Patient Engagement Using Quality Metrics Texas MGMA Fall Conference Rae Godsey, DO, MBA, CPC Corporate Medical Director Risk Adjustment & STARs September 8, 2017
Topics Medicare Stars program overview CMS official surveys Consumer Assessment of Healthcare Providers and Systems (CAHPS ) and Health Outcomes Survey (HOS) overview Healthcare Effectiveness Data and Information Set (HEDIS ) Stars overview Patient safety Stars measures Measuring the Patient Experience 2
Medicare Stars program overview 3
Medicare CMS Stars: General framework The Centers for Medicare & Medicaid Services (CMS) aims to raise the quality of care for Medicare enrollees, including those with unique challenges. CMS holds health plans accountable for care provided to enrollees by physicians, hospitals and other providers. CMS developed the Stars program with two objectives for Medicare Advantage consumers MA PD only Stars ratings calculated at overall contract level (combining Parts C and D measures) In March 2010, the Affordable Care Act mandated that CMS use Star ratings to make quality bonus payments to higherrated plans (initial bonus payouts in 2012) Ratings at contract level 4 Stars or no bonus Stars quality bonus payments invested back into plans Bonus $$$ fuel benefits 4
Medicare CMS Stars: Value proposition Higher Stars ratings can lead to better benefits and better patient health For Humana members Improve clinical program and service offerings Improve customer service and experience Enrich member benefits and reduce costs For affiliated providers Improve provider tools, rewards and experience Facilitate provider partnership Enhance provider engagement Value continuum Competitively higher Star scores Higher CMS Star bonus payments Richer member benefits/lower premiums Differentiated member experience Higher plan membership Higher revenue and investment potential 5
Calculating Stars scores Calculating Stars scores Contract Stars scores are calculated in a series of six steps. The calculation starts with measure rates and ends with a rounded score of 1 to 5 Stars, rounded to 1/2 Star increments. Each step can include complicated calculations, and CMS can change the rules from year to year. 6
Assigning Stars for individual measures The methodology for assigning Star ratings for a measure is based on grouping measure scores by industry performance so maximum differentiation between plans is achieved. 7
Star ratings breakdown for health plans (bonus year 2020) The 5 Star Scale HEDIS Patient safety CAHPS/HOS IRE/CMS Improvement Staying healthy Managing chronic conditions Drug safety and adherence Member experience with health plan, drug plan and physician Appeals timeliness Complaints about the health plan Health plan improving rates year over year CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. HOS stands for Health Outcomes Survey. IRE stands for independent review entity. 8
Stars bonus year 2020 measures 1 and weights 1 HEDIS (measured Jan Dec) ABBR Weight Rheumatoid arthritis management ART 1x Breast cancer screening BCS 1x Osteoporosis management OMW 1x Plan all cause readmissions PCR 3x Colorectal cancer screening COL 1x Controlling blood pressure CBP 3x Diabetes eye exam EYE 1x Diabetes nephropathy NPH 1x Diabetes blood sugar control HBA 3x Adult BMI assessment ABA 1x COA 2 medication review MDR 1x COA 2 functional status assessment FSA 1x COA 2 pain screening PNS 1x Medication reconciliation postdischarge MRP 1x Hospitalization for potentially preventable complications HPC 1x Statin therapy for cardiovascular disease SPC 1x Patient safety (Jan Dec) ABBR Weight Medication adherence: diabetes 3 medication MAD 3x Medication adherence: 3 hypertension (ACE/ARB) MAH 3x Medication adherence: cholesterol (statins) 3 MAC 3x Statin use in persons with diabetes SUPD 1x CAHPS (measured Feb Jun) ABBR Weight Annual flu vaccine FLU 1x Getting needed care GNC 1.5x Getting appointments and care quickly GACQ 1.5x Customer service CS 1.5x Overall rating of health care quality RHCQ 1.5x Overall rating of health plan RHP 1.5x Care coordination CC 1.5x Overall rating of drug plan RDP 1.5x Getting needed prescription drugs GNRx 1.5x HOS (measured Feb Jun) ABBR Weight Improving or maintaining physical health IMPH 3x Improving or maintaining mental health IMMH 3x Monitoring physical activity MPA 1x Improving bladder control IBC 1x IRE (measured Jan Dec) ABBR Weight Appeals auto forward (drug plan) AAF 1.5x Appeals upheld (drug plan) AU 1.5x Timely decisions about appeals PTD 1.5x CMS (measured Jan Dec) ABB R Weight Comprehensive medication review CMR 1x Complaints about the health plan CHP 1.5x Members choosing to leave the plan MLPC 1.5x Medicare plan finder accuracy MPF 1x Special needs plan care management 2 SNP 1x Call center foreign language interpreter and TTY/TDD Part C FLIC 1.5x Call center foreign language interpreter and TTY/TDD Part D Improvement measures FLID 1.5x ABBR Weight Part C improvement HPQI 5x Part D improvement DPQI 5x Display measures (2018) 4 ABBR High risk medications HRM Patient Safety Opioid overutilization Antipsychotic use in persons with dementia Formulary administration analysis Reviewing appeals decisions RAD 1.5x Beneficiary access and BAPC CMS performance problems 1. Proposed measures and weights reflect April 2017 CMS Call Letter. Subject to CMS final ruling. 2. Measures apply only to special needs plans (SNP). 3. Per CMS Advance Notice guidelines, medication adherence measures for Puerto Rico have no weight. 4. Display measures are not part of Star ratings. 2018 display measures reflect measurement year 2017 services, displayed on CMS.gov in 2018. OO APD FAA Patient Safety Patient Safety Patient Safety Reducing the risk of falls ROF HOS 9
Measures physicians can impact Measures physicians can impact: HEDIS 28% weight Improvement 13% weight HEDIS Healthcare Effectiveness Data and Information Set CAHPS Consumer Assessment of Healthcare Providers & Systems HOS Healthcare Outcomes Survey CAHPS 16% weight Patient safety 13% Weight HOS 10% weight CMS (Centers for Medicare & Medicaid Services) Administrative data on plan quality/member satisfaction IRE Independent review entity CMS 12% weight IRE 8% weight Physicians directly influence 80 percent of the Stars rating 10
CMS official surveys CAHPS and HOS overview
CAHPS survey question domains Weight Measure Components 1.5 Getting care quickly 1.5 Coordination of care 1.5 Getting needed care 1.5 Customer service 1.5 Getting needed prescription drugs Scheduling an appointment 15 minute wait time Review medications Informed about specialist care Getting specialist appointment Care, tests, treatments through the plan Customer service courteous and informative Health plan forms Ease of getting prescribed medications Obtaining medications at retail or via mail 1 Annual flu vaccine Obtaining flu vaccination during prior season 1.5 Rating health care quality 0 10 rating of health care 1.5 Rating the health plan 0 10 rating of health plan 1.5 Rating the drug plan 0 10 rating of drug plan Composite Single item Overall 12
HOS measure domains Weight Measure Components 3 Physical health 3 Mental health 1 Bladder control* 1 Fall risk 1 Physical activity Improvement Self assessment (past four weeks) Accomplishing daily activities Self assessment (past four weeks) Daily mood, emotional state Issue (past six months) Physician discussion Treatment Issue (past 12 months) Physician discussion (past 12 months) Treatment Physician discussion (past 12 months) Recommendation start, increase, maintain activity level (past 12 months) Discussion According to CMS direction on Feb. 1, 2017, bladder control is again included in overall HOS scoring. 13
CAHPS and HOS survey timelines January 2016 February March April May June July CAHPS survey 3/6 Prenotification letter 3/13 3/14 First paper questionnaire mails 4/3 Second paper questionnaire mails 4/21 Telephonic outreach begins Telephonic outreach continues (three total attempts) 6/2 Follow up calls end 6/2 Cutoff date for phone and mail surveys 6/20 6/21 Final data files due to CMS HOS survey HOS baseline cohort survey begins HOS follow up cohort survey begins HOS baseline cohort survey ends HOS follow up cohort survey ends Blackout period: Late February through June. The health plan is prohibited from asking members any CAHPS related question that could influence official survey responses. Physicians, however, may discuss CAHPS and HOS quality topics with patients during this period. 14
Why are CAHPS and HOS important? Stars category weight 14% 13% 11% 16% HOS CAHPS HEDIS IRE 12% 7% 27% CMS Patient safety Improvement measures HEDIS: Healthcare Effectiveness Data and Information Set; IRE: independent review entity At 27 percent, CAHPS and HOS make up the second largest combined slice of the overall CMS Stars rating. At a 4 Star level or above, each plan is eligible for a bonus based on membership. 15
What are my clinical and business incentives? Clinical case Positive patient experiences correlate with: o Greater adherence to medical advice 1 (especially among patients with chronic conditions) o Better health outcomes 2 Business case Providing a quality experience: o Leads to patient retention 3 o Keeps employees engaged and less likely to leave 4 o May lower risk of malpractice suits 5 1 DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians characteristics influence patients adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology. 1993; 12:93 102. 2 Rave N, Geyer M, Reeder B, Ernst J, Goldberg L, Barnard C. Radical systems change: Innovative strategies to improve patient satisfaction. Journal of Ambulatory Care Management. 2003; 26(2):159 174. 3 Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: Predictors of voluntary disenrollment from a primary physician s practice. Journal of Family Practice. 2001; 50(2):130 136. 4 Rave N, Geyer M, Reeder B, Ernst J, Goldberg L, Barnard C. Radical systems change: Innovative strategies to improve patient satisfaction. Journal of Ambulatory Care Management. 2003; 26(2):159 174. 5 Fullam F, Garman AN, Johnson TJ, Hedberg EC. The use of patient satisfaction surveys and alternate coding procedures to predict malpractice risk. Medical Care. May 2009; 47(5):1 7.
HEDIS Stars overview 17
CMS HEDIS and Parts C and D Stars measures Composed of HEDIS measures, CMS clinical Part C Stars ratings are based on two domains of care: 1. Staying healthy: screenings, tests and vaccines 2. Managing chronic (long term) conditions Plans with prescription drug coverage are subject to Pharmacy Quality Alliance (PQA) endorsed measures. CMS clinical Part D Stars ratings are based on one domain of care: 1. Drug safety and prescription drug event (PDE) (PDE is data submitted through pharmacy claims. Medicare then collects the data from Humana.) 18
HEDIS Stars measures Measure Weight Breast cancer screening 1 Colorectal cancer screening 1 Adult BMI assessment 1 Care for older adults medication review 1 Care for older adults functional status assessment 1 Care for older adults pain assessment 1 Osteoporosis management 1 Diabetes care eye exam 1 Diabetes care kidney disease monitoring 1 Diabetes care blood sugar controlled 3 Controlling blood pressure 3 Rheumatoid arthritis management 1 Plan all cause readmissions 3 Medication reconciliation post discharge 1 Hospitalization for potentially preventable complications 1 Statin therapy for patients with cardiovascular disease 1 19
Breast cancer screening (BCS) Percentage of women 50 to 74 years old who had a mammogram to screen for breast cancer between Oct. 1 two years prior to the measurement year through Dec. 31 of the current measurement year Osteoporosis management in women who had a fracture (OMW) Percentage of women 67 to 85 years old who suffered a fracture and had a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture 20
Adult BMI assessment (ABA) Percentage of patients 18 to 74 years old who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year Care for older adults (COA) Includes the following three measures and applies to the Medicare special needs plan (SNP) population of 66 years and older: Medication review Documentation of at least one medication review conducted by a prescribing practitioner or clinical pharmacist, along with a medication list or documentation of no medications Functional status assessment Documentation in the medical record of at least one complete functional status assessment during the measurement year Pain screening Documentation in the medical record of at least one pain screening assessment for more than one system during the measurement year 21
Comprehensive diabetes care (CDC) Percentage of patients 18 to 75 years old with diabetes (Type 1 or Type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing o At least one HbA1c test during the measurement year for all eligible patients HbA1c poor control (greater than 9.0 percent) o HbA1c result was greater than 9.0 percent during measurement year; therefore, the goal is for the most recent HbA1c level during the measurement year to be 9.0 percent or less. Eye exam (retinal) performed o Comprehensive eye exam by an eye care professional during the measurement year Medical attention for nephropathy o Nephropathy screening, nephrology consult or dispensed prescription for angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blockers (ARB) therapy 22
Controlling blood pressure (CBP) Percentage of patients diagnosed with hypertension and whose blood pressure (BP) was adequately controlled during the measurement year: Patients 18 59 years old whose BP was less than 140/90 mm Hg Patients 60 85 years old with a diagnosis of diabetes whose BP was less than 140/90 mm Hg Patients 60 85 years old without a diagnosis of diabetes whose BP was less than 150/90 mm Hg Colorectal cancer screening (COL) Percentage of patients 50 to 75 years old for whom there is evidence of one of the following five screenings: Fecal occult blood test during the measurement year Flexible sigmoidoscopy during the current measurement year or previous four years Colonoscopy during the current measurement year or previous nine years CT colonography during the current measurement year or previous four years FIT DNA test during the current measurement year or previous two years 23
Disease modifying anti rheumatic drug therapy for rheumatoid arthritis (ART) Percentage of patients who were diagnosed with rheumatoid arthritis (RA) and who were dispensed at least one ambulatory prescription for a disease modifying anti rheumatic drug (DMARD): The patient must meet two of the following criteria with different dates of service on or between Jan. 1 and Nov. 30 of the measurement year to be included: o Outpatient visit with any diagnosis of rheumatoid arthritis o Non acute inpatient discharge with any diagnosis of rheumatoid arthritis There are two ways to identify patients who received a DMARD: o Claim/encounter data and pharmacy data 24
Plan all cause readmission (PCR) Percentage of patients 65 years old and older discharged from a hospital stay and readmitted to a hospital within 30 days, either for the same condition or a different reason. Hospitalization for potentially preventable complications (HPC) The rate of discharges for ambulatory care sensitive conditions (ACSC) per 1,000 members, and the risk adjusted ratio of observed to expected discharges for ACSC by chronic and acute conditions for patients 67 years old and older. 25
Statin therapy for patients with cardiovascular disease (SPC) Percentage of men 21 75 years of age and women 40 75 years of age, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and were dispensed at least one high or moderate intensity statin medication during the measurement year Medication reconciliation post discharge (MRP) Percentage of discharges from Jan. 1 Dec. 1 of the measurement year for patients 18 years old and older for whom medications were reconciled from the date of discharge through 30 days 26
Hospitalization for potentially preventable complications (HPC) The ambulatory care sensitive conditions (ACSC) included in this measure are: o Chronic ACSC Diabetes short term complications Diabetes long term complications Uncontrolled diabetes Lower extremity amputation among patients with diabetes Chronic obstructive pulmonary disease (COPD) Asthma Hypertension Heart failure o Acute ACSC Bacterial pneumonia Urinary tract infection Cellulitis Pressure ulcer 27
Patient safety Stars measures 28
Patient safety measures Every time a beneficiary fills a prescription under Medicare Part D, a prescription drug plan sponsor must submit a summary record called the prescription drug event (PDE) to CMS PDEs are not the same as individual drug claim transactions, but are summary extracts using CMSdefined standard fields Medication adherence measures fall under the PDE domain All medication adherence measures have a weight of 3 Medication adherence (Part D) measures Percentage of patients 18 years old or older who fill their prescription 80 percent or more of the time for the following conditions and drug classes: 1. Diabetes biguanides, sulfonylureas, thiazolidinediones, DPP IV inhibitors, incretin mimetics or meglitinides. Note: Plan members who take insulin are not included. 2. Blood pressure ACE (angiotensin converting enzyme) inhibitor or an ARB (angiotensin receptor blocker) drug, or a direct renin inhibitor drug 3. Cholesterol statin drugs 29
Medication therapy management (MTM) Completion rate for comprehensive medication review (CMR). Measures the percent of Medicare Part D beneficiaries 18 years old or older enrolled in the MTM program for at least 60 days who received a CMR Humana s MTM eligibility criteria: Patients have three of the following five chronic diseases: Congestive heart failure (CHF), diabetes mellitus, dyslipidemia, hypertension or bone disease arthritis osteoporosis Minimum of eight Part D medications Anticipated Part D drug cost of more than $3,919 Statin use in persons with diabetes (SUPD) Percentage of Medicare Part D beneficiaries 40 to 75 years old dispensed medication for diabetes who receive a statin medication Notes: Patient is excluded if in hospice. Prescription claims data are used as a proxy for diabetes diagnosis in this measure. This measure uses only prescription claims as a source of data. 30
Measuring the Patient Experience Humana s internal survey 31
Patient experience overview Patient experience at the physician s office is key to CAHPS and HOS success. Humana measures patient experience using its own Patient Experience Survey (distinct from the official CMS surveys). Voice automated telephone survey Survey season July to early February (completion rate approximately 33 percent) Survey of patients who visited their PCP in the previous 60 days Thirteen questions aligned with the following eight CAHPS & HOS measures: - Getting needed care without delay (CAHPS) - Getting appointments and care quickly (CAHPS) - Getting needed prescription drugs (CAHPS) - Coordination of care (CAHPS) - Reducing the risk of falls (HOS) - Bladder control (HOS) - Physical activity (HOS) - Mental health (HOS) Goal: Look for best practices and areas of opportunity 3 2
Patient experience: Score calculation breakdown Q1 Q2 Q3 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Eleven questions on the Patient Experience Survey count toward the member experience score. Only questions four and five are excluded from the overall score because they are plan and physician driven measures. Coordination of Care Access to care Coordination of care Patient discussion Description Average of: Q1, Q2, Q3 scores Average of: Q6, Q7 scores Average of: Fall risk score (Q8, Q9 average), Bladder control score (Q10, Q11 average), Physical activity (Q12), Mental health (Q13) Memberexperience rating (average of three categories) Target = 80 percent 33
Patient experience: Cut points for the questions Thresholds for Patient Experience Survey questions are based on industry cut points for the related CAHPS and HOS measures. 1 Star 2 Star 3 Star 4 Star 5 Star Question Low High Low High Low High Low High Low High 1 Difficulty scheduling appointment 0 71.99 72 72.99 73 76.99 77 78.99 79 100 2 Doctor wait time 0 71.99 72 72.99 73 76.99 77 78.99 79 100 3 Referral for specialist 0 78.99 79 80.99 81 83.99 84 85.99 86 100 4 Insurance covering medications 0 87.99 88 88.99 89 90.99 91 91.99 92 100 5 Approval tests and procedures 0 78.99 79 80.99 81 83.99 84 85.99 86 100 6 Doctor review medications 0 81.99 82 83.99 84 85.99 86 86.99 87 100 7 Doctor informed specialist care 0 81.99 82 83.99 84 85.99 86 86.99 87 100 8 Fall risk discussion 0 52.99 53 56.99 57 62.99 63 72.99 73 100 9 Fall risk treatment 0 52.99 53 56.99 57 62.99 63 72.99 73 100 10 Bladder control discussion 0 30.99 31 35.99 36 59.99 60 70.99 71 100 11 Bladder control treatment 0 30.99 31 35.99 36 59.99 60 70.99 71 100 12 Physical activity 0 44.99 45 48.99 49 53.99 54 56.99 57 100 13 Mental health 0 78.99 79 82.99 83 84.99 85 86.99 87 100 1. Low threshold cut points are greater than or equal to the number shown. 2. High threshold cut points are less than, but not equal to, the number shown. 3 4
Patient experience report delivery Ratings delivered to you in three separate reports Provider scorecard Single entity view for current month or YTD Gives target vs. actual scores on all 13 questions Includes categorical scores and overall rating Year over year trend report Single entity score trend view Shows prior year score, current YTD score, and current month breakout for any selection Provider prioritization Breaks out any single entity score by its component scores for any selected time period Examples Physicians within a practice Centers within a group 3 5
Patient experience report delivery: Discussion Any insights you can pull from your Patient Experience Survey results? What type of reporting suits your practice best? How do you like to see the data? Can your practice recommend any new reporting ideas? 3 6
Incorporating the Quality Experience CAHPS related patient experience questions 37
Goals for Incorporating the quality experience Discuss each Patient Experience Survey topic Consider new tips to improve the process Explore best practices and supporting materials Assess how each topic is incorporated into your practice - Are there internal and/or external obstacles to success? 3 8
Topic: Difficulty scheduling appointment
Best practices and materials: Difficulty scheduling appointment Patient experience no. 1: Did you experience any difficulty scheduling your appointment? Appointment reminder card issuing appointment reminder cards like this one, and scheduling a followup for the patient prior to the patient leaving the office, can ease appointment scheduling stress. Connect the day before the appointment Having your office staff reach out via phone call, text, email, patient portal, social media, and any other channel available will be a key to success in this area. 40
Topic: 15 minute wait time Patient experience no. 2: How long after your scheduled appointment time did you wait to see the person you came to see? Early arrival Triaging and staging Remind patients that they need to arrive 15 30 minutes prior to their scheduled appointment time to complete necessary paperwork. Triage patients within 15 minutes of scheduled appointment time, and take them back to the exam room early. PCP Staff Off peak scheduling Scheduling fewer patients Similar appointments Greeters Encourage patients to schedule appointments on days when your practice is less busy. Schedule fewer patients whenever possible, or factor in catch up time. Book similar tests and appointments on the same day, whenever possible, to keep appointment volume down. Incorporate greeters or experience guides to welcome patients and help them through the appointment process. 4 1
Topic: 15 minute wait time Patient experience no. 2: How long after your scheduled appointment time did you wait to see the person you came to see? Educational materials Surveys and assessments Make flyers, pamphlets, posters and other health education items available to patients. Hand out short surveys or assessments that could stimulate patient thinking on important health topics. PCP Staff Comfortable environment Entertainment Food and drink Office tips sheet Provide a clean, comfortable and visually appealing environment for patients to wait in. Keep board games, decks of cards, dice, checkers, chess, magazines, a television and similar entertainment in the waiting room. Place vending machines in the office or make healthy snacks, coffee and water available. Give your staff tip sheets about how to manage patient wait time expectations and how to improve patient perceptions. 4 2
Topic: 15 minute wait time Patient experience no. 2: How long after your scheduled appointment time did you wait to see the person you came to see? Patient portal Use an online system that allows patients to check in, communicates delays, and gives patients other relevant information. Patient Consider using aformortear off pad that enables patients to give feedback feedback about their waiting room experience. PCP Staff 43
Best practices and materials: 15 minute wait time Patient experience no. 2: How long after your scheduled appointment time did you wait to see the person you came to see? Comfortable environment Offer a neat, clean and comfortable environment to help thewaitgobyfaster. (South Florida practice) Food and drink Have a snack station available with free coffee and snacks for purchase in the waiting room. (South Florida practice) Educational materials Make informative, health related material available to patients while they wait. (South Florida practice) Triaging and staging Provide a comfortable, separate room for patients to wait in once they have been triaged. (South Florida practice) 4 4
Best practices and materials: 15 minute wait time Patient experience no. 2: How long after your scheduled appointment time did you wait to see the person you came to see? 15 minute wait time poster Use this poster to help the practice hold itself accountable to the CAHPS 15 minute wait time standard. Managing wait time slide Humana has a slide to advise practices on managing patient expectations about wait time. Greeters Employ a greeter or some other ambassador to make patients feel welcome and to help them navigate the process from check in through check out. (North Florida practice) 4 5
Best practices and materials: Specialist referral Patient experience no. 3: Did you have any trouble getting a referral to see a specialist from your personal doctor? Specialist appointment reminder Humana provides branded or unbranded specialist appointment reminder pads where you can write down information about any specialist follow up appointment needed. Connect the day before the appointment Having your office staff reach out via phone call, text, email, patient portal, social media, and any other channel available will be a key to success in this area. 46
Discussion: Getting care quickly, specialist referrals Topics to Address Difficulty scheduling appointment/15 minute wait time/specialist referrals Best practices Internal Biggest barrier to improvement Work flow or process issues that can be changed to aid in improvement Other possible issues in the practice environment Ways to improve going forward Humana Are there any Humanainfluenced process barriers? How can Humana help your practice improve these areas? Which Humana teams should be engaged? 4 7
Topic: Difficulty obtaining prescribed medications Mail order Patient experience no. 4: Did you have trouble with your prescription drug plan covering any medication your doctor prescribed? Pharmacy recommendation Consider whether mail order may be appropriate to improve adherence, convenience and possibly reduce medication cost. Ask if the patient has a convenient pharmacy that he or she already goes to. If the patient doesn t, try to recommend one. PCP Staff Formulary review Prior authorization Generic or equivalent Rx Copay Understand what is covered by the patient s Humana Part D plan. If prior authorization is required, call the pharmacy and do the leg work on the patient s behalf. Check to see if there is a covered equivalent medication that could be prescribed if the proposed medication is not covered or is high tier. Call on behalf of the patient to find out how much he or she will have to pay for a news prescription. 4 8
Best practice: Difficulty obtaining prescribed medications Patient experience no. 4: Did you have trouble with your prescription drug plan covering any medication your doctor prescribed? Pharmacy recommendation If there is a convenient pharmacy that your office can recommend, it could make things easier on the patient. This office had a pharmacy on site. (South Florida practice) 4 9
Topic: Difficulty getting tests or treatment Coverage Copay Patient experience no. 5: Did you have any problem getting approval through your health plan for any tests, care or treatment your doctor said you needed? Check to see if recommended treatments, tests or procedures are covered under the patient s plan. Check on the patient cost share for any recommended test or treatment. PCP Staff Treatment location Scheduling treatment Referral paperwork Setting expectations Help the patient identify where to receive any necessary follow up treatment or tests. Book follow up appointments for tests or treatment for patients before they leave the office. Complete and send any physician referral forms and justifications to the treatment center, and ensure patient has referral before leaving. Ensure patients understand that some specialty appointments are not urgent or emergent and that waiting a few weeks to be seen is OK. 5 0
Best practice: Difficulty getting tests or treatment Patient experience no. 5: Did you have any problem getting approval through your health plan for any tests, care or treatment your doctor said you needed? Coverage and copay check A quick call to the facility can avoid any negative patient experience pertaining to follow up procedure coverage and the patient s share of costs. This practice has a backoffice team dedicated to making calls. (South Florida practice) 5 1
Discussion: Getting medications, tests and treatment Topics to Address Difficulty getting prescribed medications/difficulty getting needed tests or treatment Best practices Internal Biggest barrier to improvement Workflow or process issues that can be changed to aid in improvement Other possible issues in the practice environment Humana Are there any Humanainfluenced process barriers? How can Humana help your practice improve these areas? Which Humana teams should be engaged? Ways to improve going forward 5 2
Topic: Review medications PCP Staff 5 3
Best practices and materials: Review medications Patient experience no. No. 6: 7: Did Didyour personal doctor talk seem about informed all of the andprescription up to date about medicines the care you yougot were fromtaking? specialists? Prescription bag Consider giving patients a prescription bag, so they can bring in all of the medications they are taking. Medication list Humana can provide a medication list form to help you assist patients in writing down their medications. Medication tracking apps Smart phone applications like Carezone and Medisafe are a great option for patients to electronically keep a list and track the specifics of their medications. 5 4
Best practices and materials: Review medications Patient experience no. 6: 7: Did your personal doctor talk seem about informed all of the andprescription up to date about medicines the care you yougot were fromtaking? specialists? Educational postcard Humana has educational material on the importance of patients reviewing medications with their physicians. Cards are mailed to your patients, but they can be provided to your practice as well, for use in the office. Medication discussion button Humana has a button that physicians can wear on their shirts reminding the patient to discuss medications they are taking with the physician. 5 5
Topic: Physician informed about specialist care Request records Patient experience no. 7: Did your personal doctor seem informed and up to date about the care you got from specialists? Close discussion loop Follow up with the specialist s office to ensure that any patient care results are sent to your practice. Discuss with patients the results of specialist appointments, treatment or procedures, and recommend next steps. PCP Staff Specialist reminder pads Educational postcards Patient chart notes Follow up visit expectations Encourage patients to keep tear offs to remind them of appointments leading up to the follow up visit with the primary care physician (PCP). Provide educational material to stress the importance of PCP patient conversations about specialist care results. Keep detailed records in patient charts about recommended specialist care and expected results, for review with patients. Clearly convey to patients that you want them in for a follow up (to discuss specialist care) within one month following the specialist visit. 5 6
Best practices and materials: Physician informed about specialist care Patient experience no. 7: Did your personal doctor seem informed and up to date about the care you got from specialists? Specialist appointment reminder pads Humana provides branded or unbranded specialist appointment reminder pads, which patients can keep to remind them of appointments and the need to follow up with their PCP about the results. Educational postcard Humana has educational material on the importance of patients discussing specialist care with their physicians. Cards have been mailed to your patients, but they can be provided to your practice as well, for use in the office. 5 7
Discussion: Coordination of care Topics to Address Review medications/physician informed about patient specialist care Best practices Internal Biggest barrier to improvement Workflow or process issues that can be changed to aid in improvement Other possible issues in the practice environment Humana Are there any Humanainfluenced process barriers? How can Humana help your practice improve these areas? Which Humana teams should be engaged? Ways to improve going forward 5 8
Incorporating the Quality Experience HOS related patient experience questions 59
Topic: Falls discussion Problem assessment Educational material Patient experience no. 8: Did your doctor or other health care provider talk to you about falling or problems with balance or walking? Assess severity of the issue through dialogue with the patient. Hand out questionnaires and materials to assist patients in evaluating theissueanditsseveritypriortoseeingthephysician. PCP Staff Tripping hazards Night light Educational media Physician button Advise patient to move or secure rugs, wires and other tripping hazards. Advise patient to use a night light to avoid falls in the middle of the night. Consider using visual media in the waiting room and computer screen savers in the exam room to help educate patients. Consider wearing buttons that encourage patients to discuss fall risk. 60
Best practices and materials: Falls discussion Patient experience no. 8: Did your doctor or other health care provider talk to you about falling or problems with balance or walking? Let s Talk Using this short questionnaire canhelpthe physician identify if the patient has fall issues and can aid in discussion of falls. Educational postcard Humana has educational material on fall risk. We will mail this postcard to Humana covered patients, but it can be provided to practices as well, for use in the office. Educational media For practices able to display educational slides, Humana has this fall risk slide for waiting room media screens. 6 1
Best practices and materials: Falls discussion Patient experience no. 8: Did your doctor or other health care provider talk to you about falling or problems with balance or walking? BFP button Humana has a button physicians can wear that prompts patients to talk about fall risk. Night light Discussing the importance of keeping high traffic areas well lit at night is extremely important. Patient doctor discussion poster Hanging this poster in the waiting room can help patients self assess their level of fall risk. Fall risk flyer Humana has this educational flyer available for patients to read while waiting for their appointment. 6 2
Topic: Falls treatment Patient experience no. 9: Did your doctor or other health provider suggest any treatment, such as using a cane or walker, having your blood pressure checked or having regular vision or hearing tests? PCP Staff Blood pressure Check the patient s blood pressure in sitting and standing positions. Vision test Evaluate the patient s vision or refer to a specialist who can assist further if necessary. Physical therapy Exercise Recommend physical therapy to rehabilitate weak muscles or bones that could make the patient prone to falling. Encourage patients in good health to strengthen bones and muscles through exercise. Referral Help patients schedule any follow up treatment required for this issue assistance before they leave your office. 6 3
Best practices and materials: Falls treatment Patient experience no. 9: Did your doctor or other health provider suggest any treatment, such as using a cane or walker, having your blood pressure checked or having regular vision or hearing tests? Specialist appointment reminder These sheets can help remind patients about any specialist follow up needed for treatment of fall related injuries. Patient doctor discussion poster This poster informs patients about the falls issue and treatment options to inquire about during physician discussion. 64
Topic: Bladder control discussion Problem level assessment Educational material Patient experience no. 10: Have you ever talked with a doctor, nurse or other health care provider about leaking of urine? Assess the severity of the issue through dialogue with the patient. Hand out questionnaires and other materials to help patients evaluate the issue and its severity prior to seeing the physician. PCP Staff Night light Educational media Physician button Advise patients to hang a night light to avoid falling if bladder issues cause them to hurry to the bathroom in the middle of the night. Consider using visual media displays in the waiting room and computer screen savers in the exam room to help educate patients. Physicians can wear buttons encouraging patients to discuss the topic of bladder control. 6 5
Best practices and materials: Bladder control discussion Patient experience no. 10: Have you ever talked with a doctor, nurse or other health care provider about leaking of urine? Let s Talk Using this short questionnaire canhelpphysiciansidentifyif bladder control is an issue for the patient and can aid in discussion. Educational postcard Humana has educational material on bladder control. This card will be mailed to your Humana covered patients, but it can be provided to your practice as well, for use in the office. Educational media For practices able to display educational slides, Humana has this bladder control slide for waiting room media screens. 6 6
Best practices and materials: Bladder control discussion Patient experience no. 10: Have you ever talked with a doctor, nurse or other health care provider about leaking of urine? BFP button Humana has a button physicians can wear on their shirts prompting patients to talk about urinary incontinence. Night light Have the patient hang a night light on the route to the bathroom in case they have to get up at night. Patient doctor discussion poster Hanging this poster in the waiting room can help patients self assess the severity of the issue, if one exists. Bladder control flier Humana has this educational flier for patients to read while they wait for their appointment. 6 7
Topic: Bladder control treatment Bladder exercises Bladder medication Patient experience no. 11: Did your doctor, nurse or other health care provider talk to you about ways to control or manage the leakage of urine? Discuss bladder strengthening exercises with the patient if he or she has a minor issue. Decide if medication is appropriate to treat the issue. PCP Staff Bladder products Bladder surgery Referral assistance Protective underwear, absorbent pads, or other bladder support products might be recommended in less severe cases. In more severe cases, bladder surgery may be recommended and referral assistance can be provided. Help patients schedule any follow up treatment required for this issue before they leave your office. 6 8
Best practices and materials: Bladder control treatment Patient experience no. 11: Did your doctor, nurse or other health care provider talk to you about ways to control or manage the leakage of urine? Specialist appointment reminder These sheets can help remind the patient about any specialist follow up needed to treat urinary incontinence. Patient doctor discussion poster This poster can help patients identify bladder control as an issue and learn about treatment options to inquire about during physician discussion. 6 9
Discussion: Fall prevention and bladder control Topics to Address Fall prevention/bladder control Best practices Internal Biggest barrier to improvement Other possible issues in the practice environment Ways to improve going forward Humana How can Humana help your practice improve these areas? Which Humana teams should be engaged? 7 0
Topic: Physical activity Exercise Patient experience no. 12: Did your doctor or other health care provider advise you to start, increase or maintain your level of exercise or physical activity? Advise patient to take on an appropriate level of exercise. PCP Staff Physical activity pads Gym or club membership Activities calendar Patient newsletter Physician button Write your exercise program recommendation on a tear off pad and encourage patients to take the note with them. Encourage patients to review any plan benefits that may allow him/her to join a gym, health club or other active group for a discount. Post a calendar and include any fitness related events offered at or near your office location. Send a newsletter to patients that mentions upcoming fitness or health events sponsored by your practice or the local community. Physicians can wear buttons encouraging patients to discuss physical activity with you. 7 1
Best practices and materials: Physical activity Patient experience no. 12: Did your doctor or other health care provider advise you to start, increase or maintain your level of exercise or physical activity? Activities calendar Some practices post monthly calendars that include fitness events coming up on site or in the community. (South Florida practice) Patient newsletter Newsletters can be sent to patients monthly or quarterly to inform them of upcoming health and fitness events. (North Florida practice) Gym or club membership Certain Humana MA plans offer Silver Sneakers or a similar benefit that gives seniors access to activity clubs or gym membership discounts. 7 2
Best practices and materials: Physical activity Patient experience no. 12: Did your doctor or other health provider advise you to start, increase or maintain your level of exercise or physical activity? BFP button Humana has a button physicians can wear on their shirts prompting patients to talk about physical activity. Physical activity prescription Humana can provide physical activity pads with sheets physicians can use to prescribe appropriate weekly activity regimens to patients. 7 3
Topic: Mental health discussion Patient education Patient experience no. 13: Has your doctor or other health care provider talked to you about your mental or emotional health or things like feelings of stress, depression, or anxiety? Provider information Mental health screens Educational material Discussion reinforcement Remind yourself that many patients need help understanding that emotional health is a part of their primary care. Consider using physician educational material provided by Humana and other organizations with subject matter expertise. Encourage patients to take mental health preassessments while they wait, to assist the physician during discussion. Give patients material that educates them on signs of depression or encourages them to be upbeat. Provide reinforcement once mental health has been addressed as a concern. PCP Staff 7 4
Best practices and materials: Mental health discussion Patient experience no. 13: Has your doctor or other health care provider talked to you about your mental or emotional health or things like feelings of stress, depression, or anxiety? Provider information Depression is difficult to recognize in patients and talk about with them. Humana offers materials, such as this one page flyer and detailed presentation, to support treatment of patients who may be depressed. Mental health screens Questionnaires (PHQ 2and PHQ 9) can help you assess a patient s emotional health. 7 5
Best practices and materials: Mental health discussion Patient experience no. 13: Has your doctor or other health care provider talked to you about your mental or emotional health or things like feelings of stress, depression, or anxiety? Let s talk Using this questionnaire can help the physician identify if emotional health issues, like depression or anxiety, are affecting the patient. Educational material Humana provides this mental health poster to encourage positive feelings and emotional health among patients. 7 6
Discussion: Physical activity and mental health Topics to Address Physical Activity/Mental health Best practices Internal Biggest barrier to improvement Other possible issues in the practice environment Ways to improve going forward Humana How can Humana help your practice improve this area? Which Humana teams should be engaged? 7 7
The next steps: Enhancing the patient experience Identify process changes and best practices needed to improve each area Identify people who are crucial to executing the new process Consider asking your Stars representative for assistance Setting up the appointment 15 minute wait time Specialist referral Getting prescribed medications Getting needed tests and treatments Review medications Fall prevention Bladder control Physical activity Mental health PCP informed about specialist care 7 8
Sources Medicare 2017, Part C & D, Star Rating Technical Notes HEDIS 2017, Volume 2, Technical Specifications for Health Plans The information in this presentation is not a complete or comprehensive description of HEDIS or the Stars program. The presentation serves as an introduction to HEDIS /Stars and corresponding clinical measures. 79