Quest for Quality Why the Quest for Quality Its the RIGHT thing to do for the patientmember 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 ID: 748656
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Slide1
WellCare of Kentucky’s Quest for QualitySlide2
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
1Slide3
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.
2Slide4
State Requirements of WellCare That Affect Providers
3
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 treatmentSlide5
State Requirements of WellCare That Affect Providers, continued
4
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 resolutionSlide6
State Requirements of WellCare That Affect Providers, continued
5
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 daysSlide7
State Requirements of WellCare That Affect Providers, continued
6
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 standardsSlide8
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.
7Slide9
Our Provider Focus
Provider Tools
Identification of care gaps at eligibility checks
8
https://kentucky.wellcare.comSlide10
Provider Tools, continued
Provider Profile Report
9Slide11
Provider Tools, continued
Provider Care Gap Report
10Slide12
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
11Slide13
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
12Slide14
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
13Slide15
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
14Slide16
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 Health
Connections
Councils
Identify a network of Social Safety Net organizations
My Family Navigator
Connect members to Social Safety Net organizations that meet their specific needs
Health
Connections
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
15Slide17
Community Engagement in Action – A Kentucky Case Study
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.
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.
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.
16Slide18
Next Steps
In-depth discussion on quality with Medical Directors and Quality Staff
Contact
Ronda Warner, Director of Quality Phone:
502-253-5139
Email:
ronda.warner@wellcare.com
David Bolt, Director of Network Management Phone:
859-264-5102
Email:
david.bolt@wellcare.com
17Slide19
Questions?
18Slide20
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
19Slide21
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
20Slide22
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
21Slide23
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
22Slide24
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
23Slide25
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
24Slide26
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
25Slide27
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
;
26Slide28
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.
27Slide29
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.
28Slide30
Appendix C – EPSDT Requirements
29
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 standardsSlide31
Appendix C – EPSDT Requirements, continued
3
0
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 standardsSlide32
Appendix C – EPSDT Requirements, continued
31
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 standardsSlide33
Appendix C – EPSDT Requirements, continued
32
Visit
Component
Frequency
Age Appropriate Health Education/Anticipatory Guidance
Each visit
Dental Referral
Age 1