ICE 2016 VHP QM Workplan Table of Contents

Transcription

1 ICE 2016 VHP QM Workplan Table of Contents Tab # Signature Page 1 Clinical Improvement 2 Safety 3 Access 4 Experience Surveys (Satisfaction) 5 Member Grievances 6 Care Management 7 Clinical Practice Guidelines 8 Continuity of Care within Medical Care 9 Continuity of Care Between Medical Care and Behavioral Health 10 Member Connections - Health Appraisals 11 Delegation 2014 ICE QI Delegation Required Reports - Table of Contents 12/24/13

2 SIGNATURE PAGE Provider Organization Name: Report Type: Questions Response (Yes/No) / Comments NOTE: Reports that are sent electronically must state Signature on File on the signature line. This will be verified at the annual oversight audit. I. QM COMMITTEE MEETINGS Frequency/Month Day of the Week/Meeting Dates Time QM Committee (QMC) At least 4 times per year (Scheduled Monthly) Fourth Monday of the Month 12:00 noon - 2:00 pm January 26-Jan-16 12:00 noon - 2:00 pm February 22-Feb-16 12:00 noon - 2:00 pm March 28-Mar-16 12:00 noon - 2:00 pm No Meeting 12:00 noon - 2:00 pm May E-Vote 12:00 noon - 2:00 pm June 12:00 noon - 2:00 pm July 12:00 noon - 2:00 pm August 12:00 noon - 2:00 pm September 12:00 noon - 2:00 pm October 12:00 noon - 2:00 pm November 12:00 noon - 2:00 pm December 12:00 noon - 2:00 pm II. QM PROGRAM CONTACTS Name Phone # Mario Contreras (408) Mario.Contreras@vhp.sccgov.org QM Chairperson/VHP Medical Dr. Dolly Goel (408) Dolly.Goel@vhp.sccgov.org Director III. PERSON SUBMITTING Name Phone # Fax #: Initial Work Plan Mario Contreras (408) (408) Quarter 1 Report Mario Contreras (408) (408) Quarter 2 Report Mario Contreras (408) (408) Quarter 3 Report Mario Contreras (408) (408) Quarter 4 Report Mario Contreras (408) (408) Annual Evaluation (Separate Doc) Mario Contreras (408) (408) ICE QI Delegation Required Reports - Signature Page 12/24/13 Page 2 of 32

3 SIGNATURE PAGE IV. QM COMMITTEE APPROVAL Date Approved by QMC Signature QMC Chair Signature Work Plan 25-Jan-16 Quarter 1 Report Quarter 2 Report Quarter 3 Report Quarter 4 Report 31-May ICE QI Delegation Required Reports - Signature Page 12/24/13 Page 3 of 32

4 2016 Workplan CLINICAL IMPROVEMENT: Goals, Analysis, Interventions and Evaluation/HEDIS Measures HEDIS Report Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Present Findings to QMC with analysis Prepare annual report with November and QI improvement recommendations results/benchmark Barrier analysis of measures not at or below the Quality Compass 50th percentile Create report and educational material for providers Create newsletter update for members NCQA Program Manager MEDICAL HEDIS measures Increase by 5% from 2015 rates and exceed Evaluate Administrative and Hybrid data October Quality Compass 50th percentile for measure NCQA Program Manager Data analysis and data compilation to identify measure results BEHAVIORAL HEALTH HEDIS measures Increase by 5% from 2015 rates and exceed Evaluate Administrative and Hybrid data October Quality Compass 50th percentile for measure NCQA Program Manager Data analysis and data compilation to Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions ICE QI Delegation Required Reports Template 12/24/13 Page 4 of 32

5 YES 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 5 of 32

6 SAFETY OF CLINICAL CARE: Goals, Analysis, Interventions and Evaluation Medical - Health Record and Office Audit (Office Audit as required) Behavioral Health - Health Record and Office Audit Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Health Record Audit Score 80% Develop calendar of audits for November Office Site Audit Score 90% Health Record Audit Score 80% Office Site Audit Score 90% Audit at a minimum of least 5-10% of Medical practitioners up for recredentialing in 2016 Develop calendar of audits for Audit at least 5-10% of Behavioral Health practitioners up for re-credentialing in November 2016 Medication Recalls 100% compliance Pharmacy reports to P&T, July, October, January Pharmacy Manager Credentialing/Recredentialing/T ermination Clinic/Member Safety Potential Quality Issues (PQIs) All Practitioners are 100% credentialed/recredentialed Clinic's will implement at least one safety goal Identify quality of care issues and implement a resolution as needed On-going monitoring and primary source Credentialing Committee minutes to QMC verification on a monthly basis Semi-annual provider relations report (Credentialing Report) Monitor and review clinic reports quarterly August with annual report to QMC Reviews and investigate all PQIs as, July, October, January needed. Monitor, track, trend and analysis Identify opportunities for improvement PR Manager Chief Medical Officer Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions. 1Q Potential Quality Issues (PQIs) Identify quality of care issues and implement a resolution as needed MET - PQIs were scored within acceptable quality of care or service and overall with very small number borderline quality of care or service. None were identified as possible or direct effect on the health and welfare of a member. No office site visits were required relate to PR PQI monitoring. Credentialing/Recredentialing/ Termination All Practitioners are 100% credentialed/recredentialed MET - Credentialing minutes QMC (November and December 2015) Semi-Annual review in ICE QI Delegation Required Reports Template 12/24/13 Page 6 of 32

7 SAFETY OF CLINICAL CARE: Goals, Analysis, Interventions and Evaluation Medication Recalls 100% compliance MET - 4Q15 reported out there were no recalls/withdrawls/shortages for Commercial and Marketplace (Covered California) ICE QI Delegation Required Reports Template 12/24/13 Page 7 of 32

8 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation Practitioners/Specialist Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles All members will be offered an Review access report May, August, November, and PR Manager appointment 90% per DMHC timely access regulations Monitor, track, trend, and analyze reports Evaluate access during office audits Annual audit by Provider Relations February MS Manager Provider Appointment All members will be offered an Availability Survey (DMHC appointment 90% per DMHC methodology) timely access regulations Behavioral Health (BH) All members will be seen 90% per DMCH timely access regulations, except members will been seen by a Psychiatrist within 10 business days (NCQA standard) Wait Time in Office All members will wait less than 30 minutes in the office 90% for non-urgent situations (Definition - from when member registers to when member see practitioner/specialist) Ancillary Services All members will be seen by ancillary services within 15 business days After Hours Telephone Practitioners and Providers will Access provide emergency instructions per DMHC timely access regulations and VHP Provider Manual 100% Vendor to complete ICE survey Review and analyze results Determine if there are opportunities for quality improvement Work with practitioners/providers to improve access as needed Review access reports Monitor, track, trend, and analyze reports Evaluate BH access during office audits Annual audit by Provider Relations Review access reports Monitor, track, trend, and analyze reports March PR Manager May, August, November, and PR Manager February MS Manager Medical - May, August, November, and February Behavioral Health - November Annual ancillary service audit January Annual audit of PCPs, BH, and Ancillary by Provider Relations November PR Manager 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 8 of 32

9 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation Member Services Telephone ASA 30 seconds Access Health Information Line Telephone Access Call Abandonment Rate is 5% Covered California - 80% ASA 30 seconds, Call Abandonment Rate is 3%, and Calls Closed within 24 hours 85% ASA 30 seconds to get a live voice Call Abandonment Rate is 5% Review reports from VHP, TriZetto, Navitus Monitor, track, trend, and analyze reports Review reports from Carenet and Axis Point Health Monitor, track, trend, and analyze reports February, May, August, and November, July, October, and February MS Manager Network Adequacy/Population Analysis (including cultural/linguistics) Linguistics Access Potential Quality Issues Member Timely Access Education Compliance rate of 95% to the Annual reviews of Primary Care and Practitioner Network Mental Health/Substance Abuse, Accessibility Standards Hospitals, Specialty Care Practitioners and High Volume Specialist Annual CAPHS/QHP assessment Complete CAPHS/QHP survey of member cultural characteristics Experience Surveys - New and Disenrollee with implementation of Members, and Providers interventions as indicated Review SCVMC Language Services To have linguist services Reports - Review and implement threshold available for members language requirement in 2016 Monitor, track, trend, and analyze linguistic reports AxisPoint Health (HIL), Carenet (HIL), VHP, TriZetto, and Navitus (PBM) Identify access quality of care Reviews and investigate all PQIs as issues needed. Monitor, track, trend and analysis Identify opportunities for improvement and work with practitioner and provider organizations Annual publication of Timely In fall member perspective publish timely Access standards per DMHC access standards requirement March PR Manager CAPHS/QHP - August Experience Surveys - March Linguistic Reports - Quarterly (per Department reporting time period) VHP - Assessment (every three years - due March 2016), July, October, January November Compliance Manager Regulatory Affairs Analyst MS Manager - Pharmacy Manager UM Manager Chief Medical Officer 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 9 of 32

10 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation Report Period Metrics (if applicable) Key Findings and Analysis 1Q Health Information Line Telephone Access Potential Quality Issues ASA 30 seconds to get a live voice Call Abandonment Rate is 5% Identify access quality of care issues Member Services Telephone ASA 30 seconds Access Call Abandonment Rate is 5% List any problems in reaching the goal or relevant data (i.e. state if goals were met or MET - Carenet: 4Q/2015 MET - Axispoint Health: 4Q/2015 4Q15 - Access issues continued to be identified, however decreased from 2.99 /1000 members in 3Q15 to 1.25/1000 members in 4Q15 Analysis - Access issues continue to be attributed to the largest service provider (SCVMC). An access dashboard was implemented by SCVMC to monitor timely access in conjunction with VHP Utilization Department which may have contributed to the reduction in PQI access issues during this quarte.r Members are redirected to another network provider to ensure timely access standard is met NOT MET - Commercial/MS: 4Q15 - ASA Covered California - 80% ASA seconds in 4Q15. Abandonment rate was 30 seconds, Call Abandonment Rate is 3%, and Calls Closed within 24 hours 85% time increased from 49 seconds to 156 also increased from 4% in 3Q15 to 12% in 4Q15. Analysis - Increase in calls and assigned PR calls MET - 4Q15Marketplace/TriZetto (Covered California) Interventions / Follow-up Actions State what will be done to meet VHP Quality Management Manager and Medical Director are working with SCVMC on timely access issues. SCVMC CLT committee continues to address access issues and implement actions Beginning February 2016, SCVMC GI and Ophthalmology clinics will automatically re-direct members to an outside provider to reduce the waiting list Continue to work with staff to identify barriers, educate, and provide training to handling calls and redirecting calls. Also, continue to monitor trends and identify additional areas for improvement and institute a process improvement plan Re-measurement State target date(s) for remeasurement or completion of 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 10 of 32

11 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation Practitioners/Specialist All members will be offered an appointment 90% per DMHC timely access regulations 4Q15 Medical Groups/Practitioners PCP Appointments: MET- SCCIPA No data available from NCAMG, SJMG, SCVMC, and PAMF. There were no access issue identified during this time through the PQI process for NCAMG and PAMF. SCVMC continued to have access issues SCVMC through the CLT along with working with VHP are addressing access issues. 4Q15 Community Clinics & Medical Groups/Specialist Appointment: MET- GFHN and Planned Parenthood (Obstetric tic/gynecologist ). No data available from NCAMG, SJMG, and PAMF PCP Appointments Community Clinics: MET- All community clinics (AACI, GFHN, IHC, Mayview, PP, SHC). Medical Groups/Specialists - Continue to monitor access and compare against referral activity to ensure compliance. All medical groups are now being monitored annually through DMHC Provider Appointment Availability Survey(PAAS), VHP PQI process, and Public Report Card from the CA office of patient Advocate. Wait Time in Office All members will wait less than MET - 4Q15 Medical Groups - SCCIPA No Community Clinic/AACI will 30 minutes in the office 90% for data available from SCVMC, PAMF, SJMG, hire new practitioners to improve non-urgent situations. (Definition and NCAMG PQIs were monitored and wait times Mayview - is - from when member registers to there were no access wait times for these encouraging all practitioners to when member see clinics. track wait time going forward practitioner/specialist) MET - 4Q15 Community Clinics: School and is in the process of hiring Health clinics of SCC and IHC. Not met additional front desk staff PP- by AACI, Mayview, and PP A report is working with Coleman Group to anticipated next quarter from SCVMC, as improve workflow and facilitate VHP and SCVMC jointly work on this process improvement projects. project ICE QI Delegation Required Reports Template 12/24/13 Page 11 of 32

12 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation After Hours Telephone Access Linguistics Access Medical/BH Practitioners and Ancillary Providers will provide emergency instructions per DMHC timely access regulations and VHP Provider Manual 100% MET- Medical (118) and Chiropractors (13) PR staff provided education and were compliant. Ancillary: Initial survey findings revealed that 4 Acupuncturists out of 13 did not have after-hours emergency instructions (69%) Re-audit was done by PR staff with the noncompliant practitioners after two weeks Acupuncturists: 100% MET - Behavioral Health: 100% compliance (34 practitioners audited) Annual CAPHS/QHP assessment 4Q15 SCVMC Language Service Report of member cultural characteristics (largest service provider): There were with implementation of interventions as indicated To have linguist services available for members 53,644 interpretations provided during this quarter Spanish accounted for the largest percentage of interpretations at 84%, with Vietnamese at 14% and Mandarin at 1.15% 2015 Community Health Clinic Language Readability Review - Education brochures and patient education literature obtained from IHC, AACI, GFHN, and PP/Mountain View was reviewed by VHP Health Education Department for language readability. Feedback was provided to the clinics and consideration for quality improvement when needed New Enrollees and Disenrollees Satisfaction Survey Results; Availability of Language of Interpreter services is clearly outlined- Marketplace - 74% agree, Commercial - 86% agree. re-emphasized CA regulatory requirements to the noncompliant Acupuncturists ICE QI Delegation Required Reports Template 12/24/13 Page 12 of 32

13 ACCESSIBILITY OF SERVICES: Goals, Analysis, Interventions and Evaluation Provider Appointment Availability Survey (DMHC appointment 90% per DMHC methodology) All members will be offered an timely access regulations The survey findings for 2015 were considered in conclusive and must be reviewed with caution. The rigorous survey methodology resulted in findings being largely non-compliant even though the number of participants increased from 2014 survey. The survey methodology in 2015 included respondents who refused or did not response within the 48 hour of initial contact as non-compliant. There was not follow-up call for this survey as in Resurvey in 2016 with the DMHC methodology. Provide DMHC with feedback about the rigorous methodology and challenges that it presented the surveyors and inconclusively of the data results for the plan ICE QI Delegation Required Reports Template 12/24/13 Page 13 of 32

14 MEMBER/PRACTITIONER EXPERIENCE (SATISFACTION) : Goals, Analysis, Interventions and Evaluation CAHPS/QHP Survey CCM Satisfaction Survey DM Satisfaction Survey New Enrollee Survey Disenrollment Survey AxisPoint Health Information Line Satisfaction Survey Carenet Satisfaction Survey Navitus Satisfaction Survey Practitioner Satisfaction Survey Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Complete Annual CAPHS/QHP survey Complete implementation plan November including questions on Behavioral Health Annually evaluate members satisfaction with all aspects of the CCM program Annually evaluate the members satisfaction with all aspects of the DM program Complete the survey Review results and identify areas for improvement AxisPoint Health to complete CCM satisfaction survey Analysis of Survey data for areas of improvement Complete CAHPS Survey Review other satisfaction surveys, PQIs, and Grievances AxisPoint Health to complete CCM satisfaction survey Analysis of Survey data for areas of improvement Complete CAHPS Survey VHP review other satisfaction surveys, PQIs, and Grievances Assess satisfaction with enrollment process Complete the survey and understanding of the health plans polices and procedures To identify common reasons among disenrolled members Annually evaluate the members satisfaction with all aspects of the HIL program Annually evaluate the members satisfaction with all aspects of the HIL program Annually evaluate the members satisfaction with all aspects of the PBM program Assess practitioner satisfaction with the health plan Analysis of data for areas of improvement Complete the survey Analysis of data for areas of improvement AxisPoint Health to complete HIL satisfaction survey Analysis of data for areas of improvement VHP review report, along with PQIs, Grievances, and other survey results Carenet to complete HIL satisfaction survey. Analysis of data for areas of improvement VHP review report, along with PQIs, Grievances, and other survey results Navitus to complete PBM satisfaction survey. Analysis of data for areas of improvement VHP review report, along with PQIs, November November March MS Manager March QM/Compliance Manager November November November Grievances, and other survey results Complete the survey March Analysis of data for areas of improvement MS Manager AxisPoint Health AxisPoint Health Navitus Pharmacy Manager PR Manager 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 14 of 32

15 MEMBER/PRACTITIONER EXPERIENCE (SATISFACTION) : Goals, Analysis, Interventions and Evaluation Report Period Metrics (if applicable) Key Findings and Analysis 1Q New Enrollee Survey Disenrollment Survey List any problems in reaching the goal or not met, include what caused the problem/issue) Assess satisfaction with enrollment process Marketplace - (N=48) New enrollees and understanding of the health plans highlights - Affordability was the top polices and procedures reason why new enrollees chose VHP To identify common reasons among disenrolled members Interventions / Follow-up Actions State what will be done to meet the goal the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or relevant data (i.e. state if goals were met or (i.e. continue with plan as listed or modify completion of follow-up actions Most rate the enrollment experience favorably, though some had trouble understanding the process for obtaining care in their network and the authorization/referral process for the specialists and out-of-network care. New enrollees have had mixed experiences getting care as soon as they thought they needed it. Commercial - Over half of the enrollees are very satisfied with VHP and overwhelmingly positive with their enrollment experience Most say they received care as soon as they thought they needed it. Commercial - (N = 90) Nearly half of disenrollees were very satisfied with VHP. Disenrollees rate at VHP favorably in many areas, including cost, their doctor and overall benefits coverage. Over half did not mention any specific problems with VHP No Marketplace participation in this survey. Reviewing results for quality improvement 2017 Reviewing results for quality improvement ICE QI Delegation Required Reports Template 12/24/13 Page 15 of 32

16 MEMBER/PRACTITIONER EXPERIENCE (SATISFACTION) : Goals, Analysis, Interventions and Evaluation Practitioner Satisfaction Survey Assess practitioner satisfaction with the health plan MET - (N = 115) Nearly two thirds of providers are satisfied with VHP Claims department ratings are continuing to trend downwards among non-scvmc providers. The ease obtaining authorization and authorization/referral process continue to be of concerns for some providers Overall half of providers are satisfied that VHP is meeting standards for urgent and routine authorization Reviewing results for quality improvement 2017 CCM Satisfaction Survey Annually evaluate members satisfaction MET-A response rate of 27%. Majority of Annual due early 2017 for annual with all aspects of the CCM program the respondents rated their experience 6 or calendar year higher, based on a scale VHP staff continue to work with AxisPoint Health on improvements to the report DM Satisfaction Survey Annual Evaluate the members satisfaction MET-A response rate of 27%. Majority of VHP staff continue to work with AxisPoint Annual due early 2017 for annual with all aspects of the DM program the respondents rated their experience 6 or Health on improvements to the report calendar year higher, based on a scale 1-10 Carenet Satisfaction Survey Annually evaluate the members MET-Carenet was well above the standard 2017 satisfaction with all aspects of the HIL performance goal of 92% for overall program satisfaction AxisPoint Health Information Annually evaluate the members MET-A response rate of 32%. Overall VHP staff continue to work with AxisPoint 2017 Satisfaction Line Survey satisfaction with all aspects of the HIL satisfaction range from 83%-91% for a Health on improvements to the report program performance goal of 90% 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 16 of 32

17 MEMBER GRIEVANCES: Goals, Analysis, Interventions and Evaluation Member Grievances Grievance definition: Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Performance Goal: 2.0 grievances per Member Services monitors, analyzes and February, May, August, and November MS Manager 1000 members reports grievances 1. A written or oral expression of dissatisfaction from members or the members representative regarding VHP and/or provider, including quality of care concerns. 2. Correspondence from members include complaint, request for reconsideration or appeal made to Member Services 3. Where VHP is unable to distinguish between a grievance and an inquiry, it shall be considered a grievance Report Period Metrics (if applicable) Key Findings and Analysis 1Q Member Grievances Performance Goal: 2.0 grievances per 1000 members List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) NOT MET - 4Q15/Commercial: 3.44 per Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) 1000 members. Access grievances contacting clinic staff scheduler, clinic continue to be attributed to not meeting the manager or nurse to attempt to schedule performance measure. Access grievances appointments, request referral to another decreased from 4.10 per 1000 members to network department through UM, notify 1.67 per 1000 members. Medical Director for assistance/approval to NOT MET - 4Q15/Marketplace(Covered refer to another network California): 2.18 per 1000 members. practitioner/provider, and refer access Access grievance was at 1.10 per 1000 issues to QM for PQIs members which was a slight increase from 0.97 in 3Q15 Member Services interventions include Remeasurement State target date(s) for re-measurement or completion of follow-up actions 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 17 of 32

18 CARE MANAGEMENT: Goals, Analysis, Interventions and Evaluation Disease Management Programs/CAD & Diabetes (Care Management Programs/McKesson) Complex Case Management (Care Management Programs/McKesson) Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles To identify members and actively Review reports July and January UM Manager intervene to assist both members and practitioners in managing chronic conditions, to improve the health status of the members To assist eligible member in navigating the health care system and appropriate utilize services Annual effectiveness of the program To identify members and actively intervene to assist both members and practitioners in managing chronic conditions, to improve the health status of the members To assist eligible member in navigating the health care system and appropriate utilize services Annual effectiveness of the program Annual population assessment of membership Review reports July and January UM Manager Report Period 1Q Disease Management Programs/CAD & Diabetes Metrics - List active member participation rates for each DM program, as applicable - List formula used to calculate active member participation rate - Interventions must be based on disease To identify members and actively intervene to assist both members and practitioners in managing chronic conditions, to improve the health status of the members To assist eligible member in navigating the health care system and appropriate utilize services Annual effectiveness of the program Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) MET - Reports presented Continue to monitor program Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 18 of 32

19 CARE MANAGEMENT: Goals, Analysis, Interventions and Evaluation Complex Case Management To identify members and actively intervene to assist both members and practitioners in managing chronic conditions, to improve the health status of the members To assist eligible member in navigating the health care system and appropriate utilize services Annual effectiveness of the program Annual population assessment of membership MET - Reports presented. Continue to monitor program 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 19 of 32

20 CLINICAL PRACTICE GUIDELINES: Goals, Analysis, Interventions and Evaluation Evidenced-based Preventive Health Guidelines (PHG) for perinatal care, children up to 24 months, children 2-19 years, practitioners adults years, and adults 65 years and older Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Annual review/revision to ensure most UM Manager reviews current guidelines February UM Manager current PH guidelines are adopted Distribute updated PH guidelines to and presents information to UMC Distribute approved guidelines PR Manager Marketing Manager DM - Evidenced-based Identify and distribute guidelines to UM Manager reviews current guidelines December UM Manager Medical/Clinical Practice practitioners and providers and presents information to UMC PR Manager Guidelines (CPG) Distribute approved guidelines Marketing Manager Evidenced-based Behavioral Identify and distribute guidelines to UM Manager reviews current guidelines December UM Manager Health/Clinical Practice practitioners and providers and presents information to UMC PR Manager Guidelines which include one Distribute approved guidelines Marketing Manager guideline addressing children and adolescents Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions. 1Q DM - Evidenced-based Identify and distribute guidelines to MET - Reviewed and approved at the Annual 2016 Medical/Clinical Practice practitioners and providers (CAD and QMC Guidelines (CPG) Diabetes) Evidenced-based Behavioral Identify and distribute guidelines to MET - Reviewed and approved at the Annual 2016 Health/Clinical Practice practitioners and providers (Depression QMC Guidelines which include one and ADHD) guideline addressing children and adolescents 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 20 of 32

21 CONTINUITY AND COORDINATION OF CARE WITHIN MEDICAL CARE: Goals, Analysis, Interventions and Evaluation Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Health Record Audit Health Record Audit Score 80% Develop calendar of audits for 2014 November Audit at least 5-10% of Practitioners (PCPs) up for re-credentialing Health record review and with findings to practitioner and report to QMC Practitioner Satisfaction Survey Potential Quality Issues (PQI's) CAHPS Survey Continuity and Coordination of Medical Care Assess practitioner satisfaction with the coordination of care Increase provider survey results for coordination of care by 5% from 52% (Always/Usually) Identify coordination of care issues and implement a resolution as needed Complete Annual CAPHS survey including questions on Behavioral Health Complete Continuity and Coordination of Medical Care Annual Report Complete survey Evaluate and analyze data Review results at QMC and determine quality improvement activities Reviews all potential quality issues and investigate as needed Monitor, track, trend and analysis Identify QI opportunities as needed Complete implementation plan Complete the survey Review results and identify areas for improvement Determine areas of medical care to review Complete annual data collection, with analysis to identify four opportunities for improvement Act upon to three of the opportunities identified Measure effectiveness of improvement actions taken in 2015 March, July, October and January November November PR Manager Chief Medical Officer Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions. 1Q 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 21 of 32

22 CONTINUITY AND COORDINATION OF CARE WITHIN MEDICAL CARE: Goals, Analysis, Interventions and Evaluation Practitioner Satisfaction Survey Potential Quality Issues (PQI's) Assess practitioner satisfaction with the coordination of care Increase provider survey results for coordination of care by 5% from 35% (Always/Usually) Identify coordination of care issues and implement a resolution as needed NOT MET - Results improved by 2% MET - No PQIs were identified as coordination of care issues Reviewing for Quality Improvement activities ICE QI Delegation Required Reports Template 12/24/13 Page 22 of 32

23 CONTINUITY AND COORDINATION OF CARE BETWEEN MEDICAL CARE AND BEHAVIORAL HEALTH: Goals, Analysis, Interventions and Evaluation Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Health Record Audit Health Record Standard 80% Develop calendar of audits for 2014 November Audit at least 5-10% of Practitioners (PCPs) up for re-credentialing Health record review and with findings to practitioner and report to QMC Provider Satisfaction Survey Drug and Alcohol Services (DADS) Potential Quality Issues (PQI's) CAHPS Survey Continuity and Coordination between Medical Care and Behavioral Health Assess practitioner satisfaction with the coordination of care Increase provider survey results for coordination of care by 5% from 17% (Always/Usually) To provide member coordinated services between practitioner and addiction services Identify coordination of care issues and implement a resolution as needed Complete Annual CAPHS survey including questions on Behavioral Health Complete Continuity and Coordination between Medical Care and Behavioral Health Annual Report Complete survey Evaluate and analyze data Review results at BHMG and BH Advisory Group and determine quality improvement activities Complete audit Evaluate and analyze data If indicated take action Reviews all potential quality issues and investigate as needed Monitor, track, trend and analysis Identify QI opportunities as needed Complete implementation plan Complete the survey Review results and identify areas for improvement Determine areas to review through the BH Advisory and BHMG committees Complete annual data collection, with analysis to identify two opportunities for improvement and taken action Measure effectiveness for actions on the identified improvements from 2015 March May, July, October, and January November November PR Manager DADS Director of Quality Chief Medical Officer Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for re-measurement or completion of follow-up actions. 1Q Potential Quality Issues (PQI's) Identify coordination of care issues and implement a resolution as needed MET - No PQIs were identified as coordination of care issues 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 23 of 32

24 MEMBER CONNECTIONS - HEALTH APPRAISAL: Goals, Analysis, Interventions and Evaluation Health Risk Assessment (HRA) (Vendored to Cerner) Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Offer HRA to 100% current members HRA Program: January,, July and October Health Education Manager Twenty percent (20%) of the new enrollees complete HRA within first 30 days of enrollment New Incentive campaign for 2016 Weekly meeting with Vendor Monthly High Risk reports to UM Marketing: Perspectives member newsletter Post Card mail out January and May 2016 Monthly reminders on incomplete HRA Forced HRA screen Log In Fitness class registration promotion Health Education cross education promotion Hard copy access promotion Health Education class offerings promotion Health Education cross education promotion Community event promotion On site electronic access Dashboard website access icon New member orientation New member welcome packet Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Re-measurement State target date(s) for re-measurement or completion of follow-up actions 1Q Health Risk Assessment Offer HRA to 100% current members 4Q15-7 HRAs were completed. There is Goal will be revised for next year Manager (HRA) Twenty percent (20%) of the new enrollees limitation with the data reporting for this working with Cerner and IS to redesign the (Vendored to Cerner) complete HRA within first 30 days of year, therefore the percentage can not be data collection process Also working with enrollment calculated Marketing on Highlighting the PHA on the website for increased visibility and awareness 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 24 of 32

25 2016 QM WORKPLAN DELEGATION OVERSIGHT Vendor: Navitus (PBM), URAC certification Initial Work Plan Goals Planned Activities Target Date(s) for Reporting to QMC Responsible Person(s) and Titles Vendor is compliant with NCQA Monitor reports, URAC recertification, and perform January,, July and October Pharmacy Manager requirements annual oversight of delegated activities Identify opportunities for quality improvement as needed NCQA Program Manager Vendor: AxisPoint Health - Disease Management program & Clinical Practice Guidelines (NCQA accreditation) Vendor: AxisPoint Health - Complex Case Management program (NCQA accreditation) Vendor: Cerner - Health Risk Assessment (NCQA -HIP Certification) Vendor Written Acknowledgment (not a delegation agreement) Vendor: TriZetto (Claims and Customer Service for Covered California) Vendor Written Acknowledgment for Claims and Delegation Agreement for Member Services) Vendor: Carenet - Health Information Line (NCQA HIL certification) Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Monitor reports, and NCQA reaccreditation Certification valid up to October 2017 Identify opportunities for quality improvement as needed Monitor reports, and for NCQA reaccreditation. Certification valid up to February 2018 Identify opportunities for quality improvement as needed Monitor NCQA recertification. Certification valid up to October 2017 Identify opportunities for quality improvement as needed Monitor reports, and perform annual oversight of delegated activities Identify opportunities for quality improvement as needed Monitor reports, and NCQA recertification. Certification valid up to September 2016 Identify opportunities for quality improvement as needed Semi-annual Semi-annual Annual February, May, August and November January,, July and October UM Manager NCQA Program Manager UM Manager NCQA Program Manager Health Education Manager NCQA Program Manager MS Manager NCQA Program Manager UM Manager NCQA Program Manager Vendor: AxisPoint Health- HIL (NCQA HIL certification) Vendor is compliant with NCQA requirements Monitor reports, and NCQA recertification. Certification valid up to January 2017 Identify opportunities for quality improvement as needed January,, July and October UM Manager NCQA Program Manager Credentialing Compliant with NCQA Requirements Monitor reports, and perform annual oversight of delegated activities Identify opportunities for quality improvement as needed SCCIPA - NQCA certification valid up to May 2017 Monitor Stanford, Daughters of Charity (SJMG & NCAMG), PAMF and SCCIPA Semi-annual/Annual PR Manager Report Period Metrics (if applicable) Key Findings and Analysis 1Q Vendor: Carenet - Health Information Line (NCQA HIL certification) Vendor is compliant with NCQA requirements List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Report received and no quality improvement activity identified Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) See access tab Remeasurement State target date(s) for re-measurement or completion of follow-up actions.

26 2016 QM WORKPLAN Vendor: AxisPoint Health - HIL (NCQA HIL certification) Vendor: AxisPoint Health - Disease Management program & Clinical Practice Guidelines (NCQA accreditation) Vendor: AxisPoint Health - Complex Case Management program (NCQA accreditation) Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Vendor is compliant with NCQA requirements Report received and no quality improvement activity See access tab identified Report received and reviewed at UM See Care Mgmt. tab Reports reviewed and reviewed through UM See Care Mgmt. tab

27 OTHER QI ACTIVITIES: Goals, Analysis, Interventions and Evaluation Goal(s) Planned Activities Target Date(s) for QUALITY MANAGEMENT Annual QM Program Evaluation Complete an 2015 QM Program Evaluate all aspects of the 2015 QM Program for Annual QM Program Maintain an accurate description of the program improvement March Reporting to QMC Responsible Person(s) and Titles NCQA Program Manager Review and update the QM Program Policy - COM 6000 January NCQA Program Manager Annual QM Work Plan Document all quality activities Evaluate activities and review progress January NCQA UTILIZATION Maintain accreditation and prepare for Renewal Survey January 2018 Ensure all departments continue to meet NCQA standards Continuous to January 2018 Monitor activities per NCQA Standards MANAGEMENT Annual UM Program Evaluation Complete an 2015 UM Program Evaluate all aspects of the 2015 UM Program for Annual Program Description Annual UM Workplan Maintain an accurate description of the program Document all UM activities and measure submission March NCQA Program Manager NCQA Program Manager Chief Medical Officer improvement UM Manager Review and update the UM Program Policy - COM 5701 February Chief Medical Officer Evaluate activities and review progress February, May, August, UM Manager Chief Medical Officer against benchmarks November, UM Manager Inter-rater reliability Maintain scores 90% Complete annual questionnaire August Chief Medical Officer Utilization Management Access: UM Decision-making Criteria UM Manager Annual Approval UM Committee reviews and approve February Chief Medical Officer UM Manager UM Turn-Around-Times Report Performance Measure 95% Chief Medical Officer UM Manager Authorization Audit Report Performance Measure 93% Chief Medical Officer COMPLIANCE Timely Access Report Submit report to DMHC by March 31, 2015 Complete timely access report. Compile all access activities required by DMHC Timely Access regulations March UM Manager 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 27 of 32

28 OTHER QI ACTIVITIES: Goals, Analysis, Interventions and Evaluation Member Services Annual 95% compliance for Department of Grievance Audit Report Member Services Grievances related to Denials and Appeals Annual Audit Report Provider Dispute Resolution Audit Report Claims Audit Report Managed Health Care (DMHC) Technical Assistance Guide (TAG) 95% compliance for Department of Managed Health Care (DMHC) Technical Assistance Guide (TAG) 95% compliance for Department of Managed Health Care (DMHC) Technical Assistance Guide (TAG) 95% compliance for Department of Managed Health Care (DMHC) Technical Assistance Guide (TAG) 30 elements August August March, June, September, December January,, July, October Compliance Manager Regulatory Affairs Analyst Compliance Manager Senior Healthcare Program Analysts Compliance Manager Senior Healthcare Program Analysts Compliance Manager Senior Healthcare Program Analysts Anti-Fraud Report All departments to report anti-fraudulent activities On-going monitoring utilizing departmental anti-fraud indicators January Compliance Manager Regulatory Affairs Analyst PHARMACY SERVICES Turn-Around-Times Report Performance Measure 100% Review quarterly reports from Navitus and ensure January,, July, October Pharmacy Manager CAP/follow up when needed Inter-rater reliability Performance Measure 100% Review semi-annual reports from Navitus and ensure, October Pharmacy Manager CAP/follow up when needed MEMBER SERVICES Appeal and Grievance Audit 95% performance goal for DMHC TAG Quarterly February, May, August, MS Manager Report elements November, Turn-Around-Time and Accuracy of Information Report 100% TAT within 1 business day Semi-Annual February, August MS Manager Telephone Functionality, Quality 90% compliance rate for Telephone and Accuracy Report Information Quality and Accuracy DISPUTES & GRIEVANCE Semi-Annual February, August MS Manager Disputes Report 95% of all disputes will to be resolved within 45 business (working) days Compliance Manager Senior Healthcare Program Analysts 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 28 of 32

29 OTHER QI ACTIVITIES: Goals, Analysis, Interventions and Evaluation Report Period Metrics (if applicable) Key Findings and Analysis List any problems in reaching the goal or relevant data (i.e. state if goals were met or not met, include what caused the problem/issue) Interventions / Follow-up Actions State what will be done to meet the goal (i.e. continue with plan as listed or modify the plan: add a specific new process, etc.) Remeasurement State target date(s) for remeasurement or completion of follow-up actions 1Q QUALITY MANAGEMENT Annual QM Work Plan Document all quality activities MET - 4Q15/2015 and 2016 Annual Work plan approved UTILIZATION MANAGEMENT Annual Program Description Annual UM Workplan Utilization Management Access: UM Decision-making Criteria Maintain an accurate description of the program Document all UM activities and measure against benchmarks Annual Approval at the QMC January 2016 MET - UM and QM Committee reviewed and approve Quarterly reporting UM Program COM 5701 MET - 3Q15 activities reviewed and approved Quarterly Review 2016 MET - UM and QM Committee reviewed and approve Medical Necessity Criteria for medical and behavioral health Update as needed 2017 Annual ICE QI Delegation Required Reports Template 12/24/13 Page 29 of 32

30 OTHER QI ACTIVITIES: Goals, Analysis, Interventions and Evaluation Quality Medical Necessity Audit Performance Measure = 93% MET - 3Q15 - For Urgent, Routine and Retro at 97% which UM will review for (TAT)- Statistical Breakdown by Authorizations increased from 80% in the previous quarter Standard protocol documented cases was met at 100% additional protocols to auto approve, provide good resources during orientation period, ongoing work with the HealthLink (HL) team and Valley Express (VE) information system staff to identify items that do not require an authorization and identify the delay in migration of authorization to HL and VE Quarterly Review 2016 CLAIMS Claims Compliance Audit 95% compliance for Department of Managed Health Care (DMHC) Technical Assistance Guide (TAG) 30 elements MET - 99% 4Q15 for both Commercial and Marketplace/Covered California Group Continue to monitor quarterly MEMBER SERVICES 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 30 of 32

31 OTHER QI ACTIVITIES: Goals, Analysis, Interventions and Evaluation Appeal and Grievance Audit 95% performance goal for DMHC TAG MET - Commercial: 4/Q15 - for all elements Report elements NOT MET - Marketplace/Covered California: 9/10 elements did not meet the performance measure. All elements were at 100% except for Resolution Letter Timeliness (75%) Covered California (Marketplace) is new for both VHP Member Services and the Trizetto Customer Services staff VHP Appeal and Grievance requirements have been reviewed with the team lead and staff at Trizetto Customer Service who will continue to monitor, review and provide education to the staff The VHP Member Services Manager has also provided training to the Trizetto staff VHP will continue to monitor and evaluate quarterly Turn-Around-Time and Accuracy of Information Report 100% TAT within 1 business day COMM: NOT MET N= 101 (97%) 3 s out of 101 contacts audits for turn-around-time were not acknowledge within 1 business day MARKETPLACE: MET 100% (N=25). No CAP required VHP members are notified not to contact Member Service Representatives through personal but to use the VHP website or to call Member contacts continue to be reviewed daily and monthly by Member Services Supervisor and Manager to ensure compliance and quality of responses Any deficiencies identified are reviewed with staff, review of policies & procedures and education provided August 2014 ICE QI Delegation Required Reports Template 12/24/13 Page 31 of 32