Introduction. Accomplishments

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2 Table of Content Introduction... 3 Accomplihment... 3 Deliverable A and B... 3 Deliverable C... 8 Deliverable D and E... 8 Deliverable F... 9 Deliverable G... 1 Deliverable H and I Deliverable J and K Deliverable L Deliverable M Added-Value Deliverable Appendice Appendix A: DHCS Strategy for Quality Improvement in Health Care, Appendix B: Quality Improvement Maturity Survey Appendix C: Draft Super-utilizer Report Appendix D: Undocumented Medi-Cal Member Appendix E: Draft Health Promotion Manucript Appendix F: Pediatric Athma Preentation Appendix G: Medi-Cal Performance Adviory Committee Agenda, January Appendix H: Medi-Cal Performance Adviory Committee Agenda, March Appendix I: Champion for Change Rx Propoal Appendix J: Hypertenion Control Quality Improvement Propoal and Driver Diagram Appendix K: Tobacco Ceation Driver Diagram Appendix L: Welltopia by DHCS Facebook Summary

3 Introduction The Medi-Cal Quality Improvement Program (MCQuIP) wa etablihed on October 1, 211 through a 5- year, $4.25 million Interagency Agreement (IA) between the California Department of Health Care Service (DHCS) and the UC Davi Health Sytem Intitute for Population Health Improvement (IPHI). Under thi agreement, IPHI, in cloe collaboration with DHCS, i charged with etablihing a quality improvement (QI) program for the $9 billion per year California Medical Aitance Program (Medi- Cal); developing a ytem-level quality management trategy and providing on-going evaluation for the $3.3 billion, 5-year Delivery Sytem Reform Incentive Payment (DSRIP) Program that i part of the tate 1115 Medicaid Waiver; conducting a broad review of QI trategie and method ued by Medicaid and other relevant publicly funded health care program; upporting the development and management of lifetyle program and member communication approache to optimize population health; and providing executive-level trategic advice, thought leaderhip, and organizational change management upport within DHCS. The MCQuIP yielded material reult during the third year of the collaboration, October 1, 213 through September 3, 214. Thi report highlight the major accomplihment achieved for each deliverable in the IA. Accomplihment Deliverable A and B: Develop a written quality improvement plan whoe aim and prioritie reflect hared value and bet practice, and which i conitent with the federal Department of Health and Human Service National Quality Strategy. Update the quality improvement plan at leat annually beginning one year after acceptance of the initial plan. DHCS Strategy for Quality Improvement in Health Care In the firt year of the IA, IPHI Quality Improvement Expert Conultant (QIEC), Kenneth W. Kizer, MD, MPH, and Chief Prevention Officer (CPO), Deiree Backman, DrPH, MS, RD, worked with the DHCS Medical Director, Neal Kohatu, MD, MPH, to develop the firt DHCS Strategy for Quality Improvement in Health Care, 212 (Quality Strategy). The Quality Strategy erve a the blueprint for the Department effort to improve the health of all Californian; improve the quality of health care, including the patient care experience, in all DHCS program; and reduce the rate of increae in the Department per capita health care cot. To accomplih thee three linked goal, the Quality Strategy i upported by even prioritie, which include: (1) Improve patient afety; (2) Deliver effective, efficient, affordable care; (3) Engage peron and familie in their health; (4) Enhance communication and coordination of care; (5) Advance prevention; (6) Foter healthy communitie; and (7) Eliminate health diparitie. The CPO worked with the DHCS Medical Director and Quality Specialit, Leah Northrop, MPA, to inform the annual update of the Quality Strategy. The Quality Strategy, 213 wa approved and publihed in December 213. Thi edition of the Quality Strategy, which i hown in Appendix A, reflect ignificant growth in QI project and a deeper commitment to the three linked goal department-wide. 3

4 The CPO preented the Quality Strategy at the DHCS new employee orientation in October 213 and May 214, and preented element of the trategy with the DHCS Medical Director at a UC Davi Department of Public Health graduate eminar in October 213. Behavioral Health Integration The integration of behavioral and phyical health i an important, yet underrepreented area in the Quality Strategy. To bridge thi gap, IPHI Special Advior for Behavioral Health Integration, Efrat Eilat, PhD, MBA, ha been working cloely with the DHCS Medical Director, Deputy Director of Mental Health and Subtance Ue Diorder Service, Karen Baylor, PhD, LMFT, the CPO, and national and local expert to develop a viion and action plan, which upport the integration of phyical, ubtance ue diorder, mental health, and ocial ervice for Californian. The proce, which will commence in Fall 213, will include the following: 1) conduct a urvey of health care delivery ytem takeher and other to identify eential factor for behavioral health integration; 2) aemble an expert tak force and appropriate working group to draft a viion and action plan, including meaureable outcome, for integration; 3) receive input on the viion and action plan from a wide range of takeher; and 4) implement the action plan. The Special Advior ha made initial contact with potential funder and national and local expert to advance thi project. Building a Culture of Quality at DHCS Quality Improvement Maturity Survey IPHI Clinical Quality Officer (CQO), Ulfat Shaikh, MD, MPH, MS, worked with the DHCS Medical Director and taff to identify a validated quetionnaire to ae the culture and readine for QI at DHCS. Thi quetionnaire (Quality Improvement Maturity Survey, Appendix B) wa ditributed to DHCS executive taff, manager, and upervior in order to obtain baeline reult. Reult were then widely hared with DHCS leaderhip and taff through the DHCS Newletter and lide preentation by the CQO at DHCS leaderhip meeting. Two area where repondent reported that DHCS doe well are: 1. Agreement that the key deciion maker at DHCS believe QI i very important; and 2. Awarene that DHCS ha a QI plan. Survey reult identified four main area at DHCS where there i room for improvement: 1. Training of leader in baic method for evaluating and improving quality, uch a Plan-Do- Study-Act; 2. Capacity to engage in QI effort; 3. Specific reponibilitie related to meauring and improving quality in job decription for individual reponible for program and ervice; and 4. Ue of cutomer atifaction information by individual reponible for program and ervice. The reult of the Quality Improvement Maturity Survey will be tracked annually and will erve a a quantitative metric to determine DHCS progre on it Quality Strategy. 4

5 Quality Improvement Training A part of the DHCS Adult Medicaid Quality Grant, the CQO worked with DHCS leaderhip and taff on a erie of QI training to advance quality competency at DHCS. The firt QI training coure held in January 214 wa a 2-hour introduction to the core principle of QI for upervior and manager. The objective of the coure included: 1) dicuing the core principle of QI; 2) haring QI tool that taff can ue in their day-to-day activitie; and 3) dicuing team/group kill that can help taff play a more direct and effective role in the development and implementation of the Quality Strategy. A part of the DHCS Adult Medicaid Quality Grant, the CQO trained and coached two QI project team in the area of adult diabete management and early elective deliverie. Coaching focued on the application of QI methodology, and the goal wa to increae the ability of DHCS clinician and taff to apply QI methodology while improving health care delivery procee and outcome. The training provided participant with the undertanding and tool neceary to conduct tate-of-the-art QI project and ue QI method to manage and effectively integrate intervention. The training facilitated the development of kill and competencie needed by taff to actively lead, participate in, and direct the Quality Strategy. It built on the experience of QI expert at IPHI and brought project team member together to learn the theory and technique of: 1) deigning data ytem; 2) outcome meaurement and tracking; 3) method for rapid improvement; 4) data management; 5) information ynthei; and 6) total quality management/continuou QI. Additionally, the CQO preented everal topic at DHCS Office of the Medical Director all taff meeting and during DHCS Learning Serie eion. Example of topic were population health conideration for childhood and adolecent athma and changing clinician behavior. The CQO alo provided technical aitance to DHCS taff during their development and implementation of the DHCS Profeional Book Club. The Book Club focue on QI and patent afety publication. Uing Data to Drive Quality Improvement Data Querie, Analye, Retrieval for External Stakeher, and Modeling IPHI' Quality Scientit (QS), Brian Paciotti, PhD, MS, performed data querie and analye uing fee-forervice and encounter data to inform a number of project aociated with the Quality Strategy. Firt, the QS performed a number of analye of claim and encounter data to upport the Million Heart Initiative. Second, the QS conducted reearch about the validity of uing Medi-Cal eligibility data to etimate the number of Medi-Cal member that are eligible but are not enrolled in CalFreh. Third, the QS participated in dicuion about how to create a econd et of health diparitie fact heet uing claim and encounter data. The QS continued to upport the DHCS Information Management Diviion (IMD) by extracting data from the Medi-Cal Management Information Sytem/Deciion Support Sytem (MIS/DSS) to upport external reearch requet. The QS helped to re-define two data requet to help Dr. Uhma Upadhyay complete her Ditance to Get Abortion Project. The QS worked with the Medi-Cal Incentive to Quit Smoking (MIQS) team to identify the variable neceary for their evaluation. The QS alo retrieved claim and encounter record for a pecific cohort of patient baed on a finder file provided by the California Cancer Regitry. Finally, the QS pulled million of claim record acro three year, created the Structured Query Language code to de-identify pecific field, and completed the form and neceary jutification to create a ecure File Tranfer Protocol ite for data tranfer within IMD. 5

6 Archimede i a imulation modeling tool developed by David Eddy and Kaier Permanente. Baed on imulation that tart at the phyiological level, the application can predict outcome for a variety of health intervention. The QS upported DHCS taff to learn how to ue the application and produce output related to a variety of project. Firt, the QS created imulation output to help the Medi-Cal Managed Care Diviion (MMCD) undertand the impact of Healthcare Effectivene Data and Information Set (HEDIS) meaure improvement on health outcome. Second, the QS upported the Million Heart Initiative by evaluating likely health benefit and cot aving aociated with tobacco ceation, low-doe apirin, and hypertenion control intervention. California State Innovation Model Total Cot of Care Meaure The California Health and Human Service Agency applied for a Center for Medicare and Medicaid Innovation State Innovation Model Grant in July 214. In preparation for the grant award, numerou analytical project are being created to identify innovative way to improve health and reduce cot. The QS wa invited to work with taff from the DHCS IMD to etimate the total cot of care for all member within Medi-Cal. The member-level reult will then be aggregated by fee-for-ervice and managed care and ummarized among 17 California region. A report of the finding will be available in late 214. High-Cot Member Report ( Super-Utilizer ) The QS continued to refine preliminary report related to the highet cot Medi-Cal member, or the uper-utilizer population (Appendix C). The goal of the project i to identify Medi-Cal member with the highet cot, and then characterize the pattern aociated with demographic trait, ervice utilization, and dieae co-morbiditie. The firt et of report focued olely on fee-for-ervice expenditure in 21 and decribed the top 2, 15, 1, 5 and 1 percent of the cot curve. In 214, the QS refined the original analye to include an additional report uing more modern data, capitated rate data to ummarize managed care expenditure, and a ub-report that focue on Medi-Cal undocumented member (ee Appendix D for the ub-report on Medi-Cal undocumented member). The QS preented reult to the Medi-Cal Performance Adviory Committee (MPAC) on March 24, 214 and ubequently provided preentation about high-cot member to DHCS analyt and enior leaderhip. Health Diparitie Fact Sheet The CPO directed effort with the QS and a DHCS Reearch Scientit, Patricia Lee, PhD, to publih a erie of 24 health diparitie fact heet, baed upon the 39 health indicator in the Let Get Healthy California Tak Force Final Report ( Let%27%2Get%2Healthy%2California%2Tak%2Force% 2Final%2Report.pdf). The fact heet are deigned to highlight health diparitie among Medi-Cal beneficiarie compared to California non-medi-cal population, and the data will help inform the development of QI initiative for the eventh priority of the Quality Strategy Eliminate Health Diparitie. An executive ummary, introduction, individual fact heet, and data ource and method ection were completed, approved by Director Dougla, and publihed on the DHCS webite ( The DHCS Reearch Scientit i in the proce of developing new fact heet, baed upon departmental need. 6

7 Medi-Cal Managed Care Plan Health Promotion Survey After conducting the 212 baeline aement of QI activitie in DHCS and learning there were few reported QI initiative in the prevention area, the CPO worked with the DHCS MMCD to undertand the type of health promotion and dieae prevention ervice delivered by the Medi-Cal Managed Care Plan (MCP). The CPO learned that DHCS doe not track or ae thee ervice in a comprehenive way, depite contract pecification to deliver health promotion intervention that are effective in achieving behavior change and poitive health outcome. To reolve thi iue, the CPO aembled a mall reearch team and conducted a urvey to: 1) inventory health promotion intervention delivered through MCP; 2) identify attribute of health promotion intervention that MCP judged to have the greatet impact on their Medi-Cal member; and 3) determine the extent to which MCP refer Medi-Cal member to community aitance program and ponor health-promoting community activitie. Reult howed wide variation in the delivery of health promotion intervention. Multiple intervention delivery method were reported, with proviion of educational material, one-on-one education, and group clae being cited mot frequently. Behavior change, knowledge gain, and improved dieae management were cited mot often a meaure of effectivene. Median educational hour were limited, median Medi-Cal member participation wa modet, and the majority of intervention focued on tertiary prevention. There were alo mixed reult in MCP effort directed toward upporting or improving the ocial determinant of health and inveting in health promoting community activitie. The CPO, QIEC, QS, DHCS Medical Director, and DHCS Analyt, Jennifer Byrne, BA (formerly IPHI Reearch Aitant) produced a draft manucript (Appendix E), and the co-author plan to ubmit the manucript for publication in the American Journal of Preventive Medicine in fall 214. Additionally, the CPO and QS preented the health promotion urvey reult at the 214 American College of Preventive Medicine Conference during a poter eion. The CPO alo preented the finding to MPAC in March, Center for Medicare and Medicaid Service (CMS) Quality Technical Adviory Group and the Health Education and Cultural & Linguitic Workgroup of the MCP in June, and at the DHCS Learning Serie in Augut 214. Pediatric Athma Analyi The CQO worked with DHCS taff and UC Davi health ervice reearcher to analyze data on pediatric iue within the California Health Interview Survey. One et of recently completed analye evaluate population health iue for pediatric athma in California, including health care diparitie, emergency department ue, hopital admiion, medication ue, and chool abence. The analye, preented at the 214 American College of Preventive Medicine Conference and at the DHCS Learning Serie (Appendix F) found that children enrolled in Medi-Cal had a high number of emergency department viit compared to children with private or no inurance. The analye alo howed very low influenza immunization rate among children with athma in California, regardle of health care acce. The CQO, in partnerhip with DHCS and UC Davi taff, ha prepared a report that wa ubmitted to the American Journal of Preventive Medicine a a manucript. 7

8 Child Health and Diability Prevention (CHDP) Program From May 214 to preent, the Special Advior for Behavioral Health Integration, in collaboration with the MMCD, Sytem of Care, and Medi-Cal Dental Service Diviion, ha co-led a workgroup to analyze the impact of managed care and the CHPD Program on the proviion of Early and Periodic Screening, Diagnoi and Treatment (EPSDT), given the potential duplication of effort and funding. The goal i to develop recommendation for DHCS executive that aure high-quality and efficient proviion of EPSDT ervice to California children and adolecent. To accomplih thi goal, the workgroup: 1) developed a work plan; 2) conducted informational interview with MCP Medical Director; 3) added Medi-Cal Managed Care requirement to a requirement matrix developed by CHDP; and 4) developed an initial analyi of the matrix with DHCS recommendation. The workgroup will convene takeher meeting and then develop final recommendation for DHCS executive, which are expected to be dicued with CMS in March 215. Connecting Health Care and Communitie to Advance the Triple Aim The CPO wa invited by the DHCS Medical Director to preent model of care during a panel eion at the 214 American College of Preventive Medicine Conference in February. In preparation for the preentation, the CPO reviewed the lay and peer-reviewed literature on model of care, with an emphai on model that connect health care and communitie to advance the triple aim. The CPO prepared and delivered the preentation at the conference, which featured principle of ucceful integration of primary care and public health, and the Expanded Chronic Care Model. The information gathered for the preentation i alo helping to inform other care delivery converation, uch a the Department 1115 Waiver renewal. Deliverable C: Conduct a broad review of quality improvement trategie and method ued by Medicaid and other relevant publicly funded health care program to the extent allowed by available reource. Quality Improvement Evaluation Sytem After publihing the baeline aement of QI activitie in 213, the CPO and QS developed an evaluation ytem to ae the performance of exiting DHCS QI activitie and collect new QI activitie annually. The ytem included detailed intruction to Department taff and template to collect update on exiting and new QI activitie. Thi new ytem wa launched by the Office of the Medical Director and ued in fall 213 to collect update and new QI activitie to inform future Quality Strategy initiative. The delivery and ue of the evaluation ytem repreent the completion of Deliverable C. Deliverable D and E: Develop a Sytem-level Quality Management Strategy for DSRIP. Provide on-going evaluation of DSRIP, including providing at leat emi-annual report that ae general and pecific area of improvement. The CQO ha been providing ongoing technical upport and pecific recommendation to DHCS and the 21 participating deignated public hopital in order to optimize achievement of DSRIP Program miletone. Thi aitance ha been provided in the form of face-to-face and telephone meeting a well a electronic communication. Example of recommendation made include election of evere 8

9 epi and troke target, and aement of intervention implemented by hopital baed on publihed literature and national guideline. Semi-annual and annual report from participating public hopital, a well a aggregate report from the California Aociation of Public Hopital Safety Net Intitute (CAPH-SNI), were rigorouly reviewed. Individual feedback to hopital wa provided in written format. Thee feedback report ae implementation of miletone and addre general a well a pecific way to improve reporting and implementation of miletone. Technical aitance and mentoring wa provided to hopital on bet practice and trategie related to their QI initiative. The CQO worked with DHCS taff to develop a DSRIP Data Integrity Policy, which wa hared with CAPH-SNI and hopital in the DSRIP program. Deliverable F: Convene and lead a multi-diciplinary Medi-Cal Performance Adviory Committee (MPAC). MPAC hall routinely meet about quarterly, and more frequently if needed, and iue periodic report memorializing it finding and recommendation. Becaue of the cale and complexity of the cope of work undertaken by IPHI, the QIEC propoed and DHCS agreed that an external adviory group compoed of expert in QI and population health would be very ueful. The overarching purpoe of MPAC i to advie IPHI and the Department on how to mot effectively advance health, clinical quality, and outcome. Specific goal for the MPAC member include: Review and comment on the Department' evolving Quality Strategy; Review and comment on QI activitie currently being purued by Medi-Cal and identify where additional effort may be needed; Advie on building a culture of quality at DHCS and implementing large-cale, utainable delivery ytem reform; Review and comment on DSRIP tatu report and advie on how to optimize achievement of QI target; and Otherwie provide input on topic propoed by DHCS and the QIEC. In the firt year of the IA, the QIEC recruited and ecured even MPAC and two Ex-Officio member, and convened one MPAC meeting. For a lit of MPAC member, pleae viit: The QIEC chair MPAC and actively lead it deliberation. The QIEC and CPO worked with the DHCS Medical Director to develop the MPAC agenda for a conference call meeting in January 214 (Appendix G). Agenda topic included update and dicuion on the Quality Strategy, 213, uper-utilizer, reducing opiate overdoe, reducing overue of ervice, palliative care, diparitie/inequitie fact heet, Adult Medicaid Quality Grant, and direction for the March 214 in-peron MPAC meeting. The QIEC and CPO worked with the DHCS Medical Director to develop the MPAC agenda for the March 214 meeting (Appendix H). The agenda included update on the DHCS quality improvement aement and training, opiate management, reult of a health promotion urvey of MCP, reult of uper-utilizer analye, ocial care, and a vulnerability index. IPHI Reearch Aitant coordinated all meeting logitic, the QIEC facilitated the meeting, and the CPO preented the reult of the MCP health promotion urvey. The QS created a draft report that ummarized hi high-cot member ("uperutilizer") analye. The report decribed poible quetion and area for future reearch and provided a detailed review of method and reult that have led to the mot important finding. In addition, the QS 9

10 preented uper-utilizer data to the MPAC member. The CQO preented an update on the DHCS quality improvement training program and reult from the Quality Improvement Maturity Tool. Deliverable G: Support the development and management of lifetyle program to optimize population health with particular attention to: moking ceation, nutrition, phyical activity, and alcohol/ubtance abue. Increaing Food Availability for Medi-Cal Familie The CPO, in partnerhip with the California Department of Social Service (CDSS), led effort to increae CalFreh enrollment among the nearly 2 million Medi-Cal member who are eligible but not enrolled in the nutrition aitance program. DHCS and CDSS agreed to etablih a QI project to increae enrollment by: 1) including CalFreh in the Covered California Single Streamlined Application, which trigger direct outreach from county ocial ervice to newly enrolled Medi-Cal member; 2) linking Medi-Cal member to CalFreh through DHCS ocial media and the IPHI population health webite; 3) promoting CalFreh in Medi-Cal enrollment material; 4) ditributing CalFreh information through member mailing; and 5) delivering CalFreh enrollment training to Certified Enrollment Counelor and health educator with the MCP. The CPO, QS, and DHCS analyt, Tianna Morgan and Jennifer Byrne, worked with CDSS to et a target of increaing CalFreh enrollment by 5 percent from January 214 through January 215. A mid-point aement of the QI project howed a 2.6 percent increae in CalFreh enrollment among Medi-Cal member. Obeity Prevention To advance healthful eating, phyical activity and obeity prevention in Medi-Cal, the CPO ubmitted a $533, grant propoal in July 213 to the California Department of Public Health (CDPH) Nutrition Education and Obeity Prevention Program (NEOP) a part of their annual plan to the United State Department of Agriculture Supplemental Nutrition Aitance Program-Education (SNAP-Ed). The propoal, titled Champion for Change Rx, featured formative reearch, including takeher key informant interview and focu group with Medi-Cal member, to inform the development and evaluation of an obeity prevention program linking health care and community intervention. Although the grant wa awarded at the end of September 213, adminitrative delay at CDPH prohibited the execution of the grant during thi reporting period. The CPO wa invited by NEOP taff to ubmit a revied grant propoal for Federal Fical Year 215. The purpoe of the grant i to: 1) identify feaible, utainable, age- and culturally-appropriate obeity prevention approache in the health care etting that can be delivered to SNAP-Ed eligible Medi-Cal member; 2) identify teted NEOP/SNAP-Ed tool, reource, material, and communication method that can be applied to the health care etting; 3) identify efficient and effective way to drive SNAP-Ed eligible Medi-Cal member to participate in NEOP community-baed intervention where they live, work, learn, worhip, play, make food and phyical activity deciion, and become involved in community empowerment effort; 4) develop and produce a pilot program and evaluation plan deigned to reduce the rik and prevalence of overweight and obeity among SNAP-Ed eligible Medi-Cal member and reduce projected health care cot; and 5) begin developing the component of the pilot program in preparation for implementation and formal evaluation in FFY 216. See Appendix I for the Champion for Change Rx grant propoal. The grant i expected to be executed by January

11 A a precuror to launching the formal cope of work, the CPO conducted pre-key informant interview with five NEOP leaderhip and program taff to identify: 1) recommended and bet practice obeity prevention intervention; 2) media and ocial media tie-in; 3) contracted local health department with trong obeity prevention intervention and community collaboration; and 4) educational reource that could be readily deployed in the health care delivery ytem. Additionally, the CPO and DHCS Medical Director met with the Contra Cota Regional Medical Center, Contra Cota Public Health Department, and Contra Cota Managed Care Plan executive to dicu the obeity grant and determine whether Contra Cota County would be a good candidate to conduct future intervention teting. Executive with the medical center, public health department, and managed care plan all expreed interet in collaborating on the grant. Finally, the CPO ecured a Mater of Public Health intern from UC Davi in March 214 to complete a literature review on obeity prevention and management. The literature review will be completed in January 215. Center for Medicare and Medicaid Service Prevention Learning Network In October 213, the CPO ubmitted a propoal to CMS to participate in the Medicaid Prevention Learning Network. The aim of the propoal wa to align DHCS program and ervice, meaure and data, information technology, the Medi-Cal health care delivery ytem, and public, non-profit and private ector partnerhip to upport the Million Heart Initiative ( Specific activitie include the following: 1) conduct an aement to identify relevant program and ervice that could upport the Million Heart Initiative; 2) identify relevant cardiovacular dieae-related meaure and data that are being gathered, and identify how thee meaure could inform QI activitie; 3) analyze data from the MCP health promotion urvey to undertand the type of program being delivered to prevent and manage cardiovacular dieae; and 4) ae involvement by DHCS partner to advance cardiovacular health and identify new partner to upport the Million Heart Initiative. The purpoe of thee activitie i to inform the development of a QI initiative to reduce and prevent cardiovacular dieae among Medi-Cal member. The propoal wa approved by CMS in December 213. The CPO aembled the QS and RA, a DHCS team (Quality Specialit, Leah Northrup, MPA, Legilative Analyi, Regulation, and Inquiry Repone Unit Chief, Katherine Neto, and Reearch Scientit, Jaon Van Court, MPH), and two UC intern, Stephanie Toledo and Amanjit Laher, to participate in the project. Under the direction of the CPO, elected team member participated on monthly CMS call. The call included both tate collaborative call and California-pecific update. The team aeed DHCS program and ervice that could upport the Million Heart Initiative; identified clinical cardiovacular meaure and outcome from the MCP health promotion urvey; met with CDPH Coordinated Chronic Dieae team, Right Care Initiative partner, and MMCD taff to identify area of collaboration; and received approval to commence a hypertenion control QI project with the MCP, beginning in December 214 (ee Appendix J for the hypertenion control QI propoal and driver diagram). The team, with upport from DHCS Chief Adminitrative Officer, Gordon Slo, MPA and Project Manager, Jeica Safier, MA, alo produced a tobacco ceation driver diagram (Appendix K). Finally, the team i in dicuion with the Pharmacy Diviion to pilot tet a low-doe apirin QI project. Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) Implementation The Special Advior for Behavioral Health Integration co-led a multi-diviional project to implement the Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) benefit for adult Medi-Cal beneficiarie in the primary care etting throughout the tate. In order to upport provider in the 11

12 implementation of the new benefit, the Special Advior ubmitted a propoal to the California Health Care Foundation in February, and the grant wa awarded in May 214. The purpoe of the grant i to: 1) provide 3 face-to-face training acro the tate, to primary care provider, clinic adminitrator, medical director, and other, on how to effectively deliver SBIRT to thoe with alcohol ue diorder; and 2) provide a three-part evaluation of the training effort, including pot-training and follow-up, and quantitative and qualitative evaluation. The Special Advior managed the development of a ubcontract with the Univerity of California, Lo Angele, Integrated Subtance Abue Program, who will provide the training and evaluation, and he executed a eparate agreement with Harbage Conulting to upport DHCS with outreach and on-going communication with provider. An SBIRT webite targeted to provider wa developed and i maintained and updated under the leaderhip of the Special Advior. Medi-Cal Managed Care Plan Health Promotion Survey Refer to Deliverable A and B for a decription of the MCP health promotion urvey. Prevention and Wellne Communication Refer to Deliverable J and K. Deliverable H and I: Evaluate and analyze the delivery of clinical preventive ervice, and develop and implement trategie to improve network performance in quality meaure in thi domain. Identify and encourage adoption of effective population health trategie by DHCS contracted health plan. Medi-Cal Managed Care Plan Health Promotion Survey Refer to Deliverable A and B for a decription of the MCP health promotion urvey. The urvey finding helped inform a erie of next tep for the CPO and other DHCS taff to purue during the next 12 month. Specifically, the CPO will lead effort to determine: 1) how the MCP ae health rik among Medi-Cal member and how rik-related data are ued to inform health promotion intervention delivery; 2) the bet approach to et quality improvement target, tarting with the leading caue of preventable mortality and illne; 3) method to maximize the delivery of the US Preventive Service Tak Force A and B recommendation and other evidence-informed bet practice intervention; 4) opportunitie to enure that health care and community prevention effort are available, integrated, mutually reinforcing, and addre the ocial determinant of health; and 5) method to implement a monitoring ytem to track the delivery and performance of health promotion intervention. Deliverable J and K: Foter partner relationhip between DHCS and member through trong bidirectional communication with repect to need, reponibilitie, and preference related to healthy lifetyle. Deign a trong member education, communication, and intervention platform that drive improvement in population health. One of the prioritie of the Quality Strategy i to engage peron and familie in their health. During the firt year of the IA, the DHCS Medical Director and CPO explored the ue of ocial media and other form of communication to reach Medi-Cal member with information and reource about prevention and wellne. Recommendation from the exploratory period were ued to inform the accomplihment noted below. 12

13 Welltopia by DHCS Facebook Page and Twitter The CPO led effort, with upport from DHCS analyt, Tianna Morgan and Jennifer Byrne, and DHCS intern, Hannah Robin, to build, pilot tet, and implement a DHCS wellne Facebook page, titled Welltopia by DHCS (Welltopia). The Facebook page, located at wa launched on April 24, 213, with the goal of achieving 1, like by December 31, 213. The target audience i Medi-Cal member, with an emphai on Medi-Cal mother. The purpoe of Welltopia i to provide tip, information, and reource to help Medi-Cal member eat healthier food, engage in adequate phyical activity, reduce tre, quit moking, connect with local reource that upport the ocial determinant of health, and interact with the Facebook community. A a reult of feedback received from focu group with low-income women and men, the CPO continued to lead effort with Marketing by Deign to implement and evaluate an inexpenive Facebook advertiing campaign to increae the number of like among low-income Californian. From October through December 213, the Facebook page ecured 12,156 like, which exceeded the original goal. A of September 3, 214, the Facebook page ecured 35,673 like. New pot for the Facebook page are being developed by a DHCS intern, with overight from the CPO and aitance from DHCS analyt. In addition, the pot have been converted into Tweet, and the Tweet are being hared through the DHCS Twitter account (@WelltopiaDHCS). The team alo produced 94, Welltopia flier, which were ditributed to new Medi-Cal member in October a part of the beneficiary identification card mailer. Facebook analytic indicate that the advertiing campaign continue to urpa all other form of marketing, including the flier mailing. See Appendix L for a ummary of Facebook activitie. Population Health Improvement Webite In Augut 213, the CPO and IPHI Chief Adminitrative Officer, Allyn Fernandez-Ami ecured $5, from the California Health e-quality Program to develop and implement a population health improvement webite that will upport Welltopia and enhance the availability of prevention and wellne reource for Medi-Cal member. The purpoe of the webite i to connect Californian, epecially thoe with limited income, with credible reource for healthy peronal, family and community development, tarting with topic that addre the leading caue of preventable morality (e.g., tobacco, diet, phyical activity, and alcohol abue) and the ocial determinant of health (e.g., education, employment, houing, health inurance, acce to food, etc.). The CPO aembled a webite development team, including both IPHI and DHCS taff. The CPO and webite team completed the ite map; developed criteria to determine which reource hould be poted on the webite; aembled credible reource, with approval from the DHCS Office of Public Affair and Medical Director; completed the deign phae of the webite; ecured the webite addre (mywelltopia.com/org/net); and contracted with Communication Deign for the earch engine. The webite i cheduled to launch in January 215. Deliverable L: Support a trong prevention focu acro all DHCS program. Deliverable A-C, F-K, and M demontrate IPHI' effort to upport a trong prevention focu acro all DHCS program. In addition, there ha been teady growth in the amount and type of QI project that addre prevention. Specifically, when the baeline aement of QI activitie wa conducted in 212, four prevention-related QI project were reported in the area of tobacco ceation, family planning, American Indian infant health promotion, and newborn hearing and creening. In addition to thee 13

14 area, the Quality Strategy, 213 include more tobacco ceation activitie, four ubtance ue diorder prevention activitie, preventive dental ervice, breat and cervical cancer creening, chlamydia creening, breatfeeding promotion, overweight and obeity reduction, and more (Appendix A). Deliverable M: Provide executive-level trategic advice, thought leaderhip, and technical aitance through in-peron, teleconference, and other mean. Strategic Advice, Thought Leader, and Technical Aitance The IPHI team provided executive- and program-level trategic advice, thought leaderhip, and technical aitance in the following area: The QIEC (Kenneth W. Kizer, MD, MPH) met with DHCS leaderhip and taff regularly to provide thought leaderhip on all apect of MCQuIP, and provided direction to the CPO, CQO, and QS. The QIEC and CPO worked with the DHCS Medical Director, Contract Analyt, Citra Downey, and IPHI Program Manager, Allyn Fernandez-Ami, MPH, to produce an amendment to the MCQuIP IA. The amendment, which i in the proce of final authorization, repreent a budget increae of $1,343,42 over the original IA and three additional peronnel. The CPO (Deiree Backman, DrPH, MS, RD) met with DHCS leaderhip and taff on a daily bai to provide leaderhip and upport on the Quality Strategy, prevention and health promotion ytem-wide, member communication approache, reearch and evaluation, and IPHI adminitrative matter. She alo provided taff overight to the QS, RA, and Special Advior for Behavioral Health Integration. The QS (Brian Paciotti, PhD, MS) met with DHCS leaderhip and taff on a regular bai to provide technical aitance on data ytem and management, a well a conducted numerou, complex analye uing Medi-Cal data. The QS reviewed reearch propoal and provided data expertie in upport of Data Reearch Committee meeting, and continued to upport the Adult Medicaid Quality Grant team. Additionally, the QS delivered three preentation to large audience: 1) Maternal and Adolecent Health Sympoium about DHCS health diparitie fact heet; 2) overview of the uper-utilizer report for IMD analytic workgroup erie (June 214); and 3) DHCS maternity conference about uing Medi-Cal data for maternal quality improvement (June 214). Finally, the QS led a DHCS Journal Club dicuion about the ocial determinant of health. The CQO (Ulfat Shaikh, MD, MPH) met with DHCS leaderhip and taff on a regular bai to provide technical aitance on the DSRIP program and QI methodology. The Special Advior on Behavioral Health Integration (Efrat Eilat. PhD, MBA) met with DHCS leaderhip on a regular bai to provide expertie on behavioral health integration, SBIRT implementation, and CHDP and managed care collaboration on EPSDT. The Program Manager (Allyn Fernandez-Ami, MPH) met with DHCS leaderhip to provide technical aitance and fical management for the IA. The RA (Jennifer Byrne) provided adminitrative upport to the CPO, deigned the health diparitie fact heet, participated on the Facebook, webite, and Million Heart team, and contributed to the health promotion urvey poter and manucript. 14

15 Added-Value Deliverable IPHI provided added-value deliverable to meet the need of DHCS, including the following: In March 214, the CPO wa invited to erve on the California State Innovation Model (CalSIM) Workgroup to define the role and reponibilitie, kill and core competencie, and reimburement option for Community Health Worker (CHW) in the health care ytem. The CPO ha been reearching the current ue of CHW in Medi-Cal and policie governing CHW practice and reimburement. 15

16 Appendice Appendix A: DHCS Strategy for Quality Improvement in Health Care,

17 DHCS Strategy for Quality Improvement in Health Care Toby Dougla, Director Releae Date: December

18 Introduction and Background The Department of Health Care Service (DHCS) i placing a renewed emphai on achieving high quality and optimal clinical outcome in all departmental program. Thi focu align cloely with the Department viion: to preerve and improve the phyical and mental health of all Californian. To help achieve thi viion, we are building upon the DHCS Strategy for Quality Improvement in Health Care, 212 (referred to hereafter a the DHCS Quality Strategy), which decribe the goal, prioritie, guiding principle, and pecific program related to quality improvement (QI). Click here to view the DHCS Quality Strategy, 212. Why the renewed emphai on quality and outcome in DHCS? Mot importantly, we have an ethical obligation to provide the bet poible care and ervice to Californian and to be reponible teward of public fund. Second, the Department i implementing a five-year Section 1115 Medicaid Waiver, titled A Bridge to Reform, that eek to improve clinical quality through better coordination of care for vulnerable population, care delivery redeign, population-focued intervention, and enhanced patient afety. By improving quality, thee effort will help to bend the health care cot curve. Third, on May 3, 212, Governor Brown iued Executive Order B-19-12, etablihing the Let Get Healthy California Tak Force to develop a 1-year plan for improving the health of Californian, controlling health care cot, promoting peronal reponibility for individual health, and advancing health equity. 1 In December 212, the Tak Force iued a report with recommendation for how the tate can make progre toward becoming the healthiet tate in the nation over the next decade, and health care ytem redeign wa highlighted a an important goal in the report. 2 The DHCS Quality Strategy upport the goal outlined in the Let Get Healthy California Tak Force Final Report (ee Appendix A for a ummary of how DHCS QI activitie align with the ix goal of the Let Get Healthy California Tak Force Final Report). Finally, the Affordable Care Act (ACA) (P.L ) 3 addree many important health care quality iue in domain uch a prevention and health promotion, patient afety, coordinated and complex care, community health, and new care delivery model. Development of the DHCS Quality Strategy, 212 The initial verion of the DHCS Quality Strategy wa developed and produced with tatewide takeher input in November 212, uing the National Strategy for Quality Improvement in Health Care (National Quality Strategy or NQS) a a foundation and yet tailoring to the need of the divere California population and health care delivery ytem (ee Appendix B for a ummary of the NQS). Becaue QI i challenging and reource-intenive, it i important to look for area of vertical alignment meaning conenu at the federal, tate, regional, and provider level. The NQS ued an extenive and broad takeher engagement proce, making it a reaonable tarting point for the DHCS Quality Strategy. 1 Executive Order B-19-12, May 3, Let Get Health California Tak Force Final Report, December 19, Patient Protection and Affordable Care Act, Public Law No , enacted March 23,

19 Three Linked Goal Conitent with the Intitute for Healthcare Improvement Triple Aim and the Three Aim of the NQS, the DHCS Quality Strategy i anchored by Three Linked Goal: Improve the health of all Californian; Enhance quality, including the patient care experience, in all DHCS program; and Reduce the Department per capita health care program cot. The Three Linked Goal are integral to the development, implementation, and ongoing update of the DHCS Quality Strategy. The Department Seven Quality Strategy Prioritie The even prioritie of the DHCS Quality Strategy are to: Improve patient afety; Deliver effective, efficient, affordable care; Engage peron and familie in their health; Enhance communication and coordination of care; Advance prevention; Foter healthy communitie; and Eliminate health diparitie. The firt ix prioritie are imilar to thoe in the NQS ince they are relevant to public- and privateector care delivery acro many patient population. The eventh priority, Eliminate Health Diparitie, i particularly ignificant for the population erved by DHCS program, including Medi-Cal, and it i very imilar to the NQS Principle #3 a cro-cutting commitment to eliminate diparitie due to race/ethnicity, gender, age, ocioeconomic tatu, geography, and other factor. The order of the even prioritie doe not indicate prioritization, becaue all are needed equally to drive QI ytem-wide. Development of the DHCS Quality Strategy, 213 DHCS i committed to updating the DHCS Quality Strategy annually to reflect the bet evidence, policy, and practice in health care. To inform the development of the DHCS Quality Strategy, 213, we conducted an aement to inventory the Department QI activitie. The inventory ought to: 1) etablih a Department-wide baeline of QI activitie in three area: clinical care, health promotion and dieae prevention, and adminitration; 2) identify quality metric collected by DHCS but which were not pecifically linked to QI activitie; 3) identify gap in QI activitie; and 4) obtain recommendation for future QI effort. The baeline aement wa conducted a part of the Medi-Cal Quality Improvement Program (MCQuIP), upported through an Interagency Agreement with the Intitute for Population Health Improvement (IPHI) at the UC Davi Health Sytem. The final report i titled Baeline Aement of Quality Improvement Activitie in the California Department of Health Care Service: Method and Reult. Table 1 provide a high-level ynthei of DHCS QI activitie gathered during and following the baeline aement. QI activitie were matched with each of the even prioritie within the DHCS Quality Strategy to identify area with ubtantial QI activitie and area for future QI development and implementation. Some QI activitie fit within one priority while other cut acro two or more prioritie. 19

20 Table 1 alo capture QI activitie currently under development. Thee activitie will become formal QI project in the next 1 to 3 year. Many of thee activitie have a well-defined problem and intervention plan, but may require additional component uch a: increaed data collection and analytic capacity, augmented infratructure and funding, or, perhap, change in law or policy prior to being launched a formal QI project. 2

21 Table 1 Priority 1: Improve Patient Safety California Children' Service (CCS) Neonatal Quality Improvement Initiative: Reduce the collaborative' Central Line Aociated Blood Stream Infection rate by another 25 percent among participating Neonatal Intenive Care Unit (NICU). Payment Adjutment for Provider-Preventable Complication, including Health Care-Acquired Condition: Vacular Catheter- Aociated/Central Line-Aociated Bloodtream Infection in NICU/Pediatric Intenive Care Unit (PICU): Implement bet practice of central line inertion and maintenance reulting in a decreae in preventable infection, improvement in clinical outcome, decreaed length of tay, and decreaed cot. Improve Pychotropic Medication Ue for Children and Youth in Foter Care: Achieve improved pychotropic medication ue for children and youth in foter care by: 1) reducing the rate of antipychotic polypharmacy; 2) improving the antipychotic doe precribed to be within the recommended guideline; and 3) improving the monitoring of metabolic rik aociated with the ue of antipychotic. California Mental Health Care Management Program Collaborative' Performance Improvement Plan: Improving Antipychotic Medical Ue in the Adult Population: Achieve improved pychotropic medication ue in the adult population by reducing the rate of antipychotic polypharmacy. Maternal Health Quality Improvement Project, Medi-Cal Adult Quality Care Improvement Project: Reduce early elective deliverie (<39 week) among Medi-Cal member and in California (Related to Priority 5). Managed Care Health Plan Quality Improvement Project (QIP): Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to improve patient afety include: monitoring of peritent medication; improving rate of follow-up for member who are precribed ADHD medication; improving care for er adult, including medication review and functional tatu aement; and reducing avoidable hopital readmiion (Alo ee QIP for Prioritie 2, 3, 4, 5, and 7). Click here for the QIP report. Reduce Provider-Preventable Condition and Potentially Preventable Event Sytem-wide (Under Development): Reduce condition and event uch a: a foreign object retained after urgery, advanced preure ulcer, fall and trauma and urgical ite infection. Alo include urgical event that involve the wrong procedure, wrong ite, and/or the wrong patient. Reduce Opiate Overdoe (Under Development): Collect and analyze data and information to characterize the nature and magnitude of the opiate overdoe problem and develop effective policie and program to reduce the advere impact of opiate. 21

22 Priority 2: Deliver Effective, Efficient, Affordable Care Managed Care Statewide Collaborative-All-Caue Readmiion: Reduce the number of all-caue readmiion within 3 day of an acute inpatient dicharge for member 21 year and er. Managed Care Health Plan QIP: Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to deliver effective, efficient, affordable care include: increae the percentage receiving CD4 & viral load tet for member with HIV/AIDS; improve hypertenion diagnoi, anti-hypertenive medication fill among member with hypertenion, and hypertenion control; improve the rate of comprehenive diabete care, including HbA1C teting and control, LDL-C creening and control, retinal eye exam, nephropathy creening, and blood preure control; decreae the rate of admiion for member with peritent athma; improve the treatment and reduce the number of hopital readmiion for member with Chronic Obtructive Pulmonary Dieae (COPD); increae rate of chool attendance and decreae out of home placement for eriouly emotionally diturbed children; improve care for er adult, including advance care planning, and pain creening. Click here for the QIP report. Managed Care Healthcare Effectivene Data and Information Set (HEDIS) Performance Improvement Project: Improve HEDIS meaure that fall below the Minimum Performance Level (MPL), defined a the lowet 25 th percentile of national Medicaid plan. Delivery Sytem Reform Incentive Payment Program (DSRIP): Support California' deignated public hopital in enhancing the quality of care and health of the patient and familie they erve by tranforming the delivery ytem. All public hopital will improve evere epi detection and management and increae prevention of central line-aociated bloodtream infection. Area outide of patient afety include expanion of medical home, expanion of chronic care management model, and integration of phyical and behavioral health care, among other. View the DSRIP webite for more detail (Related to Priority 1). Cal MediConnect: 1) Tranition enior and peron with diabilitie into Medi-Cal Managed Care; 2) coordinate Medicare and Medi- Cal benefit acro care etting; 3) maximize the ability of dually eligible individual to remain in their home and communitie with appropriate ervice and upport in lieu of intitutional care; and 4) minimize or eliminate cot-hifting between Medicare and Medicaid. Eligibility and Enrollment for Medi-Cal eligible Californian: Meeting the Goal of the Affordable Care Act: Maximize enrollment of Medi-Cal eligible Californian. Dental Managed Care QI Project: Improve performance by dental managed care plan on everal dental quality meaure over a oneyear period: 1) annual dental viit; 2) continuity of care; 3) ue of preventive ervice; 4) ue of ealant; 5) treatment and prevention of carie; 6) exam/oral health evaluation; 7) overall utilization of dental ervice; and 8) uual ource of care. CCS/California Perinatal Quality Care Collaborative High Rik Infant Follow-up Quality Care Initiative (CCS/CPQCC HRIF QCI): 1) Identify infant who might develop CCS-eligible condition after dicharge from a CCS-approved NICU; and 2) improve the 22

23 Priority 2: Deliver Effective, Efficient, Affordable Care neurodevelopmental outcome of infant erved by CCS HRIF Program through collaboration between CMS/CCS and the CPQCC. Pediatric Palliative Care Waiver: Provide pediatric palliative care ervice to allow children, who have a CCS-eligible medical condition, with a complex et of need and their familie the benefit of hopice-like ervice, in addition to tate plan ervice during the coure of an illne. The objective i to minimize the ue of intitution, epecially hopital, and improve the quality of life for the participant and family. HIV/AIDS Waiver: Provide ervice that allow peron with mid- to late-tage HIV/AIDS to remain in their home, rather than hopital or nuring facilitie, by providing a continuum of care, reulting in improved quality of life and the tabilization and maintenance of optimal health. Multipurpoe Senior Service Program Waiver (MSSP): Foter and maintain independence and dignity in community etting for frail enior by preventing or delaying their avoidable placement in a nuring facility. MSSP provide ervice to eligible client and their familie that enable client to remain in their home. Aited Living Waiver: Offer Medi-Cal eligible member the choice of reiding in an aited living etting, either a Reidential Care Facility for the Elderly or Publicly Subidized Houing, a an alternative to long-term placement in a nuring facility. Home and Community-baed Service Waiver for Californian with Developmental Diabilitie: Serve Medi-Cal member with mental retardation in their own home and communitie a an alternative to placing them in hopital, nuring facilitie, or intermediate care facilitie. DHCS Univerity: Improve the knowledge, kill, and abilitie of Medi-Cal program manager, enior manager, and executive throughout the Department (Related to All Prioritie). DHCS Quality Improvement Training, Medi-Cal Adult Quality Care Improvement Project: Conduct training for DHCS upervior and manager on the core principle of QI; and provide a nine-day longitudinal coure in the application of QI methodology among DHCS clinician and taff conducting the diabete management and maternal QI project (Related to All Prioritie). Managed Care Training: Provide training on the following topic to increae program effectivene and monitoring capabilitie: 1) Healthcare Effectivene Data and Information Set (HEDIS) training on collecting, validating and uing performance meaure provided by Medi-Cal External Quality Review Organization (EQRO); and 2) Managed Care Continuou Quality Improvement (Rapid Cycle) Methodology, provided by Hunter Gatewood. 23

24 Priority 2: Deliver Effective, Efficient, Affordable Care Return on Invetment (ROI) Manual: Quantify the value/reult of Audit & Invetigation by comparing cot recoverie, aving, and avoidance againt the reource expended to complete the work. Fraud Detection and Deterrence: Field Audit Review: 1) Enure Medi-Cal provider are appropriately compenated baed on: a) medical neceity; b) appropriatene of care; c) documentation of ervice rendered; d) qualification of provider; e) Medi-Cal rule of billing; and f) tatute and regulation; and 2) identify ubtandard care or behavior that put patient at rik. Individual Provider Claim Analyi Report: Increae the accuracy of billing level for Evaluation and Management (E & M) procedure code and reduce inappropriate and cotly claim. Medi-Cal Payment Error Study: Accurately meaure the Medi-Cal paid claim error rate for eight different group of provider/ ervice type. Improve the Accuracy of the Third Party Health Inurance Record in the Medi-Cal Eligibility Data Sytem (MEDS): 1) Improve the accuracy of MEDS Health Inurance Sytem and other health coverage record; and 2) provide verified Medicare/Medi-Cal (dual) eligibility to Medicare Advantage and Medicare Special Need Plan. Family Planning, Acce, Care, and Treatment (Family PACT) Program QI/Utilization Management Monitoring Activitie: 1) Identify inappropriate ue of Family PACT ervice; and 2) identify area where cot could be aved in the Family PACT program. Improve Critical Acce Hopital' (CAH) Quality Review and Service Delivery through Multi-hopital Benchmarking : 1) Achieve at leat 75 percent of CAH ue of the Kana Hopital Aociation Foundation' Quality Health Indicator (QHi) for benchmarking and reporting purpoe; and 2) demontrate improvement in at leat one QHi per hopital. Improve CAH Operational Performance through Support of Onite Technical Aitance uing the Lean Methodology : 1) Support at leat 7 CAH participation in at leat one Lean project; and 2) demontrate improvement in operational QI/Performance Improvement meaure. CAH Participation in the Medicare Beneficiary Quality Improvement Project (MBQIP) uing Selected Meaure from the CMS Hopital Compare (HC) Data Reporting Program: 1) Identify area for QI through the ue of CAH reporting of MBQIP outpatient 1-7 meaure; and 2) demontrate improvement in one or more outpatient MBQIP meaure. Medi-Cal Specialty Mental Health Service for Children and Youth (Under Development): Develop a performance outcome ytem for Early and Periodic Screening, Diagnoi, and Treatment of mental health ervice for eligible children and youth that will improve 24

25 Priority 2: Deliver Effective, Efficient, Affordable Care outcome at the individual and ytem level and will inform fical deciion-making related to the purchae of ervice. Improve Data Quality and Management to Drive Deciion-making (Under Development): Enhance the quality and flow of data to upport robut program evaluation, quality meaurement, and drive health care and organizational deciion-making. Health Care Financing Reform: State Innovation Model (Under Development): Through the State Innovation Model (SIM) Deign Grant from the Center for Medicare and Medicaid Innovation (CMMI), develop a State Health Care Innovation Plan to improve health care quality and to reward value veru volume by changing payment tructure. Reduce Overue, Miue, and Wate (Under Development): Facilitate the ue of evidence-baed care, which i not duplicative, harmful and i truly neceary through the Chooing Wiely Campaign. Implement DHCS Kaizen Group Project to Increae Adminitrative Efficiency and Effectivene (Under Development): Initiate and implement department-wide project initiated by the DHCS Kaizen Group, including the following: 1) develop protocol and training to treamline and tandardize repone to incoming phone call; 2) develop hort video to highlight prevention trategie and provide how-to ummarie to perform adminitrative and program tak; and 3) invetigate and implement ytem to treamline and facilitate the tracking of elected adminitrative activitie (Related to Prioritie 3, 4 and 5). Priority 3: Engage Peron & Familie In Their Health Welltopia by DHCS Facebook Page: Maintain a DHCS Facebook Page, linking Medi-Cal member to prevention reource (e.g., nutrition, phyical activity, moking ceation, tre management, ocial ervice, and more). Managed Care Health Plan QIP: Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to engage peron and familie in their health include: Increae the number of advanced directive, including for member with HIV/AIDS; and increae the rate of provider documentation of nutrition and phyical education couneling. Click here for the QIP report. 25

26 Priority 4: Enhance Communication & Coordination Of Care Managed Care Health Plan QIP: Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to enhance communication and coordination of care include: Improve provider-patient communication to improve the patient care experience and percentage of member electing the top rating for overall health care and peronal MD in a patient atifaction urvey. Click here for the QIP report. Adoption of Electronic Health Record (EHR): Increae adoption of EHR by Medi-Cal provider to facilitate informed health care deciion at the point of care; improve care coordination and member engagement; and improve population health. Free the Data Initiative: Improve the functionality of the DHCS webite and improve internal data analytic procee to make information eaier to find and more acceible to the public, taff, and takeher. 211 Family PACT Client Exit Interview: Ae client' perpective on the quality of provider/patient interaction: a) to increae the proportion of new client who leave a viit with high efficacy contraception; and b) to increae the proportion of client who report that the provider aked about their uual ource of care. Diabete Quality Improvement Project, Medi-Cal Adult Quality Care Improvement Project: Improve overall diabete management in Medi-Cal by developing and implementing a two-pronged program including both provider education and patient outreach and engagement. Adoption of a Blue Button (Under Development): Etablih for Medi-Cal member the Blue Button feature, a nation-wide initiative characterized by a blue button image diplayed on patient portal and other ecure web ite. The Blue Button would allow member to view and download their health information electronically, giving member control over their own health information and making it eay to hare with their doctor, caregiver, or anyone ele they chooe. Improve Palliative and End-of-Life Care Practice (Under Development): Emphaize the importance of quality of life in the proviion of health care by engaging member, patient, and familie to enure peronal preference and value are repected. Improve Care Coordination of Super-Utilizer (Under Development): Conduct data analyi to better undertand the demographic trait, ervice utilization, and dieae co-morbiditie of the five percent of Medi-Cal member that account for approximately 5 percent of health care expenditure. Thi analyi will help identify potential intervention to drive breakthrough improvement in quality, health and health outcome, and reduce cot. 26

27 Priority 5: Advance Prevention Medi-Cal Incentive to Quit Smoking: Increae utilization of the California Smoker' Helpline among Medi-Cal member through the ue of appropriate incentive. Standard of Care for Treating Tobacco Ue: Etablih a minimum tandard of care for treating tobacco ue in the Medi-Cal Managed Care Plan by implementing the recommendation included in the Treating Tobacco Ue and Dependence: 28 Update, Clinical Practice Guideline. California Acce to Recovery Effort (CARE) Program: 1) Increae the rate of abtinence from alcohol and other drug, 2) decreae criminal jutice involvement, and 3) increae the rate of ocial connectedne among client who receive CARE ervice. Subtance Ue Diorder (SUD) Prevention Workforce Training: 1) Increae the number of prevention practitioner/profeional trained in SUD prevention theorie and framework; and 2) increae the number of prevention competency curricula implemented. Statewide Alcohol and Other Drug Prevention Outcome: Increae the number of countie that adopt the following tatewide prevention outcome meaure: reduce percentage of youth reporting the initiation of alcohol ue by age 15; reduce percentage of youth between 9th & 11th grade who report engaging in binge drinking within the pat 3 day; and reduce the percentage of youth between 9th & 11th grade who report drinking 3 or more day within the pat 3 day. Managed Care Health Plan QIP: Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to advance prevention include: Increae weight aement/couneling for nutrition and phyical activity for children/adolecent; improve the rate of cervical cancer creening; improve the rate of potpartum care viit; increae the rate of firt prenatal viit during the firt trimeter of pregnancy; increae the rate of provider documentation of BMI percentile, nutrition and phyical education couneling for children and adolecent; improve children acce to primary care provider. Click here for the QIP report. American Indian Infant Health Initiative: Educate familie on health promotion and dieae prevention including: tobacco ue, nutrition, alcohol and drug ue, immunization, teen pregnancy prevention, prenatal care, and exually tranmitted dieae. Increaing Children Ue of Preventive Dental Service and Dental Sealant: 1) Increae the rate of children, age 1-2 year, enrolled in Medi-Cal who receive any preventive dental ervice by 1 percentage point over a 5-year period; and 2) increae the rate of children, age 6-9 year, enrolled in Medi-Cal who receive a dental ealant on a permanent molar by 1 percentage point over a 5-year period. Newborn Hearing and Screening Program Quality Improvement Learning Collaborative: 1) Complete hearing creening by 1 27

28 Priority 5: Advance Prevention month of age; 2) complete diagnotic audiologic evaluation by 3 month of age; and 3) enroll infant with hearing lo in early intervention by 6 month of age. Core Program Performance Indicator for Every Woman Count: 1) Enure timely and complete diagnotic follow-up of abnormal breat and cervical cancer creening reult; 2) enure timely and complete treatment initiated for cancer diagnoed; and 3) deliver breat and cervical cancer creening to priority population. Family PACT Provider Profile with Two Clinical Indicator: 1) Improve clinical quality outcome for chlamydia creening of female member, age 25 year and younger; and 2) improve clinical quality outcome for chlamydia targeted creening of female member over age 25 year. 211 Family PACT Medical Record Review: 1) Ae whether family planning and reproductive health care ervice provided under Family PACT are conitent with program tandard: a) to increae the ue of effective contraceptive method a a reult of the Family PACT viit; b) to increae the proportion of client who receive education and couneling ervice; c) to decreae the proportion of women who receive annual cervical cytology creening tet; and 2) determine whether the quality of ervice delivered under the program improved over time. Reduce Overweight and Obeity Among Medi-Cal Member: Conduct formative reearch in collaboration with the California Department of Public Health (CDPH ) Nutrition Education and Obeity Prevention Program to inform the development of a clinical and community overweight and obeity prevention model. Increae Breatfeeding Among Medi-Cal Mother (Under Development): Enhance infant development and well-being by improving breatfeeding rate among Medi-Cal member. Increae Immunization Rate among Medi-Cal Member (Under Development): Enhance the prevention of infectiou dieae by increaing immunization rate among children and adult. Increae Screening of Adult for Alcohol Miue and Provide Brief Couneling (Under Development): Promote the ue of the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach to creen adult for alcohol miue and provide brief couneling. 28

29 Priority 6: Foter Healthy Communitie Increae CalFreh Enrollment among Medi-Cal Member: In collaboration with the California Department of Social Service (CDSS): include CalFreh in the Covered California Single Streamlined Application; 2) link Medi-Cal member to CalFreh through DHCS ocial media, webite, and mailing; 3) promote CalFreh in Medi-Cal enrollment material; and 4) train Medi-Cal Application Aiter and Health Educator on the CalFreh Program and enrollment proce. Strategic Prevention Framework Incentive Program: 1) Increae the number of countie addreing underage and exceive drinking by uing evidence-baed environmental prevention trategie, uch a retail availability, ocial availability, drinking and driving, and viibility of action in the media, and meauring outcome againt a control group; and 2) decreae community-level alcohol problem in 12 intervention communitie. Friday Night Live Compliance: Increae the number of countie achieving 1 percentage compliance with the Friday Night Live Member in Good Standing proce. Priority 7 Eliminate Health Diparitie Diparity Analyi, Medi-Cal Adult Quality Care Improvement Project: Ae the data quality of key demographic characteritic that may be ued for comparion of quality meaure between different population. Managed Care Health Plan QIP: Improve the quality of care delivered to Medi-Cal member by DHCS-contracted managed care plan. Current QIP topic to eliminate health diparitie include: Reduce health diparitie in the rate of provider documentation of BMI percentile, nutrition and phyical education couneling for children; reduce health diparitie in perinatal acce and care; and improve the rate of cervical cancer creening for enior and peron with diabilitie. Click here for the QIP report. Health Diparitie in the Medi-Cal Population Fact Sheet, Highlighting the Let Get Healthy California Tak Force Health Indicator: Develop a et of fact heet to identify health inequalitie among Medi-Cal member, and then develop initiative to eliminate critical diparitie. 29

30 Emerging QI Focu Area The DHCS Quality Strategy, 213 and ucceive annual update are intended to be apirational. We are committed, a a Department, to provide thoe we erve with the bet poible care, triving to achieve the highet level of health and health outcome. To continue to make progre toward that viion, we appreciate the need for continued innovation in cience and practice. DHCS will be working on everal important theme related to quality. While thee concept are at different tage of development, we believe that it i important to identify area requiring innovation and additional planning. The emerging focu area are decribed within each of the DHCS Quality Strategy priority area below. Improve Patient Safety Reduce provider-preventable condition through implementation of ection 272, ACA. Working cloely with takeher, the Department will reduce preventable advere event known at Provider-Preventable Condition (PPC). PPC include event uch a: a foreign object retained after urgery, advanced preure ulcer, fall and trauma, and urgical ite infection. They alo include o-called never event involving urgery: wrong procedure, wrong ite, and wrong patient. Reduce Opiate-Related Morbidity and Mortality. According to national data tracked by the Center for Dieae Control and Prevention, opiate-related morbidity and mortality ha increaed dramatically over the lat decade. The problem i complex, involving provider, patient, and, more broadly, the health care ytem. Beide the human toll, economic cot attributable to medical care and ociety, in general, are ubtantial. Furthermore, the magnitude of opiate-related morbidity and mortality i reportedly greater in the Medicaid population in comparion with the private ector. In repone, DHCS will be convening internal and external takeher to develop an effective action plan to addre thi critical health area. The plan will include collecting and analyzing data and information to characterize the nature and magnitude of the problem in Medi-Cal and developing effective policie and program to reduce the advere impact of opiate. Deliver Effective, Efficient, Affordable Care Improve data quality and ytem, data management and analytic capacity. Data and information are the foundation for the entire DHCS Quality Strategy. Under the enior leaderhip of Linette Scott, MD, MPH, DHCS Chief Medical Information Officer (CMIO), ubtantial progre ha been made to enhance the flow of data to drive health care and organizational deciion-making. For example, in December 212, DHCS wa awarded a $2 million, two-year grant from CMS to improve the ability to collect, report, and advance adult quality metric. A part of the Cal MediConnect Program, the CMIO and Medi-Cal Managed Care Diviion have been leading a buine proce improvement project to improve the quality of encounter data received from managed care plan. Encounter data i neceary to upport robut program evaluation and quality meaurement. Additional organizational improvement to upport information management in DHCS are being driven by requirement of the Medicaid Information Technology Architecture (MITA), which emphaize ue of national tandard, automation, and improved efficiencie. 3

31 Health care payment reform. California wa recently awarded a $2.7 million State Innovation Model (SIM) Deign Grant from the Center for Medicare and Medicaid Innovation (CMMI). Thi grant will be ued to develop a State Health Care Innovation Plan to improve health care quality and to reward value veru volume by changing payment tructure. A a major component of the tate health care ytem, DHCS i actively engaged in the policy work funded by the SIM grant, and view it a a tremendou opportunity to improve health, improve care, and reduce cot. The Department will be engaged with multiple external takeher in both the public and private ector to implement the State Health Care Innovation Plan. Engage Peron and Familie in their Health Social media. One of the promiing way to engage member, patient, and familie in their care i through the ue of ocial media. The availability of cell phone and martphone i increaing rapidly in low-income population and therefore repreent an important channel of two-way information haring and engagement. In addition, there are a growing number of application that may have health-promoting ue including Facebook, Twitter, Pinteret, text meaging, and other. In April 213, DHCS launched a prevention-focued Facebook page called Welltopia by the California Department of Health Care Service. Welltopia provide information, free application, video, and more on nutrition, phyical activity, moking ceation, and tre management. It alo create a pace for community member to hare their idea about healthy living. Liten to the voice of member, patient, and familie. Central to the concept of member- and patient-centered care i the need to directly engage member, patient, and familie to undertand the care experience from their perpective, to ae their need, to gather their recommendation, and to develop more effective program and policie that bet erve identified need. A number of channel are being conidered including focu group and community roundtable dicuion, adviory panel, urvey and webinar. We are aware that partner and takeher have extenive experience in thi area and hope to build on their ucceful approache. Enhance Communication and Coordination of Care Improve care for uper-utilizer. Identifying o-called uper-utilizer uing hot-potting technique ha garnered national attention through the work of Jeffrey Brenner, MD (Camden Coalition of Health Care Provider) and other. It i well known, now, that health care utilization in Medicaid population i typically kewed where five percent of member account for approximately 5 percent of health care expenditure. In Camden, NJ, Dr. Brenner oberved that one percent of reident accounted for 3 percent of health care cot. The good new i that there i a growing body of experience from many different part of the country, including California, demontrating that effective model of intenive cae management can how dramatic improvement in health and health outcome accompanied by equally dramatic reduction in cot, achieving the Triple Aim. DHCS intend to work cloely with partner in academia and the community to explore thi promiing area that ue data to drive breakthrough improvement in quality. Improve palliative and end-of-life care. One of the goal in the Let Get Healthy California Tak Force Final Report i to maintain dignity and independence at the end-of-life. Thi goal peak to the importance of quality of life in the proviion of health care. In addition, engaging member, patient, and familie to enure peronal preference and value are repected i very relevant to 31

32 thi goal. The Department will be exploring the indicator identified by the Let Get Healthy California Tak Force to determine what can be done to improve palliative and end-of-life care. Coordinate phyical and behavioral health. The prevalence of mental health and alcohol/drug concern are high in many low-income population. Many individual have both phyical and behavioral health need, which require coordinated care, if improvement in overall health are to be achieved. The recent incorporation of mental health ervice and alcohol and drug treatment program into DHCS provide an important opportunity to look at care delivery in a more comprehenive way. Uing data and bet evidence, DHCS will be working to better bridge phyical and behavioral health ervice delivery to improve clinical quality and population health. Advance adoption of health information technology (HIT) and health information exchange (HIE). One of the five prioritie for the EHR Incentive Program i to engage patient and familie in their care. Thi ha been een acro the tate with increaed adoption of peronal health record and the ue of the Blue Button. DHCS plan to follow the Medicare model and develop the Blue Button capacity o that member can view their peronal health information repreented by claim and other reporting mechanim. Another priority for the EHR Incentive Program i care coordination. In partnerhip with other Health Information Technology for Economic and Clinical Health (HITECH) program in California and nationally, DHCS ha upported the development of HIE capacity in the tate and recognize the critical role technology will play in upporting payment reform effort uch a DSRIP and Cal MediConnect Program. Advance Prevention Reduce moking prevalence. Effective prevention trategie call for a ytem-baed approach. DHCS will enure prevention activitie are caled up to have a population-wide effect. For example, our five-year, $1 million Medi-Cal Incentive to Quit Smoking Program i an important component of a larger effort to ignificantly reduce the moking prevalence among the approximately 7, Medi- Cal member who currently moke. To achieve thi reduction, DHCS i working with it managed care plan to provide the bet tandard of care for tobacco ceation, including: the availability of all even Food and Drug Adminitration-approved medication to treat tobacco ue; eliminating barrier for tobacco treatment benefit (e.g., co-pay, cot haring, utilization retriction, and Treatment Authorization Requet); and ready acce to individual, group, and telephone couneling. DHCS i alo committed to providing phyician education to enure the ytem-wide ue of Ak, Advie, and Refer, a well a helping long term care facilitie, including mental health facilitie, ubtance abue center, and nuring home, to adopt moke-free campu policie. Improve nutrition and phyical activity. The prevalence of overweight and obeity in children, adolecent, and adult require immediate attention. We are working with the Nutrition Education and Obeity Prevention Program at CDPH, Medi-Cal Managed Care Plan, and low-income communitie to develop, tet, and implement program to addre obeity in a ytematic fahion. It i too complex a problem to addre any other way. Other prevention activitie. DHCS i committed to improving breatfeeding and immunization rate among Medi-Cal member, a well a uing the cientific literature and example from the field to identity high-value intervention that have been underutilized (e.g., apirin prophylaxi for appropriate high-rik population and alcohol creening and couneling). Becaue the great majority of Medi-Cal member will be erved by managed care plan, we have begun conducting urvey aimed at aeing prevention effort in nutrition, phyical activity, moking, and behavioral health, 32

33 among other. The urvey finding are being ued to etablih and deploy a tandard of effective preventive care acro our health care delivery ytem. Foter Healthy Communitie Strengthen the link between health care and public health. There i a need to create a tronger bridge between health care and public health to tranform our dieae management, ick care ytem, into a true health care ytem that addree population health. Thi i epecially critical given that merely four modifiable health behavior lack of phyical activity, poor nutrition, tobacco ue, and exceive alcohol conumption are reponible for much of the illne, uffering, and early death related to chronic dieae. DHCS recognize the importance of the collaboration between medicine and public health, acknowledging that behavioral pattern, ocial circumtance, and environmental expoure oftentime have unfavorable effect on health outcome. To that end, DHCS i invetigating model of care and patient navigation approache that connect the health care delivery ytem with community reource to addre the ocial determinant of health, including acce to food, houing, education, job placement, and other ocial factor. The health care, public health interface i growing tronger through collaboration among DHCS, CDPH, and the California Department of Social Service (CDSS). A an example, DHCS i collaborating with CDPH and CDSS to increae CalFreh enrollment among the nearly 2 million Medi-Cal member who are eligible but not currently enrolled in the nutrition aitance program. In addition, trong collaboration and coordination exit between CDPH Tobacco Control and Diabete Program and our Medi-Cal Incentive to Quit Smoking Program. Many public health and health care partner have alo contributed content to DHCS Welltopia Facebook page. Eliminate Health Diparitie Increae undertanding of health diparitie. The Let Get Healthy California Tak Force Final Report identified a number of pecific prioritie and indicator that could be ued to help eliminate health diparitie. The Department i currently developing a erie of fact heet, titled Health Diparitie in the Medi-Cal Population, uing available metric to begin to characterize identifiable health diparitie in population erved by DHCS. Once identified, we will work with takeher and partner to develop aggreive intervention plan to eliminate addreable diparitie. A part of thi partnerhip work, DHCS ha etablihed an interagency agreement with the CDPH Office of Health Equity to optimize effectivene and efficiency in our hared effort to eliminate health diparitie. DHCS Quality Strategy Coordination On behalf of DHCS enior leaderhip, Neal Kohatu, MD, MPH, Medical Director, coordinate the development, implementation, and evaluation of the DHCS Quality Strategy in partnerhip with takeher. In addition, DHCS ha developed an Interagency Agreement with the U.C. Davi (UCD) Intitute for Population Health Improvement directed by Kenneth W. Kizer, MD, MPH, Ditinguihed Profeor, UCD School of Medicine and the Betty Irene Moore School of Nuring. Dr. Kizer and aociate are providing thought leaderhip, technical aitance, conultation, and training for the Department, including advancing the DHCS Quality Strategy. IPHI upport i 33

34 provided uing an integrated approach through MCQuIP. Key aociate within MCQuIP include: Deiree Backman, DrPH, MS, RD, Chief Prevention Officer; Ulfat Shaikh, MD, MPH, Clinical Quality Officer; and Brian Paciotti, PhD, Quality Scientit. Dr. Kizer ha alo etablihed the Medi-Cal Performance Adviory Committee (MPAC), which i a multi-diciplinary group of prominent QI thought leader from academia, health plan, hopital, foundation, and local government. MPAC provide important perpective to help IPHI provide the mot ueful, evidence-baed recommendation to advance quality and health. Summary The DHCS Quality Strategy i a living document that decribe goal, prioritie, guiding principle, and pecific program related to QI within the Department. The ultimate purpoe of the DHCS Quality Strategy i to improve health, enhance quality, and reduce per capita health care cot. In partnerhip with takeher, we will ue the DHCS Quality Strategy to build and utain a culture of quality that benefit Medi-Cal member and all Californian. 34

35 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care APPENDIX A Alignment of DHCS Quality Strategy Activitie with the Six Goal of the Let Get Healthy California Tak Force Final Report DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy 1 CA Children' Service Neonatal QI Initiative X X X Payment Adjutment for PPC in NICU/PICU X X X X Pychotropic Medication Ue for Children and Youth in Foter Care X X X X X Improve Antipychotic Medical Ue in Adult X X X Maternal Health Quality Improvement Project, Medi- Cal Adult Quality Care Improvement Project Managed Care Health Plan Quality Improvement Project (QIP): Patient Safety Reduce Provider Preventable Condition & Potentially Preventable Event X X X X X X X X X X Reduce Opiate Overdoe X X Managed Care Statewide Collaborative: All-Caue Readmiion X X X X 35

36 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy Managed Care Health Plan QIP: Effective, Efficient, Affordable Care Managed Care HEDIS Performance Improvement Project Delivery Sytem Reform Incentive Payment Program (DSRIP) X X X X X X X X X X X X X X X X Cal MediConnect X X X Eligibility/Enrollment for Medi-Cal-eligible: Meeting ACA 15 Dental Managed Care QI Project X X 16 High Rik Infant Follow-up Quality Care Initiative X X X X 17 Pediatric Palliative Care Waiver (PPC) X X X HIV/AIDS Waiver X X X X Multipurpoe Senior Service Program Waiver (MSSP) X X X X Aited Living Waiver (ALW) X X X Home and Community-baed Service Waiver for Californian with Developmental Diabilitie (DD) X X X DHCS Univerity X X X X X X X X X X X X 36 X

37 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy 23 DHCS Quality Improvement Training, Medi-Cal Adult Quality Care Improvement Project X X X X X X X X X X X X 24 Managed Care Training X X X X X X Return on Invetment (ROI) Manual X X Fraud Detection and Deterrence: Field Audit Review X X X Individual Provider Claim Analyi Report X X Medi-Cal Payment Error Study (MPES) X X Accuracy of Third Party Health Inurance Record in MEDS Family PACT QI/Utilization Management Monitoring Activitie X X X X 31 CAH Quality Review and Service Delivery X X CAH & Onite Technical Aitance uing Lean X X 32 Methodology 33 CAH Participation in MBQIP X X Medi-Cal Specialty Mental Health Service for X X X X 34 Children and Youth 35 Improve Data Quality and Management X X 37 X

38 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy Health Care Financing Reform: State Innovation Model X X X Reduce Overue, Miue and Wate X X 38 DHCS Kaizen Group Department-Wide Project X X X X X X 39 DHCS Welltopia Facebook Page X X X 4 Managed Care Health Plan QIP: Engage Member X X X Member Roundtable X X Managed Care Health Plan QIP: Communication & Coordination X X X 43 Adoption of Electronic Health Record (EHR) X X X X 44 Free the Data Initiative X X Family Pact Client Exit Interview X X Diabete QI Project, Medi-Cal Adult Quality Care X X 46 Improvement 47 Adoption of a Blue Button X X X 48 Improve Palliative and End-of-Life Care Practice X X X X 49 Improve Care Coordination of Super-Utilizer X X X X 38

39 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy 5 Medi-Cal Incentive to Quit Smoking X X 51 Standard of Care for Treating Tobacco Ue X X X California Acce to Recovery Effort (CARE) 52 Program X X X X Subtance Ue Diorder (SUD) Prevention 53 Workforce Training X X Statewide Alcohol and Other Drug Prevention 54 Outcome X X 55 Managed Care Health Plan QIP: Prevention X X X X American Indian Infant Health Initiative X X X Increaing Children' Ue of Preventive Dental Service and Dental Sealant Newborn Hearing and Screening Program Quality Improvement Learning Collaborative Core Program Performance Indicator for Every Woman Count Family PACT Provider Profile with Two Clinical Indicator (Chlamydia) 39 X X X X X X X Family PACT Medical Record Review X X X X Reduce Overweight and Obeity Among Medi-Cal X X X X 62 Member X X

40 Patient Safety Effective, Efficient, Affordable Care Engage Member Communication & Coordination Prevention Healthy Communitie Health Diparitie Healthy Beginning Living Well End of Life Redeigning the Health Sytem Creating Healthy Communitie Lowering Cot of Care DHCS QUALITY STRATEGY # Quality Strategy Activity Title Seven Prioritie LET'S GET HEALTHY CA: Six Goal Health Pathway to Acro the Health Lifepan Activity a included in the 213 DHCS Quality Strategy Increae Breatfeeding Among Medi-Cal Mother X X X X Increae Immunization Rate among Medi-Cal Member Screening of Adult for Alcohol Miue and Provide Brief Couneling Increae CalFreh Enrollment Among Medi-Cal Member X X X X X X X X X X 67 Strategic Prevention Framework Incentive Program X X X 68 Friday Night Live Compliance X X Diparity Analyi, Medi-Cal Adult Quality Care X X X 69 Improvement Project 7 71 Managed Care Health Plan QIP: Diparitie X X Health Diparitie in the Medi-Cal Population Fact Sheet X X X X X X X 4

41 APPENDIX B Summary of the National Quality Strategy (NQS) Overview. A required by the ACA, the Secretary of the United State Department of Health and Human Service (DHHS) etablihed the NQS, which wa publihed in March The NQS wa developed with the engagement of a broad range of takeher repreenting all health care ector. It erve a a roadmap for improving the quality of care in both the public and private ector. The NQS will be updated annually and enhanced to provide more detail related to goal, meaure, and action required for each component of the nation health care ytem. Three Aim. The NQS will purue three broad aim: 1. Better Care Improve the overall quality, by making health care more patient-centered, acceible, and afe; 2. Healthy People/Healthy Communitie Improve the health of the United State population by upporting proven intervention to addre behavioral, ocial, and environmental determinant of health in addition to delivering higher-quality care; and 3. Affordable Care Reduce the cot of quality health care for individual, familie, employer, and government. Six Prioritie. To advance the three aim, the NQS will focu on ix prioritie: 1. Making care afer by reducing harm caued in the delivery of care; 2. Enuring that each peron and family are engaged a partner in their care; 3. Promoting effective communication and coordination of care; 4. Promoting the mot effective prevention and treatment practice for the leading caue of mortality, tarting with cardiovacular dieae; 5. Working with communitie to promote wide ue of bet practice to enable healthy living; and 6. Making quality care more affordable for individual, familie, employer, and government by developing and preading new health care delivery model. Ten Principle. The NQS i guided by ten principle developed with extenive national takeher input. The ten principle are: 1. Peron-centeredne and family engagement, including undertanding and valuing patient preference, will guide all trategie, goal, and health care improvement effort; 2. Specific health conideration will be addreed for patient of all age, background, healt need, care location, and ource of coverage; 3. Eliminating diparitie in care including, but not limited to, thoe baed on race, color, national origin, gender, age, diability, language, health literacy, exual orientation and gender identity, ource of payment, ocioeconomic tatu, and geography will be an integral part of all trategie, goal and health care improvement effort; 4. Attention will be paid to aligning the effort of the public and private ector; 5. Quality improvement will be driven by upporting innovation, evaluating effort around the country, rapid-cycle learning, and dieminating evidence about what work; 6. Conitent national tandard will be promoted, while maintaining upport for local, community, and tate-level activitie that are reponive to local circumtance; 4 National Strategy for Quality Improvement in Health Care: Report to Congre. Wahington, D.C.: U.S. Department of Health and Human Service,

42 7. Primary care will become a bigger focu, with pecial attention toward the challenge faced by vulnerable population, including children, er adult, and thoe with multiple health condition; 8. Coordination among primary care, behavioral health, other pecialty clinician, and health ytem will be enhanced to enure thee ytem treat the whole peron; 9. Integration of care delivery with community and public health planning will be promoted; and 1. Providing patient, provider, and payer with the clear information they need to make choice that are right for them, will be encouraged. Related National Quality Initiative There are two national quality initiative, both public-private partnerhip upported by DHHS that dovetail with the NQS. Partnerhip for Patient (PfP) PfP conit of a range of health care takeher (including hopital, employer, phyician, nure, patient advocate, tate and federal government, and other) committed to developing improved model of care to achieve two goal: Keep patient from getting injured or icker. By the end of 213, preventable hopital- acquired condition would decreae by 4 percent compared to 21. Achieving thi goal would mean approximately 1.8 million fewer injurie to patient with more than 6, live aved over three year. Help patient heal without complication. By the end of 213, preventable complication during a tranition from one care etting to another would be decreaed uch that all hopital readmiion would be reduced by 2 percent compared to 21. Achieving thi goal would mean more than 1.6 million patient will recover from illnee without uffering a preventable complication requiring re-hopitalization within 3 day of dicharge. DHHS will be uing $1 billion from the ACA to addre thee goal. It i anticipated that other entitie from the public and private ector alo will be committing reource to PfP. 42

43 Indicator 211 Baeline 217 Goal Apirin ue for people at high rik 47 percent 65 percent Blood preure control 46 percent 65 percent Effective treatment of high choleterol (LDL-C) 33 percent 65 percent Smoking prevalence 19 percent 17 percent Sodium intake (average) 3.5g/day 2 percent reduction Artificial tran-fat conumption (average) 1 percent of calorie/day 5 percent reduction Million Heart Initiative (MHI) The MHI et the ambitiou national goal of preventing 1 million heart attack and troke in five year. The intervention will involve public health effort to encourage healthier nutritional choice a well a improved clinical management of rik factor (targeting the ABCS Apirin, Blood Preure, Choleterol, and Smoking Ceation) that ha been proven to reduce cardiovacular dieae mortality and morbidity. Specific goal are lited in the table below: See the NQS webite for additional information. 43

44 Appendix B: Quality Improvement Maturity Survey 44

45 45

46 Appendix C: Draft Super-utilizer Report 46

47 Analyi of Medi-Cal High-Cot Member and Super-Utilizer Executive Summary The purpoe of thi report i to ummarize the total expenditure for each Medi-Cal member in 213 and then decribe the characteritic of the highet cot member. Thi report i baed on a ummary of member-level expenditure that include both feefor-ervice paid claim and capitated payment reimbured to Medi-Cal managed care plan (MCP) on a monthly bai. After calculating total expenditure for each member, mutually excluive cot cohort were contructed baed on percentile. The report focue member at or above the 8 th percentile for expenditure The Top 2%. Our analye of the Top 2% included over 194 million claim and encounter record for over 1.5 million member. The Top -5% mot expenive member, or High-Utilizer, account for 47.4% of the total paid claim dollar, and the Top -2% of member in 213 conumed 76.3% of the total expenditure. The expenditure preented in thi report um to $43.6 billion in 213. Of thi total, $13.2 billion were capitated payment and $3.4 billion were fee-for-ervice paid claim. The report ummarize pecific attribute (e.g., demographic, eligibility, utilization, medical condition) aociated with different cot cohort. The finding illutrate September 8, 214 DRAFT 47

48 Introduction The purpoe of thi report i to ummarize the total expenditure for each Medi- Cal member and then decribe the characteritic of the highet cot member. o Thi report focue on the Top 2% highet cot member in 213 o Baed on total expenditure per member we created the following categorie: Top 5-2% - Average Utilizer Expenditure le than $21, per year Top -5% - High-Utilizer Expenditure between $21, and $194, per year Top -.1% - Super-Utilizer Expenditure greater than $194, per year Important context to undertand Medi-Cal member-level expenditure o Medi-Cal mainly erve children, adolecent, and women who are generally healthy o About 2% of member are enior or people with diabilitie they are much le healthy, and much more expenive o Starting in 211 great migration ha occurred within Medi-Cal in which a large proportion of fee-for-ervice member have been tranferred into the managed care program. Dual eligible population (Coordinated Care Initiative) Senior and People with Diabilitie (SPD Tranition) o Managed care plan pay per member per month capitated rate, but ome ervice uch a long-term care and mental health are carved out into the FFS program In addition to other ub-population, cot aving likely involve four group can we tudy high-cot member without paying cloe attention to the organizational and policy context of thee population? o Senior and People with Diabilitie (SPD) In 21, nearly all SPD were in the FFS program Medi-Cal ha recently tranitioned about 24, non-medicare SPD into managed care (June 211 May 212) o Dual Eligible Population Of the 1.9 million in the SPD population, about 1.2 million are dual eligible Dual are about 15% of Medi-Cal population, but account for 27% of Medi-Cal expene 48

49 The Coordinated Care Initiative will allow up to 456, dual eligible in eight countie to enroll in a managed care plan for both their Medi-Cal and Medicare benefit o California Children Service (CCS) CCS provide diagnotic and treatment ervice, medical cae management, and phyical and occupational therapy ervice to eligible children under age 21 (CA reident, family income under $4,, medical expene above 2% of houeh income) Managed care plan do not cover CCS-authorized ervice, but are reponible for primary care and preventive ervice CCS currently cover only cot related to the condition that make the child eligible for the program, making care coordination difficult Approximately 18, children are enrolled, with an annual cot of about $2.1 billion o Mental Health Population Medi-Cal beneficiarie with evere mental illne acce pecialty mental health ervice through a eparate county-level managed care delivery ytem, known a the County Mental Health Plan Medi-Cal beneficiarie with mild to moderate mental illne can receive more limited ervice, generally from primary care provider, through their Medi-Cal managed care plan or fee-forervice In 29, Medi-Cal pent nearly $3.8 billion providing mental health and ubtance ue ervice to nearly 565, enrollee Data MIS/DSS Data Warehoue To manage and tore a vat amount of data, the California Department of Health Care Service (DHCS) created a data warehoue and reporting ytem named the Medi-Cal Management Information Sytem/Deciion Support Sytem (MIS/DSS). MIS/DSS contain 1 year of data (about 3 billion record) that are extracted from approximately 3 different ource (e.g., eligibility, fee-for-ervice paid and denied claim, mental health claim, dental claim, and managed care encounter data). In addition, the warehoue include numerou reference data file to help uer map code to pecific label and decription. For example, there are reference table to The International Claification of Dieae, 9th Reviion, Clinical Modification (ICD-9) and other Medi- Cal pecific code. MIS/DSS allow DHCS analytical taff to query pecific type of claim or encounter and create analytical report. 49

50 Type of Data Four main type of Medi-Cal data were ued in thi report. Firt, eligibility data contain record for each month that a potential Medi-Cal member i eligible for ervice. Second, there are data related to fee-for-ervice claim. Fee-for-ervice claim are ubmitted by provider to Medi-Cal through a fical intermediary for reimburement for ervice. Third, managed care encounter data are collected to identify viit and ervice. Managed care plan are paid on a per member per month bai. Although managed care plan are not paid for individual ervice, they are required to ubmit to Medi-Cal encounter data for each viit. Fee-for-ervice claim data are known to be of higher quality in comparion to managed care encounter data given that financial reimburement i aociated with the former. Program have recently been tarted, however, to improve the quality of encounter data to enure that all data are ubmitted (without duplicate), data element are correctly coded, and the data repreent real health care viit. Finally, health plan are reimbured a pecific amount each month baed on capitated rate for each of their managed care enrollee. In general, DHCS ue actual health plan expenditure information for the pecified population in etting rate and ue a combination of plan-pecific and rik-adjuted county average experience for each plan rate. With the exception of the Rural Expanion countie, rate that are developed for Medi-Cal health plan have traditionally been county pecific, uch that even plan that are in multiple countie have eparate rate for each county. Symmetry Grouper Sytem In addition to claim and encounter data, the MIS/DSS ytem alo include numerou table derived from a product called Symmetry to pre-aggregate claim and encounter into both epiode or care and ubequently into rik categorie. Epiode Treatment Group (ETG) Epiode Treatment Group (ETG ), which became available in 1993, offer a powerful way of creating epiode of care by placing inpatient, outpatient, and ancillary ervice into mutually excluive and exhautive categorie. Although conceptually imilar to Diagnoi Related Group (DRG), the ETG identify an entire epiode of care regardle of if it wa inpatient or outpatient care. There are 524 ETG bae cla code that are further defined by complication, comorbiditie and treatment. ETG are defined by ICD-9/ICD-1 diagnoi code, but alo ue procedure code and national drug code to aign claim record into epiode of care. 5

51 Epiode Rik Group (G) There are 189 Epiode Rik Group that are created by aggregating the ETG bae code and aociated complication and treatment flag. Thi maller number of categorie allowed tatitician and clinician to create predictive model to etimate expected cot of each condition category. Our team further aggregated the 189 G into a maller number of G categorie in an attempt to implify our report without loing too much clinical pecificity. How Much Data Were Analyzed? Thi tudy focued on the Top 2% of the mot expenive Medi-Cal member in 213. The Top 2% of the member had 194,638,372 claim/encounter record. Methodology Incluion/Excluion Calendar year 213 data included in the report All Medi-Cal member included if they had a claim or encounter in

52 o Excluded: Healthy Familie, Preumptive Eligible, FPACT Report ue both fee-for-ervice and capitated rate expenditure data Included non-certified eligible member many of them had large expenditure. We can remove later. Total Medi-Cal, Health Familie, Preumptive Eligible - 1,299,196 Medi-Cal Only - 7,94,256 o Top 2% - 1,58,852 Defining Cot Cohort A number of relatively imple analytical tep were required to put Medi-Cal member into variou cot cohort. Firt, we ummed up the annual FFS dollar and per member per month capitated rate for all member in 213. We included payment regardle of managed care, or dual tatu. Second, to evaluate how paid claim are aociated with other member-level variable, we aigned each member into one of ix cot cohort: 2% to >1%, 1% to >5%, 5% to >2%, 2% to >1%, 1% to >.1% and.1% to. Thee cohort are defined by pecific cut-point baed on the following tep. Firt, we ummed up the total paid claim and capitated payment for every Medi-Cal member. Second, we calculated percentile (8 th, 9 th, 95 th, 98 th, 99 th and the 99.9 th on thi cot ditribution. The percentile allowed u to define pecific cut point for placing member into mutually excluive cot cohort (ee Table X below). For example, a member would be in the 1% to >5% cohort if their annual expenditure were between $11,691 and $21,443. Finally, for each member, we aociated other information uch a eligibility tatu, categorie of ervice, and diagnoe. Identifying the Mot Common Medical Condition We ued two method to profile the condition among member from the cot cohort. The overall problem i that member often have multiple diagnoe in the claim data, but for purpoe of reporting it i preferable to only have one primary diagnoi per member. We report on two method ince they both have pro and con (we could create an Appendix to lit the detail?). The firt method ue the Symmetry Epiode Rik Group and ue expected cot for the tudy year to elect the primary condition. The econd method, i impler, and only look at the primary diagnoi (ICD-9 code) on the claim header record. Epiode Rik Group It wa challenging to ummarize the medical condition among the Top 2% given that mot of the higher-cot Medi-Cal member have numerou medical condition. To ummarize condition, we ued the Epiode Rik Grouper and their aociated 52

53 expected cot weight for the current year to elect the top 3 highet ranked G for each member. The following tep were performed: 1. For each member, we elected their three highet ranked G baed on G expected cot weight. Expected weight were created by tatitician and clinician who ued regreion model to predict each G category againt the outcome variable of annual total cot. The coefficient, or weight, that reult from the model provide an etimate about the relative expected cot of each G. 2. For each member, we orted all of their G by the expected cot weight 3. For mot analye, we then elected the highet weighted G for each member. Thi condition wa elected a a decriptive label for the primary medical condition of the member 4. For analye of co-morbiditie, we elected the top 3 highet weighted G for each member AHRQ Clinical Claification Software For thi analyi, we looked at member from pecific cot cohort and then linked each of the ICD-9 code to the AHRQ Clinical Claification Software. Unlike the complex Symmetry grouper that create epiode of care, thi tool categorize ICD-9 code into clinically homogenou categorie. Unlike G, the AHRQ tool only ue ICD-9 data and doe not group patient claim it only group code. To elect a primary diagnoi, we calculated the frequency of AHRQ categorie that occurred on the claim record, and the elected the clinical group that wa aociated with the mot claim record. For example, a member might have 1 different diagnoe recorded on their number medical claim for a year. We counted up the total number of claim aociated with each clinical group, and then elected the mot frequent group for that member and then aigned that group a the primary diagnoi. Total Expenditure We ummed the annual paid FFS claim and the total net paid capitated rate for each member. Thee column were then ummed to create a total expenditure field. From thi overall ditribution, we created cut-point to tratify the member into lower and higher cot cohort. The purpoe of thi ection i to decribe the complete cohort of member with FFS claim. How Much Money wa pent in 213? Total capitated expenditure --- $13,174,94,435 Total FFS expenditure --- $3,427,84,162 Total expenditure -- $43,62,744,596 53

54 In thi report, we tratified the total expenditure ditribution a decribed above into cot cohort. We created percentile for the total ditribution, and then ued thee cutpoint to put member into group. For example, the 8 th percentile defined the cutpoint to be in the Top 1-2% group. In thi ection, we provide decriptive tatitic to illutrate how the cut-point can help define variou high-cot group. We decribe the cohort from cumulative and mutually excluive perpective. In mot of the ubequent ection of the report, however, we ued the following mutually excluive categorie:.1% to 1% to >.1% 2% to >1%, 5% to 2% 1% to >5%, 2 to >1%, Bottom 8% Cot Cohort Number of Member Cut-Point to Define Cohort Mean Paid Amount Median Paid Amount.1% to 7,95 > $194,228 $318,55 $271,49 1% to >.1% 71,138 $63,6- $93,64 $82,17 $194,228 2% to >1%, 79,43 $44,99- $63,6 $53,65 $53,361 5% to 2% 237,127 $21,443- $3,57 $29,254 $44,99 1% to >5%, 395,215 $11,691- $21,443 $15,496 $14,994 15% to >1% 395,211 $8,69-$11,691 $9,656 $9,534 2 to >15%, 395,213 $5,357-$8,69 $6,812 $6,898 Bottom 8% 6,323,44 < $5,357 Baed on thi ummary, we provide the following decriptive label to the cot group: o Top 5-2% - Average-Utilizer o Top -5% - High-Utilizer o Top -.1% - Super-Utilizer The follow table put the Top 2% into expenditure bin to illutrate the long tail of the expenditure ditribution a few Medi-Cal member have extremely high expenditure. 54

55 Expenditure Group Frequency Percent 18, ,12, , ,-5, 4,366, ,-1, 697, ,-2, 511, ,-5, 293, ,-1, 14, ,-2, 21, ,-5, 6, ,-1,, ,,-2,, 48 2,,-5,, 13 5,,-1,, 6 > 1,, 2 The Top 5% i reponible for 47.4% of expenditure. Cohort Expenditure Percent of Total Bottom 8% $1,318,43, % Top.1% $2,517,784, % Top 1%-Top.1% $6,658,781, % Top 2%- Top 1% $4,24,65, % Top 5%- Top 2% $7,234,164, % Top 1%- Top 5% $6,124,412, % Top 15%- Top 1% $3,816,346, % Top 2%- Top 15% $2,692,561, % Total $43,62,744,596 Average Expenditure The average capitated payment per member for 213 wa $4,313. The average FFS paid claim per member in 213 wa $16,74. Thee average mak a large number of high-cot outlier, thu it i helpful to look at the expenditure by cot cohort. CAP AMT FFS AMT TOTAL AMT COST_COHORT N Mean Mean Mean Top 1% 395,215 4,54 1,992 15,496 Top 2% 395,213 2,785 4,28 6,813 55

56 Top 15% 395,211 4,149 5,57 9,656 Top 5% 237,127 5, ,58 Top 2% 79,43 7,373 46,277 53,65 Top 1% 71,138 6,555 87,48 93,64 Top.1% 7,95 6, , ,55 The average total expenditure are conitent acro people of varying age for mot of the cot cohort. The exception i the Top.1% between the age of 1 and 2 who have relatively higher expenditure a compared to other age group in that cohort. Summary of Capitated Rate Capitated rate are created by tarting with FFS claim data ubmitted by each plan. The managed care plan are typically large enough to have a large enough et of paid expenditure data to create bae payment rate for each managed care plan operating in a pecific county. When data are inufficient, DHCS actuarie analyze a broader et of data to create rate. In addition to bae rate et by the expenditure experience of pecific plan, DHCS alo employ two efficiency adjutment MAC pricing adjutment and Potentially Preventable Hopital Admiion (PPA). Finally, tarting in 29 DHCS moved away from plan pecific rate etting to a rate development proce 56

57 that wa partially plan pecific and partially calculated from rik adjuted county average. The county average rik adjutment component are only utilized for the Adult/Family and SPD Medi-Cal only rate categorie. The table below how the percentage plit for each rate year: The rik adjutment i done uing Medicaid RX Verion 5.2 oftware developed by UC San Diego. The model ue pharmacy encounter to aign individual acuity factor that are aggregated for a plan pecific rik core. The rik-adjutment proce only include experience data for individual who have at leat ix month of total Medi-Cal eligibility within each 12-month tudy period. A dicued above, there are numerou methodological tep to creating plan and member-pecific rate. Thu, it i impoible to look olely at one dimenion to undertand how the rate are contructed. It i poible intructive, however, to look at a few dimenion aociated with the rate uch a age and cohort cot category. Firt, the rate vary a expected by age. It i intereting that after 65 the rate drop dramatically a a reult of expected payment from Medicare. 57

58 58

59 Demographic and Eligibility Demographic The Top 2% ha er member on average. AGE COST_COHORT N Mean Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1% The Super-Utilizer cohort (Top.1%) ha a greater proportion of male. All of the other cohort have relatively more female. GEND_CD F M COST_COHORT N Row % N Row % Top 1% 241, % 153, % Top 2% 247, % 147, % Top 15% 25, % 144, % Top 5% 13, % 16, % Top 2% 43, % 35, % Top 1% 35, % 35, % Top.1% 3, % 4, % A large percentage of the Top 2% are SPD (65.1%) and dually eligible for Medicare (29.9%) SPD N % of Total Non-SPD 552, % SPD 1,28, % Dual Eligible N % of Total No 1,17, % Ye 473, % 59

60 Aid Code Categorie A diproportionate number of member in the higher cot cohort are in aid code categorie aociated with diabilitie or long-term care. The Top 2% cohort ha by far the greatet percentage of member in long-term care. The public aitance category include individual eligible for CASH aitance under variou program uch a SSI, CalWORKS, In-Home Supportive Service, and foter care. Medically needy i a group of individual or familie eligible for Medi-Cal becaue they meet the federal definition of aged, blind or diabled, or familie of deprived children, but who are not enrolled in public aitance program. Medically indigent member are eligible for Medi-Cal but are not in any other major category. COST_COHORT Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1% Detail Aid Cat Column Column Column Column Column Column Column % % % % % % % Public Aitance - Diabled 48.86% 3.17% 41.47% 52.9% 38.25% 46.74% 44.76% Medically Needy - Familie 1.35% 2.81% 15.54% 6.18% 3.82% 5.24% 8.84% Public Aitance - Aged 11.3% 8.42% 9.24% 9.73% 5.9% 4.71% 1.7% Medically Needy - Aged 6.65% 9.39% 8.94% 4.98% 2.82% 2.43% 1.5% Public Aitance - Familie 5.35% 9.62% 8.31% 2.96% 1.55% 1.74% 2.19% Medically Needy - Diabled 5.92% 4.4% 4.36% 7.46% 6.19% 7.96% 6.83% Medically Needy - LTC 1.25%.46%.56% 6.8% 34.73% 22.5% 22.56% Undocumented 3.26% 6.63% 4.25% 1.96% 1.61% 1.81% 1.53% Other 2.% 4.62% 2.75% 1.31%.85% 1.42% 2.57% Unknown 1.29% 2.13% 1.36%.99%.69% 1.13% 4.7% Public Aitance % 1.17%.94% 1.3% 1.8% 1.29%.92% Adoption or Foter Care Public Aitance - Blind 1.15%.61%.78% 1.35% 1.8% 1.49% 1.13% Medically Indigent -.81%.92%.7%.92%.63%.81% 1.6% Adoption or Foter Care BCCTP.58%.35%.34%.82%.54%.65%.11% Medically Indigent - Child.28%.55%.35%.24%.14%.19%.46% Medically Indigent - LTC.3%.2%.2%.6%.12%.26%.2% Medically Indigent Adult.3%.8%.6%.1%.%.1%.3% Medically Indigent - Blind.3%.2%.2%.3%.2%.4%.% Inmate.%.%.%.%.%.%.% 6

61 Eligibility In the tudy year of 213, the majority of the member (54%) were enrolled olely in a managed care plan each month of their enrollment. A mall proportion (32%) of member wa in enrolled olely in the DHSC fee-for-ervice program. The average number for eligible month for both the MC and FFS categorie wa 9.6 month. A maller, yet more complex group (14%) ha a mixture of enrollment in both FFS and MC. Many of thee member tarted in FFS and were hifted into MC a a reult of one of Medi-Cal tranitional program to managed care. Reflecting thi pattern, thee member have a higher average number of month in the FFS program (5.1%) a compared to MC (4%). MC Mean FFS Mean MC_FFS N % of Total MC 855,63 54% FFS 59,488 32% FFS and MC 215,761 14% of Continuou Medi-Cal Eligibility With the exception of member aged -1 year, the majority of high-cot member have many year of Medi-Cal enrollment. 61

62 California Children Service Many higher-cot ervice for CCS member are carved-out and paid for in the FFS program. However, many CCS member are in managed care and the plan receive a capitated rate. 62

63 CAP AMT FFS AMT TOTAL AMT CCS Mean Mean Mean $4,29 $16,45 $2,335 1 $5,12 $35,75 $4,763 CCS No Ye COST_COHORT N Row % N Row % Top 1% 381, % 14, % Top 2% 389, % 5, % Top 15% 385, % 9, % Top 5% 223, % 13, % Top 2% 74, % 4, % Top 1% 64, % 6, % Top.1% 6, % 1, % Utilization LTC day day Claim Claim Detail Header RX CNT CNT G CNT COST_COHORT Mean Mean Mean Mean Mean Mean Mean Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1%

64 The table below how the mean number of claim by Category of Service. Utilization, a meaured by ubmitted FFS claim and MC encounter increae within the higher cot cohort. Allied Outpatient Inpatient Pharmacy LTC Mental Health COST Mean Mean Mean Mean Mean Mean COHORT Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1% Viit None Some COST N Row % N Row % COHORT Top 1% 298, % 96, % Top 2% 299, % 95, % Top 15% 293, % 11, % Top 5% 177, % 59, % Top 2% 6, % 18, % Top 1% 43, % 27, % Top.1% 3, % 4, % LTC Viit None Some COST N Row % N Row % COHORT Top 1% 379, % 16,91 4.7% Top 2% 388, % 6, % Top 15% % 7, % Top 5% 27, % 29, % Top 2% 42, % 36, % Top 1% 43, % 28, % Top.1% % % 64

65 The Top.1% and 1% Have Many Member with a Large Number of LTC and Facility Day A large number of member in the Top 1-2% and Top 5-1% have no day in acute or LTC facilitie The more cotly cohort have a greater percentage of member with both acute and LTC day COST_COHORT Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1% LTC Day ACUTE Day Column % Column % Column % Column % Column % Column % Column % None None 72.2% 74.4% 72.7% 64.5% 34.9% 32.% 32.6% Some 23.7% 24.% 25.4% 23.2% 19.1% 28.6% 4.6% Some None 3.4% 1.3% 1.6% 1.4% 41.7% 29.1% 12.7% Some.7%.2%.3% 2.% 4.3% 1.3% 14.% The Top.1%, 1%, and 2% have Older Member with Many LTC Facility Day 65

66 The Top.1% Ha Subtantially More Facility Day 66

67 G and AHRQ CCS Condition NOTE: I can quickly run querie to ummarize condition for a variety of ub-population. I can alo re-run the code that ummarize multiple condition uing dyad and triad however, the number of categorie i immene, and we would have to create a criteria to limit which dyad or triad we report. G #1: Each Member Highet Expected Cot G (% of Condition Group for each cot category) COST_COHORT Top 1% Top 2% Top 15% Top 5% Top 2% Top 1% Top.1% G #1 Column Column Column Column Column Column Column (Broad Categorie) % % % % % % % Pychiatric 16% 1% 11% 22% 24% 22% 14% Pregnancy 1% 17% 18% 3% 2% 2% 2% Cardiovacular 11% 8% 9% 11% 1% 1% 14% _Low_Cot 5% 1% 8% 4% 4% 2% 1% Orthopedic 7% 7% 7% 4% 2% 1% % _High_Cot 7% 5% 5% 7% 8% 9% 12% Congenital 6% 3% 4% 7% 9% 8% 9% Neurologic 5% 4% 4% 6% 8% 11% 15% GI 4% 6% 5% 3% 2% 2% 2% Malignancy 5% 3% 3% 6% 6% 9% 1% Diabete 5% 5% 5% 3% 3% 1% % Chronic_Lung_Dieae 3% 4% 4% 2% 1% 1% 1% Chronic_Kidney_Dieae 3% 1% 1% 5% 5% 6% 3% Hematologic 2% 2% 2% 3% 4% 4% 5% Hypertenion 2% 3% 3% 2% 2% 1% % Genitourinary 1% 2% 2% 1% 1% 1% % Ophthalmologic 1% 2% 2% 1% 1% 1% % Other_Endocrine 1% 2% 1% 1% 1% 1% 2% Other_Chronic_Infection 1% 1% 1% 1% 1% 1% 2% HIV_AIDS 1% % % 3% 3% 1% % Subtance_Abue 1% 1% 1% 1% % % % Neonatal 1% 1% 1% 1% 1% 2% 5% Obeity 1% 1% 1% 1% % % % Connective_Tiue 1% 1% 1% 1% % % % ENT % 1% 1% % % % % Infection % % % % % % % Malignacy % % % % 1% 1% 1% Obteric % % % % % % % 67

68 Dermatologic % % % % % % % Tranplant % % % % % % 1% Hyperlipidemia % % % % % % % G Frequencie for California Children Service (a member can only be counted in one cell) COST_COHORT Top 1% Top 5% Top 15% Top 1% Top 2% Top 2% Top.1% G #1 N N N N N N N Neurologic Congenital Pychiatric _High_Cot Diabete Cardiovacular _Low_Cot Malignancy Other_Endocrine GI Chronic_Lung_Dieae Orthopedic Hematologic ENT Chronic_Kidney_Dieae Pregnancy Ophthalmologic Genitourinary Obeity HIV_AIDS Other_Chronic_Infection Neonatal Tranplant Hypertenion Connective_Tiue Infection Subtance_Abue Obteric Dermatologic Malignacy Hyperlipidemia

69 California Children Service: ICD-9 Diagnoi with Highet Frequency per Member (Limited Row Shown) AHRQ Clinical Claification Categorie N % of Total Other paralyi % Rehab care; fitting of prothee; adjutment of device % Adminitrative/ocial admiion % Intellectual diabilitie % Epilepy % Diabete mellitu without complication % Diabete with ketoacidoi or uncontrolled diabete % ADD and ADHD % Reidual code; unclaified; all E code and % Depreive diorder % Medical examination/evaluation % Spina bifida % Other metabolic; nutritional; endocrine diorder % Anxiety diorder % Bipolar diorder % Learning diorder % Other and unpecified gatrointetinal diorder % Chronic kidney dieae % Communication diorder % Convulion % Diorder of the peripheral nervou ytem % All other congenital anomalie % Cytic fibroi % Leukemia 59.93% Other ear and ene organ diorder % Other aftercare % Other endocrine diorder % Diorder of teeth and jaw % Sickle cell anemia % Abdominal pain 41.75% Pervaive developmental diorder 42.73% Conduct diorder 39.71% Schizophrenia and other pychotic diorder % Down Syndrome 37.67% Outcome of delivery (V code) % Other hereditary and degenerative nervou cond % 69

70 Coagulation defect % Other athma without tatu athmaticu or exacerbation % Adjutment diorder % Late effect of cerebrovacular dieae % Other and unpecified lower repiratory dieae 38.56% Other upper repiratory dieae 36.56% Other connective tiue dieae % Oppoitional defiant diorder % Rheumatoid arthriti and related dieae % Blindne and viion defect % HIV infection 218.4% Other central nervou ytem diorder % Cancer of brain and nervou ytem % Other eye diorder % Sytemic lupu erythematou connective tiue diorder % Urinary tract infection; ite not pecified % Other diorder of infancy childhood or adolecence % Other kin diorder % Mot Frequent Diagnoi Category among Member with at Leat One Mental Health Claim AHRQ Clinical Claification Categorie N % of Total Schizophrenia and other pychotic diorder % Depreive diorder % Bipolar diorder % Anxiety diorder % Subtance-related diorder % ADD and ADHD % Adjutment diorder % Conduct diorder % Oppoitional defiant diorder % Rehab care; fitting of prothee; adjutment of device % Medical examination/evaluation % Other diorder of infancy childhood or adolecence % Diabete mellitu without complication % Intellectual diabilitie % Alcohol-related diorder % 7

71 Variation by County The table below how the percentage of Medi-Cal member from particular countie are in pecific cumulative cot cohort. For example, the data below ugget that 17.7% of Medi-Cal member from San Francico county are from the Top 1% of the overall cot ditribution. If we decide to ue thi information, I will work to create ome map. County TOP_1 TOP_1 TOP_2 TOP_5 TOP_1 Alameda Alpine Amador Butte Calavera Colua Contra Cota Del Norte El Dorado Freno Glenn Humbt Imperial Inyo Kern King Lake Laen Lo Angele Madera Marin Maripoa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange

72 Placer Pluma Riveride Sacramento San Benito San Bernardino San Diego San Francico San Joaquin San Lui Obipo San Mateo Santa Barbara Santa Clara Santa Cruz Shata Sierra Sikiyou Solano Sonoma Stanilau Sutter Tehama Trinity Tulare Tuolumne UNKNOWN Ventura Yolo Yuba Profile SU Member > 1M The following table how all 69 member with total expenditure over 1 million dollar in 213. Over half of thee are young hemophiliac. TOTAL COST Demograp hic Eligibil ity Utilizat ion Top 3 G Three mot Frequent ICD-9 Categorie (CCS) 72

73 Total $: Total $: Total $: Total $: Total $: Total $: Total $: Total $: M White 25 year M Hipanic 24 year M Hipanic 25 year M White 16 year M Black 26 year M White 2 year M White 48 year M Hipanic 19 year CCS: MC:. FFS:12 CCS: 1 MC:. FFS:11 CCS: MC:. FFS:11 CCS: 1 MC:. FFS:12 CCS: MC:. FFS:12 CCS: 1 MC:. FFS:12 CCS: MC:. FFS:9 CCS: 1 MC:. Day: Viit:. RX: 2 Day: Viit:. RX: 4 Day: Viit:. RX: 3 Day: 11 Viit: 5 RX: 5 Day: Viit:. RX:. Day: 8 Viit: 2 RX: 8 Day: Viit:. RX: 8 Day: Congenital_Hemopheli a Orthopedic Congenital_Hemopheli a _Infection _High_Cot Congenital_Hemopheli a Neurologic _Trauma Congenital_Hemopheli a _Trauma Orthopedic Congenital_Hemopheli a _Trauma Orthopedic Coagulation defect Other and unpecified benign neoplam Coagulation defect Rehab care; fitting of prothee; adjutment of device Other bone dieae and muculokeletal deformitie Coagulation defect Other non-traumatic joint diorder Coagulation defect Other non-traumatic joint diorder Medical examination/eval uation Coagulation defect Other back pain and diorder Other connective tiue dieae Coagulation defect Other non-traumatic joint diorder Hematuria Coagulation defect Coagulation defect Other non-traumatic 73

74 Total $: Total $: Total $: Total $: Total $: Total $: Total $: Total $: M White 29 year M Other 9 year M Aian 19 year M Hipanic 31 year M Other 17 year M White 28 year M Aian 29 year M Hipanic 21 year FFS:12 CCS: MC:. FFS:11 CCS: 1 MC:. FFS:12 CCS: 1 MC:. FFS:12 CCS: MC:. FFS:12 CCS: 1 MC:. FFS:11 CCS: MC:. FFS:12 CCS: MC:. FFS:8 CCS: MC:. Viit: 3 RX: 9 Day: Viit:. RX: 2 Day: 4 Viit: 1 RX: 22 Day: 7 Viit: 5 RX: 7 Day: Viit:. RX: 5 Day: Viit:. RX: 2 Day: Viit:. RX: 4 Day: Viit:. RX: 1 Day: 2 Congenital_Hemopheli a Hematologic _Trauma Congenital_Hemopheli a _High_Cot Cardiovacular Congenital_Hemopheli a Congenital_Hemopheli a Chronic_Kidney_Diea e Cardiovacular_CAD Congenital_Hemopheli a joint diorder Superficial injury; contuion Coagulation defect Medical examination/eval uation Coagulation defect Infection inflam internal prothetic device;implant;gr aft Chemotherapy Coagulation defect Other aftercare Abdominal pain Coagulation defect Hepatiti Coagulation defect Rehab care; fitting of prothee; adjutment of device Coagulation defect Other infection; including paraitic Unpecified epticemia Coagulation defect Coagulation defect Other connective 74

75 FFS:9 Viit:. RX: 11 tiue dieae Other aftercare Total $: Total $: Total $: Total $: Total $: Total $: Total $: M Hipanic 18 year M White 22 year M Hipanic 23 year F Hipanic year M White 19 year M Black 27 year M Hipanic 2 year CCS: 1 MC:. FFS:12 CCS: 1 MC:. FFS:12 CCS: 1 MC:. FFS:12 CCS: MC:. FFS:3 CCS: MC:. FFS:12 CCS: 1 MC:. FFS:12 CCS: 1 MC:. Day: 195 Viit: 13 RX: 34 Day: Viit:. RX: 12 Day: Viit:. RX: 2 Day: 26 Viit:. RX:. Day: 1 Viit:. RX: 12 Day: Viit:. RX: 9 Day: 2 Viit: 2 Malignancy_CNS Malignacy_Hematologic _Infection Cardiovacular Congenital_Pulm Congenital_Hemopheli a Genitourinary Orthopedic Leukemia Reidual code; unclaified; all E code and Dieae of white blood cell Coagulation defect Diabete mellitu without complication Rehab care; fitting of prothee; adjutment of device Coagulation defect Rehab care; fitting of prothee; adjutment of device Congenital anomalie of the diaphragm Other perinatal condition Coagulation defect Other non-traumatic joint diorder Other connective tiue dieae Coagulation defect Other and unpecified lower repiratory dieae Coagulation defect Rehab care; fitting of prothee; 75

76 Total $: Total $: Total $: Total $: Total $: Total $: M Hipanic 56 year M Other 28 year M Aian 49 year M Other 8 year F White year F Other year FFS:12 RX: 11 CCS: MC:. FFS:5 CCS: 1 MC:. FFS:12 CCS: MC:. FFS:6 CCS: 1 MC:. FFS:12 CCS: MC:1 FFS:3 CCS: MC:4 FFS:4 Day: 8 Viit: 3 RX: 12 Day: 11 Viit: 2 RX: 12 Day: 176 Viit: 4 RX: 29 Day: 9 Viit: 6 RX: 13 Day: 16 Viit:. RX:. Day: 226 Viit: 2 RX: 12 Congenital_Pulm Diabete Hypertenion Congenital_Hemopheli a Hematologic _High_Cot Cardiovacular_CHF Malignancy_Skin _Infection Congenital_Hemopheli a Cardiovacular Orthopedic Cardiovacular Neonatal Cardiovacular_CHF Cardiovacular Cardiovacular_CHF Cardiovacular adjutment of device Other non-traumatic joint diorder Eential hypertenion Reidual code; unclaified; all E code and Repiratory failure Coagulation defect Other non-traumatic joint diorder Other venou embolim and thromboi Reidual code; unclaified; all E code and renal failure Complication of tranplant and reattached limb Coagulation defect Sprain and train Other nontraumatic joint diorder Other and illdefined heart dieae Repiratory failure Congetive heart failure Hypoplatic left heart yndrome Reidual code; unclaified; all E code and Congetive heart failure 76

77 Total $: Total $: Total $: Total $: Total $: Total $: Total $: M Hipanic 5 year M Hipanic 17 year F Hipanic year M Hipanic year M Hipanic 6 year F Hipanic 1 year M White 3 year CCS: MC:4 FFS:3 CCS: 1 MC:9 FFS:2 CCS: MC:6 FFS:3 CCS: MC:8 FFS:2 CCS: MC:12 FFS:. CCS: MC:11 FFS:1 CCS: 1 MC:. Day: 28 Viit: 1 RX: 11 Day: Viit: 3 RX: 12 Day: 253 Viit:. RX:. Day: 163 Viit: 1 RX: 21 Day: 18 Viit: 1 RX: 13 Day: 332 Viit:. RX:. Day: Congenital_Hemopheli a _Trauma Congenital_Hemopheli a Cardiovacular _Trauma Cardiovacular Neonatal Cardiovacular_CHF Cardiovacular Neonatal Cardiovacular_CHF Congenital_Hemopheli a GI _Trauma Tranplant_Lung Neonatal _High_Cot Congenital_Hemopheli a Orthopedic Coagulation defect Other non-traumatic joint diorder Adminitrative/ ocial admiion Coagulation defect Other aftercare Sprain and train Hypoplatic left heart yndrome Congetive heart failure; nonhypertenive Other and unpecified lower repiratory dieae Congetive heart failure; nonhypertenive Other and illdefined heart dieae Other congenital anomalie of aorta Coagulation defect Other non-traumatic joint diorder Hemorrhage or hematoma complicating a procedure Other perinatal condition Cardiomyopathy Other and illdefined heart dieae Coagulation defect 77

78 Total $: Total $: Total $: Total $: Total $: Total $: F Black year F Aian 2 year M Hipanic 11 year M Hipanic 12 year M Hipanic 44 year M Aian 3 year FFS:6 CCS: MC:5 FFS:3 CCS: MC:8 FFS:. CCS: 1 MC:1 FFS:. CCS: 1 MC:12 FFS:. CCS: MC:12 FFS:. CCS: MC:1 FFS:. Viit:. RX: 2 Day: 212 Viit:. RX:. Day: 29 Viit: 5 RX: 34 Day: 15 Viit: 2 RX: 9 Day: Viit:. RX: 3 Day: Viit:. RX: 4 Day: 162 Viit:. RX: 7 Cardiovacular Neonatal Congenital_CNS Malignacy_Hematologic Hematologic Other_Endocrine Congenital_Hemopheli a Diabete Pychiatric Congenital_Hemopheli a _Trauma Pychiatric Chronic_Kidney_Diea e Cardiovacular_CAD Other_Endocrine _Renal Subtance_Abue Hypertenion Repiratory cond of fetu newborn; not repiratory ditre Other and unpecified perinatal condition Repiratory ditre yndrome Other metabolic; nutritional; endocrine diorder Dieae of white blood cell Aplatic anemia Coagulation defect Other aftercare Rehab care; fitting of prothee; adjutment of device Rehab care; fitting of prothee; adjutment of device Coagulation defect Other aftercare Chronic kidney dieae Other pecified anemia renal failure Other fluid and electrolyte diorder 78

79 Total $: Total $: Total $: Total $: Total $: Total $: Total $: M Hipanic 1 year M Aian 12 year F Other 3 year F Hipanic 6 year M Other 22 year M Hipanic 1 year F White 26 year CCS: MC:11 FFS:1 CCS: 1 MC:7 FFS:5 CCS: 1 MC:7 FFS:4 CCS: MC:8 FFS:4 CCS: 1 MC:9 FFS:3 CCS: MC:12 FFS:. CCS: MC:8 FFS:3 Day: 26 Viit: 2 RX: 21 Day: 21 Viit:. RX: 28 Day: 32 Viit:. RX:. Day: 188 Viit:. RX: 11 Day: Viit:. RX: 11 Day: 236 Viit: 2 RX: 22 Day: 74 Viit: 3 RX: 7 Cardiovacular Neonatal Cardiovacular_CHF Congenital_Hemopheli a _High_Cot _Infection Cardiovacular _Infection _Infection Chronic_Kidney_Diea e Malignancy_GI _Low_Cot Congenital_Hemopheli a Chronic_Lung_Dieae _Athma Hypertenion Cardiovacular Cardiovacular_CHF Other_Endocrine Malignancy Congenital_CNS _Trauma Tetralogy of Fallot Reidual code; unclaified; all E code and Other and unpecified lower repiratory dieae Coagulation defect Pervaive developmental diorder Other aftercare Intetinal infection Dieae of white blood cell Reidual code; unclaified; all E code and Cancer of liver and intrahepatic bile duct Cirrhoi of liver without mention of alcohol renal failure Coagulation defect Eential hypertenion Medical examination/eval uation Other repiratory inufficiency Aortic valve tenoi Leukemia Thrombocytopen ia Other and unpecified lower repiratory 79

80 dieae Total $: Total $: Total $: Total $: Total $: Total $: Total $: M Other 21 year M Other 1 year F Hipanic 21 year M Aian 47 year M Hipanic 16 year M Other 7 year M White 62 year CCS: MC:8 FFS:3 CCS: MC:12 FFS:. CCS: MC:8 FFS:4 CCS: MC:1 FFS:. CCS: 1 MC:12 FFS:. CCS: 1 MC:12 FFS:. CCS: MC:11 FFS:1 Day: 21 Viit: 5 RX: 11 Day: 48 Viit: 2 RX: 21 Day: Viit:. RX: 2 Day: 8 Viit: 6 RX: 15 Day: 118 Viit: 2 RX: 47 Day: 6 Viit: 3 RX: 12 Day: Viit: 1 RX: 3 Congenital_Hemopheli a Orthopedic _Trauma Cardiovacular _Infection _Infection Neurologic Cardiovacular Congenital_Metabolic Congenital_Hemopheli a _High_Cot Cardiovacular Malignacy_Hematologic _Infection _Infection Congenital_Hemopheli a _High_Cot Orthopedic Malignancy Connective_Tiue_RA Cardiovacular_CAD Coagulation defect Other non-traumatic joint diorder Other aftercare Immunity diorder Other and unpecified gatrointetinal diorder Hypovolemia Other metabolic; nutritional; endocrine diorder Congenital inufficiency of aortic valve Other otiti media and related condition Coagulation defect Cancer of kidney and renal pelvi Abdominal pain Other repiratory inufficiency Reidual code; unclaified; all E code and Other mycoe Coagulation defect Other aftercare Other non-traumatic joint diorder Radiotherapy Cancer of protate Other connective tiue dieae 8

81 Total $: Total $: Total $: Total $: Total $: M Other 17 year M Hipanic 22 year M Hipanic 32 year F Hipanic 5 year M Hipanic 31 year CCS: 1 MC:12 FFS:. CCS: 1 MC:11 FFS:. CCS: MC:12 FFS:. CCS: MC:12 FFS:. CCS: MC:9 FFS:. Day: Viit: 1 RX: 4 Day: 2 Viit:. RX: 13 Day: Viit: 2 RX: 5 Day: Viit: 2 RX: 19 Day: 6 Viit: 5 RX: 3 Other_Endocrine Cardiovacular _Surgical Congenital_Hemopheli a Congenital_CNS GI Chronic_Kidney_Diea e Congenital_Metabolic Hypertenion Chronic_Kidney_Diea e Cardiovacular_CHF Other_Chronic_Infectio n_tb Chronic_Kidney_Diea e Cardiovacular_CHF Other_Endocrine Other metabolic; nutritional; endocrine diorder Reidual code; unclaified; all E code and Pneumonia; organim unpecified Other and unpecified benign neoplam Coagulation defect Neoplam of unpecified nature or uncertain behavior Chronic kidney dieae Other cardiac dyrhythmia Other comp internal prothetic device; implant; and graft Chronic kidney dieae Other comp internal prothetic device; implant; and graft Diabete mellitu without complication Chronic kidney dieae Abdominal pain Nauea and vomiting 81

82 Total $: Total $: Total $: Total $: Total $: Total $: M Black 43 year M Other 9 year M Hipanic 19 year M Hipanic 9 year F Hipanic 18 year M White 21 year CCS: MC:12 FFS:. CCS: 1 MC:12 FFS:. CCS: 1 MC:12 FFS:. CCS: 1 MC:12 FFS:. CCS: 1 MC:12 FFS:. CCS: 1 MC:12 FFS:. Day: Viit:. RX: 11 Day: 33 Viit: 7 RX: 1 Day: 14 Viit: 1 RX: 7 Day: Viit: 1 RX: 5 Day: 17 Viit: 11 RX: 28 Day: 3 Viit: 17 RX: 13 Chronic_Kidney_Diea e Hypertenion Other_Endocrine Congenital_Hemopheli a Hematologic _High_Cot Congenital_Hemopheli a Hematologic _High_Cot Congenital_Hemopheli a Malignancy _Infection _Infection Congenital_Hemopheli a Orthopedic Other_Chronic_Infectio n_tb Chronic kidney dieae Immunization and creening for infectiou dieae Other comp internal prothetic device; implant; and graft Coagulation defect Unpecified epticemia Infection inflam internal prothetic device;implant;gr aft Medical examination/eval uation Coagulation defect Open wound of head; neck; and trunk Coagulation defect Other and unpecified circulatory dieae Other aftercare Leukemia Reidual code; unclaified; all E code and Chemotherapy Coagulation defect Hematuria Other nontraumatic joint diorder 82

83 Total $: Total $: M Other 4 year M Black 37 year CCS: MC:12 FFS:. CCS: MC:12 FFS:. Day: Viit: 2 RX: 16 Day: Viit: 29 RX: 9 Congenital_Hemopheli a Hematologic _Trauma Congenital_Hemopheli a Hematologic GI_Cirrhoi Coagulation defect Infection inflam internal prothetic device;implant;gr aft Adminitrative/ ocial admiion Coagulation defect Infection inflam internal prothetic device;implant;gr aft Other nervou ytem ymptom and diorder Appendix A: Coordination of Care for Carve Out Service DHCS ha pecific contract language to clarify which ervice are carved-out from managed care plan into the FFS program. The carve out ervice vary lightly with repect to the type of managed care plan (e.g., COHS v. Two-Plan Model), but main ervice/drug include: Aid precription Alphafeto protein tet Alcohol and ubtance abue treatment ervice California Children Service (CCS) CHDP/EPSDT upplemental Childhood lead poioning Community baed adult ervice (long-term care) Direct oberved therapy for treatment of tuberculoi Dental Service Erectile dyfunction medication Federally qualified health clinic (FQHC) Heroin detoxification Heroin detoxification drug Home & community-baed waiver ervice Lene for eyewear when billed under PIA provider type Local education authority Long-term care (pediatric ub-acute) 83

84 Long-term care mental health Mental health ervice Mental health - pychiatrit, pychologit and ocial worker Mental health - antipychotic drug Mental health pych. injection Newborn hearing creening Organ tranplant Targeted cae management ervice Carving out ervice ha both advantage and diadvantage. A carve out for complex children ervice allow familie to maintain etablihed network of provider, exempt thoe ervice from ome of managed care acce retriction, and maintain acce to expenive pecialit and ervice that managed care might otherwie dicourage. At the ame time, carved out ervice contribute to dicontinuity in individual healthcare, externalize cot that a managed care plan would otherwie need to deal with, and may poe a hurdle for beneficiarie who need both ervice covered by a plan and ervice covered in a carve out. 84

85 Appendix D: Medi-Cal Undocumented Member 85

86 Medi-Cal Undocumented Member, 213 Brian Paciotti September 1, 214 DRAFT 86

87 Introduction The United State allow undocumented immigrant the ability to acce public health ervice uch a Medi-Cal. Getting health coverage through Medi-Cal hould not impact the ability to obtain a green card. There are over 4 Medi-Cal aid code that define Medi-Cal eligibility pathway for undocumented member. Mot of thee aid code limit ervice to pregnancy and emergency ervice. Some of the aid code require that a peron pay a monthly hare of cot to be eligible for Medi-Cal Service. In general, undocumented beneficiarie are not eligible to enroll in managed care plan (MCP). Method The ame method were followed a decribed in the Total Expenditure, 213 report. Enrollment Trend The table below (econd to lat column) how the number of Undocumented member enrolled in Medi-Cal from July of 24 to July of 212. The final column how the total Medi-Cal population by month and year. Thee number are from a RASB report (ee link). It i important to note that thee are member that enrolled in Medi-Cal and were eligible for ervice. Only about half of thee eligible member actually received ervice a evidenced by the claim/encounter data hown later in the report. 87

88 pdf For 213, I calculated the following enrollment number: January - 724,672 July 718,197 December - 7,647 Trend RASB ha created a et of Acce to Care report. Thee are legilatively mandated report to enure that FFS member continue to have acce to care. The RASB report have ome important ummarie about change in the FSS population, and they pay ome attention to Undocumented member. Hopefully Jim Watkin will agree to help u review our report, and can help u add ome hitorical context about the undocumented member. Here are a few point: % of Adult FFS member that are Undocumented 88

89 o Q1 of % o Q1 of % Children in Undocumented aid code reiding in non-metropolitan countie experienced ignificant decline (-13.2%) in participation for the tudy period, while participation for thoe reiding in metropolitan area were oberved to decline at a maller magnitude (-8.7%). Unlike the population dicued previouly, hift in ytem participation from FFS to managed care were not reponible for the reduction recognized in the undocumented population. Undocumented beneficiarie are generally not eligible to participate in Medi-Cal managed care plan. Rather, the downward trend recognized in the undocumented population wa the reult of their declining enrollment in the Medi- Cal program overall, a trend that may be explained in part by changing immigration pattern nationwide, decline in birthrate among Mexican immigrant, and the reidual effect of the receion. -- Page Adult in the Undocumented aid category, who are only eligible for emergency and pregnancy-related ervice, alo continued to exhibit below average and lower than expected utilization of Phyician/Clinic, Emergency Tranportation, and Hopital Inpatient ervice. Thi lower ervice utilization further upport the argument that thee utilization pattern may be heavily influenced by the decline in overall birth tatewide and nationally,9 which i mot noticeable among the immigrant population. -- Page 17 How Many Undocumented Medi-Cal Member Received Service in 213? In 213, there were a total of 338,816 member enrolled at leat one month in Medi-Cal with an Aid Code related to the undocumented category and who had a claim or encounter record ubmitted to Medi-Cal. Demographic The follow chart and table decribe the undocumented population in 213 that had a claim or encounter record (N= 338,816). 26,3 (77.2%) of the Undocumented member are female. 9.5% are Hipanic 86.97% have peak Spanih a their primary language Average age i 32.3 Only 644 (.19%) of the Undocumented member died in

90 Ethnicity N % of Total Hipanic 36, % Other 12, % Aian 9, % White 8, % Black 1,259.37% LANGUAGE N % of Total Spanih 294, % Englih 37, % Unknown 1,971.58% Mandarin 93.27% Korean % Other Non-Englih % Arabic % Armenian % Tagalog % Cantonee 343.1% Vietnamee 27.6% Other Chinee Language 23.6% 9

91 Ruian 173.5% Portuguee 138.4% Fari 89.3% No repone, client declined to tate 82.2% Samoan 72.2% French 47.1% Thai 46.1% Japanee 44.1% Cambodian 36.1% American Sign Language (ASL) 32.1% Hmong 26.1% Lao 17.1% Turkih 17.1% Hebrew 13.% Italian 7.% Polih 7.% Other Sign Language 3.% Ilacano 2.% Mien 2.% No Valid Data Reported (MEDS genera 2.% Aid Code of Undocumented member There were 35 aid code found among Undocumented member in 213. See Appendix A for a decription of all the Aid Code related to Undocumented member. AID CD N % of Total 3V 262, % 48 24, % 58 11, % C5 8, % 3T 8, % C1 6, % 8T 3,74 1.9% 5F 2,557.75% C7 2,361.7% 5T 2,321.69% C % D % 7K 84.24% 7C % 91

92 C % 1U % 8N % 6U 297.9% D1 23.7% % D % % D2 19.3% % C3 56.2% D9 42.1% 5J 41.1% D3 16.% 5W 15.% C8 11.% C2 1.% 5R 6.% D7 2.% 5H 1.% D4 1.% Expenditure A total of 1,126,642,99 dollar wa pent on undocumented member in 213 for FFS paid claim and capitated payment. In comparion, 43.6 billion dollar wa pent on all member for FFS and capitated payment (ee total expenditure report). Concerning pecific condition, 698,78,694 dollar wa pent on member with ervice related to pregnancy. The table below illutrate the total expenditure for variou cot group. Over half of the member had expenditure le than 5 dollar. Two member had expenditure over 1 million dollar. Cot Group N % of Total % , % , % 1,-5, 58, % 5,-1, 41, % 1,-2, 18, % 2,-5, 5, % 92

93 5,-1, 1,719.51% 1,-2, 41.12% 2,-5, 17.3% 5,-1,, 5.% 1,,-2,, 1.% 2,,-5,, 1.% Baed on the complete expenditure ditribution and cut-point from the other report, we can look at the proportion of undocumented member that fall into the cot categorie (table below). It i an important finding that over 8% of the undocumented member are in the bottom 8 percent. There are a few undocumented member (N=121) in the Super-Utilizer category and a mall number in the top one percent of cot per member (N=1,29). Thi reult differ from our original FFS-only report in which a much larger number of Undocumented member were in the top 2 percent. Thi i partly the reult of a large total number of undocumented member in 21 a compared to 213. However, more of the difference i driven by the higher cut-point that define the cot categorie. Once we added in 13 billion dollar of capitated payment, there were a much greater proportion of member with expenditure in the thouand of dollar per year. COST COHORT Frequency Percent Bottom 8% 275, Top.1% Top 1% 1,29.38 Top 2% 1, Top 5% 4, Top 1% 12, Top 15% 16, Top 2% 26, Summary of Expenditure from RASD Report Service_Expenditure.apx Thi report might anwer ome of your previou quetion from the earlier FFS report. I will need to compare ome of the data in thi report to our current reult. 93

94 What i the Total Medi-Cal Budget in 213? There are numerou reference, but likely the bet place to cite i the DHCS webite. See reference below. I will have to keep working to validate how well my paid FFS and paid capitated rate correpond to publihed tatitic. General DHSC Etimate Page: Fical Year Etimate: dget_year_tab.pdf Eligibility FFS v. MCP Enrollment Undocumented member are mandated to be in the FFS program, thu it i unurpriing to ee that over are indeed aociated with FFS. The few thouand member that pent ome time in MCP generally had expenditure le than 1, dollar. I wa unable, however, to identify any clear pattern a to why thee member pent ome time in MCP given that there eem to be a policy that undocumented member cannot enroll in MCP. It i poible that ome of thee cae repreent particular exception to the policy. It i alo poible that the Aid Code were entered incorrectly. I will need to invetigate thi further. MC FFS N % of Total FFS 336, % FFS MC 1,152.34% MC 1,5.31% In the link below, a publihed DHCS report how that there were only 597 undocumented member in managed care in Jan 213: n_pathway_healthsytem.pdf 94

95 Continuou Eligibility An average month of continuou eligibility i calculated by RASD. For undocumented member, the average number of month of continuou eligibility i 41 month. Thee calculation look back in the eligibility data to Jan. 1, 2: n_length_of_continuou.pdf I ran imilar calculation looking back to 23 to identify the number of continuou month of enrollment for each member. I found a very imilar reult of 39.8 month. The chart below how the average number of month of continuou eligibility by age. Total of Eligibility The graph below how the average total month that member have been enrolled in Medi-Cal by age. Thi meaure alo look back to 23, but allow for gap in coverage, and um up all of the eligible month regardle of being continuou. 95

96 Utilization Over 75 percent of the member had no LTC or acute facility viit percent of member had no LTC day but at leat one hopital viit. Only a few hundred member had a long-term care viit unurpriing ince Undocumented member have limited cope coverage that doe not include LTC. LTC Day ACUTE_1 N % of Total None None 255, % Some 83, % Some None 218.6% Some 115.3% The average number of day in an inpatient facility varie by age, but i in general i very low. 96

97 Viit The table below how the ditribution of the total number of viit by age. For example, 55 member in the age group -1 had 1 viit and 29 had 2 viit. Although the majority of member have le than five viit, there are a few member who have dozen of viit. Coun t AGE Group ,11 41,89 75,78 112,9 51,27 9,87 4,48 4,8 1, ,387 5,597 1, ,26 2, ,4 1,

98

99 Inpatient Viit Similar to the table above, the table below how the complete ditribution of the number of acute hopital day for each member. For example, there were 7 member aged -1 that were in the hopital for 1 day in 213. The hopital viit are aociated with younger member and reflect young women giving birth. acute day AGE Group

100

101

102 Analyi of Medical Condition The firt table how the frequencie of the highet expected cot G per member. Similar to the other report, for member with multiple G during the reporting period, I elected the G with the highet expected cot in the current year baed on Optum predictive model coefficient. It i important to note that pregnancy i the dominant condition for only percent of the member becaue thi table look at ALL of the Undocumented member (N= 338,816). In addition, it i important to note that 24.4 percent of the member did not have an G many are healthy and eem to not have condition and treatment that created Epiode of Care uing our grouper ytem. G 1 N % of Total Pregnancy 89, % Miing 82, % Low Cot 48, % GI 18, % Cardiovacular 11, % Genitourinary 1, % 12

103 Diabete 9, % High Cot 8,5 2.51% Orthopedic 8, % Other Endocrine 7, % Pychiatric 6, % Chronic_Lung_Dieae 6, % Obtetric 5, % Neurologic 4, % Other Chronic Infection 4, % Hematologic 3,213.95% Ophthalmologic 2,68.77% Hypertenion 2,165.64% Malignancy 1,689.5% Congenital 1,611.48% Chronic Kidney Dieae 1,62.47% ENT 1,46.41% Infection 96.27% Subtance_Abue % Hyperlipidemia % Neonatal % HIV_AIDS % Obeity 342.1% Connective Tiue 267.8% Dermatologic 115.3% Malignancy 51.2% Tranplant 18.1% Thi table how the ame G a the one above, but only include member with expenditure over 5,357 dollar (the cut-point to be in the top 2 percent). Once we look at the more expenive member in the top 2 percent, pregnancy i aociated with 74% of the member (thi i imilar to the analyi I preented in the lat draft). G 1 N % of Total Pregnancy % _High Cot % Cardiovacular % Low Cot % Chronic Kidney Dieae % Hematologic % GI % 13

104 Malignancy % Diabete % Pychiatric % Neurologic 566.9% Congenital % Genitourinary % Obtetric 377.6% Miing % HIV_AIDS % Orthopedic 24.38% Other Chronic Infection % Chronic_Lung_Dieae 191.3% Other Endocrine % Neonatal % Infection % Hypertenion % Subtance_Abue 94.15% Obeity 58.9% Malignancy 4.6% ENT 39.6% Connective Tiue 3.5% Ophthalmologic 28.4% Tranplant 18.3% Dermatologic 9.1% Geographic Variation Thi table preent county-level rate (percent) for Undocumented member. The rate are baed on cumulative cot cohort (e.g., -1%; -5%). CNTY_DE SC CNTY_DEN OM TOP_1_R ATE TOP_1_R ATE TOP_2_R ATE TOP_5_R ATE TOP_1_R ATE Alameda Amador Butte Calavera Colua Contra Cota Del Norte

105 El Dorado Freno Glenn Humbt Imperial Inyo Kern King Lake Laen Lo Angele Madera Marin Maripoa Mendocin o Merced Modoc Mono Monterey Napa Nevada Orange Placer Pluma Riveride Sacramen to San Benito San Bernardin o San Diego San Francico San Joaquin San Lui Obipo San Mateo Santa Barbara Santa Clara

106 Santa Cruz Shata Sierra Sikiyou Solano Sonoma Stanilau Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba Profile of Super-Utilizer In thi ection, I diplay ome of the demographic, utilization and top condition of Undocumented member who had high enough 213 expenditure to meet the criteria to be a uper-utilizer. Thi cut-point wa defined a TOTAL_COS T Total: $373,264 Total: $223,193 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 12 year M Hipani c 16 year CCS: MC: FFS:1 2 CCS: MC: Day: 2 Viit : 1 RX: 4 Day: 68 Viit : RX: Congenital_Hemophelia Cardiovacular_CHF Malignancy Malignancy Coagulation defect Rehab care; fitting of prothee; adjutment of device Abdominal pain Cancer of bone and connective tiue Chemotherapy Other connective tiue dieae 16

107 TOTAL_COS T Total: $328,39 Total: $275,813 Total: $34,255 Total: $463,72 Total: $243,452 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 7 year M Hipani c 14 year F Hipani c 28 year M Hipani c 28 year F Hipani c 35 year FFS:1 2 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:1 CCS: MC: FFS:2 CCS: MC: FFS:1 2 CCS: 2 Day: Viit : 1 RX: 8 Day: 53 Viit : 6 RX: 16 Day: 138 Viit : RX: 1 Day: 33 Viit : RX: Day: 1 Congenital_Hemophilia Cardiovacular Genitourinary Malignancy Malignancy Neurologic Pregnancy Congenital Malignancy_Skin _Infection Neurologic _Infection Pregnancy Other_Chronic_Infection_TB Coagulation defect Other injurie and condition due to external caue Other aftercare Cancer of bone and connective tiue Chemotherapy Reidual code; unclaified; all E code and Liveborn Other perinatal condition Intrauterine hypoxia and birth aphyxia Other repiratory inufficiency Repiratory failure Diorder of the peripheral nervou ytem Medical examination/evaluati on Outcome of delivery (V code) 17

108 TOTAL_COS T Total: $292,131 Total: $24,972 Total: $28,899 Total: $22,951 Total: $198,69 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Other 75 year M Hipani c 14 year F Hipani c 37 year F Hipani c 32 year F Hipani c 13 year MC: FFS:8 CCS: MC: FFS:5 CCS: MC: FFS:1 CCS: MC:2 FFS:7 CCS: MC: FFS:7 CCS: Viit : 3 RX: 19 Day: 72 Viit : RX: Day: 57 Viit : 2 RX: 12 Day: 147 Viit : 2 RX: 13 Day: 92 Viit : RX: 5 Day: 47 _Infection Hematologic _High_Cot Malignancy_CNS Neurologic Congenital_Pulm Pregnancy Hematologic Hypertenion _High_Cot Pregnancy Neonatal Malignacy_Hematologic GI Chronic_Lung_Dieae_COP D Short getation; low birth weight; fetal growth retardation Diabete with other manifetation Other and unpecified lower repiratory dieae Pneumonia; organim unpecified Cancer of brain and nervou ytem Chemotherapy Reidual code; unclaified; all E code and Other compl of birth; puerperium affecting manage of mom Medical examination/evaluati on Outcome of delivery (V code) Outcome of delivery (V code) Other complication of urgical and medical procedure Liveborn Leukemia Chemotherapy Anemia; unpecified 18

109 TOTAL_COS T Total: $373,894 Total: $291,43 Total: $22,69 Total: $243,446 Total: $31,456 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 41 year M Hipani c 44 year F Hipani c 2 year F Other 1 year F White 38 year MC: FFS:7 CCS: MC: FFS:8 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:9 CCS: Viit : 1 RX: 38 Day: 13 Viit : RX: 15 Day: Viit : RX: 9 Day: Viit : RX: 1 Day: 54 Viit : 5 RX: 24 Day: 96 Cardiovacular Pregnancy Hematologic _High_Cot Congenital_Pulm Neurologic Cardiovacular Cardiovacular_CAD Pregnancy Malignancy_CNS Neurologic Neurologic Pregnancy Congenital_Pulm Neonatal Liveborn Peritent fetal circulation Diabete or abnormal glucoe tolerance comp preg Repiratory failure Malfunction of device; implant; and graft Coma; tupor; and brain damage Other and unpecified complication of pregnancy Diorder of lipid metabolim Outcome of delivery (V code) Cancer of brain and nervou ytem Radiotherapy Other central nervou ytem diorder Other and unpecified lower repiratory dieae Other compl 19

110 TOTAL_COS T Total: $23,592 Total: $3,999 Total: $197,294 Total: $219,377 Total: $228,823 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 11 year M Hipani c 13 year F Hipani c 36 year M Hipani c 8 year M Hipani MC: FFS:6 CCS: MC: FFS:1 2 CCS: MC: FFS:6 CCS: MC: FFS:8 CCS: 1 MC: FFS:1 2 CCS: Viit : RX: 3 Day: 75 Viit : 1 RX: 21 Day: 63 Viit : 2 RX: 32 Day: 74 Viit : RX: 6 Day: Viit : RX: 1 Day: Malignancy Pychiatric_Depreion Hematologic Malignacy_Hematologic Hematologic _Trauma Pregnancy Neonatal Other_Endocrine Neurologic_Epilepy GI _Infection Malignancy_Skin Neurologic of birth; puerperium affecting manage of mom Outcome of delivery (V code) Cancer of bone and connective tiue Chemotherapy Reidual code; unclaified; all E code and Leukemia Chemotherapy Other gram negative epticemia Outcome of delivery (V code) Other compl of birth; puerperium affecting manage of mom Short getation; low birth weight; fetal growth retardation Other metabolic; nutritional; endocrine diorder Other ear and ene organ diorder Other hereditary and degenerative nervou cond Other connective tiue dieae 11

111 TOTAL_COS T Total: $612,497 Total: $274,293 Total: $344,871 Total: $381,983 DEMO ELIG UTIL G (Top 3) TOP_ICD9 c 48 year M Hipani c 13 year M Hipani c 34 year M Hipani c 41 year F Hipani c 63 year MC: FFS:9 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:6 CCS: MC: FFS:1 94 Viit : 12 RX: 15 Day: 3 Viit : 3 RX: 8 Day: Viit : RX: 12 Day: 96 Viit : 4 RX: 2 Day: 75 Viit : 2 RX: 42 Hematologic Congenital_Hemophelia _Infection _Trauma Neurologic _Infection Cardiovacular _Infection _Renal _Trauma Neurologic _Infection Hematologic Superficial injury; contuion Liver abce and equelae of chronic liver dieae Coagulation defect Other male genital diorder Concuion Medical examination/evaluati on Fever of unknown origin Coma; tupor; and brain damage Medical examination/evaluati on Unpecified epticemia Repiratory failure Other repiratory inufficiency Streptococcal epticemia Repiratory failure 111

112 TOTAL_COS T Total: $36,522 Total: $194,425 Total: $232,599 Total: $445,61 Total: $229,155 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 41 year M Other 63 year F Hipani c 9 year M Hipani c 4 year M Hipani c 1 year CCS: MC: FFS:1 CCS: MC: FFS:1 2 CCS: MC: FFS:5 CCS: MC: FFS:1 2 CCS: MC: Day: Viit : RX: 5 Day: 3 Viit : 1 RX: 22 Day: 64 Viit : 1 RX: 52 Day: 54 Viit : 1 RX: 5 Day: 65 Viit : 2 Congenital_Hemophelia HIV_AIDS GI _High_Cot Malignancy_Skin _Infection Chronic_Kidney_Dieae Congenital_CNS Hypertenion Chronic_Kidney_Dieae _Infection Hematologic Cardiovacular Cardiovacular_CHF Congenital HIV infection Coagulation defect Hepatiti Other venou embolim and thromboi Repiratory failure Late effect of cerebrovacular dieae Sytemic lupu erythematou connective tiue diorder Chronic kidney dieae Nephriti; nephroi; renal cleroi Repiratory failure Pneumonia; organim unpecified Rehab care; fitting of prothee; adjutment of device Pneumonia; organim unpecified Endocardial cuhion defect Congetive heart failure 112

113 TOTAL_COS T Total: $2,585 Total: $349,857 Total: $338,74 Total: $211,34 Total: $212,1 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 68 year F Hipani c 3 year M Hipani c 35 year M Hipani c 48 year F Hipani c 13 year FFS:6 CCS: MC: FFS:1 2 CCS: MC: FFS:3 CCS: MC: FFS:1 2 CCS: MC: FFS:4 CCS: MC: RX: 1 Day: Viit : 1 RX: 2 Day: 141 Viit : 1 RX: 1 Day: 5 Viit : 1 RX: 11 Day: 11 Viit : 2 RX: 2 Day: 84 Viit _Infection Congenital_Metabolic Hematologic Pregnancy Congenital Genitourinary Congenital_Hemophelia GI Orthopedic Congenital_CNS Pychiatric Diabete Malignacy_Hematologic Malignancy_GI _Infection Repiratory failure Iron deficiency anemia Other and unpecified gatrointetinal diorder Repiratory ditre yndrome Other hemorrhage pregnancy; childbirth and puerperium Other compl of birth; puerperium affecting manage of mom Coagulation defect Other nervou ytem ymptom and diorder Other nontraumatic joint diorder Occluion of cerebral arterie Other headache Other and ill-defined cerebrovacular dieae Leukemia Dieae of white blood cell Reidual code; unclaified; all E code and 113

114 TOTAL_COS T Total: $227,18 Total: $321,549 Total: $285,647 Total: $349,332 Total: $27,366 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 3 year M Aian 29 year F Hipani c 55 year M Other 64 year F Hipani c 19 year FFS:6 CCS: MC: FFS:9 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:7 CCS: : 4 RX: 27 Day: 56 Viit : RX: 9 Day: Viit : 1 RX: Day: Viit : RX: 17 Day: 88 Viit : 2 RX: 2 Day: 73 Pregnancy GI Neonatal Neurologic_Epilepy Other_Chronic_Infection_TB Pychiatric Congenital_Pulm _Infection Cardiovacular Neurologic _Trauma _Renal Cardiovacular Cardiovacular Pregnancy Outcome of delivery (V code) Liveborn Other and unpecified complication of pregnancy Other and unpecified lower repiratory dieae Epilepy Nauea and vomiting Repiratory failure Other central nervou ytem diorder Other repiratory inufficiency Other intracranial injury Other and unpecified lower repiratory dieae Rehab care; fitting of prothee; adjutment of device Other perinatal condition Outcome of delivery (V code) Other and unpecified 114

115 TOTAL_COS T Total: $369,756 Total: $455,485 Total: $265,312 Total: $278,85 Total: $431,13 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 66 year F Hipani c 34 year M Other 51 year F Hipani c 36 year M Hipani MC: FFS:8 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:5 CCS: Viit : 5 RX: 2 Day: Viit : 1 RX: 36 Day: 55 Viit : RX: 34 Day: 14 Viit : 5 RX: 42 Day: 125 Viit : RX: 6 Day: Cardiovacular_CAD Congenital_Pulm Cardiovacular Malignancy _Infection Hematologic Chronic_Kidney_Dieae Cardiovacular_CHF _Infection Pregnancy Neonatal Other_Endocrine _Infection _Infection perinatal condition Repiratory failure Other repiratory inufficiency Inflammation; infection of eye (except TB or STD) Cancer of cervix Other and unpecified genitourinary ymptom Hydronephroi Repiratory failure Chronic kidney dieae Medical examination/evaluati on Liveborn Repiratory ditre yndrome Other compl of birth; puerperium affecting manage of mom Unpecified epticemia Other and 115

116 TOTAL_COS T Total: $284,89 Total: $275,347 Total: $247,231 Total: $298,171 DEMO ELIG UTIL G (Top 3) TOP_ICD9 c 7 year M Aian 66 year F Hipani c 46 year M Hipani c 5 year M Hipani c 34 year MC: FFS:1 1 CCS: MC: FFS:1 2 CCS: MC: FFS:2 CCS: MC: FFS:5 CCS: MC: FFS: Viit : 3 RX: 11 Day: Viit : RX: 3 Day: 21 Viit : 1 RX: Day: 13 Viit : RX: Day: Viit : RX: 14 Chronic_Kidney_Dieae _High_Cot Congenital_Pulm _Infection Congenital_Pulm Congenital_CNS Hematologic Malignacy_Hematologic Congenital_Pulm _Infection _Trauma unpecified lower repiratory dieae Repiratory failure Other injurie and condition due to external caue Repiratory failure Other repiratory inufficiency Intracranial hemorrhage Other and ill-defined cerebrovacular dieae Other aftercare Other and unpecified lower repiratory dieae Leukemia Fever of unknown origin Repiratory failure Coma; tupor; and brain damage Other repiratory inufficiency 116

117 TOTAL_COS T Total: $319,452 Total: $716,271 Total: $244,844 Total: $3,952 Total: $335,766 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 38 year F Aian 34 year M Hipani c 14 year F Hipani c 32 year M Aian 46 year CCS: MC: FFS:1 1 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:6 CCS: MC: Day: 15 Viit : 38 RX: 7 Day: 141 Viit : 1 RX: 8 Day: 58 Viit : 3 RX: 32 Day: 122 Viit : RX: 5 Day: 78 Viit : 1 Chronic_Kidney_Dieae Cardiovacular_CHF Hematologic Pregnancy _Surgical Chronic_Lung_Dieae_COP D Tranplant_Lung _High_Cot Hematologic Pregnancy Neonatal Other_Endocrine Congenital_Pulm _Infection Diabete Chronic kidney dieae Abdominal pain Hypertenive heart and/or renal dieae Hypoplatic left heart yndrome Other compl of birth; puerperium affecting manage of mom Outcome of delivery (V code) Other and unpecified circulatory dieae Cardiomyopathy Complication of tranplant and reattached limb Repiratory ditre yndrome Repiratory cond of fetu newborn; not repiratory ditre Other perinatal condition Pulmonary collape; intertitial and comp emphyema Chronic kidney dieae Other and unpecified lower repiratory dieae 117

118 TOTAL_COS T Total: $393,692 Total: $758,375 Total: $356,83 Total: $31,763 Total: $3,41,724 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 27 year M Hipani c 15 year M Hipani c 2 year M Aian 43 year M Hipani c 21 FFS:1 2 CCS: MC: FFS:5 CCS: 1 MC: FFS:1 2 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: RX: 17 Day: 82 Viit : RX: 2 Day: 1 Viit : 5 RX: 5 Day: 129 Viit : 4 RX: 41 Day: Viit : RX: 13 Day: 2 Cardiovacular Pregnancy Subtance_Abue Congenital_Hemophelia Congenital_CNS _Trauma Malignacy_Hematologic Hematologic Congenital_CNS Congenital_Pulm Congenital_CNS Diabete Congenital_Hemophelia Outcome of delivery (V code) Peritent fetal circulation Repiratory cond of fetu newborn; not repiratory ditre Other fracture of upper limb Coagulation defect Other non-traumatic joint diorder Leukemia Chemotherapy Intracranial hemorrhage Intracranial hemorrhage Repiratory failure Convulion Coagulation defect Other connective tiue dieae Other 118

119 TOTAL_COS T Total: $463,855 Total: $45,871 Total: $23,36 Total: $295,983 DEMO ELIG UTIL G (Top 3) TOP_ICD9 year F Hipani c 38 year M Hipani c 41 year F White 82 year M Hipani c 3 year MC: FFS:9 CCS: MC: FFS:8 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 Viit : RX: 11 Day: 142 Viit : 1 RX: 1 Day: Viit : 1 RX: 1 Day: 28 Viit : 4 RX: 3 Day: Viit : RX: 8 Pregnancy Other_Endocrine GI Congenital_Hemophelia Hematologic Cardiovacular GI _High_Cot Congenital_Pulm Neurologic 119 aftercare Other and unpecified gatrointetinal diorder Outcome of delivery (V code) Other compl of birth; puerperium affecting manage of mom Coagulation defect Calculu of kidney Dieae of white blood cell Repiratory failure Other and ill-defined cerebrovacular dieae Other aftercare Repiratory failure Malfunction of device; implant; and graft Total: F CCS: _Infection Chronic kidney

120 TOTAL_COS T $279,361 Hipani c 85 year Total: $1,6,76 Total: $324,865 Total: $269,11 Total: $35,121 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 18 year M Hipani c 38 year M Other 25 year M Hipani c 1 year MC: FFS:8 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:7 CCS: 1 MC: FFS:4 Day: 55 Viit : 7 RX: 33 Day: 195 Viit : 13 RX: 34 Day: 6 Viit : 1 RX: 1 Day: 13 Viit : RX: Day: 11 Viit : RX: 16 Neurologic Chronic_Kidney_Dieae Malignancy_CNS Malignacy_Hematologic _Infection _Infection Hematologic Congenital_Pulm _High_Cot HIV_AIDS Hematologic Malignacy_Hematologic _Infection _High_Cot dieae Pleuriy; pleural effuion Other repiratory inufficiency Leukemia Reidual code; unclaified; all E code and Dieae of white blood cell Repiratory failure Coma; tupor; and brain damage Fever of unknown origin Other and unpecified gatrointetinal diorder HIV infection Other and unpecified liver diorder Neoplam of unpecified nature or uncertain behavior Other and unpecified lower repiratory dieae Aplatic anemia 12

121 TOTAL_COS T Total: $39,861 Total: $292,696 Total: $218,688 Total: $246,585 Total: $195,755 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 1 year F Hipani c 16 year F Hipani c 65 year M Hipani c 16 year F Hipani c 17 year CCS: MC: FFS:8 CCS: MC: FFS:7 CCS: MC: FFS:2 CCS: MC: FFS:3 CCS: MC: FFS:1 2 Day: 168 Viit : 1 RX: 4 Day: 8 Viit : 3 RX: 26 Day: 47 Viit : 1 RX: 2 Day: 49 Viit : 1 RX: Day: 7 Viit : RX: 2 Neurologic Neurologic Malignancy_CNS Tranplant_Lung _High_Cot Pychiatric_Depreion Congenital_Pulm Congenital_CNS Hypertenion Congenital_CNS Malignancy_CNS Hematologic Hematologic Reidual code; unclaified; all E code and Epilepy Other endocrine diorder Heart failure Other and unpecified circulatory dieae Cardiomyopathy Medical examination/evaluati on Intracranial hemorrhage Other upper repiratory dieae Intracranial hemorrhage Tranient cerebral ichemia Rehab care; fitting of prothee; adjutment of device Cancer of brain and nervou ytem Chemotherapy Radiotherapy 121

122 TOTAL_COS T Total: $332,444 Total: $23,842 Total: $426,41 Total: $263,693 Total: $29,28 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Other 1 year F Hipani c 38 year F Aian 38 year F Hipani c 25 year M Hipani c 52 year CCS: MC: FFS:7 CCS: MC: FFS:1 2 CCS: MC: FFS:9 CCS: MC: FFS:4 CCS: MC: FFS:1 Day: 1 Viit : 4 RX: 26 Day: 1 Viit : 2 RX: 12 Day: 255 Viit : 1 RX: 2 Day: 143 Viit : 2 RX: 6 Day: Viit : 1 RX: 5 Malignancy_CNS Neonatal Hematologic Pychiatric_Schizophrenia GI GI Malignancy_Pulm Malignancy_Skin _Infection Pregnancy Neonatal Other_Endocrine Congenital_Pulm GI _Ingetion_ETOH Cancer of brain and nervou ytem Other metabolic; nutritional; endocrine diorder Reidual code; unclaified; all E code and Schizophrenia and other pychotic diorder Other thyroid diorder Subtance-related diorder Malignant neoplam without pecification of ite Repiratory failure Other and unpecified lower repiratory dieae Reidual code; unclaified; all E code and Medical examination/evaluati on Outcome of delivery (V code) Repiratory failure Late effect of cerebrovacular dieae Other upper repiratory dieae 122

123 TOTAL_COS T Total: $339,275 Total: $21,39 Total: $199,411 Total: $294,133 Total: $24,134 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 52 year F Other 28 year F Other 22 year M White 64 year F Hipani c 35 year 2 CCS: MC: FFS:1 2 CCS: MC: FFS:8 CCS: MC: FFS:7 CCS: MC: FFS:1 2 CCS: MC: Day: 71 Viit : RX: 29 Day: 97 Viit : 6 RX: 2 Day: 94 Viit : 3 RX: 16 Day: Viit : RX: 1 Day: 16 Viit : 2 _Infection _Infection _Renal Pregnancy Ophthalmologic Hematologic Hematologic _Trauma Cardiovacular Congenital_Pulm _Infection _Trauma Pregnancy Neonatal Other_Endocrine Repiratory failure Other repiratory inufficiency Other central nervou ytem diorder Liveborn Outcome of delivery (V code) Other perinatal condition pancreatiti Diabete mellitu without complication Other pancreatic diorder Repiratory failure Pulmonary heart dieae Coma; tupor; and brain damage Other compl of birth; puerperium affecting manage of mom Outcome of delivery (V code) Other hemorrhage 123

124 TOTAL_COS T Total: $25,456 Total: $249,823 Total: $742,257 Total: $199,371 Total: $299,91 DEMO ELIG UTIL G (Top 3) TOP_ICD9 M Hipani c 24 year F Hipani c 31 year F Hipani c 36 year M Hipani c 68 year M Hipani c 49 year FFS:7 CCS: MC: FFS:1 2 CCS: MC: FFS:2 CCS: MC: FFS:8 CCS: MC: FFS:1 2 CCS: RX: 9 Day: Viit : RX: 13 Day: 8 Viit : RX: 3 Day: 276 Viit : 4 RX: 16 Day: 89 Viit : 9 RX: 21 Day: Viit _Infection Malignancy_Skin _Trauma Pregnancy Neonatal Pregnancy Genitourinary Genitourinary Cardiovacular_CHF _Infection Chronic_Kidney_Dieae Congenital_Pulm Neurologic Diabete pregnancy; childbirth and puerperium Other repiratory inufficiency Other fluid and electrolyte diorder Other and unpecified lower repiratory dieae Repiratory ditre yndrome Short getation; low birth weight; fetal growth retardation Early onet of delivery Other and unpecified complication of pregnancy Other compl of birth; puerperium affecting manage of mom Infection of genitourinary tract during pregnancy Chronic kidney dieae Noninfectiou gatroenteriti Reidual code; unclaified; all E code and Repiratory failure Coma; tupor; and brain damage 124

125 TOTAL_COS T Total: $32,544 Total: $292,15 Total: $215,661 Total: $222,564 Total: $22,169 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 4 year M Hipani c 45 year F Hipani c 3 year F Hipani c 21 year M Hipani MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: FFS:9 CCS: MC: FFS:8 CCS: 1 : RX: 17 Day: 2 Viit : 2 RX: 15 Day: Viit : RX: 16 Day: 35 Viit : 1 RX: 4 Day: 26 Viit : RX: 9 Day: Chronic_Kidney_Dieae Hematologic Congenital_CNS Congenital_Pulm _Infection Diabete Neurologic Pregnancy Neurologic Pregnancy Neonatal Genitourinary _Infection Other_Endocrine Chronic kidney dieae Medical examination/evaluati on Other hereditary and degenerative nervou cond Repiratory failure Coma; tupor; and brain damage Intracranial hemorrhage Repiratory failure Outcome of delivery (V code) Outcome of delivery (V code) Other anomalie of bulbu cordi and cardiac eptal cloure Other compl of birth; puerperium affecting manage of mom Cytic fibroi Reidual code; 125

126 TOTAL_COS T Total: $471,734 Total: $316,81 Total: $338,786 Total: $231,954 DEMO ELIG UTIL G (Top 3) TOP_ICD9 c 12 year M Hipani c 48 year F Hipani c 2 year M Hipani c 34 year M White 59 year MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:1 2 CCS: MC: 58 Viit : 7 RX: 49 Day: 144 Viit : 1 RX: 18 Day: 52 Viit : 2 RX: 49 Day: 9 Viit : 1 RX: 9 Day: 7 Viit : 3 RX: 18 Cardiovacular Neurologic _Infection Hematologic Other_Endocrine Congenital_Pulm Diabete _Infection Hematologic Congenital_Pulm _Infection Cardiovacular_CAD _Infection unclaified; all E code and Other aftercare Medical examination/evaluati on Repiratory failure Other and unpecified lower repiratory dieae Cytic fibroi Diabete with ketoacidoi or uncontrolled diabete Empyema and pneumothorax Repiratory failure Unpecified epticemia Pneumonia; organim unpecified Other repiratory inufficiency Coma; tupor; and brain damage Other aftercare 126

127 TOTAL_COS T Total: $25,82 Total: $295,15 Total: $316,83 Total: $353,582 Total: $337,95 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F White 36 year M Hipani c 44 year F Hipani c 33 year F Hipani c 23 year M Hipani c 8 year FFS:1 2 CCS: MC: FFS:5 CCS: MC: FFS:1 1 CCS: MC: FFS:2 CCS: MC: FFS:6 CCS: 1 MC: Day: 93 Viit : RX: Day: 23 Viit : 6 RX: 38 Day: 13 Viit : RX: 1 Day: 112 Viit : 1 RX: 2 Day: Viit : RX: Pregnancy Malignacy_Hematologic Neonatal Neurologic _Infection Hematologic Pregnancy Ophthalmologic Neonatal Pregnancy Neonatal Other_Endocrine Orthopedic _Surgical Other compl of birth; puerperium affecting manage of mom Liveborn Outcome of delivery (V code) Repiratory failure Unpecified epticemia Other repiratory inufficiency Other compl of birth; puerperium affecting manage of mom Other perinatal condition Repiratory ditre yndrome Repiratory ditre yndrome Short getation; low birth weight; fetal growth retardation Liveborn Other metabolic; nutritional; endocrine diorder Umbilical hernia without obtruction/gangrene Other bone dieae 127

128 TOTAL_COS T Total: $36,25 Total: $219,775 Total: $42,165 Total: $221,115 Total: $263,11 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 32 year F Hipani c 27 year F Hipani c 23 year M Hipani c 39 year M Hipani c 44 year FFS:1 2 CCS: MC: FFS:6 CCS: MC: FFS:2 CCS: MC: FFS:3 CCS: MC: FFS:1 1 CCS: MC: 12 and muculokeletal deformitie Day: 28 Viit : RX: 5 Day: 38 Viit : RX: 8 Day: 89 Viit : RX: Day: 13 Viit : RX: 5 Day: Viit : Pregnancy Pregnancy Ophthalmologic Neonatal Pregnancy Ophthalmologic Cardiovacular Cardiovacular_CAD Cardiovacular Congenital_Hemophelia Orthopedic Orthopedic Liveborn Other perinatal condition Outcome of delivery (V code) Outcome of delivery (V code) Liveborn Repiratory ditre yndrome Other retinal diorder Liveborn Other and unpecified gatrointetinal diorder Nonrheumatic aortic valve diorder Other congenital anomalie of the heart Congetive heart failure Coagulation defect Other non-traumatic joint diorder Other aftercare 128

129 TOTAL_COS T Total: $241,67 Total: $478,792 Total: $674,632 Total: $251,37 Total: $355,26 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 33 year M Hipani c 43 year M Hipani c 35 year F Hipani c 2 year F Hipani c 65 FFS:1 1 CCS: MC: FFS:5 CCS: MC: FFS:1 2 CCS: MC: FFS:4 CCS: 1 MC: FFS:1 2 CCS: RX: 2 Day: 17 Viit : RX: 7 Day: 7 Viit : 2 RX: 19 Day: Viit : RX: 8 Day: Viit : RX: 8 Day: 17 Pregnancy Congenital Other_Endocrine Cardiovacular _Infection Cardiovacular Congenital_Hemophelia GI Orthopedic Chronic_Lung_Dieae Chronic_Lung_Dieae_COP D Cardiovacular_CAD Neurologic _Infection Liveborn Other compl of birth; puerperium affecting manage of mom Early onet of delivery Medical examination/evaluati on Other aneurym Nonpecific chet pain Coagulation defect Other non-traumatic joint diorder Medical examination/evaluati on Pulmonary heart dieae Reidual code; unclaified; all E code and Other aftercare Other repiratory inufficiency Repiratory failure 129

130 TOTAL_COS T Total: $422,25 Total: $31,968 Total: $235,744 Total: $478,985 DEMO ELIG UTIL G (Top 3) TOP_ICD9 year F Hipani c 26 year M Other 41 year F Hipani c 19 year F Hipani c 28 year MC: FFS:1 2 CCS: MC: FFS:5 CCS: MC: FFS:1 2 CCS: 1 MC: FFS:1 2 CCS: MC: FFS:7 Viit : 3 RX: 46 Day: 13 Viit : 1 RX: 6 Day: Viit : RX: 24 Day: 24 Viit : 2 RX: 37 Day: 111 Viit : 3 RX: 11 Pregnancy Neonatal Other_Endocrine _Infection Congenital_Pulm Neurologic _Infection Other_Endocrine _High_Cot Pregnancy Ophthalmologic Neonatal 13 renal failure Short getation; low birth weight; fetal growth retardation Other anomalie of bulbu cordi and cardiac eptal cloure Repiratory ditre yndrome Repiratory failure Cancer of head and neck Other repiratory inufficiency Cytic fibroi Other chronic pulmonary dieae Other bacterial pneumonia Liveborn Outcome of delivery (V code) Other hypertenion in pregnancy Total: F CCS: Pregnancy Repiratory ditre

131 TOTAL_COS T $42,452 Hipani c 31 year Total: $276,653 Total: $247,29 Total: $195,244 DEMO ELIG UTIL G (Top 3) TOP_ICD9 F Hipani c 39 year Other 3 year M Hipani c 88 year MC: FFS:4 CCS: MC: FFS:6 CCS: MC: FFS:2 CCS: MC: FFS:1 2 Day: 135 Viit : RX: 4 Day: 115 Viit : 1 RX: 7 Day: 13 Viit : RX: 2 Day: 95 Viit : 4 RX: 25 Ophthalmologic Neonatal Pregnancy Other_Endocrine Pregnancy Neonatal _Infection Cardiovacular_CAD _Infection Hematologic yndrome Short getation; low birth weight; fetal growth retardation Other aftercare Outcome of delivery (V code) Reidual code; unclaified; all E code and Other hemorrhage pregnancy; childbirth and puerperium Other compl of birth; puerperium affecting manage of mom Liveborn Preeclampia and eclampia Repiratory failure Unpecified epticemia Pleuriy; pleural effuion 131

132 Appendix A: Aid Code for Undocumented Member What i the federal and tate tatutory code ection() authorizing Medi- Cal coverage of undocumented immigrant? Could you get the pecific legal citation()? Thi link below how the California code related to Medi-Cal upport of Undoc Thi document link below (and the creenhot from page 1) provide ome additional context. It look like that when you were director of DHCS you were in a lawuit concerning addition renal ervice benefit of immigrant, Crepin v. Kizer The table below how all of the Undocumented Aid Code. We can cite the original mater Aid Code publihed on the DHCS webpage. Code Benefit C1 C2 C3 C4 Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Share of Cot No Ye No Ye Program/Decription OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Aid to the Aged Medically Needy. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Aid to the Aged Medically Needy, SOC. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Blind Medically Needy. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Blind Medically Needy, SOC. 132

133 Code Benefit C5 C6 C7 C8 C9 D1 D2 Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Share of Cot No Ye No Ye No Ye Program/Decription OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen.afdc Medically Needy. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. AFDC Medically Needy SOC. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Diabled Medically Needy. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen. Diabled Medically Needy, SOC. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen.mi Child. Cover medically indigent peron under 21 who meet the eligibility requirement of medical indigence. Cover peron until the age of 22 who were in an intitution for mental dieae before age 21. Peron may continue to be eligible under aid code 82 until age 22 if they have filed for a State hearing. OBRA Alien and Unverified Citizen. Cover eligible alien who do not have atifactory immigration tatu and unverified citizen.mi Child SOC. Cover medically indigent peron under 21 who meet the eligibility requirement of medically indigent. No OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.aid to the Aged Long Term Care (LTC). Cover peron 65 year of age or er who are medically needy and in LTC tatu.provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the 133

134 Code Benefit D3 D4 D5 Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Share of Cot Program/Decription LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for example, pharmacy, upport urface and therapie). Ye OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.aid to the Aged Long Term Care (LTC), SOC. Cover peron 65 year of age or er who are medically needy and in LTC tatu.provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for example, pharmacy, upport urface and therapie). No OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.blind Long Term Care (LTC).Provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for example, pharmacy, upport urface and therapie). Ye OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.blind Long Term Care (LTC), SOC.Provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for 134

135 Code Benefit D6 D7 D8 D9 1U Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and Share of Cot Program/Decription example, pharmacy, upport urface and therapie). No OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.diabled Long Term Care (LTC).Provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for example, pharmacy, upport urface and therapie). Ye OBRA Alien Not PRUCOL and Unverified Citizen Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL and unverified citizen. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual.diabled Long Term Care (LTC), SOC.Provider Note: Long Term Care ervice refer to both thoe ervice included in the per diem bae rate of the LTC provider, and thoe medically neceary ervice required a part of the patient day-to-day plan of care in the LTC facility (for example, pharmacy, upport urface and therapie). No Ye No OBRA Alien and Unverified Citizen Pregnant Woman. Cover eligible pregnant alien women who do not have atifactory immigration tatu and unverified citizen.mi Confirmed Pregnancy. Cover peron aged 21 year or er, with confirmed pregnancy, which meet the eligibility requirement of medically indigent. OBRA Alien and Unverified Citizen Pregnant Woman. Cover eligible pregnant alien women who do not have atifactory immigration tatu and unverified citizen.mi Confirmed Pregnancy SOC. Cover peron aged 21 or er, with confirmed pregnancy, which meet the eligibility requirement of medically indigent but are not eligible for 185 percent/2 percent or the MN program. Retricted Federal Poverty Level Aged. Cover the aged in the Aged and Diabled FPL program that do not have 135

136 Code Benefit 3T 3V emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice 48 Retricted to pregnancyrelated ervice 5F 5J 5R 5T 5W Retricted to pregnancy and emergency ervice Retricted to pregnancyrelated and emergency ervice Retricted to pregnancyrelated and emergency ervice Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice Share of Cot No No No Y/N No Ye No No Program/Decription atifactory immigration tatu. Initial Tranitional Medi-Cal (TMC). Provide ix month of coverage for eligible alien without atifactory immigration tatu who have been dicontinued from Section 1931(b) due to increaed earning from employment. AFDC 1931(b) Non CalWORKS. Cover thoe eligible for the Section 1931(b) program who do not have atifactory immigration tatu. 2 Percent FPL Pregnant Omnibu Budget Reconciliation Act (OBRA) (Income Diregard Program Pregnant OBRA). Provide eligible pregnant alien of any age without atifactory immigration tatu with family planning, pregnancy-related and potpartum, if family income i at or below 2 percent of the federal poverty level. OBRA Alien Pregnant Woman. Cover eligible pregnant alien women who do not have atifactory immigration tatu. SB 87 Pending Diability Program. SB 87 Pending Diability Program. Continuing TMC. Provide an additional ix month of emergency ervice coverage for thoe beneficiarie who received ix month of initial TMC coverage under aid code 3T. Four- Continuing Pregnancy and Emergency Service Only. Provide four month of emergency ervice for alien without atifactory immigration tatu who are no longer eligible for Section 1931(b) due to the collection or increaed 136

137 Code Benefit 55 Retricted to pregnancy and emergency ervice 58 Retricted to pregnancy and emergency ervice 6U Retricted to pregnancy and emergency ervice 69 Retricted to emergency ervice 7C 7K Retricted to pregnancy and emergency ervice Retricted to pregnancy and emergency ervice 74 Retricted to emergency ervice 8N Retricted to emergency ervice Share of Cot No Y/N No No No No No No Program/Decription collection of child/poual upport. OBRA Not PRUCOL Long Term Care (LTC) ervice. Cover eligible undocumented alien in LTC who are not PRUCOL. Recipient will remain in thi aid code even if they leave LTC. For more information about LTC ervice, refer to the OBRA and IRCA ection in thi manual. OBRA Alien. Cover eligible alien who do not have atifactory immigration tatu. Retricted Federal Poverty Level Diabled. Cover the diabled in the Aged and Diabled FPL program who do not have atifactory immigration tatu. 2 Percent Infant OBRA. Provide emergency ervice only for eligible infant without atifactory immigration tatu who are under 1 year of age or beyond 1 year when inpatient tatu, which began before 1t birthday, continue and family income i at or below 2 percent of the federal poverty level. 1 Percent OBRA Child. Cover emergency and pregnancyrelated ervice to otherwie eligible children, without atifactory immigration tatu who are age 6 to 19 or beyond 19 when inpatient tatu begin before the 19th birthday and family income i at or below 1 percent of the federal poverty level. Continuou Eligibility for Children (CEC). Provide emergency and pregnancy-related benefit (no Share of Cot) to children without atifactory immigration tatu who are up to 19 year of age who would otherwiaw loe their no Share of Cot Medi-Cal. 133 Percent Program (OBRA). Provide emergency ervice only for eligible children without atifactory immigration tatu who are age 1 up to 6 or beyond 6 year when inpatient tatu, which began before 6th birthday, continue and family income i at or below 133 percent of the federal poverty level. 133 Percent Exce Property Child Emergency Service Only. Provide emergency ervice only for eligible children without atifactory immigration tatu who are age 1 up to 6 137

138 Code Benefit 8T Retricted to pregnancy and emergency ervice Share of Cot No Program/Decription or beyond 6 year when inpatient tatu, which began before 6th birthday, continue, and family income i at or below 133 percent of the federal poverty level. 1 Percent Exce Property Child Pregnancy and Emergency Service Only. Cover emergency and pregnancyrelated ervice only to otherwie eligible children without atifactory immigration tatu who are age 6 to 19 or beyond 19 when inpatient tatu begin before the 19th birthday and family income i at or below 1 percent of the Federal poverty level. 138

139 Appendix E: Draft Health Promotion Manucript 139

140 Author: Deiree Backman, DrPH, MS, RD Senior Scientit Intitute for Population Health Improvement, Univerity of California Davi Health Sytem Chief Prevention Officer California Department of Health Care Service Neal D. Kohatu, MD, MPH Medical Director California Department of Health Care Service Brian Paciotti, PhD, MS Quality Scientit Intitute for Population Health Improvement, Univerity of California Davi Health Sytem California Department of Health Care Service Jennifer Byrne, BA Aociate Governmental Program Analyt California Department of Health Care Service Kenneth W. Kizer, MD, MPH Director, Intitute for Population Health Improvement, Univerity of California Davi Health Sytem Ditinguihed Profeor, Univerity of California Davi School of Medicine and Betty Irene Moore School of Nuring Title: Characteritic of Health Promotion Intervention Delivered by Medi-Cal Plan 14

141 Introduction Chronic condition uch a ichemic heart dieae, cancer, troke, and diabete are currently reponible for nearly 7 in 1 death among American, a well a accounting for nearly 85 percent of the nation health pending. 1,2 In 21, the United State (US) pent almot 18 percent of it Gro Dometic Product on health care much more than any other country yet ranked 42nd in life expectancy at birth. 3-5 Three modifiable health rik behavior lack of phyical activity, poor nutrition, and tobacco ue caue much of the illne, uffering, and early death related to chronic dieae. 6,7 In fact, the World Health Organization report that at leat 8 percent of heart dieae, troke, and type 2 diabete and over 4 percent of cancer could be prevented by improving thee health behavior. 8 Preventing dieae, or it progreion, and injury i the mot cot-effective and practical way to promote population health, but too often the American health care ytem focue little effort on health promotion and dieae prevention. 9 A 21 tudy found that adopting 2 preventive ervice including tobacco ceation creening, alcohol abue creening, and daily apirin ue could avert the lo of more than 2 million life-year annually and ave over $3 billion. 1 Another analyi found that the adoption of elect community-baed dieae prevention program could yield a net aving of nearly $18 billion annually in 1 to 2 year. 9 The California Department of Health Care Service (DHCS) operate Medi-Cal, the tate Medicaid program. Medi-Cal ha the larget number of beneficiarie of any tate and began enrolling member in managed care ome 3 year ago for the purpoe of delivering more coordinated health ervice and emphaizing primary and preventive care. Today, 7 percent of the approximately 11 million member are enrolled in ome form of Medi-Cal 141

142 Managed Care Plan (MCP). Thi proportion i expected to increae to 8 percent by 215 (DHCS Office of Public Affair, communication, July 17, 214). The MCP are under contract with DHCS to provide a range of creening, preventive, and medically neceary diagnotic and treatment ervice, a well a to deliver health promotion intervention that are effective in achieving behavior change and poitive health outcome Depite uch contract requirement, little i known about the characteritic and effectivene of health promotion intervention delivered to Medi-Cal member. A part of a department-wide quality improvement initiative, an aement of the MCP wa conducted in 213 to: 1) inventory health promotion intervention offered to Medi-Cal member in the area of healthful eating, phyical activity, alcohol and drug abue prevention, breatfeeding, athma management, and prevention and management of cardiovacular dieae, type 2 diabete, and obeity; 2) identify attribute of health promotion intervention that MCP judged to have the greatet impact on their Medi-Cal member; and 3) determine the extent to which health plan referred Medi-Cal member to community aitance program and ponored health-promoting community activitie, including thoe addreing the ocial determinant of health. 14,15 Method Survey Repondent One lead health educator from each of the 21 contracted MCP wa recruited to complete the aement. All thee health educator provided overight and had primary reponibility for implementation of health promotion intervention within their plan. 142

143 Survey Survey Development and Pilot Tet. A 19-item urvey intrument wa developed to addre the tudy aim. The urvey can be found in the Appendix, which i available at Tobacco ue ceation intervention were excluded from the aement becaue they were the ubject of a targeted urvey in January Each health behavior wa elected for the urvey becaue it i an important contributor to reducing the rik of morbidity and mortality (e.g., healthful eating, phyical activity, alcohol abue prevention, and breatfeeding). 6,7,17 Each dieae topic wa included becaue it i a common, cotly, and largely preventable chronic condition (e.g., cardiovacular dieae, type 2 diabete, and obeity). 18 Two other topic - drug abue prevention and athma management - were included becaue the MCP medical director and health educator, repectively, requeted their incluion during urvey development and pilot teting. The MCP contract call for the implementation of rik reduction, healthful lifetyle, and elf-care management intervention covering all topic in thi tudy A draft urvey wa reviewed by four population health expert, who compared the quetion with the tudy aim to etablih face validity. The urvey intrument wa alo reviewed by the MCP medical director, who uggeted no major change. Additionally, the urvey wa pilot-teted with the 21 MCP lead health educator to ae eae of ue, comprehenion, readability, and incluion of major health topic. Minor emantic and formatting change were made baed upon their feedback. Meaure. The urvey contained detailed intruction and a mix of open- and cloeended quetion with multiple repone categorie. An other, pleae pecify repone wa included in all quetion with multiple repone categorie to enable repondent to provide additional data. An initial et of quetion wa aked to decribe the adminitrative overight of 143

144 each MCP health education ytem. Repondent were aked to provide a brief decription of their health education ytem and pecify the number of full-time equivalent dedicated to health education. The next et of quetion evaluated how the MCP encouraged healthful lifetyle behavior and prevented and managed pecific chronic dieae. Quetion meaured whether the plan conducted any intervention to promote healthful living and dieae prevention/management and how DHCS could complement their effort. The remaining quetion for each behavior and dieae prevention/management category focued on intervention that the MCP judged to have the greatet impact on their Medi-Cal member. Thee intervention are referred to a the Greatet Impact Health Promotion Intervention (GIHPI). The repondent were aked to provide the goal and a decription of each GIHPI per behavior and dieae prevention/management category, hour of education provided, how effectivene wa meaured, documented outcome among thoe who participated, and the number of Medi-Cal member reached from January through December 212. The final et of quetion aked whether the MCP referred Medi-Cal member to community aitance program, uch a California Supplemental Nutrition Aitance Program (known a CalFreh), Special Supplemental Nutrition Program for Women, Infant, and Children (WIC), Temporary Aitance for Needy Familie, houing and utility aitance, and education and job training program, among other, to addre the ocial determinant of health. 19 Repondent were alo aked whether their health plan ponored activitie to foter healthy communitie, uch a phyical activity event, food pantrie, farmer market, and community garden, among other. 144

145 Data Collection An online urvey wa adminitered to the health educator in January 213. The health educator were given four week to complete the urvey, and 2 of the 21 MCP ubmitted urvey repone. Repeated attempt to get the one outtanding urvey were unucceful. The health educator were intructed to obtain input from their medical director and other taff to enure complete repone. Seventy percent of repondent obtained input from their MCP leaderhip and program taff. Data Analyi Online urvey repone were downloaded into an Excel file, and then exported into SAS/STAT tatitical oftware verion 9.3 for analyi. 2 All repondent and MCP name were removed from the dataet before analyi and only aggregate analye were conducted to protect privacy. Decriptive tatitic were ued to analyze quantitative data. Qualitative data, which included program decription and meaure ued to gauge the effectivene of the GIHPI, were each grouped into a lit of common attribute by two reviewer (DB and NDK). One MCP provided program decription that were unclear acro all behavior and dieae prevention/management categorie; thee decription were excluded from the analyi. Seven decription of the GIHPI were excluded due to inufficient data. Likewie, alcohol and drug abue prevention and cardiovacular dieae management decription were excluded due to low repone rate. The reviewer compared their lit and agreed to a final lit of attribute. Each reviewer independently aigned elected attribute to each program decription and meaure of effectivene, and then the reviewer compared and dicued their final aignment. Kappa tatitic were ued to meaure inter-rater reliability, which ranged from.93 to

146 Reult Table 1 how the characteritic of MCP that participated in the tudy. There wa a wide range in the number of countie erved, number of member enrolled in the MCP, number and percent of enrolled Medi-Cal member, and number of full-time equivalent health educator per MCP. Table 1. Medi-Cal managed care plan characteritic (N=2) No. of No. of all No. of Medi- % of No. of full-time California member Cal member Medi-Cal equivalent countie erved enrolled per enrolled per member health educator by the MCP MCP MCP enrollment per per MCP MCP 1 to 11 7, to 6,85,+ 3,4 to 1,,+ <1% to 1% 1 to 45 Medi-Cal Managed Care Plan (MCP) 146

147 General and greatet impact health promotion intervention Figure 1 preent the ditribution of general intervention and GIHPI for each behavior and dieae prevention/management category. Repondent were aked whether their plan conducted an intervention in each category (i.e., general intervention). There wa variation in the number of repondent reporting the delivery of thee intervention, with all MCP tating they provided healthful eating and phyical activity intervention to Medi-Cal member and only 11 noting they offered pecific cardiovacular dieae management and alcohol abue prevention program. A hown in Figure 1, compared to the general intervention, fewer health plan reported GIHPI. There wa variation in the number of repondent reporting thee intervention, with 18 MCP tating they offered high-impact healthful eating intervention and only 4 indicating they offered high-impact alcohol abue prevention program. 147

148 No. of health plan decribing general and greatet impact health promotion intervention Figure 1. Ditribution of general and greatet impact health promotion intervention by behavior and dieae prevention/management category (N=2) General Intervention Greatet Greatet Impact Health Impact Health Promotion Promotion Intervention Intervention a 4 2 a See method ection for definition. Behavior and dieae prevention/management category 148

149 Table 2 diplay the attribute of the GIHPI by behavior and dieae prevention/management category. Multiple intervention attribute were decribed, with educational material, one-on-one education, and group cla(e) repreenting the top three mot frequently cited delivery method acro all categorie. In addition, 74 percent of the GIHPI contained two or more attribute. The majority (55%) of the GIHPI were aimed at tertiary prevention, followed by econdary prevention (25%) and primary prevention (2%). There wa a wide range in the number of hour of education provided by the intervention (ranging from 15 minute to 48 hour); the median wa 2.8 hour. There wa alo a wide range in the number of Medi-Cal member that participated in the intervention (3 to 44,829) from January through December 212; the median number of member reached wa 419. Table 3 how the meaure that were ued to gauge the effectivene of the GIHPI by behavior and dieae prevention/management category. Sixty-five percent of the MCP that decribed intervention tated how they meaured effectivene. The top three mot frequently cited meaure acro all categorie were behavior change (e.g., change in dietary intake and phyical activity), knowledge, and improved dieae management manifeted by change in clinical meaure and laboratory value. When aked how DHCS could complement the MCP health promotion intervention, 39 percent of the plan uggeted that DHCS provide bet practice guideline, hare effective intervention, and pecify the level of intervention required to meet contractual requirement. In addition, 18 percent recommended the proviion of material that are culturally, linguitically, and educationally-appropriate for Medi-Cal member 149

150 Table 2. Attribute of greatet impact health promotion intervention by behavior and dieae prevention/management category Attribute Healthful Phyical Breat- Over- CVD Type 2 Weight Diabete Athma eating activity feeding weight/ prev. diabete mgmt. mgmt. mgmt. obeity prev. prev. n=18 n=15 n=12 n=17 n=9 n=12 n=14 n=14 n=12 No. % No. % No. % No. % No. % No. % No. % No. % No. % Educational 6 33% 6 4% 8 67% 6 35% 3 33% 4 33% 5 36% 6 43% 3 25% material One-on-one 5 28% 5 33% 7 58% 5 29% 3 33% 6 5% 4 29% 4 29% 6 5% education Group cla(e) 9 5% 3 2% 1 8% 1 59% 3 33% 6 5% 5 36% 2 14% 1 8% Referral to 7 39% 5 33% 4 33% 8 47% 2 22% 1 8% 7 5% 4 29% 1 8% clinical reource Health rik 7 39% 3 2% % 6 35% 3 33% 4 33% 4 29% 5 36% 5 42% 15

151 appraial, creening Dieae 2 11% 2 13% 1 8% 2 12% 1 11% 6 5% 5 36% 7 5% 4 33% management, elfmanagement tool Incentive for 3 17% 5 33% 1 8% 4 24% 1 11% 1 8% 3 21% 2 14% 1 8% member Health coaching 2 11% 4 27% % 3 18% 1 11% % 3 21% % % Referral to 1 6% 3 2% 2 17% 3 18% % % 3 21% % % community reource Cae % % 2 17% % 2 22% 1 8% % 1 7% 5 42% management Reource for 1 6% % 2 17% % % % 1 7% 1 7% 2 17% 151

152 provider Incentive for % % % % 1 11% 1 8% % % % provider Prev. = Prevention; Mgmt. = Management; CVD = Cardiovacular Dieae Note. Cardiovacular dieae management and drug and alcohol abue prevention were excluded due to low repone rate. 152

153 Table 3. Meaure to gauge effectivene of greatet impact health promotion intervention by behavior and dieae prevention/management category Meaure Healthful Phyical Breat- Over- CVD Type 2 Weight Diabete Athma eating activity feeding weight/ prev. diabete mgmt. mgmt. mgmt. obeity prev. prev. n=14 n=9 n=8 n=8 n=6 n=8 n=3 n=12 n=12 No. % No. % No. % No. % No. % No. % No. % No. % No. % Behavior change 7 5% 5 56% 1 13% 4 5% % 1 13% 1 33% 1 8% 1 8% Knowledge 5 36% 2 22% 1 13% 2 25% 2 33% 2 25% 2 67% 2 17% 1 8% Improved dieae % % % % 2 33% 3 38% % 6 5% 5 42% management a Patient 5 36% 4 44% % % 1 17% 1 13% % 2 17% 1 8% atifaction Participation 1 7% 4 44% 2 25% 3 38% % 1 13% 1 33% % 1 8% No. of member 3 21% 2 22% % 4 5% % % 2 67% % % 153

154 receiving coaching/counel ing Healthcare % % 1 13% % 2 33% 3 38% % 3 25% 2 17% Effectivene Data and Information Set 1 7% % 1 13% 3 38% 1 17% 1 13% 1 33% 1 8% 1 8% Attitude, elfefficacy Hopital % % % % 2 33% 2 25% % 2 17% 1 8% utilization Change in body 3 21% 1 11% % 2 25% % % 1 33% % % ma index No. creened % % % 1 13% 1 17% 1 13% 1 33% 2 17% % Frequency of 1 7% % 1 13% 1 13% % % 1 33% 1 8% % clinical 154

155 viit/acce to clinical ervice No. material % % 2 25% % % % % 1 8% % requeted/ ditributed Self-reported % % % % % % % 2 17% 1 8% health tatu/dieae management Medication % % % % 1 17% 1 13% % % % ue/compliance No. incentive % % 1 13% 1 13% % % % % % ditributed No repone a Change in clinical meaure, lab value Prev. = Prevention; Mgmt. = Management; CVD = Cardiovacular Dieae Note. Cardiovacular dieae management and drug and alcohol abue prevention were excluded due to low repone rate. 155

156 Community Connection Table 4 preent the number and percent of MCP referring Medi-Cal member to community aitance program. Seventy percent or more of the MCP reported referring Medi- Cal member to food and nutrition aitance, helter, utilitie, and financial upport ervice. Thirty-five percent or le of the MCP cited referral to education, employment, childcare aitance, and the 211 telephone line. The MCP were aked about the extent to which they ponored health-promoting community activitie. Sixty percent reported ponoring phyical activity event, uch a cycling, walking, and running event. Twenty-five percent ponored health fair and food pantrie, 2 percent inveted in farmer market, 1 percent upported community and chool garden, and 15 percent did not ponor community activitie. 156

157 Table 4. No. and % of Medi-Cal managed care plan referring Medi-Cal member to community aitance program (N=2) Name of aitance program No. and % of MCP referring Medi-Cal member to aitance program No. % Special Supplemental Nutrition Program for 18 9% Women, Infant, and Children (WIC) Food bank 17 85% Dometic violence helter 16 8% CalFreh (Supplemental Nutrition Aitance 16 8% Program) Houing aitance 15 75% Homele helter 14 7% Temporary Aitance for Needy Familie 14 7% (TANF) Utilitie aitance (e.g., electricity, home 14 7% heating, and phone ervice) Englih proficiency program 7 35% Job training and placement 6 3% Childcare aitance 6 3% Adult education/general Educational 4 2% Development (GED) tet preparation 157

158 Vocational education program 4 2% 211 telephone line 1 5% Do not refer to community aitance program 1 5% No repone 1 5% Medi-Cal Managed Care Plan (MCP) 158

159 Dicuion Medi-Cal MCP have had a long-tanding contractual requirement to include health promotion and dieae prevention intervention among their member benefit; however, little i known about the pecific health promotion intervention that are offered or how they are implemented. Thi tudy ought to inventory the health promotion intervention offered by MCP to Medi-Cal member, identify attribute of the GIHPI, and determine the extent to which MCP refer Medi-Cal member to community aitance program and invet in healthpromoting community activitie. There wa wide variation in the delivery of general intervention and GIHPI acro behavior and dieae prevention/management categorie. The variability in the general intervention wa not conitent with MCP contract language. Each MCP contract call for the implementation of rik-reduction, healthful lifetyle, and elf-care management educational intervention and alo pecifie particular rik factor and dieae, all of which were topic of thi invetigation Several factor may explain the variation between contract expectation and practice. Firt, the health plan may have emphaized elect behavior and dieae prevention/management topic due to local need and legitimate difference in the population erved; although thi would eem unlikely to explain the degree of variation that wa found. Second, ue of a tandardized, valid health rik appraial wa not required of the health plan, making it difficult to judge rik and tailor intervention delivery, accordingly. Third, no performance monitoring and evaluation ytem ha been ued to track health promotion intervention, thereby confounding accountability. Multiple key attribute were identified for the GIHPI. Providing educational material, one-on-one education, and group cla(e) were the top three delivery method. Nearly two- 159

160 third of the MCP that decribed thee intervention tated how they meaured effectivene, with behavior change, knowledge gain, and improved dieae management repreenting the mot commonly employed meaure. The majority of the intervention focued on tertiary prevention, median intervention hour were limited, and median Medi-Cal member participation wa modet. Several of our finding are conitent with thoe of Schauffler and Chapman aement of coverage, utilization, and evaluation of health-promoting program among California commercial health plan over 15 year ago. They found that a majority of Health Maintenance Organization (HMO) ued brochure to addre a variety of health iue and offered free educational clae. Outcome meaure ued by HMO to evaluate the impact of their program included member atifaction urvey, participation rate, behavior change, and change in health tatu. They alo found extremely low patient participation rate in health plan-ponored health promotion program. 21 While traditional health education program are important, they often have limited impact on health behavior or long-term health tatu by themelve. They are more effective when they are coupled with intervention that addre the many determinant of individual and population health. 22,23 A growing body of reearch how that the health care delivery ytem focu on treating medical condition typically overhadow and neglect the ignificant role that ocial need uch a food ecurity, afe houing, and employment aitance play in health, epecially among vulnerable population. 24 Encouragingly, health care ytem appear to be increaingly intereted in addreing health, including dieae prevention, through communitybaed prevention and ocial ervice. 9,24,25 Thi may be driven, in part, by growing evidence of the cot-effectivene of uch ervice. 9 16

161 Our tudy found mixed reult in MCP effort directed toward upporting or improving the ocial determinant of health and inveting in health promoting community activitie. The majority of MCP referred Medi-Cal member to food aitance, helter, utilitie, and financial upport ervice, though referral to education and job-related reource were limited. In addition, the majority of MCP inveted in ome type of phyical activity event, and a few ponored health fair, food pantrie, farmer market, and community and chool garden. Fifteen percent of MCP did not invet in any community activitie. Limitation There were everal limitation to thi tudy. Firt, repone to the quetion were elfreported and ubject to poible comprehenion, memory, and other reporting error. Second, the MCP are under contract with DHCS; therefore, the repone may reflect a ocial deirability bia. Third, the GIHPI were elf-determined by the MCP, o repondent may have ued different criteria to judge which intervention to decribe. Fourth, to maintain a reaonable number of urvey quetion, ome behavior and dieae prevention/management categorie were excluded from the aement. In pite of thee limitation, the overall pattern of practice in health promotion were triking and conitent with a imilarly deigned tudy of commercial health plan in California. 21 Concluion The finding of thi urvey indicate that there are ubtantial opportunitie to improve the effectivene of health promotion ervice offered to Medi-Cal member. The wide variability in the delivery of thee intervention trongly ugget that greater tandardization of program offering would materially improve the conitency of ervice delivery. Etablihing an evidence-baed meaurable conenu tandard for prevention program would likely facilitate 161

162 uch tandardization. Thirty-nine percent of MCP called for DHCS to provide bet practice guideline, hare effective intervention, and pecify the level of health promotion ervice required to meet contractual agreement. With the aitance of an expert committee and takeher, we plan to explore key factor for improving the Medi-Cal ytem in the near-term. Thi further exploration will include determining: 1) how the MCP ae health rik among Medi-Cal member and how rik-related data are ued to inform intervention delivery; 2) the feaibility of etting quality improvement target, tarting with the leading caue of preventable mortality and illne; 26 3) method to maximize the delivery of the US Preventive Service Tak Force A and B recommendation and other evidence-informed bet practice intervention; 27 4) opportunitie to enure that health care and community prevention effort are available, integrated, mutually reinforcing, and addre the ocial determinant of health; 25,28 and 5) the feaibility of implementing a monitoring ytem for tracking the delivery and performance of health promotion intervention

163 Reference 1. Heron M. Death: Leading caue for 21. Natl Vital Stat Rep. 213;62(6): Publihed December 2, 213. Acceed May 23, Anderon, G. Chronic Care: Making the Cae for Ongoing Care. Princeton, N J: Robert Wood Johnon Found; Acceed May 22, Health expenditure, total (% of GDP). The World Bank Group Web ite. Acceed July 14, Life expectancy at birth, total (year). The World Bank Group Web ite. Acceed July 14, Central Intelligence Agency. Country comparion: life expectancy at birth. The World Factbook Web ite. Publihed 213. Acceed June 17, Mokdad AH, Mark JS, Stroup DF, Gerberding JL. Actual caue of death in the United State, 2. JAMA. 24;291(1): doi:1.11/jama McGinni JM, Foege WH. Actual caue of death in the United State. JAMA. 1993;27(18): doi:1.11/jama World Health Organization. Preventing Chronic Dieae: a vital invetment. Geneva: World Health Organization; Acceed July 15,

164 9. Levi J, Segal LM, Juliano C. Prevention for a Healthier America: Invetment in Dieae Prevention Yield Significant Saving, Stronger Communitie. Wahington, DC: Trut for America Health; Acceed June 18, Macioek MV, Coffield AB, Flottemech TJ, Edward NM, Solberg LI. Greater ue of preventive ervice in US health care could ave live at little or no cot. Health Aff. 21;29(9): doi:1.1377/hlthaff California Department of Health Care Service. County Organized Health Sytem Boilerplate Contract. California Department of Health Care Service Medi-Cal Managed Care Boilerplate Contract. Publihed March 213. Acceed May 13, California Department of Health Care Service. Geographic Managed Care Boilerplate Contract. California Department of Health Care Service Medi-Cal Managed Care Boilerplate Contract. Publihed March 213. Acceed May 13, California Department of Health Care Service. Two-Plan Boilerplate Contract. California Department of Health Care Service Medi-Cal Managed Care Boilerplate Contract pdf. Publihed March 213. Acceed May 13,

165 14. Backman, D. Kizer, K. Medi-Cal Quality Improvement Program Firt Annual Report to the Department of Health Care Service. February %2(Page).pdf. Acceed September 9, Backman, D. Kizer, K. Medi-Cal Quality Improvement Program Second Annual Report to the Department of Health Care Service. December Acceed September 9, American Lung Aociation. State of Tobacco Control 213 Report. New York, NY. Hard Copy Printing. January Ip S, Chung M, Raman G, et al. Breatfeeding and Maternal and Infant Health Outcome in Developed Countrie. Evidence Report/Technology Aement, No Rockville, MD: Agency for Healthcare Reearch and Quality; Acceed Center for Dieae Control and Prevention. The Power of Prevention: Chronic Dieae the public health challenge of the 21 t century. Atlanta, GA: US Health and Human Service Department; Marmot M, Friel S, Bell R, Houwelling TAJ, Taylor S. Cloing the gap in a generation: Health equity through action on the ocial determinant of health. Geneva: Commiion on Social Determinant of Health Final Report, World Health Organization: Acceed May 2, SAS/STAT oftware (for Window). Verion 9.3. Cary, NC: SAS Intitute Inc.;

166 21. Schauffler HH, Chapman SA. Health promotion and managed care: Survey of California health plan and population. Am J of Prev Med. 1998;14(3): Barr VJ, Robinon S, Marin-Link B, et al. The expanded Chronic Care Model: An integration of concept and trategie from population health promotion and the Chronic Care Model. Hop Q. 23;7(1): Braveman PA, Egerter SA, Mockenhaupt RE. Broadening the focu: The need to addre the ocial determinant of health. Am J Prev Med. 211;4(1S1):S4-S18. doi: 1.116/j.amepre Fenton. Health Care Blind Side: The Overlooked Connection between Social Need and Good Health. Princeton, NJ: Robert Wood Johnon Foundation; 211: Publihed December 211. Acceed May 16, US Department of Health and Human Service. HHS Strategic Plan FY Acceed June 19, US Department of Health and Human Service. National Strategy for Quality Improvement in Health Care; Publihed 211. Acceed May 16, US Preventive Service Tak Force. USPSTF A-Z Topic Guide. Updated May 214. Acceed June 16,

167 28. National Prevention Council. National Prevention Strategy. Wahington, DC: US Department of Health and Human Service, Office of the Surgeon General; Acceed May 16,

168 Appendix F: Pediatric Athma Preentation 168

169 Population Health Conideration for Pediatric and Adolecent Athma in California Finding from the California Health Interview Survey Ulfat Shaikh, MD, MPH Robert S. Byrd, MD, MPH 169

170 Background: Pediatric Athma Increaingly prevalent, cotly, chronic condition Rate in US increaing over 3 year ~ 1% of U.S. children currently have athma (CDC) Increaed athma everity and poor control aociated with Poor adherence to athma management plan Not taking precribed medication Not filling precription 17

171 Background: Recommendation National Athma Education and Prevention Program guideline Annual influenza immunization Environmental tobacco moke expoure Tobacco ue aociated with increaed incidence of ED viit and lifethreatening athma exacerbation (Cook and Stachan, 1999) Children who live with moker have longer recovery time when hopitalized for athma (Abulhon, 1997) Peritent athma: Daily controller medication Optimal management enable econdary and tertiary prevention 29% of athma medication precribed by allergy pecialit to low-income children with uncontrolled athma never filled. More recue medication precription filled than written by pecialit (Bollinger ME et al. Ann Allergy Athma Immunol. 213) 171

172 Objective To identify population health conideration related to pediatric athma in California to inform development of quality improvement intervention 172

173 Method California Health Interview Survey , mot recent ample Larget tate health urvey in U.S. UCLA Center for Health Policy Reearch, California Department of Health Care Service, California Department of Public Health Random digit dial telephone urvey Public ue dataet releaed every 2 year 44, houeh from all 58 California countie 173

174 174

175 Method Generalizability Generalizable at tate and county level, rigorou ampling technique Minimum target for each geographic area for tatitically repreentative ample Adminitered in 5 language; ethnic minority group overampled to enure repreentative ample Reliability Large ample Computer randomly draw telephone number from each geographic area ampled with minimum number of people to include 175

176 Repone Rate, CHIS Screener repone rate: Landline ample 31.6% Cell phone ample 33. Extended interview repone rate for landline ample Child 73.2% Adolecent 42.7% Extended interview repone rate for cell ample Child 73% Adolecent 42.5% Overall repone rate (multiplying creener and extended rate) Landline ample Child 23.1% Adolecent 13.5% Cell ample Child 24.1% Adolecent 14% 176

177 Incluion Criteria Age: Children age 2-17 year Dependent variable: Ever diagnoed with athma, currently have athma, athma epiode CHIS quetion Ha a doctor ever t you that Doe he/he till have athma? ha athma? 177

178 Independent Variable Demographic: Urban/rural reidence, race/ethnicity Health care acce: Delay in receiving needed care, delay in filling precription medication Athma control: Health tatu, athma ymptom, ED ue, mied chool day During the pat 12 month, ha he/he had an epiode of athma or an athma attack? During the pat 12 month, how often ha had athma ymptom uch a coughing, wheezing, hortne of breath, chet tightne, or phlegm? During the pat 12 month, ha had to viit a hopital becaue of hi/her athma? I now taking a daily medication to control hi/her athma that wa precribed or given to you by a doctor? (If needed, ay: Thi include both oral medicine and inhaler. Thi i different from inhaler ued for quick relief) During the pat 12 month how many day of day care or chool did due to mi athma? 178

179 Reult 179

180 Prevalence Etimate 5,11, children 2-17 year of age live in California 15.9% (population etimate 1,312,) received diagnoi of athma by phyician 68.4% of thee children reported to currently have athma 11% (population etimate 897,) of children and adolecent in California currently have diagnoi of athma 18

181 Percent diagnoed with athma Higher rate of athma in adolecent compared to young children 2% 18% 16% Age Group 16.9% 16% 18.8% 14% 12% 11% 1% 8% 6% 4% 2% % 2-4 yr 5-11 yr yr yr Age Group 181

182 Higher rate of athma in male compared to female children (56% v 44%) Male Female 44% 56% 182

183 Rate of pediatric athma are comparable in urban and rural area (16% v. 14%) 5 Percent Rural and urban - Clarita definition (2 level) % [VALUE]% [VALUE]% Urban Rural All Percent Rural and urban - Clarita definition (2 level) 183

184 % Diagnoed With Athma Highet athma dieae burden in Aian and African American children and adolecent 5 Race / Ethnicity Latino AI/AN Aian AA White Other/Two or More 184

185 % diagnoed with athma Childhood athma in California not mainly a condition of the poor. Rate ame in -99% FPL and 3% FPL. 5 Poverty Level 212 FPL- Family of 4 1% $23,5 2% $46,1 3% $69, % FPL 1-199% FPL 2-299% FPL 3% FPL and above 185

186 Percentage of 2-17 year 29.5% of children diagnoed with athma report fair/poor health tatu compared to 3% of children in the general population Health Statu Excellent Very Good Good Fair Poor All Children Athma Dx 186

187 17.4% mied >3 day of chool in pat 12 month due to athma School day mied due to athma in pat 12 month day 1 or 2 day 3 or 4 day 5 to 1 day 11 day or more 187

188 88% of current athmatic had athma ymptom within pat 12 month Had athma ymptom within pat 12 month (current athmatic) Percentage 95% Confidence Interval Population Etimate Had athma ymptom Did not have athma ymptom 88.% , 12.% , Total 1.% 897, 188

189 Majority (93.4%) of current athmatic had a uual ource of care Have uual place to go to when ick or need health advice Ha uual ource of care Percentage 95% Confidence Interval 189 Populatio n Etimate 93.4% , Type of uual ource of care Doctor' office/hmo 65.7% , Community clinic/government clinic/community Emergency hopital room/urgent care Some other place/no one place Doe not have uual ource of care 25.6% , 1.2%* ,.8%* , 6.6% ,

190 Athma Epiode / Attack in Pat 12 Compared to children with employment-baed, private inurance and CHIP, more children with Medicaid had athma epiode /attack in pat 12 month. Children with Medicaid and other public inurance fared the ame a the uninured Uninured Medicaid CHIPdadadddd Other Public Employment-Baed Privately Purchaed 19

191 More than a third of current athmatic viited an emergency room in pat 12 month 38.5% (95% C.I ) Population etimate 345, 191

192 ED Ue % Children with Medicaid nearly twice a likely to have ued emergency ervice in pat year compared to children with other inurance type. Higher ED ue in Medicaid compared to uninured Uninured Medicaid CHIP Other publichgjhj; h Employment-Baed 15 Privately Purchaed

193 Delay / not receiving needed care occurred, although were uncommon Delayed or didn't get other medical care 7.8% (95% C.I ) Population etimate 7, Delayed or didn't get precription medicine 9.5% (95% C.I ) Population etimate 85, 193

194 A third of current athmatic ue daily medication to control athma Take daily medication to control athma 38.5% (95% C.I ) Population etimate 346, 194

195 % of current athmatic who ue daily medication to control athma Children with Medicaid likelier to ue daily medication to control athma than children with private inurance or uninured Uninured 3 Medicaid CHIP Other Public 2 Employment-Baed Privately Purchaed

196 17.4% mied >3 chool day due to athma in pat 12 month 8 Percentage of current athmatic or 2 3 or 4 5 to or more Percentage of current athmatic 196

197 No School Day Mied Due to Athma in Lat 12 Compared to children with employment-baed, private inurance, CHIP, and thoe who are uninured, children with Medicaid mi more day of chool due to athma Uninured Medicaid CHIP Other Public Employment-Baed Privately Purchaed 1 197

198 Approximately half did not received influenza vaccination in pat 12 month Children 2-11 year influenza vaccination data only available for children and adult, not adolecent 47.4% (95% C.I ) of children with athma did not receive flu vaccine Population etimate 244, 5.9% (95% C.I ) of children in general population did not receive flu vaccine in pat 12 month. Population etimate 2,62, 198

199 Environmental tobacco moke expoure for current athmatic the ame a for children in the general population Adult() moke indoor at home Current athma 2.2% (95% C.I ) Population etimate 19, All children age % (95% C.I ) Population etimate 224, 199

200 % adult who moke indoor Adult in children home who moke indoor declining, epecially for children with athma and children with Medicaid All Current Athma Medicaid 2

201 Environmental tobacco moke expoure Approx. 2.5% for current athmatic a well a general population of children Declining ince 23 Parental elf-report; poible underreporting; ocial deirability to underreport tobacco expoure may be increaed if child ha athma Serum and alivary cotinine level in children admitted with athma aociated with readmiion, but caregiver report of tobacco expoure wa not Howrylak JA et al, Pediatric Feb

202 Limitation Very large urvey, however, reult only generalizable to California Sample doe not include people without telephone Some tribe and ubpopulation have very mall ample ize that allow only minimal analye Overall repone rate low, but comparable to other imilar urvey Unable to combine multiple year due to change in quetion and data collection methodology 22

203 Implication Children and adolecent with athma, epecially thoe with Medicaid, face population-level challenge High ED ue (depite daily controller medication ue), mied chool day, low influenza vaccination rate 23

204 Implication California Medicaid (Medi-Cal) change A of 213, 8.5 million people enrolled Under ACA Medi-Cal expanion in 214 make additional 1-2 million eligible Fee-for-ervice to Medi-Cal Managed care tranition Nearly all children and adolecent in ample had regular acce to medical care; likely to increae under ACA Whole peron care: Health care organization addre ocial determinant of health Inform development of population-level health care quality improvement intervention, ep. primary care baed 24

205 Opportunitie for Intervention Primary care Enure regular/proper ue of controller medication in peritent athma If acute viit, chedule follow-up PCP viit to reae athma tatu Home athma management plan updated frequently Increae annual influenza immunization rate for all children, epecially thoe with athma Team-baed care coordination Involve pharmacit, nure educator, PCP and pecialit in teaching parent accurate medication adminitration Pharmacit track medication ue and refill. Notify PCP when patient need < 2 recue inhaler /year 25

206 Potential Intervention Public health Increae annual influenza immunization rate for all children, epecially thoe with athma School Involvement of chool nure Potential area for future Medicaid managed care QI project 26

207 27

208 Appendix G: Medi-Cal Performance Adviory Committee Agenda, January

209 MEDI-CAL PFORMANCE ADVISORY COMMITTEE Intitute for Population Health Improvement Conference Call: , Pacode: Wedneday, January 29, :am-12:pm AGENDA 11: 11:5 AM I. Welcome and Opening Comment Kenneth W. Kizer, MD, MPH, Director Intitute for Population Health Improvement 11:5 11:25 AM II. DHCS Update and Dicuion Neal Kohatu, MD, MPH, Medical Director California Department of Health Care Service - DHCS Quality Strategy - Super-utilizer - Reducing Opiate Overdoe - Reducing Overue of Service (RWJ Grant) - Palliative Care (RWJ Grant) - Diparitie/Inequitie Report - Adult Medicaid Quality Grant 11:25 11:5 AM III. March Meeting Dicu Potential Meeting Topic and Next Step All 11:5 AM 12: PM IV. Wrap Up Kenneth W. Kizer, MD, MPH, Director Intitute for Population Health Improvement 29

210 Appendix H: Medi-Cal Performance Adviory Committee Agenda, March

211 MEDI-CAL PFORMANCE ADVISORY COMMITTEE MEETING March 24, 214 Intitute for Population Health Improvement FSSB Claroom, Room nd Avenue Sacramento, CA AGENDA 1 11 V. Welcome and Opening Comment Kenneth W. Kizer, MD, MPH, Director, IPHI VI. Department of Health Care Service Update Toby Dougla, Director, DHCS Neal D. Kohatu, Medical Director, DHCS QI Training Ulfat Shaikh, MD, MPH; Clinical Quality Officer, IPHI/DHCS Opiate Management Anna Lee Deita, MD, MPH, Reearch Fellow; Samantha Pellon, Graduate Student Aitant, DHCS VII. Characteritic of Health Promotion Intervention Delivered by California Medi-Cal Managed Care Health Plan Preentation and Dicuion Deiree Backman, DrPH, MS, RD, Chief Prevention Officer IPHI/DHCS VIII. Medi-Cal Super-utilizer Preentation and Dicuion Kenneth W. Kizer, MD, MPH, IPHI Brian Paciotti, PhD, MS, Quality Scientit IPHI/DHCS Working Lunch 211

212 IX. Super-utilizer Preentation and Dicuion, continued X. Social Care and Vulnerability Index Preentation and Dicuion Beth McGlynn, PhD, Director, Center for Effectivene & Safety Reearch, Kaier Permanente Anna Roth, RN, MS, MPH, Chief Executive Officer Contra Cota Regional Medical Center and Health Center Break XI. Dicuion All XII. Wrap Up and Next Meeting Kenneth W. Kizer, MD, MPH, Director Intitute for Population Health Improvement 212

213 Appendix I: Champion for Change Rx Propoal 213

214 STATE LEVEL PROJECT SUMMARY FORM CHAMPIONS FOR CHANGE Rx: BUILDING A STRONG INTFACE BETWEEN COMMUNITY AND HEALTH CARE INTVENTIONS TO PREVENT AND REDUCE OBESITY AMONG LOW-INCOME CALIFORNIANS FFY Goal & Objective (See State Level Objective). 2. Project Title: Champion for Change Rx: Building a Strong Interface between Community and Health Care Intervention to Prevent and Reduce Obeity among Low-income Californian a. Related State Objective: Related State Objective include 1, 2, 3, and 4 b. Audience Gender: Female and Male Ethnicity: All race and ethnicitie Language: Englih and Spanih Age: Adult, epecially SNAP-Ed eligible women with children, and SNAP-Ed and Medi-Cal intermediarie who erve thi audience c. Focu on SNAP Eligible A decribed in the Narrative Summary below, a total of 3 focu group and 1 video ethnography eion will be conducted in northern, central, and outhern California with SNAP-eligible Medi-Cal member. Income eligibility will be vertified by the focu group and video ethnography participant at the time of recruitment. In addition, key informant interview will be conducted with repreentative from Medi-Cal managed care plan and provider group, a well a tate and Local Health Department leader. The Medi-Cal managed care plan repreentative and provider group will erve more than 5% SNAPeligible Medi-Cal member in their practice and the tate and Local Health Department leader will erve SNAP-eligible Californian a part of their routine cope of work. d. Project Decription Key Strategie: Key trategie will be baed upon the formative reearch reult of thi project. See the Narrative Summary below for a decription of Champion for Change Rx. Key Educational Meage: Key educational meage will be baed upon the formative reearch reult of thi project and will be conitent with the Nutrition Education and Obeity Prevention Program (NEOP) meage (e.g., childhood 214

215 obeity prevention, chronic dieae and obeity prevention, dietary quality, fruit and vegetable, healthy beverage promotion, healthier eating (general), cooking kill, phyical activity promotion (integrated with nutrition education), food hopping/preparation, and CalFreh promotion (brief promotional meage). See the Narrative Summary below for a decription of Champion for Change Rx. Intervention Site: Health care delivery organization and community ite will be identified baed upon the formative reearch. See the Narrative Summary below for a decription of Champion for Change Rx. Projected Number of Contact: Direct (unduplicated) Contact: 35 SNAP-Ed eligible Medi-Cal member reached through 3 focu group and 1 video ethnography eion in northern, central, and outhern California. See the Narrative Summary below for additional detail. Narrative Summary: Problem Statement The California Department of Health Care Service (DHCS) miion i to preerve and improve the health of all Californian by operating and financing program that deliver vital health care ervice to approximately 1.5 million individual including low-income familie and children, enior and peron with diabilitie, children in foter care, pregnant women, and thoe with certain dieae and condition. Thee ervice include medical, mental health, ubtance ue treatment, and long-term care. A part of DHCS commitment to deliver high-quality care, an aement wa conducted in 212 to inventory all Departmental quality improvement (QI) effort in the area of clinical care, health promotion and dieae prevention, and adminitration. 1 Although a wide variety of QI activitie wa reported in the area of clinical care and adminitration, little activity wa noted in the area of health promotion and dieae prevention. Mot notably, there wa an abence of QI activitie in the area of healthful eating, phyical activity, and obeity prevention depite the high rate of overweight and obeity among children (29.6%), adolecent (35.2%), and adult (65.7%) enrolled in the Department larget program, Medi-Cal. The reult of the aement provided a call to action to develop, implement, evaluate, and utain a comprehenive obeity prevention program that link the many facet of the health care delivery ytem to NEOP exiting community-baed effort. At thi time, unfortunately, there are no programmatic fund available for uch a program. Background DHCS program integrate a broad pectrum of care primarily via Medi-Cal, a federal/tate partnerhip erving individual and familie who meet defined eligibility requirement. Medi-Cal ervice are delivered by more than 4 215

216 hopital, approximately 13, doctor, pharmacit, dentit and other health care provider, and 21 managed care plan. Of the 1.5 million Medi-Cal member currently erved by DHCS, over 9.2 million (88%) have annual houeh income that are at or below 185% of the Federal Poverty Level. Thi income criterion i conitent with SNAP-Ed. To accelerate advancement in care, DHCS recently produced the Strategy for Quality Improvement in Health Care (Quality Strategy). 2 The Quality Strategy etablihe goal, prioritie, and guiding principle, a well a highlight exiting and emerging DHCS QI initiative to improve health and patient care, and reduce cot. It align with the National Strategy for Quality Improvement in Health Care 3 and reflect the bet evidence-baed practice known to date in the area of patient afety, care delivery, peron and family engagement, communication and coordination of care, prevention, healthy communitie, and elimination of health diparitie. Given the large number of SNAP-Ed eligible individual reached through Medi- Cal and DHCS newly-etablihed commitment to QI in the area of prevention and healthy communitie, DHCS i intereted in collaborating with NEOP to conduct formative reearch, develop, and then pilot tet a program to link obeity prevention effort among SNAP-Ed eligible Medi-Cal member in the health care etting with NEOP community-baed intervention. The purpoe of the program will be to reduce the rik and prevalence of overweight and obeity among SNAP-Ed eligible Medi-Cal member and reduce projected health care cot. DHCS received approval in FFY 214 for the initial phae of the project. Due to adminitrative delay in ecuring a igned Interagency Agreement (IA) between DHCS and the California Department of Public Health (CDPH), and a ubequent IA between DHCS and it partner, the UC Davi Health Sytem Intitute for Population Health Improvement (UCDHS IPHI), the project i expected to officially launch in July 214. Thu, the cope of work preented in thi propoal reflect many of the ame tak preented in the FFY 214 plan. The initial phae of the project will be to conduct formative reearch and develop the component of the pilot program from October 1, 214-September 3, 215, in collaboration with NEOP. The aim of the formative reearch and program development phae are to: Identify feaible, utainable, age- and culturally-appropriate obeity prevention approache in the health care etting that can be delivered to SNAP-Ed eligible Medi-Cal member; Identify teted NEOP/SNAP-Ed tool, reource, material, and communication method that can be applied to the health care etting; Identify efficient and effective way to drive SNAP-Ed eligible Medi-Cal member to participate in NEOP community-baed intervention where they 216

217 live, work, learn, worhip, play, make food and phyical activity deciion, and become involved in community empowerment effort. Develop and produce a pilot program and evaluation plan deigned to reduce the rik and prevalence of overweight and obeity among SNAP-Ed eligible Medi-Cal member and reduce projected health care cot. Begin developing the component of the pilot program in preparation for pilot program implementation and formal evaluation in FFY 216. Implementation Partner Thi propoal incorporate the complementary trength of three partner: CDPH, DHCS, and UCDHS IPHI. In July 27, the Department of Health Service plit into DHCS and CDPH to enable each department to focu on health care and public health, repectively. However, both department are dedicated to improving the health of all Californian and work cloely on pecific area uch a: chronic dieae prevention and management; elimination of health diparitie; advancing prevention; and building healthier communitie. In 211, DHCS initiated a five-year, IA with UCDHS IPHI to provide technical aitance, including on-ite taffing, to help the Department advance the Triple Aim of: improved health, improved care, and reduced cot. IPHI i directed by Kenneth W. Kizer, MD, MPH, Ditinguihed Profeor, UC Davi School of Medicine and the Betty Irene Moore School of Nuring. Dr. Kizer i an internationally-known expert in public health, health care quality, and ytem redeign and a member of the Intitute of Medicine. He i credited with the tranformation of the Veteran Adminitration Health Care Sytem into one of the nation preeminent health ytem. Prior to thi work, Dr. Kizer erved a Director of the California Department of Health Service where he fotered the development of the 5-a-Day Program and the internationally-known Tobacco Control Program. Thi propoal include IPHI a the ubcontractor with DHCS. Under Dr. Kizer leaderhip, IPHI taff are highly qualified to ait DHCS in carrying out the cope of work for thi project, which require expertie in population health, ytem redeign, program development, and evaluation. DHCS and UCDHS IPHI will coordinate effort, a appropriate, with other NEOP implementing agencie, including the California Department of Aging and Food and Agriculture, and UC CalFreh. In FFY 214, DHCS alo met with the Chief Executive Officer of the Contra Cota Regional Medical Center and Contra Cota Health Care Plan, and Director of Contra Cota Health Service and the Public Health Department to explore their joint interet in erving a pilot tet partner for Champion for Change Rx. Thi group wa elected a potential pilot tet partner becaue they have coniderable influence on the health care and public health delivery ytem, work well together, are dedicated to and inveting in population health improvement among SNAP-Ed eligible Medi-Cal member, and are willing to try new and refine exiting approache to improve health, provide better care, and reduce cot. The regional medical center and 217

218 it clinic are alo uing Electronic Health Record, which will ait with clinical data gathering during the future teting phae of thi project. All partie expreed interet in the pilot program and agreed to partner, upport, and be actively involved in the implementation and teting of a future pilot program in Contra Cota County. Scope of Activitie Tak 1 In collaboration with NEOP tate and Local Health Department taff, identify and compile a lit of teted NEOP, MyPlate, and other SNAP-Ed tool, material, and community-baed intervention approache that could apply to the health care etting and be implemented widely with Medi-Cal member uing DHCS ditribution channel, including hopital, clinic, pharmacit, and managed care plan. Date: October-December 214 Tak 2 Conduct a minimum of 25 key informant interview with repreentative from Medi-Cal managed care plan and provider group, a well a NEOP tate and Local Health Department leader to identify feaible, utainable, age- and culturally-appropriate obeity prevention approache in the health care etting and identify way to link Medi-Cal member with NEOP community-baed approache where they live, work, learn, worhip, play, make food and phyical activity deciion, and become involved in community empowerment effort. A broad array of health care, community-baed, and technological approache will be vetted with the key informant including, but not limited to: Firt Lady Michelle Obama Let Move Health Care Provider, 4 the American Medical Aociation expert committee recommendation on the aement, prevention, and treatment of child and adolecent overweight and obeity, 5 the Let Go! Childhood Obeity Reource Toolkit for Healthcare Profeional, 6 the California Medical Aociation Foundation Obeity Provider Toolkit, 7-8 and variou NEOP, MyPlate, and other SNAP-Ed reource. A variety of way to link SNAP- Ed eligible Medi-Cal member to the NEOP community-baed intervention will alo be explored, including the ue of targeted ocial media and web-baed application, referral by health care provider, and more. After the key informant interview have been conducted, the reult will be analyzed and a report of the finding and recommendation will be produced. Date: October 214-May

219 Tak 3 Conduct 3 focu group and 1 video ethnographie with SNAP-Ed eligible Medi- Cal member in northern, central, and outhern California to identify obeity prevention approache in health care and community etting that would bet meet their need. In addition, identify way to create an effective link between obeity prevention in the health care etting and NEOP community-baed intervention. The focu group and ethnographie will explore quetion uch a: What reource, aitance, or type of content related to nutrition and phyical activity would mot likely to be ueful in health care and community etting? What channel, format, or delivery mode would be mot effective (e.g., 1-on-1 couneling, clae, upport group, ocial media network)? What are pecific way the health care ytem could upport community-baed prevention activitie? The reult of the focu group and video ethnographie will be analyzed and a report of the finding and recommendation will be produced. Thi developmental work to better undertand local difference and in-depth conumer life experience (video ethnography) i neceary for a number of reaon. Firt, the Medi-Cal population i quite divere with repect to urban/rural reidence, race/ethnicity, language and culture. Second, the Medi-Cal Program i the larget in the U.S. with 1.5 million member and i delivered through a health care network which varie, ignificantly, acro the tate. There are over 2 individual health plan contract, a fee-for-ervice network, large multipecialty medical group, mall practice, a well a federally qualified health center. Third, there i a major expanion of Medi-Cal eligibility upported through the Affordable Care Act. One and one-half to two million more Medi-Cal member will be enrolled in the next few year. Thi expanion i driving ignificant redeign of the health care ytem including the rapid growth of patient-centered medical home, improved chronic dieae management, and enhanced working relationhip between health care and community ervice. The propoed focu group and video ethnographie acro the tate will enable the development of program for SNAP-Ed-eligible Medi-Cal member that are tailored to the varied need and environment decribed above. Date: October 214-May 215 Tak 4 Baed on Tak 1-3, develop and produce a pilot intervention and evaluation plan aimed at reducing the rik and prevalence of overweight and obeity among SNAP-Ed eligible Medi-Cal member and reducing projected health care cot, with an emphai on thoe that uffer the effect of overweight and obeity (e.g., Medi-Cal member with metabolic yndrome, type 2 diabete, and cardiovacular dieae). DHCS will collaborate with the NEOP Reearch and Evaluation Unit to develop the evaluation plan baed upon the Wetern Region 219

220 SNAP-Ed Nutrition, Phyical Activity, and Obeity Prevention Outcome Evaluation Framework, 213. DHCS will ubmit the plan for NEOP approval and prepare for intervention and evaluation execution in FFY 216. In FFY 216 and depending upon the availability of fund, DHCS plan to conduct an evaluation to determine the effect of health care and community intervention, which will be informed by the activitie in thi propoal, on elected meaure among SNAP-Ed eligible Medi-Cal member. Anticipated meaure for the FFY 216 evaluation include diet and phyical activity behavior and behavioral predictor, Body Ma Index, hemoglobin A1C, lipid level, blood preure, patient atifaction, quality of life, and projected health care cot etimate uing a ophiticated modeling program known a Archimede. Other meaure may include: practice change among health care organization, improved acce to obeity prevention intervention by SNAP-Ed eligible Medi- Cal member and their familie, and commitment of reource in the health care ector for nutrition and phyical activity. If the project i able to demontrate improvement in health behavior and outcome in a cot-effective fahion, the program will be broadly implemented acro the Medi-Cal health care delivery ytem. Baed on the experience of the implementation partner and the care with which the formative reearch will be conducted, we believe that the program will likely produce ignificant value for SNAP-Ed-eligible Medi-Cal member and for thoe organization that deliver the program. Date: May-July 215 Tak 5 Baed on the NEOP-approved pilot intervention and evaluation plan, begin developing and aembling the following pilot program and evaluation component: Confirm health care and community pilot tet ite and partner. Confirm logitic of participant recruitment for the pilot tet. Aemble health care program intervention piece and material. DHCS i planning to ue exiting NEOP/My Plate/SNAP-Ed material and health care obeity prevention tool to the greatet extent poible. Develop method to motivate and drive SNAP-Ed eligible Medi-Cal member to NEOP intervention at the community level. The method will be baed upon the finding of the formative reearch. Develop draft evaluation intrument and method to ecure health data. A noted above, health data will include, but may not be limited to the following: diet and phyical activity behavior and behavioral predictor, Body Ma Index, hemoglobin A1C, lipid level, blood preure, patient atifaction, quality of life, projected health care cot etimate uing the Archimede modeling program, practice change among health care organization, improved acce to obeity prevention intervention by SNAP-Ed eligible 22

221 Medi-Cal member and their familie, and commitment of reource in the health care ector for nutrition and phyical activity. Prepare for the launch of the pilot tet in FFY 216. Date: July-September 215 Reaching SNAP-Ed Conumer The formative reearch phae of Champion for Change Rx i deigned to inform the development of a health care/community pilot program that meet all USDA targeting criteria and pecifically reache the SNAP-Ed eligible population. Maximizing SNAP-Ed Impact The formative reearch phae of Champion for Change Rx i deigned to inform the development of a health care/community pilot program that leverage and maximize all poible connection between the NEOP and DHCS large-cale, tatewide, population health ytem. Strength through Collaboration Champion for Change Rx i deigned to timulate ynergy among CDPH, DHCS, Local Health Department funded by NEOP, other SNAP-Ed implementing agencie, the extenive Medi-Cal health care delivery ytem in California, and SNAP-Ed eligible Medi-Cal member. e. Summary of Reearch The reult from the key informant interview, focu group, and video ethnography eion will inform the development of the Champion for Change Rx pilot program and evaluation plan. f. Modification of Project Method/Strategie Champion for Change Rx i an exiting project; a uch, no modification to the project method/trategie are requeted. g. Ue of Exiting Educational Material A decribed in the Narrative Summary in Tak 1 and 2, DHCS taff, in collaboration with NEOP tate and Local Health Department taff, will identify and compile a lit of teted NEOP, MyPlate, and other SNAP-Ed tool, material, and community-baed intervention approache that could apply to the health care etting and be implemented widely with SNAP-Ed eligible Medi-Cal member uing DHCS ditribution channel, including hopital, clinic, pharmacit, and managed care plan. 221

222 In addition, during the key informant interview, a broad array of health care, community-baed, and technological approache will be vetted with the key informant including, but not limited to: Firt Lady Michelle Obama Let Move Health Care Provider, 4 the American Medical Aociation expert committee recommendation on the aement, prevention, and treatment of child and adolecent overweight and obeity, 5 the Let Go! Childhood Obeity Reource Toolkit for Healthcare Profeional, 6 the California Medical Aociation Foundation Obeity Provider Toolkit, 7-8 and variou NEOP, MyPlate, and other SNAP-Ed reource. h. Development of New Educational Material None planned. i. Key Performance Meaure/Indicator Formative reearch reult for Champion for Change Rx will help inform the development of the pilot program and evaluation plan. Key performance meaure/indicator for the future pilot program evaluation in FFY 216 may include, but are not limited to: diet and phyical activity behavior and behavioral predictor, Body Ma Index, hemoglobin A1C, lipid level, blood preure, patient atifaction, quality of life, projected health care cot etimate uing the Archimede modeling program, practice change among health care organization, improved acce to obeity prevention intervention by SNAP-Ed eligible Medi-Cal member and their familie, and commitment of reource in the health care ector for nutrition and phyical activity. 3. Evaluation Plan An evaluation plan will be developed baed upon the formative reearch reult for Champion for Change Rx. A noted previouly, in FFY 216 and depending upon the availability of fund, DHCS plan to conduct an evaluation to determine the effect of health care and community intervention, which will be informed by the activitie in thi propoal, on elected meaure among SNAP-Ed eligible Medi-Cal member. Anticipated meaure for the FFY 215 evaluation include diet and phyical activity behavior and behavioral predictor, Body Ma Index, hemoglobin A1C, lipid level, blood preure, patient atifaction, quality of life, and projected health care cot etimate uing the Archimede modeling program. Other meaure may include: practice change among health care organization, improved acce to obeity prevention intervention by SNAP-Ed eligible Medi-Cal member and their familie, and commitment of reource in the health care ector for nutrition and phyical activity. If the project i able to demontrate improvement in health behavior and outcome in a cot-effective fahion, the program will be broadly implemented 222

223 acro the Medi-Cal health care delivery ytem. Baed on the experience of the implementation partner and the care with which the formative reearch will be conducted, we believe that the program will likely produce ignificant value for SNAP-Ed-eligible Medi-Cal member and for thoe organization that deliver the program. 4. Coordination Effort Champion for Change Rx i deigned to timulate ynergy among CDPH, DHCS, Local Health Department funded by NEOP, other SNAP-Ed implementing agencie, the extenive Medi-Cal health care delivery ytem in California, and SNAP-Ed eligible Medi-Cal member. To our knowledge, thi i the firt time that CDPH and DHCS have connected their large-cale program and health care ytem to reduce the prevalence and rik of overweight and obeity among the low-income population they erve. Thi new collaboration i conitent with other large-cale partnerhip that DHCS ha forged in the lat two year. For example, DHCS and CDSS have etablihed a partnerhip to increae CalFreh enrollment among the 1.2 million Medi-Cal member who are eligible but not currently enrolled in the nutrition aitance program. CDSS and DHCS have identified and are implementing a variety of way to promote CalFreh through Medi-Cal and connect the two ytem at the time of health care enrollment and recertification. Another example of collaboration i the Medi- Cal Incentive to Quit Smoking Program, an applied reearch project being conducted by DHCS (Office of the Medical Director) and CDPH (Tobacco Control Program and Diabete Control Program). Thi a five-year, $1 million project funded by the Center for Medicare and Medicaid Innovation. 223

224 Reference 1. California Department of Health Care Service. Baeline Aement of Quality Improvement Activitie in the California Department of Health Care Service: Method and Reult. November 212; in pre. 2. California Department of Health Care Service. Strategy for Quality Improvement in Health Care, November Acceed March 29, United State Department of Health and Human Service. National Strategy for Quality Improvement in Health Care, March Acceed March 29, White Houe Tak Force on Childhood Obeity. Let Move, Take Action Health Care Provider. Acceed March 22, American Medical Aociation. Appendix: Expert Committee Recommendation on the Aement, Prevention, and Treatment of Child and Adolecent Overweight and Obeity, January 25, Acceed March 22, The Harvard Pilgrim Health Care Foundation Growing Up Healthy Initiative and MaineHealth. 521 Let Go!, Let Go! Childhood Obeity Reource Toolkit for Healthcare Profeional, Acceed March 22, California Medical Aociation Foundation and California Aociation of Health Plan. Adult Obeity Provider Toolkit, ied%2april%228.pdf. Acceed March 22, California Medical Aociation Foundation, California Office of Multicultural Health, and California Medical Aociation. Child and Adolecent Obeity Provider Toolkit, y%2toolkit% pdf. Acceed March 22,

225 Appendix J: Hypertenion Control Quality Improvement Propoal and Driver Diagram 225

226 Hypertenion Control among the Medi-Cal Population DHCS Medi-Cal Managed Care Quality Strategy Report, Problem Epidemiology and Population Health Impact National Perpective. One in three or nearly 78 million adult in the United State (US) have high blood preure, or hypertenion, and only 52.5 percent have it adequately controlled. 1 Table 1 how the hypertenion claification provided by the Eighth Joint National Committee (JNC 8) on Prevention, Detection, Evaluation, and Treatment of High Blood Preure. 2 Table 1. Hypertenion Claification Determined by Age, Sytolic Blood Preure (SBP), and Diatolic Blood Preure (DBP) 2 Hypertenion Claification Normal Prehypertenion Hypertenion Adult Year Adult 6 Year and Older SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) DBP (mm Hg) < < Hypertenion i aociated with increaed doctor viit and i a major rik factor for heart dieae, troke, kidney failure, and other eriou condition contributing to nearly 1, death a day in the US. Hypertenion wa a contributing factor for 77 percent of people who had their firt troke, 69 percent of people who had their firt heart attack, and 74 percent of people who experienced congetive heart failure. 1 High blood preure i more prevalent in men up to age 45, equally prevalent in men and women age 45 to 64, and more prevalent in women over age 65. African American have the highet prevalence of hypertenion of any race/ethnic group, and more African American women than men have hypertenion. 1 Controlling hypertenion can increae life expectancy. 3 It i etimated that 46, death in the US could be avoided each year if 7 percent of the patient with hypertenion were treated according to publihed guideline. 4 For example, reducing average population SBP by only 12 to 13 mm Hg could reduce the rik of troke by 37 percent, heart dieae by 21 percent, and cardiovacular dieae mortality by 25 percent. 5 Controlling hypertenion alo ha the potential to reduce cot. In 21, the cot aociated with high blood preure amounted to $93.5 billion in health care ervice, medication, and mied day of work. Without timely action, an etimated 1 million adult in the US will have high blood preure, and cot are etimated to reach over $24 billion by 23. 1,6 226

227 Given thee impreive opportunitie to improve health and reduce cot, the Department of Health and Human Service Million Heart Initiative ha etablihed goal, including hypertenion control, to prevent 1 million heart attack and troke by Medi-Cal Perpective. According to the California Department of Public Health, heart dieae and troke were the firt and third leading caue of death among Californian, repectively, accounting for 24.9 percent and 5.8 percent of death in According to the California Health Interview Survey (CHIS), 36.5 percent of adult Medi-Cal member who completed the urvey reponded that they have been diagnoed with hypertenion at ome point in their life. 9 An analyi of Medi-Cal claim and encounter data how that 18 percent of Medi-Cal managed care member had a diagnoi of hypertenion or had been treated for hypertenion in 212 or Thi rate exclude thoe who were covered by both Medi-Cal and Medicare. The relatively lower prevalence of hypertenion found when uing Medi-Cal claim and encounter data a compared to CHIS i the reult of everal factor. Firt, the rate doe not include patient who have been diagnoed with hypertenion and did not have medical or pharmacy encounter ubmitted in 212 or 213. Second, hypertenion diagnoe may be under-reported ince the current data tructure only allow for two diagnoi code. Finally, there could be incomplete and inaccurate encounter data ubmitted to DHCS. For example, DHCS doe not receive all encounter data for dual-eligible member when their cot were paid by Medicare; thu, thee member were excluded from the analyi. Depite difference between CHIS and Medi-Cal claim and encounter data, both data ource demontrate that a ignificant proportion of the Medi-Cal population ha a major cardiovacular dieae rik factor that warrant wift intervention. The Medi-Cal claim and encounter dataet alo offer opportunitie to explore hypertenion among variou ubpopulation. A expected, DHCS reearch cientit found that age wa a ignificant factor in hypertenion rate. Sixty percent of Medi-Cal member er than 65 year of age had hypertenion, compared to 5 percent of 55 to 64 year, 3 percent of 45 to 54 year, 15 percent of 35 to 44 year, and 3 percent of 18 to 34 year. After adjuting for age, female had ignificantly higher rate than male, and African American had nearly 2 percent higher rate than other race/ethnic group. 1 Among Medi-Cal Managed Care Plan (MCP), there were 175,22 Medi-Cal member identified with hypertenion. A hown in Table 2, more than half of the Medi-Cal member diagnoed with hypertenion were repreented by ix MCP. 1 Table 2. Six Plan Serve More than Half of Medi-Cal Managed Care Member Diagnoed with Hypertenion

228 MCP Medi-Cal Managed Care Member with Hypertenion According to Plan Audited Data (n=175,22) No. % LA Care 33, % Inland Empire San Bernardino/Riveride 16,82 9.6% CalOptima Orange 13,77 7.8% Alameda Alliance for Health 9, % Health Net LA 8,71 5.% CalViva Health Freno 6, % Sub-Total 88,86 5.7% Uing the Archimede imulation tool developed by David Eddy, MD, PhD, DHCS reearch cientit etimated the potential health benefit and cot aving of controlling blood preure among the hypertenive Medi-Cal managed care population. The imulation included people aged 18 to 59 with SBP over 14 mm Hg or DBP over 9 mm Hg and people aged 6 to 85 with SBP over 15 mm Hg or DBP over 9 mm Hg. The model provided cot and health outcome auming that each imulated member could achieve a 15 percent reduction in their SBP. Auming that 175,22 hypertenive Medi-Cal member received the intervention, the model etimated that DHCS could ave 523 million inflation-adjuted dollar over a 2-year period. The model alo illutrated improvement in health outcome, namely 19,879 additional qualityadjuted life year, 3,894 fewer major advere cardiac event, 1,786 fewer troke, and 1,158 fewer death over a 2-year period. The model predicted the following outcome per 1, Medi-Cal member: nearly 3 million inflation-adjuted dollar in aving, 113 additional qualityadjuted life year, 22 fewer major advere cardiac event, 1 fewer troke, and 7 fewer death. 11 Medi-Cal Managed Care Program Healthcare Effectivene Data and Information Set In 212, DHCS tarted including a MCP Healthcare Effectivene Data and Information Set (HEDIS) meaure for hypertenion control, which ha been endored by the National Quality Forum (NQF). The Controlling High Blood Preure meaure (NQF #18) i ued to ae the percentage of member 18 to 85 year of age who had a diagnoi of hypertenion and whoe blood preure wa adequately controlled (blood preure le than 14/9 mm Hg) during the meaurement year. 12 Uing 213 HEDIS data (to be publihed in the 214 HEDIS Report), the weighted average of Medi-Cal managed care member with hypertenion under control i percent (Figure 1). There were light performance difference among the Two-Plan, Geographic Managed Care, and County-Organized Health Sytem model. 13 Figure 1: Medi-Cal Managed Care 213 HEDIS Data for Controlling High Blood Preure by Model Type

229 Rate (%) COHS GMC Two-Plan 213 Medi-Cal Managed Care Weighted Average (56.36) A hown in Figure 2, the MCP varied widely on the HEDIS meaure, with Kaier-San Diego reporting percent and Health Plan of San Mateo reporting percent. The 9 th percentile for the national Medicaid population i percent of patient with hypertenion under control, while the 25 th percentile i only 5. percent of patient with hypertenion under control. The weighted average for the Medi-Cal managed care population i cloer to the 25 th percentile, which demontrate ignificant opportunitie for improvement

230 Figure 2: Medi-Cal Managed Care 213 HEDIS Data for Controlling High Blood Preure by Plan 13 Kaier SoCal - San Diego Kaier NoCal - Sacramento High Performance Level Kern Family Health Care Inland Empire Health Plan - San Bernardino/Riveride CalOptima - Orange Health Plan of San Joaquin - San Joaquin Partnerhip HealthPlan - Marin San Francico Health Plan Partnerhip HealthPlan - Sonoma CenCal Health - Santa Barbara Partnerhip HealthPlan - Mendocino Central CA Alliance for Health - Monterey/Santa Cruz L.A. Care Health Plan Partnerhip HealthPlan - Napa/Solano/Yolo 214 Medi-Cal Managed Care Weighted Average Health Net - LA Health Net - Stanilau Health Plan of San Joaquin - Stanilau CenCal Health - San Lui Obipo G Coat Health Plan - Ventura Molina Healthcare - San Diego Central CA Alliance for Health - Merced Anthem Blue Cro - Madera Anthem Blue Cro - Freno Contra Cota Health Plan CalViva Health - Freno Anthem Blue Cro - Tulare Santa Clara Family Health Plan CalViva Health - Madera Community Health Group - San Diego Minimum Performance Level Health Net - Tulare Anthem Blue Cro - San Francico Anthem Blue Cro - Sacramento Molina Healthcare - Sacramento Molina Healthcare - San Bernardino/Riveride Health Net - Kern Alameda Alliance for Health Health Net - Sacramento Health Net -San Diego Anthem Blue Cro - Contra Cota Anthem Blue Cro - King Care 1t - San Diego CalViva Health - King Anthem Blue Cro - Santa Clara Anthem Blue Cro - Alameda Health Net - San Joaquin Health Plan of San Mateo 86.37% 82.% 69.55% 68.37% 67.56% 67.25% 65.45% 64.77% 63.42% 6.69% 6.25% 59.55% 59.46% 57.14% 56.72% 56.36% 56.33% 56.3% 56.2% 54.43% 54.1% 53.88% 53.66% 53.36% 53.32% 53.28% 53.12% 52.99% 52.55% 52.1% 52.7% 5.% 49.39% 48.45% 48.11% 47.23% 47.22% 47.2% 45.99% 45.72% 44.72% 43.88% 43.3% 42.82% 41.3% 4.93% 34.15% 3.86% 29.93% (1) High Performance Level i HEDIS 213 National Medicaid 9th Percentile. (2) Minimum Performance Level i HEDIS 213 National Medicaid 25th Percentile. % 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% 23

231 Objective, Baeline, and Target Objective By 217, increae to at leat 7 percent the proportion of Medi-Cal managed care member 18 to 85 year of age who have a diagnoi of hypertenion and whoe blood preure i adequately controlled. Baeline and Target Baeline for each MCP will reflect the 213 HEDIS data noted in the previou ection. The target, however, will be governed by the 215 HEDIS meaure, which i baed upon the following criteria: Member 18 to 59 year of age whoe blood preure wa <14/9 mm Hg. Member 6 to 85 year of age with a diagnoi of diabete whoe blood preure wa <14/9 mm Hg. Member 6 to 85 year of age without a diagnoi of diabete whoe blood preure wa <15/9 mm Hg. MCP not included in Figure 2 will etablih a one-year baeline on the Controlling High Blood Preure meaure, and then pecific target will be etablihed thereafter. Annual target, which will be et in collaboration with the MCP, will reflect achievement of or, in ome cae, movement toward the Million Heart Initiative clinical goal of 7 percent hypertenion control by It i likely that the target will be eaier to achieve by uing the 215 HEDIS meaure, becaue the SBP i 1 mm Hg higher for thoe 6 to 85 year of age without a diagnoi of diabete. In addition, a part of improving the Controlling High Blood Preure HEDIS meaure among the Medi-Cal population at large, MCP hould ue their data to determine whether pecific ubpopulation, uch a African American adult, need pecial conideration to reduce and ultimately eliminate diparitie in hypertenion control. Etablihment of target for thi quality improvement project will be informed by outcome reported in the peer-reviewed literature and improved MCP performance on the HEDIS meaure. For example, a tudy wa conducted by Kaier Permanente Northern California (KPNC) to tet the effectivene of a quality improvement program for hypertenion. KPNC increaed hypertenion control by 36.8 percent over the coure of 8 year (43.6 to 8.4 percent), with maximum gain over 14 percentage point within a 1-year period. KPNC achieved thi by implementing five major quality improvement component, including: (1) developing a ytem-wide hypertenion regitry; (2) reporting hypertenion control rate; (3) developing an evidence-baed practice guideline; (4) conducting medical aitant viit for follow-up meaurement; and (5) promoting ingle-pill combination therapy. 15 The tudy demontrate that ound quality improvement approache can reult in ignificant gain in hypertenion control and outcome, which exceed the clinical goal of the Million Heart Initiative. In addition, when comparing 212 and 213 HEDIS data, elected MCP improved hypertenion control among their Medi-Cal member by 5.6 to 14.1 percentage point. 12,13 231

232 DHCS Intervention 1. DHCS wa elected to participate in the Center for Medicare and Medicaid Service (CMS) Prevention Learning Network, with the goal of aligning DHCS ervice, program, delivery ytem, and partnerhip to upport the Million Heart Initiative in Medi-Cal. A a reult, DHCS receive technical aitance from CMS to identify bet practice approache to advance the goal of Million Heart (e.g., increae blood preure control, increae apirin ue for econdary prevention, increae choleterol management, increae help for thoe who want to quit moking, and reduce odium and tran fat conumption). Thi quality improvement project i a reflection of the work accomplihed to date with CMS, and CMS will continue to provide technical aitance to DHCS a thi project i implemented tatewide. 2. Collaborate with MCP to etablih annual target for the Controlling High Blood Preure meaure to achieve the objective of thi project. 3. Engage MCP with performance at or below the Minimum Performance Level (5 percent) on the Controlling High Blood Preure meaure to undertand the caue of lower performance. a. Conduct key informant interview with appropriate MCP taff to identify barrier to controlling hypertenion, current activitie and intervention to addre controlling hypertenion, uccee and challenge, leon learned, and technical aitance needed from DHCS and other MCP to improve performance. 4. Etablih a learning collaborative for MCP performing at or below the Minimum Performance Level (5 percent) on the Controlling High Blood Preure meaure. MCP performing at higher level may alo join the learning collaborative, and ome highperforming MCP will be invited to hare bet practice. a. Conduct quarterly call for MCP to hare challenge and bet practice, receive DHCS technical aitance, and learn from MCP that have achieved high performance on the meaure. 5. Provide one or more of the following hypertenion-related adminitrative data output at leat annually to MCP to help inform their quality improvement project, and elicit MCP input on which data will be mot actionable. MCP demographic Identify ub-population (e.g., age, gender, race/ethnicity) to ae the difference in the MCP rik for hypertenion prevalence, co-morbiditie, medication adherence, medication monitoring, and blood preure creening. Hypertenion prevalence Ue diagnoi and treatment data to monitor hypertenion rate. Hypertenion everity To ae challenge aociated with controlling hypertenion, ue a clinical grouper ytem (Symmetry Epiode Treatment Group) to identify complication and co-morbiditie aociated with hypertenion. 232

233 Medication adherence Ue pharmacy data to ae the timeline of treatment, a well a how well Medi-Cal member are participating in their care. Medication monitoring Ue data from medical procedure code, in combination with demographic data, to ae how well provider are monitoring their patient condition with blood tet and changing precription baed on thoe reult, a well a how often the patient are coming in for their laboratory appointment and office viit. Review the HEDIS meaure, Annual Monitoring for Patient on Peritent Medication, to complement thi information on hypertenion-related medication. 6. For provider education, provide evidence-baed, bet practice, web-baed reource to achieve hypertenion control, uch a the American Medical Group Foundation Meaure Up Preure Down Provider Toolkit to Improve Hypertenion Control Develop and implement an incentive/diincentive plan to encourage achievement of quality improvement target for the Controlling High Blood Preure meaure. a. For MCP: Conider incluion of the Controlling High Blood Preure meaure a an indicator in the auto-aignment algorithm b. For member: Evaluate member incentive currently in ue and determine whether change are warranted c. For provider: Ue reult from an upcoming Integrated Healthcare Aociation urvey to identify Pay-for-Performance indicator ued by plan 8. Develop and implement a pilot program with elected MCP to offer free blood preure monitor to Medi-Cal member with hypertenion. 17,18 Reference 1. Go AS, Mozaffarian D, Roger VL, et al. Heart dieae and troke tatitic 213 update: a report from the American Heart Aociation. Circulation. 213;127:e doi:1.1161/circulationaha Jame PA, Oparil S, Carter BL, et al. 214 Evidence-baed guideline for the management of high blood preure in adult: report from the panel member appointed to the Eighth Joint National Committee (JNC 8). JAMA. 214;311(5):57-2. doi:1.11/jama Tevat J, Weintein M, William L, Toteon A, Gman L. Expected gain in life expectancy from variou coronary heart dieae rik factor modification. Circulation. 1991;83: doi: /1.CIR Farley TA, Dalal MA, Motahari F, Frieden TR. Death preventable in the US by improvement in the ue of clinical preventive ervice. Am J Prev Med. 21;38(6):6-9. doi: 1.116/j.amepre He J, Whelton P. Elevated ytolic blood preure and rik of cardiovacular and renal dieae: overview of evidence from obervational epidemiologic tudie and randomized controlled trial. Am Heart J. 1999;138(3): S211-S219. doi: 1.116/S2-873(99)

234 6. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecating the future of cardiovacular dieae in the United State: a policy tatement from the American Heart Aociation. Circulation. 211;123: doi: /CIR.b13e3182a55f5. 7. The Initiative Overview. Million Heart Initiative. Web ite. Acceed July 31, California Department of Public Health. Thirteen leading caue of death by race/ethnic group and ex, California, Web ite. Publihed October 3, 212. Acceed July 22, AkCHIS, California Health Interview Survey, Medi-Cal MIS/DSS and Symmetry EBM Grouper, Verion 8.2; January 1, 213 December 1, Schleinger L, Eddy DM. Archimede: a new model for imulating health care ytemthe mathematical formulation. J Biomed Inform. 22; 35 (1): doi: 1.116/S (2) Medi-Cal Managed Care Diviion, Department of Health Care Service. 213 HEDIS Aggregate Report for Medi-Cal Managed Care Program. Sacramento, CA: Health Service Adviory Group, Inc.; eport/ca213_hedis_aggregate_report.pdf. Acceed July 23, Medi-Cal Managed Care Diviion, Department of Health Care Service. 214 Unpublihed raw HEDIS data. Sacramento, CA: Health Service Adviory Group, Inc.; 214. Received for internal evaluation Augut 4, Wright JS, Wall HK, Bri PA, Schooley M. Million Heart where population health and clinical practice interect. Circulation. 212;5: doi:.1161/circoutcomes Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood preure control aociated with a large-cale hypertenion program. JAMA. 213;31(7): doi: 1.11/jama American Medical Group Foundation, American Medical Group Aociation. Meaure Up Preure Down Provider Toolkit to Improve Hypertenion Control. Alexandria, VA: American Medical Group Foundation; Acceed July 24, Center for Dieae Control and Prevention. Self-Meaured Blood Preure Monitoring: Action Step for Public Health Practitioner. Atlanta, GA: Center for Dieae Control and Prevention, US Department of Health and Human Service; Acceed June 24, Uhlig K, Balk EM, Patel K, et al. Self-Meaured Blood Preure Monitoring: Comparative Effectivene. 45 ed. Rockville, MD: Agency for Healthcare Reearch and Quality; Acceed July 24,

235 Aim Primary Driver Secondary Driver Metric Participate in the Center for Medicare and Medicaid Service (CMS) Prevention Learning Network Ae caue for low performance among Managed Care Plan (MCP) Etablih annual target from 215 to 217 on the Controlling High Blood Preure (CHBP) meaure for each MCP DHCS taff receive technical aitance from CMS to dieminate bet practice on HTN control Conduct key informant interview of MCP taff to identify barrier to controlling HTN, current activitie and intervention to addre the iue, uccee and challenge, leon learned, and technical aitance needed to improve performance Collaborate with MCP to et annual planpecific target to enure clear expectation to drive improvement MCP performance on the National Quality Forumendored CHBP meaure (#18) 1 By December 217, increae to at leat 7 percent the proportion of Medi-Cal member 18 to 85 year of age who have a diagnoi of hypertenion (HTN) and whoe blood preure i adequately controlled. 2 Etablih and implement a learning collaborative for MCP Provide HTN-related adminitrative data to inform MCP-pecific quality improvement effort, and meaure and report MCP performance Conduct quarterly call for MCP to hare challenge and bet practice, receive technical aitance, and learn from MCP that have achieved high performance on the CHBP meaure Provide evidence-baed, bet practice, webbaed reource for MCP and provider to achieve HTN control Elicit MCP input on which data will be mot actionable and provide relevant data at leat annually. Data may include MCP demographic, HTN prevalence and everity, and medication adherence and monitoring Update MCP performance indicator in a Dahboard quarterly, pot annual performance reult online, preent to takeher, and inform member choice of MCP via the Conumer Guide, Office of the Patient Advocate ranking Decribe MCP member education, outreach, and incentive program Increae member engagement Define the element mot ucceful at improving performance, and etablih and implement tandard of practice for MCP to engage member Develop, implement, and evaluate a pilot program with elected MCP to offer free blood preure monitor to Medi-Cal member with HTN Develop and implement an incentive/diincentive plan Include the CHBP meaure in the autoaignment algorithm, where MCP with higher performance than other() operating in the ame county are rewarded by receiving new member who do not actively chooe to enroll in a particular Plan Metric applie to all econdary driver. 2 Annual percentage point increae et in collaboration with each MCP

236 Appendix K: Tobacco Ceation Driver Diagram 236

237 Aim Primary Driver Secondary Driver Metric Increae the number of Medi-Cal member who ue the California Smoker Helpline (Helpline) Medi-Cal Incentive to Quit Smoking Project Social media and outreach material (e.g., Welltopia by DHCS Facebook page, DHCS webite, Text4Baby and Quit4Baby, Firt 5 new parenting packet, and Medi-Cal member mailing) Require Managed Care Plan (MCP) to promote the Helpline a an official Medi-Cal moking ceation reource Work with FQHC, Indian Health Clinic, and Safety Net Hopital to increae referral to the Helpline Enure all tate-level program are referring Medi-Cal member to the Helpline Develop an action plan to addre tobacco ceation in the behavioral health ytem Reult from randomized control trial meauring the effectivene of mall incentive to encourage member to acce the Helpline Helpline data: Percentage of Medi-Cal eligible caller and total number of caller erved By December 217, reduce moking prevalence among Medi- Cal member from 19.9% to the level of the general population. 1 Conduct a tobacco ceation quality improvement project among MCP tatewide Implement clinical tandard of practice to upport tobacco ceation Draw down Federal Financial Participation for Helpline ervice provided to Medi-Cal member, Effective 7/1/13 Etablih annual target from 215 to 217 on tobacco-related Conumer Aement of Health Care Provider and Sytem urvey (CAHPS) Ae caue of low performance on tobaccorelated CAHPS meaure Conduct quarterly call for MCP to hare challenge and bet practice, receive technical aitance, and learn from MCP that are ucceful in helping their member quit moking Provide evidence-baed, bet practice, webbaed reource for MCP and provider, including Ak, Advie, Refer ceation training Meaure and report MCP performance in a quarterly dahboard, pot annual performance reult online, preent to takeher, and inform member choice of MCP via the Conumer Guide, Office of the Patient Advocate ranking USPSTF A & B recommendation for adult and children/adolecent ACA Tobacco Ceation Couneling for Pregnant and Potpartum Women CMS approved State Plan Amendment #12-27 HRA MCP Conumer Aement of Health Care Provider and Sytem urvey: current moking, moker indicating they received advice from a health care provider to quit moking, moker indicating their provider dicued ceation medication, and moker indicating their health care provider dicued ceation method and trategie 1 Currently 19.9% of Medi-Cal Beneficiarie are moker, compared to 12.6% general population moker. FDA approved tobacco ceation medication Treating Tobacco Ue and Dependence: 28 Update, Public Health Service Clinical Practice Guideline Partner with the Pharmacy Benefit Diviion to educate provider about barrier-free acce to tobacco ceation medication 237 Require MCP to remove barrier to medication utilization review Pharmacy data related to precribing of and adherence to tobacco ceation medication

238 Appendix L: Welltopia by DHCS Facebook Summary 238

239 Welltopia by DHCS - Facebook Ad - Report - Summary A ummary of the Facebook Ad campaign October 214 Campaign launched on 9/11/13 thi report cover one year from 1/1/13 to 9/3/14 In October 213, a new image wa elected to run alongide the original (mot ucceful) image in the Facebook ad campaign. New Original Alo, a more localized campaign wa trialed in the LA/San Diego area. In theory, aiming our campaign to the target audience, in an area of CA where they are likely to be found, might increae the rate of Like and decreae the Cot per Like. So a Statewide campaign and a localized (LA & San Diego) campaign ran concurrently for one week. The reult of thi week howed an increae in overall Like a expected, BUT it wa clear that one campaign wa not better than the other. After one week, the localized campaign wa dropped in favor of continued tatewide expoure. STATEWIDE SOCAL DAY LIKES (gained) LIKES (gained) LiKeS (total) Wed Thur Fri Sat Sun Mon Tue Wed 6 So far 2 So far 3182 So far 239

240 LIKES - Daily Tally Example 1/9-1/16 LIKES - Daily Tally Breakdown 1/23-1/3 DAY LIKES DAY LIKES By Week 7, the Wed Thur Fri Sat Sun Mon Tue Wed 82 5 At the end of Week 5 we reached our 5 Like goal! Wed Thur Fri Sat Sun Mon Tue Wed 7 83 campaign wa well on the way to 1, Like, and it wa eaily gaining 2+ Like per day. Interet and activity wa increaing on the Welltopia by DHCS Facebook page, in alignment with the increaed expoure. It wa noted that viitor were mot intereted in pot relating to pecific campaign, uch a Red Ribbon Week. Page Pot - Content Comparion and Interet Level The campaign continued to produce reult with an upward trend, through the end of 213 and on into 214. The trategy needed no adjutment only monitoring. By May 214, the Welltopia by DHCS page had urpaed 23, Like! Succe! 239

241 In June 214, with the page at almot 27, Like, new tool were identified for targeting an audience. Facebook had aligned itelf with outide agencie uch a Axiom and Peronicx, to allow acce to data about Facebook uer. (The data i collected through elf-reporting urvey, or etimated baed on a variety of known demographic data). It wa now poible to target an audience with even more accuracy than before, from Education Level to Annual Income. A tool called Audience Inight allowed a tet-run of an audience before commiting to a campaign. By plugging in the audience attribute, we could ditinguih the mot likely job title, lifetyle, pending habit, relationhip tatu and other valuable information about the people in that audience. It wa information that could inform our trategy, and tighten our audience moving forward. Thi tool launched the next evolution of the Welltopia by DHCS campaign. 239

242 At the ame time a thi dicovery of new tool and 1 month into the campaign the Welltopia by DHCS ad wa begining to how a downward trend. 195 Like 11 Like July th At thi point, and with well over 3, Like, it wa time to realign our goal and trategy for the next tage. The new campaign wa rolled out on 9/25/214. Five ad image were ued and the language wa retained from before. 239

243 After one week the mot popular image by a large margin, wa the line of The mot ignificant factor of the new campaign, wa a more detailed and elect audience, an audience that more than ever repreented the intended Welltopia by DHCS audience: Potential Audience for thi ad: 84, people Who are: Living in California, USA Age 13-5 year Not connected to Welltopia by DHCS Intereted in: Medi-Cal CalFreh Covered California Medicaid Medicare (United State) Supplemental Nutrition Aitance Program Temporary Aitance for Needy Familie Low Income Home Energy Aitance Program Head Start Program Veteran Social welfare Section 8 (houing) 239