DENVER HEALTH MEDICAL PLAN, INC. & DENVER HEALTH MEDICAID CHOICE Medicaid Choice & CHP+ Quality Improvement Work Plan

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1 * QI Program Description-Scope The QI Program Description is reviewed annually and updated according to national and state standards and guidelines. The QI program scope, goals, objectives and structure are evaluated to assure regulatory compliance This document will clearly outline how the QI program is organized and how it uses its resources to meet program objectives. This will include functional areas and their responsibility and the reporting relationship between the QI Department and the Quality Management (). QUALITY IMPROVEMENT PROGRAM STRUCTURE Objective: Program must include the below requirements: All requirements must be met Program Structure Reviewed and updated How patient safety is addressed annually How designated physician is involved Submitted to the and the Oversight of QI functions by State Annual work plan Objectives for serving a culturally and linguistically diverse membership Objectives for serving members with complex health needs 8/2016 9/2016 DHMP Board of Directors * The QI Work Plan schedule is developed after Work Plan must address: Objective: 8/2016 9/2016 Annual QI Work review of previous year s QI Work Plan. The Quality of Clinical Care All requirements must be met Board of Plan revised work plan schedule is crafted after Quality of Service Yearly objectives must be Directors review of HEDIS and CAHPS results along Safety of Clinical Care measureable with the overall goals, objective and structure of Program Scope Work Plan must be submitted our health plan. This work plan is a dynamic Yearly Objectives to the and the State document that is frequently updated to reflect progress on the QI activities throughout the within which each activity is to year. All yearly objectives must be be achieved measureable and analyzed annually during the The staff member responsible for each Impact Analysis. activity Monitoring previously identified issues Evaluation of the QI Program Member s Experience * QI The Program Impact Analysis is written Evaluation includes: For all goals not met: 7/2017 9/2017 Program Impact Analysis (includes all indicators for annually to evaluate the results of QI initiatives in measurable terms trended over time and compared with performance objectives as A description of completed and ongoing QI activities that address quality and safety of clinical care and quality of service QI must conduct a root cause or barrier analysis to identify the underlying reasons. Board of Directors the present year.) defined in the QI work plan. Trending of measures to assess performance in the quality and safety of clinical care and quality of safety Analysis must include organizational staff that has direct experience with the Analysis and evaluation of the overall effectiveness of the QI program, including progress toward influencing network-wide safe clinical practices processes that have presented barriers to improvement. *2016 CY15-16 The QI Department works to ensure the Comprehensive evaluation of network adequacy. Objective: 8/2016 9/ P a g e

2 Strategic Access Plan Quality Management Company network has sufficient numbers and types of practitioners who provide primary care, behavioral healthcare, and specialty care to our members. This access report contains : Adjustment of availability of practitioners within network, if necessary. Determination of the types of practitioners who serve as high-volume specialty care practitioners and high-volume behavioral healthcare practitioners. Measurable and quantifiable standards for the number of practitioners of: general or family medicine, internal medicine, pediatrics, highvolume specialty care practitioners, and highvolume behavioral healthcare practitioners. Quantifiable and measurable geographic distribution of each type of practitioner providing primary care, high-volume specialty care, and high-volume behavioral healthcare. QI will analyze our annual performance against standards located in our access and availability of practitioner policy and procedure. The Quality Management () acts to plan and coordinate organization-wide improvements in quality and safety of clinical care and service to members. This includes; Primary Care Provider to Member ratio, Specialist Provider Care to Member Ratio, Access Availability, GeoAccess availability : Establish, monitor and implement improvement processes as necessary to ensure compliance with access standards for members. QI PROGRAM OPERATIONS functions include: Recommends policy decisions Analyzes and evaluates the results of QI activities Ensures practitioner participation in the QI program through planning, design, implementation or review Identifies needed actions Ensures follow-up, as needed All contractual requirements are met Continue to focus on access and availability, monitor grievances and satisfaction surveys demonstrates activities and the participation of required members (both medical plan employees and providers) by presenting clear and accurate records of minutes IS Dept. Government Product Line Board of Directors Bimonthly Ongoing Ongoing 2 P a g e

3 State QI Meetings: Health Care Policy & Finance (MQuIC ) Ambulatory QI (AQDIC) (with CHS) *2017Healthcare Effectiveness Data and Information Set (HEDIS) Annual Analysis The Medical Quality Improvement (MQuIC) is a partnership with the physical health organizations, the external quality review organization (EQRO), the Department and community to examine quality within existing and new systems of service and identify potential opportunities for improvement. Discuss collaborative interventions with CHS. Participate in work groups that will focus on diabetes, asthma, hypertension, well visits/preventative screenings, adult and pediatric immunizations, obesity and smoking cessation HEDIS is a quality requirement program which determines how well health plans perform on a variety of quality processes and outcome variables. HEDIS consists of 80+ measures that span 5 domains of care which allow for comparison of quality performance nationally across health plans. Procedure: Bimonthly participation in the HCPF/MQuIC meeting Work collaboratively with HCPF and other plans on statewide initiatives Discuss QI initiatives and participate with other Medicaid/CHP+ plans Functions include: Collaborate on interventions to reduce redundancy and increase impact Analyze HEDIS, CAHPS, PIPs, and Focused Studies Goals: Increase the quality of care for members across all quality measures: HEDIS CAHPS PIP s Technical Reports QUALITY OF CLINICAL CARE Procedure: HEDIS data is collected annually through surveys, medical charts, pharmacy data, lab reports and insurance claims for hospitalizations, medical office visits and procedures. Data validation prior to submission date Meet submission deadline Data from the HEDIS project is analyzed to determine areas of intervention and improvement. Review and recommend actions for collaborative interventions using: HEDIS, CAHPS, PIPs, focused studies and appropriate resources Evaluate resources to reduce redundancy and increase overall impact of interventions Objective: Evidence of annual analysis includes: Presentation to the Qualitative and quantitative analysis to identify opportunities for improvement must be documented in the meeting minutes. Decrease medical record noncompliance. To measure effectiveness of intervention; analysis will be accomplished by comparing 2015 results against Bimonthly Monthly QI Designee *State Contact: Jerry Ware Medical Director Ongoing Ongoing Medical Director HCPF Ongoing Ongoing 12/2016 6/ P a g e

4 *Quality of Care Concerns (QOCC) The Medical Director and QI RN appropriately investigate potential QOCC s. QUALITY OF CLINICAL CARE Timeframe requirements: Acknowledgment letter: 2 business days. Expedited Response: 72 hrs. Standard Response: 30 Calendar days. Extension letter: 14 calendar days 100% Timeframe Compliance Quarterly Ongoing Ongoing HEDIS Summer Run Full HEDIS run for the purpose of creating supplemental data sources for HEDIS (Medical record review) Records will be requested and chased prior to the regular HEDIS season. This will give QI an indication of how HEDIS care measures may score in 2016 Goals: Increase eye exam CDC and well child visits Increase AWC by 1% in Identify individuals who have not gone in for a doctor s visit for the year and engage in outreach efforts to get them in N/A HEDIS PM Medical Record Reviewer Staff 8/ /2016 Medical Director CEO *External HEDIS Audit Annual evaluation of HEDIS processes and data collection according to HEDIS and EQRO protocols : Audited by Attest, an NCQA Accredited Vendor Goals: Pass all quality standards for medical record review HEDIS PM 6/2017 7/2017 Medical Director *Adoption and Distribution of Clinical Practice and Preventive Health Guidelines The Company is accountable for adopting and disseminating clinical practice guidelines relevant to its members for the provision of non-preventive acute and chronic medical services and for preventive and non-preventive behavioral health services. Guidelines are adopted from recognized sources and/or from involvement of board-certified practitioners from appropriate specialties Clinical Practice and Preventive Health guidelines must be updated annually or when the following circumstances exist: New scientific evidence or national standards are published prior to the annual review date National guidelines change prior to the annual review date Objective: Adoption and dissemination by: Establishing the clinical/scientific basis for the guidelines Updating the guidelines annually Distributing guidelines to appropriate practitioners 1/ / P a g e

5 DENVER HEALTH MEDICAL PLAN, INC. & DENVER HEALTH MEDICAID CHOICE *Evaluating Utilization Management Criteria *Monitoring Consistency of Applying UM Criteria *Monitoring of Formulary and Pharmaceutical Management Procedures *HEDIS Impact: Breast Cancer Screening Medicaid Utilization Management conducts an annual review of the UM criteria and the procedures for applying them, and updates the criteria when appropriate. Utilization Management monitors and reviews the application of UM criteria to ensure consistency in applying criteria. If reports show there was an inconsistency, action is taken to improve the consistency of reviewer determinations. UM Department has: Written UM decision-making criteria that are objective and based on medical evidence Has written policies for applying the criteria based on individual needs Has written policies for applying the criteria based on an assessment of the local delivery system Involves appropriate practitioners in developing, adopting and reviewing criteria DHMP s Utilization Management Department annually: Evaluates the consistency with which health care professionals involved in UM apply criteria in decision making Acts on opportunities to improve consistency, if applicable Formulary and pharmaceutical management Pharmacy Department annually: procedures are presented to the Pharmacy and Reviews the procedures Therapeutics on an annual basis for Reviews its list of pharmaceuticals review and discussion. Minutes from the P&T Updates the procedures and meeting are presented and reviewed at the pharmaceuticals, as appropriate on a monthly basis. The review of the formulary and pharmaceutical management procedures is documented in the P&T minutes. Every month a list will be drawn from the data QI Department: warehouse, and run against claims and the Conducts monthly data pull active member s list using the BI Portal. All Defines eligible participants Medicaid women 50+ years old, who are in need of a mammogram, will be sent a mailer Works with Marketing to distribute mailings reminding them to schedule an appointment either with Radiology or the Denver Health s Women s Mobile Clinic. (There were major spec changes in 2015 which negatively impacted the BCS scores. QI is working collaboratively with all stakeholders to increase the scores) Criteria must consider at least the following when applying criteria to a given individual: Age Comorbidities Complications Progress of Treatment Psychosocial situation Home environment, when applicable 85% Accuracy Rate for Criteria Application Must present and review all pharmaceutical management procedures annually to address areas for improvement HEDIS % 2015 Current Benchmark: 10 th Percentile 2017 HEDIS Goal 51.59% (25 th Measure: Quarterly monitoring of intervention response rate. The numerator and denominator of the intervention response rate will be defined as the following: CM/UM CM/UM Pharmacy Director Adult Intervention 9/ /2016 UMC 11/ /2016 UMC 10/ /2016 UMC P&T 7/2016 6/2017 Outreach 5 P a g e

6 Numerator: women who had a claim for mammography during the specified quarter Denominator: the eligible population who received a breast cancer screening mailing during the specified quarter. *HEDIS Impact: Prenatal and Postpartum Care To improve HEDIS rates for Medicaid PPC QI works in collaboration with the Marketing Department to incentivize female members, who have a positive pregnancy test or OB intake visit, to adhere to recommended prenatal care visits. The Medical Plan saw an increase of 3.16% for our Post-Partum rates for HEDIS 2015 Marketing mails a letter informing mothers of the Mom and Baby Program. This is an opt in program where a member will receive a packet of coupons informing them of incentives for completed visits. Procedure: IS sends QI a claims report every two weeks, which Marketing utilizes to send out mailers. Marketing department mails letter informing member of the mom and baby program Marketing tracks completion of visits and who received an incentive Frequency: Post-Partum Bimontlhy mailing Prenatal Monthly MCD: Baseline Rate from 2006 (prior to mailing implementation): Postpartum Visit within Days After Delivery: 31.25% Post-Partum 2016 HEDIS 54.74% (10 th 2017 HEDIS 56% (25 th Prenatal Care Timeliness of Care 2016 HEDIS 81.75% (25 th 2017 HEDIS 85% (50 th Marketing Director Ongoing Ongoing Outreach *Child Annual Visit: Birthday Card) Children years of age receive a birthday card informing them to come for their annual visit. These mailings have been going out to members since January This intervention has been shown to increase QUALITY OF CLINICAL CARE Monthly Procedure: MCD: IS pulls EPSDT data Baseline Rate from 2008 (prior to QI cleans data and separates per LOB mailing implementation): QI fills out marketing request form Well-child visit within 2 months of QI proofs the birthday card and sends okay birthday: 20.67% Ongoing Ongoing Outreach 6 P a g e

7 well-child visit rate within 2 months of the member s birthday. In SFY 13-14, 19.63% of children went in to receive their annual within 2 months of receiving the postcard. QI will amend the postcard to include a checklist of different things the provider will cover in a well-child visit as a way to engage the patient and ensure all HEDIS components are covered. response to Marketing Marketing sends to the printer and they are mailed to members QI records mailings that return to DHMP. HEDIS 2016 W34: % (10 TH HEDIS 2016 AWC: 38.27% (10 th GOALS: HEDIS 2017 W % (25 th HEDIS 2017 AWC 41.76% (25 th CHP+: Baseline Rate from 2008 (prior to mailing implementation): Well-child visit within 2 months of birthday: 19.50% Baby s First Year Incentives The Marketing Department has expanded additional benefits to include Baby s First Year incentives. For each newborn visit completed in the first 12 months of life, members will receive an incentive. Procedure: IS provides Marketing with a monthly report, identifying eligible participants for the program Marketing outreaches to eligible participants Marketing tracks member response and participation rates throughout the program. HEDIS 2016 W34: 61.17% (10 TH HEDIS 2016 AWC: 48.42% (25 th GOALS HEDIS 2017W % (25 th HEDIS 2017 AWC 49.15% (50 th 10% eligible member participation Quarterly Marketing Ongoing Ongoing CEO * School Based Health Clinics As part of the Denver Health Managed Care network, children who are members of Denver QUALITY OF CLINICAL CARE Procedure (Well Child Visits): QI collaborates with the SBHC to improve the % of children by Well Child Visits: Goals for SBHC Clinics Monthly Pediatric Intervention 9/2016 5/ P a g e

8 (SBHC) - Well Child Visit Incentive Program Health Medicaid Choice or any Denver Health Medical Plan, Inc. plan, have access to the Denver Health School-Based Health Centers (SBHC). These children can receive health care services at one of the many SBHCs with no cost sharing to the member. clinic who complete a well-child visit at the SBHC Each month QI sends a designated SBHC clinic leads a list of children on our medical plans that are enrolled in the SHBC program, who still need to complete their annual well visit for the year. Since Fall of 2014students ages who receive their well visit at a SBHC receive a $10 gift card of their choice (Ross, Subway, Fandango). Clinics will work collaboratively with QI to increase completed and documented Well Child visits. MCD 2016 WCC Counseling for Physical Activity 77.37% (95% BMI Percentile 78.83% (75% Counseling for Nutrition 77.37% (75% 2017 WCC Counseling for Physical Activity 77.37% (95% BMI Percentile 85.61% (90 th Counseling for Nutrition 79.56% (90 th 2016 AWC: 38.27% 2017 AWC 41.76% SBHC Sonja O Leary CHP WCC: Counseling for Physical Activity 65.21% (90 th BMI Percentile 77.86% (50 th Counseling for Nutrition 78.59% (75% 2016 WCC Counseling for Physical Activity 76.72% (95% BMI Percentile 77.98% (75% 8 P a g e

9 Counseling for Nutrition 79.59% (90 th 2016 AWC Baseline: 48.42% 2017 AWC 49.15% *Cultural and Linguistic Appropriate Services (CLAS): Medicaid Choice and CHP+ Performance Improvement Project: Improving Follow-up Communication Between Referring Providers and Pediatric Obesity Specialty Clinics MCD and CHP+ To deliver culturally and linguistically appropriate services to Denver Health Members in accordance with Centers for Medicaid and Medicare (CMS) and the Colorado Department of Health Care Policy (HCPF). As well as continuing to train new staff and conduct annual refresher training related to cultural competency. Denver Health Medical Plan is collaborating with Denver Health Healthy Lifestyles Clinic & Pediatric Obesity Clinic at Children s Hospital Colorado to improve transitions of care for a population of overweight and obese pediatric members across PCP, specialty, and behavioral health care. Data is collected and analyzed to determine the timeliness and effectiveness of communications between specialists and PCPs in the internal and external referral process. Cultural Competency Training Cultural competency training will be made available, to educate providers and staff on the health beliefs held by diverse patient populations and to raise cultural awareness. Annual analysis will be completed to assess the percent of providers and staff that receive this cultural competency training CLAS Program Evaluation Will engage in annual assessment of the cultural and language needs of Denver Health member population and subpopulation. Reviews on-going DHMP interventions as deemed necessary identifying opportunities for improvement. Must be documented in meeting minutes. Denver Health Diversity & Inclusion : DHMP attends annual PIP Summit meetings with HSAG and HCPF to present and troubleshoot current project initiatives and activities. DHMP submits annual data and findings to HSAG for review Maintain MHC distinction for Medicaid Choice Goals: Analyze and determine the effectives of communications in internal and external referrals Propose and implement potential interventions to improve the feedback process Improve care coordination: Care coordination assures that all medical personnel working with the patient and/or the family receive timely and accurate information, helps the member receive consistent. Adult Intervention /CL AS Program Pediatric Intervention Ongoing Ongoing July/Dec. Semiannually BOD 9 P a g e

10 *Complex Case Management: Population Assessment *Disease Management: Monitoring Member Participation Rates *Monitoring Member Satisfaction Complex Case Management annually assesses member populations and subpopulations to ensure needs are being met in an appropriate manner. The Behavioral Health and Wellness Services Department annually measures active member participation rates. The Company monitors member satisfaction with its services and identifies areas of potential improvement. To assess member satisfaction with its services, the Company annually evaluates member complaint and appeals. information, support and planning to improve their health and work on self-management goals QUALITY OF CLINICAL CARE Assessment must consider and include the Goals: following: Assesses the characteristics Relevant characteristics of specific and needs of its member populations population and subpopulations DHMP/DHMC s covered population, not Reviews and updates its just members identified for complex case complex case management management processes to address member needs, if necessary Reviews and updates its complex case management resources to address member needs, if necessary The active member participation rate is defined as 2016 DM Participation the number of members who have received at Increase eligible member least one interactive contact in an intervention, participation among those divided by the number of members who are identified as eligible for either the identified as eligible for the program. Diabetes or Depression Disease Management Programs. QUALITY OF SERVICE Aggregate member complaints and appeals by Evidence of monitoring includes: reason, showing rates related to: Annual reporting to the Quality of Care Root-cause analysis provided Access to identify opportunities for Attitude and Service improvement. Billing and Financial Issues Quality and Practitioner Office Site. Case Management Clinical Behavioral Health and Wellness Member Services 1/2017 2/2017 UMC 12/2016 1/ / / P a g e

11 Monitoring Satisfaction with the Utilization Management Process Monitoring Satisfaction with Disease Management Annual State Audit The Company continually assesses member and practitioner satisfaction with its Utilization Management process to identify areas in need of improvement. The Behavioral Health and Wellness Services Department annually evaluates satisfaction with its disease management services to identify opportunities to improve member satisfaction. Participate in the annual state audit as well as participate in CMS activities as requested to determine corrective actions plans and/or opportunities for improvement Components of the process: Collecting and analyzing data on member and practitioner satisfaction to identify improvement opportunities Taking action designed to improve member and practitioner satisfaction based on assessment of the data Satisfaction data is collected through the following methods: Obtaining member feedback Analyzing complaints and inquiries Objective: Utilizing the state audit tool, the Medical Plan is responsible for collecting and delivering data/documents as evidence to meet standard specifications. HSAG audits the plan on 3-4 standards each year. Goals: Members: Of the surveyed members (CAHPS) who required an authorization for services, 90% or more reported being either Somewhat or Very Satisfied with the authorization process Practitioners: 90% of the surveyed providers will indicate a high level of satisfaction with the UM program by answering each of the Provider UM Satisfaction questions with a rating of either 4 or 5 (on a scale from 1 to 5, with 5 being extremely satisfied). Members: 95% of the respondents (former DM members) will indicate a high level of satisfaction with the program by answering DM survey questions with a rating of either 4 or 5 (on a 1-5 scale, with 5 being extremely satisfied). State Audit Goals: Pass State Audit and/or Implement any Corrective Action Plan as required to meet standard CM/UM Clinical Behavioral Health and Wellness QI Government Product Line 07/ / /2016 1/ /2016 2/2017 QI Government Product Line 11 P a g e

12 *2016 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Annual Analysis Open Shopper Study *Quality of Service Concerns (QSC) *Member Annual Communication Requirements *Member Communication Requirements Upon Enrollment and Thereafter Assess member satisfaction with quality of clinical care and services provided in practice settings through the CAHPS member satisfaction survey. The Quality Improvement Department conducts this study to determine the process a member would undertake to schedule an appointment for an urgent need, routine care, or an annual physical. A summary of this study is presented annually to the, highlighting major findings and opportunities for improvement. The develops corrective actions, when appropriate, to improve service to members. When needed, a mid-year follow-up study is conducted to provide specific data on a targeted endpoint. This endpoint is chosen based on the results from the annual study. The Grievance and Appeals Department appropriately investigates potential Quality of Service Concerns. The Marketing Department strives to ensure timely distribution of member communications and materials to promote DHMP/DHMC membership understanding of current health plan topics related to patient care and service. The Marketing Department strives to ensure timely distribution of member communications and materials to promote DHMP/DHMC membership understanding of current health plan topics related to patient care and service. The QI Department: Sends CAHPS surveys out annually to members via random blind sample. Validates data before submission Meets CAHPS submission deadline Analyzes survey results to determine areas of intervention and improvement Clinic compliance with access standards will include: Appointment Availability (in line with Access Standards) Number of prompts to reach a live person Number of call attempts made to reach a live person Review of member materials for accuracy and consistency. These materials include member handbooks, online tools, and websites that list health care providers along with telephone numbers and addresses. Timeframe requirements: Acknowledgment letter: 2 business days. Standard Response: 15 business days. Extension letter: 14 business days. Expedited: 3 business days Members receive: Information about the quality program goals and outcomes as related to member care and service Inform members of CPG s Pharmaceutical Restriction and Preference information Members are provided the following information: Member rights and responsibilities statement Subscriber information PHI use and disclosure information Evidence of annual analysis includes: Presentation to the Qualitative and quantitative analysis to identify opportunities for improvement must be documented in the meeting minutes. Results must be analyzed against performance standards and presented to the biannually. Evidence of qualitative and quantitative analysis to identify opportunities for improvement must be documented in the meeting minutes. 100% Timeframe compliance Must provide evidence of annual communication to all Medicaid and CHP+ members Must provide evidence of communication to all Medicaid and CHP+ members upon enrollment and annually thereafter Ongoing Ongoing, with mid-year follow-up as needed Quarterly Ongoing Ongoing Compliance Marketing Marketing Ongoing Ongoing 7/2016 6/2017 Outreach 1/ /2017 Outreach 12 P a g e

13 DENVER HEALTH MEDICAL PLAN, INC. & DENVER HEALTH MEDICAID CHOICE *Practitioner and Provider Annual Communication Requirements *Practitioner and Provider Communication Requirements Upon Contracting and Thereafter *Ongoing Monitoring of Network Practitioners and Providers Site Quality *Ongoing Monitoring of Practitioner The Marketing Department strives to ensure timely distribution of practitioner and provider communications and materials to promote DHMP/DHMC practitioner and provider understanding of current health plan topics related to patient care and service. The Marketing Department strives to ensure timely distribution of practitioner and provider communications and materials to promote DHMP/DHMC practitioner and provider understanding of current health plan topics related to patient care and service. Credentialing and Provider Relations has a process to ensure the quality, safety and accessibility of the offices of all network practitioners meet DHMP/DHMC s office-site standards. This is achieved by setting performance standards and thresholds for office sites and a clear process for ongoing monitoring of office site quality. DHMP/DHMC has policies and procedures for ongoing monitoring of practitioner sanctions, complaints and quality issues between The process for members to self-refer to case management How to access staff An affirmative statement about incentives Practitioners and providers are provided the following information: Information about the quality program goals and process outcomes related to member care and service Pharmaceutical Restriction and Preference information QUALITY OF SERVICE Practitioners and Providers are provided the following information: Member rights and responsibilities statement The process for the practitioner to refer members to case management Disease Management Program information Clinical practice and preventive health guidelines (to appropriate practitioners) How to obtain UM criteria How to access staff An affirmative statement about incentives Provider Relations and Credentialing: Goals: Sets performance standards and thresholds for office site quality Establishes a documented process for ongoing monitoring and investigation of threshold was met member complaints related to practice sites Ongoing review and monitoring by: Collecting and reviewing Medicare and Medicaid sanctions Goals: Must provide evidence of annual communication to all network practitioners and providers Must provide evidence of communication to all network practitioners and providers upon contracting and annually thereafter Conduct site visits of offices within 60 calendar days of determining that the complaint Deliver corrective action plans within 30 calendar days of site visit Repeat site visits are conducted 6 months after delivering corrective action plans Review sanction information within 30 calendar days of its Marketing Marketing 1/ /2017 Outreach 1/ /2017 Outreach Quarterly Ongoing 11/2016 2/2017 Quarterly Ongoing 11/2016 2/2017 Cred. Cmte. Cred. Cmte. 13 P a g e

14 Sanctions, Complaints and Quality Issues *Monitoring Member Services Telephonic Performance recredentialing cycles and takes appropriate action against practitioners when it identifies occurrences of poor quality. The Member Services Department has a process for monitoring and evaluating telephonic metrics against established thresholds. Collecting and reviewing sanctions or limitations on licensure Collecting and reviewing complaints Collecting and reviewing information from identified adverse events Reporting categories: Service level Average Delay Call Volume/Abandonment Rate releaseimplementing appropriate interventions when instances of poor quality are identified Goals: Phone Statistics: at or above 85% Time to answer: 30 seconds or less. Abandonment rate: 5% or less Quarterly Member Services Quarterly Ongoing CEO *Pharmaceutical Patient Safety Issues *Continuity and Coordination of Medical Care The Pharmacy Department receives notification of drug recalls from the Pharmacy Benefit and has a process in place to notify affected patients and practitioners in a timely manner. This represents an opportunity to provide patient safety information to practitioners and patients likely to be affected by drug recalls and withdrawals for patient safety reasons. The Company uses information at its disposal to facilitate continuity and coordination of medical care across its delivery system. SAFETY OF CLINICAL CARE Goals: 100% Compliance for: Identifying and notifying members and prescribing practitioners affected by Class II recall or voluntary drug withdrawals from the market for safety An expedited process for prompt identification and notification of members and prescribing practitioners affected by a Class I recall Annual identification of opportunities to improve coordination of medical care by: Collecting data Conducting qualitative and causal analysis of data to identify improvement opportunities Identifying and selecting opportunities for improvement Class I: Affected members and providers notified no later than seven days of the Food and Drug Administration (FDA) notification. Class II: Affected members and providers notified within thirty days of the FDA notification. Class III: Affected members and provider notified within sixty days of FDA notification. Goals: At least 70% of the providers surveyed, report a satisfaction rating of at least 4 or 5 (scale of 1 to 5) for the following factors related to coordination and continuity of care: Timeliness of information exchanged. Completeness of information exchange. Semi-annually Pharmacy Director CM/UM Ongoing Ongoing Compliance 11/2016 Ongoing UMC 14 P a g e

15 DENVER HEALTH MEDICAL PLAN, INC. & DENVER HEALTH MEDICAID CHOICE Patient Safety Initiatives The Quality Improvement Department works collaboratively with Utilization/Case Management, Pharmacy, and Behavioral Health and Wellness Departments to provide clinical quality monitoring and identify performance improvement opportunities related to member safety. Process: The Quality Improvement Department facilitates evaluation of quality of care concerns and any corrective action plan that comes from them, and implements and provides organizational support of ongoing safety and quality performance initiatives that relate to care processes, treatment, service, and safe clinical practice. In addition, the Company Medical Director is a member of the DHHA Patient Safety. If opportunities are identified to decrease medical errors, the Medical Plan will offer patient education on safety initiatives and preventive approaches. Objectives: Encourage organizational learning about medical and health care errors Incorporate recognition of patient safety as an integral job responsibility Incorporate patient safety education into job competencies Implement corrective, preventative and general medical error reduction educational programs to reduce the possibility of patient injury Involve patients in decisions about their health care and promote open communication about medical errors and consequences which occur as a result Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions Review and investigate serious outcomes where a patient injury has occurred or patient safety has been impaired in collaboration with risk management Review and evaluate actual and potential risk of patient safety in collaboration with risk management Report internally what has been found and the actions taken with a focus on processes and systems to QI Ongoing Ongoing 15 P a g e

16 reduce risk Distribute information to members and providers via newsletter and/or website to help promote and increase knowledge about clinical safety Focus existing quality improvement activities on improving patient safety by analyzing and evaluating data related to clinical safety Trend adverse events reporting in safety practices (e.g. medication errors) review and evaluate clinical practice guidelines against practice guidelines to ensure and improve safe practices 16 P a g e

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