1. Overview of Quality Compliance following implementation of the Patient Centered Medical Home Oklahomans are counting on us…. Patient centered medical home

2. Oklahomans are counting on us…. Quality Assurance and Quality Improvement The Compliance area of the Quality Assurance and Quality Improvement Department was charged with the task of developing a systematic process to educate and evaluate medical providers who opted to become a Medical Home. The Compliance area of the Quality Assurance and Quality Improvement Department was charged with the task of developing a systematic process to educate and evaluate medical providers who opted to become a Medical Home. There are three levels of complexity and expectation within the Medical Home concept. These are referred to as “Tier Levels”. There are three levels of complexity and expectation within the Medical Home concept. These are referred to as “Tier Levels”. Onsite educational reviews began in February 2009 to assess provider implementation of the Medical Home. Onsite educational reviews began in February 2009 to assess provider implementation of the Medical Home.

3. Oklahomans are counting on us…. Medical Home and Contract Compliance The Quality Assurance Department formulated an educational “tool” that combines contract requirements with Medical Home processes. The Quality Assurance Department formulated an educational “tool” that combines contract requirements with Medical Home processes. 2009 was determined to be a year for educational opportunities with SoonerCare providers. 2009 was determined to be a year for educational opportunities with SoonerCare providers. A Compliance Analyst and Compliance Nurse team together to visit providers in their office. A Compliance Analyst and Compliance Nurse team together to visit providers in their office. Medical Home audits will begin in January 2010. Medical Home audits will begin in January 2010.

4. Oklahomans are counting on us…. The 2009 Review Process It is the goal of the Quality Assurance department that each provider receive individual education about Medical Home during 2009. There are some rural providers who will be educated telephonically. It is the goal of the Quality Assurance department that each provider receive individual education about Medical Home during 2009. There are some rural providers who will be educated telephonically. There are currently three teams performing medical and administrative provider educational reviews. There are currently three teams performing medical and administrative provider educational reviews. Team 1: Ann Flores, RN and Kevin Jones Team 1: Ann Flores, RN and Kevin Jones Team 2: Patrice Calvin, RN and Cynthia Brown Team 2: Patrice Calvin, RN and Cynthia Brown Team 3: (As needed) – Beverly Rupert, RN and Kara Jennings, RN Team 3: (As needed) – Beverly Rupert, RN and Kara Jennings, RN The Quality Assurance Nurse Educator (RN) follows up with a telephone call to the provider’s office when appropriate. The Quality Assurance Nurse Educator (RN) follows up with a telephone call to the provider’s office when appropriate. The Compliance Analyst provides hands on assistance with provider office staff, taking them to the OHCA website and showing them the tools that are available. The Compliance Analyst provides hands on assistance with provider office staff, taking them to the OHCA website and showing them the tools that are available.

5. Oklahomans are counting on us…. Key Medical Home Concepts Self Management Plans Self Management Plans Formulation of a Medical Home Agreement between the provider and the member Formulation of a Medical Home Agreement between the provider and the member Referral and Laboratory tracking systems Referral and Laboratory tracking systems Care Coordination of members transitioning from an inpatient to outpatient status. Care Coordination of members transitioning from an inpatient to outpatient status. Mental Health and Substance abuse evaluation with a direct referral to the OHCA Behavioral Health Department Mental Health and Substance abuse evaluation with a direct referral to the OHCA Behavioral Health Department

6. Oklahomans are counting on us…. Audit Database Statistics As of 8/31/2009 732 Active providers 732 Active providers  395 Completed audits (54% complete)  337 Remaining audits Sep thru Dec (46%). Approx 140 (19% of all audits) will be completed by phone. Approx 140 (19% of all audits) will be completed by phone.

7. I-44 I-35 I-40

8. Oklahomans are counting on us…. Audit Database Statistics A review of the number of audits performed shows the following: About 226 providers were audited in 2007 About 226 providers were audited in 2007 About 275 providers were audited in 2008 About 275 providers were audited in 2008 About 732 providers will be audited in 2009 (592 in person) About 732 providers will be audited in 2009 (592 in person)

9. Oklahomans are counting on us…. Key findings from education reviews Most common issues to be addressed are: Problem list Problem list Medications/Allergies Medications/Allergies Referrals Referrals Medical Home Agreements Medical Home Agreements