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

2. 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

3. 2017 Incentive programs

4. 2017 KPCA Value-Based Incentive Programs
Aetna Medicaid
KPCAlliance ACO
Anthem EPHC Commercial
Anthem Medicaid
Anthem Medicare
WellCare Medicaid
WellCare Medicare

5. 2017 Program measures

6. 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)

7. 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)

8. 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)

9. 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)

10. 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)

11. 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

12. 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

13. Supplemental data Process

14. Aetna Medicaid
Securely , fax or mail care gaps to the attention of Stacie Grannis.
Fax #: (855)
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.

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

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

17. Anthem Medicare
Securely fax or mail care gaps to the attention of Tammy.
Fax #: (855)
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 or FTP upload. PHD will then submit information to Anthem on your behalf.

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

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

20. FTP Site

21. 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

22. 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.

23. Common terminology, timelines & tips

24. 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)

25. 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.

26. 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.

27. 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!

28. Connect With Our Team Mary Buckler, Quality Improvement Specialist
Cell:
Melia Hall, Director of Quality Improvement
Cell:
Lauren McGuirk, Quality Improvement Specialist
Cell:
Lisa Sanders, Quality Improvement Specialist
Cell:

29. Thank you! Any Questions?

30. HEDIS Trivia

31. 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.