Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York

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1 Capital District Physicians Health Plan, Inc. Nonprofit Health Plan Albany, New York Capital District Physicians Health Plan, Inc. (CDPHP ) is featured as a high performer in cardiovascular care, identified by NCQA. This project is in support of Million Hearts and funded by the CDC s Division for Heart Disease and Stroke Prevention. The high performers were identified based on performance data in cardiovascular care-related measures in the HEDIS and diversity with respect to geographic location, organizational structure and patient population. We interviewed the health plan leadership to learn what they do to achieve good results. The table shows HEDIS 2012 results on measures related to cardiovascular care. Overview CDPHP is a physicianfounded, member-focused and community-based nonprofit health plan that serves more than 430,000 members in 24 counties in eastern New York state. Strategies Patient Engagement and Care Management CDPHP works closely with Enhanced Primary Care (EPC the CDPHP version of the PCMH model for patient care) clinicians to give them information about the importance of the HEDIS measures listed above and their results, and where there are gaps in care. CDPHP provides clinicians with support and strategies for engaging members in maintaining a healthy lifestyle, taking prescribed medications and getting regular tests.

2 Measure Commercial (HMO/POS Combined) Medicaid (HMO) Medicare (HMO) Controlling High Blood Pressure Cholesterol Management for Patients With Cardiovascular Conditions: LDL-C Screening Cholesterol Management for Patients With Cardiovascular Conditions: LDL-C Control (<100 mg/dl) Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers To Quit Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Note: - indicates plan representatives reported that the rate of smoking in their area is too low to be able to generate a reportable measure for Medicare. The plan complements these strategies with a benefit and formulary design that promotes desired results. CDPHP embeds a community coordinator or case manager in federally qualified health centers to work with these practices to encourage Medicaid enrollees to get preventive care and manage chronic conditions. Outreach occurs when these patients come into the clinic setting, through phone calls and postcards. CDPHP also partners with a major community organization in Albany and Troy to develop a community health worker program that trains workers to reach out to the Medicaid population in their homes and communities. Because a community presence can help reach Medicaid enrollees who need care and would otherwise use the emergency room, CDPHP has also rented office space in a community in Albany with the highest number of their Medicaid enrollees and deploys case managers to offer cholesterol and blood pressure screenings. Primary care support The EPC program includes physicians and nurse case managers working in teams. Thus far, 15 practices have embedded nurse case managers from the plan. These nurse case managers are critical for helping chronically ill members achieve health goals and develop self-management care plans. The nurse case managers also work with practices to help them make the most of their EHR for Meaningful Use and to identify patients with gaps in preventive care, as well as for chronic care follow-up. Disease management, case management and care coordination CDPHP works with a disease management vendor that uses claims data to identify patients with cardiac conditions and contacts them to encourage them to participate in available programs. One specific program is for patients who have had a myocardial infarction. In this program, a health coach

3 contacts patients the same week they are discharged from the hospital to help with medication reconciliation and to ensure they have a follow-up care plan. Other case management programs are for patients with many social needs, difficulty getting prescribed medications and problems getting to their physician s office. Still another program addresses heart failure. The plan has a partnership with a large cardiology group advancing heart failure are referred into a heart failure program so that they can be closely managed. The goal is to reduce frequency of hospitalizations and ER visits by providing intensive care until patients are back on track with their health. Case management workgroup CDPHP is one of 11 health plans in New York state that participate in a case management work group with the New York State Hypertension control: CDPHP is working with the New York State Department of Health on a two-year project to improve hypertension control in the managed Medicaid population. The goal is to empower enrollees to improve their health by making small but important changes to their lifestyles. Enrollees receive a variety of educational tools to help control hypertension, and can work directly with embedded case managers in targeted EPC practices. Enrollees are educated on the importance of remaining on their medications, even if they feel well. Effectiveness outreach activities are measured using Quality Assurance Reporting Requirements (QARR)/HEDIS Medicaid rates for Controlling High Blood Pressure (CBP) and Adult BMI Assessment (ABA). The ABA data are important because of the link between obesity and hypertension. that has a dedicated nurse practitioner at two of its largest hospitals. The nurse practitioner works closely with the hospitalist, as well as with the plan s case management discharge planners and the external case manager, to identify patients who would benefit most from the program. Patients with Department of Health and meet regularly to develop case management guidelines. CDPHP has begun public reporting of case management outcomes, including cardiac health an important area for medication adherence and for engaging the Medicaid population. The plan also participates in

4 the state s Medicaid Medical Directors Workgroup. All Medicaid managed care plans in New York participate in performance improvement projects. The topic for 2013 is chronic care, with an emphasis on hypertension. Health Information Technology and Quality Improvement In embedded practices, CDPHP has access to information in EHRs. In other practices, the plan s nurse case managers have access to health information through the Health Information Exchange of New York (which furnishes lab information and information about frequency of ER and hospital visits). One large cardiology group that works with CDPHP (and receives incentive payments) offers access to EHRs for the case management team. CDPHP posts national clinical practice guidelines to its website; these are the basis for physician performance assessment, measurement and incentives. The CDPHP quality committee reviews and adopts guidelines from other organizations, and the plan monitors performance on the guidelines. Physicians receive a primary care profile each year that includes their HEDIS measure and member satisfaction results, generic prescribing rates and current NCQA certifications. The profile is tied to payment incentives. In 2012, CDPHP upgraded its system to identify and keep track of members with certain conditions, including cardiovascular issues a good example of leveraging technology to achieve better results. Wellness and Health Promotion The Shared Health program is designed for the CDPHP commercial population. The plan s wellness staff works with employers to profile employees and develop health goals (e.g., cholesterol control). Employers work with CDPHP to encourage members to achieve health goals through Life Points, where they can earn points by engaging in healthy behaviors. CDPHP offers community classes for all members through its wellness department, including a free program called Pressure Wise, an hour-long discussion about controlling hypertension and staying heart-healthy. Participants receive a blood pressure cuff and education on blood pressure readings, and learn to recognize symptoms and when they should see their physicians. Members can use My Online Wellness to complete a health assessment and receive a personalized wellness plan through the CDPHP electronic Clinical Care Advance system.

5 Engaging Physician Practices CDPHP runs monthly gap reports for HEDIS measures based on administrative data (process measures, such as whether a screening occurred). These reports tell physicians which patients need screenings throughout the year. The plan pushes gap lists to lowerperforming providers and is developing a portal where physicians can retrieve this information, eliminating the need for hand-delivered paper copies. Payment bonuses are an incentive for physicians to use the information in gap reports, whether through the EPC payment model or through CDPHP primary care or specialty care incentive programs. The plan has a pilot program with one of its cardiology groups to use a pay-for-performance methodology that includes quality metrics such as blood pressure control and LDL cholesterol control. Other incentives have included helping primary care practices achieve NCQA Level 3 Recognition as medical homes; working with the national federal pilot of the CMS Comprehensive Primary Care Initiative (CPCI),

6 which engages primary care practices and payment models in using EHRs; and achieving Meaningful Use to have patient data readily available. All primary care incentive programs align, so practices are working to build capabilities for delivering better care. Lessons Learned CDPHP is fully committed to quality as a planwide effort. Every employee can affect plan members and physicians and can help improve HEDIS scores. It is important to engage members one at a time. Population management educates across the population, but also identifies members who are not responding and engages them on their own terms. Partnering with physicians is important. The combined effort of programming and making contacts leads to success. The social aspect of care is equally important because there are many financial and social reasons why people do not adhere to care plans. CDPHP is recognized as a community leader that provides access to highquality care. Health plans can spur health care quality and innovation and can reach more community members. Success Factors CDPHP identifies the following as key success factors for strong performance on quality indicators related to cardiovascular disease: Using outreach programs for Medicaid enrollees that encourage them to get preventive care. Having a strong primary care provider strategy (called enhanced primary care ). Using EHRs to track patient care and benchmark performance. Analyzing, tracking and working to improve performance on HEDIS measures. Enhancing benefits with programs (e.g., disease management and case management) that result in quality improvement. Promoting wellness through programs for commercial members.

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