2016 Cenpatico QI Work Plan

Transcription

1 Category Goal Objectives Measurement/ QI Documentation QI Communication QI Monitoring Activities Ensure all QI Program guidance documents and work plans are current and approved. Review and Update QI Program Description Annual approval by the Cenpatico QIC and Board of Directors. Evaluation of Program Evaluate QI Plan Annual approval by the Cenpatico QIC and Board of Directors. Revise and document annual QI Update QI Work Plan Annual approval by the Cenpatico performance measurements goals. QIC and Board of Directors. Policies & Procedures Develop, review and revise QI 100% Compliance with health Policies and Procedures monthly. plan/corporate audits pertaining to QI policies and procedures. Establish Clinical Practice Guidelines Ensure that all QI Program activities and initiatives are communicated to members. Ensure that all QI Program activities and initiatives are communicated to providers. Ensure provider access to current CPGs. Monitor all providers against Quality Monitoring Standards. Complete annual Treatment Record Reviews. Develop CPGs bi-annually QIC approval of CPGs Bi-annually; no later than October, 2016 Post 2015 QI Program Summary to Cenpatico member website. Post 2015 QI Program Summary to Cenpatico provider website. Post updated CPGs to provider website. Mail hard copies when requested. Review of provider complaint, QOC concern, CI and CAPs against established thresh holds. Review provider treatment records for completeness and accuracy in IN, MA and LA. 03/01/16 Mari Bilderback Scheduled 03/01/16 Mari Bilderback Scheduled 03/01/16 Mari Bilderback Scheduled Monthly Mari Bilderback Mari Bilderback 2Q 2016 N/A 03/01/16 Mari Bilderback Scheduled N/A 03/01/16 Mari Bilderback Scheduled CPGs are posted to provider website. > one member complaint, > five QOC complaints that are leveled at a 1 or 2, >0 QOC complaints' that are leveled at a 4 or 5, > one critical incident, has an active corrective action plan. Records will be in 85% compliance with treatment record review standards. 2Q 2016 Mari Bilderback Scheduled Data collection monthly. Report to Cred Committee monthly. Annual analysis completed by 12/31/16.. Completion date 12/31/16. James George Royace Gibson Page 1 of 6

2 Category Goal Objectives Measurement/ Member & Provider Input into QI Program Provide accurate, reliable and actionable reports to market customers. Monitor BH HEDIS measures for all markets and coordinate with Cenpatico Clinical and Health Plan staff to assist with performance improvement. Ensure timely and viable response to member and provider complaints. Ensure timely and viable response to member and provider complaints. Report trends in member and provider complaints for system and individual improvement opportunities. Create comprehensive, cross functional reports based on quantifiable, valid measures for decision making. Review HEDIS for delegated BH measures and shared measures on a monthly basis. Identify and communicate trends to stakeholders as needed. Assist with performance improvement design. Acknowledge member and provider complaints within 5 days of receipt of complaint except where market contractual requirements are more strict. Resolve member and provider complaints within 30 days of receipt of complaint except where market contractual requirements are more strict. Analyze tracked and trended NA complaint data monthly and quarterly. Report to QIC at least biannually. Post trends to QI SharePoint site for business leaders monthly. NA Mari Bilderback HEDIS 75th percentile, unless otherwise specified. # of complaints acknowledged timely/total number of complaints received. : 100% # of complaints resolved timely/total number of complaints received. : 100% Monthly, Tyre Nelson/ Ed Millard Data James George/ Collection. Amy Patterson Interim monitoring/analysi s reported quarterly. Annual evaluation due 01/31/16. Data James George/ Collection. Amy Patterson Interim monitoring/analysi s reported quarterly. Annual evaluation due 01/31/16. Monthly, Amy Patterson Biannually Page 2 of 6

3 Category Goal Objectives Measurement/ Report trends in QOC concerns and CIs for system and individual improvement opportunities. Complete member and provider satisfaction surveys. PERFORMANCE MEASURES Access Assess provider appointment availability to ensure member access to care. Assess provider appointment availability to ensure member access to care. Analyze tracked and trended aggregate QOC/CI data quarterly and report to QIC and Cred Committee. Use trends in survey responses to identify areas for system improvement. Complete urgent appointment availability surveys for all markets monthly. Complete routine appointment availability surveys for all markets monthly. Abandonment Rate is below 7% Ensure timely answer to member and provider calls (average speed of answer). Ensure all call center statistics result in an overall high service level. NA Total number of positive responses/total number of responses. : 80% satisfaction rate. Number of positive responses for urgent appointment availability/number of providers surveyed. : 90% Number of positive responses for routine appointment availability/number of providers surveyed. : 90% Number of calls abandoned/total number of calls. : < 5% Time for calls answered/total number of calls. : < 30 seconds Continuous Data James George Collection. Interim monitoring and analysis conducted quarterly. Annual analysis completed 01/31/16. 09/01/16 Tyre Nelson/ Amy Patterson Monthly Total of all service level measures/total number of all calls. : > 90% Ensure all call center statistics Average hold time performance result in an overall high service level target: > 2 minutes (average hold time). Tyre Nelson/ Amy Patterson Tyre Nelson/ Amy Patterson Kick off for 2015 surveys: April, Survey administration: May-July, Annual reporting: September, 2016 Page 3 of 6

4 Category Goal Objectives Measurement/ Clinical Care Coordination Assess Access to Cenpatico Network Providers and Practitioners Assess Access to Cenpatico Network Providers and Practitioners Ensure members have access to Urgent Appointment Availability Ensure members receive timely follow up care after a hospitalization (FUH). Ensure members receive appropriate medication management for a new diagnosis of depression (AMM). Ensure members receive appropriate medication management for a new diagnosis of attention deficit disorder/hyperactivity disorder. (ADD) Ensure Initiation and Engagement of Alcohol and Other Drug Dependent members in Treatment (IET). Ensure members have easy access to all provider and practitioner types based on geographic accessibility. Ensure sufficient numbers of providers and practitioners are available to Cenpatico members. All markets should meet or exceed the target rate for access to urgent care appointments. Increase the rate of members receiving outpatient follow up care after a hospitalization within 30 days of discharge. Increase the rate of members attending medication management appointments for depression management. Increase the rate of members attending medication management appointment for ADHD management. Increase the percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and the percentage of members and whom have two or more additional AOD services within 30 days of the initiation visit. Geo Access Analysis of proximity to providers/practitioners. : > 95% Geo Access Analysis of member to provider/practitioner ratios. : 1 provider/practitioner to every 2000 members. for access to Urgent Appointment Availability should reach 90% HEDIS 75th percentile Kelley Grayson Kelley Grayson Monthly, Mari Bilderback Lanette Allendorf HEDIS 75th percentile 12/31/16 Lanette Allendorf HEDIS 75th percentile 12/31/16 Lanette Allendorf HEDIS 75th percentile 12/31/16 Lanette Allendorf/ Page 4 of 6

5 Category Goal Objectives Measurement/ Screening Case Management Ensure member adherence to Antipsychotic Medications for individuals With Schizophrenia (SAA) Ages Ensure members are notified and transitioned timely to new providers upon termination of a provider from the network. Ensure Members with Bipolar Disorder and Schizophrenia on Antipsychotics are screened for diabetes (SSD). Increase use of the PHQ-9 Depression Screening Tool. Engage pregnant and delivered women at risk for depression in health care services. Engage pregnant and newly delivered women at risk for depression in health care services. Engage pregnant and newly delivered women at risk for depression in health care services. Obtain practitioner input on Cenpatico Screening Programs Notify primary behavioral health providers and PCPs when members are discharged from inpatient care. Increase the number of members diagnosed with schizophrenia who were dispensed and remain on an antipsychotic medication for at least 80 percent of their treatment period. Complete member continuity of care notification process 30 days before the provider terminates from the network. To coordinate healthcare needs with primary care. To ensure providers and practitioners are utilizing industry best practices in the care of members with depression. Increase the successful outreach rate for members at medium/high risk for depression. HEDIS 75th percentile 12/31/16 100% of active members will be notified 30 days before a provider terminates from the network and offered a new provider. 12/31/16 Amy Patterson HEDIS 75th percentile (TBD) Monthly Lanette Allendorf 5% increase over baseline 12/31/16 Lanette Allendorf/ Total number of medium/high risk screens with successful outreach/total number of responses. : 75% successful outreach. 12/31/16 Lanette Allendorf/ Improve turnaround time from < 2 business days per screen 12/31/16 Lanette Allendorf/ receipt of screen to trigger to clinical team for outreach. Improve turnaround time from receipt of completed screen to first outreach to member Ensure applicability and viability of screening programs in the service community. To ensure continuity and coordination of care. < 5 business days per screen 12/31/16 Lanette Allendorf/ QIC review and approval 65% of all discharge assessments are communicated to PCPs and primary BH providers. ; August, 2016 Tyre Nelson Monthly Lanette Allendorf Page 5 of 6

6 Category Goal Objectives Measurement/ Provider Data Management BSO Utilization Management Reduce readmissions to inpatient care at 30 and 90 days. Improve member engagement in Cenpatico CM Program Decrease Inpatient Readmission Rates at 30 and 90 Days for Members Engaged in CM services. Reduce Service Costs for Members Engaged in CM Services. Ensure timely review and approval of credentialing provider and Ensure timely review and approval of recredentialing of providers and Ensure timely processing of provider and practitioner credentialing and recredentialing files. Increase auto-adjudication rates. Process claims within contractual TAT. IP Authorization TAT OP Authorization TAT To ensure members are connected to outpatient services in a timely fashion following discharge. To ensure members receive assistance in managing care transitions and obtain needed resources to improve self care. To ensure members receive care in their community of choice and receive services in the most appropriate, least restrictive setting. To ensure case management services are effective and efficient. Improve processing time of initial credentialing applications. Improve processing time of recredentialing applications. Improve credentialing staff production. Meet or exceed auto-adjudication rate. Process claims within 30 days or less. Meet UM Timeliness IP for all Products Meet UM Timeliness OP for all Products 3.5% at 30 days, 11.8% at 90 days.monthly Lanette Allendorf 10% increase in member CM engagement rates. 5% decrease in 30 and 90 day readmission rates 12/31/16 Lanette Allendorf 12/31/16 Lanette Allendorf 5% decrease in total care costs 12/31/16 Lanette Allendorf < 30 days < 2 years in Florida; 3 years in all other markets (36 months). > 20 complete and clean applications per staff member, per week 12/31/16 Irene Armendariz >85% 12/31/16 Jason McBride > 90% 12/31/16 Jason McBride 100% 12/31/16 Lanette Allendorf 100% 12/31/16 Irene Armendariz 12/31/16 Irene Armendariz 12/31/16 Lanette Allendorf Page 6 of 6