidelines Continued

Lead Screening in Children:

• Percentage of children age 2 years who had one or more capillary or

venous lead blood test for lead poisoning by their second birthday.

Childhood Immunizations:

• Under age 2, complete immunization series and flu shot.

Immunizations for Adolescents:

• Percentage of adolescents age 13 years who had the following by

their 13th birthday:

• One dose of meningococcal vaccine and one tetanus

• Diphtheria toxoids and acellular pertussis vaccine (Tdap) or one

tetanus

• Diphtheria toxoids vaccine (Td)


Anticipatory Guidelines Overview


Anticipatory guidelines are proactive health education and health-based

counseling services given to the patient during clinical visits, according to

the patient’s age.

Find more guidelines at BrightFutures.org or the Delaware Division of Medicaid and

Medical Assistance at dhss.delaware.gov/dhss/dmma/information.html.

1. Tobacco Free Living - discourage tobacco use or exposure

2. Preventing Drug Abuse and Excessive Alcohol Use - substance

abuse prevention

3. Healthy Eating - weight management and healthy nutrition

4. Active Living - weight management and physical activity

5. Injury and Violence-Free Living - healthy and safe lifestyles

Anticipatory Guidelines Overview


6. Reproductive and Sexual Health - preconception/interconception

health, including pregnancy risks while using narcotics

7. Mental and Emotional Well-Being - stress management and

substance abuse prevention

8. Vaccines and Preventable Disease - healthy and safe lifestyles

9. Safe Environments - healthy and safe lifestyles, including a focus on

reduction of blood lead poisoning and infant sleep-related deaths

10.Take Charge of Your Health - how patients can be proactive in their

health and how to access a primary care provider

Documenting Anticipatory Guidance during a Well Visit

Requirements

• Anticipatory guidance should be a part of every exam and emphasized

during the patient’s annual wellness visit.

• Physical, developmental, mental health and other adult wellness and

EPSDT screening components give initial context for anticipatory

guidance and health education.

Documentation

• Document giving health education and age-appropriate anticipatory

guidance in patient record.

• Use an age-appropriate anticipatory guidance list to be checked or

circled for quick documentation.

• Document additional topics identified and discussed during visit in

patient’s health record.


Scheduling EPSDT Appointments

Scheduling EPSDT Appointments

• The PCP initiates EPSDT outreach and follow-up care

• EPSDT appointments should be made within two weeks of the initial

patient request

• Care providers have 90 days to submit EPSDT encounters

• Contact the Provider Services Department for assistance: 800-600-9007


HEDIS NCQA Guidelines for Prenatal and Postpartum Care

HEDIS NCQA Quality of Care Measures for Prenatal and Postpartum

Care – what percentages are measured?

• The percentage of deliveries of live births between Nov. 6 of the year prior

to the measurement year and Nov. 5 of the measurement year

• Timeliness of Prenatal Care• The percentage of deliveries receiving a prenatal care visit:

• as a member of the organization in the first trimester or • within 42 days of enrollment in the organization.

• Postpartum Care• The percentage of deliveries having a postpartum visit on or between 21 and

56 days after delivery.


HEDIS NCQA Guidelines for Prenatal and Postpartum Care

How can care providers help improve quality of care measures and increase percentages according to HEDIS NCQA quality of care measures for prenatal and postpartum care?

• Set up an appointment reminder system for prenatal and postpartum

visits.

• Remind patients to return for their prenatal and postpartum

appointments.

• Take extra measures to remind patients who had a cesarean

section to return for their postpartum visit.

• Contact Member Services to refer members who miss appointments

to the member advocate for intervention: 877-877-8159


HEDIS Guidelines for Chronic Disease Populations Overview

HEDIS Guidelines for Chronic Disease Populations

• Comprehensive Diabetes Care

• Controlling High Blood Pressure

• Medication Management for Individuals with Asthma


Comprehensive Diabetes Care

Adults ages 18-75 with Type 1

and 2 Diabetes

• Hemoglobin A1c (HbA1c) testing

• HbA1c poor control (>9.0%)

• HbA1c control (<8.0%)

• HbA1c control (<7.0%) for a

selected population

• Eye exam (retinal) performed

• Medical attention for nephropathy

• Blood Pressure control (<140/90

mm Hg)

Event/Diagnosis

Individual identified as diabetic during

or prior to the measurement year:

• At least two outpatient visits

• At least one acute inpatient

encounter

• HEDIS data collection methods:

• Pharmacy data

• Insulin

• Hypoglycemics/

antihyperglycemics


Controlling High Blood Pressure Overview

Controlling High Blood Pressure

• Percentage of adult enrollees ages 18 to 85 who had a diagnosis of

hypertension and whose blood pressure was adequately controlled

(< 140/90) during the measurement year

• For the Medicaid Adult Core Set, states calculate and report this measure

for two age groups:

• Ages 18 to 64

• Ages 65 to 85

• HEDIS data collection methods: Hybrid only


Medication Management for Individuals with Asthma

Members ages 5 to 85 years who:• were diagnosed with persistent

asthma

• were dispensed appropriate

medications

• remained on appropriate dispensed

medications during the treatment

period.

Two rates are reported: • Percentage of members remaining

on an asthma controller for 50% of

their treatment period

• Percentage of members remaining

on an asthma controller medication

75% of their treatment period

Event/Diagnosis

• Primary diagnosis of asthma

• At least one acute inpatient

encounter

• At least four outpatient visits and

two asthma medication dispensing

events

• At least four asthma medication

dispensing events

• HEDIS data collection methods:

• Pharmacy

• Encounter data


Monitoring and Improving Quality of Care

• Accessibility of providers

• Provider availability

• Member and provider satisfaction with plan services

• Credentialing/re-credentialing standards

• Provider adherence to clinical practice guidelines

• Preventive health services

• Continuity and coordination of care process

• Access to member services

• Quality of care issues

• Patient safety


The Quality Improvement program tracks certain plan of performance to assess the quality, adequacy and appropriateness of health care resources.

Quality Initiatives: Member Health Education


Adults, Children and Teen Wellness Visits

Reminders Including:

• EPSDT Screening Communication

• Immunization and Lead Screening Reminder

Cards

• Flu Shot Campaign

• Diabetes Mailers and Education

• Pregnancy and Postpartum Mailers, Outreach

Calls

• Provider and UnitedHealthcare Cobrand

Collaborative Initiative

• Outreach calls

• Letters

• Case Management


Quality Initiatives: Healthy Rewards

Healthy Rewards

• Individuals with diabetes can earn gift

cards for taking steps to control their

disease by getting:

• HbA1c and LDL tests

• A dilated retinopathy exam

• Attending diabetic education classes

Quality Initiatives: Clinic Day Program

Clinic Day Program

• A high-touch member outreach and

intervention program to help:

• Increase HEDIS rates for all

members receiving annual

preventive care services;

• Decrease member no-show

appointments; and

• Increase compliance with HEDIS

measures.

• Pre-scheduled days with provider office

for preventive pediatric and adult visits.

• Members receive incentives to complete

preventive visits and screenings.


care providers and quality measures august 11, 2015

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