uality Program Work Plan

Transcription

1 uality Program Work Plan 2016 Approved by the Quality Improvement Committee: 3/16/16 Approved by the Quality Improvement Advisory and Credentialing Committee: 3/16/16 Approved by the Board of Directors: 3/30/16

2 UCare 500 Stinson Boulevard NE Minneapolis, MN

3 UCare Focus Admin Administrative MemX Member Experience Quality of Clinical Care QS Quality of Service SCC Safety of Clinical Care Products Choices Essentia MNCare MSC+ PMAP SNBC UFS UCare & Fairview Choices (Exchange) Essentia Care MinnesotaCare Minnesota Senior Care Plus Minnesota Senior Health Options Prepaid Medical Assistance Program Special Needs Basic Care (UCare Connect) UCare for Seniors (Medicare MN) Committees CR Credentialing Committee MMC Medical Management Committee QIC Quality Improvement Committee QIACC Quality Improvement Advisory and Credentialing Committee Focus Admin Admin 2015 Annual Program Evaluation (on 2015 QI Activities) 2016 Annual Quality Work Plan Evaluate the effectiveness of the Quality Program to include monitoring activities & clinical, operational, & satisfaction initiatives. Define quality related planning & monitoring of activities as well as clinical & operational improvement for the coming year. Complete Annual Program Evaluation. Annual evaluation report submission to DHS. Completion of 2016 Work Plan for all products based on regulator requirements and findings from previous QI Program Evaluation. NCQA QI 1B, MR , sub 8 MR MR NCQA QI 1A, MR MR MR , sub 2 Owner CR MMC QIC QIACC 2015 Program Evaluation Mar Mar 2016 Workplan Mar Mar 2016 Quality Program Work Plan 1

4 Admin QS SCC Admin Admin 2016 Quality Program Description Access & Availability Monitoring Adverse Actions Bi- Annual Annual Non- Discrimination Annual Review of Criteria for Credentialing File Review Grid Annual Review of UM Criteria Annual review of Quality Program & structure. Ensure providers are meeting community access standards.* Ensure network is sufficient to meet members' needs.* Monitor practitioner complaints and adverse events.* Track and identify any discrimination in the Credentialing process. Annual review of Credentialing File Review Grid. Annual review of UM Criteria. Complete Quality Program description. Program structure changes made as indicated. Send to MDH Annually or with any changes. Provider to member ratios Distance to providers Applicable satisfaction surveys (e.g. CAHPS) Access to Primary Care, Specialty Care, Behavioral Health, Chiropractic, Dental & Pharmacy Services Investigate practitionerspecific complaints and monitor practitioner adverse events. on findings semiannually. Monitor Credentialing and Recredentialing results to identify any discriminatory practices Review and update Criteria for Credentialing File Review Grid Review changes to UM Criteria NCQA QI 1A, MR , sub 1-13 MR , MR , sub1 NCQA NET 1 and NET 2 NCQA CR 6A NCQA CR 1A NCQA CR 1 Owner CR MMC QIC QIACC 2016 Program Description Access and Availability Adverse Actions Annual Non- Discrimination Criteria for Credentialing File Review Grid Mar Mar VP of PR Dir. Of QM Feb Aug Mar May UM 2 UM Criteria Dec 2016 Quality Program Work Plan 2

5 QS MemX Annual Utilization Management Evaluation Assessment of Network Adequacy CAHPS and ESS Annual evaluation of UM program.* Quantitative analysis and plan for implementation of interventions.* Provide comparative information on performance of Managed Care organizations & help identify areas of improvement.* Achieve a rating at or above the national average for CAHPS (UFS & ) and ESS. Achieve a rating at or above the MN average for CAHPS (MHCP). Focus s (below national average): UFS -Rating of Drug Plan Rating of Health Care Rating of Health Plan Getting Needed Care Rating of Drug Plan 8.40 Identify relevant measures and analyze results to identify opportunities for improvement. Use data from QI 4C report, review opportunities for nonbehavioral healthcare services and behavioral healthcare services. Measure satisfaction services with CAHPS questions in comparison with other MCO plans. Analyze the results against benchmarks. Work on areas below the threshold and as identified in the annual evaluation. Identify Opportunities for Improvement. NCQA UM 1 NCQA NET 3 42 CFR and Owner CR MMC QIC QIACC Annual Utilization Management Evaluation Assessment of Network Adequacy CAHPS and ESS Survey Results VP of PR Apr July 2016 Quality Program Work Plan 3

6 CCM Program Description CCM Program Evaluation Choices -Rating of Health Plan Access to Care Access to Info 2.65 PMAP -Rating of Health Plan 58% -Getting Needed Care 54% -Getting Care Quickly 55% MNCare -Rating of Health Plan 52% -Getting Needed Care 58% -Getting Care Quickly 58% MSC+ -Rating of Health Plan 69% -Getting Needed Care 50% Connect -Rating of Health Plan 54% -Getting Care Quickly 55% Annual review of CCM Program & structure. Complete CCM Program description. Program structure changes made as indicated. Improve CCM program.* Identify relevant process or outcome, measure and analyze results and identify opportunities for improvement NCQA QI 5B NCQA QI 5 A, J, K CCM Program Description CCM Program Evaluation 2016 Quality Program Work Plan 4

7 MemX SCC MemX CCM Satisfaction Chronic Care Improvement Program (CCIP) Clinical Practice Guidelines Complaint Trend UFS EssentiaCare Obtain feedback from members in order to improve CCM program.* Conduct CCIP for MA plans and report progress annually to CMS for review.* Ensure that guidelines are adopted, approved, reviewed and monitored by QIACC. Distribute to providers and members according to State & Federal standards.* Complete ongoing evaluation of all enrollee complaints, including complaints filed with participating providers.* Obtain feedback from members using a satisfaction survey Analyze member complaints to identify opportunities for improvement Plan and implement initiatives focused on clinical areas with the aim of improving health outcomes and beneficiary satisfaction, especially for those members with chronic conditions. Existing guidelines are reviewed and updated every two years. Track complaints, assess trends, and establish that corrective action is implemented and effective in improving the identified problems. NCQA QI 5I 43 CFR NCQA QI 7A MR , sub 9 Owner CR MMC QIC QIACC CCM Satisfaction CCIP Diabetes- Obesity for Adults- Heart Failure- Adults- Preventive- Adults- Preventive- Children- Prenatal- Commercial Complaint Trend Feb Mar Jul Feb 2016 Quality Program Work Plan 5

8 QS Complaints, Appeals, & Grievances Continuity and Coordination between behavioral care and medical care Continuity and coordination of Medical Care Support member by resolving issues of dissatisfaction with UCare.* Standard for meeting timelines: 95%.* External report requirements are met 100% of the time.* Serve as member advocates by processing concerns in a timely manner.* Monitor trends of complaints & appeals for improvement opportunities.* Improve coordination between behavioral and medical care. Improve coordination of Medical Care. Continue improvement and/or training if applicable. Continuous review of standards and changes. Collect and analyze data to identify opportunities for improvement of coordination between behavioral and medical care. Collect and analyze data to identify opportunities for improvement of coordination of medical care. DHS Contract, Minn. Rules, part NCQA QI 9 NCQA QI 8 Owner CR MMC QIC QIACC CAG Annual Analysis Continuity and Coordination between behavioral care and medical care Continuity and coordination of Medical Care July May June May June 2016 Quality Program Work Plan 6

9 Admin QS Delegation Oversight Regulatory Disenrollment Survey DM Annual PMAP MN Care SNBC MSC+ Perform oversight of delegated facilities & responsibilities in accordance with regulatory & contractual delegation agreements.* Determines, and follows up on, opportunities for improvement.* Measure reasons for disenrollment in the Medicaid member population. Annual audit of delegated entities. Annual schedule submitted to the State identifying delegated functions. Develop Corrective Action Plans (CAPs) based on audit findings. Provides member and clinical data, as applicable. Track disenrollment rates and reasons by product. Review rates to ensure there below state threshold of 5%. Comparison with other health plans. Identify areas of improvement. Improve DM program.* Identify relevant process or outcome, measure and analyze results and identify opportunities for improvement. NCQA CR 9/QI 10/ UM 14/MEM 9. DHS Contract NCQA QI 6 I and J Owner CR MMC QIC QIACC Compliance - Delegation Audit Findings- Credentialing- Jan/Jul (Cred Committee) Survey Results from DHS DM Satisfaction and Annual Evaluation VP Compliance Jan Jul 2016 Quality Program Work Plan 7

10 SCC Health Outcomes Survey (HOS) Healthcare Effectiveness Data Information Set (HEDIS) UFS Assess & monitor physical & mental health functional status of Medicare members.* Data used to improve functional outcomes as indicated by survey results, as a measurement tool, and as a comparative indicator of member health.* Monitor effectiveness of care, access/availability, of care, & use of services. Data used for program planning to compare UCare performance to other health plans, as an indicator of under/over utilization, and for improvement. Address issued identified in 2015 Annual Evaluation.* Achieve a rating at or above the 75th percentile. Focus areas (below the 75 th percentile): PMAP: -Antidepressant Med Mgmt 33.79% -Cervical Cancer Screening 62.53% -Chlamydia Screening 56.80% -Well Child Visits 60.04% MNCare: Do a two year cohort study on a sample of members. Review questions that pertain to physical & mental health outcomes. Compare the results to the previous surveys, & to the State & National results. Provider Education Member education Measurement Focus Groups. Effectiveness of care measures. Access/availability of care measures. Use of service measures. Compare findings to previous years & other health plans. Analyze the results against benchmarks. Work on areas below the threshold and as identified in the annual evaluation. 42 CFR and CFR and Owner CR MMC QIC QIACC HOS Survey Results HEDIS Survey Results 2016 Quality Program Work Plan 8

11 Inter-Rater Reliability (IRR) -Antidepressant Med Mgmt 46.93% -Cervical Cancer Screening 52.31% -Chlamydia Screening 55.81% SNBC: Breast Cancer Screening 63.27% -Cervical Cancer Screening 50.61% -Chlamydia Screening 52.08% MSC+ Antidepressant Med Mgmt 25% -Breast Cancer Screening 65.12% Choices -Prenatal 40% -Postpartum 60% -Chlamydia Screening 42.86% Ensure uniform application of objective measurable criteria for utilization decisions.* Percent of inter-rate reliability. Update InterQual medical criteria. Continue the testing process. NCQA UM 2C Inter-rater reliability audit results 2016 Quality Program Work Plan 9

12 MemX MemX Medical Record Standards Member Satisfaction Analysis MOC Annual Evaluation New Member Feedback UFS PMAP MNCare SNBC MSC+ Monitor quality of PCC medical records for compliance with UCare standards. Address issues identified in 2015 Annual Evaluation.* Assess and improve member satisfaction.* Improve the SNPs ability to deliver high -quality health care services and benefits to its SNP beneficiaries. Assess understanding of procedures and marketing materials. PRC will review medical records at the initial site survey for adequacy of medical record keeping. UCare's HEDIS vendor conducts the Medical Records Standards audit and Advance Directive audit. PCC & providers will be evaluated for compliance with UCare Medical Record Standards. Provider Outreach & Education Annually evaluate member complaints and appeals and CAHPS data. Conduct an annual analysis of select measures related to the MOC and identify opportunities for improvement. Monitor and identify opportunities for improvement of procedures and marketing materials for new members. Minn. Rules, part , subpart 13 NCQA CR5 DHS contract NCQA QI 4C and D and NET 4 C (Exchange only) NCQA MOC 4 NCQA RR 5C Owner CR MMC QIC QIACC Medical Record Audits Audit Results Member Satisfaction MOC Annual Evaluation New Member Feedback VP of PR & Dir. QM VP of Mkt May Mar May 2016 Quality Program Work Plan 10

13 Performance Improvement Projects (PIP) Antidepressant Medication Management (AMM) Performance Improvement Projects (PIP) Follow-up After Hospitalization for Mental Illness (FUH) Prior Authorization (PA) PMAP MNCare MSC+ SNBC Conduct focused studies directed at problems, potential problems, or areas with potential for improvement in care.* Goal is to increase antidepressant medication adherence in the non-white population by 6 percentage points after 3 years.* Conduct focused studies directed at problems, potential problems, or areas with potential for improvement in care.* Goal is to increase follow-up after hospitalization for the SNBC population by 7 percentage points for 7 days and 6 percentage points for 30 days after 3 yrs. Ensure UCare's prior authorization processes meet the needs of members & providers.* Select topic and document the study methodology and outcomes. Select topic and document the study methodology and outcomes. Review PA requirements and update as needed. DHS Contract, Minn. Rules, part DHS Contract, Minn. Rules, part N/A Owner CR MMC QIC QIACC PIP PIP CLS/BH Authorization & Notification Grid Quality Program Work Plan 11

14 Quality Improvement Project (QIP) Antidepressant Medication Management (AMM) Quality Improvement Strategy (QIS) Quality of Care Reviews UFS MSC+ Choices Focused studies conducted to address member health issues.* Goal is to increase antidepressant medication adherence in the UFS population by 3 percentage points after 3 years.* Goal is to increase antidepressant medication adherence in the population 6 percentage points after 3 yrs. Focused studies conducted to address member health issues. Complete quality reviews/investigations in a timely manner to ensure a safe & quality provider network.* Develop interventions in order to impact identified areas that impact member health or benefit utilization. Develop interventions in order to impact identified areas that impact member health or benefit utilization. Measure: Percent of cases closed that meet resolution timeline. Quarterly trend reports by volume, issues, severity, & outcome. 90% of Quality Care cases closed within 90 days of receipt. 42 CFR N/A Owner CR MMC QIC QIACC QIP QIS Dir of QM July QOC Trend Mar Jul 2016 Quality Program Work Plan 12

15 Admin SCC Regulatory Oversight Special Health Needs (SHCN) Regulatory PMAP MNCare SNBC MSC+ Ensure results from the CMS Audit, MDH Quality Assurance Examination & the TCA audit reports are reviewed & acted upon. Ensure the effective mechanisms are in place to: -Identify adult & pediatric members with SHCN.* - Assess members identified, offer care management & monitor the member's plan of care.* Identify number of deficiencies and mandatory improvements in audit reports. Discuss mandatory improvements with appropriate Directors and receive written confirmation from Directors of next steps. CAPs relating to the audit deficiencies are complete or in process. Respond to EQRO requests. Monthly tracking of select utilization indicators per contract. Monitor clinical/utilization triggers. Continue ER avoidance program. Continue to offer case management for high risk OB cases. Written description of SHCN Plan. Complete annual & quarterly reports. DHS Contract N/A Owner CR MMC QIC QIACC ATR report CMS Audit, MDH QA and TCA Screenings Referrals for Services Claims Data CCMS Data VP of GR VP Compliance July Feb 2016 Quality Program Work Plan 13

16 Admin Stars UFS EssentiaCare QS UM Satisfaction Utilization Management Plan Complete quality improvement activities based on Stars ratings with an emphasis on. * Achieve a rating of 5 Stars.* Focus s (below 75 th percentile): Goal to achieve 75 th percentile: UFS -Adult BMI 93.19% -DMARD Use for RA 80% -Osteoporosis Mgmt 14.89% -DMARD Use for RA 73.17% -Breast Cancer Screening 6.54% -Comp Diabetes A1c Control < % -Comp Diabetes Care Nephropathy 90.02% -Colorectal Cancer Screening 55.96% -Osteoporosis Mgmt 19.08% Develop and implement interventions based on overall Stars ratings. Provide activity reports to QC and QIACC. Analyze the results against benchmarks. Work on areas below the threshold and as identified in the annual evaluation. Improve UM program. Obtain feedback regarding the UM process. Identify opportunities for improvement. Annual review of UM Plan. Complete UM Plan. Plan structure changes made as indicated. N/A NCQA UM 11A UM 1A Owner CR MMC QIC QIACC Strategic Plan Stars Update UM Satisfaction Utilization Management Plan Dir of QM Mar Jun Jul Feb 2016 Quality Program Work Plan 14