QualityAdvance Program 2016 Overview

Transcription

1 QualityAdvance Program 2016 Overview Summary of changes for 2016 Category page I. Infrastructure Support Program 2 initiatives- PCMH and Efficiency, and Cultural Competency Self- Assessment Add: Medical Directors Meeting attendance requirement 3 II. Efficiency III. Health IT 2 measures- Tier 1 prescribing and ED visits/1000 CMS Meaningful Use Participation and Performance no change no change IV. Patient Experience Patient Experience Survey no change V. Rewards for Excellence 1. Diabetes HbA1c Good Control 2. Diabetes Blood Pressure Good Control 3. Appropriate Use of Antibiotics in Adults with Acute Bronchitis 4. Antidepressant Medication Management Effective Continuation Phase 5. Adolescent Well Care 6. Medication Management for people with Asthma Delete: Appropriate Use of Antibiotics in Adults with Acute Bronchitis [AAB] Add: Controlling High Blood Pressure (CBP) 10 Health Services January 1, Harvard Pilgrim Health Care QualityAdvance 2016

2 Table of Contents Category Page I. Infrastructure Support Program 3 II. Efficiency 6 III. Health IT 8 IV. Patient Experience Survey 9 V. Rewards for Excellence 10 Appendix Page 1- Program Elements Summary ISP Deliverables Cultural Competency Self- Assessment Meaningful Use measure Methodology Patient Experience Survey measure Methodology Cultural Competency Brief Self-Assessment Tool and Recommendations 19 2 Harvard Pilgrim Health Care QualityAdvance 2016

3 Introduction The QualityAdvance (QAP) Program Overview describes the components of Harvard Pilgrim Health Care s (HPHC) physician pay-for-performance program, the methodology used to assess performance, and relevant HPHC resources. See Appendix 1 for a summary of QAP program elements. For more information on the QAP program: I. Infrastructure Support Payment (ISP) The ISP is provided to support the practice and Medical Director. There are four components to the ISP measure. The Local Care Unit (LCU) must 1) have a Medical Director, 2) the Medical Director must meet their responsibilities, 3) the LCU must implement two Infrastructure Support initiatives- one in the area of Patient Centered Medical Home (PCMH) transformation and one in the area of Efficiency, and 4) conduct a Cultural Competency self-assessment, as more fully described below. Medical Director The Medical Director is the liaison between Harvard Pilgrim and the LCU s providers to support collaborative efforts to deliver high quality, cost-efficient, patient centered care to Harvard Pilgrim members through the oversight of the QualityAdvance Program and other initiatives. Responsibilities of the Medical Director include, but are not limited to, the following: Supports LCU physicians and promotes the adoption of evidence-based health care delivery Designs and implements LCU-wide population management programs Regularly reviews performance data to identify and manage outlier performance and drivers of practice variation across the LCU Implements a process to review and distribute reports made available to LCU, including claims-based medical, and pharmacy utilization reports and HEDIS performance Provides regular updates to LCU providers about Harvard Pilgrim products, policies, performance payment and recognition programs Facilitates local physician recognition and reward programs related to performance on Harvard Pilgrim s quality strategic quality initiatives, including the Quality Grants Program Assists with the resolution of Harvard Pilgrim care delivery issues and provider-related concerns Ensures compliance with HIPPA requirements and confidentiality of all Harvard Pilgrim proprietary information Attends Harvard Pilgrim Medical Directors meetings, twice annually. Ensures submission of the an annual Business Plan and 2 updates, detailing 2 initiatives as described below Ensures a Cultural Competency self-assessment is completed 3 Harvard Pilgrim Health Care QualityAdvance 2016

4 Infrastructure Support Initiatives: The LCU will submit a Business Plan and two (2) updates detailing two (2) improvement initiatives (as more fully described in Appendix 2): 1. one initiative to support the transition of its practices to a Patient Centered Medical Home care delivery model 2. one network-wide initiative to support improved care delivery efficiency (appropriate utilization and reduced total cost of care) Table 1: PCMH Initiative Topic Choices PCMH Initiative Choices The LCU implements one (1) multi-practice initiative aligned with NCQA PCMH standards. More details related to each PCMH standard can be found on the NCQA public website PCMH 1: Patient-Centered Access. The practice provides access to team-based care for both routine and urgent needs of patients/ families/ caregivers at all times. PCMH 2: Team-Based Care. The practice provides continuity of care using culturally and linguistically appropriate, team-based approaches. PCMH 3: Population Health Management. The practice uses a comprehensive health assessment and evidence-based decision support based on complete patient information and clinical data to manage the health of its entire patient population. PCMH 4: Care Management and Support. The practice systematically identifies individual patients and plans, manages and coordinates care, based on need. PCMH 5: Care Coordination and Care Transitions. The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations. PCMH 6: Performance Measurement and Quality Improvement Cultural Competency Self-Assessment: Harvard Pilgrim is committed to achieving health care equity for our members and the communities we serve. Assuring the cultural competency of our provider network is of critical importance in delivering on that commitment. The LCU will submit a self-assessment of cultural competency to ensure racial/ethnic sensitivity, language access and attention to health literacy, as further described in Appendix 3. Target Medical Director Responsibility Measure: The target is met when the Medical Director(s) attend 2 scheduled Medical Directors meetings. IS Initiatives: The target is met when the provider submits the initial business plan, mid-year update and final report, more fully described in Appendix 2. Cultural Competency self-assessment: The target is met when the LCU has submitted a Cultural Competency self-assessment further described in Appendix 3. *Please send all submissions to: HPHC_NMM@HPHC.ORG 4 Harvard Pilgrim Health Care QualityAdvance 2016

5 Payment For the first quarterly payment (January 1, 2016 through March 31, 2016), the payment will be earned based on the attendance of at least one LCU Medical Director at the HPHC Medical Directors meeting and the submission of the IS initiative business plan. For the second quarterly payment (April 1, 2016 through June 30, 2016), the payment will be earned based on the submission of the Cultural Competency self-assessment. For the third quarterly payment (July 1, 2016 through September 30, 2016), the payment will be earned based on the attendance of at least one LCU Medical Director attendance the HPHC Medical Directors meeting and the submission of the IS initiative mid-year update. For the final quarterly payment (October 1, 2016 through December 30, 2016), the payment will be earned based on the submission of thee IS initiative final business plan. 5 Harvard Pilgrim Health Care QualityAdvance 2016

6 II. Efficiency Measures a. Tier 1 Prescribing Description Measures the percent of drug prescriptions filled by LCU members that are in Tier 1 of the Plan s formulary Target The LCU will be measured on the percent of prescriptions filled by its fully-insured HMO/POS members that are in Tier 1 of the Plan s formulary, from 1/1/16 to 12/31/16. Payment will be evaluated for 2 areas: Excellence (high overall rates compared to the network) and Improvement (high rate of change from the previous year, compared to the network rate of change). The specific targets that must be met for payout are noted below. Table 2: Tier 1 Prescribing Target Excellence Improvement Measure Target Payment Quartile Rank in Tier 1 Rx as % Total Rx % point change in LCU s % Tier 1 (beyond average network change %) In Top 25 th Percentile of HPHC network (i.e., better than 75% of LCUs in network array) Two performance levels: >= 2% points > network chg >= 1% points > network chg Full Full Half Payment Payment will be made by the end of February Reporting Tier 1 reports are available on HPHConnect/Provider Reports (output is static pdf) Additional backup at the LCU, CSU, and PCP level is also available on HPHConnect, under the Pharmacy reports option, static pdfs (e.g., Prescriber Profile, Clinical Therapeutic Class Report, etc.) Additional backup at the LCU, Drug Class, and prescriber level is a drillable report in the HPHConnect Performance Reporting Tools/Provider Analytics Interactive Dashboard (PAID) folder See for more information on PAID 6 Harvard Pilgrim Health Care QualityAdvance 2016

7 b. Emergency Department Visits Per Thousand (EDV) Description Measures the LCU s risk-adjusted fully insured HMO/POS member hospital emergency department (ED) utilization from January 1, 2016 through December 31, 2016 Target The LCU will be measured on the ED utilization of its fully-insured HMO/POS members from 1/1/16 to 12/31/16. Payment will be evaluated for 2 areas: Excellence (low utilization compared to the network) and Improvement (low rate of change from the previous year, compared to the network rate of change). The specific targets that must be met for payout are noted below. Table 3: EDV Target Excellence Target In Top 25 th Percentile (i.e., better than 75% of LCUs in network) for dates of service January 1, 2016 through December 31, 2016 Payment Full Improvement If the LCU s ED visits per thousand trend (for calendar year 2016 compared to calendar year- 2015) is less than the network performance trend by at least two percentage points (2%) Ex: if Plan network trend is 5% then the LCU Improvement goal is <=3% Full If the LCU s ED visits per thousand trend (for calendar year 2016 compared to calendar year- 2015) is less than the network performance trend by at least one percentage point (1%) and by less than two percentage points (2%) Half Payment Payment will be made by end of May Reporting HPHConnect/Provider Performance Reporting Tools has reports that enable the LCU to monitor ER utilization on a monthly basis: o Provider Analytics Interactive Dashboard (PAID) reports ER Visits/1000 and ER repeat visits within 30 days are. o More high level reports are available on HPHConnect/Provider Performance Reporting Tools/Provider Analytics Self Service (PASS) displays ER utilization See for information on these reports Claims downloads as made available to LCU via secure server 7 Harvard Pilgrim Health Care QualityAdvance 2016

8 III. Health Information Technology (HIT) Harvard Pilgrim measures provider Participation and Performance in the CMS Meaningful Use (MU) program. Performance is measured on three (3) CMS Modified Stage 2 Objectives, as described in Table 4. CMS determines performance based on the provider s Stage of MU participation in Table 4: MU Performance Measures CMS Obj. # Measure Definition 2 Clinical Decision Support Measure 1: Implement clinical decision support interventions related to clinical quality measure. Measure 2: Enable and implement the functionality for drug-drug and drug allergy interaction Electronic Prescribing Public Health Reporting Measure: Permissible prescriptions are queried for a drug formulary and transmitted electronically using CEHRT. Measure Option 1 Immunization Registry Reporting: Active engagement with a public health agency to submit immunization data. Measure Option 2 Syndromic Surveillance Reporting: Active engagement with a public health agency to submit syndromic surveillance data. Measure Option 3 Specialized Registry Reporting: Active engagement to submit data to a specialized registry. Table 5: MU Targets Measure Target Payment Participation The percent of targeted specialties participating in CMS MU is > the HPHC network 75 th percentile Full The percent of targeted specialties participating in MU is > the HPHC network 50 th percentile and < 75 th percentile 75% payment The percent of targeted specialties participating in MU is > the HPHC network 25 th percentile and < 50 th percentile 50% payment Performance, each of the 3 measures GATE for earning on Performance: If the LCU meets the HPHC network 25 th percentile Participation target, then: The percent of applicable LCU providers meeting the measure is > the HPHC network 75 th percentile Full The percent meeting the measure is > the HPHC network 50 th percentile and < 75 th percentile 50 % payment See Appendix 4 for calculation of target achievement for MU Participation and Performance measures Payment Payment will be made by end of March 2017 (based on CMS December 2016 download). 8 Harvard Pilgrim Health Care QualityAdvance 2016

9 IV. Patient Experience Survey (PES)- MA Description This measure has 2 components- Participation and Performance. Participation: Measures the percent of the LCU s primary care providers (both adult and pediatric) with publicly reported PES data, collected annually by the Massachusetts Health Quality Partners (MHQP). Publicly reported data is collected for HPHC HMO/POS and PPO members. Performance: Measures participating providers on their Performance on four (4) Consumer Assessment of Healthcare Providers and Systems- Clinical and Group Surveys (CG-CAHPS) composites that are aligned with PCMH goals: 1. Getting Timely Appointments, Care and Information 2. How Well Providers Communicate with Patients 3. Integration of Care 4. Providers Support You in Taking Care of Your Own Health Table 6: PES Targets Tart PES Target Payment Participation The percent of LCU providers who have with at least one PES is > the HPHC network 25 th percentile but < the 50 th percentile The percent of providers with at least one PES is > the 50 th percentile Half Full Performance, each composite is earned individually GATE: If Participation is at or above the network 25th percentile: The LCU performance on a composite measure is > the HPHC network 50 th percentile but < 75 th percentile Half Performance on a measure is > the HPHC network 75 th percentile Full *See Appendix 5 for calculation of target achievement for Participation and Performance measures Payment Payment will be made by end of May Harvard Pilgrim Health Care QualityAdvance 2016

10 IV. Rewards for Excellence (R4E) Harvard Pilgrim supports LCU clinical quality improvement efforts and rewards excellent performance on select HEDIS process and outcome measures. The LCU must meet the Threshold measure targets to be eligible to earn on the Non-Threshold measure set. R4E HEDIS Measures: Threshold Measures: 1. Breast Cancer Screening (BCS) 2. Cervical Cancer Screening (CCS) 3. Diabetic Nephropathy testing (CDC) Non-Threshold Measures: 1. Diabetes Outcome Measure: BP Good Control < 140/90 [CDC] 2. Diabetes Outcome Measure: HbA1C Good Control < 8.0 [CDC] 3. Controlling High Blood Pressure [CBP] 4. Antidepressant Medication Management [AMM] Effective Continuation Phase (6 months) 5. Adolescent Well Care [AWC] 6. Medication Management for People with Asthma [MMA]- Controller med for >= 75% of treatment period Small LCU HEDIS measure set If LCU has an insufficient denominator (30) for the diabetes measures in the non-threshold measure set, the Plan will evaluate and reward performance on the following measures: 1. Cervical Cancer Screening [CCS] 2. Breast Cancer Screening [BCS] 3. Adolescent Well Care [AWC] Non-Threshold measure set If the LCU has sufficient denominator (30) for the diabetes measures in the Non-Threshold measures set, but does not meet denominator requirements for one or more of the other Non- Threshold measures, the LCU is not eligible to earn on the measure(s) with insufficient denominators. The minimum denominator requirements are: Controlling High Blood Pressure: 30 Antidepressant Medication Management: 20 Adolescent Well Care: 20 Medication Management for People with Asthma: Harvard Pilgrim Health Care QualityAdvance 2016

11 For three Threshold measures, Controlling High Blood Pressure, Diabetes BP and HbA1c Outcome, the LCU is required to submit lab outcome values via HPHC s secure file transfer protocol server. In March 2017, HPHC posts a data collection tool listing members eligible for the measure. For the CBP measure, HPHC will provide a random sample of 100 members. The LCU populates the tool with member data and re-posts in April See for information on Harvard Pilgrim s Quality Management Reports (QMR) and a QAP HEDIS measure primer. Target The target for threshold measures will be met if performance on each of the three measures is > the HMO/POS NCQA HEDIS national 75 th percentile (2017 Quality Compass). The targets for non-threshold measures will be based on the HMO/POS NCQA HEDIS national performance (2017 Quality Compass). National score achievement for each of the six measures for the LCU participating providers is as follows: Earnings % Measure Gate Target PMPM 1 > National 75th percentile 25% 2 3 1/3 distance between 75th percentile and 90th percentile 38% 1/2 distance between 75th percentile and 90th percentile 50% 4 2/3 distance between 75th percentile and 90th percentile 75% 5 > National 90th percentile 100% The 2017 Quality Compass reports national performance for Jan-Dec 2016 dates of service and is available in September After raw scores are calculated, a chart review factor is applied to the Cervical Cancer Screening and Breast Cancer Screening measures. Payment Payment will be made in the fourth quarter of 2017 after the NCQA HEDIS national score (Quality Compass) is released. 11 Harvard Pilgrim Health Care QualityAdvance 2016

12 APPENDIX 1 QAP 2016 Program Elements Summary The chart below highlights key elements of the Quality Advance Program for 2016 and identifies the schedules that provide more detailed information about the program. Element Payment Frequency Payment Date I. Infrastructure Support Program (ISP) 1. Medical Director Meeting Attendance 2. ISP Initiatives 3. Cultural Competency Self- Assessment Quarterly Q1, by the end of May 2016 Q2, by the end of Aug 2016 Q3, by the end of Nov 2016 Q4, by the end of Mar 2017 II. Efficiency Elements (non-shared savings contracts only) 2a. Tier 1 Prescribing 2b. ED Visit Rates Annually Annually By end of February 2017 By end of May 2017 III. Health Information Technology 3a. Meaningful Use Participation 3b. Meaningful Use Performance Annually By end of March 2017 IV. Patient Experience Survey Annually By end of May 2017 V. Rewards for Excellence HEDIS Annually By end of October 2017 if Quality Compass is available in August 2017 Please see HPHC Important Dates 2016 posted on ( Quick Links ) for ISP documentation submission dates. All submissions must be submitted electronically to the HPHC mailbox: HPHC_NMM@hphc.org with the exception of the R4E HEDIS Outcomes Tool. The Tool must be re-posted to the secure server, per instructions supplied with the data collection tool. 12 Harvard Pilgrim Health Care QualityAdvance 2016

13 APPENDIX 2 Infrastructure Support Initiatives Business Plan Deliverables Please document using the Infrastructure Support Business Plan & Update form available on 1. Business Plan: On or before February 29, 2016, the LCU will provide the following: For each Initiative please provide the following: a. Please describe any prior work done in the area b. Key activities/components (bullets) c. Project milestones and deliverables during the calendar year d. 2 measures of success 2. Interim Report, due Sept 30, (HPHC may request a meeting with LCU to discuss progress) a. Interim Progress report (project plan milestones) b. Interim metrics, if available 3. Final Report, due Jan 31, (HPHC may meet with LCU to discuss initiative results) a. Final progress report (project plan milestones) b. For each initiative, please answer the following questions: i. What barriers did you address? ii. iii. iv. What aspects of your project went particularly well and were essential to its success? What were the lessons learned in designing and implementing your project? Your next steps? v. Is the initiative transferrable to the HPHC network? 13 Harvard Pilgrim Health Care QualityAdvance 2016

14 APPENDIX 3 Cultural Competency Self-Assessment Required: Submit at least one Cultural Competency Self-Assessment survey to Harvard Pilgrim by June 30, The survey may be at the LCU level or for a large practice. Please select a practice other than the practice surveyed in 2015 for this requirement. The LCU may use the Harvard Pilgrim brief self-assessment tool in Appendix 6 (also posted on or one of the tools listed below. Send a copy of the completed self-assessment to HPHC_NMM@hphc.org by June 30, Table 1: Preferred Cultural Competency Self-Assessment Tools Culturally and Linguistically Appropriate Services (CLAS) Assessment Tool (Office of Minority Health, US Dept of Health and Human Services) Cultural Competence Implementation Measure (tool starts on page 29) (RAND; endorsed by National Quality Forum as measure 1919) Communication Climate Assessment Tool for Health Care Organizations (American Medical Association) Cultural and Linguistic Competence Policy Assessment Tool (National Center for Cultural Competence) Cultural Competence Assessment Tool (Boston Public Health Commission) Cultural Competence Self-Assessment (Andrulis, Delbanco, et. al.) 14 Harvard Pilgrim Health Care QualityAdvance 2016

15 APPENDIX 4 Meaningful Use (MU) measure Methodology 1. The Plan will download the December 2016 CMS Data file (per CMS schedule) of unique providers awarded CMS payments for meaningful use and their individual performance on the applicable measures. File includes HMO/POS and PPO members. Denominator = HPHC roster with the same date as the CMS data file. 2. The Plan will compute the participation rate by counting the number of unique providers. A unique provider will be defined as a provider with a distinct NPI. Rate = # unique providers in LCU in CMS file (a) # unique providers in LCU, per HPHC system 3. The plan will compute the performance rate (if applicable) by taking the number of applicable providers a who have met the target and dividing by the number of MU providers a in the LCU for each of the 3 performance measures: Rate = # unique providers meeting the CMS target # unique providers in LCU in CMS file (b) Note: The LCU has option of submitting their Medicaid MU data to HPHC to improve their Medicare score. (Medicaid MU data is not publicly reported). For more information, please contact us at HPHC_NMM@HPHC.org. (a) See table, p.18 (b) The denominator reflects all the unique providers in the CMS file, regardless of whether or not the provider submitted data for that performance measures (core or menu measure) 15 Harvard Pilgrim Health Care QualityAdvance 2016

16 (a) Specialties included in MU analysis, based on CMS Eligible Provider (EP) definitions Allergy & Immunology Cardiovascular Disease Dermatology Diabetes and Metabolism Family Practice Gastroenterology Geriatric Medicine Gynecologic Oncology Gynecology Hematology Infectious Disease Internal Medicine Medical Oncology Nephrology Neuromuscular Medicine/ Osteopathic Manip. Obstetrics & Gynecology Oncology/ Hematology Ophthalmology Otolaryngology Pain Physical Management Medicine & Rehabilitation Podiatry Pulmonary Disease Radiation Oncology Reproductive Endocrinology Rheumatology Surgery Surgery, Colon and Rectal Surgery, Neurological Surgery, Orthopaedic Surgery, Plastic Surgery, Thoracic Surgery, Vascular Urology MU excluded specialties: HPHC has removed from consideration those specialties with low CMS Meaningful Use participation to mitigate the impact of specialties with large number of providers, but low participation in the CMS MU program (e.g., Pediatrics, Diagnostic Radiology). Low participation is defined as < 20 unique providers having MU recognition (e.g., Sports Medicine) or if there is a low participation rate in MU within the specialty (< 20%), regardless of the number of MDs with CMS recognition (e.g., Pediatrics). 16 Harvard Pilgrim Health Care QualityAdvance 2016

17 APPENDIX 5 Patient Experience Survey measure Methodology Data Source: PES survey responses reported by MHQP HPHC Enterprise Data Warehouse Provider file Calculating Participation Rates: Numerator = Number of adult PCP's in an LCU with at least 1 member survey response Denominator = Total number of adult PCPs in an LCU, as of 6/30/16. Numerator = Number of pediatric PCP's in an LCU with at least 1 member survey response Denominator = Total number of pediatric PCPs in an LCU, as of 6/30/16. Determine the split between pediatric and adult patient membership as of 6/30/16 Using the ratio of pediatric to adult membership in the LCU, weight the participation result for adult and pediatrics to determine the final participation rate. PCPs include Family Practice (FP) General Practice (GP), Internal Medicine, Pediatrics and Adolescent Medicine. Note: FP and GP docs are counted in both the Adult and Pedi rates. Calculating Performance Rates: For each composite measure (table below) calculate the unweighted pedi and adult rates separately. Using the ratio of pediatric to adult membership in the LCU, weight the performance result for adult and pediatrics to determine the final performance for each survey item. 17 Harvard Pilgrim Health Care QualityAdvance 2016

18 Composites Getting Timely Appointments, Care and Information Survey Items In the last 12 months, when you called this provider s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? In the last 12 months, when you made an appointments for a check-up or routine care with this provider how often did you get an appointment as soon as you needed? In the last 12 months, when you called this provider s office during regular office hours, how often did you get an answer to your medical question that same day? In the last 12 months, when you called this provider s office after regular office hours, how often did you get an answer to your medical question that same day? In the last 12 months, how often did you see this provider within 15 minutes of your appointment time? How Well Providers Communicate with Patients In the last 12 months, how often did this provider explain things in a way that was easy to understand? In the last 12 months, how often did this provider listen carefully to you? In the last 12 months, how often did this provider give you easy to understand information about these health questions or concerns? In the last 12 months, how often did this provider seem to the important information about your medical history? In the last 12 months, how often did this provider show respect for what you had to say? In the last 12 months, how often did this provider spend enough time with you? Integration of Care In the last 12 months, how often did your personal provider seem informed and up-todate about the care you got from specialists? In the last 12 months, when this provider ordered a blood test, x-ray or other test for you, how often did someone from this provider s office follow up to give you these results? Providers Support You in Taking Care of Your Own Health In the last 12 months, did you and anyone in this provider s office talk about specific goals for your health? [Y/N] In the last 12 months, did anyone in this provider s office ask you if there are things that make it hard for you to take care of your health? [Y/N] If you would like more detail on the methodology please contact us at HPHC_NMM@HPHC.org 18 Harvard Pilgrim Health Care QualityAdvance 2016

19 APPENDIX 6 Cultural Competency Self-Assessment Required: Submit at least one Cultural Competency Self-Assessment survey to Harvard Pilgrim by June 30, The survey may be at the LCU level or for a large practice. Please select a practice other than the practice surveyed in 2015 for this requirement. The LCU may use the Harvard Pilgrim Brief Self-Assessment Tool below (also posted on Please let us if you prefer to use an alternative tool. Send a copy of the completed self-assessment to HPHC_NMM@hphc.org by June 30, Organizational Cultural Competency Brief Self-Assessment Tool About your organization A. Organization name B. Total number of practice sites C. Number of practice sites serving a racially/ethnically diverse population D. Number of primary care physicians (PCPs) E. Percent of PCPs who have completed cultural competency training F. Number of Primary Care Nurse Practitioners/Physician Assistants G. Percent of these NPs/PAs who have completed cultural competency training H. Number of specialist physicians I. Percent of specialists who have completed cultural competency training 19 Harvard Pilgrim Health Care QualityAdvance 2016

20 I. Diversity Assessment and Initiatives 1. Please describe and quantify the cultural, linguistic, racial and ethnic diversity within your patient population 2. Please provide one (1) example of a policy, project, process or program that you have implemented in the last 12 month to address the cultural or linguistic needs of your patient population. 3. What challenges or resource limitations have you identified in promoting cultural competency? For questions 1-19 below, please enter an X in the appropriate box. II. Governance, Leadership, and Workforce 1. Our organization ensures that the necessary fiscal and human resources including cultural tools, skills, and ledge are a priority in our organization. Agree Agree Dis Dis 2. Our organization s recruitment, hiring, and retention practices achieve a diverse and culturally competent staff, including senior leadership, reflective of our patient/client population. Agree Agree Dis Dis 3. Our organization requires diversity awareness and cultural competence training at all levels of the organization (i.e., staff, management, providers, etc.). Agree Agree Dis Dis 20 Harvard Pilgrim Health Care QualityAdvance 2016

21 III. Communication and Language Assistance 4. Our organization provides language assistance services at no cost to the patient/client. Agree Agree Dis Dis 5. Our organization posts notification of the right to an interpreter in several languages at various points of contact and by various means (print and multimedia). Agree Dis dis 6. Our organization does not use family members, friends or minors for providing interpretation for a patient/client appointment. Agree Dis dis 7. Our staff understands and respects the cultural health and illness beliefs and practices of our patient population, including beliefs about complementary and alternative medicine and medical treatments that may violate cultural and/or religious traditions. Agree Dis dis 8. Our organization assures that the patient education materials we use are culturally appropriate for our patient populations and are available in their preferred language. Agree Dis dis 21 Harvard Pilgrim Health Care QualityAdvance 2016

22 9. We explain technical or specialized terminology and make every effort to assure that our patients fully understand questions, instructions and explanations from our clinical, administrative and other staff. Our staff are expected to assess patients understanding by asking questions or having the patient repeat the information in their own words. Agree Dis dis 10. Our organization has a designated process for assuring that our printed patient/client materials are written in plain language and adhere to health literacy guidelines. Agree Dis dis IV. Engagement, Continuous Improvement, and Accountability 11. Our organization has a strategic plan that incorporates Culturally and Linguistically Appropriate Services (CLAS) goals and activities. Agree Dis dis 12. Our organization has developed measurable outcome goals regarding cultural and linguistic competence and periodically assesses our progress in meeting those goals. Agree Dis dis 13. We have identified a CLAS/cultural competency champion from within our staff to monitor our activities and advancement in cultural competency Agree Dis dis What is the name of this individual? 22 Harvard Pilgrim Health Care QualityAdvance 2016

23 14. Our organization collects race and ethnicity, preferred language, and disability status for all of our patient/clients. (If you collect 2 out of 3 enter Agree ) Agree Dis dis 15. Our organization measures clinical quality of care by race/ethnicity and language and identifies disparities in the care received by different population groups. Agree Dis dis 16. Our organization measures patient experiences by race/ethnicity, language and education to assess access, communication, coordination of care and patient engagement. Agree Dis dis 17. Our organization works to address identified disparities in care and service and to meet the social and health needs of our community. Agree Dis dis 18. Our organization has a formal grievance/complaint process that is accessible to all patient/client populations. Agree Dis dis 19. Our organization regularly provides information to the public through print materials and activities highlighting our efforts to provide culturally responsive care to all patient/clients. Agree Dis dis 23 Harvard Pilgrim Health Care QualityAdvance 2016

24 Recommendations for Improving Organizational Cultural Competency The following recommendations provide guidance for meeting the National CLAS Standards. The recommendations are numbered the same as the corresponding questions in the self-assessment. These recommendations are intended to assist organizations that responded Dis, Strongly Dis or Don t Know to the corresponding question. We hope this information will be useful in the development of quality improvement activities, action plans, and strategic designs. Governance, Leadership, and Workforce: 1. It is leadership that establishes the culture of the organization through setting priorities that include the availability of fiscal and human resources for cultural competence. 2. Identify the patient/client populations in your service area and develop a plan to recruit staff at all levels who reflect those populations. Include recruitment of staff from diverse populations in your strategic plan. 3. Create or identify staff opportunities to attend training on serving diverse patient/client populations (i.e., brown bag lunches, all staff meetings, in-services, conferences, etc.). Communication and Language Assistance 4. Review your organization s process for ensuring that a patient/client is never billed for interpreter services. 5. Post a sign in the common areas of your organization offering interpreter services. The sign should provide this offer in all of the languages spoken by at least 1% of your patients. Encourage patient to use this service and inform them it is free of charge. 6. Create a policy that family members, friends or minors should not be utilized as interpreters. The policy should explain that utilization of interpreters who are trained in medical interpretation is critical for providing safe and quality care. 7. All staff who communicate directly with patients should receive cultural competency training, including being made aware of the most common cultural beliefs and traditions of the patients seen in the practice. It should not be assumed that all patients from a particular culture share these beliefs but patients should be asked about them as part of shared decision-making about their treatment options. 8. If the target population for your patient outreach and education materials includes a significant number of racially and ethnically diverse patients, assure that these materials respect the cultural beliefs and practices of those patients while promoting high quality care. These materials should be available in the most common languages spoken by patients seen in the practice. 9. Health literacy awareness training is recommended for all staff who interact with patients. Jargon and acronyms should be avoided and a list of recommended alternatives* for commonly misunderstood words should be made available to staff. 10. Conduct periodic reviews of all patient/client materials used at your organization for reading level and compliance with recommendations for clear communication. Use of a checklist* for assessing written materials for health literacy and cultural appropriateness can be very helpful. Engagement, Continuous Improvement, and Accountability 11. Identify and incorporate some of the recommended strategies from this self-assessment into your strategic plan. Conduct periodic assessments related to cultural and linguistic services provided by your organization and share results with your staff. 24 Harvard Pilgrim Health Care QualityAdvance 2016

25 12. Utilize results from this assessment to serve as a measurement tool to determine improvements over time regarding delivery of culturally appropriate care. 13. Having an identified organizational champion for the provision of culturally and linguistically appropriate services can help to assure that this perspective is considered whenever new policies or programs are adopted. The champion should also monitor the organization s ongoing compliance with CLAS standards and recommend improvements as needed. 14. Race, ethnicity, preferred language, and disability status should be collected using an individual self report process. This information should be stored in the patient s medical record in order to facilitate the delivery of culturally appropriate care. 15. When creating patient registries, measuring quality of clinical care and conducting patient experience surveys, include race/ethnicity to enable stratification of results and identification of disparities. 16. When conducting patient experience surveys include items about the respondents race/ethnicity and educational attainment to enable identification of racial/ethnic disparities in communication and service, as well as areas where interventions to improve health literacy may be needed. 17. When disparity reduction strategies require a community-based approach, collaborate with other health care delivery organizations in the community and local community-based groups to identify and implement effective interventions. 18. Review your current complaint/grievance policy to determine if patients/clients with limited English proficiency or other cultural and communication needs would be able to access this process. 19. Create opportunities to inform your community of efforts in cultural and linguistic responsiveness - news articles, ads, health fairs, brochures, community meetings, public speaking engagements, etc. 20. Include at least one disparity reduction initiative in your annual quality work plan. * Harvard Pilgrim has developed tools in the asterisked areas noted above. If you would like to view or use these tools, please contact us at HPHC_NMM@HPHC.org 25 Harvard Pilgrim Health Care QualityAdvance 2016