UPDATE PROVIDER. A Guide: Prenatal Behavioral Risks and the New PRSI Form JUNE 2017 PAGE 9

Transcription

1 A Newsletter for West Virginia Family Health Providers and Clinicians PROVIDER A Guide: Prenatal Behavioral Risks and the New PRSI Form PAGE 9 UPDATE

2 OFFICE STAFF PROVIDER MEMBER RIGHTS AND RESPONSIBILITIES INCLUDED IN WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL UPDATE Table of Contents CLINICAL OFFICE STAFF 3 Medical Record Reviews for Documentation Completeness 4 Ensuring Quality Care and Service 5 Peer Review Information 6 Adding that Special Touch to Your Practice 6 Practitioner Availability Survey and Standards 7 Clinical Practice and Preventive Health Guidelines 8 A Guide: Prenatal Behavioral Risks & the New PRSI Form 9 Save Lives with Cervical Cancer Screening 10 After Hospital Discharge 11 Important Phone Numbers Back Cover Our members have certain rights and responsibilities that are a vital part of membership with West Virginia Family Health (WVFH). These rights and responsibilities are included in the member handbook and are reviewed annually in the WVFH member newsletter. The WVFH Member Rights and Responsibilities are available online for our network providers to help maintain awareness and support your relationship with your WVFH members. You ll find the Member Rights and Responsibilities in Chapter 1, Unit 1.1, of the West Virginia Family Health Provider Manual. The Provider Manual is available on the WVFH website under Providers > Provider Manual. A hard copy of the Member Rights and Responsibilities is available upon request by calling your Provider Relations Representative. Member Rights and Responsibilities Included in West Virginia Family Health Provider Manual 2 3

3 OFFICE STAFF OFFICE STAFF MEDICAL RECORD REVIEWS FOR DOCUMENTATION COMPLETENESS ENSURING QUALITY CARE AND SERVICE WVFH conducts an annual review of our providers medical records to ensure that the care provided to our members is properly documented as specified in the Medical Record Review Standards. The Standards, which incorporate a core set of critical factors, were developed by the QI Department and approved by the plan s Quality Improvement/Utilization Management Practitioner Committee, and adhere to regulatory requirements as prescribed by the West Virginia Department of Health and Human Resources Bureau for Medical Services. Ensuring the excellent provision of health care and services for our members is the primary goal of the WVFH Quality Improvement/Utilization Management (QI/UM) Program. WVFH continuously monitors how well we re helping our members: Beginning in June, West Virginia Family Health will start the 2017 annual review of medical records. You or your practice may or may not be selected for this review. If you or your practice is selected, you will be contacted by WVFH and given the option to mail/fax in medical records or have a reviewer come to your location. We ask that if you receive a request for medical records that you return the requested records or schedule an onsite review within 15 days. As a reminder, complying in a timely fashion with WVFH s requests for medical records is a contractual responsibility. WVFH endeavors to provide the very best quality care to our members, your patients. Please help us to ensure that your patients get the very best! For a copy of the Medical Record Review Standards, please contact your Provider Relations Representative, or visit the WVFH website at: Get preventive care Get care for long-standing health problems Understand the medicines they take Stay out of the hospital Have appropriate access to practitioners Make and keep doctor appointments Share health information with their doctors Receive care in a culturally-competent manner The Quality Program leverages results from member surveys, medical record reviews, the Healthcare Effectiveness Data Information Set (HEDIS), and other tools to measure how we are doing and to help set goals for future quality activities. We also work closely with WVFH also conducts an annual review of its QI/UM Program to see how well we ve met the health care and service needs of our members. The evaluation of the 2016 QI/UM Program is complete. We met many of the QI/UM Program goals, implemented new and innovative programs, identified areas for improvement, and are developing plans to address improvement opportunities in Please call Provider Services at if you would like to request more information about our Quality Program, QI/UM Work Plan, or summary evaluation of the 2016 QI/UM Program. See Under Appendix: Forms and Reference Materials doctors in our network to monitor the care and services our members receive, as well as determine what we can do to better serve our members. WVFH maintains a QI/ UM Work Plan to analyze activities conducted as part of its QI/UM Program. This Work Plan is evaluated every three months to identify issues and ensure that actions have been taken to address them. 4 5

4 PEER REVIEW INFORMATION WVFH offers providers the opportunity for peer reviews whenever a medical necessity decision is made to deny or reduce a service. The Utilization Management nurse phones the ordering or attending physician s office to review the details of the request and the physician s decision. The nurse will provide the WVFH physician name and a phone number so that you have the opportunity to discuss the decision, including the reason you believe the service is medically necessary. When calling the WVFH physician, please have the following information readily available to ensure a timely discussion with the appropriate physician: Name of the WVFH physician to whom you were directed to speak Member information, including the WVFH identification number and/or authorization number OFFICE STAFF ADDING THAT SPECIAL TOUCH TO YOUR PRACTICE Positive patient-provider interactions are vital to a member s overall healthcare experience. Whether it be a wellness visit or a simple call to the doctor s office, every interaction matters. Sufficiently communicating and educating your patients will help strengthen your relationship and positively impact their time with you. Here are a few things to consider during your next patient interaction: Smile! Make eye contact between typing notes into the computer Avoid long silent pauses while using the computer Speak in terms the patient will understand Share reminders for appointments, immunizations and screening tests Suggest alternative physical activities to promote a healthy lifestyle Remember, patients look to you in times of need, so it s important to make them feel comfortable and in good hands. Adding that special touch to each patient interaction will increase each patient s overall healthcare experience. Thank you for your big contribution to our members health and healthcare experience! OFFICE STAFF PRACTITIONER AVAILABILITY SURVEY AND STANDARDS Your practice may have or may soon receive a call from SPH Analytics, an NCQA certified survey vendor. SPH Analytics will be assessing practice appointment and after-hours availability. Please take a few minutes to review the standards and review with your office staff. Thank you in advance for participating in the survey! WEST VIRGINIA FAMILY HEALTH APPOINTMENT STANDARDS Your doctors have agreed to care for WVFH members in a timely manner. Please review the timeframes below for each appointment type: Appointment Type Example Standard Emergency Care (PCPs & Specialists) Urgent Care (PCPs & Specialists) Routine Care (PCPs & Specialists) EPSDT services (for PCPs treating 21 and under) WVFH member with Supplemental Security Income (PCPs) Initial Prenatal Visit (PCPs or OB/ GYNs that treat pregnant members) AFTER HOURS CARE High temperature, persistent vomiting or diarrhea or symptoms which are of sudden or severe onset but which do not require emergency room services. Persistent rash, recurring high-grade temperature, non-specific pain or fever. Psoriasis, treatment of chronic conditions such as chronic back pain. EPSDT screening for 2 month old. First appointment Initial visit for a WVFH member who is pregnant. Available the same day Within 48 hours Within 21 days Within 1 week Within 45 days Within 14 days Practices are responsible for providing 24 hour/ 7 days per week coverage for urgent or emergent care. WVFH members must be instructed to call 911 or go directly to the emergency room in the case of a true emergency. Answering services or machines must instruct members how to reach an on call physician. 6 7

5 Yes CLINICAL CLINICAL PRACTICE AND PREVENTIVE HEALTH GUIDELINES CLINICAL A GUIDE: PRENATAL BEHAVIORAL RISKS & THE NEW PRSI FORM 8 WVFH adopts clinical practice and preventive health guidelines to assist practitioners in providing appropriate health care for specific clinical conditions relevant to our members. These guidelines are developed using evidencebased clinical practice guidelines from professionally-and industry-recognized sources, or through the involvement of board-certified practitioners from appropriate specialties when guidelines from recognized sources are not available. They are provided in an effort to improve health care quality by promoting peer-reviewed standards-ofcare and best practices. The guidelines also serve as a guide for WVFH s various Disease Management programs. WVFH routinely monitors for industry changes that would affect its adopted guidelines. Before distribution, the guidelines are reviewed and approved by WVFH s Quality Improvement Committee. Some of the guidelines maintained by WVFH include: Adult with HIV Adult Preventive Care Asthma Cardiac Medical Management Child Preventive Care COPD Diabetes Hypertension Palliative Care Routine and High Risk Prenatal Care Substance Abuse A complete listing of WVFH s adopted guidelines is viewable online at Select Clinical & Behavioral Guidelines under the Provider section. Physical copies are available upon request. WVFH is dedicated to serving the women, children and families of West Virginia. There are significant perinatal risk factors that must be addressed to improve poor pregnancy outcomes, low birth weight and infant mortality. With early identification of maternal risk factors, you can make an impact on reducing negative outcomes and improve the health of women and children across the state! Case Management services provide your patients the knowledge, encouragement, and support to reinforce the prenatal and postpartum care to maximize their family s health, well-being and self-sufficiency. Case Managers offer advice, education, appointment reminders, and community service referrals that will help patients maintain healthy maternity care between office visits. You can refer patients directly to the Mom Matters Program. Patients who are not directly referred are captured using the Prenatal Risk Screening Instrument (PRSI). The PRSI is the tool that West Virginia requires all providers to submit on behalf of every pregnant women in the state. It is intended to promote early and accurate identification of prenatal risk factors. By sending WVFH a complete PRSI form, our Case Managers can evaluate the risk status of patients and determine the appropriate services required to help reduce the risk. In addition to improved and thorough care, when the PRIS is submitted with the initial visit (up to 14 weeks) the member receives a $50 gift card and providers can earn a $200 incentive! You can find the PRSI at by searching Provider Forms under the Provider Tab. Be sure to use the updated 2016 version of the form. Fax completed forms to and to WVFH Mom Matters at If you would like more information about the Mom Matters Program, call our Case Management Department at , Monday-Friday, Risk Factors to Screen For & Screening Tool Recommendations Depression Drug Use Alcohol Use Tobacco Use Intimate Partner Violence WEST VIRGINIA PRENATAL RISK SCREENING INSTRUMENT First Name: MI: Date of Birth: Last Name: Social Security #: City: Zip Code: County of Residence: Telephone: Street: State: Maiden Name: Race: (Check all that apply) U.S. Citizen: Married: Insurance Source: White Black/African American Asian Yes Yes Health Insurance: American Indian/Alaska Native No No No Insurance Native Hawaiian/Pacific Islander Ethnicity: Hispanic/Latino Not Hispanic/Latino Medicaid #: Date of 1st Prenatal Visit: (MM/DD/YYYY) OBSTETRICAL HISTORY: ORAL HEALTH: Gravida Para Sensitive/Bleeding Gums Yes No Loose/Broken/Decayed Teeth Yes No Term Pre SAB EAB Live Current Dental visit within the last year Yes No Weight (lbs) : LMP: (MM/DD/YYYY): Dental cleaning in the last year Yes No Height EDC: (MM/DD/YYYY): (Ft-inches) : BREASTFEEDING Blood Pressure: Do you intend to breastfeed? Yes No Type of Delivery: 1st Trimester: Miscarriage Abortion 2nd Trimester: Miscarriage Abortion Are you currently breastfeeding? Yes No Preterm Birth Term Birth PREGNANCY RISK Current Preg. Prior Preg. Current Preg. Prior Preg. Current Preg. Prior Preg. FACTORS Y N Y N Y N Y N Y N Y N PROM na na Hypertension Hepatitis C Preterm Delivery na na PIH/Preeclampsia Pyelonephritis Cervical Incompetence IUGR Chromosome Abnormalities Cervical Surgery Low Birth Weight <2500 grams Fetal Anomaly Macrosomia >4000 grams Ectopic Pregnancy Short Cervix Other/Unlisted Risk Factor: Gestational Diabetes Placental Previa Previous Stillbirth na na Placental Abruption Oligohydramnios Prev ious C-Section na na Bleeding during current pregnancy? Opioid Abuse Treatment Hepatitis B Trimester: 1st 2nd 3rd No FAMILY HISTORY: Current Preg. Prior Preg. Family Hist. MEDICAL CONDITIONS: Yes No On On Yes No On Y N Y N Y N Meds Meds Multiple Gestation High Blood Pressure Clotting Disorder Fetal Genetic/Structural Abnormalities Kidney Disease STD PSYCHOSOCIAL RISK FACTORS: Yes No Diabetes Seizures Disabled Asthma Rh Negative Unemployed/Inadequate Income Heart Condition Other: Husband/Partner Employed Thyroid Disease Homeless ENVIRONMENTAL RISK FACTORS: Yes No Unstable Housing Lead: House Built before 1978 Education <12 years Viral: Cats or Birds in Home Currently in Foster Care Tobacco: 2nd or 3rd Hand Smoke Inadequate Transportation Inadequate Social Support REASONS FOR LATE ENTRY INTO PRENATAL CARE: (check all that apply) Unplanned Pregnancy Does not apply Financial Do you have enough to eat Insurance Enrollment Delay Child Care Issues Eating Disorder Unaware of Importance of PNC Access to pregnancy testing Difficulty with Reading and Understanding Couldn't find a health provider Transportation Internet Access Abortion desired/unsuccessful Other: Have either of your parents had a problem with drugs? Yes No or alcohol? Yes No Have you ever smoked cigarettes? Yes No Has your partner had a problem with drugs? Yes No or alcohol? Yes No Do you currently smoke cigarettes? Yes No In the past, have you had a problem with drugs? Yes No If yes, # of cigarettes per day: or alcohol? Yes No During this pregnancy, have you used drugs? Yes No I quit (when): or alcohol? Yes No Does your partner smoke? Yes No Have you ever been a victim of abuse or violence? No In the month before you knew you were pregnant, did you take prescription drugs? Yes No Has your partner's anger ever worried or scared you? Yes No Have you ever felt down or hopeless? Yes No If YES, what were the drugs? Have you lost interest in things you used to do for fun? Yes No Who prescribed the drugs? Provider Name and Title: (print) Provider Signature: Person Completing the form: Provider Telephone No.: Date: Date of Last Delivery: I am interested in further follow-up. I give my consent for necessary referrals to be made. I understand that my participation in any referral services is voluntary and that all information provided will be held strictly confidential. Patient Name: (print) Patient Signature: Date: Postpartum Depression Scale (PDSS) Edinburgh Postnatal Depression Scale (EPDS) PP Depression Predictors Inventory (PDPI) WVDHHR/BPH/OMCFH/DPWH PRSI 12/29/2016 PLEASE COMPLETE AND FAX TO (304) Screening, Brief Intervention, & Referral to Treatment (SBIRT) Screening, Brief Intervention, & Referral to Treatment (SBIRT) Fagerstrom Test for Nicotine Dependence (FTND) Abuse Assessment Screen (AAS) The PRSI was updated by the State in December Look for the date at the bottom of the form and be sure to use the right one! 9

6 CLINICAL SAVE LIVES WITH CERVICAL CANCER SCREENING Cervical cancer is a largely preventable gynecologic cancer. Through regular screening pre-cancer cells can be detected early enough that the disease can be treated before it becomes a problem. In fact, research has shown that women who do not receive regular screenings make up the majority of new cervical cancer cases each year 1. Since the Pap test was introduced in the 1950s, the number of women screened for cervical cancer has gone up, while the death rate has decreased. The table below from the CDC 2 illustrates the decrease in the death rate since However, screening rates have plateaued in recent years and, as a result, the rate of women in the United States who die from this disease has plateaued as well. CLINICAL AFTER HOSPITAL DISCHARGE Hospital discharges can be a confusing, stressful and challenging time for patients and their caregivers. To improve patient health and reduce readmissions, patients are encouraged to follow up with their primary care providers soon after discharge. During these post-hospital discharge appointments it is important to review some key areas with patients. Some of these key areas include: Medications Complete a medication reconciliation with your patient to help them understand which medications have been added, discontinued or changed and why. Research indicates that the majority of patients do not understand the new dosing of medications they are taking or the reasons for medication changes while they were in the hospital. Ensure that your patient is able to obtain all of the medications prescribed at discharge. Sometimes cost or transportation can be a barrier to obtaining new medications, with patients reverting to old medications and thus losing the health benefit of medication adjustments made in the hospital. 10 There are a number of ways you can help to increase the screening rate for women in your practice. Make sure that they are aware of the current United States Preventive Services Task Force recommendation: Women years of age should be screened by Pap test every three years Women years of age can be screened every five years by a combination of Pap and HPV testing Also, be sure that women know the difference between a pelvic exam with and without a Pap test. Many women believe that they are up to date on cervical cancer screening even when they have only had a pelvic exam. Lastly, include a reminder in your patient s chart to discuss screening at her next check-up. You can make a big difference in a woman s willingness to get screened and save her life in the process. 1. Vesco KK, Whitlock EP, Eder M, Lin J, Burda BU, Senger CA, et al. Screening for cervical cancer: a systematic evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 86. AHRQ Publication No EF-1. Rockville, MD: Agency for Healthcare Research and Quality; Cervical Cancer Is Preventable Infographic. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 05 Nov Web. 09 May Review Discharge Instructions Ensure that your patient understands their hospital discharge instructions. This could include education and information regarding a new diagnosis, a new diet recommendation or any restrictions the patient should be following. Ensure that your patient is following up with any specialist appointments, therapies, imaging or lab work ordered post-discharge. Educate your patient about warning signs for worsening health and what to do if they have concerns or questions. Help your patient develop a self-care plan and/or sick-day plan. Home Health Services and Durable Medical Equipment (DME) Ensure that your patient is receiving any necessary home health services ordered upon hospital discharge. Check that your patient that has received any new DME knows how to use it properly. Behavioral Health Discharges Develop a plan with your patient regarding the management of their mental health needs. This may include ensuring that the member is linked to the appropriate behavioral health care services, ensuring that the member has a crisis plan, as well as knowing the phone number for their local mental health crisis hotline. Coordinate care with their behavioral health provider to ensure that the patient is not receiving conflicting information and that there are no gaps in care. Ensure timely follow-up within 7 days of discharge with their mental health provider. If the patient has been newly diagnosed with an alcohol or other drug dependence diagnosis support them in seeking treatment. Refer any patients that could benefit from additional support and education to the Care Management program at WVFH. To make a referral to Care Management, please call WVFH also has a Transition Management team that may be supporting your patient after their recent hospital discharge. This Transition Team Care Manager may be reaching out to your office for assistance in managing your patient s needs. 11

7 WVFH IMPORTANT PHONE NUMBERS CALL TO INQUIRE ABOUT: TELEPHONE NUMBER HOURS OF OPERATION FAX NUMBER Behavioral Health Monday Friday Care Management Option 1: Maternity Program Option 2: Care Management/ Disease Management Congestive Heart Failure/Asthma/ Diabetes Option 3: Preventive Health Services/EPSDT/ Outreach Option 4: Complex Care Management Dental Provider Services (Claims Inquiries and Eligibility Verification) Digital Voice Assistant - DIVA (Eligibility Check/Generate and Review Referrals) Fraud and Abuse and Compliance Hotline Medical Management (Utilization Management) Monday Friday Monday Friday (Central Time) hours a day/ 7 days a week hours a day/ 7 days a week Please do not leave multiple voic messages or call for the same authorization request on the same day. Monday Friday (Voic during off hours. The call will be returned the next day.) Member Services Monday Friday 8 a.m. to 8 p.m. Pharmacy (Non-Formulary Requests and Prior Authorizations) Provider Services (Claims Inquiries and Eligibility Verification) TTY/TDD Line 711 or Monday Friday Monday Friday 24-Hour Nurse Help Line WVFH(9834) 24 hours a day/ 7 days a week General: Prenatal Risk Forms & Member Outreach Forms: