Transcript Wellcare Deck Template

WellCare of Kentucky’s
Quest for Quality
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
Community
Educate members
Bring community advocates
together to serve members
needs
Assist in coordinating
care and removing
barriers to care
State
Find solutions for
State-wide issues
and barriers to care
Identify member social
resources
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State Requirements of WellCare That Affect Providers
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
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State Requirements of WellCare That Affect Providers,
continued
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
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State Requirements of WellCare That Affect Providers,
continued
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 reaudited within 90 days
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State Requirements of WellCare That Affect Providers,
continued
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
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WellCare of Kentucky Offices
Lexington Office
859-264-5100
Louisville Office
502-253-5100
Ashland Office
606-327-6200
Owensboro Office
270-688-7000
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.
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Our Provider Focus
Provider Tools
• Identification of care gaps at eligibility checks
https://kentucky.wellcare.com
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Provider Tools, continued
Provider Profile Report
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Provider Tools, continued
Provider Care Gap Report
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Provider Tools, continued
Member-Centered Case and Disease Management
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Member and caregiver-centered model
Service Coordination
• Proactive and collaborative face-to-face outreach and
assessment
Community /
• Discharge Planning
Advocate
• Matching members needs with most appropriate
provider and/or setting.
Family
• Driving Interdisciplinary Care Teams
Supports
• Integrating care for members
Holistic Management
Provider
• Home & Community-Based
Relations
• Behavioral Health
• Pharmacy
• Medicare and Medicaid
Culturally Competent
• Services in multiple languages
• Understanding and sensitivity to subcultural norms and
preferences
Primary Care
Physician
Specialist and
HCBS
Providers
Member
Whole Person
Orientation
Service
Coordination
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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
The Role of Health Factors on Health Outcomes
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.
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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.
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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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Questions?
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Appendix A – HEDIS Measures
Pediatric 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
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Appendix A – HEDIS Measures
Pediatric HEDIS Measures, continued
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
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Appendix A – HEDIS Measures
Adult 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
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Appendix A – HEDIS Measures
Adult HEDIS Measures, continued
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
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Appendix A – HEDIS Measures
Adult HEDIS Measures, continued
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
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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 24
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
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
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Appendix C – EPSDT Requirements, continued
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
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Appendix C – EPSDT Requirements, continued
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
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Appendix C – EPSDT Requirements, continued
Visit Component
Frequency
Age Appropriate Health
Education/Anticipatory Guidance
Each visit
Dental Referral
Age 1
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