Date post: | 17-Dec-2015 |
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Why the Quest for Quality?
• It’s the RIGHT thing to do for the patient/member• Helps your clinic reach targeted goals (clinical and financial)• Focuses on your clinic as the medical home for the patient, which many of
you have as a goal for your facility• Stresses evidenced-based approaches to care, which improve outcomes and
reduce costs
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How Do We Work Together to Achieve Our Goals?
Our approach to Quality is four-pronged. It is built on fostering partnerships and working collaboratively with providers, members, the community and State to improve health outcomes.
Improved Health Outcomes
Providers
Manage members’ care
Provide tools to assist providers
Assist in coordinating members’ care
Members
Educate members
Assist in coordinating care and removing barriers to care
Community
Bring community advocates together to serve members needs
Identify member social resources
State
Find solutions for State-wide issues and barriers to care
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State Requirements of WellCare That Affect Providers
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State Requirements :• Monitor PCPs adherence to
clinical practice guidelines• Asthma – Use of controllers
and relievers• Diabetes – Monitoring of
HbA1c, LDL, Eye Exam, Nephropathy, and BP
• Adult Depression – Use and continuation of antidepressant medication
• ADHD – Follow-up visits • Identify patterns of over- and
under-utilization
Impact to Providers:• Assess PCPs compliance with
national standards of care as measured by submission of claims with appropriate coding and medical record chart reviews
• Evaluation of claims for appropriate referral patterns and treatment
State Requirements of WellCare That Affect Providers, continued
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State Requirements :• Implement steps to improve the
health status of Medicaid members as measured by HEDIS and State-selected performance measures (Appendix A)
• Develop and implement performance improvement projects
• Behavioral health medications• ED use
• Investigate and resolve member grievances within 30 calendar days
Impact to Providers:• Conduct medical record chart
reviews and claims analysis for completion of services. Use of appropriate CPT and CPT II codes will decrease chart review
• Evaluation of claims for appropriate use of behavioral health medications and ED patterns
• Contact by our grievance team for issue resolution
State Requirements of WellCare That Affect Providers, continued
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State Requirements :• Monitor PCP adherence to the
State’s appointment waiting times • Routine and preventive care
appointments within 30 days of request
• Urgent care appointments within 48 hours of request
• After-hours calls returned within 30 minutes
Impact to Providers:• Conduct audits by telephone
assessing compliance with the appointment standards
• Providers out of compliance receive a letter and are re-audited within 90 days
State Requirements of WellCare That Affect Providers, continued
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State Requirements :• Monitor PCPs to ensure they are:
• Maintaining a current medical record for the members, including documentation of all PCP and specialty care services
• Documenting all care rendered in a complete and accurate medical record that meets or exceeds the State’s specifications (Appendix B)
• Providing primary and preventive care, recommending or arranging for all necessary preventive health care, including EPSDT for members under 21 years of age (Appendix C)
Impact to Providers:• Conduct medical record chart
audits annually to assess PCPs and OB/GYNs compliance with documentation standards
• Providers out of compliance receive a letter of corrective action and are re-audited
• Conduct medical record chart audits annually to assess PCPs compliance with EPSDT documentation standards
WellCare of Kentucky Offices
Owensboro Office 270-688-7000
Louisville Office 502-253-5100
Lexington Office 859-264-5100
Ashland Office 606-327-6200
Hazard Office 606-436-1500
Bowling Green Office 270-793-7300
We have six offices throughout the Commonwealth staffed with Provider Relations Representatives and Case/Disease Managers that live in those communities to service the needs
of members and providers.7
Our Provider Focus
Provider Tools • Identification of care gaps at eligibility checks
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https://kentucky.wellcare.com
Provider Tools, continued
Member-Centered Case and Disease Management • Member and caregiver-centered model• Service Coordination
• Proactive and collaborative face-to-face outreach and assessment
• Discharge Planning• Matching members needs with most appropriate
provider and/or setting. • Driving Interdisciplinary Care Teams• Integrating care for members
• Holistic Management• Home & Community-Based• Behavioral Health• Pharmacy• Medicare and Medicaid
• Culturally Competent• Services in multiple languages• Understanding and sensitivity to subcultural norms and
preferences
Primary Care Physician
Service Coordination
Specialist and HCBS Providers
Whole Person Orientation
Provider Relations
Family Supports
Community / Advocate
Member
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Provider Tools, continued
• Provider visits and education• HEDIS toolkits and documentation resources• Identification of members in need of screenings
• Support• Designated Provider Relations Representative• Case and Disease Managers• 24/7 Nurse Advise Line
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Our Member Focus
• Member Outreach Initiatives• Conduct targeted phone calls to members identified as needing
screenings• Remind members of any gaps in care they have when calling Customer
Service• Distribute targeted mailing reminders to members identified as needing
screenings• Conduct health risk assessments, identifying illnesses and chronic
conditions early• Offer member incentive programs to obtain specific screenings• Distribute quarterly member newsletters with information on the
importance of preventive and chronic condition care• Provide member focused Case and Disease Management services• Offer $10.00 per month in over-the-counter items to members
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Our Community Focus
What are the physicians saying?
According to a study by the Robert Wood Johnson Foundation, 85% of surveyed physicians say unmet social needs are directly leading to worse health.
In addition, 4 in 5 physicians say the problems created by unmet social needs are problems for everyone, not only for those in low-income communities.
The County Health Rankings show that much of
what affects health occurs outside of the doctor’s office.
The Role of Health Factors on Health Outcomes
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Our Community Focus, continued
How do we overcome these barriers?• Educate members at community activities
• Community Activity Tracker• Bring the community, community advocates, members, providers, and
the Health Plan together to serve members’ needs• Regional HealthConnections Councils
• Identify a network of Social Safety Net organizations• My Family Navigator
• Connect members to Social Safety Net organizations that meet their specific needs
• HealthConnections Log• Compile a library of community-specific data to identify potential areas
of need• WellCare in the Neighborhood
• Support the needs of the communities our members live in• WellCare Innovation Institute
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Community Engagement in Action – A Kentucky Case Study
o A family of six living in subsidized housing.• Mom and Dad work full time without health benefits.• 10-year-old son has special needs. • 19-year-old daughter is pregnant.• 73-year-old grandmother has dementia.
o WellCare connected the family to the following: • Health Care (along with condition-specific healthcare)
In-home services for grandmother Prenatal care for the daughter
• Social Supports WIC / SNAP support Rental / Housing assistance Adult day activity program for grandmother CIL-based independence training for the son Caregiver training through National Caregiver Assoc.
o WellCare found and closed gaps in the following: • Utility assistance• Peer supports for the daughter• Transportation assistance for mother / daughter
The Community Advocacy Response
What makes us different is that WellCare has created a function to ensure that information for referrals to social programs is readily available for the interdisciplinary team (My Family Navigator) and that the programs are still available.
The local community advocates:
• Identified faith-based LIHEAP-related programs that required funding because utility-based LIHEAP had closed.
• Created peer-support group at the local school with provider-partner to address teen pregnancy.
• Connected family to local United Way for their subsidized car loan program to ensure that the daughter could get prenatal care.
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Next Steps
• In-depth discussion on quality with Medical Directors and Quality Staff
• Contact • Ronda Warner, Director of Quality
Phone: 502-253-5139 Email: [email protected]
• David Bolt, Director of Network Management Phone: 859-264-5102 Email: [email protected]
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Appendix A – HEDIS Measures
Measure Requirement
ADHD Follow-up • One visit 30 days after diagnosis, then• Two visits within nine months
Adolescent Well Visits • One visit annually
Adolescent Immunizations • Meningococcal and Tdap/Td by age 13
Appropriate Testing for Pharyngitis
• Antibiotic and strep test
Appropriate Treatment for URI • No antibiotic dispensed
Childhood Immunizations • Have the following by age 2:• 4 DTaP, 3 IPV, 1 MMR, 3 HiB,
3 Hep B, 1 VZV, 4 Pneumococcal, 1 Hep A, 3 Influenza, Rotavirus (complete 2 or 3 dose)
Chlamydia Screening One annually
Pediatric HEDIS Measures
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Appendix A – HEDIS Measures
Measure Requirement
Dental Visit • One annually
Lead Screening • One by age two
Weight Assessment & Counseling for Nutrition & Physical Activity
• Annual assessment of BMI (value for 16 & 17-year-olds, percentile for 15 and younger
• Annual counseling for nutrition• Annual counseling for physical activity
Well-Child Visits for 3-6 Year Olds
• One annually
Pediatric HEDIS Measures, continued
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Appendix A – HEDIS Measures
Measure Requirement
Acute Bronchitis Treatment • No antibiotic dispensed
Adult BMI • Annual assessment of BMI value
Antidepressant Medication • Initiation and continuation of medication
Breast Cancer Screening • Mammogram every two years
Cervical Cancer Screening • Pap smear every three year
Chlamydia Screening • One annually
Cholesterol Management for Patients with Cardiovascular Conditions
• LDL-C annually• LDL-C level <100
Dental Visits • One annually
Adult HEDIS Measures
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Appendix A – HEDIS Measures
Measure Requirement
Diabetes Care • Annual assessment of • HbA1c & result <8%• LDL-C & result <100• Dilated eye exam• Nephropathy monitoring• BP <140/90
Controlling High Blood Pressure • BP <140/90
Low Back Pain • No imaging study within 28 days of diagnosis
Persistent Medication Monitoring • Annual lab monitoring for patients on:• ACE or ARB• Digoxin• Diuretic• Anticonvulsant
Adult HEDIS Measures, continued
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Appendix A – HEDIS Measures
Measure Requirement
Smoking Cessation • Advising smokers to quit• Recommending smoking cessation
resources• Prescribing smoking cessation aids
Spirometry Testing in COPD • Spirometry testing to confirm COPD diagnosis and/or new exacerbation
COPD Exacerbation • Systemic corticosteroid and bronchodilator dispensed
Adult HEDIS Measures, continued
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Appendix A – State-Selected Performance Measures
Measure Requirement
Height/Weight/BMI Assessment and Assessment/Counseling for Nutrition and Physical Activity for Adults
• Assess height, weight, and BMI• Assess and or counsel for nutrition and
physical activity
Height/Weight/BMI Assessment and Assessment/Counseling for Nutrition and Physical Activity for Children and Adolescents
• Assess height, weight, and BMI• Assess and or counsel for nutrition and
physical activity
Cholesterol Screening for Adults • LDL-C screening
Prenatal Risk Assessment, Counseling, and Education
• Tobacco use assessment and counseling
Adolescent Screening/Counseling • Tobacco use assessment and counseling• Alcohol and substance use assessment
and counseling• Sexual activity assessment and counseling• Mental health assessment and counseling
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Appendix B – Medical Record Documentation Requirements
• Member identification information on each page;• Personal/biographical data, including:
• Date of birth• Age• Gender• Marital status for adults• Race or ethnicity• Mailing address• Home and work addresses’ as applicable• Home and work telephone numbers’ as applicable• Employer, if applicable• School name for children• Name and telephone information for emergency contact(s)• Consent forms• Language spoken• Guardianship/parent information for children
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Appendix B – Medical Record Documentation Requirements, continued
• Date of data entry and date of encounter;• Provider identification by name;• Allergies, adverse reactions and any known allergies are noted in a
prominent location in the record;• Past medical history, including serious accidents, operations, illnesses.
For children, past medical history includes prenatal care and birth information, operations, and childhood illnesses (i.e. documentation of chickenpox);
• Identification of current problems;• The consultation, laboratory, and radiology reports filed in the medical
record shall contain the ordering provider’s initials or other documentation indicating review;
• Behavioral health summary reports as applicable, initial evaluation and routine follow-up consultations;
• Documentation of immunizations pursuant to 902 KAR 2:060;
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Appendix B – Medical Record Documentation Requirements, continued
• Identification and history of nicotine, alcohol use or substance abuse;• Documentation of reportable diseases and conditions to the local health
department serving the jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR 2:020 as applicable;
• Follow-up visits provided secondary to reports of emergency room care as applicable;
• Hospital discharge summaries as applicable;• Advanced medical directives for adults. PCPs have the responsibility to
discuss advance medical directives with adult members at the first medical appointment and chart that discussion in the medical record of the member;
• All written denials of service and the reason for the denial, as applicable;
• Signature of the provider conducting the encounter; and • Record legibility to at least a peer of the writer. Records judged illegible
by one reviewer are evaluated by another reviewer.
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Appendix B – Medical Record Documentation Requirements, Continued
• Additional Documentation Requirements for Clinical Encounters
• History and physical examination for presenting complaints containing relevant psychological and social conditions affecting the member’s medical/behavioral health, including mental health, and substance abuse status;
• Unresolved problems, referrals and results from diagnostic tests including results and/or status of preventive screening services (i.e. EPSDT) are addressed from previous visits; and
• Plan of treatment that includes:• Medication history, medications prescribed, including the strength,
amount, directions for use and refills;• Therapies and other prescribed regimen; and• Follow-up plans including consultation and referrals and directions,
including time to return.
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Appendix C – EPSDT Requirements
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Visit Component Frequency
Complete History Initial visit
Interval History Each visit
Developmental Assessment(Age-appropriate physical and mental health milestones)
Each visit
Nutritional Assessment Each visit
Lead Exposure Assessment 6-month through 6-year age visits
Complete/Unclothed Physical Exam
Each visit
Growth Chart Each visit
Vision Screen Assessed each visit according to recommended medical standards
Hearing Screen Assessed each visit according to recommended medical standards
Appendix C – EPSDT Requirements, continued
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Visit Component Frequency
Hemoglobin/Hematocrit According to recommended medical standards
Urinalysis According to recommended medical standards
Lead Blood Level (Low-Risk History)
12-month and 2-year age visit
Lead Blood Level (High-Risk History)
Immediately
Cholesterol Screening According to recommended medical standards
Sickle Cell Screening One-time documentation
Hereditary/Metabolic Screening (Newborn Screening)
According to Kentucky Statute
STD Screening According to recommended medical standards
Appendix C – EPSDT Requirements, continued
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Visit Component Frequency
Pelvic Exam (Pap Smear According to recommended medical standards
DPT Assessed each visit
DTaP According to recommended medical standards
HiB According to recommended medical standards
MMR According to recommended medical standards
Varicella According to recommended medical standards
Td According to recommended medical standards
PPD According to recommended medical standards