Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)

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1 Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP) Quality Improvement Committee Meeting Bell Canyon Conference Room at Gold Coast Health Plan 770 Paseo Camarillo, Ste. 200, Camarillo, CA Tuesday, June 28, :00 p.m. AGENDA CALL TO ORDER / ROLL CALL / INTRODUCTIONS PUBLIC COMMENT A Speaker Card must be completed and submitted to the committee secretary by anyone wishing to comment: Public Comment - Comments regarding items not on the agenda but within the subject matter jurisdiction of the Committee. Speakers are limited to three minutes. Agenda Item Comment - Comments within the subject matter jurisdiction of the Committee pertaining to a specific item on the agenda. The speaker is recognized and introduced by the Committee Chair during Committee s consideration of the item. Speakers are limited to three minutes. OPEN SESSION 1. APPROVE MINUTES Minutes of Regular Meeting on March 29, ACTION ITEMS UPDATE Action Items Log 3. OLD BUSINESS a) Member Incentive Program: PDSA Update Meeting Agenda available at ADMINISTRATIVE REPORTS RELATING TO THIS AGENDA AND MATERIALS RELATED TO AN AGENDA ITEM SUBMITTED TO THE COMMITTEE AFTER DISTRIBUTION OF THE AGENDA PACKET ARE AVAILABLE FOR PUBLIC REVIEW DURING NORMAL BUSINESS HOURS AT THE OFFICE OF THE CHIEF MEDICAL OFFICER, 711 E. DAILY DRIVE, SUITE #106, CAMARILLO, CA. IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, IF YOU NEED SPECIAL ASSISTANCE TO PARTICIPATE IN THIS MEETING, PLEASE CONTACT LUPE AT (805) REASONABLE ADVANCE NOTIFICATION OF THE NEED FOR ACCOMMODATION PRIOR TO THE MEETING (48 HOURS ADVANCE NOTICE IS PREFERABLE) WILL ENABLE US TO MAKE REASONABLE ARRANGEMENTS TO ENSURE ACCESSIBILITY TO THIS MEETING. 1

2 Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan June 28, 2016 Quality Improvement Committee Meeting Agenda (continued) LOCATION: Bell Canyon Conference Room, 770 Paseo Camarillo, Ste. 200, Camarillo, CA TIME: 3:00 p.m. Postpartum Visits Well Child Visits in the Third, Fourth, Fifth and Sixth Years b) DHCS Performance Improvement Projects (PIP) Topic #1 Update Immunizations 2 nd Year of Life Topic #2 Update Developmental Screening c) DHCS IP: Annual Monitoring for Patients on Persistent Medications (MPM) d) Antibiotics Stewardship QI Study (PDSA) e) IHA Monitoring f) FSR Report 4. APPROVAL ITEMS a) GCHP 2015 QI Work Plan Evaluation b) GCHP 2016 QI Work Plan c) Kaiser 2015 QI Work Plan Evaluation d) Kaiser 2016 QI Program Description e) Kaiser 2016 Work Plan f) VSP 2015 QI Work Plan Evaluation g) VSP 2016 QI Program Description h) VSP 2016 Work Plan 5. NEW BUSINESS a) Pay for Performance Children s Access b) Opiates Program Compliance / Delegation Oversight Update No Report this Quarter QIC Dashboard and Department / Committee Updates Quality Improvement Grievance and Appeals Pharmacy Utilization Management Meeting Agenda available at ADMINISTRATIVE REPORTS RELATING TO THIS AGENDA AND MATERIALS RELATED TO AN AGENDA ITEM SUBMITTED TO THE COMMITTEE AFTER DISTRIBUTION OF THE AGENDA PACKET ARE AVAILABLE FOR PUBLIC REVIEW DURING NORMAL BUSINESS HOURS AT THE OFFICE OF THE CHIEF MEDICAL OFFICER, 711 E. DAILY DRIVE, SUITE #106, CAMARILLO, CA. IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, IF YOU NEED SPECIAL ASSISTANCE TO PARTICIPATE IN THIS MEETING, PLEASE CONTACT LUPE AT (805) REASONABLE ADVANCE NOTIFICATION OF THE NEED FOR ACCOMMODATION PRIOR TO THE MEETING (48 HOURS ADVANCE NOTICE IS PREFERABLE) WILL ENABLE US TO MAKE REASONABLE ARRANGEMENTS TO ENSURE ACCESSIBILITY TO THIS MEETING. 2

3 Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan June 28, 2016 Quality Improvement Committee Meeting Agenda (continued) LOCATION: Bell Canyon Conference Room, 770 Paseo Camarillo, Ste. 200, Camarillo, CA TIME: 3:00 p.m. Credentials / Peer Review Member Services Medical Advisory Committee CLOSED SESSION None ADJOURNMENT Unless otherwise determined, the next regular meeting of the Quality Improvement Committee will be held on September 27, 2016 at 3:00 p.m. at 711 E. Daily Drive, Suite 106, Camarillo, CA Meeting Agenda available at ADMINISTRATIVE REPORTS RELATING TO THIS AGENDA AND MATERIALS RELATED TO AN AGENDA ITEM SUBMITTED TO THE COMMITTEE AFTER DISTRIBUTION OF THE AGENDA PACKET ARE AVAILABLE FOR PUBLIC REVIEW DURING NORMAL BUSINESS HOURS AT THE OFFICE OF THE CHIEF MEDICAL OFFICER, 711 E. DAILY DRIVE, SUITE #106, CAMARILLO, CA. IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, IF YOU NEED SPECIAL ASSISTANCE TO PARTICIPATE IN THIS MEETING, PLEASE CONTACT LUPE AT (805) REASONABLE ADVANCE NOTIFICATION OF THE NEED FOR ACCOMMODATION PRIOR TO THE MEETING (48 HOURS ADVANCE NOTICE IS PREFERABLE) WILL ENABLE US TO MAKE REASONABLE ARRANGEMENTS TO ENSURE ACCESSIBILITY TO THIS MEETING. 3

4 Location: 711 E. Daily Drive, Ste. 106, Camarillo, CA Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan Quality Improvement Committee Meeting Tuesday, March 29, 2016 (Not Official Until Approved) Committee Members in Attendance C. Albert Reeves, MD Committee Chair, Chief Medical Officer Luis Aguilar Manager, Member Services William Freeman Director, Network Operations Anne Freese, PharmD Director, Pharmacy Lupe Gonzalez, PhD MPH Director, Health Education/Cultural Linguistics/Outreach Vickie Lemmon, RN MSN Director, Health Services Stacy Luney Manager, Grievance and Appeals Kim Osajda, RN MSN Director, Quality Improvement Gagan Pawar, MD Medical Director, Clinicas Del Camino Real Dale Villani Chief Executive Officer Nancy Wharfield, MD Associate Chief Medical Officer Committee Members Absent: Brandy Armenta Compliance Officer/Director Tami Lewis Director, Operations Bryan Wong, MD Medical Director, VCMC Santa Paula GCHP Staff in Attendance David Becerra Sr. Compliance Specialist Helen Chtourou Quality Improvement Project Manager Leslie Cole Quality Improvement Data Analyst Maureen Finnigan Delegation Oversight Auditor RN Lupe Harrion Committee Secretary, Executive Assistant Call to Order / Roll Call / Introductions Dr. Reeves called the meeting to order at 3:04pm. Roll Call was conducted by sign-in sheet. 1. APPROVE MINUTES Review of the minutes of the December 15, 2015 regular meeting was conducted. Various clarifications were noted. Member Wharfield made a motion to accept the minutes with the edits indicated. Member Lemmon seconded the motion. The motion carried with the following votes: AYE: Aguilar, Freeman, Freese, Gonzalez, Lemmon, Luney, Osajda, Pawar, Villani, Wharfield NAY: None ABSTAIN: None ABSENT: Armenta, Lewis, Wong 4

5 2. ACTION ITEMS UPDATE Line Item# Topics Action Items Response 1 #27 24-hour Pharmacy in Ventura County Anne Freese, Director, Pharmacy 2 #28 Part-time/Full-time Contracted Providers William Freeman, Director, Network Operations 3 #29 Members Outside the County William Freeman, Director, Network Operations Dr. Wong stated the CVS Pharmacy in Ventura is reducing its hours and asked if there is another 24-hour pharmacy in the area. Anne to check on another 24-hour pharmacy in Ventura County. Dr. Wong asked if the number of providers contracted is full-time or part-time. Mr. Freeman responded it s both. Dr. Wong was concerned that this number could be deceiving since many providers only work part-time. Mr. Freeman agreed to look further into the provider counts and member access to see if there is an impact. Mr. Villani asked about the members indicated on the map that are out of the county. Mr. Freeman will look into why these members are showing up outside the county. Member Freese reported at this time there are no 24-hour retail pharmacies available in Ventura County. She contacted our PBM to look into what it would take for one of our contracted retail pharmacies to change to a 24-hour pharmacy but a new contract would need to be put in place with a higher reimbursement rate. Per our contract with DHCS there is no requirement that states that we need to have a 24-hour pharmacy but we must have pharmacies available during normal business hours. Member Villani asked if there have been any complaints about not having access. Ms. Freese answered there have been members near the county border that have complained about having contracted pharmacies near them but not about having a 24-hour pharmacy. Member Freeman indicated that contractually all providers need to have a medical professional present in their office during normal working hours. It was stated that Dr. Wong s major point was about access, and that is an ongoing issue with regard to a number of specialties. A strategy is being set up to attempt to resolve that issue. As the issue is now more of an access issue rather than part time or full time arrangement, this issue is still under review. Member Freeman reported a review was performed and it appears that the sampling that was selected demonstrated that many members live in zip codes that extend into Ventura County, and that members who may live outside the county along the edge are able to ask to be included under GCHP, the fact they are not living within the actual county may not be caught for a period of time. It was decided to enlarge the sampling and see what the subsequent results show. 3. OLD BUSINESS N/A 4 QIC Approved PIP #2 SBIRT Update Ms. Osajda provided an update of the PIP #2 SBIRT that was approved by the QIC previously. This topic was rejected by the State. We submitted Improving Child 5

6 Kim Osajda, Director, Quality Improvement Developmental Screening which the State approved. We will be working with Dr. Victor Dominguez from CMH and work in collaboration with the Help Me Grow Program Ventura. 4. APPROVAL ITEMS Dr. Reeves, Chief Medical Officer Line Item# Topics Comments/Discussion Action Items 5 A. QI-023 Potential Quality Issue Investigation and Resolution Policy Kim Osajda, Director, Quality Improvement 6 B. Quality Improvement 2015 Work Plan Evaluation Kim Osajda, Director, Quality Improvement Dr. Reeves reported this policy has been updated and approved by the Credentials / Peer Review Committee. Ms. Osajda gave a brief explanation of the changes throughout the document. Member Lemmon made a motion to approve the updated policy. Member Wharfield seconded the motion. The motion carried with the following votes: AYE: Aguilar, Freeman, Freese, Gonzalez, Lemmon, Luney, Osajda, Pawar, Villani, Wharfield NAY: None ABSTAIN: None ABSENT: Armenta, Lewis, Wong Member Osajda presented the 2015 Quality Improvement Work Plan Evaluation. The committee provided updates for their areas that did not meet their goal. Member Freeman reported results of the Provider Access Survey and the Satisfaction Survey. Discussion ensued by the committee. Member Villani asked if we have considered the Mystery Shopper approach, Member Freeman answered we have used this approach but have found the provider offices pick up on it quickly. The Provider Network team is working on a corrective action plan to determine how this will be monitored and improved on. Member Villani asked if we are getting complaints from members regarding access to care. Member Luney answered we have not received many grievances for access to care issues but overall we don t receive many grievances from our members. C. Quality Improvement 2016 Program Description Member Osajda next presented the 2016 QI Program Description, there were minor changes made to the document including some changes to the committee structures. Tami Lewis, Director of Operations requested a change to the Quality Improvement Committee structure, since Luis Aguilar is the chair of the Member Services Committee she requested that he be added to the QIC as well. D. Quality Improvement 2016 Work Plan Member Osajda presented the new 2016 Quality Improvement Work Plan. Some changes and updates were added to the document. Member Luney made a motion to approve the 2015 QI Work Plan Evaluation, 2016 QI Program Description and the 2016 QI Work Plan. Member Freese seconded the motion. The motion carried with the following votes: AYE: Aguilar, Freeman, Freese, Gonzalez, Lemmon, Luney, Osajda, Pawar, Villani, 6

7 Wharfield NAY: None ABSTAIN: None ABSENT: Armenta, Lewis, Wong 5. NEW BUSINESS Line Item# Topics Comments/Discussion Action Items Quality Improvement Department Report Kim Osajda, Director of Quality Improvement 7 1. Potential Quality Issues (PQI) Report 8 2. Member Incentive Program: Postpartum Visits Well Child Visits 3-6 years of Life Helen Chtourou, QI Project Manager A total of 19 PQI referrals were submitted to Quality Improvement department during the fourth quarter of Of the 19 referrals, 4 came from Health Services, 2 from Grievance & Appeals, 6 from Utilization Management, 3 from Care Managers, 3 from Delegation Oversight and 1 from Other. Of the 19 referrals 1 was identified as not being a PQI and 14 were completed and closed. Four (4) referral remains open in medical record pursuit or review phase. There were 4 high rated PQI cases that were reviewed by the Credentials/Peer Review Committee. Ms. Chtourou gave an update on the following QI projects. Postpartum Visits A New Baby Welcome Gift will be given to encourage new moms to get their postpartum visit completed between days of delivery. By December 31, 2015 there were 21 gifts have been shipped to members who have met the criteria. We almost met our goal of increasing the 2015 MY postpartum care administrative HEDIS rate by at least 5%. The 2015 preliminary admin rate increased 4.17 percentage points from This incentive was approved by DHCS in 2015 as an ongoing member incentive with no end date and we will continue the postpartum member incentive into Well-Child Visits in the 3 rd, 4 th, 5 th and 6 th Years of Life To incentivize parents to bring their children to see their primary care provider for a Well-Child Exam a monthly drawing will be conducted for $25 gift cards to Target or Wal-Mart. Parents will be entered into a monthly raffle for each child that has a wellchild visit/adolescent visit with their PCP. The child/adolescent will also be entered in the monthly raffle. Compared to prior years, this HEDIS measure is higher this year than in previous years. By December 31, forms have been returned, 167 members were awarded incentives and 46 forms were rejected due to not meeting the requirements. For the W34 measure, we did not meet our goal of increasing the admin rate by 5%. For the CAP measure, we met our goal of meeting the MPL for the age group; however this rate decreased by 1.01 percentage points. The 2015 well-child member incentive evaluation and PDSA was sent to DHCS for review in February Upon receipt of their response, the QI Department will request a renewal of this incentive for

8 9 3. California Performance Improvement Project (PIP) Transition Plan - Updates Topic #1: Immunizations 2 nd Year of Life Ms. Chtourou provided updates on the following PIPs: We are working with VCMC to improve the child immunizations rate at Las Islas Medical Clinic. This clinic was chosen because it has the largest number of children with the lowest number of immunizations. This PIP ends in June 30, The goal is to increase child immunizations from their baseline to 77.66, a 10% increase. The PIP contains 5 modules, of these 3 have been completed. In February we met with VCMC to complete Module 3 and Process Mapping. This was submitted to the state on 2/29/16. HSAG training on PIP Modules 4 & 5 will begin on 4/20/16. Topic #2: Increase Utilization of Standardized Child Developmental Screening Tools during Well-Child Exams DHCS IP: Annual Monitoring for Patients on Persistent Medications (MPM) Helen Chtourou, QI Project Manager This was reported on previously by Member Osajda. The HEDIS 2015 rates for the Annual Monitoring for Patients on Persistent Medications demonstrated decreased rates in the monitoring for the three medications; ACE inhibitors/arbs, Digoxin and diuretics that fell below the DCHS mandated MPL which equates to the National Committee for Quality Assurance 25% percentile ranking. This prompted a performance improvement plan to identify barriers in medication monitoring and devise interventions to improve patient care and the rates for these measures. The IP will require 3 PDSA cycles, each PDSA tests one intervention over a three-month study period. PDSA #1 Performance Feedback Reports tested at 5 VCMC Clinics Aim: Improve medication monitoring labs SMART Objective: By November 30, 2015, increase the combined rated of medication monitoring labs at 5 VCMC clinics by 5% from 77.03% to 82.03%. Results: Surpassed goal of increasing rate by 5%. PDSA #2 Performance Feedback Reports Testing Expanded to 17 VCMC Clinics Aim: Improve medication monitoring labs SMART Objective: By February 29, 2016, increase the combined rated of medication monitoring labs at 17 VCMC clinics by 5% from 85.48% to 90.48%. Results: Almost met 5% goal. PDSA #3 Performance Feedback Reports Testing Expanded to CMH Centers for Family Health and Clinicas del Camino Real Aim: Improve medication monitoring labs SMART Objective: By February 29, 2016, increase the rate of medication monitoring labs by 5% at the following clinic systems: o The combined rate of 5 CMH Centers of Family Health clinics from 79.14% to 84.14%. 8

9 11 5. Antibiotics Stewardship QI Study (PDSA) Helen Chtourou, QI Project Manager o The combined rate of four Clinicas del Camino Real clinics from 73.05% to 78.05%. Results: Medical record reviews scheduled in March and April There are 3 HEDIS measures related to antibiotic use in the outpatient setting: 1. Avoidance of antibiotic treatment in Adults with Acute Bronchitis 2. Appropriate testing for children with Pharyngitis; and 3. Appropriate testing for children with upper respiratory tract infection. HEDIS Rate Update Kim Osajda, Director of Quality Improvement GCHP s 2015 reporting year rates for these measures indicate opportunities for improvement. A PDSA improvement plan was implemented in August The goal was to reduce inappropriate dispensing of antibiotics in children and adults and increase strep testing for pharyngitis in children by utilizing academic detailing packets to engage providers in changing their antibiotic dispensing and pharyngitis testing behavior. At the end of 2015 the results showed that our benchmark goals were met. After the administrative refresh HEDIS data run in April 2016, we will re-evaluate the results of these measures to determine if academic detailing packets should continue. 12 HEDIS Update Member Osajda provided an update on the HEDIS audit. The audit will conclude in May Compliance Committee Report Brandy Armenta, Director of Compliance 13 David Becerra, Compliance Manager The Credentialing audits were completed in January The focused audit on specialty contracts was completed in March 2016, the results of this audit will be reported on at the next QIC meeting. Due to staffing issues, we ve postponed some claims audits to May. The annual DHCS audit is scheduled for April and we are preparing for that as well. Maureen Finnigan, Delegation Oversight Auditor RN The VSP Clinical Audit was conducted in October 2015 Findings from this audit resulted in 2 CAPs which were satisfied and closed by January Quality Improvement Dashboard with Sub-Committee Updates 14 Grievance & Appeals Committee Stacy Luney, Manager, Grievance & Appeals The Managed Behavioral Health Organization November 2015 Findings from this audit resulted in 38 CAP items. On January 13, 2016 GCHP received the 1 st CAP response from Beacon, 31 items were closed and 7 remained open. On February 26, 2016 a 2 nd CAP response was received, 4 items were closed and 3 remained open. As a result of multiple repeat findings a six month focused follow-up audit will be scheduled and conducted. The follow up audit is scheduled for May Member Luney provided an update on Dashboard items that did not meet their requirements. Resolution TAT Grievances and Provider Grievances both increased in Q4 of The Grievances & Appeals Committee met on January 20, Items discussed 9

10 were: 1. MedHOK IRE Module This module has been implemented. Testing has been completed and we are currently using this module for all our State Fair Hearings. 2. G&A Mapping Process Currently we are working with Health Services department to map the G&A process that impacts HS to capture best practices. We are developing workflows and desktops, defining the whole process from start to finish th Quarter Report Total Grievances grievances were Clinical and 269 were Administrative Top 3 Reasons for grievances were Provider Dispute, Quality of Care and Quality of Service. Clinical Appeals for Q were 19 cases: 9 upheld, 5 overturned, 2 withdrawn, 2 dismissed and 1 was in progress at the time of this report. State Fair Hearings for Q were 5: 1 approved, 1 denied, 1 withdrawn and 2 were dismissed. Quality Workgroup reviewed a total of 56 quality issues and 20 were referred as PQIs for review. 15 Pharmacy & Therapeutics Committee Anne Freese, PharmD, Director, Pharmacy 16 Utilization Management Committee Dr. Nancy Wharfield, Associate Chief Medical Officer Member Villani asked that the other delegate grievances be included in the G&A Committee report going forward. Member Freese provided an update on Dashboard items that did not meet their requirements. PA Accuracy increased in Q Language in Denial Letters maintains there high 90 s rates. We are reviewing the denial language that is sent out and making revisions to the pre-set language as needed, this is an annual exercise and will continue going forward. The P&T Committee met on February 25, Items discussed included the review of 12 new drugs with 8 added to the formulary. The formulary will be updated again to reflect the decisions from the February meeting on April 1, The committee also reviewed requests from providers regarding 2 drugs and both were added to the formulary. The UM Committee met on January 22, Items discussed included approval of the 2016 Work Plan, UM Program Description and CM Descriptions. Annual guideline updates were conducted and reports on Health Services Operations and Utilization Management were reviewed. An overview and update on the Utilization Management/Health Services Quality Improvement CCS/GCHP Project for Medical Home was given. Discharge Planning/Transition of Care was also discussed. Member Villani asked what our readmission rate is, Dr. Wharfield responded around 10. Member Osajda added we re at Member Lemmon also added the Welcome Home pilot program that was tried last year. 10

11 17 Credentials / Peer Review Committee Dr. Reeves, Chief Medical Officer The C/PR Committee met on March 10, The committee continues to monitor three (3) physicians with actions against them by the Medical Board of California. One of these providers completed his hearing, the medical board issued a public reprimand. A second provider is on a 5 year probation and continues to meet his probation requirements. The last provider is on a 10 year probation due to medical problems. He continues to meet his probation requirements as well. All providers are licensed and active. There were 19 PQI cases submitted for review. One of these cases was deemed not a PQI, 14 cases were closed and trended, and 4 cases remain open. Five cases were presented to the committee for review, no ratings were changed. The highly rated PQIs were presented. One high rated PQI case was rated a 3 for Outcome and System Issues. This was reviewed by the facility and procedure at the facility have changed to prevent a recurrence as a result of this case. Two cases were referred from the G&A department. Both cases related to access issues but did not significantly affect the member s outcome. The providers were contacted and responded that the issues would not occur going forward. One case identified as issue in which the member received anesthesia for a medical procedure but the case was cancelled because necessary equipment and personnel were not available. The member was recovered from anesthesia and returned to his room, the surgery was done the next day. A letter from the Facility indicated that policies were not followed. In-services were done to review policies with the staff. The Credentialing Delegation Oversite Report was presented to the committee. 18 Member Services Committee Luis Aguilar, Manager, Member Services The committee approved 121 new providers, 1 provider with a history of several malpractice issues and a history of an action by the medical board will have 5 previous or new cases reviewed. There were 8 recredentialed providers approved and 7 facilities approved as well. Member Aguilar provided an update on Dashboard items that did not meet their requirements. The Call Center has increased their Aggregate Average Speed of Answer to less than 30 seconds. The Member Services Committee met on January 20, Items discussed included the Membership update as of January 1, The Consumer Advisory Committee met on December 16, 2015 where updates were provided from the COO, CFO and Operations. An update was presented on the 1115 Waiver and on the Whole Person Care Pilot. Information on the Behavioral health Treatment transition was provided, the effective date is February 1, Information regarding the transition of children with unsatisfactory immigration status from restricted scope benefits into full scope benefits as of May 2016 was also presented The annual review of the Member Handbook is in process and projected to be ready for distribution with the July 2016 membership. Member Orientation 2015 attendance results were presented. As expected, attendance numbers fell towards the end of the year. Lastly, the 2016 Medicare Part A Project was discussed. GCHP sent out 377 Part A applications with a goal of 30% conversion rate. 11

12 Member Villani asked what are the circumstances for members to get Part A. Member Aguilar provided the different reasons and what the process is for members to apply. Also discussed at the last Member Services Committee meeting was the BHT Transition. GCHP has been sending out the 60 and 30-day transition notices as required by DHCS. The IVR Optimization system has been reviewed by the Plan in an effort to make it more efficient and less cumbersome for members and providers. A request has been submitted to Xerox and have targeted the end of April 2016 for the changes to be implemented. Lastly, the Call Center Metrics for Q were presented to the MS Committee for calls, average speed to answer, abandonment rate and walk-in/calls. Member Villani asked how many BHT transition notices have been mailed out. The exact number was not known because the state changed the parameters. Dr. Wharfield added the transition began in February and the process has gone smoothly. 19 Network Planning Committee William Freeman, Director, Network Operations & Provider Relations Dr. Reeves asked what the improvements on the IVR will be. Member Aguilar answered one change is that the system is asking for verification right away but with the change it will only require verification for automated transactions such as requesting an ID card. Members will be able to get to someone faster. When member information is not matched to what is in the system, they ll be immediately transferred to a live person. Member Villani asked if there is an opt out option from the IVR, the answer was yes. Metrics on the Dashboard were reported earlier in the meeting. The Network Planning Committee met in March Items discussed included Member PCP assignments. Membership is approximately 203,074. VCMC has 41% percent of membership assigned to them, Clinicas del Camino Real has 17% and other groups and individual PCPs have 42%. PCP to Member Ratio Standards show 220 PCPs results in 1 PCP for every 923 members, although the standard is 1 for every 2000 members. 99.9% of membership travels on average 1.5 miles to receive PCP care, the standard is 10 miles. Specialist to Member Access Standards show 99.5% of membership travels on average of 1.8 miles to receive specialty care where the standard is 10 miles. Other metrics presented were Timely access Appointment percentages, Required Specialty Projects in Process and Contracts Completed. These contracts were with Camarillo/Oxnard Anesthesiology Medical Group and Ventura Anesthesiology Medical Group. Also contracted were the Spanish Hills Surgery Center, Channel Islands Surgery Center and Conejo Valley Surgery Center. Home Health Care contracts included Los Robles Home Health Care and Allied Healthcare Professionals. Other services contracted were West Gastroenterology Medical Group, Premier Physical Therapy & Associates, Laurel Canyon Dialysis Center and Children s Hospital LA and Medical Group. 12

13 New Contracts actively in negotiations are with UCLA and UCLA Medical Group, City of Hope Hospital and Medical Group, Identity IPA (board base of primary care and specialty services) and Victoria Care SNF. Other projects include contract file organization and process review, SharePoint/Intranet, Managed Care Provider Data Improvement, Provider Data Process Improvement and SB137 Directories. 20 Cultural Linguistics & Health Education Committee Lupe Gonzalez, PhD MPH, Director, Health Education/Cultural Linguistics Dr. Gonzalez reported the 4Q 2015 interpreting service requests. The total number of languages provided by GCHP and interpretation vendors was 15. The total number of translation requests (excluding American Sign Language) was 54. Total number of American Sign Language interpreter requests was 62 and the total number of telephonic calls for interpreter requests was 509. Dr. Gonzalez announced the metrics on the Dashboard for Cultural Linguistics will change to include turn-around time and fulfilled as well as non-fulfilled interpreter requests. We will also be looking into creating more reportable metrics for Health Education as well. Member Villani asked if we track TTY calls and if we have a dedicated line for them. Member Aguilar answered we do track the calls but we do not have a dedicated line as most of them are hang-ups. Due to the implementation of the Group Needs Assessment (GNA) staff combined the Health Education and Cultural Linguistics Committees. The meeting was held on February 9, Items discussed included approval of the Health Education Strategic Work Plan FY , the Health Education, Cultural and Linguistic Work plan FY and the Committee Meeting Minutes from the August and September 2015 meetings. Health Education items discussed were referrals, they continue to increase with the majority coming from care management. Diabetes education classes were held at Conejo Valley Medical Group in July and August There were a total of 77 participants. Classes held at Moorpark Family Medical Group were not well attended and staff continues to work with the clinic to improve participation. HE staff is working with Community Memorial Health System Centers for Family Health to conduct diabetes education classes at 2 facilities. Health Education has also completed a director of classes and resources related to diabetes management offered throughout the county. There was Community Health Education Workshops scheduled on November 27, 2015 at the Oxnard Public Library where over 70 individuals attended and received free blood sugar screening and education materials. On February 27, 2016, the Health Education Workshop and Health Fair was held at the Oxnard Public Library as well. Participants received free blood pressure screening, blood sugar screening and COPD screening. There were over 50 people in attendance. The Health Navigator Program reported an update on the Retinal Eye Exam project. 13

14 There were 19 members that completed their eye exam and received a $25 movie gift card. The Health Navigator and Disease Management staff continues to work together to reach members diagnosed with diabetes and refer them to classes and/or to the disease management nurse coach. Cultural Linguistics Services reported on 4Q 2015 metrics for interpreter services. C&L staff conducted three trainings for Ventura Transit System employees. Overall, a total of 48 VTS employees have attended training. Member Villani asked if the request for training came from VTS. Dr. Gonzalez responded the Delegation Oversight contract requirement states we must provide C&L training to them. 21 Medical Advisory Committee Dr. Reeves, Chief Medical Officer Lastly, 40 participants attended the MICOP Indigenous Immigrants in the Ventura County workshops sponsored by the C&L Department. The last MAC meeting was held on October 29, The committee approved several guidelines for Health Services including Custodial Care Guidelines, Acute Inpatient Rehabilitation Guidelines, Home Health Guidelines, Intravenous Sedation and General Anesthesia for Dental Services Guidelines and also retired the Zostavax Recommendations guidelines. The results of the CAHP Survey were presented. Also discussed were the Quality Dashboard and HEDIS updates, the PDSA projects and member incentive programs and updates from Utilization Management, Grievance & Appeals, Credentials and Pharmacy. Adjourn: The meeting was adjourned at 5:18pm. The next regular meeting of the Quality Improvement Committee will be held on June 28, 2016 at 3:00pm. Location will be at 711 E. Daily Drive, Ste. 106, Camarillo, CA C. Albert Reeves, MD, Chair 14

15 Quality Improvement Committee OPEN - Action Items Item # Date Owner Department Action Required Response 28 12/15/15 William Freeman / Steve Peiser Network Dr. Wong asked if the number of providers contracted are full-time or part-time. Mr. Freeman responded it s both. Dr. Wong was concerned that this number could be deceiving since many providers only work part-time. Mr. Freeman agreed to look further into the provider counts and member access to see if there is an impact. UPDATE : Member Freeman indicated that contractually all providers need to have a medical professional present in their office during normal working hours. It was stated that Dr. Wong s major point was about access, and that is an ongoing issue with regard to a number of specialties. A strategy is being set up to attempt to resolve that issue. As the issue is now more of an access issue rather than part time or full time arrangement, this issue is still under review. Date Completed 29 12/15/15 William Freeman / Steve Peiser Network Mr. Villani asked about the members indicated on the map that are out of the county. Mr. Freeman will look into why these members are showing up outside the county. UPDATE : Member Freeman reported a review was performed and it appears that the sampling that was selected demonstrated that many members live in zip codes that extend into Ventura County, and that members who may live outside the county along the edge are able to ask to be included under GCHP, the fact they are not living within the actual county may not be caught for a period of time. It was decided to enlarge the sampling and see what the subsequent results show. 15

16 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: 2015 Postpartum Visit Member Reward Program June 28, 2016 QIC Update Final Postpartum HEDIS 2015 Measurement Year (MY) Rates HEDIS 2015 Final HEDIS Rates Postpartum HEDIS 2014 MY Final Rate HEDIS 2015 MY Final Rate % Point Change 59.12% 62.81% % MY Administrative HEDIS Rate Comparison Measurement Year Eligible Population Members Who Received Postpartum Care Rate % % % Conclusion Goal Not Met The final HEDIS 2015 MY rate decreased by 3.69% compared to the previous year s rate of 62.81%. Updates 2016 Postpartum Member Incentive Expand promotion of the postpartum member incentive: o Make postpartum incentive forms accessible to members on GCHP s website Completed 4/15/16 o Include member incentive information in Member Orientation packets Completed 2/8/16 16

17 o Create FAQs for Member Services and Provider Network Completed 2/8/16 Updated 5/24/16 o Continue promoting with external resources including providers and prenatal programs within the community Ventura County Medical Center on 3/21/16 Clinicas del Camino Real on 3/28/16 First 5 Ventura County on 4/12/16 CMH CFH on 4/18/16 Scheduled to present at CPSP Meeting on 7/8/16 o Include flyer with Health Education s OB Packet Sent to HE on 3/30/16 Use ICD-10 code Z3A.xx, which code for weeks of gestation, and to identify members who are close to their delivery date for the monthly mailing list. o Complete o Monthly mailings have increased Month/Year Member Mail Source to Identify Members for Mailing List Count 07/ Claims 08/ Claims 09/ Claims, Hospital Census 10/ Claims, Hospital Census 11/ Hospital Census 12/ Hospital Census 01/ No Mailings 02/ Hospital Census 03/ Hospital Census 04/ Hospital Census & ICD-10 Query 05/ Hospital Census & ICD-10 Query 06/ Hospital Census & ICD-10 Query Target high volume/low performing clinic o In process of reviewing HEDIS 2015 MY rates Medical Record Review o The QI Department reviewed a sample of 40 medical records of women who did not have postpartum care to identify any common characteristics, trends, or barriers and 70% (28/40) of the non-compliant women were multi-para 17

18 mothers. Further analysis is required to confirm if this is significant factor which may warrant a targeted intervention focusing on multi-para mothers. Include postpartum educational letter with incentive flyers mailed to members o In process Collaborate with external partners for member outreach activities, such as Text4baby. o Not started 18

19 January 28, 2016 QIC Update Analysis of 2015 Postpartum Member Incentive Postpartum Member Incentive Forms Mailed Barriers Identified Difficulty assessing gestational age from claims data o Using claims data prevented the QI Analyst from identifying members who were close to their delivery date. o Opportunity for Improvement: Using the hospital census data became the primary source for the monthly postpartum incentive mailing. With the implementation of ICD-10 codes as of October 1, 2015, the QI Department will re-evaluate the effectiveness of querying claims using the ICD-10 code Z3A.xx, which code for weeks of gestation, and will help to identify members who are close to their delivery date. 19

20 Postpartum Member Incentive Forms Returned Postpartum HEDIS Rates 2015 Quarterly Administrative HEDIS Rates Postpartum 2015 Q1 January - March 2015 Q2 January - June 2015 Q3 January - September 2015 Q4 January - December HEDIS 2014 MY Administrative Rate % Point Change * * Preliminary rates may change after Admin Refresh in April MY and 2015 MY Administrative HEDIS Rate Comparison Measurement Year Eligible Population Members Who Received Postpartum Care Rate % % % %* * Preliminary rates may change after Admin Refresh in April

21 Conclusion Goal Almost Met We almost met our goal of increasing the 2015 MY postpartum care administrative HEDIS rate by at least 5%. The 2015 preliminary admin rate increased 4.17 percentage point from for the 2014 MY to for the 2015 MY. However, due to expected claims lags resulting from contractual arrangements that allow providers to bill for services up to 180 days after services are rendered, the preliminary rates may increase after more 2015 postpartum claims are captured in the April 2016 admin refresh. Prevalance of Low Postpartum Care within the Medicaid Populaiton The 2014 MY and 2015 MY Administrative HEDIS Rate Comparison table shows there has been a yearly trend of an average of only half of new mothers receiving postpartum care. Additionally, data collected by DHCS in 2008 shows only 63% of members enrolled in Medicaid plans receive postpartum care compared to 82% of the members enrolled in commercial plans. These statistics indicate a need to continue outreach to our members to improve postpartum care Postpartum Member Incentive This incentive was approved by DHCS in 2015 as an ongoing member incentive with no end date, and we will continue the postpartum member incentive into The plan for the next PDSA cycle is to: Expand promotion of the postpartum member incentive: o Make postpartum incentive forms accessible to members on GCHP s website o Include member incentive information in Member Orientation packets o Train Member Services staff about member incentive programs o Continue promoting with external resources including providers and prenatal programs within the community Include educational letter with incentive flyers mailed to members Analyze data to determine type of mothers not receiving postpartum care, such as multi-para women Collaborate with external partners for member outreach activities, such as Text4baby. Target high volume/low performing clinic 21

22 June 15, 2015 QIC Update SUMMARY: The purpose of the member incentive is to improve postpartum visits on or between 21 and 56 days after delivery. BACKGROUND: Historical rates for postpartum visits have been low. While the HEDIS rate for this measure remained above the Department of Health Care Services (DHCS) Minimum Performance Level (MPL), rates declined 4.62 percentage points from in 2012, to in The 2014 rate improved slightly to but remains below the 2013 rate. The MPL is the 25 th percentile NCQA national Medicaid level. The 2014 rate places the Plan in the 25 th percentile. Timely postpartum visits are important for follow up of conditions such as diabetes and hypertension as well as support for breastfeeding and screening for depression. Postpartum care is a focus area for DHCS in 2015 per the DHCS Medi-Cal Managed Care Program Quality Strategy dated February 2, The QI department has developed the following member incentive program to address the low performance of this HEDIS measure. Targeted Behavior: Improve postpartum visits. Type of Incentive: New Baby Welcome Gift Set containing two jumbo packs of diapers size newborn (32 count) and size 1 (35 count), a tub of sensitive wipes and a hat and a pair of socks. The member must have a postpartum visit on or between 21 to 56 days after delivery and have the OB/Gyn or PCP sign the form. The member then mails the completed form back to GHCP in a self addressed stamped envelope provided by GHCP. GCHP will have the gift set shipped to the member s address on file. Members will receive one gift set per birth(e.g., if a member delivers twins she will receive two gift sets). Evaluation of Incentive Program: By December 31, 2015 GCHP will increase MY 2015 HEDIS rates by at least 5% over previous measurement year for Postpartum Care. QI will track rates at quarterly HEDIS data runs to identify increases. First evaluation will be measured by the 2015 HEDIS Production Admin refresh run in April As this is an ongoing incentive, subsequent yearly evaluations will occur quarterly during quarterly HEDIS runs. Goals will be determined each year after initial evaluation of rates for measurement year QI will track rates at quarterly HEDIS data runs to identify increases. Final evaluation will be measured by the 2015 HEDIS Production in Final rates are reported in July

23 HEDIS Measure: Postpartum Care. 23

24 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: 2015 Well-Child Member Incentive (Parent-Child Monthly Raffle) June 28, 2016 QIC Update Analysis by Measure Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life HEDIS 2015 MY Final HEDIS Rate HEDIS 2015 MY HEDIS Final Rate MY Final Rate % Point Change % % 2015 Q1 January - March 2015 Quarterly Administrative HEDIS Rates 2015 Q January - Q3 Q4 June January - January - HEDIS 2014 MY 2014 DHCS Age Group Admin Rate Rate MPL September December Change 3-6 Years Well-Child Visits by Month 24

25 Children and Adolescent Access to Primary Care Physician (CAP) Age Group Months 25 Months 6 Years 2015 Q1 January - March 2015 Q2 January - June 2015 Q3 January Q4 January - HEDIS 2014 MY 2014 DHCS Administrative MPL Rates Rate September December Change Years Years Conclusion For the W34 measure, we did not meet our goal of increasing the final HEDIS hybrid sample rate by 5% points. For the CAP measure, we met our goal of meeting the MPL for the age group; however this rate decreased by 0.77% points. The rates increased for the other three age groups in the CAP measure these rates did not meet the DHCS MPL. Our first attempt to increase wellness exams in children and adolescents through a member incentive did not achieve the success we had predicted. However, the importance of increasing preventive care for this population warrants continuing the well-child member incentive in 2016, but with some modifications that include: Mail the well-child member incentive letters earlier in the year o Our plan for the 2016 was to send the mailings by February/March 2016; however, due to interdepartmental delays with producing the preventive care letters, the member incentive letters were not mailed until 6/6/16. Revise the graphics on the member incentive form to be more applicable to wellchild care completed 3/22/16 Include a preventive care reminder letter with the member incentive flyer/form completed 6/6/16 Increase promotion of the member incentive by: o Adding member incentive form/flyer to GCHP website completed 4/19/16 o Promote with community Sent flyers to First 5 Ventura County completed 4/8/16 Provider eblast completed 5/15/16 25

26 o Include in Member Orientation packets completed 5/24/16 o Create FAQs for Member Services and Provider Network completed 5/24/16 June 28, 2016 QIC Attachments: PDSA for Well-Child Exam Member Incentive (Parent-Child Monthly Raffle) 2016 Member Incentive Flyer 26

27 January 28, 2016 QIC Update Analysis of 2015 Well-Child Member Incentive Total Member Incentive Letters Mailed: 19,105 Total Member Incentive Letters Returned as Undeliverable: -12 Member Participation Results of Well-Child Member Incentive Total Counts Sub-Category Counts Total Members Participating in the Member 213 Incentive Received Incentive Flyer in Mail Received Incentive Flyer from Provider Total Members Rewarded Incentives 167 Received Incentive Flyer in Mail Received Incentive Flyer from Provider Total Rejected Member Incentives Forms No Visit Date on Form Visit Date Out-of-Range No Signature/Proof of Visit Status of Returned Member Incentive Flyers

28 Well-Child Visits by Month 2015 Quarterly Administrative HEDIS Rates Age Group 3-6 Years of Age 2015 Q1 January - March 2015 Q2 January - June Well-Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of life (W34) HEDIS 2014 MY DHCS Q3 Q4 Admin Rate 2016 January - January - MPL Rate September December Change * * The preliminary 2015 MY rate may change after Admin Refresh in April 2016 Age Group Months 25 Months 6 Years 2015 Q1 January - March 2015 Q2 January - June Children and Adolescent Access to Primary Care Physician (CAP) HEDIS 2014 MY DHCS Q3 Q4 Administrative 2016 MPL January - January - Rates Rate September December Change * * Years * Years * * The preliminary 2015 MY rate may change after Admin Refresh in April

29 Conclusion For the W34 measure, we did not meet our goal of increasing the admin rate by 5%. For the CAP measure, we met our goal of meeting the MPL for the age group; however this rate decreased by 1.01 percentage points. In contrast, the other three age groups in the CAP measure had improved rates, but these increased rates did not meet the MPL. Note: The preliminary 2015 MY rate may increase after Admin Refresh in April 2016 that will capture any claims lags. Our first attempt to increase wellness exams in children and adolescents through a member incentive did not achieve the success we had predicted. However, the importance of increasing preventive care for this population warrants continuing the well-child member incentive in 2016, but with some modifications that include: Starting the member incentive earlier in the year Increasing promotion of the member incentive Revising the graphics on the flyer/form to align more with the member incentive topic Attaching a preventive care reminder letter with the member incentive flyer/form The 2015 well-child member incentive evaluation and PDSA was sent to DHCS for review on February 17, Upon receipt of DHCS s response, the QI Department will request a renewal of the well-child member incentive for January 28, 2016 QIC Attachments: Plan-Do-Study-Act form for Well-Child Exam Member Incentive November 2015 Well-Child Incentive Summary Report 29

30 December 15, 2015 QIC Update Background: Gold Coast Health Plan s rate for two HEDIS measures that report the percentage of annual well-child visits and child/adolescent access to a primary care physician have scored low and below the Department of Health Care Services (DHCS) mandated Minimum Performance Level (MPL). The first measure, Well Child Visits in the 3 rd, 4 th, 5 th, and 6 th Years of Life (W34) did improve for the 2014 measurement year (MY) and reached the DHCS MPL with a rate of compared to a rate of for the 2013 MY which was below the MPL. However, the current 2014 MY year rate of is still low and ranks in the 25th percentile, based on the National Committee for Quality Assurance (NCQA) national percentile rankings. See Table 1 for the trends in well-child visits from January 2012 to October The second measure, Children and Adolescents Access to PCP (CAP) reports the percentage of children and adolescents who had a visit with a PCP and four rates are reported for the following age groups: months; 25 Months- 6 Years; 7-11 years; and year. All groups have remained in the 10 th or <10 th NCQA national percentile ranking, with the exception of the months age group with reached the 50 th percentile in the 2013 MY, but dropped back to the 10 th percentile in the 2014 MY. The low performance of these two measures has generated concern about underutilization of care for these pediatric age groups. The American Academy of Pediatrics recommend annul well-child visits for all children and adolescents between 3 and 21 years of age because physical exams with a clinician provide the best opportunity for the early detection and prevention of developmental, psychosocial or chronic diseases. The goal of the 2015 Well-Child Member Incentive is to increase annual well-child exams in children and adolescents. Since annual wellness exams include reviewing a patient s health and developmental history, completing physical exams, providing health education/anticipatory guidance, and screening for tests/immunizations, an increase in annual well-child exams has the potential to improve the rates for the following five child and adolescent HEDIS measures: Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life Children and Adolescents Access to PCP Counseling for Nutrition and Physical Activity in Children and Adolescents Childhood Immunization Status Immunizations for Adolescents December 15, 2015 QIC Attachments: Plan-Do-Study-Act form for Well-Child Exam Member Incentive November 2015 Well-Child Incentive Summary Report 30

31 Well-Child Member Incentive Performance Improvement Timeline Date Status 03/27/2015 QI submitted well-child member incentive proposal to DHCS. 03/30/2015 DHCS approved proposal. April 2015 Three member letters drafted and submitted to Health Education/Cultural Linguistics for approval. for distribution to English and Spanish members: Notification of member incentive flyer Congratulations letter to parent Congratulations letter to child May 2015 Health Education/Cultural Linguistics approved letters. May 2015 Letters submitted to Health Education/Cultural linguistics for translation to Spanish. May 2015 English and Spanish versions of letters submitted to Communications for final formatting by publishing vendor, Coffey. June 2015 QI queried claims data to identify children and adolescents who have not had a well-child exam in June 2015 Member-incentive gift cards ordered. June 2015 QI created database to track receipt of completed member-incentive flyers and distribution of gift cards. 07/15/ ,102 member incentive flyers mailed. July 2015 to QI Analyst tracking receipt of member incentive flyers. January /11/15 Approval of readability scoring for preventive care letters sent to HE/CL. 12/15/15 Translation requests for preventive care letters sent to HE/CL. 1/29/16 Formatting requests for preventive care letters sent to Communications January 2016 QI analyzed results of 2015 Well-Child Member Incentive and determine effectiveness of member incentive. February 2016 Member incentive evaluation and PDSA sent to DHCS on February 17, /22/16 Communications completed revision of graphics on well-child member incentive flyer. 4/8/16 QI sent flyer to First 5 Ventura County. 4/19/16 Communications added member incentive to GCHP website. 5/15/16 Provider eblast memo to promote member incentives ed. 5/19/16 Communications sent QI final preventive care letter for review/approval. 5/24/16 Flyer added to Member Orientation packets. 5/24/16 Member incentive FAQs sent to Member Services and Provider Network. 6/6/16 Member incentive flyer with preventive care letter mailed to 5,060 households with minors insured through GCHP. 31

32 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: GCHP-VCMC Performance Improvement Project (PIP) Collaborative Child Immunizations June 28, 2016 QIC Update During the months of April and May 2016, the QI Department met with the key members of Las Islas Family Medical Group to develop the plan for the PDSA. The Plan portion of Module 4 s Plan-Do-Study-Act (PDSA) was submitted to HSAG/DHCS for review and approval on June 1, Module 4 outlines the planned quality improvement activities that will be tested to impact the SMART Aim goal of increasing the child immunization rate for children ( 24 months of age) at Las Islas Family Medical Group to 77.66% by June 20, The intervention the clinic chose for this PDSA is to use reports from their EHR and the CoCASA/CAIR Registry to identify children ( 24 months of age) with incomplete immunizations and contact the parents of these children to schedule appointments for immunizations. The purpose of this intervention is to implement an achievable and sustainable practice within the clinic workflow to increase the administration of immunization by using existing reports to identify children who have incomplete immunizations and then contacting the parent(s) to schedule appointments. Success with this intervention will be measured by the number of appointments successfully scheduled each month. The clinic s planned quality improvement activities for this intervention is scheduled to begin July 1, 2016, upon approval of Module 4 from DHCS and HSAG. June 28, 2016 QIC Attachments: Module 4 32

33 January 28, 2016 QIC Update Background: The Department of Health Care Services (DHCS) requires all Medi-Cal managed care health plans (MCPs) to conduct a performance improvement project (PIP) with a topic selected by DHCS. The previous PIP with a DHCS-selected topic was the All-Cause Readmission measure which ended in 2015 and on September 9, 2015, DHCS announced that MCPs would have the option to choose from one of four new topics that are related to DHCS Quality Strategy focused areas. The four topic choices were: Diabetes Hypertension Postpartum visits Immunizations of two year olds The Quality Improvement (QI) Department proposed selecting immunizations for two-year olds as the PIP topic due to the continually decreasing rates reported in 2013, 2014 and 2015 for the Childhood Immunization Status (CIS) Combo 3 HEDIS measure. (Please see Module 1 for the complete rationale for selecting this topic). The other suggested topics were not selected because Gold Coast Health Plan (GCHP) is currently working on performance improvement projects to increase annual diabetic retinal eye exams and to increase postpartum care visits. On September 29, 2015, the Quality Improvement Committee approved the proposed topic and the QI department sent this proposal to DHCS for review which was approved by DHCS in October In addition to the new PIP topic selections, DHCS and Health Services Advisory Group (HSAG), the external quality review organization contracted by DHCS to monitor the PIPs, redesigned the performance improvement process to be more aligned with the Institute for Healthcare Improvement s (IHI s) Quality Improvement Model. The previous quality improvement project (QIP) submissions have been retired and MCPs will no longer use the QIP Summary Form to submit their information to HSAG for validation. The new PIP process is divided into four phases that include five modules; each phase must be reviewed and approved by HSAG before MCPs can continue to the next phase. January 28, 2016 QIC Attachments: Module 1 Module 2 Module 3 Module 3 Process Mapping VCMC s HEDIS 2014 Measurement Year (MY) By Clinic 33

34 GCHP-VCMC Childhood Immunization Performance Improvement Project (PIP) Collaborative Timeline: Date Status 09/09/2015 DCHS announces their four topic options for the new PIP. 09/29/2015 GCHP QIC approved childhood immunizations as the PIP topic for GCHP. 09/30/2015 DHCS approved GCHP s proposal to select childhood immunizations October 2015 GCHP QI Dept. analyzed 2014 results of Childhood Immunization Status (CIS) HEDIS measure data to identify clinics with high volume child members that had low CIS scores. 10/19/2015 GCHP QI Director initiated contact with VCMC s Medical Director of Performance Improvement and Patient Care to discuss collaborating on a performance improvement project to improve childhood immunizations. 10/20/2015 GCHP QI Dept. sends VCMC report of HEDIS 2014 MY rates for CIS Combo 3 grouped by VCMC clinic. 10/22/2015 VCMC agrees to collaborate with GCHP and focus on improving the rates of Las Islas Family Medical Group. 10/28/2015 GCHP QI Dept. sent VCMC information on DHCS PIP process 10/28/2015 GCHP QI Dept. began drafting PIP Modules 1 and 2 11/16/2015 GCHP QI Dept. sent VCMC draft of Modules 1 and 2 11/20/2015 GCHP QI Dept. and CMO met with VCMC at Las Islas Family Medical Group to review Modules 1 & 2. VCMC agreed to complete portions of Module 2 regarding their data collection process and return to GCHP. 12/1/2015 VCMC informed GCHP QI Dept. that they had challenges with generating reports filtered by only GCHP members. GCHP QI Dept. re-strategized to utilize HEDIS software for reporting and completed the data collection process. 12/04/2015 Modules 1 & 2 submitted to DCHS/HSAG for review and approval before beginning Module 3. 01/27/2016 HSAG training on PIP Module 3. February Met with VCMC to complete Module 3 and Process Mapping /29/2016 QI submitted PIP Module 3 and Clinic Process Mapping to DCHS/HSAG. 02/29/2016 QI attended 2016 Q1 DHCS/HSAG Workgroup Collaborative on Improving Immunizations of Two-Year Olds 04/06/2016 HSAG requested minor revisions to Module 3 which GCHP approved. 04/20/2016 HSAG training on PIP Modules 4 & 5 04/22/2016 GCHP-VCMC Module 4 Meeting #1: Intervention Selection and Planning for PDSA 05/09/2016 GCHP-VCMC Module 4 Meeting #2: Reviews 1 st Draft of Module 4 05/26/2016 GCHP-VCMC Module 4 Meeting #3: Review Data Collection Tool 06/01/2016 QI Submitted the Plan portion of Module 4 to HSAG and DHCS 34

35 Date Status 06/03/2016 QI attended 2016 Q2 DHCS/HSAG Workgroup Collaborative on Improving Immunizations of Two-Year Olds 07/01/2016 Tentative date for VCMC to begin intervention testing to improve immunization rates for children 24 months of age. 35

36 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: GCHP-CMH Performance Improvement Project (PIP) Collaborative - Increase Utilization of Standardized Child Developmental Screening Tools during Well- Child Exams June 28, 2016 QIC Update PIP Module 3 During the month of May 2016, the QI Department met with the key staff members at the CMH CFH Arneill Road clinic to complete Module 3 which included mapping the clinic s current workflow and completing a failure modes/failure effects analysis. The purpose of Module 3 is to identify barriers in administering the child developmental screenings and to identify possible interventions to eliminate these barriers. Since this does not currently use the PEDS tool, but uses the Modified Checklist for Autism in Toddlers (M-CHAT), the QI Department consulted with HSAG on using the M-CHAT as the initial foundation for developing the process mapping and failure modes/ failure effects analysis, which HSAG approved but requested that GCHP develop a new Module 3 analysis after the PEDS is implemented to identify any barriers specific to utilization of PEDS. The completed Module 3 was submitted to HSAG/DHCS for review and approval on June 1, Collaboration with Health Services and Help Me Grow Ventura The Health Services Department and Help Me Grow Ventura is developing a process for CMH CFH Arneill to refer children, who are identified through the PEDS screening tool with developmental needs, to Health Services for care management. Collaboration with Help Me Grow Connecticut and Help Me Grow Ventura Two external organizations supporting this performance improvement collaborative are Help Me Grow Connecticut and Help Me Grow Ventura. Help Me Grow Connecticut is providing MOC continuing education credits to Dr. Hoang-Anh Pham for the QI Methodology Training the GCHP QI Department delivered on May 3, Help Me Grow Ventura will be providing CMH CFH training on June 23, 2016 for administering the PEDS screening tool and referring children with developmental needs. June 28, 2016 QIC Attachments: Module 3 and Process Mapping 36

37 January 28, 2016 QIC Update Background: The Department of Health Care Services (DHCS) requires all Medi-Cal managed care health plans (MCPs) to participate in two performance improvement project (PIP) annually, one PIP topic is selected by DCHS and the second PIP topic is selected by the health plan. On February 12, 2012 the Quality Improvement (QI) Department proposed selecting the utilization of standardized child developmental screening tools during well-child exams as a PIP topic and DHCS granted approval on February 17, This topic was selected due the result of an analysis of January 1, 2015 to December 31, 2015 claims data that showed significantly low to no utilization of standardized tools for assessing child development at Community Memorial Health System (CMHS) clinics. To assess the prevalence of well-child visits performed at CMHS clinics, a second claims query, for the same age group and dates of services, was conducted using well-child preventive care visit codes (ICD-9-CM, ICD-10-CM and CPT). The results of this second query showed that providers are providing preventive care services, but the first query shows that providers are not including standardized questionnaires during these visits resulting in missed opportunities to obtain valuable information from the child s parent (See Table 1). Children on Medicaid are particularly vulnerable to acquiring developmental issues due to living in households with lower socioeconomic status. For example, poor nutrition due to lack of financial resources to access nutritious foods, can affect physical growth and intellectual, emotional and psychological development in children. Standardized and agespecific developmental screening tools can be a critical factor in helping clinicians to identify and address any developmental issues in the earliest stages. The American Academy of Pediatrics also advises that a clinician s estimate of a child s developmental progress is more accurate when clinical assessments are coupled with standardized developmental screening tools. For these reasons, GCHP s goal to increase the utilization of standardized child developmental screening tools aligns with the State s Quality Strategy for preserving and improving the physical health of Californians and helping to reduce health care program costs. 37

38 Table 1 Prevalence of Well-Child Exams with Developmental Screening Tools in Children 24 Months in 2015 Based on 2015 Claims Data CMHS CLINIC NAME Enrolled Children Well-Child Exams Developmental Screening Tool Utilization Rate of Developmental Screening Tool Saviers % Main St % Vineyard % Arneill % Airport % Ashwood % Fillmore % Oak View % Santa Paula % Port Hueneme % Ojai % Santa Rosa % January 28, 2016 QIC Attachments: Module 1 Module 2 38

39 GCHP-CMH Childe Developmental Screening Tool Performance Improvement Project Timeline Date Status 02/12/16 GCHP proposed utilization of child developmental screening tools as the PIP topic. 02/17/16 DHCS approved PIP topic. 02/23/16 Staff from the Quality Improvement Department (Kim Osajda, Helen Chtourou) and Health Services Department (Dr. Nancy Wharfield, Vickie Lemmon) met with representatives from Help Me Grow Ventura County (Cindy Reed) and Connecticut Children s Hospital Help Me Grow (Jessica Ryan) 03/01/16 QI Department began research for Modules 1 & 2. 03/16/16 Staff from the Quality Improvement Department (Kim Osajda, Helen Chtourou, Leslie Cole) and Health Services Department (Dr. Nancy Wharfield met with representatives from CMHS Arneill Road Clinic (Dr. Victor Dominguez, Dr. Hoang-Anh Pham, Annette Des Baillets) and Help Me Grow Ventura County (Cindy Reed) to review PIP process and complete Modules 1 & 2. 03/17/16 QI Department sent CMHS the final drafts for Modules 1 & 2 to review and approve. 04/01/16 Modules 1 & 2 submitted to HSAG & DHCS for review and approval. 04/21/16 HSAG/DHCS approved Module 1 & 2. 05/03/16 QI Met with 05/04/16 QI-HMG-CMH Arneill Clinic Meeting QI Methodology Training Begin development of Module 3 05/12/16 QI-HS-HMG Meeting Referral Process 05/16/16 QI-HSAG Meeting Process Mapping and Failure Modes/Failure Effects Analysis 05/17/16 QI-HMG-HS Meeting Referral Process 05/26/16 QI-CMH Arneill Meeting Review 1 st Draft of Module 3 05/31/16 QI-CMH Arneill Reviewed Final Version of Module 3 06/01/16 QI Submitted Module 3 to HSAG and DHCS for review and approval. 06/23/16 HMG Training on PEDS Screening Tool 39

40 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: Medication Management in People on Persistent Medications (MPM) Department of Health Care Services (DHCS) Improvement Plan (IP) June 28, 2016 QIC Update MPM PDSA #2 Performance Feedback Reports Testing Expanded to high volume/low performing clinics at five Community Memorial Hospitals (CMH) Center for Family Health (CFH) clinics and four Clinicas del Camino Real (CDCR) clinics. Global Aim: Improve medication monitoring labs. SMART Objective: By February 29, 2016, increase the rate of medication monitoring labs by 5% points at the following high volume/low performing clinics (See Do II.C.1 and II.D.1 sections): The combined rate of four Clinicas del Camino Real (CDCR) clinics from to o Note: To account for labs found, during the medical record reviews, to be completed in 2015 before the performance feedback reports were distributed, the baseline was adjusted from to and the new goal is (See Do II.C.1 section). The combined rate of five CMH Centers of Family Health (CMH CFH) clinics from to o Note: To account for labs found, during the medical record reviews, to be completed in 2015 before the performance feedback reports were distributed, the baseline was adjusted from to and the new goal is (See Do II.D.1 section). 40

41 Results of CDCR Reviews: Exceeded 5% goal Increased 5.68 % points Baseline Rate New Rate after 3-Monthy Study 516/ / Findings from Medical Record Reviews Members with Labs Completed Before Distribution of Performance Feedback Reports Members with Labs Completed After Distribution of Performance Feedback Reports Members with Labs Orders but Did Not Go To Lab 0 Members with No Lab Orders 51 Members on Digoxin Require Two Labs: These members had the Metabolic Panel lab performed but no lab orders for the 2 nd Digoxin lab. Members on ACE/Arb and diuretics with Missing Lab Orders 44 Total Records Reviewed Results of CMH CFH Reviews: Exceeded 5% goal Increased 6.81 % points Baseline Rate New Rate after 3-Monthy Study 369/ / Findings from Medical Record Reviews Members with Labs Completed Before Distribution of Performance Feedback Reports Members with Labs Completed After Distribution of Performance Feedback Reports Members with Labs Orders but Did Not Go To Lab 11 Members with No Lab Orders 45 Members on Digoxin Require Two Labs: These members had the Metabolic Panel lab performed but no lab orders for the 2 nd Digoxin lab. Members on ACE/Arb and diuretics with Missing Lab Orders 41 Total Records Reviewed

42 2015 Quarterly Administrative HEDIS Rates Comparison to HEDIS 2014 MY Rates and DHCS 2016 MPL Gold Coast Health Plan s overall rates for the MPM measure increased for the HEDIS 2015 measurement year. The overall rate increase is displayed in the table below Q1 January - March 2015 Q2 January - June 2015 Q3 January Q4 January - HEDIS 2014 MY 2014 DHCS Medication Admin Rate Rate MPL September December Change ACE/ARBs Digoxin Diuretics Total Conclusion: Since the performance feedback reports help increase lab monitoring for patients on persistent medications, the QI Department will adapt this intervention and continue sending quarterly performance feedback reports to VCMC, CMH CFH, and CDCR. June 28, 2016 QIC Attachments: MPM PDSA #3 42

43 January 28, 2016 Update Background: The HEDIS 2015 rates for the Annual Monitoring for Patients on Persistent Medications demonstrated decreased rates in the monitoring for the three medications: ACE inhibitors/arbs, Digoxin, and diuretics that fell below the DCHS mandated minimum performance level (MPL) which equates to the National Committee for Quality Assurance 25% percentile ranking. Gold Coast Health Plan s Reporting Year HEDIS MPM Rates HEDIS Measure 2013 HEDIS Rate 2013 Percentile 2014 HEDIS Rate 2014 Percentile 2015 HEDIS Rate 2015 National Percentile Ranking ACE/Arbs th th <10th Diuretics th th <10th Digoxin th th th This prompted concern and motivation to implement a performance improvement plan to identify barriers in medication monitoring and devise interventions to improve patient care and the rates for these measures. Persistent use of medications warrants monitoring and follow-up by the prescribing physician to assess for side-effects and adjust drug dosage and/or therapeutic decisions accordingly. In preparation for the implementation of this quality improvement activity, in June 2015, a QI RN reviewed a sample of 112 medical records of the non-compliant members who were part of the eligible population in the denominator of the HEDIS 2015 rates and who were treated by Ventura County Medical Center providers. The QI RN found three primary barriers for therapeutic monitoring: (1) members were not compliant with provider lab orders, (2) providers offices did not perform outreach to non-compliant members, and (3) large time gaps between providers orders for therapeutic monitoring, with an average time gap of 16 months between orders/testing. This is also a DHCS mandated improvement plan for HEDIS 2015 reporting year (RY) measures with rates below the MPL. The IP will require three Plan-Do-Study-Act (PDSA) cycles; each PDSA tests one intervention over a three-month study period. Based on the barriers identified, the intervention that will be tested in all three PDSAs is if performance feedback reports, which list which members have not had medication monitoring for 43

44 persistent medication, will help remind providers to order lab tests for non-compliant members. MPM PDSA #1 Performance Feedback Reports Tested at 5 VCMC Clinics Global Aim: Improve medication monitoring labs. SMART Objective: By November 30, 2015, increase the combined rated of medication monitoring labs at five Ventura Medical Center (VCMC) clinics by 5% from 77.03% to 82.03%. Results: Surpassed Goal of Increasing rate by 5% Baseline Rate New Rate after 3-Monthy Study 1097/ / Findings from Medical Record Reviews Members with Labs Completed Before Distribution of Performance Feedback Reports Members with Labs Completed After Distribution of Performance Feedback Reports Members with Labs Performed in Outpatient Setting 97 Members with Labs Performed in Inpatient or Emergency Department Setting 7 Members with Labs Orders but Did Not Go To Lab 77 Members with No Lab Orders 146 Members on Digoxin Require Two Labs: These members had the Metabolic Panel lab performed but the 2 nd required lab for Digoxin level not performed making member non-compliant Members on ACE/Arb and diuretics with Missing Lab Orders 140 Total Records Reviewed:

45 MPM PDSA #2 Performance Feedback Reports Testing Expanded to 17 VCMC Clinics Global Aim: Improve medication monitoring labs. SMART Objective: By February 29, 2016, increase the combined rate of medication monitoring labs at seventeen Ventura County Medical Center (VCMC) clinics by 5% from 85.48% to 90.48%. Results: Almost Met 5% Goal Baseline Rate New Rate after 3-Monthy Study 2892/ / Findings from Medical Record Reviews Members with Labs Completed Before Distribution of Performance Feedback Reports Members with Labs Completed After Distribution of Performance Feedback Reports Members with Labs Performed in Outpatient Setting 156 Members with Labs Performed in Inpatient or Emergency Department Setting 3 Members with Labs Orders but Did Not Go To Lab 78 Members on Digoxin Require Two Labs: This member completed the metabolic panel lab but did not complete the 2 nd required lab for Digoxin Members on ACE/Arb and diuretics did not complete the metabolic panel lab Members with No Lab Orders 254 Members on Digoxin Require Two Labs: These members had the Metabolic Panel lab performed but no lab orders for the 2 nd Digoxin lab. Members on ACE/Arb and diuretics with Missing Lab Orders 244 Total Records Reviewed

46 MPM PDSA #3 Performance Feedback Reports Testing expanded to CMH Centers for Family Health and Clinicas del Camino real Global Aim: Improve medication monitoring labs. SMART Objective: By February 29, 2016, increase the rate of medication monitoring labs by 5% at the following clinic systems: The combined rate of five CMH Centers of Family Health (CMH CFH) clinics from 79.14% to 84.14%. The combined rate of four Clinicas del Camino Real (CDCR) clinics from 73.05% to 78.05%. Results: Medical record reviews scheduled in March and April January 28, 2016 QIC Attachments: MPM PDSA #1 MPM PDSA #2 MPM PDSA #3 46

47 To: From: Quality Improvement Committee Quality Improvement Department Date: June 28, 2016 RE: Improvement Plan to Reduce Inappropriate Dispensing of Antibiotics and Increase Step-Testing for Pharyngitis Final HEDIS 2015 MY Rates Analysis: June 28, 2016 QIC Update Percentile Goals Adjusted to Conform with NCQA s 2015 MY Rates Increase the rate of Appropriate Treatment for Children with Upper Respiratory Infection from (2014 MY Rate) to (NCQA 2015 MY 90th percentile). Increase the rate of Appropriate Testing for Children with Pharyngitis from (2014 MY Rate) to (NCQA 2015 MY 25th percentile). Increase the rate of Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis from (2014 MY Rate) to (NCQA 2015 MY 50th percentile). PDSA Results: Table 2: 2015 Quarterly Rates Analysis HEDIS Measure Q Rate Q Rate Q Rate Appropriate Treatment for Children with Upper Respiratory Infection Appropriate Testing for Children with Pharyngitis Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis * Percentiles Adjusted to NCQA s 2015 MY Rates Q Final Rate Benchmark Goal (NCQA 2015 MY Percentiles)* (90 th Percentile) (25 th Percentile) (50 th Percentile) Goal Met? 2014 MY Rate Rate Change No No No

48 Goals Not Met: o Appropriate Treatment for Children with Upper Respiratory Infection Did not meet goal of reaching the 90 th percentile Rate increased 2.15 points from to o Appropriate Testing for Children with Pharyngitis Did not meet goal of reaching the 25 th percentile Rate increased 9.97 points from to o Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Did not meet goal of reaching the 50 th percentile Rate increased 4.43 points from to Analysis by Measure: Appropriate Treatment for Children with Upper Respiratory Tract Infections (URI): This measure evaluates the percentage of 3 months to 18 years old children who had an upper respiratory tract infection and were not dispensed an antibiotic. Increase in eligible population with decrease in antibiotic utilization o Although the eligible population increased 26%, the overall administration of antibiotics decreased 11% from 474 dispensing events in 2014 to 422 dispensing events. This indicates an improvement in the reduction of antibiotics use for children with URI. Measurement Year HEDIS 2014 MY HEDIS 2015 MY Eligible Population 6,463 8,144 Numerator Rate 92.67% 94.82% Appropriate Testing for Children with Pharyngitis (CWP): The measure evaluates the percent of children 2 to 18 years of age who had pharyngitis, dispensed and antibiotic and received a step test. The quality indicator for this measure is if a step test was administered. Increase in eligible population o The eligible population increased 25% from 1345 to 1681, but the overall utilization of step tests increased 55% indicating that more step tests were administered in Measurement Year HEDIS 2014 MY HEDIS 2015 MY Eligible Population 1,345 1,681 Strep Tests Administered Rate 41.49% 51.46% 48

49 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB): This measure evaluates the percentage of adults 18 to 64 years of age who had bronchitis and were not dispensed an antibiotic. Increase in the eligible population: o The eligible population diagnosis with bronchitis increased 102% from 364 to 735. Measurement Year HEDIS 2014 MY HEDIS 2015 MY Eligible Population with Dx of Bronchitis No Antibiotics Dispenses Rate 21.15% 25.58% An analysis by AID code: o 47% (257/546) of the non-compliant members are part of the Medicaid expansion program. It is possible that these members did not have healthcare coverage prior to enrolling in Medi-Cal and are seeking medical care for their healthcare concerns. Analysis by clinic system: o A continuing trend from last year shows three clinic systems being the highest dispensers of antibiotics. Analysis by age group did not show any age group with a greater utilization of antibiotics. Age Group Count of Inappropriate Dispensing of Antibiotics Conclusion: Although the rates for all three measured improved, we did not meet our goals. To continue to improve these rates, we will resume a new stewardship campaign in the summer of 2016 and provide physicians with academic detailing packets which will include: (1) education on best practice guidelines, and (2) graphs displaying inappropriate antibiotic utilization by clinic in 2015 and (3) reports of the members who were inappropriately dispensed antibiotics. June 28, 2016 QIC Attachments: Antibiotic PDSA 49

50 January 28, 2016 QIC Update Background: Antibiotic resistance continues to be a growing problem in the United States. According to the Centers for Disease Control and Prevention, the main driving factor behind this is the inappropriate prescribing of antibiotics and each year millions of antibiotics are prescribed unnecessarily for viral upper respiratory infections. There are three HEDIS measures related to antibiotic use in the outpatient setting: (1) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis; (2) Appropriate Testing for Children with Pharyngitis; and (3) Appropriate Testing for Children with Upper Respiratory Tract Infection. Gold Coast Health Plan s 2015 reporting year rates for these three HEDIS measures indicate opportunities for improvement (see Table 1). Table 1: Measurement Year HEDIS Rates for Three Respiratory Care Measures Measure 2014 Rate 2013 Rate 2012 Rate Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 21.15% 18.24% 13.87% Appropriate Treatment for Children With Upper Respiratory Infection 92.67% 92.82% 93.04% Appropriate Testing for Children With Pharyngitis 41.49% 43.92% 42.97% A Plan-Do-Study-Act improvement plan was implemented in August to test of an antibiotic stewardship campaign for physicians would improve the rates of these three measures. The stewardship campaign involved providing physicians with academic detailing packets which included: (1) education on best practice guidelines, and (2) graphs displaying inappropriate antibiotic utilization by clinic in 2014 and (3) reports of the members who were inappropriately dispensed antibiotics. PDSA Goals: Global Aim: Improve Respiratory Care SMART Objective: By December 31, 2015, reduce inappropriate dispensing of antibiotics in children and adults and increase strep testing for pharyngitis in children by utilizing academic detailing packets to engage providers in changing their antibiotic dispensing and 50

51 pharyngitis testing behavior. The goals we aim to reach for each of the three respiratory care measures under review are: Increase the rate of Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis from (2015 RY Rate) to (NCQA th percentile). Increase the rate of Appropriate Treatment for Children with Upper Respiratory Infection from (2015 RY Rate) to (NCQA th percentile). Increase the rate of Appropriate Testing for Children with Pharyngitis from (2015 RY Rate) to (NCQA th percentile). PDSA Results: Table 2: 2015 Quarterly Rates Analysis HEDIS Measure Q Rate Q Rate Q Rate Q Rate Benchmark Goal Goal Met? 2014 MY Rate Rate Change Appropriate Treatment for Children with Upper Respiratory * Yes Infection Appropriate Testing for Children with * No Pharyngitis Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis * Yes * The preliminary 2015 MY rate may change after Admin Refresh in April 2016 Goals Met: o The 2015 quarterly rates in Table 2 shows that we reduced inappropriate antibiotic treatment and achieved our goal of meeting the 90 th percentile for Appropriate Treatment for Children with Upper Respiratory Infection and reached the goal of achieving the 50 th percentile for Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. Goals Not Met: o Table 2 shows we did not achieve our goal of meeting the 25 th percentile for Appropriate Testing for Children with Pharyngitis, but the rate did increase 9.71 points from to Consequently, the academic detail packets may have had an impact on improving the rates. 51

52 Conclusion: After the administrative refresh HEDIS data run in April 2016, we will re-evaluate the results of these measures to determine if academic detailing packets should continue. January 28, 2016 QIC Attachments: Antibiotic PDSA Antibiotic Quality Improvement Activity 52

53 To: From: Quality Improvement Committee Quality Improvement Department Date: June 14, 2016 RE: Initial Health Assessment Medical Record Review and Verification of Outreach Monitoring Report 1st Quarter 2016 BACKGROUND: The Initial Health Assessment (IHA) consists of: A comprehensive history including; o History of the patient s present illness o Past Medical History o Social History A review of organ system during the physical exam A comprehensive Physical and Mental Status Exam which is sufficient to assess and diagnose acute and chronic conditions An Individual Health Education Behavioral Assessment (IHEBA) utilizing the Staying Health Assessment (SHA) tool or pre-approved comparable tool and an SBIRT if indicated. Diagnosis and Plan of Care the plan must include all follow-up activities Timelines for the Provision of the IHA: New Plan Members- All new plan members must have a complete IHA within 120 calendar days of enrollment with GCHP. Names of new plan members are communicated to the patient s selected or assigned health care provider on a monthly basis. It is the responsibility of the health care provider to conduct outreach to the member and inform them of the availability of the IHA to them. GCHP also informs the patient upon notification of eligibility and orientation to the plan of the availability of the IHA and a physical exam. Members changing their PCP - If the member requests or the plan initiates a change in their PCP within the first 120 days of enrollment and the IHA has not been completed, the IHA must be completed by the newly assigned PCP within the established timeline for the new member. PROCESS OVERVIEW: IHA Medical Record Review Monthly GCHP conducts medical record reviews on a random sample of members. The medical record review occurs during the month immediately following the 120 day IHA expiration period. 53

54 The number of medical records reviewed is consistent with the requirements of DHCS PL and based on claims and encounter data indicating the member has had a visit with their PCP. The minimum passing score for the IHA medical record review was 80%. In response to the consistent scoring above 80% by medical providers, revision of the passing score was increased to 90% and implemented beginning May 1, Prior to each medical record review GCHP sends a copy of the Introduction to the Initial Health Assessment (IHA) information sheet. Regardless of the score, upon conclusion of each medical record review, all providers are provided with comments, instruction, resource materials and information regarding the issues identified during the IHA review and a copy of the medical record review report. IHA Verification of Outreach Monitoring Each month GCHP sends lists of new plan member names to providers accepting new patients. The health care provider conducts outreach to the member and informs them of the availability of the IHA to them. Each outreach log is required to contain minimally the following information to be considered complete: Name and address of the provider/clinic The report date from the top of the new member name list The member effective date from the top of the new member name list The IHA/SHA due date from the top of the new member name list The GCHP Subscriber number The last and first name of the member date of birth address phone number The date the IHA letter was mailed The date of the 2 phone calls made by the provider to the new member The outcome of the outreach efforts is documented according to a status legend provided by GCHP Compliance is determined by documentation of the outreach dates and entry of outcome status on each provider log and expressed as a percentage of completed entries. FINDINGS: Compliance rates are noted in the table and graph below. First Quarter 2016 IHA Medical Record Reviews: Number IHA MRRs Conducted: Number of sites with passing IHA score above 80% Number of sites with score below 80%

55 Percent Compliance Compliance 38 sites were not audited because they had no new members assigned to the provider site. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% 92% 2016 IHA Compliance 97% 91% Primary reason for not achieving 100 % on medical record audits: Incomplete, unsigned, or no Staying Healthy Assessment in the medical record and/or age appropriate preventive health screenings were missing documentation in the medical record. Comparison of performance from 4 th Quarter 2015 to 1 st Quarter 2016: 100% IHA Medical Record Review 95% 90% 85% 80% 75% VCMC CMH Clinicas Independent Providers Q Q Declines in medical record review compliance were addressed at the end of each monthly record review. Instruction in writing for the areas of missing documentation and Staying Health Assessment criteria were provided and opportunity for discussion or to address any questions offered. 55

56 Compliance Please refer to tables 1 through 7 in the attachment for clinic compliance rates. FINDINGS: The first quarter 2016 compliance for IHA verification of provider outreach is indicated in the graph below IHA Outreach Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 78% 8.3% 67% 0% 18% Primary reason for not achieving 100 % compliance on outreach logs was no outreach log submitted by the medical provider site for one or more of the months in the first quarter or logs submitted were not complete according to minimum information criteria. Intervention: Upon receipt of outreach logs that were incomplete or incorrect, the provider site was contacted and given instruction regarding how to correct their logs and encouraged to re-submit the corrected log to QI. During 4 th quarter 2015, CMH Centers for Family Health had zero percentage compliance for IHA outreach. Outreach training was provided CMH Centers for Family Health, Clinicas del Camino Real, and Identity Medical Group on outreach requirements and required submission dates of the completed logs. 56

57 Percent Compliance During 1 st quarter 2016 Identity Medical Group submitted no outreach logs to the QI department. Another training was provided late in 1 st quarter 2016 to monitor for improvement during 2 nd quarter Comparison of performance from 4 th Quarter 2015 to 1 st Quarter 2016: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 75% 78% IHA Outreach Compliance 0% 8.3% 98% 67% VCMC CMH Clinicas Identity Med. Grp. Independent Providers 0% 71% 18% 4th Q st Q Clinicas outreach compliance declined due to non-submission of outreach logs for all their clinics for the month March Outreach by QI department to Clinicas requesting the missing log and instruction for monthly submissions was provided. Independent provider offices were contacted and some reported not receiving new member name lists in 1 st quarter This was investigated and corrected. Additional instructions as well as the QI department contact phone number was provided for call-in assistance/support. Please refer to tables 8 through 16 in the attachment for clinic compliance rates. Clinics with zero percent for IHA medical record review did not receive assigned members therefore no medical record review was conducted. Clinics with rates of zero percent (0) reflect providers who did not receive lists of new member names for the quarter or the provider did not submit any outreach logs for the first quarter Providers received phone call reminders from QI with re-instruction regarding submission of logs. 57

58 Q1 -Las Posas Family Med. Grp. Q1 -Fillmore Family Med. Grp. Q1 -Moorpark Family Med. Clinic Q1 - John Flynn Community Center Q1- Magnolia Family Health Center Q1- Mandalay Bay Q1- Las Islas Family Med. Grp.-North Q1 -Piru Family Med. Center Compliance Attachment Table IHA Medical Record Review VCMC 100% 90% 89% 92% 95% 89% 96% 92% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 0% 58

59 Q1 - CMH - Camarillo Q1 - CMH -Santa Rosa Q1 - CMH-Fillmore Q1 - CMH -Oak View Q1 - CMH -Ojai Q1 - CMH -Airport Q1 - CMH -Saviers Copliance Q1 - Santa Paula Med. Clinic Q1 - Santa Paula West Q1 - Santa Paula West - Q1 - Santa Paula Hospital Clinic Q1 - Sierra Vista Family Med. Q1 - Conejo Valley Fam. Q1 - Academic Family Med. Q1 - West Ventura Medical Clinic Q1 - Pediatric Diagnostic Center Q1 - Total Compliance Table 2 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 92% 96% 2016 IHA Medical Record Review VCMC 99% 99% 81% 91% 83% 92% 85% 91% Table 3 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 85% 87% 88% 2016 IHA Medical Record Review CMH Centers for Family Health 95% 95% 93% 60% 59

60 Q1 - Santa Q1 - Maravilla Q1 - Simi Valley Q1 - Ojai Valley Q1 - Oceanview Q1 - N. Oxnard Q1 - N. Compliance Q1 - CMH -Vineyard Q1 - CMH -Santa Q1 - CMH-Ashwood Q1 - CMH -Main St. Q1 - CMH -Port Q1 - Total Table IHA Medical Record Review CMH Centers for Family Health 100% 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Table IHA Medical Record Review Clinicas del Camino Real 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 98% 98% 96% 97% 100% 98% 98% 60

61 Q1 - Dr. M. Bui Q1 - Valley Medical Q1 - Dr. A. Lyne Q1 - CMH-Midtown Q1 - Sespe Medical Q1 - Dr. Victor Lin Q1 - Dr. K. Hansuvadha Q1 - Total Copliance Q1 - Ventura Q1 - Meta St. Q1 - Newbury Q1 - Moorpark Q1 - Fillmore Q1 - El Rio Q1 - E. Simi Valley Q1 - Total Compliance Table IHA Medical Record Review Clinicas del Camino Real 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 96% 96% 98% 97% 93% 96% 0% 97% Table 7 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2016 Medical Record Review Independent Providers 100% 96% 86% 87% 91% 91% 91% 73% 61

62 Q1 - Santa Paula West Q1 - Santa Paula West - Q1 - Sierra Vista Clinic Q1 - Conejo Valley Clinic Q1 -Academic Family Q1 - West Ventura Q1 - Total Compliance Q1 - Las Posas Fam. Med. Q1 - Fillmore Fam. Med. Q1 - Moorpark Fam.Clinic Q1 - John Flynn Comm.Ctr. Q1 - Magnolia Health Ctr. Q1 - Mandalay Bay Q1 - Las Islas Fam.Med. Q1 - Piru Family Med. Q1 - Santa Paula Med. Compliance IHA Outreach Compliance rates: Table IHA Outreach -VCMC 100% 100% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 100% 100% 100% 33% 100% 100% Table IHA Outreah - VCMC 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 100% 100% 100% 0% 100% 33% 78% 62

63 Q1 - CMH Vineyard Q1 - CMH Santa Paula Q1 - CMH Ashwood Q1 - CMH Main St. Q1 - CMH Pt. Q1 - Total Compliance Q1 - CMH Q1 - CMH Santa Q1 - CMH Q1 - CMH Oak Q1 - CMH Ojai Q1 - CMH Airport Q1 - CMH Saviers Compliance Table % 80% 60% 40% 20% 0% 2016 IHA Outreach CMH Centers for Family Health 0% 0% 0% 0% 0% 67% 0% Table % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2016 IHA Outreach CMH Centers for Family Health 33% 8.3% 0% 0% 0% 0% 63

64 Q1 - Meta St. Q1 - Newbury Park Q1 - Moorpark Q1 - Fillmore Q1 - El Rio Q1 - E. Simi Valley Q1 - Total Compliance Q1 - Santa Paula Q1 - Maravilla Q1 - Simi Valley Q1 - Ojai Valley Q1 - Oceanview Q1 - N. Oxnard Q1 - N. Oxnard-Peds Q1 - Ventura Compliance Table IHA Outreach - Clinicas del Camino Real 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 67% 67% 67% 67% 67% 67% 67% 67% Table IHA Outreach - Clinicas del Camino Real 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 67% 67% 67% 67% 67% 67% 67% Clinicas del Camino Real conducts the IHA outreach through the central call center located in Ventura. Clinicas submits an outreach log with all new member names and clinics listed upon one log. A comprehensive log was submitted for January and February but not one for March

65 Q1 - Dr. Alan Lyne Q1 - Dr. Chun-Lang Q1 - CMH Midtown Q1 - FocilMed Inc. Q1 - Dr. Gurjit Marwah Q1 - Dr. Minh Q. Bui Q1 - Saviers Medical Grp Compliance Q1-400 Santa Barbara Q1-243 March St. Q1-247 March St. Q1-811 W. Telegraph Q N. Rose Ave. Q Old Conejo Q Ponderosa Dr. Q Las Posas Rd. Q1 - Total Compliance Table IHA Outreach - Identity Medical Group 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Table % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2016 IHA Outreach - Independent Providers 100% 0% 0% 0% 0% 0% 0% 65

66 Compliance Table % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2016 IHA Outreach - Independent Providers 0% 0% 0% 100% 18% 66

67 To: Quality Improvement Committee From: Quality Improvement Department Date: June 14, 2016 RE: Facility Site Review (FSR), Interim Facility Site Reviews (I-FSR), and Physical Accessibility Review Survey (PARS) for 1st Quarter 2016 BACKGROUND: Facility Site Reviews: Per the Department of Health Services MMCD Policy Letter , a Facility Site Review (FSR) is to ensure that all PCP sites used by Primary Care Case Management (PCCM) Plans for delivery of services to plan members have sufficient capacity to: 1. provide appropriate primary health care services; 2. carry out processes that support continuity and coordination of care; 3. maintain patient safety standards and practices; and 4. operate in compliance with all applicable federal, state and local laws and regulations. Definitions: Initial FSR: Prior to approval for use in providing services to members, all contracted or subcontracted sites where primary health care services are provided shall be subject to an initial onsite inspection. A full scope review consists of the MMCD Site Review Survey (Attachment A) and Medical Record Review Survey (Attachment B). Periodic FSR: After the initial full scope survey, the maximum time period before conduction of the next required full scope site survey shall be three years. Interim - Facility Site Reviews: Eighteen months from the date of an initial FSR and eighteen months between each periodic FSR an Interim-FSR (I-FSR) is conducted to survey the compliance of the provider sites to the nine critical elements of a site review which defines the potential for adverse effects on patient health or safety and have a scored weight of two points on the FSR Attachment A form. The I-FSR is determined to have a passing status when the reviewer deems the site to be in compliance and no follow up is required. 711 East Daily Drive, Suite 106, Camarillo, CA Member Services : Fax:

68 Should a facility or provider be found to be out of compliance during the I-FSR, a critical element corrective action plan (CAP) is administered immediately and the facility or provider has 10 business days to complete the corrections and submit a copy of the CAP with all corrections documented and the attestation page signed and dated. The PCCM must verify the corrective actions within 30 days of the survey date. Physical Accessibility Review Survey: Per the Department of Health Services MMCD Policy Letter (PL) and Policy Letter , health plans are required to use the FSR Attachment C to assess the physical accessibility of provider sites upon initial survey of all new PCP sites and reassessment upon periodic FSR reviews. On October 28, 2015 the Department of Health Services issued MMCD All Plan Letter The APL supplements PLs and , providing survey tools to evaluate the accessibility of provider facilities for Seniors and Persons with Disabilities (SPDs). Health plans are required to use the FSR Attachment C to assess the physical accessibility of all provider specialist sites, FSR Attachment D is to assess all Ancillary Service providers providing diagnostic and therapeutic services and Attachment E is for all Community Based Adult Services (CBAS). PROCESS OVERVIEW: Initial and Periodic FSRs: As of June 14, 2016, no Initial Facility Site Reviews with PARS were conducted and three (3) Periodic FSRs with update of PARS were conducted in the first quarter of Interim FSRs As of June 14, 2016, twelve (12) Interim-FSRs were conducted with updates to the PARS reports as needed during the first quarter of High Volume Specialist and Ancillary providers: On January 31, 2016 Gold Coast Health Plan identified and reported to DHCS 332 names of high volume specialty and ancillary service providers at 112 office/facility locations for the year 2015 for which a PARS is required. 711 East Daily Drive, Suite 106, Camarillo, CA Member Services : Fax:

69 FINDINGS: Initial and Periodic FSRs with PARS Completed during the 1st Quarter 2016 Initial FSRs with PARS Completed Periodic FSRs with PARS Completed FSR(s) with CAPS Number of CAPS closed Total number FSR and PARS Completed Interim FSRs performed during 1st Quarter 2016 Total number of I-FSR Total number of I-FSR approved Total number of critical element CAPs served Total number of critical element CAPS completed within 10 days. Total number of critical element CAPS not completed within 10 days Provider Non-Compliance: There are 0 CAPs, 0 providers are non-compliant. High Volume Specialist and Ancillary Service Providers PARS A total of 332 providers at 112 office/facility locations require completion of a PARS prior to January 1, To date 17 locations have been determined to be primary care provider facilities with updated PARS on file. The remaining PARS will be completed by December 31, East Daily Drive, Suite 106, Camarillo, CA Member Services : Fax:

70 Quality Improvement Program Evaluation Summary

71 Al Reeves, M.D. Chief Medical Officer Approved March 29, 2016 by Quality Improvement Committee (QIC) Revised and approved June, XX, 2016 by Quality Improvement Committee (QIC) Approved April 25, 2016 by Ventura County Medi-Cal Managed Care Commission (VCMMCC) Revision approved <Month, Day, Year> by Ventura County Medi-Cal Managed Care Commission (VCMMCC) 71

72 Overview The overall goal of the 2015 Gold Coast Health Plan Quality Improvement (QI) Program Evaluation is to assess the effectiveness of the organization s QI Program with respect to quality, accessibility, safety of clinical care, quality of service, and member experience. Committees, departments and data analysts annually analyze and evaluate the effectiveness of the prior year s Quality Improvement Work Plan. Oversight and Approval The annual QI Program Evaluation is reviewed and approved annually by the Quality Improvement Committee (QIC). Committee members and department managers provide input for the evaluation. The annual QI Work Plan serves as the roadmap for the QI Program and lists measurable objectives for key indicators and includes interventions to improve performance. The QI Work Plan is developed largely from recommendations from the annual QI Program Evaluation. Areas of significant focus include partially resolved and unresolved activities from the previous year. These activities include clinical and service improvement activities that have the greatest potential impact on quality of care, service and patient safety. The work plan also reflects the contractual requirements of GCHP. The Chief Medical Officer reviews the 2015 QI Program Evaluation, 2016 QI Program Description and 2016 QI Work Plan with the Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP) which is accountable to review and approve these documents. Overall Effectiveness Summary Adequate resources were dedicated to program activities. The resources and infrastructure were adequate to support a positive impact on the care and quality of services of the Plan s members. Highlights of the quality accomplishments for clinical and service performance include: Developed and implemented a Diabetes Disease Management Program Successfully developed and implemented a mandatory Department of Health Care Services (DHCS) Improvement Project for the following HEDIS measure; Annual Monitoring for Patients on Persistent Medications. Successfully implemented the first of two DHCS Performance Improvement Projects (PIP) in collaboration with a clinic partner; improve the rates of immunizations for two year olds. Developed and implemented two member incentive programs to improve the rates of well-child visits and postpartum exams. Conducted eleven (11) focus groups. 72

73 The 2015 QI Work Plan Evaluation contains the detailed qualitative and quantitative analyses of the Plan s numerous initiatives and strategies to strengthen the QI Program and to provide direction to the 2016 QI Work Plan. Performance Measure Results GHCP s performance on the following HEDIS measures improved in 2015 when compared to 2014: Weight Assessment: Counseling for Nutrition and Physical Activity Childhood Immunization Status Combination #3 Immunizations for Adolescents Combination #1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Controlling High Blood Pressure Comprehensive Diabetes Care Eye Exam (Retinal) Comprehensive Diabetes Care Medical Attention for Nephropathy Comprehensive Diabetes Care Blood Pressure Control Annual Monitoring for Patients on Persistent Medications o ACE Inhibitors or ARBs o Diuretics Medication Management for People with Asthma o Medication Compliance 75% Total Children and Adolescent s Access to Primary Care Practitioners o 25 months - 6 years o 7-11 years o years All Cause Readmission Appropriate Treatment for Children with Upper Respiratory Infection Appropriate Treatment for Children with Pharyngitis The rates for Comprehensive Diabetes Care Eye Exam (Retinal) and Medical Attention for Nephropathy improved significantly in 2015 which resulted in both these rates moving from the National Committee for Quality Assurance s (NCQA) 50 th and 75 th percentiles in 2014 to above the 90 th percentile for The rates for Annual Monitoring for Patients on Persistent Medications also improved resulting in this measure moving from below the Minimum Performance Level (MPL) in 2014 to above the MPL in DHCS bases the MPL on NCQA s national percentiles. MPLs and High Performance Levels (HPL) align with NCQA s national Medicaid 25 th percentile and 90 th percentile respectively. 73

74 The rate for Controlling High Blood Pressure also saw significant improvement, resulting in this measure moving from the 25 th percentile in 2014 to the 50 th percentile in While the rates for Children and Adolescents Access to Primary Care Practitioners improved for age ranges of 25 months 6 years, 7 11 years and years, the rates remain below the MPL for the third year. All four Children and Adolescents Access to Primary Care measures are not held to DHCS MPL due to the small range of variation between the MPL and HPL threshold for each measure. The rate for Appropriate Treatment for Children with Pharyngitis improved significantly (9.97%) in 2015 but remains below the 25 th percentile. The rates for the following measures declined in 2015 compared to 2014: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents BMI Percentile Cervical Cancer Screening Medication Management for People with Asthma Medication Compliance 75% Total Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Testing Comprehensive Diabetes Care HbA1c Poor Control (>9.0%)- lower rates are better Comprehensive Diabetes Care HbA1c Control (<8.0%) Use of Imaging Studies for Low Back Pain Children and Adolescents Access to Primary Care Practitioners months Prenatal and Postpartum Care Timeliness of Prenatal care and Postpartum Care Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life The rates for Cervical Cancer Screening (CCS) and Well-Child Visits in the Third, Fourth, Fifth and Six Years of Life declined in 2015, resulting in both measures moving from above DHCS MPL in 2014 to below the MPL in Analysis of the CCS measure shows that the eligible population increased from 12,900 in 2014 to 25,498 in Further analysis was performed on the 2015 eligible population to determine if this increase was due to a specific type of Medicaid eligibility category. Of the 14,640 non-compliant members in 2015: o 73% (10,743/14,640) were part of the Medicaid Expansion program. 74

75 o 13% (1,951/14,640) had no visits with their PCP As a result of this analysis, the following reasons could have caused the reduced CCS rates for the 2015 measurement year: Significant increase in eligible population due to Medicaid expansion this population of members may not have had regular preventive care visits due to no health coverage in the past. Significant percentage of women with no PCP visits Due to the significant decrease in this measure, this measure will become a priority for GHCP in GCHP has already identified the high volume low performing clinics and will begin outreach to those clinics. The rate for Children and Adolescents Access to Primary Care Practitioners months declined in 2015 but remains above the MPL. There are five (5) measures where we came extremely close to our goal; Immunizations for Adolescents, Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life, Children and Adolescents Access to Primary Care Practitioners 25 months 6 years, Appropriate Treatment for Children with Upper Respiratory Infection and Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. For these five (5) measures we missed the goal by less than 1%. While we have made progress with regards to certain HEDIS measures, we recognize that we must remain focused in those areas where we fell short of the goal. We believe we can continue to make progress and surpass these goals. The table on the next page contains the rates for all HEDIS measures that GCHP reports to DHCS (exception is Appropriate Treatment for Children with Upper Respiratory Infection and Appropriate Treatment for Children with Pharyngitis which GCHP chose to monitor due to the importance of antibiotic stewardship). 75

76 2016 NCQA Percentile Ranking HEDIS Measure/Data Element Effectiveness of Care: Prevention and Screening Domain of Care Rate Difference Current NCQA Percentile Ranking 10th 25th 50th 75th 90th Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Q BMI Percentile th Counseling for Nutrition th Counseling for Physical Activity th Childhood Immunization Status Q, A, T DTaP th IPV th MMR th HiB th Hepatitis B th VZV th Pneumococcal Conjugate th Combination # th Immunizations for Adolescents Q, A, T Meningococcal th Tdap/Td th Combination # th Cervical Cancer Screening Q, A th Effectiveness of Care: Respiratory Conditions Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Q th Medication Management for People With Asthma (NR= Not Reported - Requires 2 years continuous enrollment) Q Medication Compliance 50% Total th Medication Compliance 75% Total th Effectiveness of Care: Cardiovascular Controlling High Blood Pressure Q th Effectiveness of Care: Diabetes Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Testing Q, A th HbA1c Poor Control (>9.0%) Q th HbA1c Control (<8.0%) Q th Eye Exam (Retinal) Performed Q, A th LDL-C Screening Performed Q LDL-C Control (<100 mg/dl) Q Medical Attention for Nephropathy Q, A th Blood Pressure Control (<140/90 mm Hg) Q th Effectiveness of Care: Musculoskeletal Use of Imaging Studies for Low Back Pain Q th Effectiveness of Care: Medication Management Annual Monitoring for Patients on Persistent Medications Q ACE Inhibitors or ARBs th Digoxin th Diuretics th Total th Access/Availability of Care Children and Adolescents' Access to Primary Care Practitioners A Months th Months - 6 Years th Years (NR= Not Reported - Requires 2 years continuous <10th enrollment) Years (NR= Not Reported - Requires 2 years continuous enrollment) th Prenatal and Postpartum Care Q, A, T Timeliness of Prenatal Care th Postpartum Care th Utilization Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Q, A, T th Ambulatory Care Visits/1000 Visits/1000 Visits/1000 Outpatient Visits ED Visits Utilization: Risk Adjusted All-Cause Readmission Q,A 13.08% Effectiveness of Care: Overuse/Appropriateness Appropriate Treatment for Children with Upper Respiratory Infection (URI) Effectiveness of Care: Respiratory Conditions Q th Appropriate Testing for Children with Pharyngitis (CWP) Q th = improvement = decline 76

77 Member Satisfaction: Consumer Assessment of Healthcare Providers and Systems (CAHPS ) The Department of Health Care Services (DHCS) contracts with Health Services Advisory Group, Inc. (HSAG) to conduct Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Health Plan Surveys to assess the perceptions and experiences of Medi-Cal Managed Care program (MCMC) beneficiaries and evaluate the quality of the health care services they receive. Results include members global ratings in four areas: Rating of Health Plan, Rating of All Health Care, Rating of Personal Doctor, and Rating of Specialist Seen Most Often. Additionally, the results of five composite measures reflect members experiences with Getting Needed Care, Getting Care Quickly, How Well Doctors Communicate, Customer Service, and Shared Decision Making. The plan saw improvement in the global rates of the CAHPS survey in 2015 when compared to the rates in 2013, the last year that DHCS/HSAG conducted the survey. GCHP contracted with The Myers Group to conduct an off season CAHPS survey. Improvement was noted in 2015 results when compared to the results of the off season CAHPS survey with the exception of the adult area of rating of personal doctor where the rate declined by 1%. When comparing rates from 2013 and 2015, improvement was also noted in the composite measure for member s experience with the exception of the adult and child area of Getting Needed Care. A formal report is expected from HSAG later in the year. Access and Availability GCHP failed to meet the access standard for primary care access and specialty care access. Due to the poor response for specialty providers results are not considered valid. GCHP met the required availability ratios for time and distance. Provider Satisfaction Results of the Provider Satisfaction Survey indicated that all respondents rate all composites besides Pharmacy, significantly lower than the SPH Analytics (SPHA) Aggregate Benchmark. Furthermore, the 2015 Physician Satisfaction Survey results are significantly lower than all composites other than Network/Coordination of Care and Pharmacy when compared to the SPHA Medicaid Benchmark. 77

78 Providers rate their satisfaction with Gold Coast Health Plan compared to all other plans (21.1%) significantly lower than the SPHA Medicaid and Aggregate Benchmarks (36.4% and 37.8%, respectively). The 2015 score is not significantly different from 2013 (18.8%). 78

79 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Improve Quality and Safety of Clinical Care Services NCQA QI 9 Diabetes Clinical Practice Guideline (CPG) review and adoption at least every two years Review of relevant CPGs Q Distribution of guidelines to Distribute if necessary practitioners EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Completed approved at MAC 1/29/15 no substantive changes made. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS Goal Met, no barriers presently identified. NCQA QI 9 Preventive Health Guideline (PHG) review and adoption at least every two years Distribution of guidelines to practitioners Review of relevant PHGs Distribute if necessary Q EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Completed approved at MAC 7/24/15 no substantive changes made. RESULTS (Qualitative Analysis Analysis) NA BARRIER ANALYSIS Goal Met, no barriers presently identified. Action Steps & Monitoring/Improvement Activities Review and approval by Medical Advisory Committee(MAC) Annually measure performance against at least two important aspects of each of the CPGs Distribute guidelines to appropriate practitioners Review and approval by Medical Advisory Committee(MAC) Annually measure performance against at least two important aspects of two PHGs Distribute guidelines to appropriate practitioners Responsible Dept./Committee MAC MAC 79

80 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Improve Quality and Safety of Clinical Care Services Advance Prevention DHCS Increase percentage of members who smoke who report being counseled to quit in prior 6 months Action Steps & Monitoring/Improvement Activities 90% Q Measure during IHA monitoring Educate providers based on results of IHA monitoring Measure during 2016 CAHPS Responsible Dept./Committee EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Unable to evaluate as rates were reported as NA from NCQA. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS Rates reported as NA from NCQA. NEXT STEPS Education of providers will continue during the IHA monitoring. Measurement will be completed via results of the IHA monitoring and reported quarterly to QIC. DHCS Increase percentage of members who smoke who report a provider discussed tobacco cessation medication in the prior 6 months 60% Q Measure during IHA monitoring Educate providers based on results of IHA monitoring Measure during 2016 CAHPS EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Unable to evaluate as rates were reported as NA from NCQA. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS Rates reported as NA from NCQA. NEXT STEPS Education of providers will continue during the IHA monitoring. Measurement will be completed via results of the IHA monitoring and reported quarterly to QIC. QI QI 80

81 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Improve Quality and Safety of Clinical Care Services HEDIS Measures DHCS Postpartum Care Percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery Increase rates by 5% over previous measurement year Q Action Steps & Monitoring/Improvement Activities Develop member education mailings Explore possible use of text4baby program for use in educating members Promote use of GCHP Pregnancy E- newsletter Provide provider performance feedback by means of 2014 HEDIS report cards Develop and implement member incentive program; partner with CPSP staff at clinics to help promote Responsible Dept./Committee Health Education QI EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met. Rate =59.12 RESULTS (Qualitative Analysis) 2015 rate decreased by 3.69% compared to the previous year s rate of 62.81%. Medical Record Review Analysis The QI Department reviewed a sample of 40 medical records of women who did not have postpartum care to identify any common characteristics, trends, or barriers. The results of the review indicate that 70% (28/40) of the non-compliant women were multi-para mothers. BARRIER ANALYSIS Further analysis is required to confirm if this is significant factor which may warrant a targeted intervention focusing on multi-para mothers. No educational materials were developed in NEXT STEPS Health Education is currently developing a brochure aimed at motivating members to complete their postpartum exams. Member incentive will continue in Provider feedback performance reports will be disseminated to clinics and rates discussed during the HEDIS results reviews. Collaborate with community partners such as Ventura County Public Health and First5 Ventura County to promote incentive. DHCS Childhood Immunization Increase rates by 5% Q Member newsletter article on Health Education 81

82 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation percentage of children 2 years of age that had DtaP, IPV, MMR, HiB, HepB, VZV and pneumococcal conjugate (Combo 3) over previous measurement year importance of getting immunizations Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services Promote GCHP New Parent E-newsletter Develop and implement member incentive program and promote during HEDIS results visits with clinics QI EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met Rate = 75.43% RESULTS (Qualitative Analysis) Rate increased by 5.46% over previous year s rate of BARRIER ANALYSIS Goal Met, no barriers presently identified. Required By Goals Metrics Target Completion Date Objective: Improve Quality and Safety of Clinical Care Services Action Steps & Monitoring/Improvement Activities Responsible Dept./Committee 82

83 DHCS 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Immunizations for Adolescents (Combo 1) percentage of adolescents 13 years of age who received a meningococcal vaccine on or between the member s 11 th and 13 th birthday and Tdap or Td on or between the member s 10 th and 13 th birthdays (Combo1) Increase rates by 5% over previous measurement year EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met. Rate = Q Member newsletter article on importance of getting immunizations Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services Develop and implement member incentive program and promote during HEDIS results visits with clinics Health Education QI RESULTS (Qualitative Analysis) The rate for this measure increased by 4.08% over the previous year s rate missing our goal by just.92%. BARRIER ANALYSIS Quarterly member lists were unable to be generated due to delay in HEDIS run in Q3. ICD 10 testing caused delay of Q3 HEDIS run from which member lists is generated. Member incentive form lacked letter educating parents on the importance of preventive care visits. Letters were not sent out until end of July due to internal delays for obtaining approval. NEXT STEPS Continue distribution of performance feedback reports. Continue member incentive to engage parent to bring child in for preventive care visits Member incentive will have a preventive care letter attached explaining importance of these visits and receiving immunizations. The lower rate for the Tdap/Td indicates this immunization may be preventing the Combo 3 rates from achieving our goal. Further analysis is required to determine if this I a trend with specific providers. DHCS Controlling High Blood Pressure percentage of members years of age who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90) Maintain rate above MPL Increase rates by 5% over previous measurement year Q Investigate why rates decreased over previous measurement year via medical record review Provide provider performance feedback by means of 2014 HEDIS report cards Develop and implement interventions based on results of medical record review Member newsletter article on how to control blood pressure QI 83

84 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met 2015 rate = RESULTS (Qualitative Analysis) The rate showed a statistically significant improvement (9.41%) over the previous year s rate of BARRIER ANALYSIS Medical record reviews were unable to be completed due to resource issues and DHCS mandated IHA monitoring. HEDIS report cards were distributed to clinics and academic detailing completed at that time. Additionally clinics were sent lists of members diagnosed with hypertension and encouraged to bring these members in if they had not been seen at least twice in the year. NEXT STEPS Continue providing member lists to providers to encourage them to see members at least twice a year. Explore possible educational series to educate members on what steps they can take to control their blood pressure. DHCS Well Child Visits in Third, Fourth, Fifth and Sixth Years percentage of members 3-6 years of age who had one or more well-child visits with a PCP during the measurement year Increase rates by 5% over previous measurement year EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met Rate = Q Develop and implement member incentive program Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services Develop and implement member incentive program and promote during HEDIS results visits with clinics QI 84

85 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Administrative Data: Well-Child Visits By Month RESULTS (Qualitative Analysis) The rate for this measure fell below the MPL of Administrative Analysis: Analysis indicates that well-child visits continued to increase in There is a year-to-year trend of well-child visits increasing in April, August and October and decreasing in May to July. Analysis of Non-Compliant Records: Analysis of the 145 non-compliant members in the 411 sample records for the 2015 MY W34 measure showed the following reasons for not meeting our goals for the W34 Measure: Missed opportunities to provide well-child exams A sample of 55 non-compliant records were reviewed and resulted in the following findings: o 28 members had only acute/urgent care visits o 7 members had no clinic visits in 2015 o 7 members had not history of any clinic visits with their PCP o 13 members had incomplete well-child exams all required well-child assessments were not performed Providers continue to follow a periodicity schedule that allows well-child exams every two year CHDP providers continue schedule exams every other year rather than annually 85

86 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Deficient Clinical Documentation 33 of the 145 non-compliant children had well-child exams in 2015 but the exams were missing documentation required for the W34 measure. Of the 33 non-compliant records, the following types of clinical documentation were missing from the medical records: Required W34 Documentation % of Non-Compliant Charts Missing Documentation Health Education/Anticipatory 97% Guidance Mental History 79% Physical History 73% Health History 9% Physical Exam 0% BARRIER ANALYSIS An analysis of medical records indicates that providers are performing the exams every other year rather than annually as well as identification of missed components of the physical exam. Due to changes in HEDIS vendor and delay of Q3 HEDIS run due to ICD10 testing, quarterly member lists were unable to be generated as planned. We developed a member incentive program but implementation was delayed till the end of July due to delays in internal approval and this may have had an impact on the rates. NEXT STEPS Due to this measure s rate falling below the DHCS MPL, this will now require a mandated Improvement Project (IP) to be developed and submitted to DHCS. GCHP QI staff will present these findings to the clinics during the annual HEDIS rate review. Additional provider education will be developed and sent to providers. Continue member incentive and promote to increase exams from May to October. Collaborate with community partners such as First5 Ventura County to promote incentive. Due to the measure not meeting MPL, GHCP will develop and report on the IP to DHCS, QIC and MAC on a quarterly basis. DHCS Children and Adolescents access to Primary Care Practitioners percentage of members 12 months 19 years of age who had a visit with a PCP EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Partially MET Meet or exceed DHCS MPL Q Develop and implement member incentive program, promote during HEDIS results visits with clinics Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services QI 86

87 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation RESULTS (Qualitative Analysis) With the exception of the 12 month to 24 month age group, all age groups failed to meet the MPL for the third year in a row. Comparison of 2014 and 2015 rates show there was an increase in PCP utilization for three age groups (25 months to 6 years, 7-11 years, and years) but a variable affecting significant improvement in these rates was an increase in the eligible population for all age groups. 12 months to 24 months age group rate decreased slightly (0.77%) but still met the MPL. There were a total of 8,525 members for all age groups that had no visit with a PCP in Analysis by clinic showed that 48% of the non-compliant (4070/8525) members are enrolled in one clinic system. BARRIER ANALYSIS Quarterly member lists were unable to be generated due to delay in HEDIS run in Q3. ICD 10 testing caused delay of Q3 HEDIS run from which member lists is generated. We developed a member incentive program but implementation was delayed till the end of July due to delays in internal approval and this may have had an impact on the rates. NEXT STEPS GHCP will be implementing a P4P for childhood access to care. We will continue the member incentive in 2016 to engage parents to bring their child in for preventive care. Collaborate with community partners such as First5 Ventura County to promote incentive. 87

88 DHCS 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Counseling for Nutrition and Physical Activity for Children and Adolescents percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling Meet or exceed DHCS MPL Q Provide provider performance feedback by means of 2014 HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met Counseling for Nutrition rate = Counseling for Physical Activity rate = QI RESULTS (Qualitative Analysis) Counseling for Nutrition exceeded the MPL of by 3.98% and increased by 1.7% over the previous year s rate of Counseling for Physical Activity exceeded the MPL of by 5.72% and increased by 8.03% over the previous year s rate of While BMI percentile was not a metric in our work plan, the rate for this measure dropped significantly (7.54%). An analysis indicates that this was not a result of a change in the criteria for this measure where in previous years documentation of the BMI value met the criteria. This applied only to the 16 to 17 years age group. In the 2016 HEDIS specifications on which 2015 HEDIS rates are based, the BMI value option for members years was removed. Of the 117 non-compliant records, only 12 records fell into the years age group. BARRIER ANALYSIS Goal met no barriers identified. NEXT STEPS Provider performance feedback reports will continue to be provided. With implementation of new HEDIS vendor the goal is to provide performance feedback reports on a quarterly basis. Focus will be on high volume low performing clinics. Required By Goals Metrics Target Completion Date Action Steps & Monitoring/Improvement Activities Objective: Improve Quality and Safety of Clinical Care Services Over/Under Utilization DHCS Appropriate Testing for Meet or exceed DHCS Q Provide provider performance feedback QI Responsible Dept./Committee 88

89 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Children with Pharyngitis - percentage of children 2 18 years of age, who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A strep test. MPL; 2014 rate of was below the NCQA 10 th percentile EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met 2015 rate is and NCQA 25 th percentile is by means of 2014 HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing RESULTS (Qualitative Analysis) While the rate showed a statistically significant improvement (9.97%) over the previous year s rate of 41.49, the rate missed the 25 th percentile by 11.52%. Because the starting rate was so low the goal may have been too ambitious and not attainable. Analysis indicates the lowest rates for strep testing is among ages 4 years to 7 years who accounted for 42% of the non-compliant members. BARRIER ANALYSIS Providers may still be relying on clinical findings alone to diagnose strep throat. Guidelines recommend confirmation of streptococcal cause of pharyngitis s via throat culture or rapid antigen detection. If rapid antigen detection is negative, a throat culture should be obtained. Parental pressure may also be a contributing factor. Parents want their children to feel better soon and often do not understand that sore throat is usually caused by a virus and will not resolve with the use of an antibiotic. NEXT STEPS Continue provider education using evidence based articles and focus on those clinics that require the most improvement. Continue to provide lists of member who have been prescribed an antibiotic inappropriately. Provide links to educational material that providers can give to parents such as those from the CDC and AWARE (Alliance Working for Antibiotic Resistance Education). DHCS Appropriate Treatment for Children with Upper Respiratory Infection - percentage of children 3 months 18 years of age who were diagnosed with an upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Meet or exceed NCQA 90 th Percentile Q Provide provider performance feedback by means of 2014 HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing QI 89

90 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met 2014 rate was 92.67; 2015 rate is RESULTS (Qualitative Analysis) The rate for this measure fell just below the 90 th percentile rate of 95.17, however it increased by 2.15% over the previous year s rate. BARRIER ANALYSIS Parental pressure may be a contributing factor. Parents want their children to feel better soon and often do not understand that URIs are caused by a virus and will not resolve with the use of an antibiotic. NEXT STEPS Continue educating providers using evidence based articles of the importance of not prescribing antibiotics unless necessary. Continue to provide lists of members who have been prescribed an antibiotic inappropriately. QI will continue to provide performance feedback reports and HEDIS report cards to providers. Provide links to educational material that providers can give to parents such as those from the CDC and AWARE (Alliance Working for Antibiotic Resistance Education). DHCS Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis - percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met Meet or exceed NCQA 50 th Percentile Q Provide provider performance feedback by means of 2014 HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing QI 90

91 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation RESULTS (Qualitative Analysis) While 2015 s rate of improved by 4.43% over the previous year s rate it missed the 50 th percentile by just 0.72%. BARRIER ANALYSIS Member expectations to receive an antibiotic may be a contributing factor. 90% of bronchitis infections are caused by viruses and will not resolve by use of antibiotics. However member misunderstanding of when antibiotics work can contribute to the expectation of being prescribed antibiotics. NEXT STEPS Continue to provide provider reports, resources from the CDC and AWARE (Alliance Working for Antibiotic Resistance Education) and discussion during HEDIS results review. These resources can provide member educational materials that providers can share with their members. Provide education via use of evidenced based articles. DHCS Ambulatory Care- Summarizes Utilization of Ambulatory Care Outpatient Visits per 1,000 Member Months EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Meet Medi-Cal Managed Care Performance Dashboard Rate Q Analyze data to determine clinic that is outlier Send report to clinic for investigation of low rates Meet with clinic to discuss results of investigation and implement interventions based on outcome of investigation QI QI IT Operations RESULTS (Qualitative Analysis) While outpatient visits improved significantly in 2015 when compared to 2014 we continue to lag behind the Medi-Cal Managed Care Performance Care Dashboard rates. 91

92 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation BARRIER ANALYSIS This may be related to access issues. Additionally the plan experienced a large increase in members, mostly in the adult expansion aid codes. This population may not have had health coverage in the past and therefore do not understand the importance of preventive care visits. NEXT STEPS QI developed a letter that will be sent out to all members who have not received preventive care visits in 2016 to educate the members on the importance of preventive care. A text message pilot is also underway to see if this communication method will engage members to visit their PCP. 92

93 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Action Steps & Monitoring/Improvement Activities Objective: Improve Quality and Safety of Clinical Care Services DHCS External PIP: TBD by DHCS Quality Improvement Projects Select topic and submit to DHCS for approval by September 30, 2015 Determine PIP topic Approval by QIC Submit proposal form to DHCS Submit Modules as directed by DHCS Modules 1 & 2 Modules 3,4 and 5 submit separately Responsible Dept./Committee QI EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met. RESULTS (Qualitative Analysis) Immunizations for 2 Year Olds chosen and approved by QIC on 9/29/15. PIP topic proposal submitted to DHCS/HSAG and approved on 9/30/15. Modules 1 & 2 submitted and passed after second submission. Module 3 submission date is Feb BARRIER ANALYSIS Initial submission of Modules 1& 2 did not pass. Clinic having difficulties pulling data and generating report. GHCP submitted data collection tool to clinic for approval, clinic approved tool. Modules 1& 2 resubmission to DHCS 1/6/16. DHCS/HSAG informed GCHP on 1/13/16 that modules passed. Currently working on Module 3 with clinic. NEXT STEPS Continue working with clinic to complete and submit Module 3 to DHCS/HSAG by 2/29/16. DHCS Internal PIP Select topic and submit to DHCS by January 2016 January 2016 Determine PIP topic Approval by QIC Submit proposal form to DHCS QI EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal met. RESULTS (Qualitative Analysis) Screening, Brief Intervention, and Referral to Treatment (SBIRT) as second topic approved at QIC on 12/10/15. Submitted topic proposal to DHCS/HSAG on 1/25/15. BARRIER ANALYSIS Notification by DHCS/HSAG on 2/4/16 suggesting another topic due to statistically significant changes in other measures. QI submitted 93

94 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Developmental Screening as a topic on 2/12/16. Approval was received from DHCS on 2/17/16. GCHP Internal PIP: Increase retinal eye exam for diabetic members Increase rate by 5% over previous year rate Q EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met Member incentive letters Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services VSP letter to members Report quarterly to QIC Health Education QI RESULTS (Qualitative Analysis) The rate for this measure exceeded the 90 th percentile by 13.77% and increased by 21.41% over the previous year s rate. BARRIER ANALYSIS Goal met no barriers identified. NEXT STEPS Continue to monitor this measure. This PIP will be discontinued in Interventions used in 2015 will continue in Member incentive will not continue. Only 19 members sent back the incentive form. 94

95 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Improve Quality of Nonclinical Services NCQA QI 5 DHCS Primary Care Access Members are offered: Non-urgent primary care within 10 business days of request Urgent care within 24 hours Standards met for minimum of 90% of providers Q Action Steps & Monitoring/Improvement Activities Monitor performance and complaints relating to appointments Report quarterly performance to QIC Develop and implement corrective action plans when timely access standards not met Responsible Dept./Committee Network Operations Grievances and Appeals Specialty Care Access Members are offered: Non-urgent specialty care appointment within 15 business days Non-urgent ancillary services within 15 business days EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal not met. Appointment Access results: Primary Care Access Non-urgent PCP appointment within 10 business days 87.8% Urgent Care within 24 hours 75.4% Specialty Care Access Non-urgent specialty care appointment within 15 business days 54.1% Non-urgent ancillary appointment within 15 business days 88.9% Grievances A total of 27 Access to Care grievances were received in Of these 27 grievances four (4) were related to Primary Care Access and four (4) were related to Specialty Care Access. A RESULT (Qualitative Analysis) There was a 20% decrease in grievances related to Access to Care from 2014 to In 2015 a total of 27 grievances related to Access of Care were received compared to 34 grievances in The number of grievances related to Primary Care Access decreased from six (6) 95

96 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation in 2014 to four (4) in Grievances related to Specialty Care Access also decreased over the same time period; 13 in 2014 versus four (4) in The result of the access survey was received in March, A total of 141 providers were sampled in this survey. Those specialties selected were the same as those pre-determined by DMHC for access review in The breakdown of specialties included in the survey was 90 PCPs and 51 Specialists. 90 PCPs (100%) completed the survey. However not enough of the specialists within each specialty type responded to make the specialty results valid. None of the access standards met the goal. BARRIER ANALYSIS Poor completion rate for Specialists. NEXT STEPS Meet with providers within the network to determine obstacles preventing timely access, and in those cases where access is due to limited number of contracted providers in a specialty type, outreach to those providers not currently under contract for that specific specialty. Required By Goals Metrics Target Completion Date Objective: Improve Quality of Nonclinical Services DHCS After Hours Availability Members are able to reach a provider after hours Standards met for 90 % of providers Q EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met; Survey not completed. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS NA NEXT STEPS Plan is to perform survey in 2016 using Industry Collaboration Effort. Action Steps & Monitoring/Improvement Activities Monitor performance and complaints relating to after-hours availability Report quarterly performance to QIC Develop and implement corrective action plans when timely access standards not met Responsible Dept./Committee Network Operations Grievances and Appeals 96

97 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation DHCS Availability of Practitioners Ratios: 1 PCP 1:2000 Total Physicians 1: 1200 Physician Supervision to Non-Physician Practitioner Ratio Nurse Practitioners 1:4 Physician Assistants 1:4 Network maintained PCP located within 30 minutes or 10 miles Conduct monthly ratio analysis and monthly distance analysis using a Quest Analytics tool for primary care and high volume specialties Identify gaps and implement corrective action plan Monitor progress towards action plans to maintain or improve our time and distance standards Report bi-annual ratio analysis and annual time and distance findings to QIC Network Operations EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met. Results of the Quest Analytics indicate that ratios for PCPs are 1:857 and total physician ratio is 1:177. Standard of 30 minutes and 10 miles was met based on our quantitative results shown below. Average distance to PCP is.8 miles while average time is 1.1 minutes. 97

98 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation RESULTS (Qualitative Analysis) 99.9% of our population have access to their PCP within the required time and distance standard. BARRIER ANALYSIS Goal Met, no barriers presently identified. NEXT STEPS Continue to monitor availability of practitioners annually. 98

99 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Action Steps & Monitoring/Improvement Activities Objective: Improve Quality of Nonclinical Services Practitioner Availability: Cultural Needs & Preferences NCQA QI 5 DHCS Practitioner Availability: Cultural and Linguistics Needs & Preferences: Assess the cultural, ethnic and linguistic needs of our members Complete Annual Assessment Q Analyze the demographic needs of our members to identify opportunities for improvement Responsible Dept./Committee Cultural and Linguistics EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met, Assessment was not completed. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS No barriers presently identified. NEXT STEPS Work with Member Services to analyze demographic needs of our members in order to determine if opportunities for improvement exist and provider network needs to be adjusted. NCQA DHCS Assess the provider network and adjust the availability of providers within the network, if necessary, to meet membership needs and preferences Complete Annual Assessment Q Monitor how effectively the practitioner network meets the needs and preferences of our members Network Operations EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met, Assessment was not completed. RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS No barriers presently identified. NEXT STEPS Work with Member Services to analyze demographic needs of our members in order to determine if opportunities for improvement exists and the provider network needs to be adjusted. Provider Satisfaction Survey Complete Survey Q Analyze results and identify opportunities for improvement Develop and implement interventions as needed to improve rates Network Operations 99

100 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Not Met, Survey results were received and reviewed by leadership. 100

101 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Loyalty Analysis 101

102 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Utilization Management and Quality Network/Coordination of Care 102

103 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Priority Matrix RESULTS (Qualitative Analysis) Overall Satisfaction: GCHP respondents rate all composites beside Pharmacy significantly lower than the SPH Analytics (SPHA) Aggregate Benchmark. Furthermore, the 2015 Physician Satisfaction Survey results are significantly lower than all composites other than Network/Coordination of Care and Pharmacy when compared to the SPHA Medicaid Benchmark. Providers rate their satisfaction with Gold Coast Health Plan compared to all other plans (21.1%) significantly lower than the SPHA Medicaid and Aggregate Benchmarks (36.4% and 37.8%, respectively). The 2015 score is not significantly different from 2013 (18.8%). Recommend to Other Physician Practices: The highest performing attribute is 8A (Willingness to recommend Gold Coast Health Plan to other practices), while the lowest performing attribute is 6D (overall satisfaction with health plan s call center service) with Summary Rates of 74.8% and 13.5%, respectively. Loyalty Analysis: Loyalty Analysis shows 7.8% of respondents are loyal physicians who indicate they are completely satisfied and likely to recommend the plan to other practices. Utilization Management and Quality: When compared to the SPHA Medicaid and Aggregate Benchmarks, all attributes within the Utilization and Quality Management composite are rated significantly lower. Additionally, respondents rated Question 3F significantly lower in 2015 than in The following composites are determined to be top priorities for Gold Coast Health Plan as they are highly correlated with overall satisfaction and their 103

104 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation summary rates fall below the 75th percentile: Finance Issues, Health Plan Call Center Service Staff, Utilization and Quality Management, and Provider Relations. BARRIER ANALYSIS Low response rates NEXT STEPS Re-survey for Based on 2015 results Network and Provider Relations have implemented several programs to respond to Top and Medium Priority Issues. Evaluate ways in which to increase provider response rate. 104

105 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Improve Patient Safety DHCS Complete Initial and Tri-annual Facility Site Reviews Complete Interim Reviews Action Steps & Monitoring/Improvement Activities 100% Year End 2015 Monitor FSR database Submit bi-annual reports to DHCS Responsible Dept./Committee FSR Nurse QI EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met RESULTS (Qualitative Analysis) All site reviews completed for 2015 and bi-annual reports submitted to DHCS. BARRIER ANALYSIS Goal Met, no barriers presently identified. DHCS Complete Physical Accessibility Site Reviews 100% Year End 2015 Compile reports for high volume/ancillary specialists Submit report to State Complete PARs for new provider sites EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met RESULTS (Qualitative Analysis) All PARs completed for Reports completed and submitted to DHCS. BARRIER ANALYSIS Goal Met, no barriers presently identified. NCQA DHCS Improve Safe Clinical Practice Tracking Ongoing Monitor site visit results from practitioner credentialing Monitor member complaints involving clinical quality of care concerns (safety) FSR Nurse QI Credentialing/Peer Review Grievances and Appeals EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met RESULTS (Qualitative Analysis) Four (4) site visits were completed in 2015 based on grievances received, no issues were found for any site. Results of these visits are reported to Credentialing Coordinator for consideration during the recredentialing process. Grievances continue to be monitored and site visits completed within 30 days as needed. BARRIER ANALYSIS Goal Met, no barriers presently identified. 105

106 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Member Experience: CAHPS, Complaints/Grievances DHCS Conduct annual assessment of complaints and grievances, and CAHPS results to identify opportunities for improvement Meet or exceed 50 th percentile for : Getting Needed Care (2014 rate =78.2%) Getting Care Quickly (2014 rate =79.8%) Q Action Steps & Monitoring/Improvement Activities Member Interventions: Article in member newsletter regarding access standards Develop and implement process to assist members in obtaining appointments when requested Provider Interventions: Article in POB regarding required access standards Provider access survey Q2 2015; follow up with providers not meeting standards Responsible Dept./Committee Member Services QI Health Services Network Operations Customer Service (2014 rate =82.7%) Customer Service Interventions: Monitor results/reports of after call survey performed by call center; follow up if issues identified Operations Monitor complaints and grievances Measure during 2016 CAHPS Grievances and Appeals EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Shared Decision Making (2014 rate =49.7%) POB article regarding shared decision making Conduct Focus Groups Conduct Monthly Access Tracking Survey (6 months July to December) upon completion present findings to clinics QI QI QI 106

107 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation CAHPS Survey please refer to the above tables 107

108 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Rates for Overall Rating of Health Plan, All Health Care, Personal Doctor and Specialist Seen Most Often improved in 2015 when compared to 2013 (last year of DHCS/HSAG CAHPS survey) with the exception of the adult survey where a slight decline of.3% was noted for Overall Rating of All Health Care and a 3% decline noted for Overall Rating of Specialist Seen Most Often. The Child survey results saw improvement across all four areas with the exception of the specialist where a rate was not reported by HSAG/NCQA. Call Center: An after -call survey of the call center was completed in Focus Groups: A total of eleven (11) focus groups were conducted in Monthly Access Tracking Survey: Composite Summary Rate Definition Summary Rate Scores Your Overall Appointment Experience Excellent/Very Good 64.7% Ease of Accessing the Care You Need Strongly Agree/Agree 87.1% Ease of Accessing the Care You Need Summary Rate Scores Q5. The office has timely appointments available when you (your child) need care. 70.9% Q6. It was easy for you to schedule an appointment (for your child) with this doctor. 87.1% Q7. You can reach someone at this doctor s office in a timely manner when you (your child) 70.8% need care or advice after regular office hours. Complaints and Grievances: RESULTS (Qualitative Analysis) CAHPS Survey: 108

109 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation The plan saw improvement in the global rates of the CAHPS survey in 2015 when compared to the rates in 2013, the last year that DHCS/HSAG conducted the survey. GCHP contracted with The Myers Group to conduct an off season CAHPS survey. Improvement was noted in 2015 results when compared to the results of the off season CAHPS survey with the exception of the adult area of rating of personal doctor where the rate declined by 1%. When comparing rates from 2013 and 2015, improvement was also noted in the composite measure for member s experience with the exception of the adult and child area of Getting Needed Care. A formal report is expected from HSAG later in the year. Call Center: The 2015 results of the after-call survey performed by the call center showed some dissatisfaction related to the Interactive Voice Response System (IVRS) % of the callers that answered the question about their satisfaction using the IVRS were not satisfied. A review of the IVRS, which looked at prompts and self-service options, was completed in December 2015 and identified areas for improvement. Changes to the IVRS are expected to be completed in the second quarter of Complaints and Grievances: There were 27 grievances received in 2015 versus 26 grievances in 2014 involving grievances against GHCP. There were a total of 7 grievances related to customer service in 2015 compared to 4 received in When compared to the total volume of grievances against GCHP received in 2015 (26), grievances related to customer service comprise 26% of that total versus 15% in Based on the low volume of these types of grievances there does not appear to be a trend in the increase of member grievances related to customer service. Focus Groups: Focus groups were conducted in October for both English and Spanish speaking members. Groups were conducted for both adults as well as for parent of children. The purpose of these groups was to assess the experiences of the plan s members in order to improve their experience and satisfaction since some of the questions on the CAHPS survey did not allow the plan to discern between issues with their provider or the plan itself. 78 members were recruited, however only 44 participated despite a gift card incentive and transportation being provided. Results of these focus groups indicated that members were unaware of the difference between the Call Center and GCHP Member Services. Customer Service: Members indicated they were experiencing challenges with the phone system including dropped call, the amount of time required to get connected, lack of training and/or knowledge of the representatives and lack of follow-up by representatives. Providers: Eleven (11) of the participants indicated scheduling of appointment with providers presented challenges. Scheduling of appointments with a specialist indicated that there were long wait times, not being able to get an appointment on the same needed when they felt they needed to see someone right away. GCHP: Among members whose experience did not measure up to their expectations issues included: o Challenges in getting approved for coverage o Challenges finding the right primary care physician o Challenges in making appointments, getting access to specialists and accessing care after the work day The challenge most often cited by participating members was that of getting an approval for a referral through Gold Coast. Eight of the 19 participants who responded to this prompt had some challenge getting a referral to a specialist. Concerns included the amount of time waiting for the approval, the miscommunication (or lack of communication) between the doctor s office and Gold Coast, a hostile representative, and lost paperwork. Monthly Access Tracking Survey: A Monthly Access Tracking Survey was begun in July 2015 and completed at the end of December. The purpose of the survey was to measure member experience with their physician, specifically in the areas of access to care and physician communication. Members who have had a recent visit with a doctor were included in this survey. The sample size was 7200 eligible members surveyed over a six month period, targeting 350 completed surveys per month. A final report was available on April 8, A total of 1,896 surveys were completed. From the results we can conclude that our members are experiencing difficulties in obtaining appointments within the required standard of 10 business days for a routine or preventive care visits. This was a key driver identified in the off-season CAHPS survey. The lowest scoring questions were related to 109

110 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation ease of accessing care. Member and Provider Education: Access standards were published in the member newsletter in Summer 2015 as well as in the October 2015 Provider Operations Bulletin. BARRIER ANALYSIS No barriers were identified. NEXT STEPS: Monthly Access Tracking Survey: The results of the findings were shared with the leadership of GCHP and plans are being developed to share the results with leadership of those clinics that were surveyed. Call Center: Implement changes to the IVR include elimination of some of the options on the member and provider menus, rearranging options to allow calls to flow more logically and adding clarity to the prompt messages. Complaints and Grievances: Monitoring and trending of grievances related to customer service will continue in 2016 and results reported to Member Services as well as the Quality Improvement Committee. Provider Access Survey: The plan is to schedule more frequent visits to primary care offices to determine the access availability of primary care services. 110

111 Required By 2015 Gold Coast Health Plan Quality Improvement Work Plan Evaluation Goals Metrics Target Completion Date Objective: Health Plan Quality NCQA DHCS Update QI Program Description Complete 2014 QI Program Evaluation Develop and Implement 2015 QI Program Work Plan 100% April 2015 April 2015 April 2015 Action Steps & Monitoring/Improvement Activities 1. Review and revise annual QI Program Description, Work Plan and Evaluation 2. Obtain approval of 2015 QI Program and Work Plan and Evaluation of 2014 QI Program 3. Evaluate the adequacy of resources, committee structure, practitioner participation and leadership involvement in the QI Program in order to restructure or change the QI Program for subsequent year as necessary Responsible Dept./Committee Chief Medical Officer QI Director Quality Improvement Committee EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal met. QI Program Description and Work Plan approved at QIC on March 31, 2015 and at Ventura County Medi-Cal Managed Care Commission meeting on April 27, RESULTS (Qualitative Analysis) NA BARRIER ANALYSIS Goal Met, no barriers presently identified. NCQA DHCS Completion of Delegation Oversight Delegated Activities Credentialing QI UM Members Rights Claims 100% Q Complete audits 2. Issue CAPs as applicable 3. Follow-up on CAPs as applicable 4. Report to Compliance Committee and QIC Compliance EVALUATION OF 2015 WORK PLAN RESULTS (Quantitative Analysis) Goal Met, 100% of audits completed. RESULTS (Qualitative Analysis) Completed all audits as defined in the 2015 annual audit schedule and reported outcomes to QI & Compliance Committees, CAPS issued and monitored as required. BARRIER ANALYSIS Goal Met, no barriers presently identified. Attach UM Work Plan to QI Work Plan Monitoring via use of Dashboard 111

112 Required By 2016 Gold Coast Health Plan Quality Improvement Work Plan Goals Metrics Target Completion Date Objective: Improve Quality and Safety of Clinical Care Services NCQA QI 7 NCQA QI 7 DHCS DHCS DHCS Diabetes Clinical Practice Guideline (CPG) review and adoption at least every two years Distribution of guidelines to practitioners Preventive Health Guideline (PHG) review and adoption at least every two years Distribution of guidelines to practitioners Advance Prevention Increase percentage of members who smoke who report being counseled to quit in prior 6 months Increase percentage of members who smoke who report a provider discussed tobacco cessation medication in the prior 6 months Increase rates of Initial Health Assessment (IHA) Review of relevant CPGs Distribute if necessary Review of relevant PHGs Distribute if necessary Q Q TBD Action Steps & Monitoring/Improvement Activities Review and approval by Medical Advisory Committee(MAC) Annually measure performance against at least two important aspects of each of the CPGs Distribute guidelines to appropriate practitioners Review and approval by Medical Advisory Committee(MAC) Annually measure performance against at least two important aspects of two PHGs Distribute guidelines to appropriate practitioners 90% Q Measure during IHA monitoring Educate providers based on results of IHA monitoring Measure during 2016 CAHPS 60% Q Measure during IHA monitoring Educate providers based on results of IHA monitoring Measure during 2016 CAHPS 90% Q Measure during medical record reviews for IHA and provide performance feedback at time of completion of record review Educate providers of requirements and components of IHA Article in POB regarding requirements of IHA, including outreach requirements Responsible Dept./Committee MAC MAC QI QI QI 112

113 DHCS Postpartum Care Percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery 2016 Gold Coast Health Plan Quality Improvement Work Plan HEDIS Measures Increase rates by 5% over previous measurement year TBD Q Develop member education mailings to compliment member incentive forms Explore possible use of text4baby program for use in educating members Promote use of GCHP Pregnancy E- newsletter Provide provider performance feedback by means of HEDIS report cards Develop and implementcontinue member incentive program to engage members; partner with CPSP staff at clinics and Ventura County Public Health to help promote Health EducationHealth Education QI DHCS Childhood Immunization percentage of children 2 years of age that had DtaP, IPV, MMR, HiB, HepB, VZV and pneumococcal conjugate (Combo 3) Increase rates by 5% over previous measurement year Q Member newsletter article on importance of getting immunizations Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services Promote GCHP New Parent E-newsletter Develop and implement member incentive program and promote during HEDIS results visits with clinics Health Education QI DHCS Immunizations for Adolescents (Combo 1) percentage of adolescents 13 years of age who received a meningococcal vaccine on or between the member s 11 th and 13 th birthday and Tdap or Td on or between the member s 10 th Increase rates by 5% over previous measurement year Q Member newsletter article on importance of getting immunizations Provide provider performance feedback by means of HEDIS report cards Provide quarterly bi-annual member lists with members who have not received services Health Education QI 113

114 and 13 th birthdays (Combo1) 2016 Gold Coast Health Plan Quality Improvement Work Plan Develop and implementcontinue member incentive program and promote during HEDIS results visits with clinics DHCS Controlling High Blood Pressure percentage of members years of age who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90) Maintain rate above MPL Increase rates by 5% over previous measurement year Q Q Investigate why rates decreased over previous measurement year via medical record review Provide provider performance feedback by means of 2014 HEDIS report cards Develop and implement interventions based on results of medical record review Member newsletter article on how to control blood pressure QI QI DHCS Well Child Visits in Third, Fourth, Fifth and Sixth Years percentage of members 3-6 years of age who had one or more well-child visits with a PCP during the measurement year Increase rates by 5% over previous measurement year Q Develop and implement member incentive program Provide provider performance feedback by means of 2014 HEDIS report cards Provide quarterly member lists with members who have not received services Develop and implement member incentive program and promote during HEDIS results visits with clinics QI DHCS Children and Adolescents Access to Primary Care Practitioners percentage of members 12 months 19 years of age who had a visit with a PCP Meet or exceed DHCS MPL Q Develop and implementcontinue member incentive program to engage members with addition of preventive care reminder letter ppromote during HEDIS results visits review with clinics Collaborate with First5 Ventura to help promote incentive QI Formatted Table 114

115 2016 Gold Coast Health Plan Quality Improvement Work Plan Provide provider performance feedback by means of HEDIS report cards Provide quarterly bi-annual member lists with members who have not received services Pay-for-Performance Program for childhood access to care QI Network Operations DHCS Counseling for Nutrition and Physical Activity for Children and Adolescents percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of counseling Meet or exceed DHCS MPL Q Provide provider performance feedback by means of HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates QI DHCS DHCS Appropriate Testing for Children with Pharyngitis - percentage of children 2 18 years of age, who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A strep test. Appropriate Treatment for Children with Upper Respiratory Infection - percentage of children 3 months 18 years of age who were diagnosed with an upper respiratory infection (URI) and Meet or exceed DHCS NCQA MPL25th percentile; rate of was below the NCQA 10 th percentile Meet or exceed NCQA 90 th Percentile Over/Under Utilization Q Q Provide provider performance feedback by means of HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing Provide provider performance feedback by means of HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing QI QI 115

116 were not dispensed an antibiotic prescription Gold Coast Health Plan Quality Improvement Work Plan DHCS Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis - percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Meet or exceed NCQA 50 th Percentile Q Provide provider performance feedback by means of HEDIS report cards Provider Operations Bulletin article Meet with clinics to discuss rates Academic detailing QI DHCS Ambulatory Care- Summarizes Utilization of Ambulatory Care Outpatient Visits per 1,000 Member Months Meet Medi-Cal Managed Care Performance Dashboard Rate Q Analyze data to determine clinic that is outlier Adult and child member letters for appointment reminders/engage members to see their PCP Send report to clinic for investigation of low rates Meet with clinics to discuss results of investigation and implement interventions based on outcome of investigationclinic rates QI QI IT Operations DHCS External PIP: Improve the rates for Childhood Immunization Status (CIS) Combo 3 HEDIS measure Quality Improvement Projects Increase rates at Las June 30, 2017 Submit Modules as directed by DHCS for Islas Family Medical approval Group from 67.66% to Modules 3,4 and 5 submit 77.66% separately QI DHCS Internal PIP: Increase rates of developmental screenings Select and engage clinic and begin modules Metric TBDIncrease December 2016June 30, 2017 Report 3 month PDSA cycle results to QIC and DHCS/HSAG Submit Modules as directed by DHCS for approval Modules 1 & 2 Modules 3, 4, and 5 submit QI Help Me Grow Ventura 116

117 GCHP Internal PIP collaborative with Ventura County Public Health (VCPH): Increase rates of perinatal 4Ps Plus Perinatal Substance Use Screening and linkage to services 2016 Gold Coast Health Plan Quality Improvement Work Plan rates at CMH CFH Arneill Road from 0.77% to 15% DHCS IP: Cervical Cancer Screening Meet or exceed DHCS MPL DHCS IP: Well Child Visits in Third, Fourth, Fifth and Sixth Years separately Report 3 month PDSA cycle results to QIC and DHCS/HSAG Metric TBD TBD VCPH conduct training on 4Ps Plus VCPH to track rates and report to GCHP Increase rates by 5% over previous measurement year Q Q Implement alternative method of engaging members: text program Provider performance feedback by means of 2015 HEDIS report cards Provide bi-annual member lists of members who have not received services Provide performance feedback reports at least twice to clinics Continue member incentive program to engage members Provide provider performance feedback by means of 2015 HEDIS report cards Provide bi-annual member lists with members who have not received services Provider education of required periodicity of exams and required components of exams HEDIS results visits with clinics QI VCPH QI QI Formatted: Normal GCHP Required By Opioid Use Improvement Strategy Develop strategy Q Formulary Edits Provider education Benefit alternatives Goals Metrics Target Completion Date Action Steps & Monitoring/Improvement Activities Pharmacy Responsible Dept./Committee 117

118 Objective: Improve Quality of Nonclinical Services NCQA NET 2 DHCS Primary Care Access Members are offered: Non-urgent primary care within 10 business days of request Urgent care within 24hours 2016 Gold Coast Health Plan Quality Improvement Work Plan Standards met for minimum of 90% of providers Q Monitor performance and complaints relating to appointments Report quarterly performance to QIC Develop and implement corrective action plans when timely access standards not met Conduct survey Network Operations Grievances and Appeals Specialty Care Access Members are offered: Non-urgent specialty care appointment within 15 business days Non-urgent ancillary services within 15 business days DHCS NCQA NET 1 DHCS After Hours Availability Members are able to reach a provider after hours Availability of Practitioners Standards met for 90 % of providers Ratios: 1 PCP 1:2000 Total Physicians 1: 1200 Physician Supervision to Non-Physician Practitioner Ratio Nurse Practitioners 1:4 Physician Assistants 1:4 Q Q Q Monitor performance and complaints relating to after-hours availability Report quarterly performance to QIC Develop and implement corrective action plans when timely access standards not met Conduct survey Conduct bi-annual ratio analysis and annual GeoAccess analysis for primary care and high volume specialties Identify gaps and implement corrective action plan Monitor progress towards action plans to maintain or improve GeoAccess standards Report bi-annual ratio analysis and annual GeoAccess findings to QIC Network Operations Grievances and Appeals Network Operations 118

119 2016 Gold Coast Health Plan Quality Improvement Work Plan NCQA NET 1 DHCS Network maintained PCP located within 30 minutes or 10 miles Practitioner Availability: Cultural Needs & Preferences Practitioner Availability: Cultural and Linguistics Needs & Preferences: Assess the cultural, ethnic and linguistic needs of our members Complete Annual Assessment Q Analyze the demographic needs of our members to identify opportunities for improvement Member Services Network Operations NCQA NET 1 DHCS Assess the provider network and adjust the availability of providers within the network, if necessary, to meet membership needs and preferences Complete Annual Assessment Q Monitor how effectively the practitioner network meets the needs and preferences of our members Network Operations Required By Provider Satisfaction Survey Complete Survey Q Analyze results and identify opportunities for improvement Develop and implement interventions as needed to improve rates Goals Metrics Target Completion Date Objective: Improve Patient Safety DHCS Complete Initial and Tri-annual Facility Site Reviews Complete Interim Reviews Action Steps & Monitoring/Improvement Activities 100% Year End 2016 Monitor FSR database Submit bi-annual reports to DHCS Network Operations Responsible Dept./Committee FSR Nurse QI DHCS Complete Physical Accessibility Site Reviews 100% Year End 2016 Compile reports for high volume/ancillary specialists Submit report to State Complete PARs for new provider sites FSR Nurse QI 119

120 NCQA CR 5 & 6 DHCS 2016 Gold Coast Health Plan Quality Improvement Work Plan Improve Safe Clinical Practice Tracking Ongoing Monitor site visit results from practitioner credentialing Monitor member complaints involving clinical quality of care concerns (safety) Objective: Member Experience: CAHPS, Complaints/Grievances TBD NCQA QI 4 DHCS Conduct annual assessment of complaints and grievances,. and Conduct Six Month CAHPS Member Access and Satisfaction Survey results to identify opportunities for improvement Meet or exceed 50 th percentile forincrease rates by 5% over previous year : Your Overall Appointment Experience Adult: % Child: % Ease of Accessing Care Adult: % Child: % Getting Needed Care (2014 rate =78.2%) Getting Care Quickly (2014 rate =79.8%) Customer Service (2014 rate =82.7%) Q Member Interventions: Article in member newsletter regarding access standards Develop and implement process to assist members in obtaining appointments when requested Provider Interventions: Article in POB regarding required access standardsreview 2015 Member Access and Satisfaction Survey final results with clinics Provider access survey Q ; follow up with providers not meeting standards Customer Service Interventions: Monitor results/reports of after call survey performed by call center; follow up if issues identified Monitor complaints and grievances Measure during 2016 CAHPS POB article regarding shared decision making Conduct Focus Groups Conduct Monthly Access Tracking Survey (6 months July to December) upon completion present findings to Credentialing/Peer Review Grievances and Appeals Member Services QI Health Services Network Operations Operations Grievances and Appeals QI QI QI 120

121 2016 Gold Coast Health Plan Quality Improvement Work Plan clinics Objective: Health Plan Quality NCQA QI 1 DHCS NCQA QI 10 DHCS Update QI Program Description Complete 2015 QI Program Evaluation Develop and Implement 2016 QI Program Work Plan Completion of Delegation Oversight Delegated Activities Credentialing QI UM Members Rights Claims Shared Decision Making (2014 rate =49.7%) 100% April 2016 April 2016 April Review and revise annual QI Program Description, Work Plan and Evaluation 2. Obtain approval of 2016 QI Program and Work Plan and Evaluation of 2015 QI Program 3. Evaluate the adequacy of resources, committee structure, practitioner participation and leadership involvement in the QI Program in order to restructure or change the QI Program for subsequent year as necessary 100% Q Complete audits 2. Issue CAPs as applicable 3. Follow-up on CAPs as applicable 4. Report to Compliance Committee and QIC Attach UM Work Plan to QI Work Plan Monitoring via use of Dashboard Chief Medical Officer QI Director Quality Improvement Committee Compliance 121

122 TO: FROM: Gold Coast Health Plan Commission C. Albert Reeves, MD, Chief Medical Officer DATE: June 27, 2016 SUBJECT: Pay-for-Performance Program to Improve Children s Access to Care SUMMARY: As part of Gold Coast Health Plan s ARCH Program, the Plan seeks to improve children s access to care as measured in the 2016 Healthcare Effectiveness Data and Information Set (HEDIS) Measure for access for children by offering to providers caring for children a pay-forperformance program to develop strategies to improve access to care for children. BACKGROUND: Gold Coast Health Plan has failed to meet the Department of Health Care Services requirement to reach the 25 th percentile for the children s access to care HEDIS Measure three (3) years in a row. The Plan attempted by various means to improve the score and access by offering a member incentive and by providing providers with the names of members not seen in the first half of the year. The scores have improved but the scores have not reached the required 25 th percentile. The Plan is proposing to improve access with a pay-for-performance program to incentivize providers to institute programs to increase visits by children. DISCUSSION: The Plan will budget 1.4 million dollars for this pay-for-performance program. The amount made available to any group or provider will be roughly related to the ratio of eligible children assigned to that group or provider. One-third of the monies available will be paid to the group or provider when the group or provider has submitted an acceptable proposal for their program to improve access. Examples of strategies that would be considered would be: Expanded office hours to evenings or weekends Adding providers who care for children Outreach to their assigned members who have been identified as not being seen in the year and making appointments for them Improving the provider s encounter data submitted to the Plan 122

123 To be eligible for the pay-for-performance component of this program, the group or provider must submit a progress report to the plan on September 30, 2016, and December 31, 2016, which shows that their proposed strategies have been instituted. The group or provider will receive a defined monetary payment if they achieve a 5%, 7.5% or 10% improvement in their access for children for the 2016 measurement year as reported on the National Committee for Quality Assurance Certified result released on July 15, If all groups and providers develop an acceptable program and achieve a 10% improvement in the HEDIS Score the Plan will score well above the 25 th percentile and the entire 1.4 million dollars will be paid. If any of the groups or providers do not participate or achieve the maximum results the monies not paid will return to the Plan s Alternative Resources for Community Health Program Fund. 123

124 Legend: Dark Green = Performance P90 Percentile Yellow = Performance < P50 Percentile Red = Performance P25 Percentile Responsible Description Department (AAB) Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis AAB (Bronchitis) (AMB) Ambulatory Care The percentage of adults years old with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or within three days after the episode start date. Quality Improvement Benchmark Source Rate Rate Rate Rate P10 P25 (MPL) P50 P75 P90 (HPL) 2016 Q1 HEDIS NR Non-SPD DHCS Medi-Cal Managed Care SPD Division requires that managed DHCS NR Quality care plans calculate an overall Improvement Non-SPD Medi-Cal readmission rate, a DHCS NR Health readmission rate for the SPD Services Total (SPD and Non SPD) population, and a readmission DHCS NR rate for the non-spd population (CAP) Children and Adolescents' Access to Primary Care Practitioners CAP: age months CAP: age 25 months - 6 The percentage of members who Quality years HEDIS had a visit with a PCP. Improvement CAP: age 7 to 11 NR CAP: age 12 to 19 NR (LBP) Use of Imaging Studies for Low Back Pain LBP The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MR, CT scan) within 28 days of the diagnosis. Quality Improvement Gold Coast Health Plan HEDIS Measures -- Quality of Care Indicators Outpatient Visits NR Medi-Cal This measure summarizes Quality Managed Care utilization of ambulatory care. Improvement Performance (Visits/1,000 Member Months) Dashboard ED Visits NR (MMA) Medication Management for People with Asthma HEDIS NR Annual Trend Interventions Statewide Utilization is 677 as of 12/15/2015 Statewide Utilization is 39 as of 12/15/2015 Implemented Well- Child member incentive program on July 31, Medication Compliance 50%: Total Medication Compliance 75%: Total Quality Improvement NR TBD TBD NR NR NR (MPM) Annual Monitoring for Patients on Persistent Medications 124

125 Gold Coast Health Plan HEDIS Measures -- Quality of Care Indicators Legend: Dark Green = Performance P90 Percentile Yellow = Performance < P50 Percentile Red = Performance P25 Percentile Measure Description Responsible Benchmark P25 P50 P75 P90 P10 Department Source Rate Rate Rate Rate (MPL) (HPL) 2016 Q1 The percentage of members 18 ACE Inhibitors or ARBs years of age and older who NR received at least 180 treatment days of ambulatory medication Digoxin therapy for a select therapeutic Quality agent during the measurement Improvement HEDIS NR year and at least one therapeutic monitoring event for the Diuretics therapeutic agent in the NR measurement year. Annual Trend Interventions Implemented improvement plan with Provider Report Cards, Performance Feedback Reports, and Academic Detailing. 125

126 Legend: Dark Green = Performance P90 Percentile Yellow = Performance < P50 Percentile Red = Performance P25 Percentile Measure (CCS) Cervical Cancer Screening Description Responsible Department Gold Coast Health Plan HEDIS Measures -- Quality of Care Indicators Benchmark Source Rate Rate Rate Rate P10 P25 (MPL) P50 P75 P90 (HPL) 2016 Q1 Annual Trend Interventions CCS The percentage of women years old who had at least one Pap test during the past 3 years. Quality Improvement HEDIS QI sent reminder letters to non- Compliant members and their Providers, asking them to schedule an appointment for the service. (CBP) Controlling High Blood Pressure The percentage of members that that were years of age with a dx of hypertension and Quality CBP adequately controlled BP Improvement (<140/90) during the measurement year. (CDC) Comprehensive Diabetes Care HEDIS CDC: A1c Testing CDC: Poor A1c control (> 9.0%); lower rate is better (Inverted rate) CDC: Good A1c control (< 8.0%); higher rate is The percentage of members that better received a subset of services Quality HEDIS CDC: Diabetic Eye Exam essential to diabetes Improvement CDC: LDL Testing management CDC: LDL Control (<100 mg/dl) CDC: Nephropathy Monitoring CDC: Blood Pressure (<140/90 mm Hg) (CIS) Childhood Immunization Status The percentage of children 2 years of age that had DTaP, IPV, CIS MMR, HiB, HepB, VZV, Pneumococcal Conjugate (Combo 3) (IMA) Immunizations for Adolescents Adolescents who received one meningococcal vaccine on or between the members 11th and IMA 13th birthday and one Tdap or Td on or between the members 10th and 13th birthdays. Combo 1 Quality Improvement Quality Improvement HEDIS HEDIS Potentially impacted by Well-Child member incentive program on July 31, Potentially impacted by Well-Child member incentive program on July 31,

127 Legend: Dark Green = Performance P90 Percentile Yellow = Performance < P50 Percentile Red = Performance P25 Percentile Measure (PPC) Prenatal and Postpartum Care PPC 1: Timeliness of Prenatal Care PPC 2: Postpartum Care (W34) Well Child Visits in Years 3-6 Description The percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment in the organization. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. The percentage of members that that were 3, 4, 5, or 6 years of W34 age and had 1 or more well care visits with a PCP during the measurement year. (WCC) Weight Assessment for Children Responsible Department Quality Improvement Quality Improvement Gold Coast Health Plan HEDIS Measures -- Quality of Care Indicators Benchmark Source HEDIS Rate Rate Rate Rate P10 P25 (MPL) P50 P75 P90 (HPL) HEDIS Q1 Annual Trend Interventions Implemented member incentive program on July 31, Implemented Well- Child member incentive program on July 31, WCC: BMI % The percentage of members 3-17 years of age who had an outpatient visit with a PCP or WCC: Nutrition OB/GYN and who had evidence Quality of BMI percetile documentation, Improvement HEDIS counseling for nutrition and counseling for physical activity WCC: Physical Activity during the measurement year Implemented Well- Child member incentive program on July 31, Over/Under Utilization CWP: Appropriate Testing for Children With Pharyngitis URI: Appropriate Treatment for Children with Upper Respiratory Infection The percentage of children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. The percentage of children 3 month-18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription. Quality Improvement Quality Improvement HEDIS NR HEDIS NR Implemented an antibiotic stewardship program and academic detailing rates reflect measurement year data from January 1, 2012, through December 31, rates reflect measurement year data from January 1, 2013, through December 31, rates reflect measurement year data from January 1, 2014, through December 31, Unofficial 2015 rates reflect measurement year data from January 1, 2015, through December 31,

128 Legend: Green = Met or exceeded Benchmark Red = Did not meet Benchmark Description Benchmark Source Quality Improvement Benchmark 2014* Q1 Quarterly Trend Q2 Interventions Facility Site Audit (Medi-Cal) - Scoring The overall percentage of applicable DHCS site audit criteria met. DHCS/ Title 22 80% 99% 92% Facility Site Audit (Medi-Cal) - Compliance The percentage of providers that passed facility audits without or following completion of a corrective action plan. DHCS/ Title 22 NA 100% 100% Medical Record Quality Audit (Medi-Cal) - Scoring The overall percentage of applicable DHCS medical record audit criteria met. DHCS/ Title 22 80% 96% 88% Medical Record Quality Audit (Medi-Cal) - Compliance The percentage of providers that passed medical record audits without or following completion of a corrective action plan. DHCS/ Title 22 NA 100% 88% Coordination of Care The overall percentage of applicable DHCS Coordination of Care criteria met as determined by medical record audits. NA Tracking 100% 93% *2014 data available for Q2, Q3, and Q4 only. No Initial or Periodic FSR's or MRR's were required during 2014 Q1 128