4.3.7 Section 7 Quality Assessment and Performance Improvement

Transcription

1 Clinical Initiatives This response applies to Texas Children s Health Plan s STAR and CHIP programs. Texas Children s Health Plan is not bidding on the STAR+PLUS program. 1. For each MCO Program bid, describe data-driven clinical initiatives that the Respondent initiated within the past 24 months that have yielded improvement in clinical care for a managed care population comparable to the population in the Respondent s MCO Program bid. Texas Children s Health Plan has initiated the following clinical initiatives for both STAR and CHIP programs which have yielded improvement in clinical care provided to our Members: P. PP7-1 Skin and Soft Tissue Infections Quality Improvement Project designed to reduce the incidence of Community Associated Methicillin Resistant Staph infections (CA-MRSA); Appropriate Treatment of Ambulatory Care Sensitive Conditions designed to direct Members to appropriate, non-emergent care; and Emergency Room Use Reduction Strategy designed to reduce unnecessary and avoidable use of the emergency room by implementing a multi-pronged approach emphasizing Provider outreach and incentives and use of alternatives (e.g. after hours care and urgent care sites) to the emergency room. Each of these initiatives was informed by analysis of data on service utilization and Member outcomes, research on best practices, input from our Provider partners, and our Members. All of these clinical initiatives are overseen by Texas Children s Health Plan s Multidisciplinary Strategic Initiatives Committee (MSIC) which is charged with identifying and assessing the Health Plan s clinical and service issues, performing causal analysis, and developing, implementing and evaluating interventions to address clinical and service issues. MSIC reports to the Quality Improvement Committee and the Medical Advisory Committee and is responsible for continuous quality improvement activities for assigned projects. All of these initiatives will continue at least into the first year of the new contract and will remain beyond that period as long as they continue to achieve clinical improvements for our Membership. Each of these initiatives is described below. Skin and Soft Tissue Infections QI Project- for STAR and CHIP. An analysis of the Health Plan claims for STAR and CHIP Members showed that a primary diagnosis of skin infection was a significant contributing factor to avoidable acute care, including emergency room and inpatient usage. When left untreated or treatment is delayed, these infections can become serious enough to require care in the emergency room or inpatient setting. Moreover, the Centers for Disease Control identified Houston area as a hotbed for Community Associated Methicillin Resistant Staph infections, since this area is humid and home to multiple insects. (Bug bites are often the precipitating factor to these skin infections, and infection is more likely to develop in a moist or humid environment). Texas Children s Health Plan identified the following barriers to appropriate, early treatment of CA-MRSA skin and soft tissue infections: delay in medical care, use of ineffective antibiotic, and lack of incision and drainage of the abscess early in treatment. In order to design an effective and targeted intervention, Texas Children s Health Plan assessed occurrence of skin and soft tissue infections for seasonality, geographic distribution, and Primary Care Provider practice patterns. Based on the assessment, the Member interventions were scheduled to occur one month prior to and during the seasonal peaks of March, April, May and August, and September. Based on geographic distribution, the East side of Houston was targeted for interventions first followed by the Northwest area. Additionally, the Health Plan provided targeted outreach to Primary Care Providers based on number of skin and soft tissue infections within their panel.

2 P. PP7-2 A Provider specific pattern analysis was conducted to determine if there were claims indicating performance of incision and drainage of abscess. This was compared to the overall data analysis which showed that incision and drainage was more frequently performed at the emergency room, despite the fact that this procedure can be provided in a Provider s office. Moreover, in many cases, the incision and drainage performed at the emergency room was done so on the same day as a PCP visit. We then interviewed PCPs to investigate why this practice pattern occurred and found that many PCPs were uncomfortable performing the procedure because they felt they lacked adequate training and that the reimbursement rate was insufficient to justify the office time. In response, Texas Children s Health Plan developed training materials (and obtained CME credit designation for completion) and increased the office based reimbursement rate for the procedure. Interventions to impact the incidence of skin infections occurred at both the Member and Provider level. To educate Members, we developed a Member-education campaign and related materials with three simple messages: keep it clean; keep it dry; keep an eye on it - if it becomes the size of a quarter go to the doctor. Since bug bites are a common source of these infections, we developed bug bite kits that included educational material as well as topical antibiotic cream, bug spray, and other first aid items. These kits are tremendously popular and frequently requested by Members. Texas Children s Health Plan distributes the kits at community events in the targeted geographic areas. To address education for the Provider community, the Health Plan developed a traveling Continuing Medical Education program utilizing New England Journal of Medicine and Clinical Infectious Diseases Society material. The program offers Providers the following tools: a pocket card with differential diagnosis and treatment algorithm developed by Texas Children s Health Plan; Practice Guidelines for the Diagnosis and Treatment of Skin and Soft Tissue Infections developed by the Clinical Infectious Diseases Society; a New England Journal of Medicine article on Incision and Drainage of Abscess; and Member educational materials to distribute. Appropriate Treatment of Ambulatory Care Sensitive Conditions QI Project for STAR and CHIP. Historical review of the Health Plan claims data for STAR and CHIP Members showed an increasing use of Emergency Rooms and Inpatient Hospitals for Ambulatory Care Sensitive Conditions. Texas Children s Health Plan follows the Agency for Healthcare Research and Quality definition of Ambulatory Care Sensitive Condition diagnoses: appendicitis, asthma, bronchitis, cellulitis, diabetes, epilepsy, gastroenteritis, otitis media, nausea & vomiting, urinary tract infection and upper respiratory infection. Texas Children s Health Plan analyzed the occurrence of Ambulatory Care Sensitive Conditions treated in the emergency room or hospital inpatient department for seasonality (increased in winter), geographic distribution, and primary care Provider (PCP) practice patterns. Based on geographic distribution, the East side of Houston was targeted for the first set of interventions followed by the Southwest area and the Northwest area. Targeting interventions by geographic areas allows Texas Children s Health Plan to address specific regional issues and available services. PCPs with higher than average Emergency Room (ER) utilization were surveyed to identify other possible causes for the high number of Ambulatory Care Sensitive Conditions treated in the ER. The lack of after-hour alternatives was repeatedly mentioned which lead to our initiatives to 1)increase contracting with Urgent Care Centers 2) development of Provider performance payments for extension of their office hours and 3) participation with three FQHC in a grant funded pilot project for pediatric after-hours operations. Texas Children s Health Plan reinforces this clinical initiative by offering Primary Care Providers a financial incentive (implemented January 2009) that focuses on decreasing ER utilization rates. The Member education portion of this initiative focuses on self-care and increased awareness of ER alternatives for non-emergencies. Texas Children s Health Plan provides Members with educational materials on alternatives to the Emergency Room such as calling the doctor s after hours clinic, calling the Health Plan s nurse help line, or going to a nearby urgent care center. Texas Children s Health Plan has developed an innovative mailer to Members that is customized to the Member s own address displaying the address and map to local clinics offering after hours and urgent care. This not only helps to reinforce the idea of using more appropriate care, but also simplifies the process of locating alternatives to the

3 Emergency Room. Texas Children s Health Plan recognizes that Members often respond best to information that comes directly from their physician, so we provided the PCPs with prescription pads that note: Doctor s orders after leaving my office if you feel your child is getting worse, you can call me or call Texas Children s Health Plan nurse call line; self-care instructions including children s Motrin dosages; and addresses/maps to local clinics offering after hours care and urgent care centers. Texas Children s Health Plan Member educational materials are also widely distributed at community events in the targeted geographic areas. Emergency Room Use Reduction Strategies. Texas Children s Health Plan developed a multi-pronged, data driven strategy to reduce unnecessary emergency room use by our Members. After analyzing Emergency Room claims data, we developed strategies to reduce unnecessary ER use that respond to the key reasons Members appeared to access the ER when an alternative option could have been used. There are four components to our strategy: 1. Financial Incentives for STAR Providers that offer a quarterly incentive bonus for instituting extended office hours on evenings or weekends, demonstrating best practice in ER visits per 1000 Member utilization in their panel (top performing quartile) as compared to all PCPs, or for improving the percent of their Membership who used the Emergency Room compared to same calendar quarter prior year. A Provider can earn up to $15,000 per quarter based on success in all three components. 2. Contracting with urgent care centers to provide Members with close and convenient alternatives to Emergency Rooms. One of our most popular urgent care centers has been the Nightlight a high quality pediatric urgent care clinic operating from 5-11pm on weekdays and noon to 7pm on Saturday and Sundays. Texas Children s Health Plan assisted with funding the expansion of a second location of the Nightlight clinic in a highly populated Medicaid area of the city which has proven valuable in offering a convenient and more appropriate alternative to the emergency room. 3. Developing the Close to Home Member education campaign, which directs Members to use the urgent care or hospital emergency room closest to their home, rather than coming to Texas Children s Hospital. We launched these initiatives after reviewing claims data for Emergency Room visits to Texas Children s Hospital and found that many Members were traveling long distances to come to Texas Children s Hospital. We interviewed Members to determine why and found that many Members believed they were required to go to Texas Children s Hospital in an emergency. We needed to correct this false assumption since Texas Children s Hospital is a tertiary facility reserved for the most severe cases and in most cases the children can be successfully and safely treated at their local community network hospital. The Close to Home initiative was designed to carry the message that Members have alternatives in their area and if emergency care is needed, they are free to choose a closer hospital than Texas Children s. 4. Targeted outreach to any Member (and their PCP) following a visit to the Emergency room. The outreach focuses on changing Member behavior through messages from the Health Plan and from the Member s Provider if the visit was not a true emergency. When identified, the Health Plan sends Member materials to assist with identifying emergencies from urgent situations, information about the Nurse Call Line and locations for urgent after-hours care. Additionally, we send the Member s PCP a notice that their Member used the ER, so that they can monitor any clinical issues as needed and reinforce messages about appropriate after hours care. 2. For STAR+PLUS only, propose two (2) clinical initiatives focused on Community-based Long-Term Services and Supports for STAR+PLUS Members, including how Members will be involved in such initiatives and the Respondent s experience implementing similar clinical initiatives. Texas Children s Health Plan is not bidding on the STAR+PLUS program. P. PP7-3

4 3. For each MCO Program bid, describe two (2) new or ongoing Acute Care clinical initiatives that the Respondent proposes to pursue in the first year of the Contract. Document why each topic warrants quality improvement investment, and describe the Respondent s measurable goals for the initiative. Texas Children s Health Plan will pursue the following ongoing and new acute care clinical initiatives in the first year of the contract. These initiatives will apply to both STAR and CHIP Members and will continue beyond the first year if they continue to prove effective in improving quality. Acute Care Clinical Initiatives On-Going Initiative: Appropriate Care of Ambulatory Care Sensitive Conditions to Decrease Emergency Room Utilization Rates New Initiative: Asthma in the Medical Home to Decrease Emergency Room Utilization Rates Rationale for Quality Improvement Focus Unnecessary emergency room usage contributes to the growth in health care costs, leads to lost school and work time for Members, and contributes to crowding at already overburdened emergency rooms. Clinical interventions are effective at redirecting ACSCs away from the ER to primary care and ER alternatives. Asthma is prevalent among our STAR and CHIP Membership and is a significant source of inpatient admissions. With effective outreach and training to PCPs, (including strategies to improve Member s and caregiver s management) many Members with asthma can be managed in their medical home, preventing the need for inpatient and emergency room care. Baseline SFY 2010 STAR Members: per 1,000 Member Months CHIP Members: per 1,000 Member Months STAR Members: per 1,000 Member Months CHIP Members: 6.22 per 1,000 Member Months Goal by End of Contract Year One STAR Members: per 1,000 Member Months CHIP Members: 58.3 per 1,000 Member Months STAR Members: per 1,000 Member Months CHIP Members: 6.03 per 1,000 Member Months 4. For STAR+PLUS only, describe the planned approach the Respondent will take towards quality assessment and ongoing review of providers with whom it intends to contract, using the following provider types as an example: a. Adult Day Health Facilities; b. Personal Assistance Services providers, and c. Home and Community Support Services Agencies (HCSSAs). Texas Children s Health Plan is not bidding on the STAR+PLUS program. 5. For Respondents that already participate in an HHSC MCO Program, provide a copy of the most recent QAPI Plan. For Respondents that do not participate in an HHSC MCO Program, provide a copy of a 2009 quality assurance plan for a comparable managed care population. For both STAR and CHIP, please see Exhibit A (QAPI Plan). 6. Many Texas Medicaid and CHIP children reportedly receive their immunizations through Local Health s. Discuss the impact this has on creating a Medical Home for child Members, and what steps, if any, the Respondent proposes to take to improve child preventive services delivery. Texas Children s Health Plan recognizes that Members receiving immunizations in locations other than their PCP s office interferes with the goal of developing a medical home and reduces the PCP s ability to oversee and coordinate the child s care. When immunizations are separated from the well child visit, the situation raises the risk that parents will incorrectly assume the entire well child visit has been completed. This shots only event leaves other critical parts of the well-child visit left undone. Additionally, since PCPs cannot easily access immunization records of local health departments, it also raises the possibility of P. PP7-4

5 children receiving duplicate immunizations when their PCPs in later visits try to ensure that the child s immunization record is up to date. Texas Children s Health Plan emphasizes the need for complete Texas Health Steps checkup and CHIP well child visits in communication and outreach to parents and caregivers. We have developed messages that are designed to communicate that the checkups are about more than immunizations and that regular visits to the child s PCP are essential to the child s health and development. The PCP offices are audited as part of their recredentialing cycle to determine if documentation of Texas Health Steps checkups are complete and accurate. The PCP s point score on medical record audit is part of the total scoring which determines the ability of offices to receive referral of new Members who have not chosen a PCP. P. PP7-5

6 Action Plan: CHIP Perinate RFP Section RFP Requirement The Health Plan Comparable Experience and Capabilities Goal/Purpose Clinical Initiatives The HMO will provide for the delivery of quality care with the primary goal of improving the health status of Members and, where the Member s condition is not amenable to improvement, maintain the Member s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. The HMO will work in collaboration with Providers to actively improve the quality of care provided to Members, consistent with the Quality Improvement Goals and all other requirements of the Contract. The HMO will provide mechanisms for Members and Providers to offer input into the HMO s quality improvement activities. Texas Children s Health Plan currently develops data-driven clinical initiatives to improve the clinical care for pregnant women and newborn children in the CHIP and Harris County Service Area STAR Programs. Texas Children s Health Plan will develop data-driven clinical initiatives to improve the clinical care for pregnant women and newborn children in the CHIP Perinate Program. HHSC HMO Contract Responsibilities Task Timeline Resource Educate Quality staff regarding requirements for CHIP Perinate Program participation in accordance with Uniform Managed Care Manual (UMCM) Review Quality data collection tools to assure specific needs of pregnant women and newborn children in the CHIP Perinate Program are addressed in accordance with American Congress of Obstetricians and Gynecology (ACOG) Review Quality Improvement Project documents to assure CHIP Perinate issues are clearly identified and addressed in accordance with American Congress of Obstetricians and Gynecology (ACOG) Nine months prior to Nine months prior to Nine months prior to Rose Calhoun, Quality and Outcomes Rose Calhoun, Quality and Outcomes Rose Calhoun, Quality and Outcomes P. PP7-6

7 Action Plan: Pharmacy Services RFP Section RFP Requirement The Health Plan Comparable Experience and Capabilities Goal/Purpose Clinical Initiatives The HMO will provide for the delivery of quality care with the primary goal of improving the health status of Members and, where the Member s condition is not amenable to improvement, maintain the Member s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. The HMO will work in collaboration with Providers to actively improve the quality of care provided to Members, consistent with the Quality Improvement Goals and all other requirements of the Contract. The HMO will provide mechanisms for Members and Providers to offer input into the HMO s quality improvement activities. Texas Children s Health Plan currently develops data-driven clinical initiatives to improve the clinical care of Members in the CHIP and Harris County Service Area STAR Programs. Texas Children s Health Plan will develop data-driven clinical initiatives to improve the clinical care for Members. HHSC HMO Contract Responsibilities Task Timeline Resource Establish clinical rules and define custom interventions to support clinical initiatives targeting at-risk populations as defined by the Health Plan and the PBM. Identify and develop any new reporting/interfaces needed to monitor progress of clinical initiatives. Six months prior to Five months prior to. PBM and Rose Calhoun, Quality and Outcomes PBM and Rose Calhoun, Quality and Outcomes Educate Quality staff regarding requirements for Pharmacy Program. Three months prior to Rose Calhoun, Quality and Outcomes P. PP7-7

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9 P. PP Health Plan Employer Data and Information Set (HEDIS) and Other Quality Data HHSC s External Quality Review Organization (EQRO) will perform HEDIS and Consumer Assessment of Health Plans Survey (CAHPS) calculations required by HHSC for MCO Program management. The following questions are designed to solicit information on a Respondent s proposed approach to generating its own clinical indicator information to identify and address opportunities for improvement, as well as the Respondent s approach to acting on clinical indicator data reported by HHSC s EQRO. This response applies to Texas Children s Health Plan s STAR and CHIP programs. Texas Children s Health Plan is not bidding on the STAR+PLUS program. 1. Identify the MCO-level HEDIS and any other statistical clinical indicator measures the Respondent will generate to identify opportunities for clinical quality improvement; Texas Children s Health Plan uses a variety of statistical clinical indicator measures to identify opportunities for clinical quality improvement. The Health Plan generates HEDIS-like reports for both STAR and CHIP using HEDIS criteria. Texas Children s Health Plan currently produces the following measures: Well Child Visits age 0-15 months, 3-6 years, and years; Timeliness of Prenatal Care, Postpartum Care; Number of births by age group; Number of C-Sections by age group; Cervical Cancer Screening; Appropriate Asthma Medication; Routine Visit of Members with Asthma to Primary Care or Specialist by age group; o Age ranges: 1-4 years; 5-9 years; years; years; Asthma Controller Medication by fill number group and by age group; o Number fill ranges: 0-2, 3-4, 6 or more canisters filled; o Age ranges: 5-9 years; years; years; Follow up with Primary Care or Specialist post Inpatient Stay or ED Visit for Asthma by age group; o Age ranges: 1-4 years; 5-9 years; years; years; Prescription post Inpatient Stay or ED Visit for Asthma by age group; o Number fill ranges: 0-0, 1-3, 4-5, 6 or more prescriptions filled; o Age ranges: 1-4 years; 5-9 years; years; years; Appropriate Testing for Children with Pharyngitis; Follow Up after Hospitalization for Mental Illness, 7-day and 30-day; Comprehensive Diabetes Care including HemoglobinA1c screening, Low Density Lipoprotein Cholesterol (LDL-C) screening, and Diabetic Retinal Exam (DRE); Adult Access to Preventive/Ambulatory Health Services; Children and Adolescent Access to Primary Care Practitioners; and, 7 and 30 day post Behavioral Health Stay Follow-Up. Texas Children s Health Plan will begin collecting Follow-Up Care for Children Prescribed ADHD Medication and of Antidepressant Medication as part of our HEDIS-like administrative measures in The Health Plan reviews External Quality Review Organization reports of HEDIS measures and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys to evaluate our performance against other Texas health plans and national benchmarks. This provides us with a means of assessing opportunities for improvement. In addition to these routine reports, the Health Plan generates Ad Hoc reports to identify additional opportunities for improvement and monitor results of interventions. These reports include: Member use

10 of services by disease (Ex: skin and soft tissue infections, peritonitis, bipolar disorder); place of service (Ex: inpatient, Emergency or outpatient); age of Member; Provider type (Ex: Family Practice, Pediatrics, Internal Medicine); and, geographic distribution either high level (Ex: East, Northeast, North, Northwest) or more specific (Ex: zip code or street address). 2. Document examples of statistical clinical indicator measures previously generated by the Respondent during for a managed care population comparable to the population in the MCO Program bid. Texas Children s Health Plan uses a number of statistical clinical indicators to create a comprehensive view of Members and their needs. In addition, Texas Children s Health Plan creates HEDIS-like administrative measures that are updated monthly to permit monitoring of changes or improvement in compliance with clinical guidelines. Examples of clinical indicator measures generated during for the STAR and CHIP population are provided below. Benchmarks obtained from HHSC Annual Chart Books. Measure 7 Day Follow Up After Hospitalization for Mental Illness 30 Day Follow Up After Hospitalization for Mental Illness Appropriate Testing for Children with Pharyngitis Well Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life STAR TX Children s Health Plan All STAR MCOs Mean MCOs in the Harris SDA Mean HEDIS Mean 39.3% 36.5% 38.8% 42.5% 71.2% 65.5% 68.4% 61.0% 57.9% 45.5% 42.5% 58.2% 68.8% 71.0% 70.2% 65.3% Adolescent Well Care Visits 51.5% 51.1% 49.8% 42.0% Access to Primary Care Practitioners 25 Mo to 6 Yrs Access to Primary Care Practitioners 7 to 11 Yrs Access to Primary Care Practitioners 12 to 19 Yrs Percent of Emergency Visits with a Primary Diagnosis of an Ambulatory Care Sensitive Condition 92.9% 92.3% 92.8% 84.3% 81.3% 93.2% 93.4% 85.8% 76.7% 91.1% 90.4% 82.6% 49.9% 48.9% 48.5% N/A P. PP7-10

11 Measure 7 Day Follow Up After Hospitalization for Mental Illness 30 Day Follow Up After Hospitalization for Mental Illness Appropriate Testing for Children with Pharyngitis Well Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life CHIP 2008 TX Children s Health Plan All CHIP MCOs Mean 38.3% 39.8% N/A 76.0% 70.8% N/A 68.7% 53.0% 53.5% 66.1% 58.7% 59.9% Adolescent Well Care Visits 48.5% 39.0% 41.7% Access to Primary Care Practitioners 25 Mo to 6 Yrs Access to Primary Care Practitioners 7 to 11 Yrs Access to Primary Care Practitioners 12 to 19 Yrs Percent of Emergency Visits with a Primary Diagnosis of an Ambulatory Care Sensitive Condition 93.1% 89.2% 91.2% 84.0% 93.1% 95.1% 77.0% 90.4% 91.8% 34.5% 29.0% 28.7% MCOs in the Harris SDA Mean In addition to the standard HEDIS measures for which there are national benchmarks, Texas Children s Health Plan has added the following Asthma Disease data to the HEDIS-like internal reports. Follow Up with PCP or Specialist After an Inpatient Admission or Emergency Room Visit with a Diagnosis of Asthma. This measure identifies opportunities for the Health Plan to support the medical home by improving communication of an Inpatient Admission (IP) or Emergency Room Visit (ER) with a Diagnosis of Asthma. By assessing the coordination of care between the various levels of Providers, Texas Children s Health Plan can develop focused outreach to any PCP whose performance is less than their peers. Texas Children s Health Plan s Care team is working to improve these outcomes. Follow up with PCP or Specialist post Asthma IP Stay or ER Visit CY 2008 Age Group 1 4 yrs. 5 9 yrs yrs yrs. All Ages STAR 56.01% 43.40% 35.70% 39.47% 49.03% CHIP 66.49% 54.60% 42.96% 30.00% 53.03% 3. Describe efforts that the Respondent has made to assess member satisfaction during for a managed care population comparable to the population in the MCO Program bid. Texas Children s Health Plan uses Member Satisfaction as a central component of our approach to continuous quality improvement and has adopted strategies to ensure collection of Member satisfaction information that is timely and actionable. The Member Satisfaction Surveys conducted each year for both STAR and CHIP Members are Provider specific, which enables the Health Plan to evaluate the findings by physician. This approach allows the Health Plan to use the results of the Member Satisfaction surveys to P. PP7-11

12 develop targeted intervention reinforced by the Texas Children s Provider Relations staff. The information gained from the Member Satisfaction Surveys and the actions of the Provider Relations staff in response to that information are both key tools in the Health Plan s quality improvement strategy. An outside consultant conducts the Member Satisfaction surveys within the month following a Member s visit to their Primary Care Provider (PCP). High volume PCPs are rotated through the process and their Members are surveyed through a random selection. Each month Texas Children s Health Plan provides the consultant with a list of Members who received care from their PCP in the last thirty days and the consultant uses this list as the basis from which to survey Members. This approach decreases time between Provider-Member contact and the satisfaction survey and provides Texas Children s Health Plan with actionable data to share with Providers. Each year, 4,500 Members from high volume PCPs and 500 Members from low volume PCPs are surveyed. The Member Satisfaction Surveys ask Members questions in three areas: 1. Care from their physician (e.g., How well did the doctor explain things to you?) 2. Care from the Physician s staff and office (e.g., How would you rate the staff and office?) 3. Care from the Health Plan (e.g., How helpful was the Health Plan in solving your problem?) By categorizing Member satisfaction in this way, Texas Children s Health Plan obtains information that is sufficiently detailed to develop targeted and effective interventions and to measure the impact of those interventions. The questions regarding satisfaction with Texas Children s Health Plan are addressed in the Quality Improvement Committee along with educational outreach plans for targeted Providers (based on their survey results). The 2009 survey results of the two satisfaction questions are listed below as an example. The results show both STAR and CHIP Members and demonstrate satisfaction with the care received from their doctor as well as their overall satisfaction with the entire office visit (including appointment scheduling, wait times, staff interaction and follow-up instructions). The rates scale is from 1-5, with 5 being the highest. Q7 Satisfaction with Overall Care from the Doctors Q17 Satisfaction With Overall Care Good (3) 16.3% Very Good (4) 19.9% Fair (2) 3.1% Poor (1) 1.0% Excellent (5) 59.7% Good (3) 23.0% Very Good (4) 25.3% Fair (2) 6.3% Poor (1) 2.2% Excellent (5) 43.2% 4. Describe management interventions implemented in 2008 or 2009 based on member satisfaction measurement findings for a managed care population comparable to the population in the MCO Program bid, and whether these interventions resulted in measurable improvements in later member satisfaction findings. To better manage volume, Texas Children s Health Plan surveys high volume PCPs on a two year cycle. Half of the PCPs are surveyed in year one and the other half in year two. As a result, 2008 is compared to 2010 and 2007 is compared to 2009 so that the same set of PCP scores are correctly compared. In 2009, the Health Plan found that Member satisfaction with their PCP and office staff declined from 2007 results. In response, Texas Children s Health Plan initiated a project to identify the reasons behind this decline and developed an intervention to improve Member experiences with their PCP and the office staff. As part of P. PP7-12

13 our investigation, we found there was limited opportunity for formal training in customer service for the Receptionist or Office Manager. We responded by developing a training for Provider office staff entitled Through the Customer s Eyes. The training emphasizes the significant role that office staff can play in creating a successful medical home, both by the tone thet establish when the Member enters the office as well as their role in ensuring that Members fully understand instructions and have the necessary information for follow up appointments and tests at the completion of the visit. In 2009, Quality and Provider Relations staff conducted trainings at PCP offices and staff luncheon meetings and in offices of PCPs with the lowest Member satisfaction scores. (The use of the Providerspecific analysis of the Member satisfaction surveys, as noted above, makes this type of targeted approach possible.) The training for Provider office staff increased staff awareness of Members needs and reviewed every day office practices as viewed by a Member. Throughout the training, Texas Children s Health Plan staff reinforced that office staff are responsible for the first and last impression Members have of their PCP visit. For example, the training emphasized that the front office person is in an ideal position to identify needed services when signing in a Member and has an opportunity to be a key component in quality of care. Feedback from office managers and office staff was positive. The office staff actively participated in the discussions and identified processes that could be improved in their offices to make Members more comfortable and to better ensure Members have all the information they need to improve health outcomes. Additionally, Provider Relations staff visit targeted, high volume Providers on a monthly basis and use Member Satisfaction findings to inform the content and frequency of their visits. These visits are constructed as a partnership with PCPs to help them understand the needs of their Members, how their Members view their care, and how interventions can be structured to respond to Member needs. The 2010 Member Satisfaction results showed statistically significant improvement in all nineteen measures compared to 2008 indicating that staff training intervention was effective. On a scale of one (as lowest) and five (as highest), the category of Care From Staff and Office increased from 3.96 to 4.13 and the category of Likelihood of Recommending the Provider increased from 4.62 to Texas Children s Health Plan also uses Member Satisfaction Surveys to identify areas for clinical intervention. For example, the Health Plan used Member Satisfaction Surveys to respond to a decline in compliance with asthma controller medication. To aid in assessing possible causes of the decline in compliance with asthma Controller Medication, Texas Children s Health Plan added questions from the Asthma Therapy Assessment Questionnaire (ATAQ) to the 2009 Member Satisfaction Survey. At the end of the general satisfaction survey, the parent is asked if the child had ever been diagnosed with asthma. If the respondent answered yes, the ATAQ was given. The responses from the ATAQ are reviewed each year and guide enhancements to asthma initiatives. One such enhancement is the development of the PCP High Risk Asthma Panel Report identifying Member medical and pharmaceutical utilization. This provides the PCP with information not previously available such as prescription fill rate, visits to other Providers, Emergency visits, and Inpatient stays. PCP feedback on this new asthma report has been positive. This approach to Member satisfaction surveys is illustrative of Texas Children s Health Plan s approach to quality improvement, which is to integrate and coordinate efforts from across Health Plan operations in order to achieve improved Member care. We will continue this strategy of using Member satisfaction to guide, inform, and measure our quality improvement initiatives into the new contract. P. PP7-13

14 Action Plan: CHIP Perinate RFP Section RFP Requirement The Health Plan Comparable Experience and Capabilities Goal/Purpose Health Plan Employer Data and Information Set (HEDIS) and Other Quality Data Identify MCO-level HEDIS and any other statistical clinical indicator measures Respondent will generate to identify opportunities for clinical quality improvement. Texas Children s Health Plan currently generates HEDIS and other statistical clinical indicator measures to identify opportunities for clinical quality improvement for pregnant women and newborn children in the CHIP and Harris County Service Area STAR Programs. Texas Children s Health Plan will generate HEDIS and other statistical clinical indicator measures to identify opportunities for clinical quality improvement for pregnant women and newborn children in the CHIP Perinate Program. HHSC HMO Contract Responsibilities Task Timeline Resource Educate Quality staff regarding requirements for CHIP Perinate Program participation in accordance with Uniform Managed Care Manual (UMCM). Review HEDIS and other Quality data to assure specific needs of pregnant women and newborn children in the CHIP Perinate Program are addressed in accordance with American Congress of Obstetricians and Gynecology (ACOG) and National Committee for Quality Assurance (NCQA) Review HEDIS and other Quality data reports to assure CHIP Perinate issues are clearly identified in accordance with American Congress of Obstetricians and Gynecology (ACOG) and National Committee for Quality Assurance (NCQA) Nine months prior to Nine months prior to Nine months prior to Rose Calhoun, Quality and Outcomes Rose Calhoun, Quality and Outcomes Rose Calhoun, Quality and Outcomes P. PP7-14

15 Action Plan: Pharmacy Services RFP Section RFP Requirement The Health Plan Comparable Experience and Capabilities Goal/Purpose Health Plan Employer Data and Information Set (HEDIS) and Other Quality Data Identify MCO-level HEDIS and any other statistical clinical indicator measures Respondent will generate to identify opportunities for clinical quality improvement. Texas Children s Health Plan currently generates HEDIS and other statistical clinical indicator measures to identify opportunities for clinical quality improvement for Members in the CHIP and Harris County Service Area STAR Programs. Texas Children s Health Plan will generate HEDIS and other statistical clinical indicator measures to identify opportunities for clinical quality improvement for Members. HHSC HMO Contract Responsibilities Task Timeline Resource Establish clinical rules and define custom interventions to support clinical initiatives targeting at-risk populations as defined by the Health Plan and the PBM. Identify and develop any new reporting/interfaces needed to monitor progress of clinical initiatives. Six months prior to Five months prior to. PBM and Rose Calhoun, Quality and Outcomes PBM and Rose Calhoun, Quality and Outcomes Educate Quality staff regarding requirements for Pharmacy Program. Three months prior to Rose Calhoun, Quality and Outcomes P. PP7-15

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17 Clinical Practice Guidelines This response applies to Texas Children s Health Plan s STAR and CHIP programs. Texas Children s Health Plan is not bidding on the STAR+PLUS program. 1. For each MCO program bid, describe two (2) clinical guidelines that are relevant to the enrolled populations and that the Respondent believes are currently not being adhered to at a satisfactory level. Texas Children s Health Plan recognizes that medical professionals are sometimes slow to adopt evidence based clinical guidelines. As a result, we actively monitor clinical indicators to identify when there is a need for greater Provider outreach to encourage adoption of guidelines. The two clinical practice guidelines described below are relevant to both our STAR and CHIP populations. A. Diagnosis and Treatment of Skin and Soft Tissue Infections Texas Children s Health Plan has determined that Providers are not adhering to the Practice Guidelines for the Diagnosis and Treatment of Skin and Soft Tissue Infections at a satisfactory level. Although Texas Children s Health Plan had initial success encouraging Providers to adhere to this guideline when we first launched a quality initiative regarding skin and soft tissue infections (as described in Section ), our intervention efforts to date are not plan wide and have only focused on targeted regions. We had initial success in the East and Northwest sections of Harris County, but have not yet expanded to the remaining parts of our service area. In addition, Texas Children s Health Plan has continued to monitor the incidence of emergency department and inpatient utilization related to this condition in the regions we targeted for outreach and have found that despite initial improvements, we have not yet achieved sustainable change, indicating that continued education and focused outreach will be necessary to achieve satisfactory adherence to these clinical guidelines. This guideline is relevant for the enrolled population based on the CDC s categorization of Houston as a hotbed for Community Associated Methicillin Resistant Staph infections (CA-MRSA). MRSA is associated with skin and soft tissue infections requiring Emergency (ED) visits or Inpatient Admissions. By SFY 2008, skin infections were responsible for: 12.3 Emergency visits and 2.29 Inpatient Admissions per 1,000 STAR Members and 6.3 ED visits and 1.3 Inpatient Admissions per 1,000 CHIP Members. Improving the adherence to these guidelines will help improve our infection rate and help reduce ED overcrowding. B. Texas Health Steps Texas Children s Health Plan believes that improvement is needed in our Provider s compliance with HHSC s Guidelines for Texas Health Steps. We focus on these guidelines because complete documentation is a critical element in our ability to ensure that all components of a Texas Health Steps checkups are complete. Well child visits are critical to assessing a child s development and necessary in making referrals for additional care. Because parents value their phycisian suggestions, these visits provide parents and caregivers with important education and anticipatory guidance to help them foster their child s healthy growth and development. Texas Children s Health Plan recognizes that having a positive effect on Texas Health Steps delivery requires a collaborative relationship with our Provider Network to ensure Providers deliver and document services correctly. Documentation of services is critical to quality improvement, in that it ensures that adequate baseline measurements for comparison. Evaluation of quality assurance medical record reviews identified incomplete Texas Health Steps and Well Child documentation as an area in need of improved clinical guideline adherence. In response to this finding, we work with the PCPs to identify the root cause of incomplete documentation. One cause related to poorly designed forms linked to a poor understanding of state requirements. As a result, we worked with Providers to redesign their visit forms to ensure they included the necessary prompts for P. PP7-17

18 all relevant Texas Health Steps components with the appropriate space to document the results. We loaded sample templates on portable zip drives and made these available to practices that wanted to incorporate this information into their current medical record forms. While these steps have led to improved Texas Health Steps documentation, we believe that further improvement in our Provider s compliance with HHSC s guidelines for Texas Health Steps is still warranted. 2. Describe what steps the Respondent will take to increase compliance with the guidelines noted in its response to question number 1 above. A. Diagnosis and Treatment of Skin and Soft Tissue Infections Texas Children s Health Plan is working with our Multi-disciplinary Strategic Initiatives Committee to increase Provider education and develop the focused outreach necessary to sustain the gains we achieved when this initiative was initially launched in the East and Northwest regions of our service area. We will continue the steps outlined previously which prove effective and include: Assessing skin and soft tissue infection occurrence for seasonality, geographic distribution, and Primary Care Provider practice patterns in order to target where and when Member and Provider outreach is most needed. Distributing Member educational materials (including the popular bug bites kits noted earlier) at community events in the targeted geographic areas and provided to Primary Care Providers for distribution to Members. The Member education materials will reinforce the three simple messages for care of skin and soft tissue infections: Keep it clean. Keep it dry. Keep an eye on it. If it becomes the size of a quarter go to the doctor. Instituting targeted Provider education and outreach. Primary Care Providers will be stratified for outreach based on number of skin and soft tissue infections and practice pattern (number of cases treated in Emergency Center or Inpatient; and whether or not Incision & Drainage of abscess was provided). The Provider education component consists of a traveling Continuing Medical Education program utilizing New England Journal of Medicine and Clinical Infectious Diseases Society material. Providers also receive a pocket card with differential diagnosis and treatment algorithm developed by Texas Children s Health Plan; Practice Guidelines for the Diagnosis and Treatment of Skin and Soft Tissue Infections, and training video on a pediatric-specific Incision and Drainage developed by Baylor College of Medicine and Texas Children s Health Plan. Outreach will also involve ensuring the Providers know that Texas Children s Health Plan has increased the reimbursement rate for incision and drainage. The above steps were successfully employed in specific regions of Texas Children s Health Plan s service area (e.g. the East and Northwest). The chart below indicates Texas Children s Health Plan s success in changing Provider practice patterns to move Incision and Drainage procedures from the emergency room to the PCP office. We believe that following this model coupled with continued Provider and Member outreach and education will allow us to sustain the progress and ensure improvements can be taken plan wide. East Corridor Number of Incision & Drainage performed in Emergency Center Number of Incision & Drainage performed in Physician Office Pre-intervention Year (July June 2008) Intervention Year (July June 2009) Change during Intervention Year P. PP7-18

19 B. Texas Health Steps Texas Children s Health Plan will continue to focus on increasing compliance and documentation with Texas Health Steps checkups. Texas Children s Health Plan will take the following steps: Re-circulating the revised well child visit forms Texas Children s Health Plan created with Provider input. These forms were revised to include prompts for each element of the well child visit and to encourage documentation of each element of the visit by including space for the documentation. Conducting periodic trainings with our Providers. These trainings will be available to all Providers but will specifically target Providers with low rates of documentation. Trainings will use information from the reviews conducted for complete documentation and will also include input offered by Providers who participated in this review. Distributing Member education materials on the importance of the well child visit. These materials include the message that well child visits are important to ensure the healthy development of children is about more than immunizations. Direct intervention by Texas Children s Health Plan s Quality Improvement Nurse Support for Providers with audited low rates of Texas Health Steps documentation. 3. Provide a general description of the Respondent s process for developing and updating clinical guidelines, and for disseminating them to participating providers. The Texas Children s Health Plan Medical Advisory Committee and its subcommittees, the Behavioral Health Advisory Committee and the Perinatal Advisory Committee, adopts clinical practice guidelines for prevention, early detection of illness, and disease management. The committees determine a need for clinical practice guidelines based on: literature that impacts Health Plan Members; concerns raised by network Provider; or trends identified in Peer Review, Utilization Review or Quality Improvement activities. The practice guidelines are based upon Provider recognized expert sources, such as professional associations or public health experts. The practice guidelines are reviewed at least every two years. The guidelines are disseminated via the Texas Children s Provider Portal and given to all newly enrolled Providers during visits by the Provider Relations staff and Quality nurses. Clinical guidelines are also disseminated to Providers whose practice patterns show opportunities for improvement when compared to their peers. In such cases, one of the Associate Medical Directors will often meet with the Provider to share the clinical guidelines,offer counsel on the importance of the guidelines, and work to reach the Provider s agreement to accept use of the guidelines. This one on one, physician-to-physician approach has been extremely effective in improving adherence among Provider who initially showed little interest in or awareness of the guidelines and has translated into improved health outcomes for Members. P. PP7-19