Quality Improvement Program (QIP) Measurement Specifications

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1 Quality Improvement Program (QIP) Measurement Specifications Developed by: Marya Choudhry Contributors include: Robert Moore Jess Liu Jennifer Dionisio Carolyn Stewart Melanie Lam Jessica Thatcher Contact: 1

2 Table of Contents I. Quality Improvement Program Contact Information... 3 II. Quality Improvement Program Overview. 3 III. Summary Of Measurement Set.4 IV. Fixed Pool Measures I- Clinical Domain Clinical Domain Measurement Specifications for less than 10 members in the denominator Child BMI (ages 3-17) Nutrition Counseling Physical Activity Counseling Well Child (ages 3-6) Cervical Cancer Screening (ages 24-64) Childhood Immunization- DTaP Immunizations for Adolescents Controlling High Blood Pressure Annual Monitoring for Patients on Persistent Medications Diabetes Management.18 V. Fixed pool Measures II- Appropriate Use of Resources Acute Bed Days/ Readmission Rate Follow-up Post Discharge Pharmacy Utilization...26 VI. Fixed Pool Measures III-Access & Operations Avoidable ED Visits/1000 Members Per Year Practice Open to New PHC Members PCP Office Visits Per Member Per Year Operations Measures...29 VII. Fixed Pool Measures IV- Patient Experience. 33 VIII. Unit of Service Measures Advance Care Planning Access/Extended Office Hours and Exception Achieving PCMH Recognition Starting or Continuing Peer-Led Self Management Support Group Utilization of California Immunization registry (CAIR).41 Appendix I: DHCS Statewide Avoidable ED Diagnosis Codes..43 Appendix II: Submission Template for Operations Measure...48 Appendix IIIA.1: Submissions Template for Patient Experience- Survey Option.. 55 Appendix IIIA.2: Submissions Template for Patient Experience- Option Patient Feedback.. 63 Appendix IIIB: Submissions Template for Patient Experience- Training Option...66 Appendix IVA: Advance Care Planning Attestation Template Appendix IVB: Advance Care Planning Medical Record Components Appendix V: Patient-Centered Medical Home Documentation Template Appendix VI: Submission Template for Peer Led Self Management Support Group.78 Appendix VII: Submission Template for CAIR.. 79 Appendix VIII: Submission Timeline...80 Appendix IX: Reporting Entity Table

3 I. Quality Improvement Program Contact Information Fax: (707) Phone: Marya Choudhry (QIP Project Manager, Redding): (530) Jess Liu (QIP Project Manager, Fairfield): (707) II. Quality Improvement Program Overview The PCP Quality Improvement Program (QIP), designed in collaboration with PHC providers, offers sizable financial incentives and technical assistance to primary care providers so that they can make significant improvements in the following areas: Prevention and Screening Chronic Disease Management Diabetes Appropriate Use of Resources Primary Care Access and Operations Patient Experience Advance Care Planning Primary Care Providers include: Pediatric Medicine, Family Medicine/Health Centers/Medical Groups, and Internal Medicine. Although the PCP Quality Improvement Program evaluates performance on PHC's Medi-Cal line of business, PHC encourages quality, cost-efficient care for all our members. Incentives are based on meeting specific performance thresholds in measures that address the above areas (Please see p.4-5 for a Summary of Measures). To participate in the QIP, you must be a contracted provider for the entire measurement year (July 1, 2014 June 30, 2015). 3

4 III. Summary of Measures (A) Fixed Pool Per Member Per Month (PMPM) Measures Providers have the potential to earn a total of 100 points in four measurement areas: 1) Clinical Care; 2) Appropriate Use of Resources; 3) Access and Operations; and 4) Patient Experience. Clinical Domain Family Practice: 5 pts each, 35 pts total 1. Child BMI (3-17 yrs) (5 pts) 2. Cervical Cancer Screening (5 pts) 3. Diabetes Management (18 75 yrs) (4 out of 6, 5 pts each) LDL testing, HbA1C testing, HbA1C good control, Retinal eye exam, Nephropathy, Blood pressure control 4. Well Child Visits (3-6 years) (5 pts) Internal Medicine: 5 pts each, 35 pts total 1. Cervical Cancer Screening 2. Diabetes Management (18 75 yrs) (4 out of 7) LDL testing, HbA1C testing, HbA1C good control, Retinal eye exam, Nephropathy, Blood pressure control 3. Monitoring for Patients on Persistent Medications 4. Controlling High Blood Pressure Pediatric Specialty: 50 pts total 1. Child BMI (3-17 yrs) (5 pts) 2. Nutrition Counseling (3-17 yrs) (5 pts) 3. Physical Activity Counseling (3-17 yrs) (5 pts) 4. Well Child Visits (3-6 years) (10 pts) 5. Adolescent Immunization (10 pts) 6. Childhood Immunization DTaP (15 pts) Appropriate Use of Resources Family Practice & Internal Medicine: 30 pts total 1. Acute Bed Days/1000 Or Follow-Up Post Discharge* (10 pts) 2. Readmission Rate Or Follow-Up Post Discharge* (10 pts) 3. Pharmacy Utilization (10 pts) *Follow-up post discharge can be the back-up measure for either Acute Bed Days/1000 or Readmission Rate, but not both. 4

5 Pediatric Practice: 10 pts total 1. Pharmacy Utilization (10 pts) Access and Operations Family Practice & Internal Medicine: 25 pts total 1. Avoidable ED Visits (6 pts) 2. Practice open to PHC members (7 pts) 3. PCP Office Visits (6 pts) 4. Submit data on one access measure (e.g. 3NA) and one operations measure (e.g. No Show Rate, Call Abandonment Rate, Provider Continuity) (6 pts total) Pediatric Practice: 30 pts total 1. Avoidable ED Visits (8 pts) 2. Practice open to PHC members (8 pts) 3. PCP Office Visits (8 pts) 4. Submit data on one access measure (e.g. 3NA) and one operations measure (e.g. No Show Rate, Call Abandonment Rate, Provider Continuity) (6 pts total) Patient Experience All Sites: 10 pts total Providers can select any one of the following: 1. Training Option 2. Survey Option 3. Align with PCMH Patient Experience Criteria (B) Unit of Service Measures Providers receive payment for each unit of service they provide. Unit of Service All Sites: 1. Advance Care Planning attestations 2. PCMH Certification 3. Access/Extended Office Hours 4. Peer-led self management support groups 5

6 I. Fixed Pool Measures I Clinical Domain Eligible Population The eligible population in the denominator used to calculate the final rates is defined as those capitated Medi-Cal members continuously enrolled with their PHC assigned provider (which is based on state membership assignments) for 11 out of the 12 months of the measurement year. Assigned Provider is defined as the reporting entity designated for the QIP. Medi-Medi members (dually eligible members) are excluded from the denominator for the clinical measures. Member Months Final PMPM payment will be based on all capitated member months accrued throughout the measurement year not just for those continuously enrolled. Medi-Medi members (dually eligible members) are excluded from the payment for the clinical measures. Member months is defined as the total number of capitated Medi-Cal patients assigned to a site each month (i.e. if a provider has 100 Medi-Cal Partnership patients assigned each month for all 12 months of the measurement year, the provider s total member months will be 1200). ereports ereports, an online system built for the QIP Clinical Domain measures, is the mechanism by which providers can submit supplemental data to PHC to enhance and monitor their performance. You may access ereports at Clinical Domain Specifications for Small Denominators (Less-than-10) All providers, regardless of denominator size, will be held against the established thresholds (50 th percentile, 75 th percentile or 90 th percentile depending on the measure). However, we are aware that the point earnings of providers with small denominators may be affected by a few noncompliant members. Therefore, if a provider 1) has fewer than 10 members in the denominator for any measure after continuous enrollment is applied and 2) does not meet the threshold, there will be an additional opportunity to submit evidence of outreach efforts to non-compliant members conducted during the measurement year. In July 2015, PHC will release a template to complete for less-than-10 denominators in measures that do not meet the threshold. 1. Child BMI Description of Measure The percentage of continuously enrolled Medi-Cal members 3-17 years of age who had an outpatient visit with a PCP or an OB/GYN during the measurement year (July 1, 2014 June 30, 2015) and who had evidence of BMI percentile* documentation. *Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. *For members who are younger than 16 years of age on the date of service, only evidence of the BMI percentile or BMI percentile plotted on an agegrowth chart meets criteria. A BMI value is not acceptable for this age 6

7 range. *For adolescents ages 16-17, documentation of a BMI value expressed as kg/m2 is acceptable. * Ranges and thresholds do not meet criteria for this indicator. A distinct BMI percentile or value, if applicable, is required for numerator compliance. Data Sources CHDP visits, office visit claim or encounter (HCPCS, CHDP, ICD-9 diagnosis), entries into PHC ereports. Denominator (Eligible Population) The number of continuously enrolled Medi-Cal members ages 3-17 as of June 30, 2015 (i.e. DOB between July 1, 1997 and June 30, 2012) who had an outpatient visit with a PCP or an OB/GYN during the measurement year (July 1, 2014 June 30, 2015). The number of children in the eligible population with evidence that BMI percentile was documented at least once during the measurement year (July 1, 2014 June 30, 2015). Numerator OR For adolescents years of age on the date of service, a BMI value expressed as kg/m2 also meets criteria. Denominator: Codes to identify Outpatient Visits from Claims/Encounter Data: Refer to Table 2C on Code List Codes Used Numerator: Codes to identify BMI percentile from claim/encounter data: Refer to Table 2A on Code List Codes to identify BMI Value from claim/encounter data: Refer to Table 2B on Code List Exclusions (only if not numerator hit) Members who have a diagnosis of pregnancy during the measurement year. Codes to identify exclusions: Refer to Table 2D on Code List 2. Nutrition Counseling Description of Measure The percentage of continuously enrolled Medi-Cal members 3-17 years of age who had an outpatient visit with a PCP or an 7

8 OB/GYN during the measurement year (July 1, 2014 June 30, 2015) and who had evidence of counseling for nutrition. Data Sources CHDP visits, office visit claim or encounter (HCPCS, CHDP, ICD-9 diagnosis), entries into PHC ereports. Denominator (Eligible Population) The number of continuously enrolled Medi-Cal members ages 3-17 as of June 30, 2015 (i.e. DOB between July 1, 1997 and June 30, 2012) who had an outpatient visit with a PCP or an OB/GYN during the measurement year (July 1, 2014 June 30, 2015). The number of children in the eligible population with evidence that counseling for nutrition was documented at least once during the measurement year (July 1, 2014 June 30, 2015). Numerator Documentation must include a note indicating the date and at least one of the following: Discussion of current nutrition behaviors (e.g., eating habits, dieting behaviors). Checklist indicating nutrition was addressed. Counseling or referral for nutrition education. Member received educational materials on nutrition during a face-to-face visit. Anticipatory guidance for nutrition. Weight or obesity counseling Codes Used Denominator: Codes to identify Outpatient Visits from Claims/Encounter Data: Refer to Table 2C on Code List Numerator: Codes to identify counseling for nutrition from claim/encounter data: Refer to Table 3A on Code List Exclusions (only if not numerator hit) Members who have a diagnosis of pregnancy during the measurement year. Codes to identify exclusions: Refer to Table 2D on Code List 8

9 3. Physical Activity Counseling Description of Measure The percentage of continuously enrolled Medi-Cal members 3-17 years of age who had an outpatient visit with a PCP or an OB/GYN during the measurement year (July 1, June 30, 2015) and who had evidence of counseling for physical activity. Data Sources CHDP visits, office visit claim or encounter (HCPCS, CHDP, ICD-9 diagnosis), entries into PHC ereports. Denominator (Eligible Population) The number of continuously enrolled Medi-Cal members ages 3-17 as of June 30, 2015, (i.e. DOB between July 1, 1997 and June 30, 2012) who had an outpatient visit with a PCP or an OB/GYN during the measurement year (July 1, June 30, 2015). The number of children in the eligible population with evidence that counseling for physical activity was documented at least once during the measurement year (July 1, June 30, 2015). Documentation must include a note indicating the date and at least one of the following: Numerator Discussion of current physical activity behaviors (e.g., exercise routine, participation in sports activities, exam for sports participation). Checklist indicating physical activity was addressed. Counseling or referral for physical activity. Member received educational materials on physical activity during a face-to-face visit. Anticipatory guidance for physical activity. Weight or obesity counseling. Codes Used Denominator: Codes to identify Outpatient Visits from Claims/Encounter Data: Refer to Table 2C on Code List Numerator: Codes to identify counseling for physical activity from claim/encounter data: Refer to Table 4A on Code List Exclusions (only if not numerator hit) Members who have a diagnosis of pregnancy during the measurement year. Codes to identify exclusions: Refer to Table 2D on Code List 9

10 4. Well Child Visits (ages 3-6) Description of Measure The percentage of continuously enrolled Medi-Cal members 3 6 years of age who received one or more well child visits with a PCP during the measurement year (July 1, 2014 June 30, 2015). Data Sources CHDP Visits, office visit claim or encounter (CPT, ICD-9 diagnosis), and entries into PHC ereports. Denominator (Eligible Population) The number of continuously enrolled Medi-Cal members 3-6 years of age as of June 30, 2015 (i.e. DOB between July 1, 2008 and June 30, 2012). Numerator The number of children in the eligible population with at least one well child visit with a PCP during the measurement year (July 1, 2014 June 30, 2015). Denominator: No codes applicable as eligibility is solely defined by age. Codes Used Numerator: Codes to identify Well Child Visits from claims/encounter data: Refer to Table 7A on Code List 5. Cervical Cancer Screening (ages 24-64) Description of Measure The percentage of continuously enrolled Medi-Cal women years of age who were screened for cervical cancer according to the evidence-based guidelines: Women age who had a Pap test in the measurement year or the two years prior (July 1, 2012 June 30, 2015). Women age who had a Pap test and an HPV test on the same date of service in the measurement year or the four years prior (July 1, 2010 June 30, 2015). Data Sources Office visit claim or encounter (CPT, ICD-9 diagnosis), lab data, and entries into PHC ereports. Denominator (Eligible Population) The number of continuously enrolled Medi-Cal women years of age as of June 30, 2015 (i.e. DOB between July 1, 1950 and June 30, 1991). 10

11 Numerator The number of women in the eligible population who were appropriately screened according to evidence-based guidelines. Please refer to the steps and flow chart below. Codes Used Denominator: No codes applicable as eligibility is defined by age and gender. Numerator: See below. Step 1: Identify women years of age (DOB between July 1, 1950 and June 30, 1991) who had a Pap test in the measurement year or the two years prior (July 1, 2012 June 30, 2015) Codes to Identify Cervical Cancer Screening from Claims/Encounter Data: Refer to Table 1A on Code List Step 2: From the women who did not meet Step 1 criteria, identify women years of age (DOB between July 1, 1950 and June 30, 1985) who had a Pap test and HPV test on the same date of service in the measurement year or the four years prior (July 1, 2010 June 30, 2015) Codes to Identify Cervical Cancer Screening from Claims/Encounter Data: Refer to Table 1A on Code List Codes to Identify HPV Test from Claims/Encounter Data: Refer to Table 1B on Code List Step 3: Add the numbers from Steps 1-2 to obtain a total rate for women who were identified with appropriate screening for cervical cancer. Exclusion (only if not numerator hit) Women who had a hysterectomy with no residual cervix any time during the member s history through June 30, 2015 Codes to Identify exclusions: Refer to Table 1C on Code List 11

12 Monitoring for Appropriate Cervical Cancer Screening Step 1: Is there a Pap test in the measurement year or the two years prior (July 1, 2012 June 30, 2015)? YES Member is compliant NO Step 2a: Is the member years of age? NO Member is NOT compliant YES Step 2b: Is there a Pap test and HPV test on the same date of service in the measurement year or the four years prior (July 1, 2010 June 30, 2015)? YES Member is compliant Step 3: Add the numbers from Step 1 and Step 2b to obtain a total rate 6. Childhood Immunization - DTaP Description of Measure The percentage of children 2 years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP) vaccines by their second birthday. Data Sources Office visit claim or encounter (CPT, ICD-9 diagnosis), lab data, and entries into PHC ereports. Denominator The number of continuously enrolled Medi-Cal members who 12

13 (Eligible Population) turn 2 years of age between July 1, 2014 and June 30, 2015 (DOB between July 1, 2012 and June 30, 2013). Numerator The number of children with at least four DTaP vaccinations, with different dates of service, on or before the child s second birthday. Do not count vaccinations administered prior to 42 days after birth. Denominator: No codes applicable as eligibility is solely defined by age. Codes Used Numerator: Codes to identify DTaP Immunization: Refer to Table 5A on Code List Exclusion (if not numerator hit) Any of the following on or before the member s second birthday would meet the exclusion criteria. Look for exclusions as far back as possible in the member s history: DTaP: Encephalopathy (Refer to Table 5B on Code List) with a vaccine adverseeffect code (Refer to Table 5C on Code List). Any particular vaccine: Anaphylactic reaction to the vaccine or its components (Refer to Table 5D on Code List). 7. Immunizations for Adolescents Description of Measure The percentage of continuously enrolled Medi-Cal adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13 th birthday. Data Sources Office visit claim or encounter (CPT, ICD-9 diagnosis), lab data, and entries into PHC ereports Denominator (Eligible Population) The number of continuously enrolled Medi-Cal members who turn 13 years of age between July1, 2014 and June 30, 2015 (i.e. DOB between July 1, 2001 and June 30, 2002). Numerator At least one meningococcal conjugate or meningococcal polysaccharide vaccine with a date of service on or between the member s 11th and 13th birthdays. 13

14 AND Any of the following with a date of service on or between the member s 10th and 13th birthdays meet criteria: At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine OR At least one tetanus, diphtheria toxoids (Td) vaccine. OR At least one tetanus vaccine and at least one diphtheria vaccine on the same date of service or on different dates of service. *For meningococcal and Tdap or Td, count only evidence of the antigen or combination vaccine. Denominator: No codes applicable as eligibility is solely defined by age. Codes Used Numerator: Codes to identify Meningococcal vaccine: Refer to Table 6A on Code List Codes to identify Tdap vaccine: Refer to Table 6B on Code List Codes to identify Td vaccine: Refer to Table 6C on Code List) Codes to identify Tetanus Vaccine: Refer to Table 6D on Code List Codes to identify Diphtheria Vaccine: Refer to Table 6E on Code List Exclusions (only if not numerator hit) The exclusion must have occurred on or before the member s 13th birthday. Either of the following meets the exclusion criteria: Anaphylactic reaction to the vaccine or its components: Refer to Table 5D on Code List Anaphylactic reaction to the vaccine or its components: Refer to Table 5E on Code List, with a date of service prior to October 1,

15 8. Controlling High Blood Pressure Description of Measure The percentage of members years of age who had a diagnosis of hypertension (HTN) and whose most recent BP reading, taken during the measurement year, was adequately controlled (<140/90). Data Sources Entries into PHC ereports. The number of continuously enrolled Medi-Cal members years of age as of June 30, 2015 (i.e. DOB between July 1, 1929 and June 30, 1997) Denominator (Eligible Population) WITH At least one outpatient with a diagnosis of hypertension during the first six months of the measurement year (i.e. July 1, 2014 Dec 31, 2014). Numerator The percentage of members year of age in the denominator who had a diagnosis of Hypertension and whose most recent BP reading taken during the measurement year (July 1, 2014 June 30, 2015) was adequately controlled must be <140/90. Note: The member is not compliant if the BP reading is 140/90 or is missing, or if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing). Codes Used Denominator: Codes to identify outpatient visits: Refer to Table 8A on Code List Codes to identify Hypertension: Refer to Table 8B on Code List Numerator: No codes applicable to this measure. Please use ereports to upload data. Exclusion (if not a numerator hit) Exclude from the eligible population all members with evidence of end-stage renal disease (ESRD) (Refer to Table 8C on Code List) or kidney transplant (Refer to Table 8D on Code List) on or prior to June 30, Documentation in the medical record must include a dated note indicating evidence of ESRD, kidney transplant or dialysis. 15

16 Exclude from the eligible population all members with a diagnosis of pregnancy (Refer to Table 2D on Code List) during the measurement year (July 1, 2014 June 30, 2015). Exclude from the eligible population all members who had a nonacute inpatient stay (Refer to Table 8E on Code List) during the measurement year (July 1, 2014 June 30, 2015). 9. Annual Monitoring for Patients on Persistent Medications (MPM) Description of Measure The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report as a total rate: Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin. Annual monitoring for members on diuretics. Data Sources Office visit claim or encounter (CPT, ICD-9 diagnosis), pharmacy data, lab data, and entries into PHC ereports. The number of continuously enrolled Medi-Cal members 18 years of age or older as of June 30, 2015 (DOB on or before June 30, 1997) who, during the measurement year, received at least 180 treatment days of: ACE inhibitors or ARBs Digoxin OR Denominator (Eligible Population) Diuretic OR Treatment days are the actual number of calendar days covered with prescriptions within the measurement year (i.e., a prescription of 90 days supply dispensed on June 1 of the measurement year counts as 30 treatment days). Sum the days supply for all medications and subtract any day s supply that extends beyond June 30 of the measurement year. Medications dispensed in the year prior to the measurement year must be counted toward the 180 treatment days. 16

17 At least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year (July 1, June 30, 2015). The member must meet one of the following criteria to be complaint: A lab panel test OR Numerator A serum potassium test and a serum creatinine test OR A serum potassium test and a blood urea nitrogen test Note: The tests do not need to occur on the same service date, only within the measurement year Denominator: Codes to identify ACE inhibitors or ARBs: Refer to Table CDC L on Code List Codes to identify Digoxin: Refer to Table MPM B on Code List Codes to identify Diuretic: Refer to Table MPM C on Code List Codes Used Note: Members may switch therapy with any medication listed in any one of the three tables during the measurement year and have the days supply for those medications count toward the total 180 treatment days. Numerator: Codes to identify lab panel test: Refer to Table 9A on Code List Codes to identify serum potassium: Refer to Table 9B on Code List Codes to identify serum creatinine test: Refer to Table 9C on Code List Codes to identify blood urea nitrogen test: Refer to Table 9D on Code List. Exclusion (if not numerator hit) Exclude members from each eligible population rate who had an inpatient (acute or nonacute) claim/ encounter during the measurement year: Refer to Location Code Table on Code List. 17

18 10. Diabetes Management Description of Measure The percentage of continuously enrolled Medi-Cal members ages years with diabetes who had measurements done or threshold achieved on 4 of the 6 following indicators: HbA1c Testing LDL Testing Retinal eye exam HbA1c Good Control (<9%) Blood Pressure <140/90 mmhg Nephropathy screening test or evidence of nephropathy Data Sources Office visit claim encounter (CPT II), lab data (service and lab values), and entries into PHC ereports The number of continuously enrolled Medi-Cal members years of age with diabetes identified as of June 30, Denominator (Eligible Population) There are two ways to identify members with diabetes: by pharmacy data and by claim/ encounter data. PHC will use both methods to identify the eligible population, but a member only needs to be identified by one method to be included in the measure. PHC may count services that occur during the measurement year or the year prior, i.e. July 1, 2013 June 30, Claim/encounter data: Members who had two face-to-face outpatient visits, observation visits, and/or non-acute inpatient encounters, on different dates with service, with a diagnosis of diabetes, or one face-to-face encounter in an acute inpatient or ED setting, with a diagnosis of diabetes. Pharmacy data: Members who were dispensed insulin or hypoglycemics/antihyperglycemics on an ambulatory basis Codes Used Denominator: Codes to identify diabetes diagnosis: Refer to Table 10D on Code List Codes to identify outpatient visits, observation visits and nonacute inpatient encounters: Refer to Table 10A on Code List Codes to identify acute inpatient encounter: Refer to Table 10E 18

19 on Code List Codes to identify ED visits: Refer to Table 10F on Code List Codes to identify insulin or hypoglycemics/antihyperglycemics: Refer to Table CDC-A on Code List HbA1c Testing Numerator Codes Used An HbA1c test performed during the measurement year i.e. July 1, 2014 June 30, 2015, as identified by claim/encounter or automated laboratory data and entries into ereports. Codes to Identify HbA1c Tests: Refer to Table 10G on Code List LDL-C Screening Numerator Codes Used An LDL-C test performed during the measurement year, i.e. July 1, 2014 June 30, 2015, as identified by claim/encounter or automated laboratory data and entries into ereports. The organization may use a calculated or direct LDL for LDL-C screening Codes to Identify LDL-C Screening: Refer to Table 10H on Code List Retinal Eye Exam Numerator Codes Used An eye screening for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following. A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist or teleoptometry service such as EyePACs) in the measurement year (July 1, 2014 June 30, 2015). OR A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year (July 1, 2013-June 30, 2014) Codes to identify diabetic retinal screening: Refer to Table 10I on Code List billed by an eye care professional during the measurement year (July 1, June 30, 2015). For exams performed with a negative result in the year prior to the measurement year (July 1, June 30, 2014), a result must be available. 19

20 HbA1c Good Control (<9%) Numerator Codes Used The number of diabetics in the eligible population with evidence of the most recent measurement (during the measurement year July 1, 2014 June 30, 2015) at or below the threshold for HbA1c 9.0%. No codes applicable to this measure. Please use ereports to upload data. Blood Pressure <140/90 mmhg The number of diabetics in the eligible population with evidence of the most recent measurement (during the measurement year July 1, 2014 June 30, 2015) below the threshold for BP <140/90 mmhg. Numerator Codes Used Note: If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date as the representative BP. Note that the member is not compliant if the BP is 140/90 mm Hg, if there is no BP reading during the measurement year or if the reading is incomplete (e.g., the systolic or diastolic level is missing.) If there are multiple BPs on the same date of service, use the lowest systolic and lowest diastolic BP on that date as the representative BP. No codes applicable to this measure. Please use ereports to upload data. Nephropathy screening test or evidence of nephropathy The number of diabetics in the eligible population with a nephropathy screening test or evidence of nephropathy, as documented through administrative data. Numerator This includes diabetics who had one of the following during the measurement year: A nephropathy screening test Evidence of treatment for nephropathy or ACE/ARB therapy Evidence of stage 4 chronic kidney disease Evidence of ESRD Evidence of kidney transplant A visit with a nephrologist, as identified by the organization s specialty provider codes (no restriction on the diagnosis or procedure code submitted). A positive urine macroalbumin test 20

21 A urine macroalbumin test where laboratory data indicates a positive result ( trace urine macroalbumin test results are not considered numerator compliant). At least one ACE inhibitor or ARB dispensing event Note: A process flow diagram is included below to help implement this specification. Codes Used Codes to identify a nephropathy screening test: Refer to Table 10N on Code List Codes to identify evidence of treatment for nephropathy or ACE/ARB therapy: Refer to Table 10O on Code List Codes to identify evidence of stage 4 chronic kidney disease: Refer to Table 10P on Code List Codes to identify evidence of ESRD: Refer to Table 10Q on Code List Codes to identify evidence of kidney transplant: Refer to Table 8D on Code List Codes to identify ACE inhibitor or ARB dispensing event: Refer to Table CDC-L on Code List Exclusion (if not a numerator hit) Identify members who meet either of the following criteria: A diagnosis of polycystic ovaries (Refer to Table 10U on Code List), in any setting, any time during the member s history through June 30 of the measurement year. A diagnosis of gestational diabetes or steroid-induced diabetes (Refer to Table 10V on Code List), in any setting, during the measurement year or the year prior to the measurement year (July 1, 2013 June 30, 2015). 21

22 Monitoring for Diabetic Nephropathy STEP 1: Is there documentation of ESRD, chronic or acute renal failure, renal insufficiency, diabetic nephropathy or dialysis or renal transplant? YES STOP! Member is compliant NO STEP 2: Review for a urinalysis test that indicates a protein test was run or a dipstick was performed for gross protein macroalbuminuria in the measurement year. Was the test positive for the measurement year? YES STOP! Member is compliant NO STEP 3: Review for a microalbumin lab test. Was the test done in the measurement year? YES STOP! Member is compliant NO STEP 4: Review for evidence of ACE inhibitor/arb therapy. Is there evidence of therapy in the measurement year? YES STOP! Member is compliant NO STOP! Member is not compliant Page 22

23 V. Fixed Pool Measures II Appropriate Use of Resources 1. Acute Bed Days/1000 Members Description of Measure Total number of patient days in an acute care hospital during the measurement year per 1000 members per year Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Internal Medicine and Family Medicine providers. Full points (10 points): 110% or less than target Half points (5 points): % of target Targets are set using plan-wide mean, adjusted for each site based on age, gender, and Medi-Cal Aid Code mix. Targets to be released in September, OR *Back-up measure: If Bed Days per 1000 threshold /or Readmission rate threshold is not met, providers may earn points based on performance on a back-up measure: Follow up visit within 4 days of discharge (See Specifications below). Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, behavioral health. Acute stays for maternity care and newborn nursery days as identified by revenue code. A three month run-out of data from the measurement period is applied in order to increase the completeness of encounter data. For example, 1st qtr. DOS (Jul-Sep) is not reported until December 31 st. Process for submitting or extracting data PHC will calculate the total number of days using PHC allowable claims and encounter data from acute care hospitals for services provided to the physician s assigned members. An estimate for incurred but not yet paid/processed claims data will be included. o Inpatient Days/1000 = (Total # of days / Total member months) * 12,000 Page 23

24 2. Readmission Rate Description of Measure Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Ratio of acute hospital admissions that are within 30 days of a discharge to total number of inpatient stays. Internal Medicine and Family Medicine providers. Full points (10 points): 110% or less than target Half points (5 points): % of target Targets are set using plan-wide mean, adjusted for each site based on age, gender, and Medi-Cal Aid Code mix. Targets to be released in September, OR *Back-up measure: If Bed Days per 1000 threshold /or Readmission rate threshold is not met, providers may earn points based on performance on a back-up measure: Follow up visit within 4 days of discharge (See Specifications below). Exclusions Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, behavioral health. Acute stays for maternity care and newborn nursery days identified by revenue code. Process for submitting or extracting data A three month run-out of data from the measurement period is applied in order to increase the completeness of encounter data. For example, 1 st qtr. DOS (Jul-Sep) is not reported until December 31st. Using paid claim and capitated encounter data, PHC will identify all acute inpatient stays not subject to the exclusion criteria with a discharge date within the measurement period. The denominator is the count of all continuous stays; the numerator is the count of all 30-day readmissions. For acute-to-acute transfers, the original admission date is the admission date for the entire stay and the transfer s discharge date is the discharge date for the entire stay. Transfers to rehabilitation, sub-acute, or nursing facilities will be counted as discharges. Page 24

25 3. Back-Up Measure: Follow-Up Post Discharge (If target for either Acute Bed Days/1000 or Readmission Rate is not met) Description of Measure Percentage of inpatient stays followed by an office visit or telephonic encounter within 4 calendar days of discharge for acute care hospital admissions incurred during the measurement year. Provider Eligibility (Practice type/specialty) Internal Medicine and Family Medicine providers. Full points (10 points): 50% of discharged members contacted Half points (5 points): 25-49% of discharged members contacted Criteria for meeting the measure Follow-Up Post Discharge can be the back-up measure for either Acute Bed Days/1000 or Readmission Rate, but not both. If a provider exceeds thresholds for both Bed Days/1000 and Readmission Rate, the back-up measure will only be counted for one of the measures. Follow-up visits include both primary care and specialty care visits and excludes follow-up visits to hospitals. A telephonic encounter may count if it is made by the clinician or a licensed staff member who can assess the patient s status, do a medication review, and educate the patient about when to follow up in person. Exclusion Stays at the following facility types: Long Term Care, Intermediate Care, Sub-acute, rehabilitation, behavioral health. Acute stays for maternity care and newborn nursery days identified by revenue code. Process for submitting or extracting data For practice sites that have not met their targets for Bed Days per 1000 or Readmission Rate, PHC will collect preliminary inpatient stay data 30 days after the conclusion of the measurement year (June 30, 2014) and identify stays with no associated office visit claim with a date of service within 4 calendar days of discharge. PHC will distribute to practice sites a list of their patients hospitalizations. Practice sites will return the list to PHC indicating the date a telephonic encounter or office visit occurred if applicable. This returned data will be incorporated into the final follow-up percentage calculation. Data Page 25

26 submitted is subject to audit of patients medical charts. Only one visit or phone call per discharge will be counted. Percentage of discharges with follow up = (Total # of office visits and phone calls)/(total # of discharges) 4. Pharmacy (PCP s prescription only): Generic Prescription and Formulary Compliance Rates Description of Measure The percentage of generic prescription fills compared to total fills (generic + brand) for prescriptions written by professional staff assigned to the primary care site for the site s assigned members only. The percentage of formulary compliant prescription fills compared to total fills (formulary + non-formulary) for prescriptions written by professional staff assigned to the primary care site for the site s assigned members only. Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Internal Medicine, Family Medicine, and Pediatric Medicine providers. Full points (10 points): At least 85% generic rate or 98% formulary compliance rate Half points (5 points): % generic rate or % formulary compliance rate Exclusions Prescriptions for products not classifiable as either brand of generic, such as supply-type items. Drugs dispensed directly by the primary care site. Process for submitting or extracting data A three month run-out of data from the measurement period is applied in order to increase the completeness of encounter data. For example, 1st qtr. DOS (Jul-Sep) is not reported until December 31st. PHC will calculate total number of pharmacy fills using pharmacy claims data from MedImpact (PHC s PBM): Generic Prescription Rate = (generic fills/generic + brand fills) Formulary Compliance Rate = (formulary fills/ formulary + nonformulary fills) Page 26

27 VI. Fixed Pool Measures III Access and Operations 1. Avoidable ED Visits/1000 Members Per Year Description of Measure The average rate of assigned members' ER visits per member per year considered avoidable based on diagnosis code. Refer to Appendix I for DHCS Statewide Avoidable ED Diagnoses Codes. Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Internal Medicine, Family Medicine, and Pediatric Medicine providers. At or below target. Target is adjusted based on PCP s patient mix: Medi-Cal aid code, age, and gender. Targets to be released in September Exclusion N/A A three month run-out of data from the measurement period is applied in order to increase the completeness of encounter data. For example, 1st qtr. DOS (Jul-Sep) is not reported until December 31st. Process for submitting or extracting data PHC will calculate the total eligible non-dual capitated member months after the month-end eligibility reconciliation load from the State. Member months are calculated by counting the total number of members who are eligible at the end of each month. PHC will extract facility or professional claims with a location code indicating an Emergency Department, using allowable PHC claim and encounter data, for services provided to the PCP site s assigned members. Only claims with at least one of the diagnoses codes included in Appendix II below will be included. The presence of at least one diagnosis code not considered avoidable will deem the visit as not avoidable. To calculate Avoidable Emergency Dept. Visits PMPY: Avoidable ED Visits per 1000 = (Avoidable ED visits / Non-Dual Capitated Member Months)*12,000 Page 27

28 2. Practice Open to New PHC Members Description of Measure Practice must remain open to new PHC members for a full quarter to obtain points. 1 point earned for each full quarter practice is open to new patients. Open all year equals 5 points. Partial points (1/2 point) earned for Family Medicine practices open for a full quarter but with age restrictions. Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Exclusion Process for submitting or extracting data Internal Medicine, Family Medicine, and Pediatric Medicine providers. Must remain open to new PHC Medi-Cal Members for full quarter in order to receive points. None Provider Relations department verifies the status of PCP site member acceptance by auditing providers on a monthly/quarterly basis. 3. PCP Office Visits Per Member Per Year Description of Measure The average number of assigned members' visits to PCP per member per year. Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Internal Medicine, Family Medicine, and Pediatric Medicine providers. At or above target. Targets are set using a plan-wide mean adjusted for each site based on age, gender, and Medi-Cal Aid Code mix. Targets to be released in September, Exclusion Process for submitting or extracting data N/A A three month run-out of data from the measurement period is applied in order to increase the completeness of encounter data. For example, 1st qtr. DOS (Jul-Sep) is not reported until December 31st. PHC will calculate the total eligible non-dual capitated member months after the month-end eligibility reconciliation load from the State. Member months are calculated by counting the total number of members who are eligible at the end of each month. Page 28

29 PHC will extract the total number of PHC office visits using allowable PHC claim and encounter data submitted by primary care sites for services provided to assigned members or on-call services provided by another primary care site. An estimate for incurred but not yet paid/processed claims data will be included. To calculate PCP Office Visits PMPY: PCP Office Visits PMPY = (# Office Visits/ Non-Dual Capitated Member Months)*12 4. Operations Measures QIP Measure Summary Refer to Appendix II for submission templates for this measure Submit quarterly data on one Access measure and one Operations measure and a brief explanation: Measure Choices for Access Measure: 3NA Days from scheduling to check in Other metrics monitoring appointment access (must be pre-approved by the QIP team) Measure Choices for Operations Measure: No show rate Provider Continuity Call abandonment Other metrics monitoring visit operations (must be preapproved by the QIP team) AND Please include a paragraph of brief explanation that explains how this data is reviewed and used at your site. Measurement Periods: Quarter 1: July 1, 2014 September 30, 2014 Quarter 2: October 1, 2014 December 31, 2014 Quarter 3: January 1, 2015 March 31, 2015 Quarter 4: April 1, 2015 June 30, 2015 Quarterly data are due the last business day of the following month: Page 29

30 Quarter 1: October 31, 2014 Quarter 2: January 31, 2015 Quarter 3: April 30, 2015 Quarter 4: July 31, 2015 Third Next Available (3NA) Appointment Measure Payment/Thresholds: For each quarter, submission must include total of 2 measures, one from each choice category and a paragraph of brief explanation on how the data is used and monitored internally at your site. If 4 quarters of data are submitted, provider will receive full credit (6 points total). If 3 quarters of data are submitted, provider will receive partial points (4 out of 6 points). If 2 quarters of data are submitted, provider will receive partial points (2 out of 6 points). Description of Measure Provider Eligibility (Practice type/specialty) This is a count measure for each primary care provider who has at least 20 clinical hours per week: 1) Pick a consistent day and time when you will be collecting data on 3NA for the QIP year. This should be a day during the last full week of each Quarter. 2) If the provider has clinic that day, the day is designated Day Zero. 3) If the provider does not have clinic that day, move to the next date with a scheduled clinic. This day is designated Day Zero. 4) Count the number of calendar days between the date of Day Zero and the date of the third next available appointment, including Saturdays, Sundays, holidays, and days when the provider has time off. For example, if Day Zero is Tuesday and the third next available appointment is the same day, Tuesday, then the day-count would be zero. If the third next available appointment is the next day, Wednesday, then the day-count would be one. If the third next available appointment is on Monday the following week, then the day-count would be six. 5) For each provider, report their 3NA using the template provided by PHC. All Primary Care Providers who have at least 20 clinical hours per week. Clinicians who have less than 20 clinical hours per week PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 30

31 Exclusions Process for submitting or extracting data Appointments saved for urgent care, after-hours care, and specialty clinics Submit data quarterly using the template provided (See Appendix II for reporting templates) per the measurement timeline described in the QIP measure summary above. Days from Scheduling to Check in Description of Measure Provider Eligibility (Practice type/specialty) Description of Measure This data is a measure of the average time between when a patient made their appointment to when they were seen (or noshow). This data will show the average experience of all patients who came in the previous month. All Primary Care Providers who have at least 20 clinical hours per week. Only include appointment that were kept or resulted in a no show. This is a measure for each primary care provider who has at least 20 clinical hours per week: 1) Begin with a list of all Kept and No show appointments for each provider for the one full month during the reporting quarter (include the rendering provider, the date it was scheduled and the actual appointment date (i.e. date of check in) 2) Subtotal each provider s appointments by averaging the date scheduled and the actual appointment date or date of check in. 3) Then calculate the average days between scheduling to check in by applying a simple formula (Average of Appointment dates (i.e. date of check in) Average of date scheduled = Average days from scheduling to checkin) Exclusions Clinicians who have less than 20 clinical hours per week Appointments cancelled or rescheduled Process for submitting or extracting data Submit data quarterly using the template (See Appendix II for reporting templates) per the measurement timeline described in the QIP measure summary above. Call Abandonment Rate Description of Measure Call Abandonment Rate is a common surrogate measure for call response time. It measures the number of incoming phone calls where the caller hangs up before talking to a person. It is higher when call response time is long, and shorter when call response PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 31

32 time is short. Data Sources Provider Eligibility (Practice type/specialty) Denominator Numerator Process for submitting or extracting data Telephone management system. All Primary Care Providers who have at least 20 clinical hours per week. Total number of incoming phone calls during business hours, as measured by phone management system. Measured for all incoming phone calls that occur during a week during the reporting quarter. Number of incoming phone calls that did not stay on hold long enough for their call to be answered by a clinic staff person. Submit data quarterly using the template (See Appendix II for reporting templates) per the measurement timelines described in the QIP measure summary above. Provider or Team Continuity Measure Description of Measure Provider Eligibility (Practice type/specialty) Denominator (Eligible Population) Numerator Process for submitting or extracting data This measure tracks your practice site s efforts to encourage patients to see their own provider to whom they are empanelled or a provider that is part of their care team/shared panel. Report continuity by provider for those with at least 20 clinical hours per week. All Primary Care Providers who have at least 20 clinical hours per week and have an assigned panel of patients. Total number of visits by a provider s or his/her care team s panel of patients in the last month of the reporting quarter. Of the total number of visits in the denominator, the number of these visits where the patient saw the provider or a member of the care team. Care Team is defined as sharing a panel of patients. Submit data quarterly using the template (See Appendix II for reporting templates) per the measurement timeline described in the QIP measure summary above. No Show Rate Description of Measure Provider Eligibility (Practice type/specialty) Denominator This measure is to track the no-show rate of appointments made by site All Primary Care Providers who have at least 20 clinical hours per week. Total number of pre-scheduled appointments for a provider PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 32

33 (Eligible Population) Numerator Process for submitting or extracting data within the last full month of the reporting quarter. Exclude walkins (same day appointments DO NOT count as a walk-in and can be included in your denominator). Total number of appointments that were not kept by patients in the last month of the reporting quarter without the patient calling to cancel or reschedule the appointment. Submit data quarterly using the template (See Appendix II for reporting templates) per the measurement timelines described in the QIP measure summary above. Other Metrics If your site is using a different methodology for monitoring appointments access or visit operations and would like this to count towards the QIP operations measure, please submit a brief explanation of the methodology to QIP@partnershiphp.org for approval no later than September 30, The same quarterly deadlines apply. VII. Fixed Pool Measures IV Patient Experience Refer to Appendix III for submission templates for this measure This measure aims to improve the patient experience. Providers can complete one of the following options to earn points: Survey Option Training Option PCHM patient experience criteria Description of Measure Survey Option This option allows providers to fulfill the requirements by soliciting feedback from patients and implementing changing to improve the patient experience. Refer to the Criteria for Meeting the Measure section below for detailed specifications. Training Option This option allows providers to fulfill the requirements by attending training on improving the patient experience and applying lessons learned at their site. A patient feedback component must be included. Refer to the Criteria for Meeting the Measure section below for detailed specifications PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 33

34 PCMH Patient Experience Criteria This option allows providers to fulfill the requirements by using the PCMH patient experience criteria outlined by accreditation organizations such as NCQA, AAAHC or JCAHO. Refer to the Criteria for Meeting the Measure section below for detailed specifications. Provider Eligibility (Practice type/specialty) Internal Medicine, Family Medicine, and Pediatric Medicine providers. Must be a contracted capitated provider for the entire year to participate in the QIP. Survey Option There are two parts to this option. Please follow the steps below and fill out the submission templates (Appendix IIIA.1) accordingly. Criteria for meeting the measure Part I: 1) Implement a survey which must include at least two questions regarding access to care (questions do not need to come from the Consumer Assessment of Healthcare Providers and System survey, i.e. CAHPS, although we encourage using CAHPS or another well vetted survey) 2) Analyze baseline data, select measures from survey to target for improvement, identify change(s) to implement, and report these on the Survey Option Part I submission template Part II: 3) Implement change(s) for improvement 4) Re-measure patient experience using the same survey at least once after implementing changes 5) Report changes implemented and re-measurement survey results on the Survey Option Part II submission template The baseline survey should be completed between January 1, 2014 and December 31, 2014, prior to the submission of Part I. The re-measurement survey should be completed between January 1, 2015 and June 1, A minimum sample of 100 completed is required per site for each measurement cycle. Sample can include non-partnership patients. If your site participated in this measure in the QIP Year, your remeasurement survey result can be used as Part I submission for Note: Beginning the QIP Year, providers can fulfill PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 34

35 the Patient Experience Survey Option requirements by using other ways to collect patient feedback including patient advisory groups. To ensure patient representation, it is required that the total count of patient feedback must be at least 100; for example, 10 patients meeting 10 times for an advisory council would qualify. If your site does not meet this requirement, please submit a description of how your site ensures that your patient feedback is representative of your patient population. If your site is collecting patient feedback outside of a bi-annual survey, please submit the completed template in Appendix IIIA.2 to QIP@partnershiphp.org for approval, no later than January 31, Appendix IIIA.2 would qualify as a Part I submission if approved. You may use the Survey Option Part II submission template to fulfill the Part II requirements, summarizing progress, successes, and lessons learned. Due date for Part I submission: January 31, 2015 Due date for Part II submission: July 31, 2015 OR Training Option There are two parts to this option. Please follow the steps below and fill out the submission templates (Appendix IIIB) accordingly. Part I: 1) Participate in a PHC-approved program or training aimed at improving patient experience in a core CAHPS domain (provider-patient communications, office staff-patient communication, access to care, or care coordination). At least 2 staff members are involved in the training for clinics, 2 staff members for solo providers, and 3 providers for medical groups; training should total at least 4 hours per staff member/provider involved. If uncertain whether a training would qualify, you may contact qip@partnershiphp.org for approval prior to the training 2) Draft an improvement plan, which includes measures, goals, planned activities, and an evaluation strategy that incorporates patient feedback. Report these on the Training Option Part I submission template PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 35

36 Part II: 3) Complete the improvement plan and collect patient feedback 4) Submit a progress report using Training Option Part II submission template to show how improvements were measured The training should take place any time between January 1, 2014 and December 31, The improvement plan should be implemented and patient feedback collected between January 1, 2015 and June 1, Due Date for Part I submission: January 31, 2015 Due Date for Part II submission: July 31, 2015 OR PCMH Patient Experience Criteria Sites can fulfill this measure by using the PCMH patient experience criteria outlined by accreditation organizations such as NCQA, AAAHC or JCAHO. For using PCMH patient experience criteria to count for this measure, please submit the following by July 31, 2015: PCMH documentation template in Appendix V A detailed description of the methodology used for patient experience as outlined by the accreditation body Proof of submission to the accreditation body, in the form of a report with summarized patient feedback Exclusions Process for submitting or extracting data None Submit the Patient Experience Submission Template (Appendix III A-C) via fax or to QIP@partnershiphp.org. VIII. Unit of Service Measures 1. Advance Care Planning Description of Measure Refer to Appendix IV for submission template for this measure Providers will receive payments for each eligible advance care planning attestation submitted ($100 per form) PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 36

37 Provider Eligibility (Practice type/specialty) Clinicians (including doctors, nurses, physician assistants) at all contracted provider sites, including specialists. Submit an Attestation Form (Appendix IVA) or medical record evidence of the Advance Care Planning conversation. Only one submission per patient per fiscal year. Criteria for meeting the measure If submitting medical record, you may refer to Appendix IVB for components to be documented. The minimum would be documentation that an advance care planning conversation took place on the date of service being billed, with a summary of the outcome. In terms of ideal components of an advance care planning discussion to document in the chart, they are: Conversation about patient goals, general preferences around end of life, and prognosis (if appropriate) Documentation of conversation with family or recommendation for patient to talk with family Status of the Advance Directive: discussed, given to patient, completed, copy in chart, patient refused Summary of patient wishes, whether from conversation or from Advance Directive. Some options: Full treatment, comfort care, hospice, DNR, DNI, other (tube feeds and blood transfusion and transfer to hospital are common items) If POLST appropriate, some status options: discussed, given to patient, completed, copy in chart, patient refused Plan for next conversation. Providers are encouraged to have ACP discussions with all adult patients, but credit for this measure is only given for patients who are 65 or older and/or have major life-limiting diseases. Examples include but are not limited to: advanced cardiac disease (end-stage CHF, severe CAD, CM [LVEF <25%]); advanced COPD; amputation due to vascular disease; cancer (metastatic/recurrent); dementia; diabetes mellitus with creatinine clearance under 50, or an amputation; dnd stage renal disease; generalized debility and decreased functioning; long term resident of SNF; stroke (w/at least 50% decreased function). Exclusions Members below 18 of age Process for submitting or Submit completed Attestations or medical record evidence PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 37

38 extracting data via fax or to To receive reimbursement, documentation must be submitted for each completed conversation. Attestations must be submitted to Partnership no later than July 31, Each provider site can submit up to 100 attestations for the measurement year. All attestations will be reviewed by PHC. Payments will be made on a quarterly basis, included in the year-end payment. 2. Access/Extended Office Hours Description of Measure PCP sites receive quarterly payments, equal to 10% of capitation, if the site holds extended office hours for a full quarter. PCP sites and PCP sites that are part of a large organization and within a 5-mile radius of each other are eligible for the increased cap. Provider Eligibility (Practice type/specialty) Example 1: A parent organization has two sites within five miles of each other (Site A and Site B). Site A meets the criterion for holding extended office hours. Site B does not hold extended office hours. Since Site B is within a 5-mile radius, patients who are seen at Site B can easily access Site A during the extended hours of service. Both Site A and Site B are eligible for the payment. Example 2: Site A and Site B are located 15 miles apart. Only Site A holds extended office hours and meets the criterion. In this scenario, Site A is eligible for the payment but Site B is not eligible for the payment. Criteria for meeting the measure PCP site must be open an additional 8 hours per week or more, beyond the normal business hours, defined as Monday-Friday, 8:00 a.m. to 5:00 p.m., for the entire quarter. Exclusions No points awarded if, during a quarter, the practice site no longer offers extended office hours or reduces the hours and no longer meets the 8-hour minimum. Process for submitting or extracting data Provider Relations department verifies extended office hours by secret shopper audit. No submission is required for this measure PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 38

39 Extended hours exception Under this exception, any PHC site with less than 2000 members and more than 30- minute drive to the nearest ED can qualify for the incentive payment. They would need to demonstrate the following: Have on-call arrangements available where by the on-call physicians come to the office to see urgent problems (arrangement to be submitted in writing annually to the PR representative of your county, including what types of urgent issues will be seen in the office) after hours. Deadline to submit arrangement is December 31 st, Demonstrate the use of arrangement with at least three PHC members seen in the office after hours per quarter, to be submitted quarterly by the site to their Provider Relations representative of your county. Deadlines are as follows: o Q1 & Q2: Dec 31 st, 2014 o Q3: March 31 st, 2015 o Q4: June 30 th, 2015 Please note this measure is subject to an audit by the Provider Relations department. This exception is retroactive to 7/1/ PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 39

40 3. Patient-Centered Medical Home Recognition Refer to Appendix V for submission template for this measure Description of Measure One-time payment for achieving Level 1 ($2,000), Level 2 ($3,000), or Level 3 ($3,500) recognition from NCQA, or equivalent from AAAHC or JCAHO Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Primary care provider sites with a minimum of 50 assigned Partnership members Sites must receive accreditation within the measurement year (i.e. July 1, 2014 June 30, 2015). Documentation of PCMH recognition from NCQA, AAAHC, or JCAHO must be faxed or ed to QIP@partnershiphp.org by July 31, Payments for each level are not aggregate. Exclusions Process for submitting or extracting data Primary care provider sites with fewer than 50 assigned Partnership members. You may refer to Appendix V for the documentation template, which can be faxed or ed to QIP@partnershiphp.org by July 31, Peer-Led Self Management Support Groups Refer to Appendix VI for submission template for this measure Description of Measure Payment for starting or continuing a peer-run self-management support group at a contracted primary care provider site ($1,000 per group). Provider Eligibility (Practice type/specialty) Criteria for meeting the measure Primary care provider sites with a minimum of 50 assigned Partnership members Qualifying Peer Groups: Group must meet at least 4 times in the period Group can serve both PHC and non-phc members, but PHC QUALITY IMPROVEMENT PROGRAM Last updated 12/03/2014 Page 40

41 must include at least 16 PHC total member visits per year (For example, if there are 4 PHC members in the group and the group meets for 4 sessions, the group will meet this criterion) For group visits to qualify there must be a peerfacilitation component and a self-management component The groups may be general, for patients with a variety of conditions, or focused on specific diseases or conditions, such as: Diabetes, Rheumatoid Arthritis, Chronic Pain, Hepatitis C, Cancer, Congestive Heart Failure, COPD, Asthma, Depression, Anxiety/Stress, Substance use, Pregnancy Exclusions Maximum number of groups eligible for payment: 2 per credentialed Partnership provider Up to a maximum of 10 per site and 20 per corporate entity Primary care provider sites with fewer than 50 assigned Partnership members Documentation for each group: (Appendix VI) Process for submitting or extracting data 1. Name of group 2. Name and background information/training of group facilitator 3. Site where group visits took place 4. Narrative on the group process that includes: location and frequency of the group meetings 5. List of major topics/themes discussed at each meeting 6. A description of the way that self-management support is built into the groups 7. An assessment of successes and opportunities for improvement of the group 8. Documentation of minimum of 16 PHC patient visits, via list of attendees with DOB and dates of meetings Documentation will be reviewed and approved by the CMO or physician designee. Proposed groups may submit elements 1-7 above prospectively for review and feedback at any time in the year, before groups start, to ensure program will be eligible for bonus. Examples of the curriculum and evidence base for this approach Page 40

42 can be found at: All documentation must be submitted on the Peer-led Self Management Support Group template (Appendix VI) by July 31, 2015, and can be faxed or ed to 5. Utilization of California Utilization Registry (CAIR) Description of Measure Refer to Appendix VIII for submission templates for this measure Providers will receive payments for demonstrating relative improvement in utilization of CAIR or for meeting the specified threshold. Provider Eligibility (Practice type/specialty) All contracted providers with 20 or more patients ages Submit Provider ID assigned by CAIR and registration date using the submission template (Appendix VIII) by Sept 30, 2014 Actively utilize CAIR; utilization during the measurement period is calculated using this formula: # of shots entered for assigned members aged 0 13 Total number of assigned members aged 0 13 Criteria for meeting the measure Providers may earn financial incentive for showing improvement in CAIR usage from last year or meeting the measure threshold. Each site s maximum potential earning for this measure varies, depending on the size of the practice. The maximum potential earning is the sum of the base rate and Per Member Per Year (PMPY) rate Practice Size Small (20-50 members ages 0-13) Medium ( members ages 0-13) Large (600+ members ages 0-13) Base Rate PMPY Rate Example (Potential Earning) $1000 $2.0 A site with 30 members: $1000+$2*30 members = $1060 $1500 $1.5 A site with 100 members: $1500+$1.5*100 members = $1650 $2000 $1.2 A site with 30 members: $2000+$2*700 members = $3400 Page 41

43 Performance Threshold Below please find the threshold developed based on sites that participated in this measure in Performance Threshold (full earnings): 1.87 (per assigned member per year) OR Improvement Thresholds 25 th percentile (partial earnings): 59.1% 50 th percentile (partial earnings): 94.4% 75 th percentile (full earnings): 178.5% Payment for sites showing improvement will be graded on a scale (percentiles based on PHC performance): <25 th percentile = 25% of maximum potential earning 26 th 50 th percentile = 50% of maximum potential earning 51 st 75 th percentile = 75% of maximum potential earning >75 th percentile = 100% of maximum potential earning Exclusion Process for submitting or extracting data Providers with 20 or fewer patients who are 0-13 years old Submit Provider ID assigned by CAIR and registration date using the submission template (Appendix VIII) by Sept 30, PHC will receive activity reports from CAIR using each site s Provider ID to measure utilization. Page 42

44 Appendix I: DHCS Statewide Avoidable Emergency Department Diagnoses Codes ICD-9 Code Medi-Cal Avoidable ICD 9 Diagnosis Codes for ER Collaborative No-Decimal Dermatophytosis of Body 1105 Candidiasis Of mouth 1120 Candidiasis 112 CandidalVulvovaginitis 1121 Candidias Urogenital NEC 1122 Cutaneous Candidiasis 1123 Candidiasis - Other specified sites 1128 Candidal Otitis External Candidal Esophagitis Candidal Enteritis Candidiasis Site NEC ICD-9 Code Medi-Cal Avoidable ICD 9 Diagnosis Codes for ER Collaborative No-Decimal Candidiasis Site NOS 1129 Acariasis 133 Scabies 1330 Acariasis NEC 1338 Acariasis NOS 1339 Disorders of Conjunctiva 372 Acute Conjunctivitis 3720 Acute Conjunctivitis unspecified Serous Conjunctivitis Ac Follic Conjunctivitis Pseudomemb Conjunctivitis Ac Atopic Conjunctivitis Chronic conjunctivitis, unspecified Chronic Conjunctivitis 3721 SimplChr Conjunctivitis ChrFollic Conjunctivitis Vernal Conjunctivitis ChrAllrgConjunctivis NEC Parasitic Conjunctivitis Blepharoconjunctivitis 3722 Blepharoconjunctivitis, unspecified Angular Blepharoconjunct Contact Blepharoconjunct Page 43

45 Other and unspecified conjunctivitis 3723 Conjunctivitis, unspecified Rosacea Conjunctivitis Conjunctivitis NEC Other mucopurulent conjunctivitis Xeroderma of Eyelid Suppurative and unspecified otitis media 382 Acute suppurative otitis media without spontaneous rupture of ear drum Acute suppurative otitis media 3820 Ac Supp Om w Drum Rupt ChrTubotympanSuppur Om 3821 ChrAtticoantral Sup Om 3822 Chr Sup Otitis Media NOS 3823 Suppur Otitis Media NOS 3824 Otitis Media NOS 3829 Ac Mastoiditis-compl NEC Acute nasopharyngitis 460 Acute pharyngitis 462 Acute laryngopharyngitis 4650 Acute upper respiratory infections of multiple or unspecified sites 465 Acute Uri Mult Sites NEC 4658 ICD-9 Code Medi-Cal Avoidable ICD 9 Diagnosis Codes for ER Collaborative No-Decimal Acute Uri NOS 4659 Acute Bronchitis 4660 Acute bronchitis and bronchiolitis 466 Chronic rhinitis 4720 Chronic pharyngitis and nasopharyngitis 472 Chronic Pharyngitis 4721 Chronic Nasopharyngitis 4722 Chronic Maxillary sinusitis 4730 Chronic sinusitis 473 Chr Frontal Sinusitis 4731 ChrEthmoidal Sinusitis 4732 ChrSphenoidal Sinusitis 4733 Chronic Sinusitis NEC 4738 Chronic Sinusitis NOS 4739 Chronic tonsillitis and adenoiditis 4740 Chronic tonsillitis Chronic disease of tonsils and adenoids 474 Chronic Adenoiditis Page 44

46 Chronic Tonsils&adenoids Hypertrophy of tonsils and adenoids 4741 Tonsils with adenoids Hypertrophy Tonsils Hypertrophy Adenoids Adenoid Vegetations 4742 Chr T & A Dis NEC 4748 Chr T & A Dis NOS 4749 Cystitis 595 Acute cystitis 5950 ChrInterstit Cystitis 5951 Chronic Cystitis NEC 5952 Trigonitis 5953 Cystitis in Oth Dis 5954 Other specified types of cystitis 5958 Cystitis Cystica Irradiation Cystitis Cystitis NEC Cystitis NOS 5959 Urinary tract infection, site not specified 5990 Inflammatory disease of cervix, vagina, vulva 616 Cervicitis and endocervicitis 6160 Vaginitis and vulvovaginitis 6161 Female Infertility NEC 6288 Pruritic Conditions NEC 6988 Pruritic Disorder NOS 6989 ICD-9 Code Medi-Cal Avoidable ICD 9 Diagnosis Codes for ER Collaborative No-Decimal Prickly Heat 7051 Lumbago 7242 Backache NOS 7245 Disorders of coccyx 7247 Other Back Symptoms 7248 Headache 7840 Follow up examination V67 Surgery Follow-up V670 Following surgery, unspecified V6700 Follow up vaginal pap smear V6701 Following other surgery V6709 Radiotherapy Follow-up V671 Chemotherapy Follow-up V672 Page 45

47 Psychiatric Follow-up Fu Exam Treatd Healed Fx Following other treatment High-risk Rx NEC Exam Follow-up Exam NEC Comb Treatment Follow-up Follow-up Exam NOS Encounters for administrative purposes Issue Medical Certificat Disability examination Other issue of medical certificates Issue Repeat Prescript Request Expert Evidence Other specified administrative purposes Referral-no Exam/treat Other specified administrative purposes AdministrtveEncount NOS General medical examination Routine Medical Exam At Health facility Psych Exam-authority Req Gen Psychiatric Exam NEC Med Exam NEC-admin Purpose Exam-medicolegal Reasons Health Exam-group Survey Health Exam-pop Survey (population) Exam-clinical Research General Medical Exam NEC General Medical Exam NOS Special investigations and examinations Eye & Vision Examination Ear & Hearing Exam Medi-Cal Avoidable ICD 9 Diagnosis Codes for ER Collaborative Encounter for hearing examination following failed hearing screening Encounter for hearing conservation and treatment Other examinations of ears and hearing Dental Examination Gynecologic Examination Routine gynecological examination Encounter for papanicolaou cervical smear to confirm findings of recent normal pap smear following initial abnormal pap smear V673 V674 V675 V6751 V6759 V676 V679 V68 V680 V6801 V6809 V681 V682 V688 V6881 V6889 V689 V70 V700 V701 V702 V703 V704 V705 V706 V707 V708 V709 V72 V720 V721 ICD-9 Code No-Decimal V7211 V7212 V7219 V722 V723 V7231 V7232 Page 46

48 Preg Exam-pregUnconfirm Pregnancy examination or test, pregnancy unconfirmed Pregnancy examination or test, negative result Pregnancy examination or test, positive result Radiological Exam NEC Laboratory Examination Skin/sensitization Tests Examination NEC PreopCardiovsclr Exam Preop Respiratory Exam OthSpcfPreop Exam Preop Exam Unspcf Oth Specified Exam Encounter blood typing Examination NOS Notes: NOS - Not Otherwise Specified NEC - Not Elsewhere Classified V724 V7240 V7241 V7242 V725 V726 V727 V728 V7281 V7282 V7283 V7284 V7285 V7286 V729 Page 47

49 Appendix II: Submission Templates for 3NA and Operations Measures 4665 Business Center Dr. Fairfield, CA Template A Quality Improvement Program Operations Measures Reporting Template: Third Next Available Appointment (3NA) Submit quarterly data either using this template via at QIP@partnershiphp.org or fax at (707) Measurement Period Due Date Quarter 1: July 1, 2014-September 30, 2014 October 31, 2014 Quarter 2: October 1, December 31, 2014 January 31, 2015 Quarter 3: January 1, March 31, 2015 April 30, 2015 Quarter 4: April 1, June 30, 2015 July 31, 2015 Provider Site: Name of Staff: Date of Submission: Please describe how this data is used internally at your site: Provider 1 name: Provider 2 name: Provider 3 name: Date of Day Zero (the date of the first clinic): Date and time of third open appointment: Third Next Available Appointment (Days): Date of Day Zero (the date of the first clinic): Date and time of third open appointment: Third Next Available Appointment (Days): Date of Day Zero (the date of the first clinic): Date and time of third open appointment: Third Next Available Appointment (Days): Add additional rows as necessary. Average 3NA: Page 48

50 4665 Business Center Dr. Fairfield, CA Template B Quality Improvement Program Operations Measures Reporting Template: Days from Scheduling to Check In Provider Site:_ Name of Staff: Date of Submission: Please describe how this data is used internally at your site: Rendering Provider Provider 1 name: Average Date Scheduled Average Date of Check In Average Days between Scheduling and Check In Provider 2 name: Provider 3 name: Provider 4 name: Add additional rows as necessary. Page 50

51 4665 Business Center Dr. Fairfield, CA Template C Quality Improvement Program Operations Measures Reporting Template: Provider/Team Continuity Provider Site: Name of Staff: Date of Submission: Please describe how this data is used internally at your site: Name of Provider/Care Team 1: Denominator (Total number of pre scheduled appointments for a provider visit within the last full month of the reporting quarter. Exclude walk ins; same day appointments DO NOT count as a walk in and can be included in your denominator): Numerator (Of the total number of visits in the denominator, the number of these visits where their patients visits saw them or a member of their care team): Percent of visits to assigned provider/care team (Num/Denom*100): Name of Provider/Care Team 2: Denominator: Numerator: Percent of visits to assigned provider/care team: Add additional rows as necessary. Page 51

52 4665 Business Center Dr. Fairfield, CA Template D Quality Improvement Program Operations Measures Reporting Template: No Show Rate Provider Site: Name of Staff: Date of Submission: Please describe how this data is used internally at your site: Denominator (Total number of pre scheduled appointments for a provider visit within the last full month of the reporting quarter. Exclude walk ins; same day appointments DO NOT count as a walk in and can be included in your denominator): Numerator (Total number of appointments that were not kept by patients in the last month of the reporting quarter): No Show Rate (Num/Denom*100): Page 52

53 4665 Business Center Dr. Fairfield, CA Template E Quality Improvement Program Operations Measures Reporting Template: Call Abandonment Rate Provider Site: Name of Staff: Date of Submission: Please describe how this data is used internally at your site: Denominator (Total number of incoming phone calls during business hours, as measured by phone management system. Measured for all incoming phone calls that occur during a week of the reporting quarter): Numerator (Number of incoming phone calls that did not stay on hold long enough for their call to be answered by a clinic staff person: Call Abandonment Rate (Num/Denom*100): Page 53

54 Appendix IIIA.1: Patient Experience Survey Option 4665 Business Center Dr. Fairfield, CA Quality Improvement Program Patient Experience Survey Option Submission Template and Example Due date for Part I submission: January 31, 2015 Due date for Part II submission: July 31, 2015 Below you will find the submission template and example for the Survey Option. This is a guide for your submission, and if you decide to not use it, points will still be rewarded as long as all areas are addressed in your submission. For detailed instructions, please refer to the Measure Specifications. Page 54

55 Survey Option: Part I Submission Template (Due January 31, 2015) 1. Attach a copy of the survey instrument administered (Survey must include at least two questions on access to care. For examples of access questions, please refer to the CAHPS questions listed on the last page of this document) 2. Provide descriptions for the following: A. Population surveyed B. How the survey was administered (via phone, point of care, web, mail, etc.) C. The time period for when the surveys were administered D. Total number of surveys distributed E. Total number of survey responses collected/received F. Response Rate 3. Based on the results from your survey, what specific measure(s) have you selected to improve? 4. For each measure or composite of questions selected for improvement, what is your specific objective? 5. For the measures selected for improvement, describe the specific changes/interventions/actions you believe will improve your performance. Submitted by (Name & Title) on (Date) Page 55

56 Survey Option: Part II Submission Template (Due July 31, 2015) 1. Describe specific changes/actions/interventions you implemented to improve your performance in the measures you selected in Part I. Include specific timelines, who implemented the changes, and how changes were implemented. 2. Provide descriptions for the following for your re-measurement period: A. Population surveyed B. How the survey was administered (via phone, point of care, web, mail, etc.) C. The time period for when the surveys were administered D. Total number of surveys distributed E. Total number of survey responses collected/received F. Response Rate 3. Comparing your re-measurement period (s) to baseline and other sources of data, did you observe improvements in the measures targeted? Did you meet your stated objectives in your improvement plan? Please describe changes in performance and which changes you believe contributed to improvements observed. 4. What challenges did you experience and how did you overcome these? Submitted by (Name & Title) on (Date) Page 56

57 EXAMPLE Survey Option: Part I Submission 1. Attach a copy of the survey instrument administered: See below Dear Patient, We want every patient to have a positive experience every time they come to our clinic. We would like to know how you think we are doing. Please take a few minutes to fill out this survey and drop it off at the comment box on your way out. Thank you so much. Please rank the following statements based on your visit today: 1. The non-clinical staff at this office (including receptionists and clerks) were as helpful as I thought they should be Strongly Agree Agree Disagree Strongly Disagree 2. The non-clinical staff at this office were friendly to me 3. The non-clinical staff at this office addressed my concerns adequately. 4. I was given more than one option in terms of how and when to schedule the next appointment. 5. I felt comfortable asking the non-clinical staff questions. 6. When I called for an appointment, the wait time was reasonable. 7. I was given an appointment when I wanted it. 8. I feel confident that my personal information is kept private. 9. Charges were explained to me clearly. Page 57

58 2. Provide descriptions for the following a. Population surveyed b. How was the survey administered? (via phone, point of care, web, mail, etc.) c. What was the time period for when the surveys were administered d. Total number of surveys distributed e. Total number of survey responses collected/received f. Response Rate Between September 1, 2014 and November 1, 2014, our site mailed a survey to all our adult patients who came in for an office visit between July 1 and October 1, The first mailing was sent on September 1, followed by a second mailing on October surveys were mailed and 250 surveys were returned; yielding a 50% response rate 3. Based on the results from your survey, what specific measures in the survey have you selected to improve? I was given an appointment when I wanted it 4. For each selected measure or composite of measures selected for improvement, what is your specific objective? 80% of patients surveyed will select strongly agree. 5. For the measures selected for improvement, describe the specific changes/interventions/actions you believe will improve your performance. To improve the appointment wait times, our clinic will test adding same day appointments and extending visit intervals for well controlled patients with chronic conditions to improve the time it takes to get a routine appointment. Submitted by Elizabeth Jones (QI Director) (Name & Title) on Dec 10, 2014 (Date) Page 58

59 EXAMPLE Survey Option: Part II Submission 1. Describe specific changes/actions/interventions you implemented to improve your performance in the measure(s) you selected in Part I. Include specific timelines and who implemented the changes and how changes were implemented. We had a consultant train our site over a two-month period (January-February 2015) on how to add same day appointments. The trainings included improvements to our scheduling system such as reducing the number of appointment types from 50 to 4. We developed and implemented scripts for the front desk staff so that they can educate our patients on the change in scheduling. We also collected data daily on our patient demand, supply and activity. This helped us determine where we can shift appointment slots based on our demand and corresponding supply. We also tried extending visit intervals for our well controlled patients with diabetes. Rather than bringing them in every 3 months, we now bring them in every 6 months. 2. Provide descriptions for the following for your re-measurement period: a. Population surveyed: b. How the survey was administered (via phone, point of care, web, mail, etc.) c. The time period for when the surveys were administered d. Total number of surveys distributed: e. Total number of survey responses collected/received: f. Response Rate: Between April 15, 2015 and May 1, 2015, our site mailed a survey to all our adult patients who came in for an office visit between March 1 and April 1. We were only able to do one re-measurement cycle. The mailing was sent on April 15. Two hundred surveys were mailed and 110 surveys were returned; yielding a 55% response rate. 3. Comparing your re-measurement period (s) to baseline and other sources of data, did you observe improvements in the measures targeted? Did you meet your stated objectives in your improvement plan? Please describe changes in performance and which changes you believe contributed to improvements observed. In the question, I was given an appointment when I wanted it, we exceeded our goal in that 83% of our patients reported Strongly agree, compared to our goal of 80% and our baseline score of 72%. Page 59

60 4. What challenges did you experience and how did you overcome these? We learned a lot while facing many challenges. The most important lesson was that patients were very skeptical about getting appointments same day. It took a lot of educating our patients on this change. There was also a lot of resistance from some of the providers as they were concerned that the no-show rate would increase. We started collecting no show rate data to monitor this in combination with appointment availability (3NA). We encountered challenges with reducing the number of appointment types. We had to re-train our scheduling staff and in the end, they preferred this as it was simple and they were more efficient with scheduling. Submitted by Elizabeth Jones (QI Director) (Name & Title) on July 10, 2015_ (Date) Page 60

61 CAHPS QUESTIONS NOTE: Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask consumers to evaluate their patient experience. You are not required to include all or any of these questions in your survey. Nonetheless, they serve as a good reference when designing a tool to assess the patient experience. Follow this link to access and download: Full length CAHPS surveys and resources 1. In the last 12 months, did you phone this provider s office to get an appointment for an illness, injury or condition that needed care right away? Yes No If No, go to #3 2. In the last 12 months, when you phoned 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? (REQUIRED) Never Sometimes Usually Always 3. In the last 12 months, did you make any appointments for a check-up or routine care with this provider? Yes No If No, go to #5 4. In the last 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed? (REQUIRED) Never Sometimes Usually Always 5. In the last 12 months, did you phone this provider s office with a medical question during regular office hours? Yes No If No, go to #7 Page 61

62 6. In the last 12 months, when you phoned this provider s office during regular office hours, how often did you get an answer to your medical question that same day? (REQUIRED) Never Sometimes Usually Always 7. In the last 12 months, did you phone this provider s office with a medical question after regular office hours? Yes No If No, go to #9 8. In the last 12 months, when you phoned this provider s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? (REQUIRED) Never Sometimes Usually Always 9. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this provider within 15 minutes of your appointment time? (REQUIRED) Never Sometimes Usually Always 10. Would you recommend this provider to your family and friends? (REQUIRED) Yes, definitely Yes, somewhat No Page 62

63 Appendix IIIA.2: Patient Experience Survey Option (if patient feedback is collected in ways other than a bi-annual survey) 4665 Business Center Dr. Fairfield, CA If you choose the optional Patient Feedback measure for the Patient Experience Survey Option, approval from PHC must be received. The following template must be submitted no later than Jan 31, 2015 via at qip@partnershiphp.org or via fax at , in place of the Survey Option Part I submission. You may use the Survey Option Part II submission template to fulfill the Part II requirements, summarizing progress, successes, and lessons learned. Please answer the following questions: A. Describe the methodology used for patient feedback at your site? B. How many PHC patients participate in your methodology? What are their demographics (e.g. sex, age, gender, race etc.)? C. Describe the topics discussed or surveyed for gaining patient feedback? D. What methodology is being used for choosing the topics and/or questions to gain patient feedback? E. Based on the results from your survey, what specific measure(s) have you selected to improve? F. For each measure or composite of questions selected for improvement, what is your specific objective? G. For the measures selected for improvement, describe the specific changes/interventions/actions you believe will improve your performance? Submitted by (Name & Title) on (Date) Page 63

64 EXAMPLE Patient Feedback: Template Please answer the following questions: A. Describe the methodology used for patient feedback at your site? We have a patient & family advisory council established at our site which acts as a voice for improvement and is a conduit to bring issues of patients and families to the health centers attention. Council is a group of volunteer patients, family members of patients, and clinicians and administrators who meet monthly with the goal of improving the Health centers programs and overall quality and safety. B. How many PHC patients participate in your methodology? What are their demographics and payer mix (e.g. age, gender, race, insurance etc.)? Council members were selected based on their backgrounds, experiences and strengths to represent the broad spectrum of patients served by our Health Center. We are a group of 20 patients, 10 of which are PHC patients. We meet on a monthly basis i.e. about 12 times a year. Our patient population is very diverse; it s made up of Hispanic, African Americans, White and Pacific Islander. The advisory council has 60% women and 40% male population. About half are Med-Cal patients, 40% Medicare and 10% privately insured. C. Describe the topics discussed or surveyed for gaining patient feedback? At the Patient and Family Advisory Council meetings: We recommend improvements to health centers operations Enhance communications and marketing materials for patients Strengthen patient education programs Review patient satisfaction results Offer suggestions for improving the patient experience Provide feedback on the Health Centers space planning Evaluate any issues which are referred to the council by other Health Centers committees D. What methodology is being used for choosing the topics and/or questions to gain patient feedback? Page 64

65 The activities performed in the group are listed above. Some of the topics we discuss during the meetings are a result of reviewing the patient satisfaction survey results. Any questions that have low satisfaction scores are discussed in depth with the group. E. Based on the results from your discussion, what specific measure(s) have you selected to improve? I was given an appointment when I wanted it F. For each measure or composite of questions selected for improvement, what is your specific objective? 80% of patients surveyed will select strongly agree. G. For the measures selected for improvement, describe the specific changes/interventions/actions you believe will improve your performance? To improve the appointment wait times, our clinic will test adding same day appointments and extending visit intervals for well controlled patients with chronic conditions to improve the time it takes to get a routine appointment. Submitted by John Smith (QI Director) (Name & Title) on Dec 31, 2014 (Date) Page 65

66 Appendix IIIB: Patient Experience Training Option 4665 Business Center Dr. Fairfield, CA Quality Improvement Program Patient Experience Training Option Submission Template and Example Due date for Part I submission: January 31, 2015 Due date for Part II submission: July 31, 2015 Below you will find the submission template and example for the Training Option. This is a guide for your submission, and if you decide to not use it, points will still be rewarded as long as all areas are addressed in your submission. For detailed instructions, please refer to the Measure Specifications. If you are not sure whether certain training would qualify for this measure, you may ask for approval from PHC prior to the training. Please us at qip@partnershiphp.org with the following information: 1. Name of training entity/organization 2. Description of the training 3. Number of hours of the training 4. Number of team members who attend the training and their roles/titles Page 66

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