San Francisco Health Plan Medical Management Department Quality Improvement Utilization Management 2011 Program Evaluation

Transcription

1 201 Third Street, 7 th Floor San Francisco, CA Medical Management Department Quality Improvement Utilization Management 2011 Program Evaluation

2 List of Contributors Prepared by Title e mail Odalis Bigler, MBA Project Manager, Quality and Performance Improvement [email protected] Contributors Title e mail Ann Marie Molyneaux, BSN Senior Manager, Care Management [email protected] Anna Le Mon, MPH Project Manager, HECLS [email protected] Anne Simson Quality Improvement Coordinator [email protected] Betsy Price, RN, MPH Senior Clinical Compliance Manager [email protected] Cynthia Lamond, MPH Provider Relations Specialist [email protected] Hunter Gatewood, MSW Director, Health Improvement [email protected] Jennifer Beach Quality Improvement Coordinator [email protected] Kelly Pfeifer, MD Chief Medical Officer [email protected] Lauren Zutler, MPH Project Manager, Performance Improvement Programs [email protected] Rosa Lee Customer Services Senior Manager [email protected] Sari Weis, MPA Manager, Clinical Quality [email protected] Sharon Bowers, R Ph Manager, Pharmacy Services [email protected] Suzanne Bruun Coordinator of Health Improvement Programs [email protected] 2

3 Table of Contents Executive Summary Improving the Health Status of Our Members Promoting Preventive Care Preventive Care for Infants and Toddlers Check Ups for Children and Adolescents Women s Health Nutrition and Physical Activity: Piloting Healthy Weight Initiatives Initial Health Assessment (IHA) Individual Health Education Behavioral Health Assessment (IHEBA) Nurse Advice Line Improving Chronic Care Asthma Diabetes HEDIS Results HEDIS Results for Preventive Care Measures HEDIS Results for Chronic Care Indicators HEDIS Results for Healthy Families Improvements at the Practice: Partnering with Providers Strength in Numbers Program Panel Management Training Practice Improvement Program San Francisco Quality Culture Series (SFQCS) Health Education Compensation Program (HECP) POLST Research Project and Provider Incentive Health Education and Cultural and Linguistic Services Health Education Health Education on the Web Targeted Health Education Mailings Promoting Cultural Competency and Language Access Cultural Awareness Training Language Access Measuring and Improving the Member Experience Providing Excellent Telephone Service Call Center Performance New Enterprise Information Management Platform

4 3.3. Member Satisfaction with Customer Service Monitoring Member Grievances Tracking and Trending Grievances Ensuring Member Satisfaction Improvement Initiatives based on 2010 Medi Cal CAHPS Results Provider Level 2011 CAHPS Survey: Preliminary Results by Medical Group and Line of Business Quality Improvement Projects (QIPs) Reducing Avoidable Emergency Room Visits QIP Improving the Patient Experience QIP Provider Relations Provider Network Access Monitoring Access to Primary Care Providers Access to Specialists PCP Language Concordance Clinical Quality Monitoring Medical Group Oversight Audit Results Provider Satisfaction Provider Education and Training Managed Care Care Management Services Utilization Management Utilization Management Notice of Action (NOA) Letter Audit Patient Navigator Pilot Care Support Program Coordination of Care with Community Agencies and Waiver Programs Care Management Training Grant Program for Providers: Accessible Equipment Pharmacy Services Quality Leadership

5 Executive Summary The goal of s (SFHP) Quality Improvement Program is to assure high quality care and services for our members by aggressively seeking opportunities to improve the performance of our health care delivery system. This report is a summary of activities that SFHP completed in 2011 to monitor and improve the health status of our members. It highlights our successes, examines lessons learned, and outlines our next steps. The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP s health care delivery system. It reviews and approves SFHP Medical Management Department s policies and procedures, clinical guidelines and studies, and the activities of all entities delegated for utilization management services. During 2011, The QIC met seven times. SFHP maintains minutes of each QIC meeting and submits them to the California Department of Health Care Services (DHCS) on a quarterly basis. SFHP also relies on its Pharmacy and Therapeutics Committee and the Physician Advisory/Peer Review/Credentialing Committee to implement and oversee its QI and UM Programs. SFHP manages many interventions to encourage members to seek the recommended care that is measured by the Healthcare Effectiveness Data and Information Set (HEDIS). We continue to look for ways to make our interventions more effective and to find new opportunities for improvement. We offer preventive health programs for infants and toddlers, children, adolescents, and women. Our chronic disease programs focus on improving the care of members with diabetes and other chronic conditions. A 24 hour Nurse Advice Line ensures access to timely clinical advice for our members. These efforts have been successful, as measured by our HEDIS results on key preventive care measures. In 2011, 14 out of 21 publicly reported Medi Cal measures were above the 90 th percentile benchmark of Medicaid plans nationwide. To support improved quality, SFHP continually explores new ways to collaborate with its providers to transform from a visit based model to a population health based model. In 2011, we launched two programs to help our providers improve their systems and services, Strength in Numbers 2011 and our new pay for performance program, the Practice Improvement Program (PIP). Where the Strength in Numbers program focuses on the population health efforts of front line staff in safety net clinics, PIP focuses on our whole primary care network, and targets clinical quality, data quality, and key system improvements needed for high performance. Health education and cultural and linguistic competency principles are actively integrated into our quality improvement activities. In making decisions about quality improvement interventions, we examine the demographic characteristics of our member population to ensure delivery of culturally appropriate materials. We believe that health education is better for the member when provided by his or her primary care provider or the provider care team. For this reason, our Health Education Compensation Program reimburses provider offices and provider affiliated organizations for health education provided to our members in one to one and group settings. SFHP maintains a library of health education materials in a wide range of topic areas. We make the materials available in both paper and online formats. Upon request, we also make materials available in alternative formats including large print, audio, or Braille. Our website includes an easy to navigate repository of educational materials that providers, members, and visitors can access and print. Currently, we have 5

6 on line materials in multiple languages that address topics including asthma, diabetes, breastfeeding, and weight management. We continuously upload newly developed, and revised, materials to our website for both members and providers to access directly. In 2011, SFHP conducted or sponsored several Cultural Awareness Trainings open to SFHP staff and contracted medical groups and providers. One of SFHP s top four organizational goals is to offer exemplary service to our members and providers. The Customer Service Department helps members understand and take full advantage of their health plan benefits. Members can contact SFHP Customer Service by phone, fax, TDD/TTY, , mail, or in person. Members receive assistance with ID cards, PCP changes, covered benefits, medical bills, grievances, access to doctors, enrollment, renewal, and other needs. We monitor grievances on a quarterly basis to identify trends and problems. Our quarterly reports identify ways to improve service to our members. We also monitor grievances in order to gauge our own timeliness and regulatory compliance. Our goal is to provide excellent service and, at a minimum, meet the California Department of Manage Health Care (DMHC) standards for responding to and resolving grievances. SFHP closely monitors the adequacy of its provider network to ensure that our members have access to the care they need in a timely manner. We measure network access in a variety of ways to assess language capacity and availability of specialists and PCPs. In 2011, SFHP revised its policies and procedures regarding network access to reflect the new changes in the access standard regulations and services to Seniors and Persons with Disabilities. SFHP participated in the Industry Collaboration Effort (ICE) Timely Access Workgroup to develop a standard methodology and survey tool for monitoring provider appointment availability. Clinical quality monitoring is also critical to SFHP s success. We have a Memorandum of Understanding (MOU) with Anthem Blue Cross of California to review all jointly contracted primary care providers and sites, in order to ensure compliance with criteria from the California Department of Health Care Services (DHCS). In addition, SFHP delegates and oversees the facility site and medical record reviews and interim monitoring activities with its medical groups. Provider satisfaction is important to us. The 2011 Provider Satisfaction survey indicated that, overall, 75% providers report high satisfaction with SFHP. SFHP s Utilization Management Program utilizes a set of policies to ensure that effective and appropriate health care services are delivered to our members. Under our QI Program, we monitor utilization as well as continuity and coordination of care. We comply with strict standards for issuing denials and responding to appeals to assure members rights are protected. SFHP Quality Improvement Committee and Physician Advisory and Peer Review Committee address instances of poor quality. SFHP assures the quality of its pharmacy services by offering a generous formulary, maintaining good relationships with pharmacy providers, and overseeing the pharmacy credentialing process. Our pharmacy services and formulary are constantly reviewed and updated by our Pharmacy and Therapeutics Committee, a sub committee of our Quality Improvement Committee. We monitor pharmacy usage monthly through cost and utilization reports At, we take pride in the many ways we partner with our members and our provider network to improve quality and access to care. We follow the Model for Improvement; since it is not always clear what is the best way to achieve a goal, we frequently pilot interventions, measure the outcomes, and then revise our approach. 6

7 1. Improving the Health Status of Our Members 1.1. Promoting Preventive Care Our goal is to be among the top ten percent of health plans nationwide for measures showing that our members are getting the right care at the right time, using the HEDIS measures required by the State of California. We have multiple programs to encourage members to seek care. We continue to look for ways to make our interventions more effective and find new opportunities for improvement. Below is a summary of our preventive health programs: Preventive Care for Infants and Toddlers Immunization Reminders Cards: Families with children turning five and eight months of age receive an Immunization Reminder Card with educational information about vaccinations. SFHP mailed 4,211 reminder cards in Immunization Incentives: We mail an offer to families with children turning 13 and 17 months of age for them to receive a $50 gift card for completing all immunizations on time. In 2011, 12% (468) of members who were offered the incentive participated in the program. Immunization Reminder Phone Blasts: Families with infants and toddlers receive four recorded telephone calls when their child turns 12, 13, 17, and 22 months of age, reminding them of upcoming well visits and immunizations. Outreach for Immunizations and Well baby Check ups: Families with children under the age of two, who are assigned either to the Department of Public Health clinics or to clinics using the California Immunization Registry, receive reminder calls for well child checks and immunizations. Parents are also sent reminder cards showing which immunizations their children need in order to earn the $50 gift card incentive Check Ups for Children and Adolescents Well child Member Incentive: Families with a child between the ages of three and six years old receive a birthday card from SFHP, offering them a $25 gift card for bringing their child for an annual check up. In 2011, 35% (1,873) of members who were offered the incentive participated in the program. Well child Phone Blast: Along with the birthday card, families also receive a recorded telephone message encouraging them to take their child to the doctor and take advantage of our member incentive. 7

8 Well adolescent Member Incentive: Teen members receive a birthday card from SFHP offering them movie tickets or a $15 gift card for having an annual check up. In 2011, 30% (4,049) of members who were offered the incentive participated in the program with valid submissions of incentive cards. Well adolescent Phone Blast: Along with the birthday card, teens receive a recorded telephone message encouraging them to see their doctor and take advantage of our member incentive. Well adolescent Provider Incentive: We offer provider sites $20 for each comprehensive well adolescent visit completed. We also provide clinics with outreach lists of teens due for check ups. In 2011, 15 provider sites participated. The total number of eligible members who participated was 2,449. Well adolescent Summer Campaign: We worked with the San Francisco Unified School District to distribute posters encouraging teens to see their doctor for a check up during the summer. All teen members were sent a flyer that encouraged them to make an appointment and reminded them about the well adolescent Incentive. This flyer also reminded members to ask their providers about getting a pertussis vaccine, as part of SFHP s collaboration with the Department of Public Health and the school district to help adolescents meet the new mandate for this important immunization. Well adolescent Raffle: Every year SFHP holds a raffle for an ipad and an ipod for teens who had a visit with their doctor during the calendar year. Teens were informed of the raffle through the Member Incentive Offer and additional mailings at the beginning of summer. Targeted Provider Support for Adolescent Outreach: SFHP encourages clinics to host dedicated teen clinic sessions. We provided additional support for these clinics by offering them outreach lists and automated calls. The automated calls encouraged teens to make an appointment before the end of the summer and to get a Pertussis shot. In 2011, six sites requested outreach lists, and two sites requested automated calls. Well Child and Well Adolescent Outreach List: During the month of November, all providers who had at least one SFHP member who was due for a well child or welladolescent visit, per HEDIS specifications, received an Outreach List and a follow up call to encourage them to call these patients and offer a well exam. More frequent lists are available to providers upon request. 8

9 Women s Health Well woman Preventive Health Mailing: Upon enrollment and then once per year, our female members aged 27 years old and over receive a brochure with preventive health care guidelines for women and health education messages. The mailer also includes a promotion for our prenatal and postpartum incentive programs for members who may be pregnant or who recently have given birth. Your Body, Your Baby Incentive Program: In 2011, SFHP initiated a member incentive program for postpartum care. The Timely Prenatal Care Incentive Program became the Your Body, Your Baby program. This program offers a $25 gift card for receiving timely prenatal care and a $25 gift card for receiving timely postpartum care as per HEDIS specifications. In 2011, 90% of members who were offered to participate completed the visit as required. Women s Health Outreach List: During the month of November, all providers who had at least one SFHP member who was due for a pap smear or a diabetic screening, per HEDIS specifications, received an Outreach List and a follow up call to encourage them to call these patients and offer a well exam. More frequent lists are available to providers upon request Nutrition and Physical Activity: Piloting Healthy Weight Initiatives Completed in 2011, our most recent Health Education Group Needs Assessment indicated that the top health education needs of our members and providers are in the area of nutrition and physical activity, as well as in chronic disease management. To support our provider network in providing tools for maintaining a healthy weight, SFHP has materials such as cookbooks, educational placemats, and exercise bands, which are available to our providers upon request. These materials are disseminated to clinic sites and are used for health education and as incentives in targeted campaigns such as a Diabetes Days and Nutrition Classes. BMI Interventions Addressing the obesity epidemic is a top priority for SFHP. In spring 2011, SFHP distributed approximately 150 Weight Assessment Toolkits for providers, medical office, and clinic staff, through mailings and at meetings with Medical Group representatives. The toolkits contained BMI wheels and information about calculating and documenting BMI and nutrition and physical activity counseling in the patient s chart (following HEDIS specifications), tips for communicating with patients, and sample member educational materials. As a separate 2011 intervention, to support our provider network in caring for new Seniors and Persons with Disabilities, SFHP financed and distributed wheelchair/bariatric scales to 34 sites across its network. 9

10 San Francisco Childhood Obesity Taskforce In 2011, SFHP continued to participate in a citywide coalition of health care providers and managed care organizations to find resources for PCPs to help families find low cost ways to engage their children in healthy eating and physical activity. The coalition has planned a summit on Early Childhood Obesity Prevention and Early Intervention for March The summit will aim at promoting communication, collaboration, and sharing best practices Initial Health Assessment (IHA) SFHP sends (by either mail or electronic mail) monthly reports to its providers with demographic information about their new patients. SFHP asks them to reach out to those members to receive an Initial Health Assessment within 120 days, as mandated by DHCS (60 days for members 0 18 months old). New members receive a mailer, in their primary language, encouraging them to call their providers and make an appointment to receive this service. SFHP monitors performance against this requirement by reviewing administrative data (claims/encounters) and calculating the percentage of new members who receive an IHA visit within the DHCS recommended periods. Measurement Year: July 1, 2009 June 30, 2010 IHA Rate for 120 days (members over 18 months old) 56.60% IHA Rate for 60 days (members 18 months and younger) 83.21% According to the DHCS requirement, the following exceptions apply to the expectation of a completed IHA for each new member. These reasons for not doing an IHA help explain why our completion rate is not higher. The new member is assigned to a PCP who completed an IHA with the member prior to the member s enrollment at SFHP, The elements of the IHA were completed within 12 months prior to member s effective date of enrollment, The PCP has documented in the medical record that all findings have been reviewed and updated accordingly, The new member was not continuously enrolled in the plan for the required number of days, The new member disenrolled from SFHP during the IHA period, The new member or a member s parent/guardian refused to complete an IHA and this refusal is documented in the chart, The new member missed a scheduled appointment with the PCP and at least two additional attempts were made to reschedule the appointment, without success; these attempts were documented. 10

11 In spite of the above exceptions, SFHP continuously make every effort to assess members needs and provide them with appropriate care. With the enrollment of SPD members in 2011, SFHP contracted with Nurse Response to conduct Health Needs Assessments to SPD members. Our CareSupport staff uses that information to further assess their needs and provide care coordination services Individual Health Education Behavioral Health Assessment (IHEBA) Scoring of the IHEBAs during medical record reviews continues to be suspended by DHCS. However, SFHP educates providers on the importance of completing this evaluation as part of the Initial Health Assessment (IHA) Nurse Advice Line SFHP informs its members that they can call SFHP s Nurse Advice Line (NAL) at (877) in the following situations: If they are unable to reach their doctor during the day or after hours. To speak with a trained registered nurse to answer health questions, give advice, and instruct them to go to the emergency room, urgent care center, or contact their provider after being triaged with standardized McKesson protocols. Members assigned to Kaiser Permanente, or to a clinic with its own call center/nurse advice line, are transferred through a live voice to voice transfer from the SFHP NAL to the advice line operated by their provider organization. SFHP has marketed the NAL in a variety of ways: The NAL phone number is included on the back of member s SFHP ID card. NAL postcards and NAL magnets were mailed, in five languages, to each household and to new members beginning in July 2011, including new SPD members. Stickers advertising the NAL were included on a variety of member educational materials. The NAL phone number was added to the Evidence of Coverage The NAL was advertised in our quarterly member newsletter. As of December 2011, the most frequent reasons for calls to the Nurse Advice Line were the following: Adult: Cough Upper Respiratory Infections Premenopausal Vaginal Bleeding 11

12 Pediatric: Fever Rashes Cough Diarrhea SFHP receives and reviews monthly NAL statistics from Nurse Response (the vendor providing NAL services) that are subsequently reported quarterly to the SFHP Quality Improvement Committee (QIC) and annually to the Department of Managed Health Care (DMHC). The DMHC Timely Access standard requires triage or screening by phone within 30 minutes of the call. The table below shows the NAL s performance relative to this standard. Nurse Advice Line 2011 Call Statistics Average Total Speed of Inbound Answer Calls (sec) Abandoned Calls Over 30 Seconds Abandonment % # Calls Triaged = to or > 30 Minutes % of Outlier Calls January % % February % % March % % April % % May % % June % % July % % August % % September % % October % % November % % December % % Total (*) % (*) (*) average In 2011, the number of inbound calls steadily increased, and consequently so did the number of abandoned calls. Even with this increase, our rate of abandoned calls stayed below 5% of the total inbound calls, which is the NQCA standard to measure efficiency of the service. During the month of November there was a significant increased in the number of abandoned calls due to shortage in staffing during the holidays. SFHP and Nurse Response implemented a corrective action plan to prevent this issue from happening again. 12

13 1.2. Improving Chronic Care Asthma Health Education Materials for Members: Health education materials related to asthma are available in the member and provider sections of our website in English, Chinese, and Spanish. Asthma Supplies for Providers: Upon request, SFHP supplies provider practices with free spacers, peak flow meters, hypoallergenic pillowcases and mattress cover sets in multiple sizes to distribute to SFHP members with asthma. Asthma Task Force: the Project Manager of Health Education and Cultural Linguistic Services is a member of the San Francisco Asthma Task Force Clinical Committee, and participates in the planning of programs and provider trainings aimed at improving the management of asthma among San Francisco residents. On October 14, 2011, The SF Asthma Task Force hosted its annual Networking Forum, Autumn Update which was advertised to providers in San Francisco and included sessions conducted by experts on the following topics: o Allergy Skin Testing: An Overview o Improving Communication o The Russian Patient Diabetes Diabetes Reminder Card: Annually, all members with diabetes are sent a Diabetes Reminder Card and information about our Diabetes Incentive Program, which encourages them to complete screening tests including HbA1c, LDL cholesterol, monitoring for nephropathy, foot exam, blood pressure, and eye exam. Member Incentives: In 2011, we continued to offer a $25 gift card as incentive for completing the following six regular screenings within the calendar year: o HbA1c o LDL o Eye exam o Foot exam o o Monitoring for Nephropathy (Urine micro albumin screening or prescription for ACE/ARB, or other evidence of medical attention for nephropathy) Blood pressure 13

14 Response rate: In 2011, 19% (308) of members who received cards returned them, compared to 13% (312) in We attribute this increased participation in part to more completed outreach calls in September and October 2011 compared to outreach calls completed in 2010, as noted below. Compliance Rate: 59% (234) of the members who returned their cards completed all tests and labs required to receive the incentive gift card during the calendar year. Outreach Calls to Members with Diabetes: In September and October 2011, a contracted call center made live calls to 1,728 members with diabetes who had not yet completed all their necessary exams in SFHP nearly doubled the number of live calls made in 2011 compared to 2010 (870 live calls were made in 2010). In order to reach all members with diabetes, the live calls were supplemented with 611 automated phone calls. The calls encouraged members to complete their regular screening tests. Eye Exam Reminder: In October, SFHP members with diabetes who had not received an eye exam in the past 12 months were sent a reminder card along with the information about the Diabetes Incentive Program. The card provides information regarding the importance of having an annual eye exam and information regarding how to schedule an appointment for this service HEDIS Results Our HEDIS programs have been successful, as measured by our HEDIS results on key preventive care measures HEDIS Results for Preventive Care Measures As evaluated through the HEDIS pursuit process of February May 2011, SFHP demonstrated improvements in most Medi Cal measures during Measurement Year (MY) Fourteen out of 21 publicly reported Medi Cal measures were in NCQA s 90 th percentile benchmark of Medicaid plans. The scores highlighted in yellow are above the 90 th percentile. In Measurement Year 2010, 11 out of 15 measures were above the 90 th percentile. The table below shows our Medi Cal results compared to last year s results and the 90 th percentile. Scores for measures highlighted in orange are those used by the California Department of Health Care Services to calculate the percentage of Medi Cal enrollees who do not choose a health plan, and are subsequently automatically assigned to SFHP. 14

15 HEDIS Measure 2010 Medicaid th % Avoidance of Inappropriate Antibiotic Treatment in Adults 44.5% 46.6% 35.9% Adolescent Well Care Visits 64.4% 60.6% 63.2% Breast Cancer Screening 62.0% 60.3% 63.8% Cervical Cancer Screening (Combination 3) 79.4% 79.7% 78.9% Childhood Immunization Status 87.3% 87.0% 82.0% Comprehensive Diabetes Care BP<140/ % 74.1% 73.4% Comprehensive Diabetes Care Eye 70.1% 67.8% 70.1% Comprehensive Diabetes Care HbA1c Control <8 64.1% 58.0% 58.8% Comprehensive Diabetes Care HbA1c 90.4% 89.7% 90.3% Comprehensive Diabetes Care LDL Screening 83.2% 82.8% 84.0% Comprehensive Diabetes Care LDL< % 46.0% 45.5% Comprehensive Diabetes Care Neph 85.1% 85.9% 86.2% Comprehensive Diabetes Care Poor Control >9 (lower rate is better) 26.3% 21.8% 27.7% Use of Imaging Studies for Low Back Pain 82.2% 85.1% 84.1% Postpartum Care 63.6% 66.4% 74.4% Prenatal Care 90.3% 88.8% 92.7% Appropriate Treatment for Children with Upper Respiratory Infections 96.8% 97.2% 94.9% Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 85.2% 86.6% 82.5% Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents BMI Percentile 60.7% 72.7% 63.0% Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Nutrition 78.5% 74.5% 67.9% Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Physical Activity 70.4% 55.8% 56.7% Auto Assignment Measure SFHP above NCQA s 2010 Medicaid 90th Percentile HEDIS Results for Chronic Care Indicators SFHP reached the national HEDIS 90 th percentile in all diabetes measures with the exception of LDL screening and monitoring for nephropathy. SFHP scored in the 90 th percentile for the eye exam indicator in We attribute this improvement from last year to reminder calls, eye exam reminder fliers, member incentive programs, and SFHP s support of provider population management efforts. SFHP attributes statistical variation to the small rate decreases in the monitoring for nephropathy, blood pressure and HbA1c poor control indicators. 15

16 Measure Medicaid 90 th Percentile MC Eye Exam 70.1% 67.8% 70.1% MC HbA1c Screening 90.4% 89.7% 90.3% MC LDL Screening 83.2% 82.8% 84.0% MC Screening for Nephropathy 85.1% 85.9% 86.2% MC Blood Pressure Control (<140/90) % 73.4% MC HbA1c Poor Control (>9) 26.3% 21.9% 29.2% MC HbA1c Good Control (<8) 64.1% 58.0% 58.8% MC LDL Good Control (<100) 47.9% 46.0% 44.7% SFHP above NCQA s 2010 Medicaid 90th Percentile HEDIS Results for Healthy Families In Measurement Year (MY) 2010, nine Healthy Families measures were in the 90 th percentile, whereas in MY 2009, 10 Healthy Families measures were in the 90 th percentile. SFHP attributes this slight decrease to the change in the Childhood Immunization measure. In MY 2010, the Managed Risk Medical Insurance Board (MRMIB) required plans to report on Childhood Immunization Status (CIS) Combination 10, rather than CIS Combination 3 indictor. The CIS Combination 10 indicator requires that members receive Hepatitis A, Rotavirus and Influenza vaccines, in addition to the vaccines required in the CIS Combination 3 indicator (DTaP, IPV, MMR, HiB, Hep B, VZV, Hep A and PCV). The higher standard for the number of required immunizations contributed to lower rates in the Childhood Immunization measure. 16

17 Measure Medicaid 90 th % Adolescent Well Care Visits 69.7% 74.1% 63.2% Childhood Immunization Status Combination 10 (New indicator) 19.51% NR 20.9% Childhood Immunization Status Combination 3 (Retired indicator) NR 88.8% NR Well Child Visits in the First 15 Months of Life 81.1% 90.0% 76.3% Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 87.7% 89.5% 82.5% Children and Adolescent's Access to PCP (12 24 months) 96.2% 100% 98.5% Children and Adolescent's Access to PCP (25 months to 6 years) 94.1% 93.4% 94.1% Children and Adolescent's Access to PCP (7 to 11 years) 96.1% 95.2% 95.6% Children and Adolescent's Access to PCP (12 18 years) 94.0% 94.0% 93.7% Use of Appropriate Medication for Asthma (all ages) 95.2% % 92.8% Appropriate Testing for Children with Upper Respiratory Infection 95.8% 95.0% 94.9% Appropriate Testing for Children with Pharyngitis 25.2% 23.4% 80.9% Lead Screening in Children 77.2% NR 88.4% Chlamydia Screening in Women 19.2% 12.3% 69.5% Immunizations for Adolescents (New Measure) 66.4% NR 65.9% NR= Not Reported SFHP above NCQA s 2010 Medicaid 90th Percentile 1.4. Improvements at the Practice: Partnering with Providers SFHP is continually exploring new ways to partner with its providers to transform a visit based model to a population health based model. This section describes two initiatives developed to support population management through providing training, consultation, incentives, and project funding Strength in Numbers Program The Strength in Numbers program engages primary care clinics in the SFHP and Healthy San Francisco (HSF) provider networks to share quality data and improve performance on key population health and access measures. Through this program, participating clinics receive financial incentives linked to performance in key diabetes and chronic care measures as well as technical assistance in the form of trainings to support population management activities. 17

18 The 2011 program had an expanded measurement set that included standardized preventive and chronic care measures, as well as a continued focus on diabetes. Strength in Numbers 2011 also included measures to gauge patients ability to access care at their primary care clinic. Every medical home also selected up to an additional two measures that were clinically relevant and meaningful to their population. Some of these measures assessed pain management, depression screening and treatment, and mammogram screening. As part of the program, every medical home received the following interventions: Incentive payments based on performance. Incentives were paid quarterly, dependent on level of improvement achieved in measures. Clinics were scored relative to their own baseline, or based upon meeting national thresholds. Centralized purchasing and distribution of health education materials, to support chronic care interventions in the medical home. Technical assistance to improve integration of registries into care: health coaching and panel management trainings. Clinics self reported results through the third quarter of 2011 show the following: Starting with the baseline measures data on four diabetes measures in spring 2009, medical homes self reported data (n=18) showed improvement from baseline in all four diabetes measures (see Chart below) from , with maintenance of scores in Taken together, participating clinics showed statistically significant improvement on the initial four diabetes measures over the first two years of the program. However, collective performance on these measures has stayed at a plateau over the past four quarters. Given the earlier improvement and current competing priorities for clinics resources and attention, maintenance of performance is seen as a success by many clinic leaders, who report that Strength in Numbers allowed them to maintain focus on chronic illness care despite competing priorities. Averages of all participating medical homes on four diabetes measures ( ) Note: Data are self reported quarterly measures from ten Department of Public Health clinics and eight San Francisco Consortium clinics from July 2009 through September For 18

19 quarters when data were not reported, averages were calculated based on the number of medical homes for which data were obtained. Relative improvement, all participating clinics, Spring 2009 Baseline compared to Q Panel Management Training As part of our Strength in Numbers 2011 Program, technical assistance and panel management trainings were made available to all participating medical homes. The University of California San Francisco s Center for Excellence in Primary Care (CEPC) led the panel management training and in clinic mentoring. Representatives from the Department of Public Health and Community Clinic Consortium led the registry software component of the training in collaboration with CEPC. The Strength in Numbers 2011 Technical Assistance training included: Panel Management: Getting Started and Adding Skills (5 hours two sessions held) Objective: A classroom style, interactive training focused on in reach and outreach practices, health coaching, and utilization of a disease registry in flagging patients in need of preventative exams. Audience: Panel Managers, MAs, MEAs, Health Workers, Data Reporters, Quality Improvement staff, interested staff. 39 staff members from 18 medical homes participated in this training. i2i Technical Assistance Disease Registry Training Two separate technical assistance training sessions were offered in June and July: 1. i2i Tracks for Panel Mangers (3 hours two Sessions held): Objective: Learn and practice using i2itracks and DPH LCR for panel management 19

20 Audience: Panel Managers, MAs, MEAs, Health Workers, Data Reporters, Quality Improvement staff, interested staff. 17 staff members from 18 medical homes participated in the training. 2. i2i Tracks for Data Reporting and Analysis (4 hours two Sessions held): Objective: Support population management work through setting up searches for panel managers and reporting on quality outcomes. Audience: Data Reporters, Quality Improvement staff, and others. Long term volunteers when attending with permanent staff. 24 staff members from the 18 medical homes participated in the training One on One Mentoring Six clinic sites were selected to receive one on one on site clinic mentoring on panel management practices, workflow mapping, and additional related training. Mentoring efforts were lead by the CEPC team. On site mentoring took place from July 2011 through March Overall, Strength in Numbers has been very popular with providers, allowing clinics across the safety net to focus on the same set of standardized measures, and integrate clinical reporting into the work of provider MA teams. In the 2011 Provider Satisfaction Survey, over 80% of providers were highly satisfied with the program incentives, health coaching training, technical assistance from SFHP staff, and the quarterly newsletters Practice Improvement Program In 2011, SFHP launched its pay for performance program, called Practice Improvement Program (PIP). The overall goal of PIP is to reward system improvements and drive better outcomes in clinical care and patient experience by providing financial incentives and technical assistance. An advisory board governs the PIP program with member representatives from our entire provider network. The advisory board approves measurement sets and advises on issues of both feasibility and clinical relevance. SFHP s Governing Board and Executive Team determine funding streams for the PIP program on an annual basis. Incentive payments were provided to PIP participants on a semi annual basis and were based on capitation rates and member months per site. Participants in the first year of the program included 19 community health centers, five medical groups, and two individual providers. The first year of PIP focused on measures in four main domains: Clinical Quality, Data Quality, Patient Experience, and Systems Improvement. The table below lists some examples of measures. 20

21 Domain Example of a Measure within Domain Clinical Quality (25 pts) Design QI Project focused on one of six HEDIS measures. Data Quality (30 points) Regular, timely, electronic submission of encounter and claims data using appropriate HIPPA compliant format. Attending Data Quality meetings at SFHP. Patient Experience (20 points) Participate in a CG CAHPS patient satisfaction survey with SFHP. Systems Improvement (25 points) Select at least three members of the staff, including a senior leader to participate in SF Quality Culture Series, or a similar leadershiptraining program. A few highlights of the 2011 program year s success include: All 26 participating sites submitted a QI project plan related to a clinical area of focus, which aligned with SFHP HEDIS priorities. All eligible sites (n=24) verified that they sent at least three staff members, including at least one senior leader, to a formal and intensive QI/leadership team training. 96% of all eligible sites began sharing comparative data reports to their providers and staff, at least annually. These reports included data spanning the spectrum of patient experience to performance on chronic care measures San Francisco Quality Culture Series (SFQCS) San Francisco clinics face three major challenges in the next few years: 1) compliance with timely access regulations, requiring primary care appointments within 10 days of request; 2) national focus on improving the patient experience, including integration of behavioral health and primary care; and 3) meaningful use of Electronic Health Records, as tools for quality and safety. Studies on high performing organizations frequently name leadership commitment and alignment as the foundation for success. Redwood Community Health Coalition, a consortium of clinics in four North Bay counties, created the Quality Culture Series and saw a dramatic acceleration of improvements in the areas of chronic care, access, EHR, and patient experience, after 100% of their clinic leadership teams went through the training together. They attribute their success to the fact that the entire leadership team attended all sessions, and then spread the training to their clinic staff. San Francisco s Quality Culture Series was based on this model. The SF Quality Culture Series was a year long collaborative learning program for clinic management teams. Nineteen safety net clinic management teams participated, with the aim of building their improvement capacity and skills as managers of dynamic primary care practices. 21

22 The program was supported by the Gordon and Betty Moore Foundation, with additional support from SFHP and Healthy San Francisco (HSF). Eight one day training sessions were held over the course of nine months, with expert faculty from the UCSF Center for Health Professions and other Bay Area leaders. Each clinic team worked on a project related to either access improvement, patient experience, or preparing for electronic health record implementation, and each team was given access to an improvement coach. SFQCS was a transformative experience for clinic leadership teams. The excellent attendance rate, active engagement and program ratings across clinic participants demonstrated the high value they placed on their experience. This perceived value also translated to real changes. Almost all clinics reported measurable improvements in their clinic s capacity for quality, the majority of teams saw improvements in team effectiveness and engagement scores, and almost all clinics saw improvement in at least one project measure. In addition, leadership teams continue to bring the content home and report increased engagement and participation in quality improvement activities across clinic staff. People cannot drive quality improvements without being able to manage people, change, and conflict, among other leadership, teamwork, and management skills. Thus, the fusion of the learning session content (management training, leadership development, quality improvement basics) with training (train the trainer skills for adult learners) and technical assistance (shoulder to shoulder help applying the concepts to the realities of the clinics) was particularly effective. There is now a clear shift in leadership across the SF safety net from a blame focus to systems focus, and teams across clinics have been strengthened by this process. A ripple effect was created that is changing how leaders view and shape their responses to problems. Opportunities for networking and sharing of best practices, and the creation of a leadership structure within a larger organization has led to greater role identification in a larger team of leaders. This experience has fostered a sense of safety net cohesion and unity across clinic teams. Organizations within a small city that once did not know about each other now identify as we are the safety net. SFQCS will continue the momentum with twice yearly alumni sessions, with invitations to clinics who did not participate in the past Health Education Compensation Program (HECP) The purpose of the HECP program is to provide financial support for health education classes and counseling in the primary care setting, and to reward providers for doing health education counseling during individual and group visits. In July of 2011, SFHP expanded the HECP program to offer additional funding to primary care sites that offer health education services to SFHP members even if these member are assigned to other medical homes. Participating sites fall into one of the following categories, and payment is awarded according to the number of SFHP members they serve. 22

23 Group 1 Primary Care Sites serving their own patients: 20 PCP sites enrolled in the HECP program in Group 2 Health Education Center Sites & Primary Care Sites serving SFHP members assigned to other Clinic/Medical Home Sites: A total of eight health education centers and PCP sites enrolled in group two. This includes health education centers that do not have assigned SFHP members, but that serve SFHP members. The 2011 participating sites provided health education classes and individual counseling sessions on the following topics: Diabetes Asthma Perinatal Nutrition and weight management Hyperlipidemia Hypertension Tobacco Abuse Behavioral Counseling Dental hygiene/ fluoride varnish Parenting/ family wellness Four of the clinic sites also receive additional reimbursement for providing fluoride varnish services to pediatric members POLST Research Project and Provider Incentive POLST (Physician Orders for Life Sustaining Treatment) is a legal document that is completed by the physician and patient which serves as a set of standing orders for patients, regardless of their location. POLST specifies the patient s preference for CPR, administration of antibiotics and fluids, use of mechanical ventilation, and provision of artificial nutrition. Early in 2011, SFHP partnered with the community based San Francisco Palliative Care Initiative and the Sutter Health Institute for Research and Education (SHIRE) to improve the quality of care for SFHP members in the last stages of life. The goal was to promote the use of the California POLST form for patients in the last stages of life and to evaluate the effectiveness of health plan sponsored interventions to promote POLST with its primary care provider network. SFHP developed and implemented an incentive program for the use of Physician Orders for Life Sustaining Treatments (POLST) forms. Funded 50% by SHIRE and 50% by SFHP, the incentive program provided a $75.00 to a group or physician for each submitted attestation certifying that a POLST conversation occurred with a patient. The incentive became effective in May 2011 and training began in April 2011 to targeted provider groups. SFHP and SHIRE together completed four major trainings specifically 23

24 targeting providers in the SFCCC Community Clinic Consortium, Department of Public Health, and North East Medical Services. As of August of 2011, two attestation forms had been received. SFHP scheduled follow up calls with trained providers to get feedback, identify barriers, and identify any additional support needed. We determined that the main reason for low uptake on the incentive component of the POLST initiative were the low numbers of older SFHP members at the outset of this program. We also learned from peer health plans that more intensive academic detailing type visits and support of providers is effective in generating completed POLST forms with patients; this level of staff resources were not a part of this POLST initiative but is something we would strongly consider for any future work on the important issue of patient centered end of life care. 2. Health Education and Cultural and Linguistic Services Health education and cultural and linguistic competency principles are actively integrated into our quality improvement activities. In making decisions about quality improvement interventions, we examine the demographic characteristics of our member population. In response to provider recommendations and member input, we continued many existing projects in Health Education SFHP maintains a library of health education materials in a wide range of topic areas. We make the materials available in both paper and online formats. Upon request, we also make materials available in alternative formats including large print, audio, or Braille. Our website includes an easyto navigate repository of educational materials that providers, members, and visitors can access and print. Currently, we have on line materials in multiple languages that address topics including asthma, diabetes, breastfeeding, and weight management. We continuously upload newly developed, and revised, materials to our website for both member and provider access Health Education on the Web To assess website use, we track the frequency of hits to our Health Education pages. In 2011, the Health Education sections of the SFHP website (Provider, Visitor, and Member sections) were accessed 3,858 times. Provider Section (total 1,877) Health Education Material for Members: 1,064 Health Education Material for Providers: 171 Health Education Classes: 459 HECP:

25 Member Section (total: 809) English: 690 Spanish: 36 Chinese: 83 Visitors Section (total: 1,172) English: 1,042 Spanish: 27 Chinese: Targeted Health Education Mailings As part of our quality improvement initiatives to promote preventive care and management of chronic conditions, SFHP mails health education materials to members. In 2011, we mailed information and health reminders on the following health topics: Immunizations for 0 2 year olds Well checks for 3 6 year olds Well checks for year olds Cervical cancer screening Breast cancer screening General women s health, ages 27+ General young women s health, ages General diabetes management, including information on exercise and nutrition Diabetic eye exams Initial health assessments Pregnancy education books What To Do When Your Child Gets Sick parent/caregiver education book Our quarterly member newsletter continues to be an important means for communicating health education messages to our members. The newsletter, Your Health Matters, regularly includes articles on topics such as child safety, member rights pertaining to language access services, wellness tips, and SFHP s community partnerships. In 2011, SFHP began the enrollment of a large number of Seniors and Persons with Disability. We are committed to serving their needs by offering any, and all, health education materials in alternative formats such as Braille, large print, audio, and tactile graphics for illustrations and maps. 25

26 2.2. Promoting Cultural Competency and Language Access Cultural Awareness Training In 2011, SFHP conducted or sponsored several Cultural Awareness Trainings open to SFHP staff and contracted medical groups and providers. The trainings offered in 2011 included the following: A. Improving Personal Effectiveness through Cultural Awareness Date: July 13 and 14, 2011 Target Audience: SFHP Staff Training conducted by N. Gene Ramos, Expert Consultant Training Objectives: Define culture, and why it matters for our work with members and each other. Discuss how cultural factors affect health care delivery. Discuss how cultural factors affect our work at SFHP. Discuss emergent issues for members who are Seniors and Persons with Disability. B. Cultural Awareness for Managers Date: July 27, 2011 Target Audience: SFHP Managers and Directors Training conducted by N. Gene Ramos, Expert Consultant Training Objectives: Review Improving Personal Effectiveness through Cultural Awareness presented to SFHP staff on July 13 and 14th. Identify responsibilities and liabilities for managers working with culturally diverse staff. Discuss staff management scenarios about how cultural factors affect our work at SFHP. C. Reducing African American Infant Mortality in San Francisco: A Cultural Competency Training for Providers Date: October 12, 2011 Target Audience: SFHP Provider Network Training conducted by Gene Ramos, Expert Consultant; Dr. Carol Miller, MD Training Objectives: Discuss infant mortality rates and disparities in San Francisco. Understand and delineate three ways to improve the patient encounter in the area of race and culture. Name three models of effective patient communication. Identify next steps in developing institutional cultural awareness. strengthen advocacy to eliminate disparities in African American infant mortality in San Francisco. 26

27 Language Access SFHP monitors language access through medical group oversight audits, grievances and provider network monitoring. A. Medical Joint Administrative Meeting with Contracted Medical Groups Dates: Multiple dates throughout Fall and Winter 2011 Target Audience: Medical Group Staff Contacts Kaiser Foundation Health Plan San Francisco Chinese Community Health Care Association (CCHCA) North East Medical Services (NEMS) Hill Physicians Medical Group (HILL) SFHP staff educated medical group contacts on resources and requirements for complying with State mandates. Resources are available to medical groups at any time and include the following: Cultural and Linguistic Services Requirements Tips for Communicating Across Language Barriers Tips for Working with Interpreters Employee Language Skills Self Assessment Tool Issues related to adding on members who are Seniors and Persons with Disability B. Reducing Disparities in Care: Examining HEDIS Rates by Race/Ethnicity and Language While we continue to make progress in improving our overall rates for almost all HEDIS measures in 2010, an analysis of HEDIS data from measurement year 2011 by race/ethnicity and language showed continued disparities in the rates for some measures. SFHP analyzes HEDIS data to identify health care disparities. We are currently working with our Quality Improvement Committee and Member Advisory Committee to identify health disparities and determine areas for targeted interventions. Some initial findings by focus areas from both Medi Cal and Healthy Families LOBs are summarized below: Access o English speakers (African Americans and Caucasians) have the lowest rates across children s access measures. Prevention o African Americans had the lowest rates across obesity prevention measures (BMI, Physical Activity, Nutrition Counseling). o Chinese speaking group had the best rates childhood immunizations measures. Women s Health o Prenatal rates were lowest for African Americans and highest for Caucasians. Among language groups, rates were lowest for English speakers and highest for Chinese speakers. 27

28 o Postpartum rates were lowest for African Americans and highest for Asian/Pacific Islanders. Diabetes o Across almost every diabetes measure, African Americans fared poorest. We are working with the Quality Improvement Committee to improve our ability to effectively analyze member data related to health care equity. Better analysis will lead us to design more targeted interventions to improve equity among the various language and ethnic groups represented in membership. Strategy #1: Self efficacy/communication for members: expand advertising and outreach and increase capacity of existing self management workshops to increase members health related self efficacy. Strategy #2: Health education materials development and dissemination: continue to increase outreach and promote culturally matched educational materials regarding well baby visits, overweight/obesity, heart health, and member use of ER for acute symptoms. Strategy #3: Training and outreach to providers: training to contracted health care providers, practitioners, and allied personnel regarding these findings to increase understanding of member needs; in addition, we will partner with our provider network to identify strategies for addressing gaps. 3. Measuring and Improving the Member Experience One of SFHP s top four organizational goals is to offer exemplary service to our members, participants, and providers. The Customer Service Department helps members understand and take full advantage of their health plan benefits. Members can contact SFHP Customer Service by phone, fax, TDD/TTY, , mail, or in person. By contacting Customer Service, members can get assistance with ID cards, PCP changes, covered benefits, medical bills, grievances, access to doctors, enrollment, renewal, disenrollment, etc. We represent a safety net for any member who needs help Providing Excellent Telephone Service Our members find it easiest to reach us by telephone. Therefore, we are committed to ensuring that we provide excellent customer service over the phone. One way we do this is by tracking and monitoring calls. Real time performance is displayed in the call center area so that Customer Service Representatives are aware of the performance and call traffic. We monitor our performance in several ways and continue to work on improving our processes. 28

29 Call Center Performance We received 70,072 incoming calls through our telephone automated distribution system in We met or exceeded our performance standards on the following metrics. Our service level, which measures efficiency and speed of service, was 93.8%, exceeding our goal of 90% by 3.8%. We continuously improve in this area. The industry benchmark for call abandonment is 5%; SFHP s average abandonment rate in 2011 was 1.4%. We maintained language coverage in our four threshold languages, English, Chinese, Spanish, and Vietnamese. Our Customer Service team speaks additional languages such as Russian and Burmese. Our Customer Service metrics electronic wallboard displays real time information throughout the day to remind us of our performance standards and to allow up to the moment tracking. The metrics we track are: Service level Total call volume handled Abandonment rate Total abandoned calls Calls waiting in different language queues Number of agents available at each language queue SFHP adopted a new electronic telephone system in 2011, to allow continued operational efficiency and improvement in our service to members. The phone system provides the following benefits to improve customer service: Customer Service staff can be assigned to different queues by the supervisor based on the volume of calls and calls waiting in queues in real time so that members calls can be answered promptly. Provide current queue status information to staff members so that they can take action appropriately to handle calls. Different levels of alerts are set with assigned colors. Staff can be informed easily about the status, which motivates staff to handle incoming calls more efficiently and promptly. Management can react to unusual situations and assign customer service staff based on skill level to take care of calls effectively New Enterprise Information Management Platform In 2011, SFHP acquired a new managed care platform, QNXT. Effective December 1, 2011, Customer Service staff can provide information of benefits, and claims and authorization status to members and providers immediately without transferring calls to other departments. Benefits information 29

30 provided to members is more accurate and specific to the member. More member inquiries can be handled with a single call Member Satisfaction with Customer Service The Customer Services Department conducted its tenth annual member satisfaction survey in the last quarter of The purpose of this survey is to assess the level of satisfaction with the services provided by the Customer Service Department and to improve our services based on feedback from members. The survey was conducted in English, Spanish and Chinese. The format was the same as in previous surveys: members provided responses to the following statements regarding recent interactions and experience with SFHP Customer Service staff. My call to SFHP Customer Service Call Center was answered quickly. I received polite service from the Call Center Representative. I received the information that I needed. 8,403 survey cards were sent to members who contacted Customer Service by phone during the months of October through December % more members were surveyed in 2011 than in The response rate for the survey cards was 14.1%. Chinese speaking members had the highest response rate at 19.11%. An average of 95.5% of our members reported satisfaction with the services provided by Customer Service team, 94.7% for quick service, 96.6% for polite service, and 95.2% for receiving needed information. The results were consistent with those achieved in previous years. We have been getting excellent results from this survey through the years. These very positive responses from our members indicated that they were highly satisfied with the services they received from the SFHP Customer Services team in Satisfaction Rate Member Satisfaction: Telephone Service % 80.00% 94.73% 96.61% 95.20% 60.00% 40.00% 20.00% Quickly Polite Information 30

31 3.4. Monitoring Member Grievances SFHP monitors grievances on a quarterly basis to identify trends and identify ways to improve service to our members. In addition to looking for trends in our grievances, we also monitor the way we handle grievances for timeliness and regulatory compliance. Our goal is to provide excellent service and, at a minimum, meet DMHC standards for responding to and resolving grievances (response within 30 days). Below is an overview of the grievances received in 2011 and key indicators showing our compliance with regulatory standards: 211 member grievances were processed by SFHP and Kaiser. 161 of these grievances were non delegated and handled directly by SFHP, all which were resolved within the 30 day period mandated by DMHC. 18 grievances (11%) handled by SFHP were resolved by the next business day. 149 grievances (89%) handled by SFHP were resolved within 30 days. 100% of non exempt grievances met state regulatory requirements for timeliness of resolution letters sent within 30 days. Four grievances (2%) handled by SFHP had a Cultural and Linguistic Component Tracking and Trending Grievances In order to identify patterns and changes in our grievances, we report grievance rates by line of business, medical group, and grievance category. Looking at the comparison of SFHP annual rates below, Medi Cal has the highest rate per 1000 members per month, with an increased rate in 2011 from 2010, which is attributed to the transition of SPD Medi Cal recipients into SFHP. Healthy Kids saw an increase in the grievance rate, while Healthy Families decreased. Healthy Workers grievances decreased by 10%. The top three categories were Denials/Refusals, Quality of Service, and Enrollment. Below are the grievance statistics for 2011 and the highlights from our analysis. Lines of Business ranked by grievances per 1000 members per month: Line of Business 2010 Grievance Rates 2011 Grievance Rates Medi Cal Healthy Kids Healthy Workers Healthy Families

32 Medical Groups (SFHP & Kaiser) ranked by grievances per 1000 members per month: Medical Groups 2010 Grievance Rates 2011 Grievance Rates University of California San Francisco Brown and Toland Physicians N/A 0.47 Hills Physicians Community Health Network Chinese Community Health Care Association Kaiser Permanente North East Medical Services Grievances handled by SFHP by grievance category: Category 2010 Grievances 2010 % of Total 2011 Grievances 2011 % of Total Denials/Refusals 54 49% 64 40% Quality of Service 26 23% 53 33% Enrollment 5 5% 13 8% Access 9 8% 10 6% Quality of Medical Care 7 6% 9 6% Benefits/Coverage 2 2% 6 4% Billing 6 5% 5 3% Cultural and Linguistic 1 1% 1 1% Other 1 1% 0 0% Total % % 32

33 Important Findings of 2011 Denials/Refusals remained the top category and increased by 19% from Quality of Service issues increased by 104% from o Of the 53 grievances filed, 35 were regarding poor communication with providers, medical office staff, and SFHP staff Ensuring Member Satisfaction Experience surveys assist us in evaluating the quality of service our members receive from SFHP and from our provider network. In 2011, SFHP implemented strategies to improve health plan services and provider level care, using SFHP s scores on the Medi Cal member experience survey in 2010 as our guide. Specifically, as a result of the 2010 survey results, SFHP was requested to address three target areas for improvement: rating of all health care, customer service, and getting needed care. Our interventions to address this survey feedback are described below Improvement Initiatives based on 2010 Medi Cal CAHPS Results Our trended member satisfaction results, as measured by the CAHPS survey, indicate that there is room for improvement, particularly in the areas of provider patient communication, shared decision making, and access to appointments. As reported previously, launched two year long collaboratives in 2010 aimed at improving two key dimensions of the patient experience: access to care and patientcentered communication. These pilots ended successfully in April The access collaborative, Optimizing the Primary Care Experience (OPCE), focused on improving access to appointments and office efficiency during appointments. Four clinics participated in the program. National expert Dr. Mark Murray provided content expertise; a SFHP staff practice coach trained in performance improvement provided ongoing project support. The goals of the OPCE project were to: 1) Reduce waiting times both for and at appointment services, and 2) Optimize health outcomes by improving clinical care delivery. The results of the project as of April 2011 included each clinic achieving at least a 50% reduction in their patients wait time to see his or her own primary provider or primary care team member, as measured by the Third Next Available Appointment (TNAA) measure. Two clinics saw their delays shortened to within one week for regular return appointments. All clinics continued tracking their progress on delay reduction through 2011, with less frequent reporting to SFHP after the project s end. All clinics shared successes with one another and other clinic sites in a series of improvement meetings. The second collaborative, Patient Centered Communication (PCC), focused on targeted changes 33

34 to improve the provider patient and staff patient relationships so that patients feel their most important concerns are addressed during their visit. Five clinics participated. Communication technique trainings were led by the Institute for Healthcare Communication. These clinics were also supported by a SFHP practice coach. The goals of the PCC project were to: 1) Optimize health outcomes by improving communication and shared decision making, and 2) Improve provider, staff and patient satisfaction. The CAHPS visit based survey was administered using a standardized methodology at three points in time during the project baseline, 3 months post intervention, and 6 months post intervention. Highlights include the following results: The five clinics showed improvement from baseline in all provider communication and composite measures, staff communication and composite measures, and in global measures such as overall rating of provider and recommending clinic to family and friends. All five clinics improved at least 5% in two measures. There were four statistically significant improvements (p<.10): doctor spends enough time, doctor s explanations are understandable, doctor provides easy to understand instructions, and clerks and receptionists are helpful. Four out of the five clinics improved in more than 50% of the measures from baseline; one clinic improved in all measures; followed by two clinics that improved in 75% of the measures. The table below shows final project results. The final 10 month post intervention surveys were fielded in December 2010, with data aggregated in January 2011 to report at the project s completion in March Measure Baseline Survey Final Survey Absolute Change Doctor knows important medical history 90.3% 91.9% 1.5% Doctor explanations easy to understand 94.8% 95.0% 0.2% Doctor shows respect 96.6% 96.9% 0.3% Office Staff (composite) 94.1% 95.9% 1.8% Rating of provider 86.1% 89.0% 2.9% Patient recommends clinic 89.7% 92.7% 3.0% Clerks and receptionists respectful 96.0% 96.9% 0.9% Clerks and receptionists helpful 92.3% 94.8% 2.5% Provider Level 2011 CAHPS Survey: Preliminary Results by Medical Group and Line of Business In 2011, SFHP also invested in improving the member experience by making patient experience improvement in itself one of four measurement domains in our pay for performance program, 34

35 PIP. See section for more information on PIP. As part of PIP, the Clinician and Group version of the CAHPS survey was administered in October through December via an automated telephone response system. For the first time, following data analysis underway in 2012, SFHP and its providers will have statistically valid survey data at the practice level to guide improvement. Data analysis and survey results were finalized outside the scope of the period covered in this report. However, preliminary results available at this writing show valuable information that will help SFHP and our providers continue our partnership in the Practice Improvement Program to improve patient experience. For example, the highest performance across respondents in Medi Cal (704 total valid responses), Healthy Families (411 total valid responses) and Healthy Kids (120 total valid responses) was on the question of overall rating of providers, with 86% of respondents in all three groups giving their providers the highest scores. This value was comparable to a benchmark survey conducted across the Massachusetts state Medicaid program in 2008, where the score was 85%. SFHP will use the data from this provider level CAHPS survey in its improvement work with clinics and medical groups in 2012, as the pay forperformance program PIP requires all participating organizations to complete plans based on their CAHPS scores and SFHP s recommendations for improvements. 4. Quality Improvement Projects (QIPs) All Medi Cal managed care health plans are contractually required by the Department of Health Care Services (DHCS) to develop, implement, and evaluate two State mandated quality improvement projects (QIPs). The Department lead statewide collaborative, and either an internal QIP or a health plan lead group collaborative; State mandated QIPs run for a period of three years. During 2011 SFHP completed the Reducing Avoidable Emergency Room Visits QIP, and continued its work on the Improving the Patient Experience QIP Reducing Avoidable Emergency Room Visits QIP The Reducing Avoidable Emergency Room Visits QIP (ER QIP) was a DHCS led project; it started in 2008 and closed in October of SFHP analysis showed that, for SFHP members, St. Luke s Hospital has the highest ER rates, and that the majority of these SFHP members belong to the Hill Physicians Medical Group. Therefore, during the time this QIP was active, SFHP initiated a series of activities aimed at reducing avoidable ER utilization at St. Luke s Hospital (SLH) for members with Hill Physicians Medical Group (HPMG). Although we have met our requirement with the Department for this QIP, we continue the following activities for this project: ER data from St. Luke s Hospital is reviewed weekly 35

36 A SFHP health navigator calls patients who had a recent visit to the ER to review alternatives and ensure the patients know about the Nurse Advice Line and the availability of their PCP. Hill Physicians offers case management services to members with three or more ER visits within six months. SFHP sends an ER History report to the St. Luke s providers for patients who had three or more ER visits within six months, and encourages them to reach out to these patients. Our goals: Decrease overall emergency room utilization for SFHP members utilizing the St. Luke s ER by 2% by December 2012 (from 24% CY2009 to 23.52% CY2012) Decrease avoidable ER rates for SFHP members utilizing the St. Luke s ER by 10% by December 2012 (from 5% CY2009 to 4.5% CY2012) Improving the Patient Experience QIP SFHP selected Improving The Patient Experience as its internal QIP because year to year trended results from our CAHPS survey showed that SFHP lags behind the state and national benchmarks in the areas of provider communication, shared decision making, and timely access to appointments. The focus of the QIP are to improve overall ratings of care, targeting interventions in providerpatient communication since this is highly correlated with overall ratings of care and therefore a high leverage area in which to begin improvements to impact the patient experience with care. For this QIP, the eligible population for receiving interventions is all Medi Cal members. Members with special health care needs were not excluded from the study. However, in the CAHPS survey process, a random sample minus ineligible members were included. Ineligible members met at least one of the following criteria: they were deceased, had invalid SFHP coverage, were mentally ill or physically incapacitated (adult population only) or had a language barrier. Our overarching aim is to improve our CAHPS scores by 25% in the following measures/composites by 2013: Rating of all health care Rating of personal doctor To accomplish our aim, year 1 focused on testing proven interventions effective in other organizations in a sample of five of our community clinics (pilot clinics) that care for a high number of Medi Cal members to achieve three goals for the year: 1) understand how to adapt the interventions to make improvements in our environment; 2) learn about resources and infrastructure required to support clinics in making improvements; and 3) to learn about effective strategies for engaging clinics and their staff in making improvements. Our testing phase was completed by April 2011 (last measurement cycle) with five clinics that provide care to 5,109 Medi Cal members that represents 14% of our total Medi Cal membership. Unlike larger medical groups and Independent Practice Associations (IPA), safety net community 36

37 clinics do not have the quality improvement infrastructure to support training and measurement; therefore, providing technical assistance to the community clinics was a priority for SFHP in the first year of the overall project. 5. Provider Relations 5.1. Provider Network Access Monitoring SFHP closely monitors the adequacy of our provider network to ensure that our members have access to the care they need in a timely manner. We measure network access in a variety of ways to assess language capacity, wait times, and availability of specialists and PCPs. SFHP joined the ICE (Industry Collaboration Effort) Workgroup to develop a standard methodology and survey tool for monitoring appointment availability Access to Primary Care Providers Our stable network of PCPs is more than adequate to care for our approximately 74,000 members. Regulatory requirements set forth in our Knox Keene license guide our accessibility standards. State regulations require that a primary care physician panel should contain no more than 2000 patients. While our ratio of members to PCPs falls well within those standards, we cannot accurately measure true PCP panel size because our PCPs see patients from several different payors as well as care for the uninsured. Below is a table that shows a snapshot of our PCP and member counts: Medical Group Members < age 18 PCPs caring for children Members > age 18 PCPs caring for adults BTP 1, , CCHCA 4, , UCSF 3, , NEMS 7, , HILL 3, , CHN 10, , Note: PCPs caring for children include physician and mid level PCPs designated as adolescent medicine, family medicine, family practice, general practice, pediatric adolescent medicine, or pediatrics. PCPs caring for adults include physician and mid level PCPs designated as family medicine, family practice, general practice, geriatric medicine, internal medicine, or Ob/Gyn. 37

38 Access to Specialists We regularly monitor the number of physicians in our network in specialty areas that our members access the most. UCSF provides the bulk of specialty care even for members assigned to other medical groups. The table below shows that each of our medical groups had at least one specialist in every key specialty in 2011: Specialty BTP CCHCA CHN NEMS HILL UCSF Total Cardiology Endocrinology Gastroenterology Ob/Gyn Ophthalmology Pulmonary Disease Radiology Total PCP Language Concordance SFHP works to ensure that our members have access to either a primary care provider who speaks their language or have access to professional interpreter services. We monitor the number of PCPs who speak Chinese, Spanish, Vietnamese and Russian because they are the most common non English languages spoken by our members. Members are encouraged to choose a PCP when they enroll, but if they do not choose a PCP, our systems help optimize the number of members who are assigned to a PCP that speaks their language. The table below shows the number of PCPs who speak one of the predominant SFHP threshold languages at the end of 2011: Medical Group Chinese Speaking PCPs (Cantonese, Mandarin or Both) Spanish speaking PCPs Vietnamese speaking PCPs Russian speaking PCPs BTP CCHCA CHN NEMS HILL UCSF Total

39 5.2. Clinical Quality Monitoring (SFHP) has a Memorandum of Understanding (MOU) with Anthem Blue Cross of California to share review of all jointly contracted primary care providers and sites, in order to ensure compliance with criteria from the California Department of Health Care Services (DHCS). In addition, SFHP delegates and oversees the full scope (FS facility site and medical record) reviews and interim monitoring (IM) activities with its medical groups. In January 2010, SFHP delegated facility site reviews to Kaiser Foundation Health Plan after conducting a side by side review with their nurse reviewer and collaborating on the corrective action plan for their new Family Health Center. The site review portion evaluates 139 criteria in the areas of access and safety, personnel, office management, clinical services, preventive services, and infection control. The medical record review portion evaluates 32 criteria in the areas of chart format, documentation, continuity and coordination of care, and preventive care. Below are summaries of the full scope (facility and medical records) and interim monitoring reviews conducted in Summary of Facility Site Reviews Medical Group Brown and Toland Physicians (BTP) Chinese Community HealthCare Association (CCHCA) Community Health Network (CHN): Dept of Public Health clinics, Consortium Clinics, Sister Mary Philippa, BAART, and four solo practice providers # Reviews in 2011 Scores 90% 100% Scores 80% 89% Scores <80% new clinics 7 (3 new, 2 4 periodic) new clinics (3 new, 8 periodic) Kaiser Hill Physicians (HIL) NorthEast Medical Services (NEMS) 2 (1 was 78% and fully corrected; 1 termed from SFHP) (1 reopened and 1 periodic) UCSF 2 new clinics Totals in

40 Summary of Medical Record Reviews Medical Group # Reviews in 2010 Review Scores 90% 100% Review Scores 80% 89% Review Scores <80% BTP 2 new 1 new 0 0 CCHCA CHN 2 new; periodic KAISER HILL (at 75% termed from SFHP) NEMS UCSF 1 new clinic Totals in FSR and MRR Summary: 90% of the 38 facility site reviews (FSR) scored over 90%; 2 were Not pass and were reported to the providers participating medical groups 79% of the 28 medical record reviews (MRR) scored 90% or better; 1 was Not pass and was reported to the provider s participating medical groups There were 38 site and 28 record reviews completed in calendar year Fourteen initial reviews were conducted in clinics or provider offices that had not been in our network previously. One additional initial review was in a North East Medical Services clinic that re opened in December The network primary care providers who received a score below 80% ( not pass per the Department of Health Care Services) were taken to the SFHP s February 9, 2012 Physician Advisory/Peer Review Committee. The primary care internal medicine provider with Chinese Community Health Care Association s (CCHCA) network (FSR score of 76% and MRR score of 75%) decided to term from effective January 1, The PCP who scored 78% on his facility site review is with four of our medical groups: Hill, BTP, CCHCA and CHN. The results were shared with each medical group and with Anthem Blue Cross. Hill and CCHCA nurse reviewers conducted the review. The Hill nurse reviewer returned multiple times as the corrective action plan was being implemented and was able to sign her approval on August 29, This provider s office will be reviewed again for critical elements and the items on the corrective action plan during the interim monitoring visit. Interim Monitoring/Focused (IM) reviews are conducted approximately 18 months following the last facility site review. There were 51 completed in

41 Summary of Interim Monitoring (IM) Reviews: Medical Group # Interim Monitoring Reviews by Medical Group BTP 1 CCHCA 21 CHN 6 KAISER None to complete in 2011; all FSRs HILL 14 NEMS 6 UCSF 3 Total in SFHP continues to distribute its Facility Site Review Survival Toolkit to newly contracted provider offices/clinics, which will be available on our website in Other resources include the Immunization Vaccine Information Statement (VIS) binders, since federal law requires that VIS forms be shared before obtaining consent for immunizations. SFHP added three new nurse reviewers in ; 1 with NEMS and 2 with CCHCA. All of SFHP s nurse reviewers participated in the Department of Health Care Services Inter Rater Reliability (IRR) chart review conducted by SFHP Master Trainer Betsy Price, and all nurses passed. Challenges for 2012: DHCS released new facility site and medical record review tools and guidelines in 2011; to implement in January All of SFHP s certified nurse reviewers were trained on these new tools and guidelines; they were used for the 2011 IRR. SFHP has distributed electronic FSR and MRR tools that will calculate scores; we will be monitoring the effectiveness of this process. SFHP is implementing a new 2012 FSR Work Plan on an external Share Point Site; we will be monitoring the effectiveness of this new process Medical Group Oversight Audit Results 2011 To the degree that SFHP delegates functions to its medical groups, it implements an oversight program that makes clear the division of responsibilities. These functions are delineated annually in the Medical Group s Responsibilities and Reporting Requirement document (R3 Grid) which is approved by the Executive Director or Chief Executive Officer at the medical group and then signed by SFHP s CEO. 41

42 Through required submissions of reports, policies and procedures, and work plans, and through an annual medical group audit, SFHP monitors how the medical groups have implemented its delegated responsibilities. Delegated standards are from our contracts with the Department of Health Care Services and the Department of Managed Health Care. The plan maintains ultimate responsibility for these delegated functions and has oversight of these functions Delegated Audited Functions as Listed and Delineated in the Medical Group s Responsibilities and Reporting Requirement Grids Network Grievances (Member Rights & Responsibilities) Credentialing Cultural and Linguistic Services Utilization Mgmt, Case Mgmt,/SPD Care Support DHCS Contract Requirements (Addendum) DHCS Timely Access Regulations and DHCS Dwell Studies Claims Kaiser Yes Yes Yes Yes Yes Yes Yes CCHCA NA Yes Yes Yes Yes Yes Yes NEMS NA Yes Yes Yes Yes Yes Yes HILL NA Yes Yes Yes Yes Yes Yes BTP NA Yes Yes Yes Yes Yes Yes CHN NA Yes In NA NA NA NA contract St. Mary s NA Yes Yes NA NA NA NA UCSF NA Yes NA NA NA NA NA Medical Group Key: Kaiser: Kaiser Foundation Health Plan San Francisco CCHCA: Chinese Community Health Care Association NEMS: North East Medical Services HILL: Hill Physicians Medical Group effective 8/1/10 BTP: Brown & Toland Medical Group effective 11/1/2010 Credentialing Contract Key: CHN: Community Health Network with San Francisco General Hospital s Medical Staff Office contracted to perform credentialing services St. Mary s: St. Mary s Medical Staff Office is contracted to perform credentialing services for Sister Mary Philippa Health Center UCSF: University of California San Francisco, Medical Staff Office contracted to perform credentialing utilizes a standard industry tool to perform the quarterly and annual reviews / audits; meets with, and offers technical support on an ongoing basis to, its medical groups 42

43 and Medical Staff Offices; reviews requested annual, biennial, and/or quarterly submissions; and develops and signs off on any corrective action plans (CAP) when deficiencies are identified. Oversight Audits by Medical Groups (See Attachment 1 for detailed results.) Medical Group Audit Date Kaiser Foundation Health Plan October 18 and 19, 2011 CCHCA October 26, 2011 Claims audit: October 26, 2011 NEMS November 7, 2011 HILL October 24, 2011 Credentialing audit: October 10, 2011 Claims audit: October 13, 2011 BTP October 11, 2011 Claims audit: October 3, 2011 Credentialing Oversight (Credentialing P&Ps and Initial & Recredential Files) SFGH Medical Staff Office for the Community Health Network St. Mary s Medical Staff Office for Sister Mary Philippa Health Center UCSF Medical Staff Office for the Medical Center and Clinics Audit Date December 9, 2011 December 15, 2011 December 1, 2011 SFHP decisions following the oversight audits in 2011: 1. Timely Access Regulations: Medical Groups informed their providers about the regulations. They disseminated the information to practitioners, office staff, and members. SFHP did not recommend any major corrective action plans. However, during the audit periods we found opportunities to help our medical groups keep their providers and members informed and upto date with the requirements. For 2012, SFHP is developing a Timely Access Regulation Training Manual for providers, which will serve as a review guide and a training tool for new providers. 2. Dwell Studies: Both of our newest medical groups (BTP and Hill) are developing primary care provider dwell studies (the total amount of time a patient waits from their scheduled appointment to the moment the doctor walks into their exam room to start the appointment). SFHP is helping the medical groups by sharing tools, reports and processes. 43

44 3. Credentialing: In 2010 oversight audits, SFHP emphasized the importance of training new providers utilizing the SFHP Key Summary of Information document within ten business days of the provider s credentialing approval date. During the 2011 audits, we had three corrective action plans for this requirement: one medical group (Hill) and two of our medical staff offices (UCSF and St. Mary s). Each implemented a corrective action plan that was fully approved by SFHP. In addition, SFHP is working with Hill to have mid level credentialing information, available onsite for our audit. DHCS requires the maintenance of current mid level licenses and DEA licenses. 4. DHCS Addendum: SFHP added Seniors and Persons with Disabilities (SPD) deliverables to its Responsibilities and Reporting Requirement grids in 2011, per the 1115 Waiver requirements. Medical groups were required to have Care Support (complex case management, basic case management, person centered planning, discharge planning and transition of care) policies and procedures. In addition, they need to have job descriptions for the full time equivalent staff working on these requirements. Overall, our medical groups did very well in implementing these new requirements. SFHP is supporting the development of their Care Support activities by offering a PMPM reimbursement that was approved by the SFHP Governing Board, for monthly reporting that we will start receiving quarterly in April Grievances (delegated only to Kaiser Permanente): SFHP added quarterly SPD grievance reporting during 2011, as a response to the DHCS s SPD Plan Reporting Instructions document. Kaiser forwarded its SPD report(s) to SFHP. In addition, we continue to receive quarterly Compliant, Grievance and Appeal reports from them. 6. Cultural and Linguistic Services: Four medical groups were identified as having deficiencies in Cultural and Linguistic Services requirements: CCHCA, NEMS, and BTP did not show proof of staff training for cultural competency. Hill and BTP did not show proof of informing members of access to free interpreter services 24/7 or of having an interpreter language skills assessment tool in place for staff and providers with member contact. These medical groups were given Corrective Action Plans to rectify this issue. 7. Claims: There were no claims corrective action plans in The results from the annual audits are shared with the Quality Improvement Committee. All audit deficiencies are being incorporated into the Medical Group Responsibility and Reporting Requirement grids and will be included in the 2012 oversight audit tools for Grievances, Credentialing, Utilization Management, SPD Care Support/Case Management, DHCS Addendum, Cultural and Linguistic Services, Claims, etc Provider Satisfaction Annually, SFHP conducts a Provider Satisfaction Survey to gather information about network provider issues and concerns with SFHP and our members. Similar to 2010, the survey was evaluated by our Physician Advisory Committee, and SFHP staff eliminated questions that would not 44

45 yield actionable feedback. In December of 2011, 136 out of 402 PCPs and clinics returned surveys, giving us a response rate of 34%. Once again, a mixed method approach was used; sending hard copies of the survey to those who did not have addresses listed with SFHP, and survey for ease of completion through the internet for all others. This is the first year that BTP was included in the survey, as they joined the plan in November Below are response rates by medical group. Medical Group Number of Responses Response Percentage Community Health Network (CHN) 70 42% North East Medical Services (NEMS) 16 40% Chinese Community Health Care Association (CCHCA) 15 30% University of California, San Francisco (UCSF) 12 16% Hill Physicians (HILL) 12 48% Brown and Toland Physicians (BTP) 11 26% Total % NOTE: Kaiser was excluded from data collection, as in previous years, because of the relative distance of Kaiser Providers from the Kaiser SFHP relationship, as Kaiser is fully delegated for all functions. Providers report 75% overall with SFHP. This is, however, a decrease from 80% in The decline in satisfaction may be related to several challenges and changes in Mandatory enrollment of Medi Cal SPDs into managed care presented providers with new policies and processes necessary to ensure continuity of care for new members with complex needs. The implementation of our new managed care system presented several challenges including a loss of functionality of the provider portal to check UM Authorizations, and increased turnaround time for authorization reviews. In addition, there were considerable SFHP staff changes during this time that may have affected our relationships with providers. Despite these issues, the general feedback from the survey included positive reviews as well as constructive critique. The following is a summary of other key findings: Strengths: Exemplary Service: Providers reported a high level of satisfaction with Customer Services, Provider Relations, Clinic/Provider Visits, and reports received (HEDIS, ER utilization, and outreach lists). More providers reported being satisfied with the utilization management pre authorization process and referral procedures. 45

46 Quality Care & Access: Increase in satisfaction with timely access to urgent care, non urgent primary care, and non urgent specialty care. For those participating in Strength in Numbers programs, high levels of satisfaction were expressed on all components. Opportunities for Improvement: Survey Sample: Increase promotion of the survey completion in order to improve the percentage of providers who participate in the survey to give us more complete feedback. In 2012, we will be targeting a return rate of 50% of our primary care network. Pharmacy Improvements: Explore options for increasing satisfaction with the Pharmacy formulary, breadth of therapeutic options and friendliness of network pharmacies. Online Resources: Identify ways to improve the use and satisfaction with the various functions of the SFHP public website and secure provider website. Looking ahead, we seek to further our ability to leverage resources that aid our improvement efforts. This year, we are making a concerted effort to conduct site visits that aim to develop relationships further and address providers concerns. We continue to work towards making meaningful impacts on increased Provider Satisfaction with SFHP Provider Education and Training In response to feedback from our Provider Satisfaction Survey, we continued to work to make more resources and training available to our providers. In 2011, we expanded the content for providers on our website with the following: Health education materials in our threshold languages that can be downloaded and printed for distribution at the provider office. New links to important member materials, such as Advanced Directives in all threshold languages. Updated best practices in key practice areas such as access, chronic care, office management, pain management, standing orders, clinical guidelines, etc., to determine authorization for safely net providers. Updated community resources for providers Managed Care 101 SFHP maintained a curriculum to inform new providers about the basics of working with managed care plans. Training content includes information about SFHP history, lines of business, network structure, membership figures, benefits (medical, pharmacy, vision, dental and behavioral health), how to obtain authorizations, website resources, health education, and 46

47 more. We provided this training to Internal Medicine and Pediatric residents through UCSF and SFGH. 6. Care Management Services SFHP and its medical groups work under a Utilization Management Program and a set of policies and procedures to ensure that effective and appropriate health care services are delivered to our members. These policies are based on sound clinical principles. Under our QI Program, we monitor utilization as well as continuity and coordination of care. We comply with strict standards for issuing denials and responding to appeals to assure members rights are protected. SFHP Quality Improvement Committee and Physician Advisory and Peer Review Committee address instances of poor quality Utilization Management SFHP provides utilization management services for members assigned to UCSF, members assigned to the community health centers, and in some instances to members assigned to other medical groups to whom SFHP delegates prior authorization responsibilities of medical services. We monitor inpatient admissions and emergency department visits for our provider network. In 2011, we continued to focus our efforts on making sure services were utilized within the members assigned medical group. Inpatient Bed Days In 2011, utilization data for Medi Cal changed dramatically with the mandatory enrollment of SPDs into managed care. Enrollment began in June and we observed an immediate increased in utilization. To address the increase in utilization and needs of the SPD population SFHP implemented a Care Support program. The program targets members with complex medical needs and high service utilization and is described in more detail below. The acute hospital bed days per 1000 members per month for Medi Cal SPD members was This is a significant increase from the 2010 rate of 74.1 and is likely attributable to the complex health and social needs of the newly enrolled SPD members. The rate for Healthy Kids for 2011 was 2.1, similar to the 2010 rate of 2.3. For Healthy workers the 2011 rate was 14.7 compared to the 2010 rate of For Healthy families the 2011 rate is 1.5, which is lower than the 2010 rate of 2.1. SFHP will continue to monitor and analyze the data to better understand utilization trends. 47

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49 Emergency Room Visits SFHP Medi Cal non SPD members emergency room usage was 25.4 visits per 1000 member per month, and for SPD members the rate was 69.2 per 1000 member per month. The national average ER usage rate as reported in JAMA 2010 is per 1000 member per month. We are working to better understand how SFHP Medi Cal SPD members emergency room utilization compares to similar populations in other managed Medi Cal plans. We have also begun to identify members with high ER use and to intervene through the Care Support program to encourage them to seek care in more appropriate settings. The usage rate for our other lines of business is significantly lower than that of Medi Cal members. This is most likely because the members of the other lines of business are generally younger and healthier. The annual average of ER visits per 1000 members per month for Healthy Workers was 11.9 for 2011, which has decrease from the average of 12.1 in

50 50

51 Inpatient Admissions The acute hospital admission rate for Medi Cal non SPD members was 3.5 acute admissions per 1000 member month per The rate for Medi Cal SPD members was 16.0 per 1000 member per month. The Medicaid average is 4.6 admits per 1000 members per month. As with the ER visits, we are working to compare the SPD admission rate to other comparable populations. The Healthy Families acute hospital admission rate decreased slightly from 0.5 to 0.4 admits per 1000 members per month, similar to rates in 2009 and In January through October of 2011, the Healthy Kids admission rate was 0.9 admits per 1000 members per month, which is the same as the admission rate in The admissions rates for Healthy Workers in January through October 2011 at 2.8 admits per 1000 members per month was similar to what we saw in admits per 1000 members per month. 51

52 Utilization Management Notice of Action (NOA) Letter Audit The Utilization Management Department has measures in place to ensure members receive NOA letters meeting regulatory guidelines and strict quality standards. In 2010, the Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS) audited SFHP. Pharmacy and medical authorization request files were reviewed by the DMHC/DHCS auditors for medical decision, completeness, appropriate notification language and fit with member language needs. SFHP passed the audit with one minor corrective action plan formatting of DMHC and DHCS phone numbers needed to be bolded; this was remedied. In 2011, we audited the letters internally and no errors were found. With the implementation of 52

53 the new managed care system, we clarified denial reasons to be more easily understandable to members and providers. We will continue to monitor the utilization management and NOA letter process to ensure quality and efficiency Patient Navigator Pilot Background SFHP, Healthy San Francisco, and St. Francis Memorial Hospital decided to collaborate and create a Patient Navigator pilot program, funded by the three institutions. The patient navigator staff position was hired by SFHP. The program built on a previous navigator program, which was a joint effort between South of Market Health Center and St. Francis Memorial Hospital. The program launched in May 2010 and continued through July 2011, with a full time Navigator housed at St. Francis. Our navigator was well suited to the population served in the progam, as she had previous experience working with low income populations with a high prevalence of substance use. The program was designed as a pilot, to test the hypothesis that putting a full time navigator in the emergency department would increase the ability of patients to access primary care follow up appointments, and keep the appointments. The theory was that the personal touch and the focused care coordination of the Navigator would increase the engagement of the patients, and the willingness of the clinics to make the urgent appointments available. The over arching goal was to decrease over use of the emergency room for primary care sensitive conditions. The pilot initially aimed to also navigate patients into primary care after an inpatient stay, but that part of the pilot never was fully launched, due to transitions in case management leadership at the hospital at that time. Results The program was not designed as a research study, and there were IT challenges that prevented the development of a database early in the program. Therefore we cannot yet answer the question did this program prevent ER overuse or did this program save money? St. Francis is working on an analysis of utilization data to see if this question can be answered in the future. The navigator screened over 4,029 patients for navigation through chart review and referral, and completed 689 navigation encounters for unduplicated patients in the first year. The navigator successfully coordinated follow up care for more than 65% of those eligible for navigation that needed coordinated medical follow up. Of the 425 patients requiring primary care follow up, 54% kept their medical home appointments, 27% no showed, and the remaining 19% were canceled, rescheduled, or we were unable to verify the outcome of the appointment. A 27% no show rate for this high utilizing, unengaged population was considered a very successful achievement. 53

54 Impact on Identified Barriers To Care Many patients who were assigned to medical homes had difficulty accessing urgent appointments when needed, often because they had not previously established care at the clinic. A big breakthrough from the navigator program was the negotiated agreement from SF community and public health clinics to prioritize high risk patients for urgent appointments, even when the patient may not have established care at that site. The year long Patient Navigation pilot showed that the personal touch of an in person patient contact, and the focused care coordination effort of a talented navigator, were successful in achieving high patient show rates and low no show rates for a transient population not yet bought into the value of primary care. The program also demonstrated that improved communication (and facilitated medical records) between an emergency department and primary care clinics can successfully allow urgent follow up appointments to be scheduled directly from the emergency department, decreasing one of the barriers to follow up care. The financial and utilization analysis of the program is still pending Care Support Program In preparation for the addition of the SPD members, SFHP implemented a Care Support Program in March The multidisciplinary team consists of the Medical Directors, Pharmacist, Manager of Care Management, Care Managers (RNs and MSW) and non licensed care coordinators. The program staff works closely with the utilization management team. Through this program, high utilizer and high risk members are identified and assisted with care coordination and case management for complex medical needs. SFHP works closely with its delegated groups and assists them in offering support for SFHP members. Ongoing data collection is in progress to measure the success of the program. We have implemented several pilot programs for the management of these members. We will monitor the impact of interventions closely and redesign the program as necessary for improved effectiveness Coordination of Care with Community Agencies and Waiver Programs SFHP members who need specialty care are referred by their primary care practitioners to specialists who provide these services. Members may also receive services from many agencies in the community with which SFHP has Memorandums of Understanding. These community programs include California Children s Services, Golden Gate Regional Center, Early Start, Women, Infants and Children (WIC), Community Behavioral Health Services, Sexually Transmitted Disease/Infections Services and the Tuberculosis Direct Observed Therapy (TB DOT) Assistance Program. SFHP members are also eligible for services from the federal waiver programs: HIV/AIDS Waiver Program, the Multipurpose Senior Services Program, Nursing 54

55 Facility/Acute Hospital Waiver, and Home and Community Based Services Waiver for the Developmentally Disabled. SFHP informs its members and practitioners about these services and how to access them through the SFHP Provider Referral Contacts brochure, Joint Administrative Meetings with our Medical Groups, PCP Meetings, and featured articles in our Provider Newsletters. In addition, SFHP is responsible for assuring that there is comprehensive care coordination when PCPs make referrals Care Management Training SFHP supports care management in the medical home, when possible. In the effort to help clinics and medical groups launch or improve existing care management programs, SFHP sponsored a training in June of 2011, Care Management Plus, that provided two days of training on motivational interviewing and care management skills, combined with 8 weeks of web based care management training. SFHP sent 70 providers and case managers to this training from our SFHP network Grant Program for Providers: Accessible Equipment SFHP aims to ensure a physically accessible provider network; for that purpose, SFHP supplied 35 wheelchair accessible bariatric scales and 25 height adjustable tables to all providers who requested assistance. This program will be expanded to allow financial assistance to providers who need certain equipment to pass the facility site review, in order to add more PCPs to our network. 7. Pharmacy Services SFHP assures the quality of its pharmacy services by offering a generous formulary, maintaining good relationships with pharmacy providers, and overseeing the pharmacy credentialing process. Our pharmacy services and formulary are constantly reviewed and updated by our Pharmacy and Therapeutics Committee, a sub committee of our Quality Improvement Committee. We monitor pharmacy usage monthly through cost and utilization reports. The pharmacy cost per member per month (PMPM) for Healthy Families and Healthy Kids increased slightly from 2010 to 2011 but represents only 3% of total pharmacy cost for SFHP Medi Cal pharmacy cost increased to $26 PMPM primarily due to the mandatory enrollment of Seniors and Persons with Disabilities (SPDs) starting June 1,

56 Pharmacy Cost PMPM: Medi Cal (MC), Healthy Kids (HK), Healthy Families (HF) Pharmacy Cost PMPM Medi Cal SPDs SFHP manages pharmacy costs through its generic preferred formulary and prior authorization process. In 2011, nearly 86% of prescriptions were filled with generic medications and the average cost per prescription (all prescriptions, brand and generic) was $38.76 (compared to $29.31 in 2010). The Increase in average cost per prescription is due to the increased utilization of specialty medications (i.e. oral oncolytics and medications to treat hepatitis C, rheumatoid arthritis, and pulmonary hypertension) that are highly utilized in the SPD population. SFHP recognized that pain management was a major challenge for many new SPD members, and many PCPs and clinics are not well equipped to manage the complex pain management needs of the new population. With that need in mind, SFHP created several resources to help providers in improving pain management services, such as low literacy informed consent and treatment agreements, translated into several languages. SFHP developed resource documents on cost effective prescribing, a guideline on how to safely transition patients from short acting or brand name opiates to long acting formulary 56

57 opiates, and resources to support improved pain management programs at clinics (such as office protocols). In addition, the SFHP pharmacist and associate medical director visited 19 high volume sites to provide workshops for providers on effective pain management. In late 2011, SFHP also contracted with Dr. David Gorchoff, an expert in pain management systems in community clinics, to work with clinics seeking technical assistance to improve their pain management programs, and he is starting work with three SFHP clinics. In 2011, our Pharmacy and Therapeutics (P&T) Committee met four times to maintain the SFHP formulary and added new drugs as appropriate. The Committee reviewed medications and supplies in the following categories: anti emetics, anti asthmatics/bronchodilators, anti epileptics, anticoagulants, NSAIDs, topical steroids, drugs used to treat neuropathic pain, allergic rhinitis, hypertension, diabetes, acne, HIV wasting, and ADHD. Additionally, the Committee reviewed drugs that were new to the market in 2011 to determine formulary status. The SFHP pharmacy department has maintained and optimized the electronic review and filing of pharmacy prior authorization requests. In 2011 we focused on new SPD membership and how best to accommodate the needs of these members. The Pharmacy Services department saw a dramatic increase in the number of medication authorization requests received. This increase led to greater opportunity to better manage our SPD membership in terms of offering alternatives for cost effective drug therapy. The Pharmacy Services department increased staffing capacity to manage the increased workload and achieved prior authorization turn around times greater than 90% for Total Prior Authorizations 8. Quality Leadership The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP s health care delivery system. It reviews and approves SFHP Medical Management Department s policies and procedures (QI, UM, CLS, PR, and Pharmacy), clinical guidelines and studies, the QI and UM Programs, 57

58 and the activities of all entities delegated for utilization management services. The QIC is scheduled to meet six times a year; during 2011, the committee met seven times; the additional meeting was to review policies and procedures and clinical guidelines, which required updates to address members medical needs. SFHP policies and procedures are reviewed biannually; however, clinical guidelines require an annual review or more frequent if necessary. SFHP maintains minutes of each QIC meeting and submits them to DHCS on a quarterly basis. SFHP also relies on its Pharmacy and Therapeutics Committee and the Physician Advisory/Peer Review/Credentialing Committee to implement and oversee its QI and UM Programs. In 2011, SFHP opened three additional seats to increase QIC membership to a total of 18 members. QIC membership is distributed as follows: a minimum of two seats are held by members of the Member Advisory Committee (MAC); one seat will be held by a labor representative. All other seats are filled by persons with relevant experience, such as selected representatives from the SFHP provider network, following our bylaws. QIC Membership as of December 2011 Governing Board 1. Sai Ling Chan Sew, LCSW. San Francisco Behavioral Health. Reappointed: Jan 15, Retired in late 2011; replacement pending. Member Advisory Committee 1. Mrs. Irene Conway. Member Advisory Committee. Reappointed: Jan 15, Mr. Edward Evans. Member Advisory Committee. Reappointed: Jan 15, 2011 Provider Network 1. Daniel Chan, MD. North East Medical Services. Reappointed: Jan 15, Kenneth Tai, MD. North East Medical Services. Reappointed: Jan 15, Michael Drennan, MD. SF Department of Public Health. Reappointed: Jan 15, Retired in Replacement pending. 4. Hali Hammer, MD. Family Health Center, SFGH. Reappointed: Jan 15, Claire Horton, MD. General Medical Center, SFGH. Reappointed: Jan 15, Christina Lee, MD. Laguna Honda Hospital. Reappointed: Jan 15, 2011 (representing providers with SPD expertise) 7. Dexter Louie, MD. Chinese Community Health Care Association. Reappointed: Jan 15, Carol Miller, MD. University of California Medical Center. Reappointed: Jan 15, Ms. Amy Rassbach. Hill Physicians Medical Group. Reappointed: Jan 15, Jaime Ruiz, MD. Mission Neighborhood Health Center. Reappointed: Jan 15, Albert Yu, MD. Chinatown Public Health Center. Reappointed: Jan 15, Richard Zercher, M.D. Curry Senior Center. Reappointed: Jan 15, 2011 (representing providers with SPD expertise) 13. Kam Reams, MPH. Brown and Toland. Appointed: December

59 SFHP Quality Improvement Committee Structure QIC Membership PAC Membership P&T Membership Member Advisory Committee 2 seats Labor Representative 1 seat Provider Network 15 seats SFHP Staff CMO (Chair) As needed: Associate Medical Director Director of Health Improvement Director of Provider Relations PM, Quality and Performance Improvement Provider Network 11 members SFHP Staff CMO (Chair) As needed: Associate Medical Director Provider Relations Staff Provider Network 7 members SFHP Staff CMO or Associate Medical Director (Chair) Manager Pharmacy Services Pharmacy Utilization Management 59