2017 Quality Improvement Work Plan Summary

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1 Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how the member s plan works. Member Service and Satisfaction Tufts Health Plan Medicare Preferred Product: Tufts Medicare Preferred HMO Project Description: To improve the caller s experience Patient Safety Enhancement of Inpatient Commercial Occurrence Reporting Product: Commercial, Tufts Medicare Preferred HMO, Tufts Health Public Plans Create work group to discuss trends identified through customer service, appeals, behavioral health and claims. Create task force focused on member education materials Identify opportunities through the web, IVR and POM to educate members. Tools will help drive performance improvement through enhanced and complete information, improved consistency and accuracy. Enforce the use of SupportPoint workflow and other education tools to help provide answers member service representatives need to become more confident on the phone when responding to members questions. Collaborate with Business Consulting and Transformation Services team to assess current utilization of all nonphone channels. Outcome measurement will indicate upward trends towards a goal of timely management of quality events. Utilizing performance reports to assist staff in managing timeframe expectations Project Description: Provider quality improvement specialist (PQIS) will investigate and close out 90% of all occurrences, BH AI s and other such events within 90 days of receipt. This will allow for more real time provider of concern reporting which will in turn provide more timely patient safety reporting to the Quality of Care Committee. Cultural and Linguistic Services Product: All Products Project Description: Collect and utilize race, ethnicity and language (REL) data in order to find and address any health care inequities, to create new quality improvement initiatives where necessary, and to promote high-quality care for all our members. Collect members self-reported race, ethnicity and language information on an ongoing basis Perform an annual assessment of member grievances related to culture/language and members cultural needs and preferences Perform an annual assessment of disparity related to quality metrics. Using 2015 self reported and estimated REL data (where self reported data is not available); analyze quality metrics for any significant differences in quality 1

2 Readmission Management Tufts Health Plan Medicare Preferred Product: Tufts Medicare Preferred HMO Project Description: To reduce admission and readmission rates for the identified population (members returning to the community from SNF facilities covered by Tufts Health Plan SNF rounding program). Behavioral Health Antidepressant Medication, Initiation and Engagement of Alcohol and Substance Abuse Product: Commercial, Tufts Medicare Preferred HMO Project Description: The Antidepressant Medication Management (AMM) project is focused on working with members and providers in supporting members with a diagnosis of major depression who were newly prescribed an antidepressant medication, to remain compliant with their medication for an acute phase of treatment (12 weeks) and also for a continuation phase of treatment (six months). The Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) project is focused on working with providers to support members with a new episode of alcohol or other drug dependence to initiate treatment within 14 days of the initial diagnosis (initiation phase) and to continue in treatment with two or more additional visits within 30 days (engagement phase). Tufts Health Plan Senior Care Options (SCO) Readmission Reduction care by race, ethnicity or language. Members will be identified as high risk based on the criteria with the LACE scoring tool and NP discretion. Program Overview/Package of Services: Initial in home post discharge joint visit with Tufts Health Plan NP and Group s CM within seven calendar days of discharge. Joint follow up visit within 30 days of initial SNF discharge, as determined by the team, including Tufts Health PlanP NP/Groups CM/VNA. Case remains open for 30 days. Availability of telephonic care coordination and consultation between Tufts Health Plan NP, PCP, Group s CM (as needed) through entire 30-day post-snf-discharge intervention. Through Quality Focus Bulletin, educate providers regarding diagnosis and treatment of depression and compliance with the HEDIS antidepressant medication management measure. Information to be included in medical and behavioral health provider newsletters, as well as posted on the Quality section of the website. Provider education about the National Depression Screening Day on the Tufts Health Plan website Educational depression brochures are offered to members who contact the Tufts Health Plan behavioral health telephone queue. Educational depression brochures are mailed to members when the behavioral health providers have indicated that members are in treatment for depression when requesting further visits that require review. Continue depression screening for commercial members as part of the Priority Care Program. Behavioral Health (BH) Department to continue to develop the Substance Use Transitions care management program for members with alcohol and substance use disorder diagnoses. The program provides support to members who are in early recovery from the use of opiates, alcohol or other substances. Care managers work with members to understand and follow through with their aftercare plans, and begin to take charge of their recovery. Reduce risk of hospitalization/rehospitalizations for community and institutional enrollees, which includes: Provide care management services to all Tufts Health 2

3 Products: Tufts Health Plan SCO Project Description: Acute hospital readmissions contribute to increased costs and reduced quality of life. By focusing on readmissions, members' quality of life will improve and health care costs for members and the health plan will be reduced. The goal of this project is to reduce all cause readmission rates for all Tufts Health Plan SCO enrollees aged 65 or older that were discharged from an acute inpatient facility. Clinical Practice Guidelines Product: Commercial, Tufts Medicare Preferred HMO, Tufts Health Together, Tufts Health Direct, Tufts Health Unify Project Description: Tufts Health Plan utilizes evidence based guidelines that are adopted from national sources or developed in collaboration with specialty organizations and/or regional collaborative groups. These guidelines, which are not intended to replace clinical judgment, are statements that are designed to assist practitioners in making decisions about appropriate health care for specific clinical circumstances. Tufts Health Plan clinical practice and preventive health guidelines are designed to support preventive health, acute disease treatment protocols, and/or chronic disease management programs. Case Management and Utilization Management & Continuity and Coordination of Medical Care Product: Commercial, TMPHMO Project Description: The Tufts Health Plan Care Management (CM) Department 11.a Plan SCO enrollees discharged from an inpatient facility, which includes assessing the member s medical, behavioral, social and functional needs, and developing and/or adjusting the plan of care (POC) to address the enrollee s individualized needs and barriers that may prevent them to achieve their goals of care Medication reconciliation post-discharge Review admissions/readmsisions with MD and Tufts Health Plan SCO clinical team as part of the Preventable Hospitalization Program to evaluate for root cause and identify if the admission was avoidable. If it is determined the admission was avoidable, the root cause will be analyzed to help identify potential gaps in care. If educational needs are found an action/education plan will be implemented to mitigate future similar issues. Review current guidelines for updates Define the need for a new clinical practice or preventive health guidelines Participate in relevant coalitions as required (MHQP, MassPro, etc.) Frequency of ED use O Define implementation time frame and develop process for high ED utilizers to be referred for engagement in priority care for complex CM. Diagnosis/condition O Track and trend engagement rate of members identified 3

4 implemented a pilot program for support to members following emergency department (ED) visits. This project enables the CM department to partner departments including behavioral health (BH), Member and Provider Services and Pharmacy. While this project offers a unique and exciting opportunity to partner for a multidisciplinary approach to management, the CM Department s focus for continuity and coordination of medical care continues to be vetting the right members for the right level of care management or transition of care (ToC) intervention, improving provider awareness of the program and maximizing early identification leveraging internal and external provider/facilities. Member engagement in the program at the CM or ToC levels will demonstrate the transition support and continuity of care for members following discharge from emergency department services. Project #11b. In 2015 the Basic Transitions program, with transition coordinators, supports members following hospitalization and emergency room usage to ensure continuity of transition of care needs. The referral inputs for this program primarily come from the Utilization Management (UM) department. This projects demonstrates the partnership of the UM and CM departments to ensure members are identified and referred into the CM programs. The CM specific focus is on the Basic Transitions program to demonstrate member engagement and successful follow through on member after care provider visits. The UM specific focus is to demonstrate an effective process for referring members for Basic Transitions and other CM programs that are identified from facilities without an onsite Transition Manager, through the system enhanced Transition of Care flag. While the referral work process is the responsibility of the UM Coordinator and UM RN staff; the focus of this project will be the UM Coordinator s referral rate. by diagnosis or condition for incremental engagement gains quarterly. 11.b Develop education plan to support contracted provider units on care setting options and avoidable ED usage Coordination of the UM coordinator and transition coordinator roles to help support the quality and continuity of care for members: Effective identification and referrals of members after discharge from a CM programs, supported by a new operational measures. The transition coordinators establish support to members by following referrals by the UM coordinator supported by standard CM operational measures. 4

5 Coordination Between Medical and Behavioral Healthcare Product: Commercial 12a. Designated facility communication with member s PCP: communication with a member s PCP is recommended to occur during the course of an inpatient behavioral health admission to inform the provider of the admission, to review the course of inpatient treatment, and to assist with coordination of care and discharge planning. All designated facilities must routinely document communication with the PCP for every member who has an assigned PCP. The Behavioral Health Department will conduct medical record reviews two times a year to review appropriate documentation of PCP communication by the designated facility. 12b. Behavioral Health and Medical Case Managers Coordination of Care project: Tufts Health Plan medical case managers (CM) and behavioral health (BH) case managers are working together in consultation with each other and comanage to share cases where there are comorbid medical and behavioral health issues. 12c. ER Diversion Program: Tufts Health Plan medical case managers and behavioral health case managers are working collaboratively to establish an Emergency Room (ER) diversion program in an effort to reduce unnecessary ER utilization and to redirect members to appropriate and optimum care. Many members make repeated visits to the ER with medical symptoms and, it may be determined that there is a significant behavioral health component that has not been addressed. Also, members who appear in the ER with behavioral health symptoms may also have co-morbid medical issues. The ER diversion program focuses on medical and BH case managers referring members, ages 23 and older, to one another for consultation or comanagement of cases where there are 12.a Work with designated facilities to prevent behavioral health readmissions for Commercial population. A primary focus of this project is to increase collaboration with a member s PCP through PCP communication. 12.b Behavioral Health (BH) case managers to consult with medical case managers on cases where there are coexisting medical and behavioral disorders. This occurs for both members who are inpatient as well as on an outpatient basis. 12.c Tufts Health Plan Medical CMs and behavioral health CMs are working together to establish an ER diversion program in an attempt to reduce unnecessary ER utilization and to redirect members to appropriate and optimum care. Medical and behavioral health CMs will contact the member to address issues that brought the member to ER and determine optimum next steps for ongoing medical or behavioral health care. 5

6 comorbid medical and behavioral health diagnoses. This project will track members referred and engaged with the program, along with member satisfaction with the program. Tufts Health Public Plans Member Services & Satisfaction Products: Tufts Health Direct, Tufts Health Together, Tufts Health Unify Project Description: To improve the overall Member Service experience for members. Improve current process to address gaps prior to possible automation of reimbursements Continue working with Ops Quality Assurance to update/add information to SupportPoint. Implement and evaluate self-service IVR solution. Tufts Health Public Plans - AMM Performance Improvement Product: Tufts Health Together Project Description: Improving antidepressant medication adherence among MassHealth adult members diagnosed with major depression. Increase the percentage of Tufts Health Public Plans MassHealth members who are 18+ and newly diagnosed with major depression who remain on an antidepressant medication through acute (at least 12 weeks) and continuation (at least six months) phases* by 2% by 12/31/16. Case manager telephonic outreach focused on members who meet HEDIS AMM denominator criteria. Outreach to members to offer support and education, and remove barriers to antidepressant medication compliance, including referrals to BH CM and clinical community outreach (CCO) 6

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