WellCare of Kentucky’s Quest for Quality

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WellCare of Kentucky’s Quest for Quality

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WellCare of Kentucky’s Quest for Quality. Why the Quest for Quality?. It’s the RIGHT thing to do for the patient/member Helps your clinic reach targeted goals (clinical and financial) - PowerPoint PPT Presentation

Transcript of WellCare of Kentucky’s Quest for Quality

Page 1: WellCare of Kentucky’s   Quest for Quality

WellCare of Kentucky’s Quest for Quality

Page 2: WellCare of Kentucky’s   Quest for Quality

Why the Quest for Quality?

• It’s the RIGHT thing to do for the patient/member• Helps your clinic reach targeted goals (clinical and financial)• Focuses on your clinic as the medical home for the patient, which many of

you have as a goal for your facility• Stresses evidenced-based approaches to care, which improve outcomes and

reduce costs

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How Do We Work Together to Achieve Our Goals?

Our approach to Quality is four-pronged. It is built on fostering partnerships and working collaboratively with providers, members, the community and State to improve health outcomes.

Improved Health Outcomes

Providers

Manage members’ care

Provide tools to assist providers

Assist in coordinating members’ care

Members

Educate members

Assist in coordinating care and removing barriers to care

Community

Bring community advocates together to serve members needs

Identify member social resources

State

Find solutions for State-wide issues and barriers to care

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State Requirements of WellCare That Affect Providers

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State Requirements :• Monitor PCPs adherence to

clinical practice guidelines• Asthma – Use of controllers

and relievers• Diabetes – Monitoring of

HbA1c, LDL, Eye Exam, Nephropathy, and BP

• Adult Depression – Use and continuation of antidepressant medication

• ADHD – Follow-up visits • Identify patterns of over- and

under-utilization

Impact to Providers:• Assess PCPs compliance with

national standards of care as measured by submission of claims with appropriate coding and medical record chart reviews

• Evaluation of claims for appropriate referral patterns and treatment

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State Requirements of WellCare That Affect Providers, continued

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State Requirements :• Implement steps to improve the

health status of Medicaid members as measured by HEDIS and State-selected performance measures (Appendix A)

• Develop and implement performance improvement projects

• Behavioral health medications• ED use

• Investigate and resolve member grievances within 30 calendar days

Impact to Providers:• Conduct medical record chart

reviews and claims analysis for completion of services. Use of appropriate CPT and CPT II codes will decrease chart review

• Evaluation of claims for appropriate use of behavioral health medications and ED patterns

• Contact by our grievance team for issue resolution

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State Requirements of WellCare That Affect Providers, continued

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State Requirements :• Monitor PCP adherence to the

State’s appointment waiting times • Routine and preventive care

appointments within 30 days of request

• Urgent care appointments within 48 hours of request

• After-hours calls returned within 30 minutes

Impact to Providers:• Conduct audits by telephone

assessing compliance with the appointment standards

• Providers out of compliance receive a letter and are re-audited within 90 days

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State Requirements of WellCare That Affect Providers, continued

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State Requirements :• Monitor PCPs to ensure they are:

• Maintaining a current medical record for the members, including documentation of all PCP and specialty care services

• Documenting all care rendered in a complete and accurate medical record that meets or exceeds the State’s specifications (Appendix B)

• Providing primary and preventive care, recommending or arranging for all necessary preventive health care, including EPSDT for members under 21 years of age (Appendix C)

Impact to Providers:• Conduct medical record chart

audits annually to assess PCPs and OB/GYNs compliance with documentation standards

• Providers out of compliance receive a letter of corrective action and are re-audited

• Conduct medical record chart audits annually to assess PCPs compliance with EPSDT documentation standards

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WellCare of Kentucky Offices

Owensboro Office 270-688-7000

Louisville Office 502-253-5100

Lexington Office 859-264-5100

Ashland Office 606-327-6200

Hazard Office 606-436-1500

Bowling Green Office 270-793-7300

We have six offices throughout the Commonwealth staffed with Provider Relations Representatives and Case/Disease Managers that live in those communities to service the needs

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Our Provider Focus

Provider Tools • Identification of care gaps at eligibility checks

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https://kentucky.wellcare.com

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Provider Tools, continued

Provider Profile Report

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Provider Tools, continued

Provider Care Gap Report

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Provider Tools, continued

Member-Centered Case and Disease Management • Member and caregiver-centered model• Service Coordination

• Proactive and collaborative face-to-face outreach and assessment

• Discharge Planning• Matching members needs with most appropriate

provider and/or setting. • Driving Interdisciplinary Care Teams• Integrating care for members

• Holistic Management• Home & Community-Based• Behavioral Health• Pharmacy• Medicare and Medicaid

• Culturally Competent• Services in multiple languages• Understanding and sensitivity to subcultural norms and

preferences

Primary Care Physician

Service Coordination

Specialist and HCBS Providers

Whole Person Orientation

Provider Relations

Family Supports

Community / Advocate

Member

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Provider Tools, continued

• Provider visits and education• HEDIS toolkits and documentation resources• Identification of members in need of screenings

• Support• Designated Provider Relations Representative• Case and Disease Managers• 24/7 Nurse Advise Line

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Our Member Focus

• Member Outreach Initiatives• Conduct targeted phone calls to members identified as needing

screenings• Remind members of any gaps in care they have when calling Customer

Service• Distribute targeted mailing reminders to members identified as needing

screenings• Conduct health risk assessments, identifying illnesses and chronic

conditions early• Offer member incentive programs to obtain specific screenings• Distribute quarterly member newsletters with information on the

importance of preventive and chronic condition care• Provide member focused Case and Disease Management services• Offer $10.00 per month in over-the-counter items to members

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Our Community Focus

What are the physicians saying?

According to a study by the Robert Wood Johnson Foundation, 85% of surveyed physicians say unmet social needs are directly leading to worse health.

In addition, 4 in 5 physicians say the problems created by unmet social needs are problems for everyone, not only for those in low-income communities.

The County Health Rankings show that much of

what affects health occurs outside of the doctor’s office.

The Role of Health Factors on Health Outcomes

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Our Community Focus, continued

How do we overcome these barriers?• Educate members at community activities

• Community Activity Tracker• Bring the community, community advocates, members, providers, and

the Health Plan together to serve members’ needs• Regional HealthConnections Councils

• Identify a network of Social Safety Net organizations• My Family Navigator

• Connect members to Social Safety Net organizations that meet their specific needs

• HealthConnections Log• Compile a library of community-specific data to identify potential areas

of need• WellCare in the Neighborhood

• Support the needs of the communities our members live in• WellCare Innovation Institute

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Community Engagement in Action – A Kentucky Case Study

o A family of six living in subsidized housing.• Mom and Dad work full time without health benefits.• 10-year-old son has special needs. • 19-year-old daughter is pregnant.• 73-year-old grandmother has dementia.

o WellCare connected the family to the following: • Health Care (along with condition-specific healthcare)

In-home services for grandmother Prenatal care for the daughter

• Social Supports WIC / SNAP support Rental / Housing assistance Adult day activity program for grandmother CIL-based independence training for the son Caregiver training through National Caregiver Assoc.

o WellCare found and closed gaps in the following: • Utility assistance• Peer supports for the daughter• Transportation assistance for mother / daughter

The Community Advocacy Response

What makes us different is that WellCare has created a function to ensure that information for referrals to social programs is readily available for the interdisciplinary team (My Family Navigator) and that the programs are still available.

The local community advocates:

• Identified faith-based LIHEAP-related programs that required funding because utility-based LIHEAP had closed.

• Created peer-support group at the local school with provider-partner to address teen pregnancy.

• Connected family to local United Way for their subsidized car loan program to ensure that the daughter could get prenatal care.

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Next Steps

• In-depth discussion on quality with Medical Directors and Quality Staff

• Contact • Ronda Warner, Director of Quality

Phone: 502-253-5139 Email: [email protected]

• David Bolt, Director of Network Management Phone: 859-264-5102 Email: [email protected]

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Questions?

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Appendix A – HEDIS Measures

Measure RequirementADHD Follow-up • One visit 30 days after diagnosis, then

• Two visits within nine monthsAdolescent Well Visits • One visit annually

Adolescent Immunizations • Meningococcal and Tdap/Td by age 13

Appropriate Testing for Pharyngitis

• Antibiotic and strep test

Appropriate Treatment for URI • No antibiotic dispensed

Childhood Immunizations • Have the following by age 2:• 4 DTaP, 3 IPV, 1 MMR, 3 HiB,

3 Hep B, 1 VZV, 4 Pneumococcal, 1 Hep A, 3 Influenza, Rotavirus (complete 2 or 3 dose)

Chlamydia Screening One annually

Pediatric HEDIS Measures

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Appendix A – HEDIS Measures

Measure RequirementDental Visit • One annually

Lead Screening • One by age two

Weight Assessment & Counseling for Nutrition & Physical Activity

• Annual assessment of BMI (value for 16 & 17-year-olds, percentile for 15 and younger

• Annual counseling for nutrition• Annual counseling for physical activity

Well-Child Visits for 3-6 Year Olds

• One annually

Pediatric HEDIS Measures, continued

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Appendix A – HEDIS Measures

Measure RequirementAcute Bronchitis Treatment • No antibiotic dispensed

Adult BMI • Annual assessment of BMI value

Antidepressant Medication • Initiation and continuation of medication

Breast Cancer Screening • Mammogram every two years

Cervical Cancer Screening • Pap smear every three year

Chlamydia Screening • One annually

Cholesterol Management for Patients with Cardiovascular Conditions

• LDL-C annually• LDL-C level <100

Dental Visits • One annually

Adult HEDIS Measures

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Appendix A – HEDIS Measures

Measure RequirementDiabetes Care • Annual assessment of

• HbA1c & result <8%• LDL-C & result <100• Dilated eye exam• Nephropathy monitoring• BP <140/90

Controlling High Blood Pressure • BP <140/90

Low Back Pain • No imaging study within 28 days of diagnosis

Persistent Medication Monitoring • Annual lab monitoring for patients on:• ACE or ARB• Digoxin• Diuretic• Anticonvulsant

Adult HEDIS Measures, continued

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Appendix A – HEDIS Measures

Measure RequirementSmoking Cessation • Advising smokers to quit

• Recommending smoking cessation resources

• Prescribing smoking cessation aidsSpirometry Testing in COPD • Spirometry testing to confirm COPD

diagnosis and/or new exacerbationCOPD Exacerbation • Systemic corticosteroid and

bronchodilator dispensed

Adult HEDIS Measures, continued

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Appendix A – State-Selected Performance Measures

Measure RequirementHeight/Weight/BMI Assessment and Assessment/Counseling for Nutrition and Physical Activity for Adults

• Assess height, weight, and BMI• Assess and or counsel for nutrition and

physical activity

Height/Weight/BMI Assessment and Assessment/Counseling for Nutrition and Physical Activity for Children and Adolescents

• Assess height, weight, and BMI• Assess and or counsel for nutrition and

physical activity

Cholesterol Screening for Adults • LDL-C screening

Prenatal Risk Assessment, Counseling, and Education

• Tobacco use assessment and counseling

Adolescent Screening/Counseling • Tobacco use assessment and counseling• Alcohol and substance use assessment

and counseling• Sexual activity assessment and counseling• Mental health assessment and counseling

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Appendix B – Medical Record Documentation Requirements

• Member identification information on each page;• Personal/biographical data, including:

• Date of birth• Age• Gender• Marital status for adults• Race or ethnicity• Mailing address• Home and work addresses’ as applicable• Home and work telephone numbers’ as applicable• Employer, if applicable• School name for children• Name and telephone information for emergency contact(s)• Consent forms• Language spoken• Guardianship/parent information for children

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Appendix B – Medical Record Documentation Requirements, continued

• Date of data entry and date of encounter;• Provider identification by name;• Allergies, adverse reactions and any known allergies are noted in a

prominent location in the record;• Past medical history, including serious accidents, operations, illnesses.

For children, past medical history includes prenatal care and birth information, operations, and childhood illnesses (i.e. documentation of chickenpox);

• Identification of current problems;• The consultation, laboratory, and radiology reports filed in the medical

record shall contain the ordering provider’s initials or other documentation indicating review;

• Behavioral health summary reports as applicable, initial evaluation and routine follow-up consultations;

• Documentation of immunizations pursuant to 902 KAR 2:060;

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Appendix B – Medical Record Documentation Requirements, continued

• Identification and history of nicotine, alcohol use or substance abuse;• Documentation of reportable diseases and conditions to the local health

department serving the jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR 2:020 as applicable;

• Follow-up visits provided secondary to reports of emergency room care as applicable;

• Hospital discharge summaries as applicable;• Advanced medical directives for adults. PCPs have the responsibility to

discuss advance medical directives with adult members at the first medical appointment and chart that discussion in the medical record of the member;

• All written denials of service and the reason for the denial, as applicable;

• Signature of the provider conducting the encounter; and • Record legibility to at least a peer of the writer. Records judged illegible

by one reviewer are evaluated by another reviewer.

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Appendix B – Medical Record Documentation Requirements, Continued

• Additional Documentation Requirements for Clinical Encounters

• History and physical examination for presenting complaints containing relevant psychological and social conditions affecting the member’s medical/behavioral health, including mental health, and substance abuse status;

• Unresolved problems, referrals and results from diagnostic tests including results and/or status of preventive screening services (i.e. EPSDT) are addressed from previous visits; and

• Plan of treatment that includes:• Medication history, medications prescribed, including the strength,

amount, directions for use and refills;• Therapies and other prescribed regimen; and• Follow-up plans including consultation and referrals and directions,

including time to return.

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Appendix C – EPSDT Requirements

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Visit Component FrequencyComplete History Initial visit

Interval History Each visit

Developmental Assessment(Age-appropriate physical and mental health milestones)

Each visit

Nutritional Assessment Each visit

Lead Exposure Assessment 6-month through 6-year age visits

Complete/Unclothed Physical Exam

Each visit

Growth Chart Each visit

Vision Screen Assessed each visit according to recommended medical standards

Hearing Screen Assessed each visit according to recommended medical standards

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Appendix C – EPSDT Requirements, continued

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Visit Component FrequencyHemoglobin/Hematocrit According to recommended medical

standards

Urinalysis According to recommended medical standards

Lead Blood Level (Low-Risk History)

12-month and 2-year age visit

Lead Blood Level (High-Risk History)

Immediately

Cholesterol Screening According to recommended medical standards

Sickle Cell Screening One-time documentation

Hereditary/Metabolic Screening (Newborn Screening)

According to Kentucky Statute

STD Screening According to recommended medical standards

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Appendix C – EPSDT Requirements, continued

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Visit Component FrequencyPelvic Exam (Pap Smear According to recommended medical

standards

DPT Assessed each visit

DTaP According to recommended medical standards

HiB According to recommended medical standards

MMR According to recommended medical standards

Varicella According to recommended medical standards

Td According to recommended medical standards

PPD According to recommended medical standards

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Appendix C – EPSDT Requirements, continued

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Visit Component FrequencyAge Appropriate Health Education/Anticipatory Guidance

Each visit

Dental Referral Age 1