Go Lean! You can t manage what you don t measure! That Happens. Working together to help improve health outcomes.

Transcription

1 Go Lean! You can t manage what you don t measure! Be The Change That Happens Quality Improvement Newsletter Working together to help improve health outcomes. For provider use only. Not intended for distribution to Medicare Advantage members or prospects. Y0067_PR_CAHPS_0318 WellCare_2018 SPRING 2018

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3 NEW! High Blood Pressure Guidelines Introduced by the American College of Cardiology and the American Heart Association The new blood pressure categories are as follows: Normal: Less than 120/80 mm Hg Elevated: Systolic between and diastolic less than 80 Stage 1: Systolic between or diastolic between Stage 2: systolic at least 140 or diastolic at least 90 mm Hg Hypertensive crisis: Systolic over 180 and/or diastolic over 120 3

4 Member Surveys HOS, CAHPS and HEDIS The Health Outcomes Survey (HOS) and Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) are designed to give Medical Advantage Plans a snapshot of member perception regarding key areas of service and Star measures that are vital to member health and wellness. In both recent surveys, the top chronic condition reported was Hypertension. Data from 2017 shows that approximately 46% of our total membership for TexanPlus and Today s Options has Hypertension (statistic includes TexanPlus HMO-SNP membership). The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America s health plans to measure performance on important dimensions of care and service. HEDIS measurement results identify opportunities for performance improvement. Higher scores increase competitiveness in health plan marketing and result in higher reimbursement. Controlling high blood pressure is an important HEDIS measure. The Centers for Medicare & Medicaid Services (CMS) mandates a system wide three (3) year Quality Improvement Project. The project must meet certain criteria that includes: Taking a multi-disciplinary approach Using the Plan, Do, Study, Act (PDSA) Methodology for Improved Outcomes and Satisfying one (1) or more of the CMS quality strategies: Make care safer by reducing harm caused in delivery of care. Ensure each person and family is engaged as partners in their care. Promote effective communication and coordination of care. Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Work with communities to promote wide use of best practice to enable healthy living, and Make quality of care more affordable for individuals, families, employees, governments, and communities by developing and spreading new health care models. Elevated blood pressure or hypertension is a major contributor to many health-related complications, including heart disease, stroke, peripheral vascular disease, and kidney failure. While blood pressure control can be supported by the health plan, it is vital to ensure correct blood pressure technique, education, and counseling at the provider level. 4 TEXANPLUS

5 Million Hearts Initiative 2022 Heart disease, stroke and other cardiovascular diseases kill over 800,000 Americans each year, accounting for one in every three deaths. It s the nation s number one killer among both men and women and the leading cause of health disparities across the population.* To address this issue, the U.S. Department of Health and Human Services (HHS) established Million Hearts, a five-year initiative co-led by the Centers for Disease Control and Prevention (CDC) and CMS. Launched in 2012, the national initiative alongside 120 official partners and 20 federal agencies successfully aligned national cardiovascular disease prevention efforts around a select set of evidence-based public health and clinical goals and strategies. As a result, significant progress was made toward the ambitious aim of preventing a million cardiovascular (CV) events in five years. However, many challenges confront our collective effort to help Americans live longer, healthier lives. An aging population and increasing rates of obesity and diabetes threaten to undo the progress of the past few decades. After decades of steady improvements, the rate of decline in both heart disease and stroke mortality have essentially flattened in the U.S. This change in trend illustrates how important it is to continue the Million Hearts mission and accelerate efforts and implement policies aimed at CV disease prevention. Over the next five years, Million Hearts will redouble its efforts to engage and equip partners and stakeholders nationwide to reach or exceed aggressive goals that will improve CV health and care for all Americans. Based on extensive modeling, expert interviews, and literature review, and an aim to prevent a million CV events in five years, the priorities of Million Hearts are: Optimizing Care by using teams, health information technology, and evidencebased processes to improve the ABCs (Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation), increase use of cardiac rehab, and enhance hearthealthy behaviors. Keeping People Healthy with public health efforts that promote healthier levels of sodium consumption, increased physical activity, and decreased tobacco use. Improving Outcomes for Priority Populations selected based on data showing a significant CV health disparity, evidence of effective interventions, and partners ready to act. Building on the experience, expertise, and partnerships of the first five years, Million Hearts 2022 seeks strong and specific commitments to these priorities so that together, we can improve CV health for all. * 5

6 Quality Improvement in Primary Care Quality Improvement is essential to achieving the triple aim of improving the health of the population, enhancing patient experiences and improved outcomes, according to the Agency for Healthcare Research and Quality. Improving Processes in Your Practice Dr. Paul Batalden, author of Quality By Design: A Clinical Microsystems Approach, says: We most often view healthcare as different from other products or services, especially in how quality is perceived. Historically, healthcare has been Structure Process Outcome judged by the end result rather than the steps that go into the day to day and member to member process that yields the outcome. A paradigm shift needs to occur in which the focus is on how we get to the end result to improve outcomes by being more customer driven, cost effective, and effi cient. Use your staff to form a tactical team to standardize the structure of the organization (procedures, templates, dashboards, training and cross training), streamline processes (identify and improve bottlenecks, identify what drives you crazy ) to improve outcomes (preventive care in all members, reasonable turnaround times, medications reconciled, improve communication and member understanding). 6 TEXANPLUS

7 The Voice of the Member Each year, a select number of plan members are asked to participate in two annual industry surveys: the Consumer Assessments of Healthcare Providers and Systems Survey (CAHPS) and the Health Outcomes Survey (HOS). The survey results help us understand if members are generally satisfied or dissatisfied with the health care services we provide. And collectively, the results offer us an important snapshot of the overall member experience shedding light on our areas of strength and challenge. In this edition, we ll review some of this feedback in the Members Voice, and consider ways in which we can continue providing the highest quality of health care to those we serve. Let s get started! Here are some examples of the Members Voice and Suggested Actions It is hard to just be ignored and keep waiting. Suggested Action Periodic updates of estimated wait time assures members that the office recognizes and respects the value of their time. Keep those waiting informed of delays and avoid overbooking. Give those who have been waiting over 45 minutes an opportunity to reschedule. I am going through problems getting care. I have numbness in my hands and arms and my primary care doctor keeps dropping the ball on getting authorization for me to see a neurologist and get an MRI. Suggested Action Ensure that the approval process is effective and efficient. Provide realistic turnaround times. Routine authorizations may take up to 2 weeks to process. Expedited authorizations are done only when medically necessary. 7

8 They (doctors) should avoid looking at their phone or laptop. All the attention should be on me. Doctors should look me in the eye to prove they are listening. My doctor has a computer in the exam room to look in my chart. With the computer we can sit down together and review my medical information, like test and lab results or any communication from other providers. My doctor can look up my medical history, medications and family history in pretty short order. I like that I know what my provider knows. Suggested Actions Consider using a scribe who takes notes while the provider talks and assesses the member. Situate the computer so it is between the provider and the member, so the conversation can occur while the provider enters information, but has eye contact with the member. Utilize the side by side method, so the member sees what is being entered and why it is important. Use a variety of the actions discussed, as may be appropriate. Reinforce the benefits of the electronic health record: no lost medical records, medications and history always available, and improving safety with alerts to medication contraindications and need for preventive and diagnostic care. I cannot stand doctors who make jokes or derisive comments. Sometimes a reassuring pat on the shoulder goes a long way. Suggested Action Ensure providers and staff are helpful and professional as well as empathetic and comforting in acknowledging members concerns. A handshake when the provider first walks in and a personal Hello goes a long way to make me feel the doctor is someone I can confide in. It is a good doctor who really talks to you without giving me the bum s rush after 5 minutes. Suggested Action Greet the member personally and warmly by name. Listen and pay attention to the member. Provide adequate and thorough care and avoid rushing the member. 8 TEXANPLUS

9 Diagnostic tests should be back within a week. It is hard to feel good when waiting on test results. If my test results are all normal, I am willing to wait until I have an appointment to go over them. However, if there is something not right, they should notify me right away. Suggested Actions Notify the member of troubling results immediately. Communicate test results as soon as possible. Give realistic turnaround times for results to be communicated and clarify how the member should receive results: phone call, office visit, mail, portal, etc. Ensure the member understands his or her test results. I am on blood pressure medicine, and the doctor had to increase the dosage. He discussed it with me first and gave me my options. I do everything I can to avoid taking medications, so a discussion of lifestyle changes and age related issues comes up constantly. Suggested Actions Reconcile medications at each visit. Seek member feedback on prescription effectiveness, Discuss alternatives to medications with the member. Discuss prescription options with the member. Educate member on potential side effects and what to do if they experience side effects. 9

10 Compliance and Member Grievances The Quality Improvement Department collaborates with the Appeals/Grievances Department to listen to the voice of the member in the investigation of member s individual concerns, problems, or misunderstanding. Mandated by CMS, the Health Plan must institute a process for review and resolution of potential quality of care disputes. In order to fulfi ll our responsibility in the CMS shared vision of transparency, the Quality Improvement department needs provider assistance in acquiring requested medical records. Medical records help with the investigational process. Since most member grievances stem from perception, misunderstanding, or miscommunication and not necessarily quality of care, Medical Records are a vital tool as a part of our analysis. Documentation is initially reviewed by the Quality Improvement clinical nursing review staff. The review may be shared with the Health Plan s Medical Director. The plan does not discuss, confi rm or deny any part of the grievance, nor are the outcomes of the review shared with the member or the provider unless the Medical Director or the Quality Care Committee deems it necessary. Complete, thorough and timely documentation is appreciated in order to adequately and quickly assess and identify trends that may be opportunities for improvement. 10 TEXANPLUS