2015 Quality Improvement Work Plan Summary

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1 2015 Quality Improvement Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how their 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 Medication Safety/Medication Reconciliation Project Description: The Behavioral Health Department requires that all their Designated Facilities (DFs) report every member discharge using the reporting tool located on the Tufts Health Plan website (tuftshealthplan.com). The tool includes 28 questions required to complete in order to be compliant with reporting all discharges. Tool includes questions that are relevant to medication reconciliation: Was medication reconciliation completed with the patient or the patient s caregiver as part of the discharge? Is the patient taking five or more medications of any class? Was this readmission within 30 days of a previous admission? Members will be able to retrieve their 1099HC information from the public portal. Introduce Concierge pilot program; offering personalized service for members with complex issues. New IVR system will allow for self service options such as language assistance, coverage and costs, benefits, reimbursements, and claims inquiry. In collaboration with the Sales department, refresh member onboarding program to educate and provide outreach to facilitate carrier transition, product transition, or strategic client support. Customer Relations will launch a new type of training for all representatives, called MAGIC. This new training will improve the interaction between the call center and the members, placing strong awareness of how to better response to the callers appropriately and politely, ideally increasing the satisfaction of our members. Customer Relations will review and current processes and identify improvement opportunities that align to both feedback we hear at member focus groups and through the member satisfaction surveys, where possible. A working team has been established and a division wide campaign will be launched titles, Members Matter. Pain points and suggestion swill be identified from staff suggestions and work teams will be put in place to address actionable items. By working to understand the member s perspective, we can make sure the callers experience is both efficient and effective from the member s standpoint. A scoring system is being developed to identify providers with less than 95% compliance with the tool and whether outreach is required for those providers. Monthly reports to confirm that DFs are completing the Mental Health Facility Online Discharge tool and whether any corrective action plan is required for those DFs Quarterly reports are reviewed to confirm compliance per the scoring tool and to assess effectiveness of the discharge report form specific to elements relative to medication reconciliation. Reports will also include whether a trend is noted with any particular provider relative to medication reconciliation and, if so, whether there has been outreach to the provider Quality Improvement

2 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. Readmission Management Tufts Health Plan Medicare Preferred Product: Tufts Medicare Preferred HMO Project Description: To reduce acute readmission rate (any member discharged from the acute inpatient setting and returned to any hospital with any admission diagnosis within 30 days of their original discharge.) Behavioral Health Antidepressant Medication, Initiation and Engagement of Alcohol and Substance Abuse 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 (6 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 Collect members self reported race, ethnicity and language information on an on going 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 care by race, ethnicity or language. Integration with STAR workplans and team: o Clinical Health Events team monitoring readmission rate and interventions. Implement Cognitive Screening into network wide Care Management programs: o Cognitive impairment is related to high readmission rate among seniors and CM programs do not currently screen for cognitive issues. 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 mental 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 Mental Health telephone queue. Educational depression brochures are mailed to members when the mental 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. Working on developing clinical guideline summaries to be posted on the web for Substance clinical guidelines. This would allow providers access to more user friendly guidelines highlighting the significant aspects of the full clinical guidelines. These guidelines support the HEDIS IET measure. Behavioral health case managers to consult with medical case managers on cases where there are co existing medical and behavioral disorders. This occurs both for members who are inpatient as well as on an outpatient basis. Readmission prevention program: Continue to work with Designated Facilities to prevent psychiatric readmissions for both commercial and Tufts Medicare populations. A primary focus of this project is to increase collaboration with a member s PCP through PCP communication as well as medication reconciliation with a member s PCP Quality Improvement

3 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 Products: Tufts Health Plan SCO Project Description: Prevent acute hospital admissions and readmissions for this population (community and institutionalized members), and to identify members who are at risk for preventable hospital admissions and readmission, focusing on pneumonia, dehydration, injuries from falls, and skin breakdown. Clinical Practice Guidelines, Together, Direct 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. Preventative Health Breast Cancer, Cervical Cancer, Colorectal Cancer Project Description: Member reminders for timely cancer screenings Reduce risk of hospitalization/re hospitalizations for Community and Institutional enrollees, which includes: o Assign a Care Manager/RN to assess risk during initial and ongoing assessments. The evaluation will include clinical, functional, nutritional status, in addition to physical and social well being for all SCO enrollees. o Evaluate SCO enrollees with Potential Risk for Hospitalization, and adjust the Plan of Care (POC) to ensure timely provision of appropriate preventive care and treatment interventions. 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.) Evaluate adherence to guidelines and clinical value of guidelines Providers receive lists of members who are in need of breast cancer screening. For members, send a letter reminding them to schedule a screening Quality Improvement

4 Case Management Product: Commercial, TMPHMO Project Description: Two new roles have been created for the new DRG and Transition of Care models: transition coordinator and utilization management (UM) coordinator. The transition coordinator role has been created to support the new Transition of Care model associated with the DRG project. The transition coordinator will constitute Level 1 of the Transition to Home care management program. The transition coordinator will conduct two surveys designed to identify potential gaps in the member s discharge plan that may place the member at risk for a readmission to an acute facility. The UM coordinator role is to perform activities that support the clinical, business and programrelated work of the Inpatient Acute Care Management Team as well as that of the basic monitoring process. The UM coordinator will be responsible for management of a subset of acute UM admission events ensuring timely requests for clinical updates to support the role of the transition manager (RN). The UM coordinators will also be responsible for obtaining discharge information from their assigned facilities to ensure timely closing of admission events to ensure accurate and timely claims payment. Attempts to reach members identified for Level 1 Transition to Home will be made within 48 hours of facility discharge. Monthly reports are run detailing the enrollment rate for the transition coordinator. Reports will be run that identify whether an appointment with the PCP/aftercare provider was scheduled within 7 days post discharge from a facility. Daily department operational reports will be utilized to monitor timely closing of admission events to ensure timely claims payment supporting provider satisfaction. Tufts Health Public Plans Product: Together Demonstration by an MCO of a diverse care management staffing structure aligned with the range of diversity among members receiving Co management of high risk members with multiple complex comorbidities by assigning to CMs with same or similar cultural backgrounds. Annual review of customer service language needs and of languages spoken by customer service representatives. Letter to providers notifying them of member(s) who recently refused case management services Quality Improvement

5 care management. Project Aim/Question: Is Tufts Health Plan adequately staffed and supported to reflect a diverse membership seeking or in need of CM services Train staff in motivational interviewing techniques to increase engagement. Design and implement one strategy for members who are identified, but refuse care management. Project Aim/Question: Increase the number of members included in the CM program Quality Improvement

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