Transformation & Quality Strategy

Transformation & Quality Strategy

UMPQUA HEALTH ALLIANCE CCO 2018

OHA Transformation and Quality Strategy (TQS) CCO: Umpqua Health Alliance

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Section 1: Transformation and Quality Program Information A. CCO governance and program structure for quality and transformation:

i. Describe your CCO’s quality program structure, including your grievance and appeal system and utilization review: Umpqua Health Alliance (UHA) is the CCO working closely with the Oregon Health Authority to manage Medicaid members that reside in Douglas County. UHA currently covers approximately 26,000 lives in Douglas County including the initial Medicaid population, the Affordable Care Act expansion members and a number of Dual Eligible members managed jointly with ATRIO, our partner in the Medicare Advantage program.

Our equity partners are DCIPA, The Physicians of Douglas County, and Mercy Medical Center.

UHA delegates dental services to the Advantage Dental and Willamette Dental, Non emergent transportation to Bay Cities Ambulance, Behavioral Health Services to Compass Behavioral Health, and Substance Use Disorder Services to ADAPT and Serenity Lane. UHA contacts with MedImpact for Pharmacy Benefit Management services.

UHA’s Quality Improvement program is ongoing and comprehensive, dealing with a full range of services focused on:

• Quality performance metrics defined by the OHA

• Utilization management and prior authorization

• Case management and care coordination

• Close to 100% participation in the Primary Care Patient Centered Medical Home model (PCPCH)

• Four well-managed Performance Improvement Projects (PIPs)

• Appeals and Grievances system

• Member satisfaction and CAHPS

• Active participation in the ongoing OHA Transformation & Quality Strategy.

• Special quality projects focused on specific community/membership:

o New Day, a care coordination effort designed to assist pregnant members with substance use disorder, spousal abuse, and peri/postpartum depression.

o Transitional Care, a UHA affiliated program that provides care management for those members with chronic disease, following hospitalization, using the Coleman Model of Care Management.

o UHA Palliative Care, an effort that engages our most vulnerable members in better understanding their disease processes and assists these members in accessing care.

The Leadership Team at Umpqua Health directs the spectrum of initiatives described in the UHA Transformation and Quality Strategy (TQS). Senior management assist in the development and


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implementation of all quality programs and oversee all programs focused specifically on addressing the social determinants of health, ensuring health equity and avoiding the pressures of structured racism within the practicing community. All quality initiatives including the performance improvement projects and TQS receive oversight and direction from the UHA board.

ii. Describe your CCO’s organizational structure for developing and managing its quality and transformation activities (please include a description of the connection between the CCO board and CAC structure):

Umpqua Health Alliance has formulated reporting criteria for Decision Support to query and identify unique members for targeted clinical engagement and population health management. The team utilizes the reporting capabilities of Milliman’s MedInsight for Mara Risk scoring, and PreManage when working with Emergency Department (ED) providers. UHA also utilizes the inteligenz software package to generate provider performance report cards and the Coordinated Care Organization’s (CCO) Metrics Manager to manage care gaps. In addition, we have a provider facing population health team who continuously interface with providers and their employees to discuss progress in completion of all CCO metrics, attest to PCPCH performance status, and discuss new programs to gauge provider interest.

The Quality Advisory Committee and the Clinical Advisory Panel meet quarterly, to oversee all ongoing quality initiatives under the TQS. All of the group findings report up to senior management and the Umpqua Health Alliance Board of Directors.

All quality projects are assessed utilizing the Plan, Do, Study, Act (PDSA) methodology since it serves our needs for action-oriented learning. It is also the model utilized by the Institute for Healthcare Improvement and is well recognized as a best scientific method.

The UHA Board has a strong link with our Community Advisory Council (CAC). The CAC chairperson is a member of the UHA Board, and attends all UHA board meetings. The chairperson also provides a monthly report to the UHA Board and shares any pertinent information learned at UHA Board meetings with CAC members.

The CAC also plays an integral role in transformation and quality activities. Members hear regular presentations on UHA projects and programs, where they have the opportunity to discuss their thoughts and concerns with UHA personnel. Their extensive knowledge of a wide range of UHA activities, coupled with their experiences as both consumers and community leaders, puts CAC members in a unique position to provide input on transformation and quality activities. Traditionally, CAC members have advised UHA on all Transformation Plan reports.

iii. Describe how your CCO uses its community health improvement plan as part of its strategic planning process for transformation and quality: UHA’s Community Health Improvement Plan (CHIP) is the guiding document for much of the CAC’s work. CAC members are tasked with identifying community programs and projects that align with UHA’s CHIP and overall mission. Through the application process, projects are chosen through the use of a scorecard that asks CAC members to evaluate an application through the lens of UHA’s


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CHIP priority areas. Once these projects and programs are selected for funding, the CAC continues to work with project leaders to identify ways their programs can successfully address the TQS. Since UHA completed its most recent CHIP in 2014, the document has directed CAC members on the allocation of more than half a million dollars in funding for community projects.

iv. Describe how your CCO is working with community partners (for example, health systems, clinics, community-based organizations, local public health, local mental health, local government, Tribes, early learning hubs) to advance the TQS: Within the last year the UHA approach to managing this rural population has expanded to engage a broader range of health care providers, community –based organizations, foundations, behavioral health agencies and surrounding CCOs. Umpqua Health Alliance has transformed the approach to patient care beyond the scope of physical medicine to embrace the impact of behavioral health disorders, poor dental health and the complex collection of social determinants of health that create significant challenges in delivering on the goal of the Triple Aim in health care. Umpqua Health Alliance has made an effort to share best practices with the care management teams within the surrounding CCOs. Umpqua Health Alliance has begun to explore the feasibility of developing new joint initiatives with the CCOs to take advantage of the economies of scale in program planning. New innovative projects either underway or on the list of goals for 2018 include: • A combined effort with CCOs in Grants Pass and Josephine Counties, the Ford Family

Foundation and the UHA CAC will bring an Adverse Childhood Experiences Summit (ACES) to Roseburg in the Spring of 2018. UHA will be engaging with thought leaders in Trauma Informed Care to provide an in-depth training session on ACEs to community primary care providers and local educators, focused specifically on how providers can best incorporate the delivery of high quality primary care within the framework of a patient population significantly affected by that trauma.

• A twenty-month program by the Oregon Pediatric Improvement Partnership has been established with OHP to engage all of the CCOs in identifying within their populations all children with High Complexity Health Problems so that a structured process can be developed to raise the quality of care for this difficult population.

• The New Day Program designed to engage with pregnant members who are dependent on opiates and other substances has been established within this year and Umpqua Health Alliance is looking to better identifying and supporting these women troubled with addictions that can harm fetal development, induce Neonatal Abstinence Syndrome and create long-term effects on child development. The New Day staff have also developed methodologies to identify additional behavioral health issues affecting the new moms.

• This year UHA contracted with Umpqua Health Transitional Care to provide much needed concurrent review for our members admitted emergently to the inpatient units. The program is designed to identify high-risk members and assist with their transition from the inpatient stay back to the home setting in our efforts to lessen the possibility of early readmission to the hospital. “At risk” members will be seen in the transitions clinic within 72 hours of discharge by the team nurse practitioner to gauge clinical stability, reconcile medications, and insure reconnection with their primary care clinic and to address any specific home issues that may


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contribute to progressive clinical decline and subsequent readmission. Such home needs might be a requirement for caregiver support, correction of home safety concerns, access to rehabilitative services, identification of fall risk etc.

• UHA has donated funding for the community Blue Zones Discovery Project that began initial analytic proceedings in 2017. The project team has completed the background research and met with key leaders from the community to learn more about the institutions and economy as well as understanding the complexity of the health issues facing the community. In the coming year many of the proposed projects will begin. UHA is well- positioned in its focus on improving health within the community.

• UHA has collaborated with the Ford Family Foundation on future planning focused on Trauma Informed Care through a proposed project with the Early Learning Hub in Roseburg. Initial focus meetings with the directors of a number of Day Care Centers and Preschool Classrooms will meet early in 2018 to identify a unified focus on the initiative.

• UHA contributed significantly to new funding to establish a Mental Health Court (MHC) within Douglas County and continue to support this project.

• Umpqua Health Alliance has begun the transition from the concept of flexible spending initiatives to a better-structured Health Related Services strategy in 2018. Health Services expenditures are designed to improve health quality and increase the likelihood of desired health outcomes in ways that can be objectively measured. The process should be grounded in evidence-based medicine, widely accepted best clinical practice and recognized by national health care quality organizations. We see particular relevance in closing the gaps in the transitional care process, improving community access to diabetes education, allowing more widespread development of public Health Education Campaigns and engaging our workforce in training on Health Coach techniques to improve their performance in case management and member engagement

• In 2017 Umpqua Health broke ground on the construction of a new clinic in eastern Roseburg that will provide an additional number of new primary clinicians, an urgent care facility and on site laboratory and advanced imaging center. East Roseburg is a designated High Poverty Hotspot with a 26% American Community Surveys Poverty rate.

• In 2017 UHA contributed significant funding to Adapt, our partner in behavioral health, to establish a Opioid Treatment Program (OTP) clinic in Roseburg. The Program provides methadone or buprenorphine therapy for our members with opioid use disorder. Coupled with their Crossroads detoxification program and the centralization of community behavioral health workers as Compass, we have been able to significantly improve both access and quality of behavioral health care in Douglas County.

B. Review and approval of TQS

i. Describe your CCO’s TQS process, including review, development and adaptation, and schedule: The entire program is reviewed/evaluated annually to determine whether certain projects merit continuation or whether new direction from the OHA signals project planning focus on new areas. The annual review falls under the Director of Quality Improvement and the VP of Clinical Strategy and Operations.

The review shall include a complete analysis of the entire quality program menu to include:

http://www.oregon.gov/dhs/business-services/ofra/Documents/High%20Poverty%20Hotspots%20Douglas.pdf

http://www.oregon.gov/dhs/business-services/ofra/Documents/High%20Poverty%20Hotspots%20Douglas.pdf


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• Member complaints to determine adverse trends that require correction. • Ensure members receive second opinions from a qualified professional for behavioral, dental,

and physical health care as indicated in UHA’s policies and member handbook. • Status of current PIPs and value decisions to continue or to retire the PIP. Consideration to be

replaced for a more meaningful effort based upon OHA requests or current organizational “hot topic”.

• Current status of the CCO performance metrics. • Review of special programs that focus on special needs members especially those with SPMI or

other high MARA Risk scores. • Fraud waste and abuse compliance issues. • Review of delegated entity performance as it reflects on overall plan quality performance

and/or future planning considerations. Goals of the Annual Evaluation include:

• Resource allocation for budgetary planning • Corrective Action Plan development where indicated • Improve member service related QAPI directives • Realign incentives for the coming year relative to all CLAS /cultural considerations • Identify project champions for special recognition • Findings to serve as a basis for future planning through a guided analysis of areas that demand

o closer inspection o refined structure o more ordered planning o increased analytic investment o increased staffing o response to member needs/suggestions o provider feedback o OHA guidance o best practices and/or o wish list allocation/placement

C. OPTIONAL i. Describe any additional CCO characteristics (for example, geographic area, membership numbers, overall

CCO strategy) that are relevant to explaining the context of your TQS: UHA is one of 15 CCOs serving the Oregon Health Plan (OHP). Our Roseburg-based organization, located in Douglas County, covers an expansive 5,071 square miles and extends from the Cascade Mountains at elevations of over 9,000 feet to sea level at the Pacific Ocean with nearly 2.8 million acres of commercial forestlands. Douglas County encompasses the entire Umpqua River watershed, much of which flows through dramatic canyons and narrow valleys. Both the County’s rugged terrain and federal landholdings limit development and according to the Douglas County website www.co.douglas.or.us the United States Forest Service and Bureau of Land Management administer more than 50% of the county's land. Due to federal administration, these lands are not

http://www.co.douglas.or.us/


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subject to local property taxes, greatly diminishing the local government’s tax base. As a CCO, UHA is focused on expanding access, improving care, and reducing unnecessary costs across the clinical space for more than 26,000 Douglas County residents on the Oregon Health Plan. As described in a 2016 Community Benefit Report by CHI Mercy Health system and Mercy Medical Center Community Benefit Report 2016, Douglas County, Oregon is comprised of 12 incorporated cities including Roseburg – the county seat, Canyonville, Drain, Elkton, Glendale, Myrtle Creek, Oakland, Reedsport, Riddle, Sutherlin, Winston, and Yoncalla. As with many rural jurisdictions, the communities in Douglas County face the challenges of an in-migration of seniors as well as a baby boomer aging population, high rates of unemployment and poverty, few educational opportunities, high rates of tobacco and other drug use, and fewer local resources dedicated to addressing these and other known health risk factors. Nearly 70% of residents live outside the county seat of Roseburg, where most health services are provided. Douglas County is a federally designated medically underserved area, as well as a primary care shortage area. The economy in Douglas County has traditionally been led by the timber and wood product industry. Even through recent economic downturns, timber and wood products are still one of the biggest sources of employment in the area. Healthcare is also a leading industry, with CHI Mercy Health, including Mercy Hospital, being one of the largest employers in Roseburg. The Cow Creek Indian Tribe, City, County and Federal government including the VA healthcare system, agriculture, the warehouse industry, building trades and education are other large employers in the region. Stagnant economic recovery continues to greatly impact the lives of all Douglas County residents, as we see one of the highest poverty and unemployment rates in Oregon at 6.1% in March of 2016. According to the 2014 American Community Survey, 15.5% of Douglas County residents over the age of 25 have a bachelor's degree or higher compared to the Oregon State average of 30.8%. The median household income is $42,000, compared with the Oregon State average of $51,075. 20.1% of all residents and 29.4% of children under 18 lived in poverty and 68% of children in schools located outside of Roseburg are on the free-and-reduced lunch program, a widely held poverty indicator. The Robert Wood Johnson Foundation’s 2016 County Health Rankings rank Douglas County 31st out of 36 Oregon Counties for Health Outcomes – which represent how healthy a county is; and 25th out of 36 counties for Health Factors - which are what influences the health of the county. Douglas County rankings are significantly worse than the state’s most metropolitan county that includes the City of Portland.

http://www.mercyrose.org/assets/community-benefit-report-2016_final.pdf


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The 2010-2013 Oregon Behavioral Risk Factor Surveillance Survey shows that Douglas County has higher instances of major chronic diseases as compared to state averages and poor health behaviors, as shown by the table below. As our community ages, there comes greater need for health services and particularly services related to chronic conditions. The Health Factors table below show some of these disparities, illustrating the work that needs to be done in our Douglas County communities.

With over 2400 calls to the Oregon Sexual and Domestic Violence Programs Hotline to report allegations of abuse or neglect toward seniors and people with disabilities in 2014, the impact of domestic violence in Douglas County is another indicator of need in our region. According to the Battered Persons Advocacy (BPA) in Roseburg, there were 3,300 shelter nights at BPA with 259 families fleeing domestic violence in 2014. BPA reports that there were 647 calls to the Oregon Department of Human Services in Douglas County asserting that domestic violence was occurring, with 176 found cases in 2014 and in 2015.

Douglas County Oregon

Fair to Poor Health Days 24.0% 17.0%Tobacco Usage (Cigarette, Smokeless) 30.0% 21.0%Arthritis 30.9% 24.5%Asthma 15.1% 10.4%Diabetes 10.5% 8.2%Obesity 34.4% 25.9%Risk for Hypertension 34.4% 27.7%High Blood Cholesterol 41.3% 31.8%

www.mercyrose.org/assets/community-benefit-report-2016_final.pdf

Health Factors

Robert Wood Johnson Foundation Rankings of 36 Oregon Counties

Douglas County

Multnomah County (Portland)

HEALTH OUTCOMES 31 15 Length of Life 29 11 Quality of Life 27 19 HEALTH FACTORS 25 8 Health Behaviors 30 16 Clinical Care 11 6 Social & Economic Factors 27 11 Physical Environment 9 19



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In 2016, United Community Action Network (UCAN) of Douglas and Josephine County published a 2016 Community Needs Assessment with the purpose of providing an understanding of the needs and resources of residents in the UCAN service area. In this comprehensive assessment, the regions and communities of Douglas County and its residents are discussed with some summary analytics included. Below are some pertinent facts as stated in the UCAN 2016 Community Needs Assessment: • Roseburg, the Douglas County seat, is located approximately 70 miles south of the edge of the

greater Eugene area. (a drive of over one hour) • The next closest urban area is Medford, a drive over 1 ½ hours south. Medford has

approximately 78,557 residents. • Because of this geographic location, Douglas County residents generally conduct their daily

business within the County, rarely traveling to Oregon’s metropolitan areas. • Although Douglas County is larger than Connecticut, it has fewer than 110,000 residents.

UCAN also used demographic descriptions to shed light on some of the challenges faced by Douglas County residents in their Needs Assessment. Although more than 93% of residents are of Caucasian decent and most speak English in their home and are not foreign born, UCAN points out that the Douglas County population is overrepresented by three groups that create unique, significant demands on the area’s social service system. The three groups identified are veterans, seniors, and people with disabilities. The chart below was included in UCAN’s 2016 Community Needs Assessment and captures this disproportion well.

Though many of these individuals, particularly veterans, do not face additional life challenges, a number do. The disproportionate numbers of these three populations add to pressure in the region for such services as: • Medical/dental • Case management and life skill support • Food • Affordable housing


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These needs may also differ from the general population’s needs for such services. For example, seniors and people with disabilities needing affordable housing are also more likely to require home modifications. Veterans with health needs are more likely to have incidences of brain trauma and post-traumatic stress disorder. The resources available to address these needs may also differ from those available to the general population. Douglas County has medical facilities specifically addressing veterans’ needs, and has special programs only offered to veterans, seniors and people with disabilities. In general, these special programs do not fully meet the many needs of these populations, creating disparity in finding resources for all vulnerable populations. Analysis of these regional priorities, strengths, limitations, and critical demographic information is used by the UHA Clinical Engagement and Quality Improvement teams to inform the work that is done to better identify and meet the needs of our members


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Section 2: Transformation and Quality Program Details

A. TQS COMPONENT(S)

Primary Component:

Integration of care (physical, behavioral and oral health) Secondary Component:

Severe and persistent mental illness

Additional Components: Social Determinants of Health, Health Integration Technology

Subcomponents: HIT: Health information exchange

Additional Subcomponent(s):

HIT: Analytics; HIT: Patient Engagement

B. NARRATIVE OF THE PROJECT OR PROGRAM Emergency Room Use Performance Improvement Project: Problem Statement Emergency Room utilization continues to be a focus area for UHA. Our staff including intensive case management and care navigation staff review daily census reports from the ED and actively outreach to members to arrange for follow-up appointments with the member’s primary care provider, behavioral health care provider, and/or dental provider. Connecting patients with addiction services is provided when indicated, and if a patient has not established care with a provider staff help the member connect with the appropriate services. Barriers such as transportation issues are navigated and staff maintain focus on those members discharged from an inpatient stay since this is an integral part of the Transitions of Care process.

The Work UHA is Doing Integration of Care: Five area clinics that care for >70% of the UHA membership now have co-located physical and behavioral health care. Two of these clinics also provide in-house dental services. Co-location has been successful in providing members with physical and behavioral health care in the same location. The clinics work to facilitate same-day appointments in an effort to increase access and reduce ER utilization. Providers are also actively working to decrease no-show rates and to increase preventative health care visits. HIT: UHA Care Management staff have created reports in Pre-Manage to assist in identifying those members utilizing the Emergency Department in an effort to identify members with high utilization. Daily reports have been created in Pre-Manage and are used to identify members with visits from the previous day. An annual report is used to create a cohort of highest ED utilizers that sends an alert when one of those members is admitted to the ED. UHA has a behavioral health coordinator who utilizes Pre-Manage notifications when members are admitted to psychiatric or behavioral health facilities throughout Oregon, which is crucial since there is no psychiatric inpatient unit in Douglas County. The behavioral health coordinator works with discharge planners to assist members in connecting with inpatient, outpatient and community-based behavioral health, medical, and addiction services based on notifications through Pre-Manage. SPMI: The UHA behavioral health coordinator functions as an Intensive Care Manager/Care Coordinator (ICM) for those members with SPMI. This ICM identifies members with SPMI who are utilizing the ED or experiencing inpatient admissions either for medical or psychiatric care. Once identified, the ICM works with discharge planners at both the inpatient and ED level to coordinate appropriate transition to behavioral health services in the community including services through the delegated community mental health provider. Interdisciplinary Team (IDT) meetings are coordinated by this ICM when necessary to address more extensive community needs for members with multiple co-


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morbid conditions and SPMI. Community members included in these IDT meetings include SUD treatment providers, Community Mental Health providers including ACT team, DHS, Dental provider, Probation and Parole, Adult or Child protective services and child welfare, and specialty and PCP providers. Treatment plan goals are discussed with providers in this process in an effort to better coordinate care and facilitate meeting member needs. Social Determinates of Health: Both the UHA Care Managers focusing on ED utilization and UHA Behavioral Health Coordinator work with DHS, Adult Protective Services, dental providers, Area Agency on Aging, Care Navigators in PCP offices, Community Mental Health Providers, Substance Abuse Treatment Providers and other community providers in facilitating the development of holistic approaches in member care.

In addition, UHA staff participate in community partnerships including Blue Zone Project – Umpqua, The South-Central Oregon Early Learning HUB with representation on both the action committee and the governance board, Douglas County Mental Health Court, and other organizations working to make a positive impact on the communities served.

C. QUALITY ASSESSMENT Evaluation Analysis: Umpqua Health Alliance (UHA) has assigned an Intensive Care Manager (ICM) to work

specifically with our UHA CCO members utilizing the Emergency Department (ED) at Mercy Medical Center in Roseburg. The primary role for this ICM is to coordinate care among community agencies and UHA providers for these members and assist them in finding the appropriate use of medical services. We have identified the following goals as a part of this Performance Improvement Project:

1) Decrease the frequency of ED visits for those members (per 1000 member months) 2) Increase outpatient utilization visits. (per 1000 member months) 3) Increase the number of PCP visits for members identified as having 10 or more ED

visits per year. 4) Increase the number of community agencies that the ICM is working with in

reducing ED visits for high utilizers.

D. PERFORMANCE IMPROVEMENT Activity 1: Decrease the frequency of ED visits (per 1,000 member months). ☐ Short-Term Activity or

☒ Long-Term Activity How activity will be monitored for improvement

Baseline or current state

Target or future state Time (MM/YYYY)

Benchmark or future state

Time (MM/YYYY)

Monitored quarterly 50.75 Visits/1000 Member Months

3% improvement by decreasing ED visits to 49.22 Visits/1000 MM

12/2019

Activity 2: Increase outpatient visits (per 1,000 member months). ☐ Short-Term Activity or

☒ Long-Term Activity

How activity will be monitored for improvement




Time (MM/YYYY)


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Monitored quarterly 329 Visits/1000 Member Months as of Q4 of 2017

3% improvement by increasing OP visits to 339 Visits/1000 MM

Q4 of 2019

Activity 3: Increase the number of PCP visits for members identified as having 10 or more ED visits per year.

The desired outcome in this measurement is to examine patterns in individual members and to see a lowered ratio of ED to PCP visits over time. This tool should be used by the Clinical Engagement Team and Care Management Team to help prioritize intervention on the individual member level. Analysis as of Q4, 2017: 13 of the top 30 ED Utilizers had more PCP or OP visits than they had ED visits. This includes the top 2 ED Utilizers and 3 of the 5 highest ED Utilizer members 15 of the top 30 ED Utilizers had more than one PCP or OP visit but fewer than they had ED visits. Only 2 of our highest 30 ED Utilizers had ZERO PCP or OP visits during the same time period.

☐ Short-Term Activity or






Time (MM/YYYY)

Monitored quarterly N/A N/A N/A N/A N/A

Activity 4: Increase our Emergency Department Intensive Care Manager’s coordination with community agencies serving the populations identified as frequenting the Mercy Medical Center Emergency Department. This goal is measurable by monitoring the number of referrals to or consultation with community resources by our UHA Intensive Care Manager and by monitoring the number of agencies that we are working with in the communities served by UHA.







Time (MM/YYYY)

Monitored monthly Currently referring to 22 community partners

Increase our footprint by adding 5 referral sources by Q4 2019

N/A N/A N/A


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A. TQS COMPONENT(S)

Primary Component: Special health care needs Secondary Component:

Integration of care (physical, behavioral and oral health)

Additional Components: SPMI, Social determinates of health, PCPCH, Utilization Review

Subcomponents: HIT: Patient engagement Additional Subcomponent(s): Add text here.

B. NARRATIVE OF THE PROJECT OR PROGRAM

Re-admission Reduction

Work UHA is Doing

Transitional Care:

Umpqua Health has established a Transitional Care (TC) program to work specifically to reduce readmissions of our UHA members admitted to Mercy Medical Center (MMC) for hospitalization. In 2017, Umpqua Health Transitional Care program launched based on the Coleman Care Transitions Interventions (CTI) program. The primary role for this new program is to promote a smooth transition from the inpatient status to home. The concepts of this model will be utilized for a subset of inpatients who are at high risk of readmission within 30 days. The CTI model was chosen because it is uniquely focused on providing patients and caregivers with the skills, confidence, and tools they need to assert a more active role in their care. CTI, co-designed with patients and families, was validated using the most rigorous scientific approach of randomized controlled trials and patients who received the CTI coaching were significantly less likely to be readmitted to the hospital. Research results revealed the benefits were sustained for five months after the end of the one-month intervention period. The model incorporates two face to face encounters with the patient, one during the hospitalization and a second in the home after discharge. After the home visit the interventions continue with three follow up phone calls are made at various intervals over the next three weeks. The following goals have been identified for this program:

1) Identify a baseline for all-cause 30-day readmission rates. 2) Identify high risk patients using LACE scores to develop a risk stratification process and identify patients with a

high likelihood of all cause 30-day readmission. 3) Initiate UHA’s Transitional Care program utilizing the CTI model to appropriately identify and follow the CCO

members at high risk for hospital readmissions. 4) Develop a sound process to ensure the transitions of care from hospitalization to the home setting adheres to

the criteria as defined in the CTI model. 5) Complete medication reconciliation by review of pre-hospitalization medications, hospital medications and

construct a complete medication list with the patient and caregiver(s). 6) Discuss medication management with the patient and caregiver(s).


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7) Explain the concept of a Personal Health Record (PHR) and reinforce the importance of bringing the PHR to medical appointments.

8) Discuss self-management of conditions by reviewing the red flags associated with the patient’s condition worsening.

9) Address the social determinants of health during the home visit. 10) Refer patients to the appropriate mental health services. 11) Coordinate care with the patient primary care home.

Palliative Care Case Management:

The UHA Palliative Care Nurse provides patient and family centered consultations for members facing serious life limiting conditions. Goals of palliative care focus on providing relief from symptoms, pain, physical stress and psychological distress of serious illness with a desired outcome of improved quality of life, clarification of treatment goals, avoidance of futile health care, Advance Care Planning, symptom management, and support. Any member facing serious, life-limiting illness is a candidate for referral to the UHA Palliative Care Case Manager. This service is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Our UHA Palliative Care Nurse works in collaboration with pharmacy, case managers, pain management committee internally while coordinating with the member’s PCP, the local Cancer Center, specialists, pain clinics, behavioral health providers, and local Hospice and home health care providers. Members are identified for Palliative Care Case Management using a variety of methods, including PreManage, internal referrals from case managers and pharmacy staff, direct referrals from providers. If patient referral is internal, the Palliative Care Nurse contacts primary care or specialist caring for the patient to get order to visit with patient. Once identified as a candidate or referred, the member is contacted by the UHA Palliative Care Nurse, and a meeting is arranged at a time of their convenience. Although most members’ needs are met in 1-2 visits, care may be ongoing through the course of the illness. Referring providers are given documentation of what is covered in the visit. Palliative Care Case Management activities include a completion of Advance Directive and POLST (if appropriate), medication management, symptom management, assessment and recommendations, home health and hospice referrals, disease management education, documentation in CIM, faxing visit notes to providers, serious illness conversations, and grief counseling. Hepatitis C Case Management: The UHA Hepatitis C Case Manager screens potential patients for treatment appropriateness and provides ongoing education and support during the treatment process of their disease. The goals of the program is to ensure adherence to the medication regimen and laboratory testing, collect data needed to evaluate the program, support the patient and provider and prevent gaps in medication supply. In addition, it is hoped that the patient will be cured and will avoid reinfection in the future. All members with active Hepatitis C infection with fibrosis score of 2 or greater are considered for this specialty Case Management program. Our Nurse Case Manager utilizes resources both internal to UHA and our community partners in coordinating care for this vulnerable population. The booklet: Saying Goodbye to Hepatitis C, Treatment Guidelines is reviewed and left in their possession and the member is encouraged to work closely with UHA Case Manager, mail order pharmacy and prescriber of medication. The PCP, infectious disease specialist or gastroenterologist identify members who would benefit from treatment and contact UHA pharmacist or UHA Hepatitis C Case Manager for treatment. Once contacted, the UHA pharmacist or UHA Hepatitis C Case Manager does initial screen to assure that medication requested meets all approval criteria for Hepatitis C direct-acting antivirals. If approved, the member is contacted by case manager to enroll in case


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management. A member may opt out of case management with approval of the prescribing provider by completing an opt-out form. Once engaged, the Hepatitis C Case Manager has an initial face-to-face meeting with member in the location of their choice to discuss pathophysiology, transmission, risk factors, natural disease progression, drug therapy, immunizations, life style changes, lab work, drug interactions, cost, length of therapy or any other questions the member may have. After the initial visit, phone calls are made at least weekly to assess how member is doing with treatment. Members may request additional face-to face visits if desired. The prescribing provider is provided with documentation of issues discussed in any face-to-face encounter. Activities include face-to-face visits to address member concerns, phone calls, documentation in UHA’s Case Management System and Hepatitis C case management spread sheet, assurance that viral load testing is completed, collaboration with UHA pharmacy department and providers.

C. QUALITY ASSESSMENT

Evaluation Analysis: 30-day hospital readmission will be tracked and a 10% reduction by the end Q4 is the goal.

D. PERFORMANCE IMPROVEMENT

Activity: Decreased the frequency of readmission within 30 days of discharge. ☐ Short-Term Activity or




Target or future state

Time (MM/YYYY)


Time (MM/YYYY)

Monitored quarterly. 2017 Q4: 13.3% 10% reduction of all-cause readmission to 12%

Q4 of 2018 Add text here. Add text here.

A. TQS COMPONENT(S)

Primary Component: Integration of care (physical, behavioral and oral health) Secondary Component: Utilization review

Additional Components: Social Determinants of Health, Special Health Care Needs, SPMI, Health Equity and Data

Subcomponents: HIT: Health information exchange Additional Subcomponent(s):

HIT: Analytics; HIT: patient engagement; Health Equity: Data; Health Equity: Cultural Competence


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Prenatal Performance Improvement Project – Decreasing the Number of Newborns with Neonatal Abstinence Syndrome: The New Day Program: As the abuse of Opioids in Douglas County have continued to rise, so have the number of babies born who may suffer from the effects of addiction. UHA OB-GYN providers in our community have expressed concern for the health of their patients who may be abusing drugs and for their unborn babies. These providers have committed to participation and collaboration in assisting in identifying pregnant women with substance use disorders and are committed to assist in coordinating care with addiction services, behavioral health care, and UHA’s New Day Program that began in February 2017. The New Day program provides behavioral support in pregnancy and is coordinated by UHA staff individual with knowledge and background in this area. She will work closely with the OB-GYN provider offices in identifying pregnant women who need the care, meeting with the member, and coordinating appropriate services for on-going treatment during pregnancy. The Effects of NAS & ODA in Newborn Babies: Neonatal Abstinence Syndrome (NAS) is the term used to represent a pattern of clinical findings associated with opioid or narcotic withdrawal experienced by a baby exposed during pregnancy. NAS has a range of severity of symptoms depending on the type and amount of opioid exposure experienced by the infant and the point in prenatal gestation of exposure as well as other complex factors. Common withdrawal effects develop shortly after birth and symptoms include loud, high-pitched crying, sweating, yawning and gastrointestinal disturbances. PubMed Health Glossary (Source: NIH - National Library of Medicine) In addition to concerns about NAS withdrawal, prenatal opioid exposure may lead to long-term challenges for the child as well. In a July 2011 article published in the NIH publication Addiction Science & Clinical Practice titled: Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes and Practice Implications, the authors included the following 2 tables describing potential effects of prenatal drug exposure on the child. The first table lists possible outcomes of pregnancy while the second lists potential long-term effects to CNS development, cognitive function, and behavior.

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024264/


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Why New Day? Knowing that abrupt discontinuation of opioid use during pregnancy can result in pregnancy complications ranging from premature labor to miscarriage, and identifying pregnant UHA members and coordinating appropriate, evidence based treatment that are approved for pregnancy is our best opportunity to reduce pregnancy risk and to lower the number of infants born with effects of NAS. According to SAMHSA, “Opioid use in pregnancy is not uncommon, and the use of illicit opioids during pregnancy is associated with an increased risk of adverse outcomes. The current standard of care for pregnant women with opioid use disorders is referral for opioid-assisted therapy with methadone, but evidence suggests that buprenorphine also should be considered. Medically supervised tapered doses of opioids during pregnancy often result in relapse to former use.

Abrupt discontinuation of opioids in an opioid-dependent pregnant

woman can result in preterm labor, fetal distress, or fetal demise. During the intrapartum and postpartum period, special considerations are needed for women who are opioid dependent to ensure appropriate pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies. Patient stabilization with opioid-assisted therapy is compatible with breastfeeding. Neonatal abstinence syndrome is an expected and treatable condition that follows prenatal exposure to opioid agonists. All infants born to women who use opioids during pregnancy should be monitored for neonatal abstinence syndrome and be treated if indicated” (Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment


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of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Available at: http://store.samhsa.gov/). Specialized treatment, including Medication Assisted Treatment (MAT) is available to pregnant women who are using or abusing opiates. Access to the program can be through their OB-GYN, PCP, self-referral, or through the Emergency Room or any other source and the New Day Care Coordinator can help members access this care. The role of the UHA coordinator is to:

• Assess barriers to care • Assist in engaging the patient in treatment and encourage healthy and realistic goal setting • To be available to meet with the patient where the patient needs to be seen. • Connect patients with community support and resources • Provide education about behavioral risk factors such as smoking and nutrition • Provide on-going support throughout the pregnancy • Work as a liaison between medical and community providers • Assist these members in finding support for other realities face by these women including: spousal abuse,

domestic violence, trauma, poverty, food hunger, inadequate housing, lack of transportation, and how to address being surrounded by an environment of addiction.

Who the New Day Program Serves: Our target population for the New Day Program is pregnant women with Substance Use Disorder including other healthcare and social needs, who are UHA CCO members. These women may, or may not, be currently engaged in treatment, and they need only be at risk of using to qualify for the New Day Program. Working with UHA providers as well as community agencies in a collaborative effort, the UHA Intensive Care Manager will work to identify and assess UHA members in the communities that UHA serves who are pregnant and who are using or are at risk of using opioids or other drugs. Intakes can be received from PCPs or OB GYN providers or through other provider settings. It is one of our goals to expand our referral network to include many community partners in identifying at risk individuals. The primary goal of the UHA New Day Program is to:

1) Increase the number of referrals received for the program. This effort requires a collaboration from our community and will only be successful long term if we can receive referrals from our community partners as well as our providers.

2) Increase engagement in the UHA New Day Program to maximize the chance for healthy pregnancy outcomes. 3) Increase the average length of engagement during pregnancy.

Success in this program is reliant on the engagement of moms during pregnancy. By increasing the number of members referred to the program, the number of members engaged in the program, and the length of time of that engagement, UHA expects to see a decrease in severity of symptoms and eventually in the overall number of newborns with Neonatal Abstinence Syndrome (NAS) or those born with Other Drugs of Addiction (ODA) complications within the UHA population. See the New Day Driver Diagram next page

http://store.samhsa.gov/


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Evaluation Analysis: Outcome Measure

Baseline Measurement/Data

Measure #1 Number of members participating in this Care Coordination Program

Measure #2 The week of pregnancy that each member became engaged in the Program

Measure #3 Length of engagement in the Program Measure #4 A widening of our footprint in the communities served.

Because we can only succeed by increasing community involvement in this effort, we will measure the number of sources that refer members to our Care Coordinator for this Program.

Measure #5 Number of babies born with NAS or with other drugs or alcohol in their system.


Activity 1: Increase the number of members engaged with the New Day Case Manager. See “Prenatal PIP Table” on page 24.




Baseline or current state Target or future state

Time (MM/YYYY)


Time (MM/YYYY)

By tracking the Case Manager roster: See “Prenatal PIP Table” on page 24.

As of January 1, 2018 we had 35 members engaged.

Increase engagement by 2 per month

01/2018 See weekly increases in engagement

6/2018

Activity 2: Work with community partners in identifying and engaging at-risk members earlier in their pregnancy.





Time (MM/YYYY)


Time (MM/YYYY)

By tracking the Case Manager roster: See “Prenatal PIP Table” on page 24.

Trimester of pregnancy at the time of engagement with New Day Program:

1st Trimester: 29% 2nd Trimester: 43% 3rd Trimester: 29%

See a higher percentage of engagement occur during the 1st trimester.

01/2018 Increase 1st Trimester engagement by 3%

12/2018


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Activity 3: Increase the number of weeks during pregnancy that members are engaged with the New Day Case Manager.





Time (MM/YYYY)


Time (MM/YYYY)

By tracking the Case Manager roster: : See “Prenatal PIP Table” on page 24.

As the week during pregnancy is lowered in Activity 2 above, this measurement should increase.

Activity: Increase the number of community partners making referrals to the New Day Program.





Time (MM/YYYY)


Time (MM/YYYY)

See “New Day Referral Sources” on page 24.

10 different community partners had made referrals as of 1/1/2018

1/2018 Increase to 15 different community partners

6/2018

Activity: By targeting our engagement efforts with pregnant members, UHA anticipates a reduction in the number of babies born with Neonatal Abstinence Syndrome and complications from Other Drugs of Addiction and in the severity of symptoms that these babies experience. While treatment may include medication assistance, abstinence is not the goal. Our larger effort of offering interventions such as controlled and safe use of MAT, early and supportive treatment during and after pregnancy, connections to community support and resources, and other supportive coordination will result in a healthier baby for each New Day participant. UHA will continue to measure the number of babies born with NAS diagnoses and those born with ODA related complications and will look for correlations between the number of moms engaged in the New Day program and a reduction in these birth rates.





Time (MM/YYYY)


Time (MM/YYYY)

Qualitative Analysis of newborn status including withdrawal reactions at birth, NICU stays, DHS involvement and other similar information.

N/A N/A N/A N/A N/A


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Prenatal PIP Table


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New Day Referral Sources

A. TQS COMPONENT(S)

Primary Component: Patient-centered primary care home Secondary Component:

Health information technology

Additional Components: Value-Based Payment Models, Health Equity and Data

Subcomponents: HIT: Health information exchange


HIT: Analytics; HIT: patient engagement; Health Equity: Data; Health Equity: Cultural Competence


Population Health Program: Value-Based Payment Model: UHA uses multiple payment methodologies for its various providers. These include value-based incentive payments tied to population health metrics including the CCO Incentive Metrics established by OHA, performance standards tied to quality, risk, non-visit based PMPMs, case rates, and capitation arrangements.


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HIT: Analytics: UHA uses claims and EMR data sets to provide detailed visibility on specific quality metrics. The providers and office staff have the benefit of seeing metrics data at the point of care, in the EMR, via a custom form, directly integrated with the Intelligenz reporting engine (UHA analytics vendor), where the provider and office staff have the ability to view and take action on health care gaps for CCO metrics. It provides a workflow solution to help close quality gaps, improve member health outcomes, and maximize financial opportunities with OHA. The providers and fffice staff also have the ability to log directly into the Intelligenz web portal site, separate from the EMR, to view their metrics Direct Secure Messaging: Umpqua Health subsidizes an EMR for many of the independent providers in the community. This EMR has functionality that allows secure messaging between providers. Providers and office staff have the ability to send messages to other entities that have a Direct Secure email address. This can include sending and/or receiving transitions of care to/from other offices. The EMR is also interfaced with Tiani HIE, a regional health information exchange. Providers and Office Staff have the ability to pull in health care information, regarding patients, into the EMR, from other regional locations, if available.

Health Equity and Data: Qualitative and quantitative data regarding disparities in health care delivery and health outcomes is present in UHA’s Community Health Assessment. The Community Health Assessment (CHA) was completed using the Mobilizing for Action through Planning and Partnerships (MAPP) model. The process included key informant interviews, community focus groups, secondary quantitative data collection, and review by UHA’s CAC. The focus groups were targeted to particular populations, in an effort to ensure that data collection was representative of different populations in our service area, including those typically underrepresented. The eight target populations for the 2013 focus groups were: seniors, WIC participants, CAC members, homeless teens, Latino/Spanish-Speakers, individuals with chronic mental health conditions, Reedsport residents, and individuals with developmental disabilities. The CHA process was initially completed in 2013. UHA is currently working with a local Federally Qualified Health Center and a local service organization to complete a CHA update, expected to be finished in spring 2018. The current CHA process is also utilizing the MAPP model, and includes community focus groups, community-wide surveys, secondary quantitative data collection, and review by UHA’s CAC. Focus group target populations were again chosen to reflect populations in our service area that are traditionally underrepresented. The 10 target populations for the 2018 CHA are: Latino/Spanish Speakers, CAC members, OHP members, the disabled, geographically underserved, the underemployed, behavioral health and addictions, parents and children, seniors, and people experiencing homelessness. Quantitative data collected in the 2013 CHA includes demographic trends, population characteristics, health status, health behavior and lifestyle factors, and additional social determinants of health. Qualitative data collected in the 2013 CHA generally fell into six categories: health behavior and lifestyle, social determinants of health, the community’s health, access to health and medical services, health literacy, and individual health. Using data from the CHA, UHA developed a Community Health Improvement Plan (CHIP). The CHIP outlines five prioritized health issues: access, addictions, mental health, parents & children, and healthy lifestyles. The CHIP has been the guiding document for work by the CAC, and CAC members have contributed efforts toward activities that support the identified focus areas. Partnership and collaboration on CHIP activities has included representation of local physical and oral health providers, area service organizations, the South-Central Early Learning Hub, area schools, and local citizens. Patient-Centered Primary Care Homes: UHA has a robust network of primary care providers that serve as PCPCH. UHA recognizes that its members receive a better experience when being served in a PCPCH environment. This includes having better access, higher quality, stronger care coordination, in a patient and family centered setting. All To that end, over 95% of UHA’s contracted PCPCH are at a Tier 3 or higher, with 100% of its membership enrolled in a


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PCPCH. As part of UHA’s Value Based Care Program, PCPCH are paid an additional PMPM incentive for obtaining at least a Tier 3 status. Recognizing the importance of reaching the highest levels possible, UHA further incentivizes these organizations reach higher tier statues. C. QUALITY ASSESSMENT

Evaluation Analysis: Patient-Centered Primary Care Homes: UHA Population Health Team works with our networked providers to assist them in meeting attestation requirements for PCPCH designation. In 2017, the percentage of members enrolled in PCPCH by Tier is represented in the table below:

2017 Quarter Q1 Q2 Q3 Q4 No Tier 2.20% 2.03% 1.92% 1.84% Tier 1 0.00% 0.00% 0.00% 0.00% Tier 2 1.10% 1.07% 1.03% 1.01% Tier 3 93.80% 83.25% 80.10% 68.07% Tier 4 2.90% 13.65% 15.90% 27.63% Tier 5 0.00% 0.00% 0.00% 0.00% Tribal Clinic 0.00% 0.00% 1.05% 1.45% TOTAL 100.00% 100.00% 100.00% 100.00%


Activity: Increase the number of assigned members to providers with a Tier 4 or higher recognition






Time (MM/YYYY)


Time (MM/YYYY)

Increase in assigned members to PCPCH Tier 4 or higher providers

Tier 4+:

27.63% of members

Tier 4+:

35% of members

12/2019

A. TQS COMPONENT(S)

Primary Component: Utilization review Secondary Component: Choose an item.


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Additional Components: Add text here.

Subcomponents: Choose an item. Additional Subcomponent(s): Add text here.


Utilization Review: Medical Utilization Review: UHA is committed to the Triple Aim: improve the lifelong health of all Oregonians; increase the quality, reliability, and availability of care for all Oregonians; and lower or contain the cost of care so it is affordable for everyone. UHA has a duty and obligation to manage costs. To that end, UHA has created a Utilization Management Committee (“UM Committee”) to serve that purpose. The purposes of the UM Committee includes the following:

1. Monitor and identify UHA costs and utilization trends in a routine manner in an effort to make timely informed decisions as necessary;

2. Identify areas for potential remediation of over/under or inappropriate utilization; and 3. Recommend improvement strategies, including additional care coordination to potentially reduce costs and

improve patient outcomes (e.g., hospital readmissions). Claims data is analyzed to determine trends, both at the specialty-level and health-plan level. More recent data is compared against less recent data within the same categories to determine utilization trend. This data is also compared against the expected budget. Drug Utilization Review: UHA’s Pharmacy and Therapeutics (P&T) Committee was developed to establish and maintain UHA’s a drug list (formulary) and drug policies based upon peer-reviewed, clinical literature and evidence-based practice guidelines from national and/or international professional organizations and in accordance with all applicable state and federal regulations. UHA’s P&T committee’s mission is to promote safe and effective use of high value medications for Douglas County members. Additionally, the UHA P&T Committee advises on administration of retrospective and prospective drug use review (DUR) programs. Prospective DUR includes utilization controls, prior authorization requirements, step therapy, quantity limits and other conditions for coverage. Retrospective DUR may include a review based on clinical criteria or predetermined standards to determine the population at risk of a clinically significant adverse event or inappropriate utilization (over- or under-utilization). This review may look across providers and patients to determine the provider outliers whose prescribing, dispensing, or consumption practices may not conform to accepted standards of care.


Evaluation Analysis:

UHA members approved for residential or detox substance abuse treatment often have already completed that level of care but have failed and are eventually seek additional residential or detox treatment. Reducing recidivism at higher levels of care in substance abuse treatment by monitoring member compliance with outpatient (OP) treatment may lead to a higher success rate for those individuals affected. Using PSDA strategies, this project will include identifying members with 2 or more residential or detox stays within 12 months and then monitoring and evaluating OP treatment patterns. Members with no OP treatment may be referred to UHA Care Management Coordination for assistance in coordinating OP care.


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The overall goal of this process improvement project will be to:

• reduce recidivism in residential treatment by coordinating compliance with OP treatment.

DATA: The table below reflects the number of members who had residential treatment in 2017 and of those members, the number with zero OP claims found during the same time period:

• 30% of members who had 2 or more residential stays had 0 outpatient treatment. • 36% of members who had 1 or more residential stays had 0 outpatient treatment.


Activity: A review of claims history for OP substance abuse treatment will be conducted for all members who have had a residential treatment admission within 12 months prior to the request. Members with no OP treatment may be referred to UHA Care Management Coordination.






Time (MM/YYYY) Benchmark or future state

Time (MM/YYYY)

Quarterly claims based reporting

30% of members who had 2 or more residential

5% decrease in residential SA treatment

01/2019 25% of members who had 2 or more residential


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stays had 0 outpatient treatment.

recidivism after no outpatient treatment

stays had 0 outpatient treatment.

A. TQS COMPONENT(S)

Primary Component: Access Secondary Component: CLAS standards and provider network


Subcomponents:

Access: Quality and appropriateness of care furnished to all members


Access: Availability of Services; Access: Second Opinions; Access: Timely Access; Access: Cultural Considerations


Member Services and Provider Network Adequacy:

Access: UHA is committed to the Triple Aim: improving the patient experience of care for its members, improving the health of its members, and reducing the cost of health care. To that end, UHA routinely monitors its network for adequacy, including monitoring provider availability and provider access. UHA monitors its network annually and prepares a Network Adequacy Study, which reports the following: 1. UHA’s Provider Availability Requirements; 2. Time and Distance Standards; 3. Member-to-PCP Ratio; 4. Grievance Analysis; 5. Special Requests and Accommodations; 6. Utilization Trends; 7. Requests for Out-of-Network Services; 8. Requests for Second Opinions; 9. Community Needs Assessment; and 10. CAHPS Access to Care and Satisfaction Survey Results. Within each of those sections, UHA identifies its requirements, how it is evaluated, the findings, a discussion of the findings, and recommended actions. UHA Provider Availability Requirements: Monitoring Network Availability, UHA network providers must meet the following requirements: 1. UHA’s providers shall meet the following availability standards for appointment wait times.

a. Primary Care Providers (“PCPs”) are required to meet the following availability standards: i. Timeframe for Urgent Appointment – Within 72 hours. (OAR 410-141-3220(8)(b).)


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ii. Timeframe for Routine Appointment – Within four weeks. (OAR 410-141-3220(8)(c).) iii. Timeframe for follow up visit following an ER visit or post hospital discharge – Within 72 hours.

b. Specialists are required to meet the following availability standard. i. Timeframe for Urgent Appointment – Within 72 hours. (OAR 410-141-3220(8)(b).)

ii. Timeframe for Routine Appointment – Within four weeks. (OAR 410-141-3220(8)(c).) c. Dental Care Providers (“DCPs”) are required to meet the following availability standards:

i. Timeframe for Emergent Dental Care – Within 1 business day. (OAR 410-141-3220(8)(d). ii. Timeframe for Urgent Dental Care – Within one to two weeks. (OAR 410-141-3220(8)(e).

iii. Timeframe for Routine Dental Care: a. Within an average of 8 weeks (OAR 410-141-3220(8)(f)); and b. Within no longer than 12 weeks (OAR 410-141-3220(8)(f)).

d. Behavioral Health Providers are required to meet the following availability standard: i. Non-urgent behavioral health – Within 2 weeks from the date of request (OAR 410-141-3200(8)(g).)

UHA monitors network availability several ways, including reviewing grievances and appeals from members, reviewing member complaints received by Members Services, utilization trends, requests for out-of-network services, requests for special accommodations, requests for second opinions, community health assessments, and member satisfaction survey results. However, although UHA evaluates availability several ways, there is not a concise way to routinely measure and report the results. UHA Time and Distance Standards: Monitoring Network Access, network providers must meet the following time and distance requirements: Provider Access Requirements: 1. UHA shall ensure that its network is meeting the following time and distance access standards.

a. UHA’s in-network PCPs are required to meet the following time and distance standards for at least 90% of UHA’s members.

i. Travel time for member to PCP: 30 minutes urban/60 minutes rural (OAR 410-141-3220(4)); or ii. Distance for member to PCP: 30 miles urban/60 miles rural (OAR 410-141-3220(4)).

b. UHA’s in-network Specialists are required to meet the following time and distance standards, which are based on the proposed specialties and standards for Qualified Health Plans in Oregon in 2017.

i. Dental – within 80 minutes or 60 miles of member. ii. Endocrinology – within 100 minutes or 75 miles of member.

iii. Gynecology (OB/GYN) – within 80 minutes or 60 miles of member. iv. Infectious Diseases – within 100 minutes or 75 miles of member. v. Oncology (Medical/Surgical) – within 60 minutes or 45 miles of member.

vi. Oncology (Radiation/Radiology) – within 100 minutes or 75 miles of member. vii. Mental Health – within 60 minutes or 45 miles of member.

viii. Pediatrics – within 80 minutes or 60 miles of member. ix. Cardiology – within 50 minutes or 35 miles of member. x. Rheumatology – within 100 minutes or 75 miles of member.

xi. Hospitals - within 80 minutes or 60 miles of member. xii. Outpatient Dialysis – within 80 minutes or 60 miles of member.

xiii. Inpatient Psychiatric Facility Services – within 100 minutes or 75 miles of member. UHA runs a report comparing the most up-to-date list of providers, by specialty and location, with the monthly member list to determine the time and distance members are from each provider specialty listed above.


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Results of 2017 review: DCOs

• 99.8% of members are within either 60 miles or 80 minutes of a dental care provider. PCPs

• 99.3% of members are within either 30 miles or 30 minutes of a PCP. • 99.8% of members are within either 60 miles or 60 minutes of a PCP.

Specialists • 99.8% of members are within either 75 miles or 100 minutes of an endocrinologist. • 99.8% of members are within either 60 miles or 80 minutes of an OB/GYN. • 99.8% of members are within either 75 miles or 100 minutes of an infectious disease specialist. • 99.5% of members are within either 45 miles or 60 minutes of an oncologist. • 99.8% of members are within either 75 miles or 100 minutes of a radiation oncologist. • 99.8% of members are within either 60 miles or 80 minutes of a pediatrician. • 99.4% of members are within either 35 miles or 50 minutes of a cardiologist. • 99.8% of members are within either 75 miles or 100 minutes of a rheumatologist. • 99.8% of members are within either 60 miles or 80 minutes of an outpatient dialysis center.

Hospitals • 99.8% of members are within either 60 miles or 80 minutes of a hospital.

Mental Health • 99.9% of members are within either 45 miles or 60 minutes of a mental health provider. • 99.9% of members are within either 75 miles or 100 minutes of inpatient psychiatric facility services.

UHA’s network of providers meets all of the above time and distance standards. Member-to-PCP Ratio Requirement 1. UHA shall ensure that its network is meeting the following member-to-provider ratio.

a. UHA’s ratio of member-to-PCP shall not exceed 1,500 members per PCP. b. No clinic shall have greater than 1,500 members per PCP.

UHA’s network of PCPs meets the above member-to-PCP ratio standards. UHA also monitors when a practice is open or closed to accepting new UHA members, so PCPs are able to take into account their entire patient population and payer mix. With that information, UHA’s Members Services Department will then assign members accordingly to ensure that the above standards are met. Special Requests and Accommodations Requirement: Pursuant to the CCO Contract, UHA must provide culturally and linguistically appropriate care to its members. To that end, UHA requirements include, but are not limited to, alternate format materials, such as translation and interpretation services. UHA’s Member Services and Clinical Engagement Departments receive requests for special requests and accommodations for members. Member Services tracks each request for alternate format materials. Clinical Engagement also receives certain requests related to interpretation services. Since mid-July 2017, Member Services has maintained a log of the requests for alternate format materials. In that time, Member Services has received 39 requests for alternate format materials. Of the 39 requests, 13 were requests for alternative format materials in another language besides English, with a majority (9) of those requests for Spanish.


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There were no requests directly asking for a provider who speaks the language requested for the alternative format materials. Clinical Engagement has received approximately half a dozen requests related to translation services, with one or two requests for Spanish-speaking services and the rest requesting sign language interpreter services. Since mid-2017, there have been approximately half a dozen requests for translation services, related to either a Spanish-speaking translator or sign-language interpreter services. UHA’s records indicate that there have not been any requests for a Spanish-speaking provider. In addition, UHA has used a local provider from Yoncalla for translation services for those members that request sign-language interpreter services. Recognizing the importance to enhance health equity, and reduce health case disparities, UHA closely monitors special requests and accommodations. UHA population mixed is a bit unique to Douglas County, in comparison to more urban environments. Therefore, while CLAS Standards may not be explicitly comparable to a major metropolitan area, UHA is mindful that its population does have diverse needs, which if not addressed, can drastically impact health outcomes. Accordingly, UHA routinely reviews specials requests and accommodations to either provider support on an individual basis, or if need be, identifying longer sustainable solutions. At this time, UHA appears to have an adequate network and process in place to handle special requests and accommodations. C. QUALITY ASSESSMENT

Evaluation Analysis: UHA monitors network availability several ways, including reviewing grievances and appeals from members, reviewing member complaints received by Member Services, utilization trends, requests for out-of-network services, requests for special accommodations, requests for second opinions, community health assessments, and member satisfaction survey results. UHA did not see data trends in 2017 that indicate any meaningful conclusions with respect to particular provider standards for appointment wait times. It does appear though, that members may be having difficulty being seen in a timely manner for both scheduled appointments and urgent/emergent care based on grievances received in 2017. At present, UHA does not have a process in place to routinely monitor provider availability. UHA is currently developing a process to monitor the availability of its providers. In addition to the activities described below, UHA is looking at other solutions such as the ability to request schedules from practices from their practice management software to determine the time from initial member request for an appointment and the date of the appointment.


Activity: UHA intends to do the following beginning in 2018: • Send quarterly surveys to network providers to collect each office’s current

availability and wait times for the relevant standards for its particular specialty or specialties.

• Randomly, approximately two times a year or on an as-needed basis, perform

secret shopper calls to determine if the office’s current wait times align with the responses provided in its surveys.




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Time (MM/YYYY)


Time (MM/YYYY)

Quarterly provider survey

0% of contracted providers are providing data related to availability.

Increase percentage to 50% of contracted PCP, specialists, DCO, and mental health providers

01/2019

A. TQS COMPONENT(S) Primary Component: Grievances and appeals Secondary Component: Access Additional Components:

Subcomponents: Access: Timely access Additional Subcomponent(s):

B. NARRATIVE OF THE PROJECT OR PROGRAM Grievances and Appeals: If UHA denies a service authorization request, reduces a previously authorized service request, or authorizes a service in an amount, duration, or scope that is less than requested, members have the right to appeal. If upon UHA’s review of the adverse benefit determination, the original decision is upheld, the member then has the right to request a contested case hearing. Members also have the right to file a grievance at any time for any matter other than an appeal or contested case hearing. UHA investigates and resolves grievances in compliance with OAR 410-141-3235. During the course of the investigation, UHA outreached to related entities for a resolution when appropriate. Members may also present their grievance to the Department of Human Services (Department) Client Services Unit or the Authority’s Ombudsman. UHA reports appeal and grievance data to the OHA on a quarterly basis. Grievances are categorized as Access, Interaction with Provider or Plan, Consumer Rights, Quality of Care, and Client Billing Issues. The timeliness and categorization of these requests are reviewed by UHA to ensure compliance and to identify trends, and also presented to the Clinical Advisory Panel. If a trend is identified, outreach is done to Providers Relations, Member Services, or other related entities to collaborate and address the issue. UHA is committed to ensuring members have access to high quality care through a provider network that demonstrates communication, collaboration, and shared decision making with the various providers and care settings. While there was not a substantial repeat of individual providers, a majority of the grievances were related primary care as a service type. In most cases, the member had concerns that they could not see a provider as fast or as frequently as they had requested. In 2017, UHA received a total of 230 grievances. Approximately 17% of the total grievances were related to access.


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For each grievances related to access, the provider’s office was contacted if appropriate. Members have been assisted with finding a different provider if necessary. The results of the quarterly reports will be shared with the Clinical Advisory Panel. In addition, the reports will be shared with Provider Relations to identify opportunities for provider outreach, education, or other corrective action. C. QUALITY ASSESSMENT

Evaluation Analysis: Decrease the number of grievances against provider offices. This includes all of the Grievance Type Descriptions from the “Interaction with Provider or Plan: IP category sections that are related to providers/provider offices: a, b, d, f, g, j, k, l, m. This category receives the highest number of grievances from UHA members. The chart below shows the number of grievances from these categories in 2016 and 2017:


Activity: UHA will develop and provide education to provider office staff regarding customer service.






Time (MM/YYYY)


Time (MM/YYYY)

Monitor the number of grievances received in the “IP” category.

65 grievances from this category in 2017

Reduce by 10% 12/31/2018 58 grievance from this category in 2018

12/31/2018


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A. TQS COMPONENT(S)

Primary Component: Fraud, waste and abuse Secondary Component: Grievances and appeals


Subcomponents: Choose an item. Additional Subcomponent(s): Add text here.


FWA Investigations: Number of investigations for 2017: 67 total Number of referrals submitted to MFCU/PAU for 2017: 2 cases

FWA Recoveries from an audit or investigation:

2016: $0.00 2017: $24,667

FWA Analysis:

This is conducted annually by the UHA Compliance Officer. The analysis compares our current policy and procedure to the new regulations and contract requirements. Once the analysis is complete, the policy is revised then approved by the Compliance Board. The analysis will also address any changes need in processes. Additionally, any other Compliance policies found lacking during the FWA analysis are also updated (this aspect is in progress for the 2017 FWA analysis).

Training and Education: Umpqua Health employees, compliance officer, and subcontractors receive the following trainings: i. Fraud, waste, and abuse. ii. Health Insurance Portability and Accountability Act (HIPAA). iii. Compliance training (Compliance Plan and Code of Conduct and Ethics).

See UHA Compliance Plan (attached) C. QUALITY ASSESSMENT

Evaluation Analysis: A review of UHA’s FWA audits and investigation resulted in no recoveries for 2016. In 2017, UHA decided to do more targeted proactive FWA audits, took steps to further educate its workforce on FWA, and made its hotline more visible. In 2018, UHA will continue to engage in more targeted proactive FWA audits and will review the recoveries at the end of 2018.


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Activity: Increase the number of FWA recovery stemming from FWA audits or investigation.






Time (MM/YYYY)


Time (MM/YYYY)

Annual reporting of FWA recoveries.

$24,667 recovered in 2017 from FWA audits and investigations.

10% increase from 2017 performance

01/2019

Section 3: Required Transformation and Quality Program Attachments A. Attach your CCO’s quality improvement committee meeting minutes from three meeting

See Attached: UHA TQS 2018_1st QAUM Minutes UHA TQS 2018_2nd QAUM Minutes

UHA TQS 2018_3rd QAUM Minutes

B. Attach your CCO’s consumer rights policy See Attached: UHA TQS 2018_Consumer Rights Policy

C. OPTIONAL: Attach other documents relevant to the above TQS components, such as policies and procedures, driver diagrams, root-cause analysis diagrams, data to support problem statement, or organizational charts. See Attached: UHA TQS 2018_Compliance Plan

Transformation & Quality Strategy

Documents

Transcript of Transformation & Quality Strategy