Meeting HighlightsTennCare Health Plan Meeting, February 11, 2020

Meeting ObjectivesAs Tennessee’s designated External Quality Review Organization (EQRO), Qsource facilitates health plan meetings to benefit TennCare and its managed care contractors (MCCs). These triannual meetings provide opportunities for learning from guest subject-matter experts who can share success stories and best practices, for earning nursing and the Certified Professional in Healthcare Quality (CPHQ) continuing education units (CEUs), and for networking to stay abreast of pertinent topics to Medicaid and managed care. Objectives for February attendees were the following:

� Explain how to drive quality of life outcomes through person-centered planning

� Describe barriers to and strategies for treatment for pregnant and postpartum women with opioid use disorder

� Discuss possible quality improvement interventions for chronic kidney disease and end-stage renal disease

� Understand how primary care office-based strategies can address pediatric obesity prevention

� Learn tips for writing accurate PIP summaries based on the 2019 PIP validation

While our shared goal has always been to improve the quality of care and services provided to TennCare members, this program was informed by your feedback and suggestions, and carefully designed by Qsource and TennCare to cover topics relevant to the requirements, needs and concerns of your health plan. It is our hope that you will find the presentations both helpful and informative when preparing procedures and crafting policies. This document contains highlights for a quick refresher on the day’s speakers and topics. Contact Qsource with suggestions or questions at 615.244.2007.

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Driving Transformation: The Power of Person-CenterednessPamela Browning, RN—Director of Quality Outcomes and Stephanie Gibbs, JD—Director of System Transformation and Innovation, Department of Long-Term Services and Supports (LTSS), TennCare

� The LTSS delivery system is being revamped to better align with person-centered thinking and practices, shift the focus from compliance to quality outcomes, and address program challenges. This includes a redesigned person-centered support plan template.

� Person-centered planning begins with the application for LTSS program enrollment and continues throughout the person’s life. It focuses on the individual’s strengths and establishes the foundation for how the individual wants to live their life.

� Quality Improvement in Long-Term Services and Supports (QuILTSS) is a statewide initiative to promote the delivery of high-quality LTSS via nursing facilities and home- and community-based services (HCBS) through value-based purchasing initiatives and workforce development. Workforce development is based on competency-based training, non-recurring investment in capacity-building supports, and workforce and provider incentives. In QuILTSS, quality is defined from the perspective of the person receiving services and their caregivers.

� QuILTSS pilot projects focused on nursing facilities and enhanced respiratory care (ERC) resulted in increased participation in person-centered care/culture change assessments, reduction in antipsychotic usage, and an increase in ERC reimbursement spending; the latter resulted in the launch of a quality improvement initiative to determine ways to control spending.

Opioid Use Disorder in Pregnancy: Optimizing CareJessica Young, MD—Associate Professor, Vanderbilt University Medical Center

� The goal of the Tennessee Opioid Use Disorder (OUD) in Pregnancy Project is to decrease complications of OUD in pregnancy by optimizing the care for women through education, resource mapping, screening, access to treatment services, and protocols for prepartum, intrapartum, and postpartum care by the end of June 2020.

� OUD should be viewed and treated as a chronic medical condition. It is influenced by many factors, such as genetics and changes in the brain resulting from trauma. Stigma limits care availability and treatment options and discourages drug users from seeking help, so patient and provider education and resource mapping are needed.

� Universal screening for substance use should be part of comprehensive obstetric care and should be completed at the first prenatal visit by using validated tools. Screening based only on factors such as poor adherence to prenatal care can lead to missed cases, and may add to stereotyping and stigma. Routine urine testing should not be used as a screening method because it can result in false positives and negatives.

� Women who are OUD-positive need comprehensive prenatal, intranatal, and postnatal treatment plans that include methadone or buprenorphine maintenance or opioid detoxification, as well as contraception options. If the mother is undergoing treatment for OUD, breastfeeding is encouraged.

� All newborns from mothers who are OUD-positive should be screened for neonatal abstinence syndrome (NAS), and non-pharmacologic interventions for NAS-positive infants have a high success rate. If required, engage the Department of Children’s Services at discharge to develop safe care protocols tailored to the patient and family’s OUD treatment and resource needs.

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Gaps in Kidney Care: Opportunities for Improved Outcomes and Cost Savings Amanda Ryan, PharmD—Clinical Pharmacy Specialist, Qsource

� Chronic kidney disease (CKD) is condition in which the kidneys are damaged and unable to filter the blood effectively. The disease progresses slowly and leads to waste buildup in the body. End-stage renal disease (ESRD) is the last stage of CKD, with high complication and mortality rates and the requirement of dialysis or transplant.

� Many people with early CKD do not have any symptoms, but as the disease progresses, symptoms include insomnia, fatigue, loss of appetite, muscle cramps, increased urination, and swelling in the legs and feet. Clinical consequences of ESRD include bone disease, anemia, stroke, heart attack, hypertension, and early death. Treatment of diabetes and hypertension can help prevent CKD from developing, and Kidney Profile screening, proper treatment, and avoiding kidney-harming medications can help prevent CKD from developing into ESRD.

� The Qsource CKD Environmental Scan in Tennessee was conducted between August and October of 2019 and assessed data sources, current interventions, infrastructure, gaps, and barriers. The scan found that kidney foundations work in silos and that there is a lack of infrastructure to mandate the collection and reporting of the limited amount of CKD data available. While health information exchanges are reliable resources, data collection can be expensive and time-consuming, and lag times are common. In 2017, the average Medicare treatment cost for CKD was $22,000 per patient and $80,000 per ESRD patient.

� The scan also found that current interventions include fistula toolkits, education, free kidney health checks, and a diabetic prevention program.

� The CKD Quality Improvement Intervention with PCMH Integration involved the National Kidney Foundation (NKF) training primary care physicians on CKD testing, risk stratification, and interventions. Results included a significant increase in nephrology referrals and number of nephrology visits for severe CKD patients, along with reductions in hospital admissions and readmissions for these patients.

Putting Science to Work for Childhood Obesity Prevention and InterventionShari Barkin, MD—Division Chief of General Pediatrics, Vanderbilt University Medical Center

� To help prevent pediatric obesity, pregnant women need healthy nutrition support and parents need to master the skills of responsive parenting, satiety cues, portion sizing, and understanding nutrition content. High-risk exposures also need to be addressed via the reduction of inappropriate antibiotic use, food security screening, and policies and programs that support access to nutritious foods.

� Short- and long-term behavioral interventions for parents and young children help promote balanced diets and healthy body mass index (BMI) measurements. Nutritional skills should be reinforced for all family members as a standard part of counseling, using plain language, clear pictures, and actionable advice.

� For overweight/obese treatment, frequent follow-up visits for behavior change therapy are effective, as well as addressing behavioral change techniques related to sleep and stress. Slow and consistent weight

Meeting materials will remain available through our EQRO Division Webpage. 20.EQRTN.01.001

www.qsource.org

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loss, self-monitoring, metabolic adaptation, physical activity, and meal plans/replacements should also be discussed during the counseling process.

� For adolescents with severe obesity, bariatric surgery can be an effective option for weight loss and remission of type 2 diabetes, abnormal kidney function, and elevated blood pressure. However, improvements in the feasibility of weight-loss surgery, as well as counseling and behavioral interventions, are needed.

� If you are interested in accessing Dr. Barkin’s educational materials that include plain language, clear pictures, and actionable advice, please contact her at shari.barkin@vumc.org.

Tips for PIPsSwapna Mehendale, MHA—EQRO Program Manager, Qsource

� Every PIP title needs to be consistent in the Excel spreadsheet sent to TennCare and the PIP Summary Form. Where applicable, include specific information in the PIP Summary Form for each region. If the same information applies to all regions, clearly state this. Also, do not submit the entire HEDIS report.

� For PIPs in the Baseline Measurement Year, complete Activities I–VI only. For those in Remeasurement Year 1, complete Activities I–IX. For those in Remeasurement Year 2 and beyond, complete Activities I–X. Ensure each activity is complete by addressing each element. For example, some PIP study leaders copy and paste the elements into the PIP Summary Form and use a question/answer format.

� Tips for Activity III: Provide the dates used to identify continuous enrollment and define the study population accurately and consistently throughout the PIP Summary Form.

� Tips for Activity IV: Describe numerators and denominators, ensure baseline results do not change from year-to-year, change goals between years if needed (e.g., HEDIS measure 90th percentile), include measurement periods, and ensure that each study indicator aligns with the study question and allows for it to be answered.

� Tip for Activity V: If two indicators are utilized, including one that uses sampling and one that does not, then describe the methodology, representation, and techniques for the indicator that used sampling.

� Tips for Activity VI: Identify one data source per indicator, establish a timeline for the collection of baseline and remeasurement data that has both starting and ending dates for all measurement periods, and state the estimated degree of administrative data completeness (specify region).

� Tips for Activity VII: Include statistical differences between measurement years for each study indicator; factors that may have affected the year-to-year comparisons or a statement indicating that no factors were identified that could affect the MCC’s ability to compare rates; and consistent rates.

� Tips for Activity IX: Accurately report statistics, benchmarks, and results, and thoroughly discuss potential causes and significance of rate changes over time.

� Tip for Activity X: Thoroughly discuss barriers to intervention effectiveness, statistical significance or lack thereof between remeasurements, and implications for the study’s results.