Quality Improvement Committee Minutes

Transcription

1 Quality Improvement Committee Minutes Date: February 11, 2016 Meeting Place: San Francisco Health Plan, 50 Beale Street 13 th Floor, San Francisco, CA Meeting Time: 7:30-9:00 am Present: Edwin Batongbacal, Jeanette Cavano, PharmD; Daniel Chan, MD; Ellen Chan, MD; Irene Conway, Jeffery Critchfield, MD; Lukejohn Day, MD; Edward Evans, Todd May, MD; Dennis McIntyre, MD; Kenneth Tai, MD; Ana Valdes, MD Staff Present: James Glauber, MD; Fiona Donald, MD; Collin Elane, Jim Soos, Abby Wolf, Nicole A. Ylagan Topic Discussion [including Identification of Quality Issue] Call to Order Meeting was called to order at 7:30 am Follow Up Items There were no public comments. Follow up from October QIC 2015: investigate if adult immunizations as a covered benefit apply to Healthy Workers? Additional question: Is the shingles vaccine is included as a pharmacy benefit for the Healthy Worker line of business. Follow-up [if Quality Issue identified, Include Corrective Action] Resolution, or Closed Date [for Quality Issue, add plan for Tracking after Resolution] No follow up needed No follow up needed No follow up needed. Is the shingles vaccine included in the Healthy Worker line of business? Adult immunizations as a covered benefit applies only to the Medi-Cal line of business. Follow up needed. Consent Calendar The consent calendar was reviewed and approved unanimously. Review of QIC minutes December 10, No follow up needed Entire Consent Calendar approved Review of QIC minutes 1 Page

2 2015 Health Services update Membership report Q Appeals Report Update of Pharmacy & Therapeutics Committee membership and minutes Policies and Procedures o QI-01 Quality Improvement Committee o QI-11 Physician Advisory Peer Review Credentialing Committee o Pharm-08 Pharmacy Formulary; Prior Authorization Criteria and Policy Annual Review. o Pharm-09 Pharmaceutical Patient Safety UM Committee Minutes o December 2015 o January 2016 The committee was reminded that SFHP s UM Committee discusses UM related criteria, appeals etc. on a monthly basis. Policies that are included in the consent calendar interium changes or changes in workflow in response to DHCS and DMHC. Any bi-annual review of policies are brought to the committee for approval. December 10, 2015 Health Services update Membership report Q Appeals Report Update of Pharmacy & Therapeutics Committee membership and minutes Policies and Procedures o QI-01 Quality Improvement Committee o QI-11 Physician Advisory Peer Review Credentialing Committee o Pharm-08 Pharmacy Formulary; Prior Authorization Criteria and Policy Annual Review. o Pharm-09 Pharmaceutical Patient Safety UM Committee Minutes o December 2015 o January 2016 No follow up needed. 2 Page

3 Policies and Procedures Care-04 Complex Medical Case Management Dr. Donald presented the updatedpolicy to the committee. The policy was revised to ensure all NCQA requirements were met. San Francisco Health Plan (SFHP) Complex Medical Case Management (CMCM) provides case management to members identified as high risk due to complex medical conditions that require medical management and intervention. The CMCM program requires assessment of members qualifying medical conditions and contributing psychological factors, coordination with providers and community partners, and engagement of members in the development of their care plan. Members enrolled in CMCM receive intensive medical management, coaching and guidance for their medical conditions, and referrals to resources that allow them to regain optimum health and functionality. Care plans include significant support with health system navigation and coordination to facilitate appropriate delivery of care and services and condition-specific education and assistance with goal attainment, No follow up needed Approved: Care-04 Complex Medical Case Management 3 Page

4 monitoring, and follow-up. CMCM member assessments used for initial and on-going case management are based on clinical best practices. SFHP CMCM is an opt-out program; all eligible members have the right to participate or to decline participation. Question 1: Approximately how many members would be eligible for this program? Answer 1: Currently, SFHP is identifiying members by high ED utilizers and lack of PCP engagement. In the future, SFHP will be using MARA( predictive modeling) software to identify members.. SFHP has approximately 50 who have been enrolled in the CMCM program. Question 2: How will this program work for members who have a chemical dependence? Answer 2: Access to Substance Abuse and Chemical dependency treatment services is part of the care planning process. SFHP is working on a CHCF funded care integration planning grant for Opiate Dependent High Utilizers Hopefully, we will be able to develop a model to enhance our care coordination activities with Substance 4 Page

5 Abuse treatment services. Question 3: How would Delegated Medical Groups (DMG) or Dual Eligible members be involved with this system? Answer 3: The DMGs can refer members to SFHP s program if there is a need. Members can also self refer. This program is only available for Medi-Cal members. SFHP will not turn away dual eligible members but the focus will be on members who only have the Medi-Cal benefit. Questions 4: Will the program include pharmacy and pharmacist to help the population with their medication? Answer 4: Yes, this is a requirement of the program. Quality Improvement Motion to Approve. Approved. Q Grievance Report Nicole A. Ylagan represented the Q report. A total of 159 grievances were reported in the third quarter of 2015 (from July 1 - September 30). In comparison to the second quarter of 2015 (147 grievances), this is an 8.1% increase. There were five grievances out of 159 grievances Approved: Q Grievance Report 2015 Facility Site Review Follow up with member regarding transportation to other programs to clinics/hospital outside of San Francisco. 5 Page

6 in which the acknowledgement letter was not sent out within five calendar days. The acknowledgement letters were overlooked and sent out late. There were 19 out of 159 grievances in the third quarter that were not closed in required 30 day timeframe, as mandated by the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS). These grievances were not acknowledged and closed within their timeframes because of a new SFHP internal process that ensures all components of the grievance have been resolved appropriately and have been discussed by the weekly Grievance Review Committee (GRC). Question 1: Would it be possible for member s to be surveyed to check if they are satisfied with the resolution of their grievances? Answer 1: This is a great suggestion and something we can integrate into the Quality Improvement Plan Question 2: Can the grievances drill down to the clinic level for SFHN? Answer 2: Yes, that information can be incorporated in the quarterly grievance report to SFHN. 6 Page

7 Question 3: Is it possible to classify the resolutions? Answer 3: Yes, we can include that data in the next grievance report. Motion to Approve. Approved. Facility Site Review (FSR) Abby Wolf presented the 2015 FSR results. DHCS requires Medi-Cal Managed Care Plans to conduct a Full Scope Facility Site Review (FSR) for every Primary Care Provider (PCP) site as part of the initial credentialing process and at least every 36 months thereafter. The Full Scope FSR consists of two scored components that help ensure consistent compliance with DHCS administrative and clinical guidelines: 1. Site Review Survey (SRS) 2. Medical Record Review (MRR) Both FSR components are scored by Certified Nurse Reviewers (CNRs) using standardized audit tools developed by DHCS. FSRs are conducted by SFHP and Anthem Blue Cross in the City and County of San Francisco. Per DHCS guidelines, FSR results are shared between the two Health 7 Page

8 Plans to avoid over-auditing PCP sites. The following SFHP Medical Groups are delegated to perform FSRs: Brown and Toland (BTP), Chinese Community Health Care Association (CCHCA), Hill Physicians (HPMG), Kaiser, and North East Medical Services (NEMS). Starting in 2016, FSR scores will be tracked closely and compared with previous scores for each PCP site. An FSR measure has been added to the 2016 Quality Improvement Plan with a target of SRS and MRR score increases of 2 percentage points from 2013 reviews when possible (N/A for scores of %). Activities that will help reach this target include more comprehensive CAP follow-up, increased provider outreach and training, and regular training of Certified Nurse Reviewers. Question 1: Are ADA accessibility, scales etc part of the FSR process? Answer 1: ADA access is reviewed at all SFHP PCP sites, per DHCS, using the FSR- C audit tool. The FSR-C is for informational purposes only and corrective action plans (CAPs) are not issued per DHCS. SFHP cannot require PCP sites to make structural changes. Information for handicap parking, adjustable scales are included in the provider directory for members to review. 8 Page

9 Question: 2: Previously, Ms. Betsy Price worked on a grant program where money was given to providers for height adjustment scales etc. Answer 2: This program is no longer available but most of the provider sites are adequate. Follow up with member regarding ADA accessibility at clinics and hospitals in SFHP's network. Question 3: There are programs that are offered at other clinics/hospitals outside of San Francisco that are not ADA accessible. Is there anything SFHP can do to assist? Answer 3: Ms. Wolf replied that she can work with the committee member offline to better understand his concern and provide assistance if possible. Telemedicine Dr. Glauber informed the committee that SFHP is planning to implement Telehealth in Q Telehealth will enable members to receive direct patient access to primary, specialty, BH providers etc via video, , smart phones and other wireless tools. Another benefit for telemedicine is that it can help avoid members going to the emergency room. There will be no specific coding for telemedicine visits. SFHP anticipates 10 15% of members will utilize this 9 Page

10 benefit. Having telemedicine is one component of SFHP s overall access improvement strategy. In addition, SFHP wants to improve current CAHPS scores. Beacon is moving forward to contract with Telehealth. Currently, Telehealth has 71 licensed clinicans. SFHP is hoping that network physicians will join Telehealth and this allows network physicians to have access to member s medical records. Telehelath physicians are credentialed through the NCQA process. The average wait time is under 10 minutes. The average visit is minutes but there is no clock that will time out after a certain amount of time. Question 1: How secure via the internet, smart phone etc would this be for members? Answer 1: SFHP is working to ensure that the information given over the internet is secure. Question 2: What does access mean to members? Answer 2: SFHP s Member Advisory Committee (MAC) defined access as physically seeing someone for their appointment and at SFHP s focus group, members defined telemedicine as saving a 10 Page

11 bus ride to see a phyisican. QI Committee Chair's Signature & Date: 3/3/15 Minutes are considered final only with approval by the QIC at its next meeting. 11 Page