Quality improvement terms & tips Presented By Mary Buckler, Lauren McGuirk & Lisa Sanders

Topics of Discussion KPCA Incentive Programs for 2017 QI Specialist Tips KPCA Program Measures per MCO HEDIS Trivia Supplemental Data Process per MCO FTP Site Review & Update Common HEDIS Terminology HEDIS Timeline

2017 Incentive programs

2017 KPCA Value-Based Incentive Programs Aetna Medicaid KPCAlliance ACO Anthem EPHC Commercial Anthem Medicaid Anthem Medicare WellCare Medicaid WellCare Medicare

2017 Program measures

2017 KPCA Aetna Medicaid Program Measures HEDIS: Childhood Immunization Status – Combo 10 (CIS) HEDIS: Adolescent Well-Care Visits (AWC) HEDIS: Well-Child in the First 15 Months of Life (W15) HEDIS: Breast Cancer Screening (BCS) HEDIS: Diabetes HbA1c Testing (CDC) HEDIS: Cervical Cancer Screening (CCS) Ambulatory Care: ED Visits/1000 (AMBED) HEDIS: Retinal Eye Exam for Members with Diabetes (CDC) Plan All-Cause Readmission Rate (PCR) HEDIS: Chlamydia Screening (CHL)

2017 KPCA Anthem EPHC Commercial Program Measures HEDIS: Adult Access to Preventive/Ambulatory Health Services (AAP) Childhood Immunization Status MMR Childhood Immunization Status VZV HEDIS: Adolescent Well-Care Visits (AWV) HEDIS: Diabetic Eye Exam (CDC) HEDIS: Appropriate Follow-up/Management of Children with Newly Prescribed Medication for ADHD (ADD) HEDIS: Diabetic HbA1c Testing (CDC) HEDIS: Diabetic Nephropathy Screening (CDC) HEDIS: Appropriate Testing for Children with Pharyngitis (CWP) HEDIS: Medication Management for People with Asthma (MMA) HEDIS: Appropriate Treatment for Children with Upper Respiratory Infection (URI) HEDIS: Well-Child Visits in the First 15 Months of Life (W15) HEDIS: Breast Cancer Screening (BCS) HEDIS: Well-Child Visits in the 3rd, 4th, 5th & 6th Years of Life (W34) HEDIS: Cervical Cancer Screening (CCS)

2017 KPCA Anthem Medicaid Program Measures HEDIS: Adult Access to Preventive/Ambulatory Health Services (AAP) HEDIS: Cervical Cancer Screening (CCS) HEDIS: Diabetic Eye Screening (CDC) HEDIS: Adolescent Well-Care Visits (AWV) HEDIS: Diabetic HbA1c Testing (CDC) HEDIS: Appropriate Follow-up/Management of Children with Newly Prescribed Medication for ADHD (ADD) HEDIS: Diabetic Nephropathy Screening (CDC) HEDIS: Medication Management for People with Asthma (MMA) HEDIS: Appropriate Testing for Children with Pharyngitis (CWP) HEDIS: Well-Child Visits in the First 15 Months of Life (W15) HEDIS: Appropriate Treatment for Children with Upper Respiratory Infection (URI) HEDIS: Well-Child Visits in the 3rd, 4th, 5th & 6th Years of Life (W34) HEDIS: Breast Cancer Screening (BCS)

2017 KPCA Anthem Medicare Program Measures HEDIS: Adult BMI Assessment (ABA) Care of Older Adult: Functional Status Assessment HEDIS: Breast Cancer Screening (BCS) Care of Older Adult: Medication Review/List HEDIS: Colorectal Cancer Screening (COL) Care of Older Adult: Pain Assessment HEDIS: Controlling High Blood Pressure (CBP) Medication Adherence: Cholesterol HEDIS: Diabetic HbA1c Control ≤ 9 (CDC) Medication Adherence: Diabetes HEDIS: Diabetic Eye Exam (CDC) Medication Adherence: Hypertension HEDIS: Diabetic Nephropathy Screening (CDC) Statin Use in Persons with Diabetes (SUPD) HEDIS: Medication Reconciliation Post Discharge (MRP) HEDIS: Osteoporosis Treatment for Women (OMW) HEDIS: Rheumatoid Arthritis Management (ART)

2017 KPCA WellCare Medicaid Program Measures HEDIS: Adolescent Well-Care Visits (AWC) HEDIS: Adult BMI Assessment (ABA) HEDIS: Breast Cancer Screening (BCS) HEDIS: Diabetic Eye Exam (CDC) HEDIS: Diabetic HbA1c Control ≤ 9 (CDC) HEDIS: Childhood Immunization Status – Combo 10 (CIS) HEDIS: Chlamydia Screening (CHL) HEDIS: Cervical Cancer Screening (CCS)

2017 KPCA WellCare Medicare Program Measures HEDIS: Breast Cancer Screening (BCS) Care of Older Adult: Functional Status Assessment HEDIS: Colorectal Cancer Screening (COL) Care of Older Adult: Medication Review/List HEDIS: Diabetic Eye Exam (CDC) Care of Older Adult: Pain Assessment HEDIS: Diabetic HbA1c Control ≤ 9 (CDC) Medication Adherence: Diabetes Medications HEDIS: Osteoporosis Treatment for Women (OMW) Medication Adherence: Blood Pressure Medications HEDIS: Rheumatoid Arthritis Drug Therapy (ART) Medication Adherence: Statins

2017 KPCAlliance ACO Program Measures Fall Risk Screening Diabetes Composite – HbA1c <9 and Eye Exam Medication Reconciliation Post- Discharge Statin Therapy for the Prevention of Cardio Disease Adult BMI Screening and Follow Up HTN Tobacco Use Assessment IVD Depression Screening Influenza Immunization Depression Remission at 12 Months Pneumococcal Vaccination Colorectal Cancer Screening Screening Mammography

Supplemental data Process

Aetna Medicaid Securely email, fax or mail care gaps to the attention of Stacie Grannis. GrannisS@aetna.com Fax #: (855) 415-1215 HEDIS/Stacie Grannis Aetna Better Health of Kentucky 9900 Corporate Campus Drive Ste. 1000 Louisville, KY 40223 Measures must be separated and individually labeled. Include Name, Date of Birth, Clinic Name & Measure for each submission.

Anthem EPHC Commercial Anthem does NOT accept supplemental data for the Commercial line of business. This data is ONLY captured through claims.

Anthem Medicaid Fax all information directly to Anthem. Include Name, Date of Birth, Clinic Name & Measure for each submission.

Anthem Medicare Securely fax or mail care gaps to the attention of Tammy. Fax #: (855) 870-9862 HEDIS Medical Record Review 6740 North High Street Worthington, OH 43085 Mail Drop OH 0903-A351 The Mail Drop location must be included if mailing the records. Include Name, Date of Birth, Clinic Name & Measure for each submission. OR Submit all information directly to your QI Specialist via fax, secure email or FTP upload. PHD will then submit information to Anthem on your behalf.

WellCare Medicaid iHOP – If you need assistance with this process then notify your QI Specialist. FTP Site Upload (Immunizations only) Flat File Submission

WellCare Medicare iHOP – If you need assistance with this process then notify your QI Specialist. Flat File Submission

FTP Site

FTP Site Updates & Dashboard Reports PHD is working to improve the FTP Site functionality to make it more user friendly and efficient. Separate Dashboard Reports Login/Access Reminder

Tableau Update Chronic Condition (Patient Cluster) Report Tool that targets subsets of patients to improve patient health & reduce utilization. Each patient is assigned a “cluster” with similar chronic conditions & demographic factors. Based on all claims history with current payer. Goal: attempt to correct behaviors within each cluster before their spending increases. More information to come during IPA Call/Webinar on May 17th at 2pm. Click on “Chronic Conditions” to access report.

Common terminology, timelines & tips

Common HEDIS Terminology NCQA – National Committee for Quality Assurance HEDIS – Healthcare Effectiveness Data and Information Set NQF – National Quality Forum CAHPS – Consumer Assessment of Healthcare Providers & Systems Survey HEDIS Measure Appreviations (see slides 6-12)

HEDIS Timeline Jan-May: HEDIS Requests & Chart Review May-Nov: Work Care Gaps Oct-Dec: Submit Supplemen-tal Data HEDIS Requests come from all payers, all lines of business and are fluid. They can change daily. Supplemental data can be and should be submitted throughout the entire year. Oct-Dec are high priority months. Care gaps should be worked throughout the year (Jan-Dec). If you wait too long then there may not be enough time to schedule the patients.

QI Specialist Tips Use Z diagnosis codes to capture previous procedures, such as a total hysterectomy or bilateral mastectomy. These need to be resubmitted on a claim each year to indicate a pre-existing condition. Verify PCP at check-in. Use more than one source for verification. Have staff review patient’s chart prior to scheduled appointment. Flag all services that need to be discussed, offered and/or completed. Ranges and thresholds do not meet criteria for HbA1c. A distinct numeric result is required. They want the last one of the year. On Medication Reconciliation Post Discharge measure: if member had a readmission or direct transfer to an acute or non-acute facility on the discharge date through 30 days after discharge (31 total days), then count only re-admission discharge. Documentation must include notation of the MOST recent BP in the medical record in order to meet the Controlling High Blood Pressure measure. Childhood Immunizations must occur on or prior to the 2nd birthday in order to meet Childhood Immunizations measure. A note that says “Immunizations are up to date” does not count. Use the Immunization Registry to help build immunization records.

Tips Continued Take advantage of SICK visits. Use that opportunity to complete a well visit & address preventive measures. If the patient is on birth control then they must have a chlamydia test each year. This can be done at the same time as a urine pregnancy test. When documenting in patient’s record, only use approved abbreviations. For instance, do not refer to a patient who is pregnant as “prego.” Double, no triple check your billing & coding. Sometimes an outside eye may be helpful in catching errors. It takes 10 days to create a habit. Repetition is key to changing behavior!

Connect With Our Team Mary Buckler, Quality Improvement Specialist Cell: 859.475.8859 Email: mbuckler@phdelivery.com Melia Hall, Director of Quality Improvement Cell: 502.338.6110 Email: mhall@phdelivery.com Lauren McGuirk, Quality Improvement Specialist Cell: 859.797.8583 Email: lmcguirk@phdelivery.com Lisa Sanders, Quality Improvement Specialist Cell: 606.524.6695 Email: lsanders@phdelivery.com

Thank you! Any Questions?

HEDIS Trivia

Instructions Get into groups of 8-10. Select Team Name. Each team will receive a stack of answer tickets. After each question is read aloud by a QI Specialist, you will take an answer ticket and write your team name, the answer and your point wager (1-5 points per question)? You will have 1 minute to determine an answer. When the time is up, one person from each team will drop the answer ticket in the bowl at the front of the room. QI Specialists will track points earned/lost for each team. Team with the most points wins. Team with the most creative team name also wins. In the event of a tie, a bonus question will be presented.