I. Table of Contents

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2 I. Table of Contents Table of Contents... 2 Introduction and Philosophy... 3 Program Description... 5 Purpose and Scope... 5 Strategic Aims... 5 Implementation Strategy... 7 Measurement... 7 Data Collection and Analysis... 7 Outreach and Education... 8 Provider Participation... 9 Community Collaboration Program Structure Governance Organizational Structure Committee Structure and Function Project Teams Confidentiality Appendix A Quality Improvement Work Plan Appendix B Quality Improvement Work Plan Evaluation Appendix C Implementation Methodology Appendix D Organizational Structure Appendix E Committees

3 I. Introduction and Philosophy (Health Plans) supports an active, ongoing, and comprehensive Quality Improvement Program based on and aligned with the National Quality Strategy, the Triple Aim, the Institute of Medicine aims, the State of Utah Managed Care Quality Strategy, CMS guidelines and University of Utah Healthcare Strategic Goals. It is our belief that the Quality Improvement Program is an integral part of business operations and is embedded throughout all Health Plans departments. Quality Improvement staff work with all Health Plans staff in developing programs, monitoring progress, assisting with care coordination, and providing technical assistance for process improvement. A. National Quality Strategy The National Quality Strategy 1 was first established in 2011 and later mandated by the Affordable Care Act. The overarching aims build on the Institute for Healthcare Improvement s Triple Aim, supported by six priorities. The strategy outlines nine levers to align core organizational functions to drive improvement. In keeping with the spirit of the Strategy, the Quality Improvement Program focuses on these priorities: Reducing harm in care delivery (appropriate care without over- or underutilization). Engaging members and their families, to promote wellness, shared decision making regarding care, and member safety. Promoting effective prevention and treatment practices beginning with cardiovascular disease. Working in the community to promote healthy living. Applying innovative delivery and payment models designed to make quality of care more affordable. We focus on these levers to achieve our quality improvement goals: Performance feedback Public reporting Technical assistance and education Consumer incentives Invest in staff who are innovative, able to facilitate adoption of improved processes, and who value using data to drive improvement. B. Triple Aim The Health Plans Quality Improvement Program is based on the Triple Aim 2 Improving the experience of care (quality and satisfaction) Improving the health of populations Reducing health care costs

4 C. Institute of Medicine Improvement Aims The Institute of Medicine (IOM) 3 defines quality as The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. The IOM, in 2001, proposed six aims intended to provide a framework for narrowing the gap between what we know is good health care and the healthcare that is actually delivered. The IOM s six Aims for Improvement are to provide healthcare that is: 1. Safe: No one should be harmed by healthcare. 2. Effective: Care should be evidence-based and not over- or under-used. 3. Patient-centered: The patient should be an active partner in healthcare decision making. 4. Timely: Care should be delivered without excessive waiting. 5. Efficient: The system should constantly work to reduce waste. 6. Equitable: High quality care should be equally available to all. The UUHP applies this definition of quality and fully subscribes to the IOM aims. D. State of Utah Managed Care Quality Strategy The mission of the Utah Division of Medicaid and Health Financing (DMHF) is to provide access to quality, cost effective health care for eligible Utahns. In keeping with that mission the DNHF, in January 2013, implemented Accountable Care Organizations (ACO) for the purpose of maintaining quality of care, improving health outcomes, and controlling costs. The Quality Strategy is based National Quality Strategy and the Triple Aim and its highest priority is to promote effective coordination of care. Health Plans fully supports the Quality Strategy. E. University of Utah Healthcare Strategic Goals University Healthcare FY 2015 Strategic Goals are focused on patient experience, quality, and financial strength. To support these Strategic Goals, the Quality Improvement focuses on: Patient Experience - Improve access - Improve care transitions Quality - Improve quality of care - Provide exceptional value Financial Strength - Monitor under- and over-utilization The Quality Improvement Program s alignment with these strategies and goals is evidenced in our provider selection, ongoing measurement and feedback, quality improvement initiatives, and our overall structure

5 II. Program Description A. Purpose and Scope The purpose of the Quality Improvement Program is to assess and improve the quality, availability, and appropriateness of care, member safety, and service to our members. We do this by: assessing care and service delivery; identifying opportunities for improvement; implementing quality improvement initiatives that will have the greatest impact on our members; and measuring the effectiveness of our interventions and using those results to plan future quality improvement initiatives. The Quality Improvement Program and all associated activities apply to all plans: U of U Health Plans Hospitals and Clinics, U of U Health Care Plus Campus, Healthy U Medicaid, and Healthy Advantage Plus Medicare. B. Strategic Aims These aims broadly represent what we intend to accomplish through activities related to care, service, and administrative functions. These activities are outlined in the Quality Improvement Work Plan (Appendix A) which is developed annually by the Quality Improvement Committee. The Work Plan is also evaluated (Appendix B)annually to assess the effectiveness of our interventions and to prioritize our work for the coming fiscal year. Briefly, the aims include: 1. Administration and Leadership leadership is responsible to adopt and support an Accountable Care Organization (ACO) business model. To meet this obligation requires a shift from episodic care with fee for service payment, to population management with payment methodologies aligned to achieve value-based payment. The overall outcome is intended to be improved population health, improved experience of care (quality and satisfaction), and reduced costs. 2. Quality Assessment and Performance Improvement employs a systematic quality assessment and performance improvement process based on the Nolan model, Plan-Do-Study-Act, and the HIVQUAL interdependent project/program model. The process applies to all aspects of Health Plans. 3. Enrollee rights and Responsibilities Enrollees are entitled to care that is safe, effective, efficient, timely, equitable and patient-centered. has established functions, operating under established policies and procedures, which are designed to provide services to our members that meet these goals. Those functions include member and community education and outreach, an efficient enrollment process, accurate and timely claims processing, avenues to communicate appeals and grievances, and mechanisms to assist members to make informed decisions about their care. 5

6 4. Access and Availability ensures that all services are available, accessible, and provided to members in a culturally and linguistically appropriate manner. We utilize primary language information in the claims system to provide member materials for languages spoken by 5% or more of the enrolled population. In addition to having bilingual staff in Customer Service, Care Management, and Marketing, translation services are provided for members as needed. We serve a diverse population and continually strive to increase access to and availability of services to all members through culturally and linguistically appropriate scheduling, technology, expanded service, and expanded service hours. 5. Coordination and Continuity of Care is committed to providing coordinated care across the continuum. Strengthening the care management team with physician leaders, using technology to expand care managers reach, engaging members in selfmanagement of chronic illnesses, and improving the potential and quality of life for children with special needs are key strategies. 6. Utilization Management In order to provide evidence-based, efficient, and equitable care and services to our members, is committed to a utilization management program based on nationally recognized criteria that are accurately and appropriately applied in all cases. 7. Provider Participation engages providers through newsletters, updates, and performance feedback. Providers are active participants on Health Plans committees, advise care managers, and lead population-based care. Providers serve as subject matter experts for evidence-based guidelines, perform periodic guideline review, and alert UUHP when guidelines change. Performance feedback on quality measures provides additional opportunities for engagement and collaboration. 8. Program Integrity The Fraud, Waste and Abuse Program is designed to prevent and detect fraudulent and/or abusive behavior by providers, members, and other individuals or organizations associated with the operations of the Health Plans. The program is linked to the re-credentialing process through regular reviews of the Fraud and Abuse audit log prior to credentialing/re-credentialing meetings. 9. Information Systems Information systems supports the overall improvement strategy by facilitating the collection, aggregation, analysis, tracking, and reporting of utilization, cost, quality, and service data. Information systems include claims, registries, databases, electronic medical records, and analytical programs. The Provider Database serves as a resource for claims processing, customer service, and provider directories. Increasing the accuracy of the Provider Database will result in more accurate provider directories, better customer service 6

7 to members and providers, a decreased number of misdirected payments, and increased efficiency during the credentialing process. 10. Resource Allocation administrative team is aware and fully supportive of quality improvement initiatives as evidenced by encouraging innovative ideas and solutions, use of technology, and use of resources that will better serve members, providers, staff, and the community. 11. Financial Solvency uses sound financial management and accounting best practices to ensure financial solvency. A key marker of success is the ability to manage the Medical Loss Ratio. 12. Quality Improvement Program Update and Evaluation maintains an active Quality Improvement Program. The program is organized through the Quality Improvement Program Description, Quality Improvement Work Plan, and Quality Improvement Program Evaluation C. Implementation Strategy Quality improvement activities are designed using the Model for Improvement developed by Langley, et. al. 4, (Appendix C, Figure 1)the Best Care and Administrative Practices (BCAP) 5 improvement model, and the HIVQUAL Program and Process Cycles 6 (Appendix C, Figure 2). For studies reviewed by the External Quality Review Organization we use the Centers for Medicare & Medicaid Services protocol 7. D. Measurement UUHP measures performance against internal and external benchmarks and thresholds when available and where applicable. Whenever possible, measures and associated benchmarks are based on national measurement standards, i.e., HEDIS, CAHPS, measures endorsed by the National Quality Forum, the Centers for Medicare & Medicaid Services, including Star Ratings, and local measures established by the Bureau of Managed Health Care or the respective partnerships in which we participate. Baselines are established and improvement monitored over time. Interventions are assessed to determine whether process changes have led to improvement or have corrected identified issues. E. Data Collection and Analysis Data are collected to quantify clinical and service performance against targeted benchmarks and thresholds. Data sources include, but are not limited to, medical records, claims data, customer satisfaction surveys, utilization management activities, 4 Langley G, Nolan K, Nolan T, Norman C, and Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass, Center for Health Care Strategies: Best Care and Administrative Practices (BCAP) Quality Improvement Model Department of Health and Human Services Centers for Medicare & Medicaid Services. Conducting performance improvement projects: a protocol for use in conducting Medicaid external quality review activities. Final Protocol: Version 1.0. May 1,

8 complaints and appeals data, pharmacy utilization data, CAHPS surveys, and care management assessments. Data are analyzed to identify trends, variances, improvements, and improvement opportunities. Results are reported to the Quality Improvement Committee quarterly. Contractually required reports are submitted as required. F. Outreach and Education 1. Providers Outreach and education regarding quality improvement initiatives is accomplished internally through existing committee structure, monthly staff meetings, and ongoing written and electronic communications. Provider Relations and Quality Improvement staff collaborate to educate providers and provider organizations regarding quality improvement initiatives through provider meetings, on-site quality improvement technical assistance visits, provider newsletters, and our website. 2. Members Member outreach and education is accomplished collaboratively by health plan departments including Enrollment, Marketing, Quality Improvement, and Care Management. All new enrollees also receive the Member Handbook and a new enrollee education call to ensure they understand the benefits and services available to them. New enrollees receive an enrollment form with a health questionnaire used to identify members with special health care needs; high-risk members are referred to Case Management, and receive written self-care education. All members receive the member newsletter, which is aimed at providing members with evidence-based health care information. Outreach is culturally and linguistically appropriate. We continuously update members primary language information in our system, which allows us to customize education by language preference. Outreach materials are provided in both English and Spanish, and translation services are available to any member needing additional assistance. Staff are required to complete. Culturally and Linguistically Appropriate Services (CLAS) training annually and prepare and evaluate materials with cultural and language preferences in mind. Quality Improvement staff reaches out to members in order to provide important health information and to promote services to which they are entitled. General health and member safety information is disseminated primarily through member newsletters and on our website. We promote services directly to members through reminder letters and calls. Examples include: Reminders to parents about well child and CHEC exams and childhood immunizations. Women s health services reminders: Breast and cervical cancer screening, chlamydia screening, and HPV vaccination. Monthly health information linked to national health observances and seasonal health topics. 8

9 Preventive health and wellness program offerings. G. Provider Participation 1. Credentialing, Recredentialing, and Provider Profiling: The Credentialing Program ensures that providers approved to participate in the Plan network have met professional and clinical standards that reflect their ability to render quality medical care. Provider profiling consists of the identification of outliers in billing practices or clinical performance. The primary purpose is to identify nonstandard behavior that may include fraud and abuse, safety, and quality of care issues. If identified, health plans management and the Provider Contracting Committee institute corrective actions plans. If the issue is related to clinical care, safety, competence, or conduct, the Credentialing Committee may also take action up to and including termination of the provider s participation or application for network participation. Data used for profiling include Billing data obtained from claim detail reports, the pended claim process, the claim editing system that detects improper coding, and provider profile reports that identify variances in billing patterns as compared to their peer group; Clinical performance data obtained from medical record review including HEDIS and CHEC and Abortion, Hysterectomy, and Sterilization audits; Utilization management data reflecting aberrancies detected through pended claims, medical necessity, benefit determination, and benefit exception reviews; Customer service data including complaints related to access and availability, quality of care, or behavior issues. 2. Performance Feedback Performance feedback is provided through special mailings, provider newsletters, or meetings with provider organizations. Feedback may include, but is not limited to, information about evidence based guidelines, HEDIS and CAHPS results, health management program audits, covered services, and proper coding. Specific performance feedback regarding individual actions or patient data is communicated directly to providers and/or the provider organization. Specific feedback may include, but is not limited to: List of members who require specific care or services; Discussions regarding the findings from medical record review, health management program audits, complaints, appeals, referral patterns, utilization, suspected fraud or abuse, access and/or availability, and compliance with contractual requirements, policies, or procedures. Recognition for performance or contributions. 3. Service to Health Plans Participating providers serve on Health Plans committees whose role is to: 9

10 Review and provide feedback on preventive health standards, clinical protocols, health management programs, quality outcomes and HEDIS results, new technology and other clinical issues as needed; Review proposed quality improvement interventions and study design; Participate in the development of interventions to improve care, service, or safety. Providers may also be asked to: Support the Quality Improvement Program by serving as a physician champion; Provide consultation as a subject matter expert for improvement initiatives; Provide independent peer review for utilization review and appeals. H. Community Collaborations We actively participate in the DMHF s Quality Improvement Council, and collaborate with several groups in the Utah Department of Health Division of Disease Control and Prevention and the Division of Family Health and Preparedness. We participate with, and our work is supported by: Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ) Utah Mammography Action Coalition (UMAC) Utah Cancer Action Network (UCAN) Utah Adult Immunization Coalition (UAIC) Health Plan Partnership (HPP) University of Utah College of Health, School of Medicine, College of Nursing, and College of Pharmacy Community initiatives such as Green and Healthy Homes, ActiveCare, Living Well with Chronic Disease, and Million Hearts are important components of our efforts to provide high quality, cost effective care for individuals and populations. IV. Program Structure A. Governance The Executive Medical Director has ultimate responsibility for the quality of care and service delivered to members, and is the highest level of oversight for Health Plans Quality Improvement Program. The Executive Medical Director delegates authority and responsibility for the to the Medical Director for Quality, the Quality Improvement Committee, and the Health Plans Executive Director. The Medical Director for Quality oversees implementation of the Quality Improvement Program and delegates day-to-day management and implementation of the program to the Clinical Operations Director and the Quality Improvement Manager, who is responsible for: Oversight and implementation of the Quality Improvement Work Plan Support for the Quality Improvement Committee Identifying and tracking opportunities for improvement. 10

11 Facilitating quality improvement data collection and analysis. Designing quality improvement interventions. Facilitating the preparation and completion of the annual Medicaid review. B. Organizational Structure Appendix D Figure 1 shows the Health Plans overall organizational structure and its relationship to University of Utah Healthcare. Health Plans departments include: Health Plans Management, Operations (Enrollment, Claims, Customer Service), Clinical Operations (Care Management, Quality Improvement), Provider Network, Information Systems, Actuarial Services, Finance, and Programs and Marketing. Appendix D Figure 2 shows the Clinical Operations structure. Primary responsibility for the implementation and maintenance of the Quality Improvement Program is within Clinical Operations. Quality Improvement staff are integrated with Health Plans Care Management staff, Community Clinics Quality Improvement staff, and work closely with the Molina as a partnered plan for Healthy Advantage and Healthy Advantage Plus Medicare, University of Utah Medical Group, and other providers to ensure that all aspects of care and service are evidence-based, appropriately assessed, improved, and monitored and evaluated over time. The Quality Improvement Team supports program development, designs improvement interventions, facilitates provider-directed improvement interventions, conducts process and outcomes measurement and remeasurement, and provides performance feedback. The Care Management Teams implement primarily member-directed interventions, advise the Quality Improvement Team of quality of care concerns, member safety and members who may be at risk as a result of a lack of care giver support or threats of violence, participate in internal and external quality improvement projects, and recommend member and provider outreach activities. 11

12 Complex case High risk/cost Treatment plans Home visits CM/UM Community outreach Team expertise QI QI Program/Work Plan/Evaluation Project development HEDIS and Stars measures; overall data management Process mapping Prevention Provider outreach Outcome reporting Collaboration QI aligned with the CM/UM Teams Program development Member stratification Process mapping Data management Outcome tracking HEDIS and Stars measures Quality initiatives: Work Plan, Best Practice C. Committee Structure and Function Committees are structured according to contractual requirements and business needs and may be oversight, decision making, or advisory bodies. Committee composition and functions are driven by the committee s purpose. Committees having purpose and function central to Health Plans operations and quality of care and service are detailed in Appendix E. D. Project Teams Cross functional project teams support ongoing quality improvement initiatives and address quality improvement and member safety concerns. Teams may include staff from any or all health plans departments depending on the initiative or concern. Teams accomplish their work using the Nolan model and rapid cycle improvement. The Quality Improvement Manager reports progress and results of quality improvement initiatives to the Quality Improvement Committee quarterly. E. Confidentiality All content produced by Health Plans, written or electronic, that impact business operations, members, or providers are confidential. Access is limited to the Clinical Advisory Council, the Quality Improvement Committee, health plan personnel with a need to know, DMHF staff, and contracted entities for the sole purpose of quality review and delegation audits. Content is privileged and prepared in a manner to 12

13 maintain confidentiality, meet HIPAA requirements, and are stored securely. Privileged and confidential information may not be disclosed outside of the committees or review entities. 13

14 Campus Healthy U Appendix A FY 2015 Quality Improvement Work Plan 1. Administration and Leadership Under the direction of the Governing Body and, with its support, leadership is responsible to adopt and support an Accountable Care Organization (ACO) business model. To meet this obligation requires a shift from episodic care with fee for service payment, to population management with payment methodologies aligned to achieve value-based payment. The overall outcome is intended to be improved population health, improved experience of care (quality and satisfaction), and reduced costs. Goal Methods Target Date Project Lead Ongoing ACO development: Implementation of new payment methodologies. X X Continue to expand value-based payment to other network providers. Explore value-based payment for disease managed populations. 1. Strengthen payment models with Community Clinics, UPC, and South Main Clinics. 2. Risk stratification to identify high priority populations for care management. 3. Incorporate currently defined (HEDIS) quality measures into the model. 1Q2015 and ongoing Wilson/ Muhlestein/ Borer 2. Quality Assessment and Performance Improvement employs a systematic quality assessment and performance improvement process based on the Nolan model, Plan-Do-Study-Act, and the HIVQUAL interdependent project/program model. The process applies to all aspects of the health plans and the associated contractual requirements. Addressed here are measures of the experience of care (quality and satisfaction) captured through HEDIS and the CAHPS survey. Goal Methods Target Date Project Lead Collaborate with the UUMG data warehouse initiative. 14 X Improve the timeliness, accuracy, and efficiency of HEDIS data collection. 1. Provide EDW staff with HEDIS measures. 2. Validate results obtained from EDW. September 2014 and ongoing Johnson

15 Campus Appendix A Goal Methods Target Date Project Lead Wellness X X Engage members as active partners in their health and wellness. Improve chronic disease care for children and adults X Increase A1c testing rates for people with diabetes to 90% (Baseline 82.39%) 1. Publish member focused, timely information, on our website and in member newsletters. 2. Expand the All About U pilot wellness program and associated activities to Health Plan and Healthy U members 1. Provider office outreach - documentation, coding, and billing. Ongoing December 2014 and Ongoing Dorius Dorius/ Johnson/ Armour-Roth Increase annual eye exam rates for people with diabetes to 55% (Baseline 44.23%) 1. Reminders via MyChart and ActiveCare app. 2. Engage Moran Eye Center. 3. Segment American Academy of Ophthalmology DVD to be useful to providers and members. 4. Consider offering education sessions for members using the DVD. 5. Member incentives. 6. Work with Community Clinics/Moran to arrange backto-back appointments. 15 Improve the Asthma Medication Ratio to 65% (Baseline 61.69%) Improve appropriate asthma medications for children age 5 11 to 1. Collaborate with Community Clinics pharmacy. 2. Symptom.ly pilot implemented July Pilot of 50 in first 90 days, then expand. 3. Monitor asthma medication use

16 Campus Appendix A Goal Methods Target Date Project Lead 90% (Baseline 88.6%)8 and medication ratio data. 4. Partner with UPIQ. 5. Engage providers through UUMG, newsletters, and outreach. 6. Use Department of Health resources currently under development (Rebecca Giles). 7. Implement Home visit folder that includes a home assessment tool designed to surface needs for asthma education. 8. Implement the Asthma Education Booklet and children s coloring book. 9. Magnetic folders will house the Asthma Action Plan to be posted on the home refrigerator. Physician champions: Tim Graham, MD Chuck Norlin, MD Julie Day, MD Improve care for children with pharyngitis X Improve blood pressure control for patients with hypertension. Baseline 58.39% Improve Appropriate Testing for Children with Pharyngitis to 70%. (Baseline 67.89%) 1. Continue participation in the Health Plan Partnership hypertension initiative. 2. Partner with HealthInsight on Million Hearts. 3. Member outreach related to hypertension. 1. Provider office outreach - documentation, coding, and billing. 2. Incorporate performance into December 2014 and Ongoing Dorius/ Johnson/ Armour-Roth 16

17 Campus Appendix A Goal Methods Target Date Project Lead Physician champions: Chuck Norlin, MD Julie Day, MD Decrease the incidence of vaccine preventable conditions X Maintain Appropriate Treatment for Children with URI at 95%. Maintain childhood immunization Combo 3 compliance at 75% or improve to 80%. UPC value based payment. 3. Engage with UPIQ to create messaging and drive antibiotic stewardship 1. Incorporate performance into UPC value based payment. 2. Engage with UPIQ to create messaging and drive antibiotic stewardship 1. Continue to promote and educate regarding immunizations for all ages, with an emphasis on children and adolescents. 2. Pair immunization reminders with CHEC reminders. 3. Engage the Patient Advisory Group to understand barriers. 4. MyChart reminders. 5. Children s health infographic. 6. Partner with UPIQ and the Vaccine Advisory Committee December 2014 and Ongoing Dorius/ Johnson/ Armour-Roth Increase adolescent immunization compliance rate (Combo 1) to 70%. (Baseline 63.65%) 1. Measure using hybrid method. 2. Age appropriate member outreach through member newsletters and our website. 17 Increase the HPV vaccination rate to 20%. (Baseline 13.38%) 1. Link to the Department of Health HPV Awareness Campaign. 2. Targeted outreach to parents of

18 Campus Appendix A Goal Methods Target Date Project Lead Physician champions: Ellie Brownstein, MD Julie Day, MD Tamara Sheffield, MD (UAIC) Increase women s health screening rates X Promote adult immunizations. Increase mammography screening rate to 55% and cervical cancer screening rate to 65% (Mammography baseline 45.49%) (Cervical baseline 42.82%) year olds. 3. Link to adolescent immunizations. 4. Educate the pediatric care managers and our partner pediatric providers, i.e., Community Clinics, UPC, and South Main Clinic using the Invisible Threat video. 1. Continue active participation in UAIC and the Vaccine Advisory Committee. 2. Promote adult immunizations in August. 3. Targeted outreach to pregnant women for Tdap. 1. Implement recommendations from the cancer screening stakeholder group, e.g., MyChart, social media, infographic. 2. Partner with Community Clinics to improve or spread their processes and practices. 3. Partner with Strong Start. 4. Engage physician champions in impacting provider performance. 5. Institute directed provider feedback. 6. Work with Community Clinics to December 2014 and Ongoing Dorius/ Johnson/ Armour-Roth 18

19 Campus Appendix A Goal Methods Target Date Project Lead adapt methods successful in previous cancer screening initiatives. Physician champion: Julie Day, MD Continued reduction in preterm births Physician champion: Erin Clark, MD Continued improvement in prenatal and postpartum care Increase the overall chlamydia screening rate to 57% (Baseline 25%) X X Maintain the rate of preterm births <36 weeks to < 5%. X Reduce total preterm births by 1%. Continue to increase the expected number of prenatal visits by 5% (Baseline 56.93%) 1. Targeted outreach to year olds. 2. Engage UPC and South Main Clinic, CHCs. 1. Continued participation in Strong Start. 2. Emphasize contraception and 17P 1. Encourage the use of telehealth in low risk populations. 2. Provider outreach to encourage telehealth and implement reminders. 3. Develop a prenatal infographic. Ongoing December 2014 and ongoing Dorius/ Johnson/ Armour-Roth Dorius/ Johnson/ Armour-Roth Increase prenatal care in the 1 st trimester or w/in 42 days of enrollment to 25% (Baseline 72.26%) 1. Validate administrative data and review MRR method for this measure. 2. Work with providers to complete a prenatal visit on enrollment. Physician champion: Erin Clark, MD Karen Buchi, MD 19 Increase postpartum visits between 21 and 56 days post-delivery to 65% (Baseline 60.1%) 1. Work with providers using cocoon visits to work within the date parameters. 2. Track appropriate care that falls outside the HEDIS time frame.

20 Campus Appendix A Goal Methods Target Date Project Lead Continued improvement in well child care X Increase well child visits at 0 15 months to 65% (Baseline 58.64%) 1. Combine CHEC and well child visits, as well as immunizations into a targeted, ongoing program. 2. Consider using social media to reach families more timely. 3. Create and post an infographic related to childhood wellness. December 2014 Dorius/ Johnson/ Armour-Roth Physician champion: Karen Buchi, MD Reduce resource utilization, cost, and radiation exposure by eliminating imaging for low back pain Physician champion: XXXXX, MD Annual CAHPS Survey Physician champion: Michael Magill, MD Julie Day, MD UUMG Increase well child visits at 3 6 years to 72% (Baseline 62.04%) X X Improve the percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis to 80%. (Baseline 71.72%) X X Improve CAHPS scores to the level of the national average or above for: Getting needed care (Baseline76.0%) Getting care quickly (Baseline 87.0%) Customer service rating (Baseline 84.9%) 1. Adapt the above for this age group. 1. Link with the Radiology Department initiative. 2. Support hard stop in Epic. 1. Continue customer service focus. 2. Outreach to specialty groups through CAC and the UUMG to improve timeliness. 3. Attempt to increase response rate. December 2014 December 2014 and ongoing Dorius/ Johnson/ Armour-Roth Peterson/ Muhlestein/ Harkness/ Dorius 20

21 Campus Healthy U Campus Appendix A 3. Enrollee Rights and Responsibilities have established functions, operating under established policies and procedures, which are designed to provide safe, effective, efficient, timely, equitable and patient-centered services to our members. Those functions include member and community education and outreach, an efficient enrollment process, accurate and timely claims processing, avenues to communicate appeals and grievances, and mechanisms to assist members to make informed decisions about their care. Goal Methods Target Date Project Lead Member and Community Outreach X X Increase effectiveness of communications by leveraging technology to reach members and providers. Continue to decrease the total number of adjusted claims X X Decrease overall claims adjustments by 2% Increase member engagement X Increase member engagement through various member touch points. 1. Increase the number of MyChart accounts. 2. Engage more members with social media. 1. Organize recurring meeting. 2. Review reason for adjustments and identify areas of improvement. 3. Implement identified changes. 1. Implement online chat functionality 2. Reach out to members for welcome call 3. Implement phone survey option in customer service 2Q2015 3Q2014 4Q2014 1Q2015 2Q2015 Peterson/ Dorius Harkness/Smi th Harkness 4. Access and Availability ensures that all services are available, accessible, and provided to members in a culturally and linguistically appropriate manner. We utilize primary language information in the claims system to provide member materials for all languages making up 3% or more of the enrolled population and provide translation services for all situations. We continually strive to increase access to and availability of services to all members through scheduling, technology, expanded service hours and expanded services within those hours Goal Methods Target Date Project Lead Increase access to services X X Improve the availability and use of 1. Identify patients utilizing the ED 2Q2015 Dorius/ 21

22 Campus Healthy U Campus Appendix A Goal Methods Target Date Project Lead after-hours, Saturday, and remote services. Direct scheduling by care managers. on Saturdays and after hours. 2. Outreach mailer and care manager notification of urgent care services within their geographic locations. 3. Communicate the availability and location of after-hours and Saturday service to members. 4. Utilize telehealth, Project ECHO. Day 5. Coordination and Continuity of Care is committed to providing coordinated care across the continuum. Strengthening the care management team with physician leaders, using technology to expand the care managers reach, engaging members in self-management of chronic illnesses, and improving the potential and quality of life for tech dependent children are key strategies to achieve coordinated care across the continuum. The outcomes will include increased member satisfaction, higher quality care, improved member health, increased access to care, and lower overall cost. Goal Methods Target Date Project Lead Ongoing development of the care management program X X Continue to advance care management teams in the population management approach. 1. Compile ROI for each team using process mapping and the Harvard methods. 2. Identify outcomes for each team and monitor progress. 3. Increase focus on high cost, high risk pharmacy. 4. Implement programs for: a. Palliative care b. Pain management c. Disease management 1Q2015 Dorius/ Armour-Roth/ Johnson 22

23 Campus Appendix A Goal Methods Target Date Project Lead Access to Care Management services X X Outreach to our members so they are aware of the range of our care management services. Self-management programs for diabetes, heart disease, and asthma Physician champion: Tim Graham, MD Christopher McGann, MD Chuck Norlin, MD Improved quality of life for ventilator dependent children and their families Physician champion: Nancy Murphy, MD Improve care coordination for members requiring both medical and psychiatric care Physician champions: Kristi Kleinschmidt, MD Encourage enrollment in MyChart, CM telephone outreach and home visits, text messaging, telehealth visits. X X Engage and empower patients in selfmanagement programs using community services and technology. X X Better align the needs of these children and their families through effective collaboration among specialty providers, PCP, and health plan. Increase the number of Community Clinics with integrated medical and mental health services to 10. Increase use of GATE Utah. 1. Encourage member enrollment in MyChart. 2. Care manager outreach: a. Telephone and text messaging b. MyChart communication c. Home visits d. Telehealth visits 1. Enroll members in ActiveCare. 2. Promote the Living Well Program. 3. Partner with the Million Hearts initiative. 4. Enroll members in Symptom.ly 5. Monitor outcomes and ROI. 1. Implement telehealth visits. 2. Monitor parent stress scores. 3. Measure patient and family satisfaction. 1. Continue participation in the BHP Care Coordination Partnership. 2. Monitor GATE Utah referrals. 3. Assess patient and provider satisfaction. 1Q2015 1Q Q2014 2Q2015 Dorius/ Armour-Roth Dorius/ Armour-Roth/ Johnson Dorius/ Armour-Roth/ Johnson Dorius/ Armour-Roth/ Johnson 6. Utilization Management In order to provide evidence-based, efficient, and equitable care and services to our members. is committed to a utilization management program based on nationally recognized criteria that are accurately and appropriately applied in all cases. 23

24 Campus Healthy U Campus Appendix A Goal Methods Target Date Project Lead Encourage and enforce appropriate utilization of services. Physician champions: Dean Smart, MD Nate Wanner, MD Scott Junkins, MD Complete the redesign of the DME process. X X Implement programs to address high risk, high cost drugs. Evaluate new and/or high cost procedures. Better use the palliative and pain management services. X X Streamline DME approval processes and reduce expenditures. 1. Establish a Utilization Management Team. 2. Train staff on palliative care resources. 3. Better utilize the Pain Clinic. 4. Adopt drug protocols. 1. Implement process changes identified in process mapping. 2. Complete fee schedule changes. 3. Review DME rentals. 4Q2014 3Q2014 Dorius/ Armour-Roth Dorius/ Muhlestein/ Smith 7. Provider Participation engages providers through newsletters, updates and performance feedback. Providers are active participants on Health Plans committees; advise care managers; and lead population-based care management teams. Implementing a provider portal adds another level of engagement. Increasing performance feedback on all quality measures will provide additional opportunities for engagement and collaboration. Goal Methods Target Date Project Lead Physician Connection (formerly Plan Link) implementation X X Recruit additional Physician Connection participating providers. 1. Epic 2014 upgrade will be completed in Q and will have several changes that will need to be tested and communicated to providers. 2. Provider groups who use both the clinical and health plan 2Q2015 Muhlestein/ Smith 24

25 Campus Healthy U Campus Appendix A Goal Methods Target Date Project Lead Provider feedback for continuous improvement in compliance with CHEC guidelines. X Achieve 90% compliance with CHEC physical exam component guidelines. features will be implemented in Q Enhance training environment and roll out to additional pilot practices. 4. Solicit feedback from additional pilot practices. 5. Develop criteria for additional offices. 6. Implement with minimum 20 offices. 1. Continue to improve the CHEC audit process: a. Conduct quarterly audits b. Redesign the audit tool and methodology 2. Reinstitute member letters. 3. Establish a provider outreach program. December 2014 Dorius/ Johnson 8. Program Integrity The Fraud, Waste and Abuse Program is designed to prevent and detect fraudulent and/or abusive behavior by providers, members, and other individuals or organizations associated with the operations of the. The program is linked to the re-credentialing process through regular reviews of the Fraud and Abuse audit log prior to credentialing/re-credentialing meetings. Goal Methods Target Date Project Lead Continued refinement of the Fraud, Waste, and Abuse Program X X Provide training to providers (internal and external) identified through the fraud/waste/abuse program. 1. Set up random quarterly audits with provider types that abuse trends are more prevalent, i.e., Ongoing Peterson/ Muhlestein 25

26 Campus Healthy U Campus Appendix A Goal Methods Target Date Project Lead Home Health, DME. 2. Monthly audits. 3. Develop process for reporting identified substance abuse to the OIG/MFCU. 9. Information Systems Information systems supports the overall improvement strategy by facilitating the collection, aggregation, analysis, tracking, and reporting of utilization, cost, quality, and service data. Information systems include claims, registries, databases, electronic medical records, and analytical programs. Two important focus areas are the CMS mandated ICD-10 and an improved Provider Database which serves as a resource for claims processing, customer service, and provider directories, among other uses. Increasing the accuracy of the Provider Database will result in more accurate provider directories, better customer service to members and providers, a decreased number of misdirected payments, and increased efficiency during the credentialing process. Goal Methods Target Date Project Lead ICD-10 Implementation X X Continue to prepare and test systems to achieve successful ICD-10 implementation Additional testing of EDI claims with internal providers. 2. Testing of EDI claims with external providers. 3. Review of build completed by coding auditor position. 4. ices upgrade to version for additional remediation of ICD Testing with other outside vendors (Crimson, Verisk, etc.). 6. Actuarial analysis of ICD10 conversion on inpatient claims. 1/15-3/15 3/15-6/15 10/14-12/14 1/15 3/15-6/15 Continued improvement in the setup X X Achieve 80% accuracy of the 1. Complete redesign of provider 3Q2014 Muhlestein/ TBD Smith

27 Campus Healthy U Campus Appendix A Goal Methods Target Date Project Lead and population of the provider database Use available technology to reduce workload and improve turnaround time. database. X X Expand chie access for facility documentation. database. 2. Continue new process. 3. Audit 5% of delegated credentialing audits. 4. Hire additional coordinator position by 10/14. New executive position starts 7/7/ Expand included populations. 2. Begin looking at hospital admissions and discharges. 4Q2104 Smith Dorius/ Armour-Roth MyChart access for plan/member communication and documentation review. 1. Obtain MyChart security access to communicate with members. 2. Review electronic documentation before requesting additional records. 3. Monitor workload and workflow. 10. Adequate Resources administrative team is aware and fully supportive of quality improvement initiatives as evidenced by encouraging innovative ideas and solutions, use of technology, and use of resources that will better serve members, providers, staff, and the University community. Goal Methods Target Date Project Lead Administrative and leadership support for quality improvement initiatives X X Inform leadership of current and planned QI activities and projects. Establish a link to University 1. Restructure the Population Management Committee. 2. Partner with the Health System Innovation and Research (HSIR) 4Q2104 and Ongoing Wilson/ Magill 27

28 Campus Appendix A Goal Methods Target Date Project Lead Physician champions: Mike Magill, MD John Bohnsack, MD Rachel Hess, MD Expand the program to curb nonemergent, non-urgent use of the Emergency Department Physician champion: Scott Youngquist, MD Healthcare committees approving lean projects. Increase awareness of health plan activities within the University community. X X Continue to reduce ED utilization for non-emergent, non-urgent care. Department. 3. Continue to design lean projects within Health Plans. 1. Continue to work with the ED High Utilizer Committee to identify patients that have high ED utilization for non- emergent care. 2. Implement a program incorporating linkage to primary care, community-based services, telehealth technology, member and provider engagement and follow up. 3. Align payment with the appropriate/desired levels of care. 1Q2015 Dorius 11. Financial Solvency uses sound financial management and accounting best practices to ensure financial solvency. A key marker of success is the ability to manage the Medical Loss Ratio. 28

29 Campus Healthy U Appendix A Goal Methods Target Date Project Lead Manage Medical Loss Ratio (MLR) X X Healthy U MLR 92.1% MLR 86.1% Continued emphasis on Care management OB & ED diversion initiatives, as well as other programs. 1. Revamp deductible, copay benefit structure 2. Care management for OB and other programs June 2015 Finlinson 12. Quality Improvement Program Updates/Program Evaluation is contractually obligated to maintain a Quality Improvement Program. The Quality Improvement program is organized through the Quality Improvement Program Description, Quality Improvement Work Plan, and Quality Improvement Program Evaluation. Goal Methods Target Date Project Lead QI Program Description and Work Plan X X Monitor, improve, and document the quality of care and service provided to our members QI Program Evaluation X X Evaluate and document the quality of care and service provided to our members. Continue to update the program annually and maintain quarterly accountability to the Work Plan Continue to evaluate progress at least quarterly. For goals that are no longer applicable or not feasible, consider finalizing evaluation of those goals at the time they are determined to be non-operational. Ongoing Ongoing Johnson Johnson 29

30 Appendix B FY 2014 Work Plan Evaluation 1. Administration and Leadership Under the direction of the Governing Body and, with its support, leadership is responsible to adopt and support an Accountable Care Organization (ACO) business model. To meet this obligation requires a shift from episodic care with fee for service payment, to population management with payment methodologies aligned to achieve value-based payment. The overall outcome is intended to be improved population health, improved experience of care (quality and satisfaction), and reduced costs. Ongoing ACO development: Implementation of new payment methodologies. (Dorius/Wilson/ Muhlestein) X X UUCC payment methodology fully implemented by July 1, 2013 Adopt an OB bundled payment by January 1, Move value based payment methodology to other providers in the network by January Consider value based payment for new initiatives as they are implemented. 1. Engage physician, clinic, hospital, and plan leadership to align payment based on quality (value-based payment). 30 MET NOT MET 1. OB Bundled payment not yet implemented. 2. a) Clinical working group has developed 95% of care pathway. b) Operational working group (including billing, contracting) have resolved 90% of issues. OB Bundle Payment a) Care pathway pending final approval from physicians. b) Operational working group on hold until physicians approve care pathway and bundle definition. Harvard Business Group was brought in to this process to help determine accurate costing and return on investment Value Based Payment with additional network providers delayed due to hiring of Director. Quality measures Pending approval from appropriate leadership committees and provider s contracting office. Continue FY 2015 Implement pilot OB bundle program upon approval of final criteria and care pathway. Finalize quality measures in VBP contract upon approval from leadership and provider s contracting office. Finalize contract including quality measures upon approval from leadership and provider s contracting office.

31 Appendix B 2. Establish criteria for physician participation in quality measures and incentives to set expectations. 3. Align claims, system support, and reporting capabilities to measures provider compliance, pay claims correctly, identify incentives earned, proper patient attribution to measure progress, and appropriate measures to show increased quality at lower cost 4. Revise contract and credentialing process as needed to reflect this alignment. 5. Continuously evaluate methodologies and measures as value-based payment is implemented and as new initiatives are incorporated into the methodology. Value Based Payment Implemented with General Pediatrics effective 7/1/2014. Meet monthly with leadership to review quality gaps, risk stratification of patients. Includes action plans by patient. 31

32 Appendix B 2. Quality Assessment and Performance Improvement employs a systematic quality assessment and performance improvement process based on the Nolan model, Plan-Do-Study-Act, and the HIVQUAL interdependent project/program model. The process applies to all aspects of the health plans and the associated contractual requirements. Addressed here are measures of the experience of care (quality and satisfaction) captured through HEDIS and the CAHPS survey. Improve the accuracy and efficiency of HEDIS reporting by establishing discreet data elements in Epic. (Dorius/Smith) Establish ongoing HEDIS administrative data reporting and monitoring. (Dorius/Smith) Wellness (Dorius/Day) X X X X Identify and establish discreet data elements in Epic for State Quality Committee Measures Work with data warehouse to establish standard reporting formats. Continuously improve HEDIS measures 1. Establish a regular (monthly or quarterly) refresh of administrative HEDIS data for targeted measures. 2. Modify methods to improve measures based on progress. Engage members in leading healthy lifestyles 1. Assess members current knowledge of wellness and their participation in 32 MET We now participate on the UUMG Clinical Decision Support team working in collaboration with the Knowledge Management and Mobilization initiative to collect HEDIS clinical data elements from the EHR. MET We have the capability to collect data, in near real time, through our analytics tool and are evaluating 1Q2014 data, along with findings from the MRR, to develop interventions for improvement. MET We have provided information and references via newsletters and our website on: We learned that the data warehouse has been programming Epic to pull HEDIS data however, they did not understand the HEDIS specifications and the data were inaccurate. It has taken longer than expected to program and validate the data. Baseline data had to be established because past HEDIS data collection was not consistent in method in the past, i.e., MRR was performed on different measures each year, prior year s data were reported. Our member engagement initiative is still developing and, until we had more complete data, we were unsure of target populations and areas of need. Continue to participate with the UUMG in collecting, analyzing, and improving HEDIS data. We will continue to refine this process internally, but not as part of our FY 2015 Plan. Expand the All About U pilot wellness program and associated activities to Health Plan and Healthy U members.

33 Appendix B wellness activities. 2. Educate members on the difference between wellness and prevention. 3. Develop wellness activities specific to the Healthy U population. 4. Capitalize on the existing wellness program and associated activities spreadable to Healthy U. We have done community outreach related to healthy pregnancy and well child exams with South Main Clinic and CHCs. We are doing general wellness outreach to Hispanic community groups. 42% of members use MyChart, which provides reminders of recommended screening, immunizations, etc. We are active in the UCAN, UMAC, UAIC initiatives and the Health Plan Partnership. 33 What is Prevention? published on our website in July 2013 Screening Tests for Men, Screening Tests for Women published on our website July Skin Cancer Awareness published on our website July 2013 February is Heart Month published on our website February 2014 Alcohol Awareness published on our website March 2014

34 Appendix B Improve diabetes care (Dorius/Day) Improve care for children with pharyngitis (Dorius/Day) X X Increase A1c testing rates to 90% Increase annual eye exam rates to 60% 1. Identify population from Crimson. 2. Mine U of U provider data warehouse using CPT codes and A1c lab values. 3. Reminder notices to PCP and members regarding eye exam. 4. Participate in the Health Plan Partnership. Improve Appropriate Testing for Children with Pharyngitis to 75%. Improve Appropriate Treatment for Children with URI to 95%. Melanoma Awareness published on our website April 2014 Safety Awareness published on our website May 2014 NOT MET 82.39% 44.23% We have reports of our diabetes population and the IDDM subpopulation. These measures are estimated for completion and validation in the clinical data warehouse by August % 94.42% NOT MET MET We were late in the year in our attempts to impact these measures and did not have current, reliable data. The Health Plan Partnership was in flux for much of the year, and has now changed its focus away from diabetes. Reminders aren t working. Care delivered outside the PCP office is not consistently captured in the medical record. We are concerned that coding for strep tests may be inconsistent or, in the case of Quick Strep, not coded. Continue to improve rates to goal in FY Partnership with Community Clinics 2. Collaborate with Community Clinics on interventions 3. Transfer UDOH grant interventions to eye exam interactive apps. 4. ActiveCare webbased/smartphone app that sends alerts to MDs and care managers (pilot). 5. American Academy of Ophthalmology DVD. Continue to improve rates to goal in FY Engage with UPIQ to create messaging and drive antibiotic 34

35 Appendix B Decrease the incidence of vaccine preventable conditions (Dorius/Day) X 1. Newsletter article aimed at parents reminding them of the dangers of overusing antibiotics. 2. Reminder to PCP to complete strep testing prior to initiating antibiotics. 3. Reminder to PCP of antibiotic stewardship. Increase childhood immunization Combo 3 compliance to 80%. 1. Reminder to parents of the need for childhood immunizations. 2. Distribute CDC immunization schedule. 3. Promote the UDOH Vaccine for Children (VFC) Program. Promote adult immunizations. 1. Distribute CDC adult immunization schedule. 2. Participate on the UAIC. 3. Newsletter or web article on the importance of adult immunizations. Parents Beware of Antibiotic Overuse published in our spring 2014 Member Newsletter. PARTIALLY MET 75.16% Improved, but not to goal. Immunization schedules posted on our website. We have been invited to participate on the Utah Scientific Vaccine Advisory Committee. MET We remain active in the UAIC and the Tdap in Pregnancy initiative. We secured a KUTV interview with Dr. Tamara Lewis Sheffield on Tdap in Pregnancy We have observed that well child checks after the first 15 months are not consistent and suspect that this may impact the vaccine schedule. stewardship 2. Review Community Clinics coding and documentation practices 3. South Main and UPC are now partners 4. Monitor antibiotic use in peds URI. 5. Incorporate in VBP with pediatric clinic 7/1. Continue to promote and educate regarding immunizations for all ages, with an emphasis on children and adolescents, and continue to improve rates to goal in FY Include immunization reminders with CHEC reminders. 2. Partner with Community Clinics on interventions. 3. Query the Patient Advisory Group on potential barriers. 4. Use MyChart more effectively. 35

36 Appendix B Improve asthma care in children and adults (Dorius/Day) X Improve the Asthma Medication Ratio to 70% Improve appropriate asthma medications for children age 5 11 to 95% 1. Monthly asthma report by PCP. 2. Partner with the PCPs identified. 3. Use available UDOH asthma program materials to educate members, parents, and providers. 4. Encourage staff participation in UDOH asthma telehealth series. 5. Provide asthma resources and care manager follow up for members with asthma who need assistance with medication management. 6. Participate in UPIQ Asthma project. 36 eatures/baby/stories/vid_151.s html Immunization schedules are posted on our website. PARTIALLY MET 61.69% Unchanged, not to goal % NOT MET UUHP participates tin the UPIQ Asthma project and forwards monthly asthma member reports. Pediatric and adult team care managers provide educational materials to members and their families regarding medication compliance. Working with Symptom.ly to enroll 50 members with UPC as a pilot project to self -monitor medication compliance. Programs anticipated to impact the measures were implemented later than expected. 5. Create an infographic on children s health. 6. Partner with UPIQ and the Vaccine Advisory Committee Continue to improve rates to goal in FY Collaborate with Community Clinics pharmacy. 11. Symptom.ly pilot implemented July Pilot of 50 in first 90 days 12. Monitor asthma medication use and medication ratio data. 13. Partner with UPIQ. Increase women s X Increase mammography and NOT MET Time constraints and competing Continue to improve

37 Appendix B health screening rates (Dorius/Day) cervical cancer screening rates to 55% 1. Mammogram birthday card reminder program 2. Track impact of reminders monthly/quarterly. 3. Newsletter or web article on breast cancer screening. 4. Consider Televox reminders. 5. Provide cervical cancer screening materials to members and PCPs. 6. Promote UDOH screening services. 7. Participate in UCAN % 42.82% Rates remain flat despite targeting eligible members for mammography on their birthday rather than on a random date. Reminders have had an impact, but it is small. Screening rates increased from 18% to 25% during the last half of Reduce Your Risk for Breast Cancer published in our 2014 Spring Newsletter. Cervical Cancer Awareness Month published on our website in January priorities may create access issues. Our only intervention was a change in our reminders. Confusion related to conflicting screening schedules may discourage screening. rates to goal in FY Use interventions recommended by our cancer screening stakeholder group such as MyChart, Infographic, and social media. 2. Partner with Community Clinics to improve or spread their processes and practices. Increase the overall chlamydia screening rate to 25% 1. Participate in UDOH Chlamydia Screening Project. 2. Distribute project materials to PCPs and members. 3. Newsletter or web article on transmission and complication of chlamydia and testing and treatment options. MET 24.81% We have participated in the Department of Health s project to increase chlamydia screening rates. Can You Say Chlamydia published in our 2014 Spring Newsletter. Continue to increase screening rates. 1. Engage UPC and South Main. 2. Incorporate HPV and piggyback on current HPV ad campaign to improve both rates. 37

38 Appendix B Continued reduction in preterm births (Dorius/Day) X X Reduce the rate of preterm births <36 weeks to < 5% by: 1. Continued participation in the Strong start initiative. 2. Providing care management on all high risk pregnancies. 3. Providing assistive devices to moms on restricted activity to promote compliance and improve quality of life. MET 4% January - June 2014 Preterm births < 36 weeks July May % July - December % January - May % Total Preterm Births July May % July - December % January - May % Reduction in preterm births will continue to be a major quality improvement effort with emphasis on contraception and the use of 17P. Continue participation in Strong Start. Continued improvement in prenatal and postpartum care (Dorius/Day) X Increase the expected number of prenatal visits by 10% by providing incentive cards for moms. Increase prenatal care in the 1 st trimester or w/in 42 days of enrollment to 25% by 1. Care management tracking 2. Education booklet to be 38 Focus on Strong Start in our July 2013 Provider Newsletter Methods of Contraception January 2014 community event presented in Spanish MET 56.93% Incentive cards were given to mothers who completed risk assessments however, the significant increase in rate is the result of having done MRR. MET 72.26% We believe the significant rate increase is the result of having done MRR. We will continue to work toward maximizing improvement in prenatal and postpartum care rates. 1. Continue to engage with University Pediatric and South Main Clinics. 2. Develop interventions in conjunction with Strong Start.

39 Appendix B given to moms with preterm births at NBICU discharge. Increase postpartum visits by 56 days post-delivery to 65% through Care manager call for post -partum follow up. PARTIALLY MET 60.1% Significantly improved from 48.64% the prior year, but not to goal. Baby and mom visits don t coincide, leading to a high no show rate for postpartum visits. Recognizing this, clinics have adopted Cocooning, a family visit at one month postpartum. This was borne out in our MRR. Continued improvement in well child care (Dorius/Day) X Increase well child visits at 0 15 months to 50% and Increase well child visits at 3 6 years to 64% by: 1. Identify members not currently receiving well child visits. 2. Care manager outreach to identify barriers to completing visits. 3. Outreach regarding the importance of well child visits (possibly link to 58.64% MET PARTIALLY MET 62.04% Annual Checkups Help Kids Stay Healthy published in our Spring 2014 Member Newsletter We hesitate to discourage this practice in order to comply with the HEDIS measures since we believe it is a best practice that addresses both quality of, and access to, care. Well child checks for this age group are not linked to immunizations as with the 0-15 month visits. Parents may not see the need if they believe their child to be healthy. Continue to improve rates for the 3-6 year age group to goal in FY Query the Patient Advisory Group on potential barriers. 2. Check no show rates to see if this is an issue. 3. Link visit with flu shot. 4. Partner with UPC, 39

40 Appendix B Reduce resource utilization, cost, and radiation exposure by eliminating imaging for low back pain (Dorius/Day) Annual CAHPS Survey (Peterson/Muhlestein /Harkness/Dorius) X X X X immunizations). 4. Incentive cards. Improve the percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, and CT scan) within 28 days of the diagnosis to 80%. 1. Low back pain (LBP) analysis in place. 2. Partner with the College of Health to promote appropriate LBP care. 3. Work with PCPs at Community Clinics to identify best practice. 4. Monitor hospital outpatient measure OP-8 rates (MRI for LBP). Improve CAHPS scores to the level of the national average or above for: NOT MET 71.72% Working with a professor with the College of Health (Julie Fritz) regarding provider and member education regarding imagery and low back pain. Currently working on submitting a grant opportunity. This grant would incorporate Living Well regarding decisions on care for low back pain. Pilot with U of U Orthopedic Center. PARTIALLY MET Compared to 2012 child CAHPS results we show overall improvement. We are currently working with staff at the College of Health but targeted interventions are not yet in place. The hospital outpatient measure (OP_8) only addresses MRI rates. The rates for the current reporting period are: U of U 63.9% Utah average: 56.2% National average: 62.8% Customer Service hours were not extended due to budget limitations. South Main, and Community Clinics. 5. Provide incentives and/or transportation support. Continue to improve rates to goal in FY Continue to work with the College of Health on educational video for patients to help them make appropriate choices for LBP care. 2. Work with PCPs at Community Clinics to identify best practice. 3. Review the findings of the Performance Excellence team that is studying the imaging issue and coordinate on interventions where appropriate. Continue in FY Continue customer service focus. 5. Outreach to specialty 40

41 Appendix B Getting needed care Getting care quickly Customer service rating 1. Extend customer service hours % CRM turnaround time within 48 hours second wait time. 4. 2% abandonment rate. 5. Coach customer service staff below 95% compliance with customer service monitoring. 6. Increase survey response rate through member outreach. 7. Coordination between customer service and care management. 8. Encourage members to contact the health plan if they have access issues (See also Direct Scheduling and Nurse Triage) 76.0% 87.0% 84.9% Our success was achieved through the efforts of Customer Service to meet their goals. Timely appointments with specialists continues to be an issue and the one that impacts perceptions of getting needed care. Clinical Advisory Committee and the University of Utah Medical Group (UUMG) are working with physicians to improve access, i.e., shorter wait times for appointments. This will require education, coaching, and follow up before results will be realized. Alternating survey populations each year makes it difficult to compare and impact results. groups through CAC and the UUMG to improve timeliness. 6. Attempt to increase response rate. Educate physicians and clinics on the importance of access to our members via Provider Relations outreach and the Clinical Advisory Committee. 41

42 Appendix B 3. Enrollee Rights and Responsibilities have established functions, operating under established policies and procedures, which are designed to provide safe, effective, efficient, timely, equitable and patient-centered services to our members. Those functions include member and community education and outreach, an efficient enrollment process, accurate and timely claims processing, avenues to communicate appeals and grievances, and mechanisms to assist members to make informed decisions about their care. Member and Community Outreach (Peterson/Dorius/ Harkness) 42 X X Increase effectiveness of communications by leveraging technology to reach members and providers. Establish best practice for measuring the impact of outreach methods. 1. Mail and phone reminders to members enrolled in Care Management programs. 2. Letter and phone communications will be reviewed for effectiveness. (Analyze previous years preventive screens to those that have received notification and completed testing, i.e., Mammogram Birthday cards.) 3. Implement technologybased communication, e.g., social media, My Chart, chie, etc. MET We have continued to work toward using technology as another avenue to connect with our members. MyChart use for our employee plans is up 33% in the last 10 months and our Healthy U MyChart use is up 10%. We are also extending our outreach services to social media by informing members about our new enhancement programs, i.e., car seat and cell phone benefits. There have multiple levels of increasing communication with providers and members. Site visits have been conducted at a number of our provider offices to discuss care management, U Baby initiatives around preterm birth prevention, women s health, and home health care. Continue in FY 2015.

43 Appendix B Continue to decrease the total number of adjusted claims (Harkness/Smith) Evaluate the effectiveness of new member calls (Harkness) X X X Decrease overall claims adjustments by 2% 1. Retro provider contracts, benefit retro, impactable errors 2. Further develop reporting functionality and improve our ability to report on adjustments 3. Continue to develop and perform system audits 4. Trend and analyze based on dates of service 5. Focus on high volume adjustment projects to identify areas of improvement. 6. Evaluate the impact of the JIRA system on preventing future adjustments Evaluate the effectiveness of our current process of contacting new members through a third party vendor. Staff have conducted community education outreach for the Hispanic community in Midvale and at the South Main Clinic. Not Met Healthy U 11.6% (0.4% ) 4.6% (0.8% ) Systems improvements are in place and system audits are in process. Provider contracts, benefits, and errors are still unresolved MET Evaluation was completed as planned. Staffing constraints impacted our ability to fully deploy all the activities required to decrease adjustments to the desired level. Continue in FY No carry over in FY Evaluate the number of

44 Appendix B Improve the appeals and grievance process (Peterson) Assist members to make informed decisions about their care (Peterson) X X times the member answers the phone. 2. Evaluate the number of times the new member calls go to voic . 3. Evaluate the cost/benefit ratio of changing this process from the third party vendor. X Appeal and grievance management will be more effective and efficient through Epic, reducing processing time and improving member satisfaction. 1. Move the program from Excel to Epic 2. Create daily dashboards 3. Provide more detailed, actionable reports. X Evaluate options for making facility and provider cost and quality information more transparent to members. 1. Identify available quality and cost information sources. 2. Evaluate sources for accuracy and usability 3. Inform members of the MET Tracking has improved and errors reduced with the move to Epic. We are now have daily dashboards and are able to generate reports showing appeal type, trends, and totals. Reports are reviewed and acted on by the Operations Committee. NOT MET Promotion throughout the University Healthcare System for people to enroll in My Chart to communicate with their providers, view the Explanation of Benefits and request appointments. The cost information is still under review on what should be shared. This discussion is Epic One Chart roll out delayed all other initiatives. No carry over in FY 2015 No carry over in FY

45 Healthy U Appendix B availability of the information via newsletters, special notices, social media, etc. throughout the University Health Sciences leadership. Ongoing development and enhancements are occurring with the website for both Healthy U and UUHP members. Monthly updates, on the website and in the newsletter, are provided to help members know what information is pertinent for their health management. Introduced the cell phone option for Healthy U members. 4. Access and Availability ensures that all services are available, accessible, and provided to members in a culturally and linguistically appropriate manner. We utilize primary language information in the claims system to provide member materials for all languages making up 3% or more of the enrolled population and provide translation services for all situations. We continually strive to increase access to and availability of services to all members through scheduling, technology, expanded service hours and expanded services within those hours Maintain an effective CLAS program (Peterson) X X 100% staff participation in online CLAS training to maintain an effective MET The online module was successfully developed and The program is ongoing however, we will not carry it over as a FY 45

46 Appendix B program that supports member needs and promotes customer satisfaction. we achieved 100% staff participation in online CLAS training 2015 Work Plan initiative. Improve use of after-hours and Saturday service (Dorius/Day) X X 1. Develop online CLAS training module. 2. Develop Quiz 3. Implement online training in LMS 4. Track staff completion Communicate the availability and location of after-hours and Saturday service to members. 5. Identify patients utilizing the ED on Saturdays and after hours. 6. Outreach mailer and care manager notification of urgent care services within their geographic locations. PARTIALLY MET Community Clinics have extended hours and Saturday hours available. Clinic hours noted on website and with the answering service and phone triage. Appointments are made available for evening and Saturday for urgent and routine appointments. UUHP has been working closely with the Community Clinics to improve access and availability of after hour and Saturday clinic time. A stratification tool was designed that shows the high risk members and those using the ED for non -emergent care. This tool is used by the Community Clinics care managers to help identify those members needing outreach and care planning coordination. Continue for FY The magnets and mailers have been on hold until there was a consistent process in place to identify the members

47 Appendix B Direct scheduling by Care Managers (Dorius/Day) Expand nurse triage (Dorius/Day) X X X X Care Managers will be able to schedule an appointment when they have the member on the phone to facilitate continuity of care and compliance. J Dorius will work with Kim Pacheco in EPIC scheduling to determine work flow and PCP scheduling options for care managers to access EPIC scheduling Expand the nurse triage/access service for members and Healthy U for 6:00 a.m. to 11:00 p.m. 7 days/week. 1. Send out an RFP to Community Clinics and College of Nursing. 2. Award based on best value. NOT MET NOT MET RFPs were received and reviewed by leadership. Due to projected costs of the program it was agreed that UUHP Care Managers would continue taking call. On call availability is 24/7. requiring additional support and intervention. Due to implementing One Chart Epic in the hospital any upgrades that were not related to the inpatient implementation were put on hold. Will re-introduce the option of UUHP care managers having the ability to schedule appointments once One Chart implementation is completed Outside vendor support is cost prohibitive. Continue for FY 2015 No carry over. 5. Coordination and Continuity of Care is committed to providing coordinated care across the continuum. Strengthening the care management team with physician leaders, using technology to expand the care managers reach, engaging members in self-management of chronic illnesses, and improving the potential and quality of life for tech dependent children are key strategies to achieve coordinated care across the continuum. The outcomes will include increased member satisfaction, higher quality care, improved member health, increased access to care, and lower overall cost. 47

48 Appendix B Continued development of the care management program (Dorius/Day) X X Continue to advance care management teams toward a population management approach, i.e., prevention, maintenance, and targeted care management. 1. Each team will have a core physician leader to assist with best practice, patient engagement, strategy design, and treatment plan design: 2. Work with the Clinical Advisory Council to discuss case specifics, establish best practice, and policy & procedure. MET Population management in place for: Inpatient Navigator ED/Restricted (includes social work consult services) Maternal Child Health Adult/Pediatric Special Needs/Chronic care Wellness and Prevention High Cost/Catastrophic Pharmacy Specialty Meds, High utilizers- Catastrophic Review Community Clinic Care Collaboration Community Clinic Value Based Payment Program Continue in FY Develop pharmacy program 2. Focus on outcome reporting 3. Determine ROI. 48 Each team is fully staffed and there are collaborative efforts with the Community Clinics and hospital care managers throughout the valley. Behavioral health integration has been adopted by both the pediatric and adult teams. LCSW meets weekly with the care management teams to discuss complex cases, provide inservice, and

49 Appendix B educate on how to work with members dealing with mental health and medical co-morbidities. Access to Care Management services (Dorius/Day) X X Outreach to our members so they are aware of our care management services. Encourage enrollment in MyChart, CM telephone outreach and home visits, text messaging, telehealth visits. 1. Track open care management cases in Tapestry and treatment plans. 2. Identify low, medium, and high care manager involvement. Each care manager is carrying a 75 to 275 case load based on members complexity and risk scoring. MET Introduced a scoring methodology for the new enrollees that have completed a Health Risk Assessment (HRA). All HRAs that are marked as poor are forwarded to the care management assistant. The completed answers are compiled to determine level of care management intervention: Score Activity 7-12 Coordinator Call RN Call RN site visit Continue in FY 2015 A stratification tool was developed to show an acuity rating for all members and help identify those members 49

50 Appendix B needing outreach and care planning coordination. Diabetes medical home, selfmanagement program, and diabetes and heart disease prevention program (Dorius/Day) X X Healthy U: Identify our diabetes population (Adult and pediatric) : Identify our diabetes, pre-diabetes, and metabolic syndrome populations (Adult) Identify our diabetes population. (Pediatric) 1. Provide PCPs with a basic screening kit. 2. In collaboration with PCPs and the Diabetes Center, and using a multidisciplinary The tool looks at the health risk score from our analytics tool as well as mental health diagnosis, ED visits, inpatient events, pharmacy compliance for asthma patients, and PCP attribution. UUHP and Community Clinics care managers receive a monthly report of the high risk members and those using the ED for non - emergent care. PARTIALLY MET UUHP has been able to identify the diabetic population and those being treated at the Community Clinics and the Utah Diabetic Center. A basic screening tool has been developed and there is currently a plan to have a diabetic advance practice nurse working at various PCP offices at the Community Clinics. The diabetic group visits are occurring at 3 Looking for an effective partner to assist with implementing an application that could be used by our member s that have smart phone capabilities. Continue in FY Vendor identified and currently working on a BAA and contract to address technology support for selfmanagement. 2. Living Well 3. Million Hearts 50

51 Appendix B Adult and pediatric asthma selfmanagement program (Dorius/Day) approach, stratify the population according to risk. 3. Support PCPs in implementing tailored interventions to better manage their at risk population. 4. Support members through care management intervention. X X Offer a self-management program to adult and pediatric asthma populations. Community Clinics with roll out to others throughout this year. PARTIALLY MET Working with Symptom.ly, Dr. Norlin, Dr. Buchi and the University Pediatric Clinic (UPC) to enroll pediatric asthma patients into the Sypmtom.ly application. This allows the members to answer a set of questions related to their asthma. The information is sent electronically to UUHP Care Manager and the UPC. Staffing constraints and competing priorities slowed progress. Continue in FY Include outcome reporting and ROI. Continue partnership with the asthma medication compliance program. MET 51 Partner with PCMC to introduce care pathway for NOT MET

52 Appendix B Improved quality of life for ventilator dependent children and their families (Dorius/Day) X asthma, bronchiolitis management of pediatric patients. Better align members home health needs through effective collaboration among specialty providers, PCPs, health plan, and affected children and their families. 1. Implement a team approach through home telehealth visits that includes the physician, care manager, and home health agency 2. Establish a work group to address funding and home health needs of the tech dependent members to include Healthy U, Legislative representatives, parents, disability advocates, providers, UDOH, and waiver program representatives. PARTIALLY MET Pediatric care managers have met with each family and patient to help build relationships and assure continuity of services. Please refer to Attachment A for outcomes example. Continued close collaboration with Specialty Clinics on care management needs and medical necessity, and active involvement in the care planning process. We are building relationships with each agency in order to provide triangular support of the patient, agency, and Healthy U and have developed a calendar for the families and home care agencies to use to coordinate services provided through Healthy U. Telehealth visits have been delayed in order to ensure the tablets are HIPAA compliant. Technology is now available and purchasing is being coordinated with training and implementation plan to follow. Continue in FY # telehealth visits Patient satisfaction Parent Stress Index scores. 52 PDN acuity grid is being reviewed by agencies and

53 Appendix B Improve care coordination for members requiring both medical and psychiatric care (Dorius/Day) X Integrate medical and mental health services for members in 10 Community Clinics. 1. Partner with UNI to establish an integrated service (GATE Utah). 2. Align payment to encourage use of an integrated service and maintain the PCP relationship. Healthy U with the hope to share ideas and concerns with UDOH. PARTIALLY MET Introduced GATE Utah to the Community Clinics for University of Utah Hospital and Clinic employees. Minimal use by the PCPs as the patients were often already linked with a mental health provider or using EAP. Introduced GATE Utah to South Jordan Pediatrics and University Pediatric Clinic for the Healthy U Pediatric patients to help PCPs with mental health issues for their Healthy U pediatric cases. Continue in FY Monitor GATE referrals 2. Assess member and PCP satisfaction 53

54 Appendix B 6. Utilization Management In order to provide evidence-based, efficient, and equitable care and services to our members. is committed to a utilization management program based on nationally recognized criteria that are accurately and appropriately applied in all cases. Encourage and enforce appropriate utilization of services (Dorius/Day) X X Introduce and adopt a nationally recognized criteria for UM decisions, i.e., inpatient., outpatient., DME etc. Identify UM guidelines that can be system automated or established as triggers for care managers to allow for timely review and reduction of delay due to nurse review requirements. MET This is an ongoing process to stay current with technological advancements, new drugs, procedures etc. Policy is reviewed minimally on an annual basis with ongoing reporting to track UM trends. Continue in FY 2015 Focus on: 1. New technology 2. High cost high risk drugs 3. New and/or high cost, high risk procedures 54 Using the Utilization management functions as a trigger to identify areas of focus for care management will expand throughout this coming year. Review with Leadership, Quality Committee, Medical Directors the importance of a standardized tool. 1. Assess the # of parties that would utilize the criteria and the electronic interface. 2. Determine institutional Care managers have identified key UM triggers for each team to assist in identifying members that could benefit from an outreach call and care management. These triggers are reviewed quarterly to monitor effectiveness. UM team has been meeting biweekly to review UM pend status for claim and referral review. Updating system to comply with Medicaid UM

55 Appendix B Redesign the DME authorization process (Dorius) X X costs compared to effectiveness of outcomes 3. Identify reports that can be disseminated to stakeholders demonstrating the value of a standardized criteria base. Establish appropriate guidelines and automated system rules to allow DME claims to pay appropriately while reducing the risk of Health Plan over payment for DME and supplies that are under the current $5,000 per claim policy. 1. Map the current process for DME claims. 2. Identify current Medicare and (local) commercial guidelines. 3. Identify health plan members with recurring DME claims, including DME provider, type of service, frequency of service, and amount paid. 4. Apply guidelines guidelines and best practice. Developed a dashboard for UM activity by coordinator and care manager. This report is shared with all team members on a monthly basis. Performance Excellence Team (PET) designed to identify areas of improvement related to DME process, referral and payment. Completed the review and presentation to leadership and UUHP staff. Staff turnover resulted in shifting priorities and therefore the fee schedule upload has not happened to date. Provider relations is looking at revising all contracts and this will be incorporated with the revamp on the contracts as a whole. Continue in FY Complete fee schedules 2. Investigate rentals 55

56 Healthy U Appendix B identified during research to these cases. 5. Provide training to all staff on new guidelines. Need to upload fee schedule in EPIC and provider contract addendum updates. 7. Provider Participation engages providers through newsletters, updates and performance feedback. Providers are active participants on all Health Plans committees; advise care managers; and lead population-based care management teams. Implementing a provider portal adds another level of engagement. Increasing performance feedback on all quality measures will provide additional opportunities for engagement and collaboration. Plan Link implementation (Smith/Muhlestein) X X Recruit 10 Physician Connection participating providers. 1. Implementation of hardware 2. Customization of Epic software 3. Marketing, branding 4. Staff Education 5. Testing / Go live 6. Identify pilot provider practices 7. Create provider training 8. Implement pilot with PARTIALLY MET 1. Hardware was implemented 7/ Epic software was customized and completed 5/ Branding/marketing was completed 4/ Staff education was completed in 5/ Go live was completed in 5/ Pilot offices identified in 3/14 with all information obtained for 2 practices Requests for customizations and enhanced functionality will continue to be reviewed based on provider requests and Epic system upgrades. Provider groups eligible for Physician Connection were limited to those who only used the health plan features and were not using the clinical features of the previous provider portal for Cerner. Continue in FY Epic 2014 upgrade will be completed in Q and will have several changes that will need to be tested and communicated to providers. 8. Provider groups who use both the clinical and health plan features will be implemented in Q

57 Appendix B Provider feedback for continuous improvement in compliance with CHEC guidelines (Dorius/Day) X provider offices and solicit feedback within 90 days of pilot Achieve 90% compliance with CHEC physical exam component guidelines. Increase eye exams to at least 10% Increase hearing exams to at least 5% by 5/2. 7. Provider training manual completed in 5/ Implemented with 3 practices by 6/14. PARTIALLY MET We are conducting quarterly audits and have identified trends, especially around documentation of anticipatory guidance. We have not begun process redesign with providers. Limited ability to train provider practices due to test environment constraints. Training on hold while develop options. There was confusion surrounding member letters from the State and staffing constraints limited our ability to improve our program to the level we wanted. 9. Enhance training environment and roll out to additional pilot practices. 10. Solicit feedback from additional pilot practices. 11. Develop criteria for additional offices. 12. Implement with minimum 20 offices. Continue in FY Continue to improve the CHEC audit process 2. Reinstitute member letters. 3. Establish a provider outreach program. 1. Conduct quarterly audits 2. Identify opportunities for improvement and trends common to specific providers and/or measures. 3. Review results with providers, identify process failures, and The eye and hearing exam data are erroneous because they are claims-based. Record review identified appropriate documentation. 57

58 Healthy U Appendix B assist providers to redesign processes. 8. Program Integrity The Fraud, Waste and Abuse Program is designed to prevent and detect fraudulent and/or abusive behavior by providers, members, and other individuals or organizations associated with the operations of the. The program is linked to the re-credentialing process through regular reviews of the Fraud and Abuse audit log prior to credentialing/re-credentialing meetings. Continued refinement of the Fraud, Waste, and Abuse Program (Peterson) X X 58 Increase the number of fraud, waste, and abuse alerts by2 5%. 1. Implement new claims module through EPIC adding additional Fraud, Waste, & Abuse edits. 2. Increase frequency of data sets through Verisk to identify code edit violations, potential patterns of fraud/abuse, and provider outliers. 3. Continue to review program description and leadership based on new department MET Increased fraud, waste, and abuse alerts from 4 in 2013 to 32 in 2014, a 700% increase. Implemented a fraud and abuse detection application, designed to identify provider billing behaviors and patterns. Monthly surveillance reports identify potential FWA, based on billing practices and specialty comparisons. The FWA team conducts research and develops a plan for provider follow up. Continue in FY Work with Provider Relations to provide training to providers (internal and external) identified through the fraud/waste/abuse program. 5. Set up random quarterly audits with provider types that abuse trends are more prevalent, i.e., Home Health, DME. 6. Monthly audits

59 Appendix B infrastructure and tracking tools. 4. Add staff for auditing and investigating fraud/waste/abuse that is identified by 1 & Work with Provider Relations to provide training to providers identified through the fraud/waste/abuse program 6. Set up random quarterly audits with provider types that abuse trends are more prevalent The Provider Network Director is notified of the providers who have been identified and contacted. Implemented the use of the EPIC CRM, to document FWA Alerts/Tips. The Alerts come from staff, providers, members and their families. The CRM allows for information regarding the Alert, to be documented and forwarded to the FWA team, and allows for tracking of the concerns. The FWA team investigates the concern and makes a referral to the Care Management team if needed. The UUHP staff was trained on how to submit an FWA CRM, and the information to include in the CRM, for the FWA team. 7. Develop process for reporting identified substance abuse to the OIG/MFCU 59 Random audits are currently conducted based on alerts and tips. We also can pull reports and conduct random audits on providers identified

60 Healthy U Appendix B in the OIG, MFCU meetings, as applicable. 9. Information Systems Information systems supports the overall improvement strategy by facilitating the collection, aggregation, analysis, tracking, and reporting of utilization, cost, quality, and service data. Information systems include claims, registries, databases, electronic medical records, and analytical programs. Two important focus areas are the CMS mandated ICD-10 and an improved Provider Database which serves as a resource for claims processing, customer service, and provider directories, among other uses. Increasing the accuracy of the Provider Database will result in more accurate provider directories, better customer service to members and providers, a decreased number of misdirected payments, and increased efficiency during the credentialing process. ICD-10 Implementation (Smith) X X Successfully implement by October Benefits Engine, Rules, Vendor Contracts, Cost Tracking and Referrals 2. Benefits Engine, Rules, Vendor Contracts, Cost Tracking and Referrals testing of build upgrade 3. Clarity, Reporting Workbench testing 4. Internal EDI testing with the University 5. External EDI testing with UHIN to be completed by PARTIALLY MET 1. Build in Epic was completed and tested 8/ Build in was completed and tested 8/ ices professional was upgraded and remediated 12/ Testing for UB and HCFA claims with University providers was completed 12/ Reporting testing was completed in 6/14. Due to the announcement of the ICD10 delay in early Q2, external trading partners have not submitted test files. Intermountain HealthCare has expressed interest in testing in Q3. Continue in FY Additional testing of EDI claims with internal providers. 2. Testing of EDI claims with external providers. 3. Review of build completed by coding auditor position. 4. ices upgrade to version for additional remediation of ICD Testing with other outside vendors (Crimson, Verisk, etc.). 60

61 Appendix B Continued improvement in the setup and population of the provider database (Muhlestein/Smith) Use available technology to reduce workload and improve turnaround time. (Dorius) X X Achieve 80% accuracy of the database. 1. Audit 10% of new providers records for accuracy 2. Audit 10% of new providers contract files for accuracy 3. Audit 5% of initial and recredentialing applications submitted during FY 2013 for accuracy. 4. Update data as changes are required. 5. Allocate additional staff resources X X chie access for facility documentation and home health agency requests. MyChart access for PARTIALLY MET 1. Not completed 2. Developed auditing process by 4/2014. Have started auditing new provider contracts within 90 days of effective date. 3. Passed delegated credentialing audit for HA members with 100% accuracy. Passed annual HEDIS credentialing audit. Have not completed audit of UUHP s delegated credentialing files. 4. Hired provider relations coordinator to assist with data base maintenance and credentialing process. Another FTE posted. Additional provider relations and contracting executive hired as of 7/7. MET We are successfully using the chie to alert us to changes in members condition. We are currently testing Implementation of One Chart has put multiple technologybased efforts on hold for an extended period. 6. Actuarial analysis of ICD10 conversion on inpatient claims. Continue in FY Expand use of the chie. 2. Continue to pursue MyChart access. 61

62 Healthy U Appendix B plan/member communication and documentation review. 4. Obtain access to chie records for health plan members. 5. Obtain MyChart security access to communicate with members. 6. Review electronic documentation before requesting additional records. 7. Monitor workload and workflow. MyChart access. 10. Adequate Resources administrative team is aware and fully supportive of quality improvement initiatives as evidenced by encouraging innovative ideas and solutions, use of technology, and use of resources that will better serve members, providers, staff, and the University community. Administrative and leadership support for quality improvement initiatives (Wilson/Magill) X X Inform leadership of current and planned QI activities and projects. Establish a link to University Healthcare committees approving lean projects. MET Dr. Magill chairs the Population Management Committee where UUHP Health Plans is the pilot entity to roll out proposed best practice and quality Continue in FY

63 Appendix B Increase awareness of health plan activities within the University community. 1. Re-establish regular quarterly meetings of the QI Leadership Collaborative (formerly QI Committee). 2. Establish a QI Learning Collaborative to move forward value-driven outcomes and approve lean projects. 3. Establish a mechanism of ongoing reporting. improvement initiatives. Implemented a Clinical Advisory Council that meets bi-monthly. The council s functions are described in Attachment A. 63

64 Appendix B Implement a program to curb non-emergent, non-urgent use of the Emergency Department (Dorius) X X Reduce ED utilization for non-emergent care for Healthy U and members. 4. Continue to work with the ED High Utilizer Committee to identify patients that have high ED utilization for nonemergent care. 5. Implement a program incorporating linkage to primary care, community-based services, telehealth technology, member and provider engagement and follow up. 6. Align payment with the appropriate/desired levels of care. MET The ED Committee meets monthly with strong support from University Hospital, UNI, ED Physicians, Community Clinics, UUHP Care Managers, Salt Lake City Fire Department (Mobile Health Medics), 4 th Street Clinic, and Community Nursing Services. The goals of the committee, utilization trends, and behavioral health diversions are outlined in Attachment B. Continue in FY

65 Appendix B 11. Financial Solvency uses sound financial management and accounting best practices to ensure financial solvency. A key marker of success is the ability to manage the Medical Loss Ratio. Manage Medical Loss Ratio (MLR) (Finlinson) X X Healthy U MLR 94% MET Currently running around 93% so UUHP has been effective in driving down medical costs despite unexpected costs such as Sovaldi hitting in State funding Healthy U MLR 92.1% MLR 87% Care management OB & ED diversion initiatives, as well as other programs. 1. Revamp deductible, copay benefit structure 2. Care management for OB and other programs Currently running around 92% due to projected RBCBS savings not materializing, high cost cases higher than anticipated, and Sovaldi. RBCBS contract MLR 86.1% Continued emphasis on Care management OB & ED diversion initiatives, as well as other programs. 3. Revamp deductible, copay benefit structure 4. Care management for OB and other programs 65

66 Appendix B 12. Quality Improvement Program Updates/Program Evaluation is contractually obligated to maintain a Quality Improvement Program. The Quality Improvement program is organized through the Quality Improvement Program Description, Quality Improvement Work Plan, and Quality Improvement Program Evaluation. QI Program Description and Work Plan (Peterson) X X Monitor, improve, and document the quality of care and service provided to our members 1. Identify and prioritize areas of focus for the QI Program. 2. Collaborate with other health plan departments to ensure projects are reasonable, authorize the work, and document progress. 3. Annually review and update the Program Description and Work Plan. MET The Quality Improvement Program is a collaborative effort between all Health Plan departments and leadership. Areas of focus are prioritized according to: 1. Measures defined by the Department 2. Health plan activities directed at specific populations, e.g., U Baby 3. Value-based payment methodologies in place with our partners 4. Our ability to impact the measure at the patient and/or provider level. We are in a period of rapid growth and change. As a result, areas of the Work Plan may not evolve or be met as planned, due to shifting priorities. Continue to update the program annually and maintain quarterly accountability to the Work Plan. The overall program is reviewed at least annually and the Work Plan quarterly. 66

67 Appendix B QI Program Evaluation (Peterson) X X Evaluate and document the quality of care and service provided to our members 1. Review progress on active QI projects 2. Use the evaluation to develop new projects and modify existing projects, and to allocate resources based on the project s impact to members care and service. 3. Annually document the results of QI activities, the degree to which the goal was met, and determine whether the project is complete or will be carried over. MET The evaluation of the QI Program is an ongoing process with regular review of progress toward goals. Continue to evaluate progress at least quarterly. For goals that are no longer applicable or not feasible, consider finalizing evaluation of those goals at the time they are determined to be non-operational. 67

68 Appendix C Figure 1 Systematic Improvement Process Where do we want to be? Vision & Objectives Where are we now? Assessments How do we get to where we want to be? Process Change How will we know we ve arrived? Metrics Langley, G.J., Nolan, K. M., Nolan, T.W., Norman, C.L. & Provost, L.P. (1996). The improvement guide: A practical approach to enhancing organizational performance. San Francisco: Jossey-Bass 68