2016 Quality Improvement Work Plan Summary

Transcription

1 2016 Quality Improvement Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how their plan works Member Service and Satisfaction Tufts Health Plan Medicare Preferred Product: Tufts Medicare Preferred HMO Project Description: To improve the caller s experience Patient Safety - Enhancement of Inpatient Commercial Occurrence Reporting Medicare Preferred HMO Project Description: Education of Commercial Inpatient Medical Management Team regarding reporting of appropriate occurrence referrals. Development of collaborative relationships between Clinical Quality Improvement (CQI) RN team, Utilization Management (UM) RN team and inpatient transition managers to enhance case discussion to serve as a vehicle for enhancing the quality of occurrence referrals. Appropriate referrals will ultimately lead to enhanced patient safety by proper identification of trends and potential for development of effective provider communication of areas of improvement. Evaluate a customer segmentation model that better identifies unique needs of customers and route them to the most appropriately trained staff member to help resolve their issue. Implement Support Point process guidance software to give call center staff step-by-step guidance to accurately and efficiently complete even the most complex task. Tools will help drive performance improvement through enhanced and complete information, improved consistency, and accuracy. Enforce the use of Support Point workflow and other education tools to help provide answers Member Service Representatives need to become more confident on the phone with members questions. Increase side by side and call auditing to help representatives improve call processing efficiency by developing best call handling practices. Enhancement of education materials Partnership development by facility assignment allowing for 1:1 facility-specific consultation Regular quarterly meetings to discuss trends in referrals 01/ Quality Improvement

2 Cultural and Linguistic Services Product: All Products Project Description: Collect and utilize Race, Ethnicity and Language (REL) data in order to find and address any health care inequities, to create new quality improvement initiatives where necessary, and to promote high-quality care for all our members Readmission Management - Tufts Health Plan Medicare Preferred Product: Tufts Medicare Preferred HMO Project Description: To reduce acute readmission rate (any member discharged from the acute inpatient setting and returned to any hospital with any admission diagnosis within 30 days of their original discharge) Behavioral Health - Antidepressant Medication, Initiation and Engagement of Alcohol and Substance Abuse Medicare Preferred HMO Project Description: The Antidepressant Medication Management (AMM) Project is focused on working with members and providers in supporting members with a diagnosis of major depression who were newly prescribed an antidepressant medication to remain compliant with their medication for an acute phase of treatment (12 weeks) and also for a continuation phase of treatment (6 months). The Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) Project is focused on working with providers to support Collect members self-reported race, ethnicity and language information on an ongoing basis. Perform an annual assessment of member grievances related to culture/language, and members cultural needs and preferences. Perform an annual assessment of disparity related to quality metrics. Using 2015 self reported and estimated REL data (where selfreported data are not available), analyze quality metrics for any significant differences in quality care by race, ethnicity or language. Groups with performance issues are being asked to complete a Readmission Action Plan (RAP) tool. The purpose is to formalize initiatives focused on areas of weakness for the individual group. The group is provided with a set of metrics from Tufts Health Plan Medicare Preferred to inform them of performance on utilization as well as key care management elements. Additionally, they are supplied with an action plan template in which they are required to document the following: Intervention description Basis for selection of population and intervention content Project benchmark and goal Updates will include: o Best practices and lessons learned Through Quality Focus Bulletin, educate providers regarding diagnosis and treatment of depression and compliance with the HEDIS antidepressant medication management measure. Information to be included in medical and mental health provider newsletters as well as posted on the Quality section of the website. Provider education about the National Depression Screening Day on the Tufts Health Plan website. Educational depression brochures are offered to members who contact the Tufts Health Plan Mental Health telephone queue. Educational depression brochures are mailed to members when the mental health providers have indicated that members are in treatment for depression when requesting further visits that require review. Continue depression screening for Commercial members as part of the Priority Care Program. Discuss with Designated Facilities (DFs) network, through presentations at DF meetings, issues of members identified with substance abuse disorder diagnoses and the importance of their follow-up treatment plan. 01/ Quality Improvement

3 members with a new episode of alcohol or other drug dependence to initiate treatment within 14 days of the initial diagnosis (initiation phase) and to continue in treatment with two or more additional visits within 30 days (engagement phase). Tufts Health Plan Senior Care Options (SCO) Readmission Reduction Products: Tufts Health Plan SCO Project Description: Prevent acute hospital admissions and readmissions for this population (community and institutionalized members), and to identify members who are at risk for preventable hospital admissions and readmission, focusing on pneumonia, dehydration, injuries from falls, and skin breakdown Clinical Practice Guidelines Medicare Preferred HMO, Tufts Health Together, Tufts Health Direct, Tufts Health Unify Project Description: Tufts Health Plan utilizes evidencebased guidelines that are adopted from national sources or developed in collaboration with specialty organizations and/or regional collaborative groups. These guidelines, which are not intended to replace clinical judgment, are statements that are designed to assist practitioners in making decisions about appropriate health care for specific clinical circumstances. Tufts Health Plan clinical practice and preventive health guidelines are designed to support preventive health, acute disease treatment protocols, and/or chronic disease management programs. Reduce risk of hospitalization/re-hospitalizations for community and institutional enrollees, which includes: Assigning a Care Manager/RN to assess risk during initial and ongoing assessments. The evaluation will include clinical, functional and nutritional status, in addition to physical and social well-being for all SCO enrollees. Evaluating SCO enrollees with Potential Risk for Hospitalization and adjust the Plan of Care (POC) to ensure timely provision of appropriate preventive care and treatment interventions. Collaborating with the PCP and other members of the Primary Care Team (PCT) to coordinate care and the timely delivery of treatments to avoid unnecessary hospitalizations. Review current guidelines for updates. Define the need for new clinical practice or preventive health guidelines. Participate in relevant coalitions as required (MHQP, MassPro, etc.). 01/ Quality Improvement

4 Preventative Health - Breast Cancer, Cervical Cancer, Colorectal Cancer Medicare Preferred HMO Project Description: Member reminders for timely cancer screenings Case Management and Utilization Management & Continuity and Coordination of Medical Care Medicare Preferred HMO Project Description: Project# 11.a: In March of 2015, the Tufts Health Plan Care Management (CM) Department implemented a pilot program for support to members following Emergency Department (ED) visits. This project enables the CM department to partner departments including Behavioral Health (BH), Member and Provider Services and Pharmacy. While this project offers a unique and exciting opportunity to partner for a multidisciplinary approach to management, the CM Department focus for continuity and coordination of medical care continues to be vetting the right members for the right level of Care Management or Transition of Care (ToC) intervention, improving provider awareness of the program and maximizing early identification leveraging internal and external provider/facilities. Member engagement in the program at the CM or ToC levels will demonstrate the transition support and continuity of care for members following discharge from emergency department services. Project #11b: In 2015 the Basic Transitions program, with Transition Coordinators, Providers receive lists of members who are in need of breast cancer screening. For members, send a letter reminding them to schedule a screening. 11.a Frequency of ED use o Define implementation time frame and develop process for high ED utilizers to be referred for engagement in Priority Care for complex CM Diagnosis/condition o Track and trend Engagement Rate of members identified by diagnosis or condition for incremental engagement gains quarterly. Develop education plan to support contracted provider units on care setting options and avoidable ED usage. 11.b Coordination of the UM Coordinator and Transition Coordinator roles to help support the quality and continuity of care for members: Effective identification and referrals of members after discharge from a CM programs, supported by a new operational measures. The Transition Coordinators establish support to members by following referrals by the UM Coordinator supported by standard CM operational measures. 01/ Quality Improvement

5 supports members following hospitalization and emergency room usage to ensure continuity of transition of care needs. The referral inputs for this program primarily come from the Utilization Management (UM) department. This projects demonstrates the partnership of the UM and CM departments to ensure members are identified and referred into the CM programs. The CM specific focus is on the Basic Transitions program to demonstrate member engagement and successful follow through on member after care provider visits. The UM specific focus is to demonstrate an effective process for referring members for Basic Transitions and other CM programs that are identified from facilities without an onsite Transition Manager, through the system enhanced Transition of Care flag. While the referral work process is the responsibility of the UM Coordinator and UM RN staff, the focus of this project will be the UM Coordinator s referral rate. Coordination Between Medical and Behavioral Healthcare Product: Commercial 12.a: Designated Facility communication with member s PCP: Communication with a member s PCP is recommended to occur during the course of an inpatient behavioral health admission to inform the provider of the admission, to review the course of inpatient treatment, and to assist with coordination of care and discharge planning. All designated facilities must routinely document communication with the PCP for every member who has an assigned PCP. The Behavioral Health department will conduct 12.a Work with designated facilities to prevent behavioral health readmissions for Commercial population. A primary focus of this project is to increase collaboration with a member s PCP through PCP communication. 12.b Behavioral Health (BH) Case Managers to consult with Medical Case Managers on cases where there are co-existing medical and behavioral disorders. This occurs for both members who are inpatient as well as on an outpatient basis. 12.c Tufts Health Plan Medical CMs and Behavioral Health CMs are working together to establish an ER diversion program in an attempt to reduce unnecessary ER utilization and to redirect members to appropriate and optimum care. Medical and Behavioral Health CMs will contact the member to address issues that brought the member to ER and determine optimum next steps for ongoing medical or behavioral health care. 01/ Quality Improvement

6 medical record reviews two times a year to review appropriate documentation of PCP communication by the designated facility. 12.b: Behavioral Health and Medical Case Managers Coordination of Care Project: Tufts Health Plan Medical Case Managers (CM) and Behavioral Health (BH) Case Managers are working together in consultation with each other and co-manage to share cases where there are co-morbid medical and behavioral health issues. 12.c: ER Diversion Program: Tufts Health Plan Medical Case Managers and Behavioral Health Case Managers are working collaboratively to establish an Emergency Room (ER) diversion program in an effort to reduce unnecessary ER utilization and to redirect members to appropriate and optimum care. Many members make repeated visits to the ER with medical symptoms and it may be determined that there is a significant behavioral health component that has not been addressed. Also, members who appear in the ER with behavioral health symptoms may also have co-morbid medical issues. The ER diversion program focuses on medical and BH case managers referring members ages 23 and older to one another for consultation or co-management of cases where there are comorbid medical and behavioral health diagnoses. This project will track members referred and engaged with the program, along with member satisfaction with the program. 01/ Quality Improvement

7 Tufts Health Public Plans Member Services & Satisfaction Products: Tufts Health Direct, Tufts Health Together, Tufts Health Unify Project Description: To improve the overall Member Service experience for members Tufts Health Public Plans - AMM Performance Improvement Product: Tufts Health Together Project Description: Improving antidepressant medication adherence among MassHealth adult members diagnosed with major depression Increase the percentage of Tufts Health Public Plan s MassHealth members who are 18+ and newly diagnosed with major depression who remain on an antidepressant medication through acute (at least 12 weeks) and continuation (at least 6 months) phases* by 2% by December 31, Tufts Health Unify - Diabetes Chronic Care Improvement Program Product: Tufts Health Unify Project Description: The Tufts Health Unify diabetes Chronic Care Improvement Program (CCIP) is focused on collaborating with members and their Integrated Care Team (ICT) in assisting the Tufts Health Unify members to better self-manage their disease to affect the disease progression. This will be accomplished through an emphasis on identifying members with diabetes and providing targeted care and support in their management of diabetes. Develop/deliver a refresher claims training to Member Service Representatives (MSR). Implement access to Symon Inview, training software, for the department. Implement Panviva s software tool, Support Point, to improve MSR s access to information. Support Point is an educational tool designed to reduce staff angst and effort trying to find the correct answer. Case Manager telephonic outreach focused on members who meet HEDIS AMM denominator criteria Communicate the importance of taking antidepressants as directed and talking with provider about side effects Outreach to members discharged from inpatient BH facility regarding aftercare All Tufts Health Unify members identified as having diabetes will be enrolled in the program. Members with low and moderate risk will be provided educational materials, access to a home assessment and texting. Members identified as high risk will be outreached to by their care manager for special attention to managing their diabetes. 01/ Quality Improvement

8 Tufts Health Unify - Emergency Department (ED) Utilization and the Effect of Independent Living Long Term Service and Support (IL-LTSS) on ED Use Product: Tufts Health Unify Project Description: The Emergency Department Quality Improvement Project (QIP) is focused on working with members and providers to understand over-utilization of the ED, attempting to reduce ED utilization by promoting alternative care options, reinforcing appropriate ED use, educating members on resources available when urgent care is needed, outreaching to members who visit the ED four or more times in 12 months, and promoting the use of LTSS services and LTS Coordinators. Include a one-page flier in the Welcome Packet that is sent to new Tufts Health Unify members, and annually thereafter, that outlines the services available through IL-LTSS, how a coordinator can add value to their health care, and how to sign up for services through Tufts Health Plan. Provider Relations team will educate providers who provide care to Tufts Health Unify members on the services available through IL-LTSS Coordinators and related supportive services. 01/ Quality Improvement