Care Providers and Quality Measures August 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 2 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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Annual Quality of Care Performance Measures

• •

Care 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. 3 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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EPSDT Requirements

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.

• • • • •

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 4 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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.

5 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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

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 6 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 13 th birthday: • • One dose of meningococcal vaccine and one tetanus Diphtheria toxoids and acellular pertussis vaccine (Tdap) or one • tetanus Diphtheria toxoids vaccine (Td) 7 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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.

2.

Tobacco Free Living -

discourage tobacco use or exposure

Preventing Drug Abuse and Excessive Alcohol Use -

substance abuse prevention

3.

4.

5.

Healthy Eating -

weight management and healthy nutrition

Active Living -

weight management and physical activity

Injury and Violence-Free Living -

healthy and safe lifestyles 8 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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.

9.

Vaccines and Preventable Disease -

healthy and safe lifestyles

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 9 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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.

10 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 11 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 within 42 days of enrollment in the organization.

or

Postpartum Care • The percentage of deliveries having a postpartum visit on or between 21 and 56 days after delivery.

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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 13 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 14 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 15 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 16 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 17 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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Monitoring and Improving Quality of Care

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

• • • • • • • • • • 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 18 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 19 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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 20 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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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. 21 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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