Transcript HEDIS Guidelines - UHCCommunityPlan.com

Care Providers and Quality Measures
August 11, 2015
Overview
• Annual Quality of Care Performance Measures
• Early and Periodic Screening, Diagnostic and Treatment
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(EPSDT) Requirements
HEDIS Guidelines
Documenting Anticipatory Guidelines
Monitoring and Improving Quality of Care
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Annual Quality of Care Performance Measures
Care Effectiveness
• Reduce gaps in quality of health care delivery
• Identify barriers to preventive care
Care Access and Availability
• Location of care providers in health plan service area
• Does the network provide multi-lingual care providers
• Are member cultural needs considered when creating the
network
Use of Service
• Quality measures indicating how health plans use physician
visits, hospital stays and other resources to care for
members identified having one of five chronic diseases:
cardiovascular disease, chronic obstructive pulmonary
disease (COPD), diabetes, hypertension and asthma.
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EPSDT Requirements
Early and Periodic Screening, Diagnostic and Treatment services
encompass a wide array of prevention, diagnostic and treatment services for
infants, children and adolescents under age 21 who are enrolled in Medicaid
and from low-income families.
Screening requirements include:
• Comprehensive health and development history assessment for
physical and mental health, and substance use disorders
• Comprehensive physical examination
• Immunizations, according to the pediatric vaccine schedule
established by the Advisory Committee on Immunization
Practices
• Laboratory testing, including blood lead screening if appropriate
for age and risk factors
• Health education and anticipatory guidance for children and
caregivers
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EPSDT Periodicity Schedule
States must establish a periodicity schedule for each type of EPSDT
screening to help ensure patients are receiving the following
age-appropriate services:
• Medical
• Vision
• Hearing
• Dental
Visit BrightFutures.org to view EPSDT periodicity schedules for
pediatric and adolescent members.
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HEDIS Guidelines: Immunizations/Well
Child Visits/Adolescent Well Visits
Pediatric Wellness Screenings
Well Child 0–15 months of age:
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At least six screenings before age 15 months
Well Child Ages 3–6 years:
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One visit annually beginning at age 3
Adolescent Well Care:
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Percentage of enrolled members ages 12–21 years who had at least one
comprehensive well-care visit with a PCP or an OB/GYN in the measurement year
Child and Adolescent Access to PCPs:
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Children 12–24 months and 25 months–6 years who had a visit with a PCP during
the measurement year
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Children ages 7–11 years and adolescents ages 12–19 years who had a visit with a
PCP during the measurement year or the year prior
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HEDIS Guidelines Continued
Lead Screening in Children:
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Percentage of children age 2 years who had one or more capillary or
venous lead blood test for lead poisoning by their second birthday.
Childhood Immunizations:
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Under age 2, complete immunization series and flu shot.
Immunizations for Adolescents:
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Percentage of adolescents age 13 years who had the following by
their 13th birthday:
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One dose of meningococcal vaccine and one tetanus
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Diphtheria toxoids and acellular pertussis vaccine (Tdap) or one
tetanus
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Diphtheria toxoids vaccine (Td)
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Anticipatory Guidelines Overview
Anticipatory guidelines are proactive health education and health-based
counseling services given to the patient during clinical visits, according to
the patient’s age.
Find more guidelines at BrightFutures.org or the Delaware Division of Medicaid and
Medical Assistance at dhss.delaware.gov/dhss/dmma/information.html.
1. Tobacco Free Living - discourage tobacco use or exposure
2. Preventing Drug Abuse and Excessive Alcohol Use - substance
abuse prevention
3. Healthy Eating - weight management and healthy nutrition
4. Active Living - weight management and physical activity
5. Injury and Violence-Free Living - healthy and safe lifestyles
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Anticipatory Guidelines Overview
6. Reproductive and Sexual Health - preconception/interconception
health, including pregnancy risks while using narcotics
7. Mental and Emotional Well-Being - stress management and
substance abuse prevention
8. Vaccines and Preventable Disease - healthy and safe lifestyles
9. Safe Environments - healthy and safe lifestyles, including a focus on
reduction of blood lead poisoning and infant sleep-related deaths
10.Take Charge of Your Health - how patients can be proactive in their
health and how to access a primary care provider
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Documenting Anticipatory
Guidance during a Well Visit
Requirements
• Anticipatory guidance should be a part of every exam and emphasized
during the patient’s annual wellness visit.
• Physical, developmental, mental health and other adult wellness and
EPSDT screening components give initial context for anticipatory
guidance and health education.
Documentation
• Document giving health education and age-appropriate anticipatory
guidance in patient record.
• Use an age-appropriate anticipatory guidance list to be checked or
circled for quick documentation.
• Document additional topics identified and discussed during visit in
patient’s health record.
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Scheduling EPSDT Appointments
Scheduling EPSDT Appointments
• The PCP initiates EPSDT outreach and follow-up care
• EPSDT appointments should be made within two weeks of the initial
patient request
• Care providers have 90 days to submit EPSDT encounters
• Contact the Provider Services Department for assistance: 800-600-9007
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HEDIS NCQA Guidelines for
Prenatal and Postpartum Care
HEDIS NCQA Quality of Care Measures for Prenatal and Postpartum
Care – what percentages are measured?
• The percentage of deliveries of live births between Nov. 6 of the year prior
to the measurement year and Nov. 5 of the measurement year
• Timeliness of Prenatal Care
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The percentage of deliveries receiving a prenatal care visit:
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as a member of the organization in the first trimester or
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within 42 days of enrollment in the organization.
• Postpartum Care
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The percentage of deliveries having a postpartum visit on or between 21 and
56 days after delivery.
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HEDIS NCQA Guidelines for
Prenatal and Postpartum Care
How can care providers help improve quality of care measures and
increase percentages according to HEDIS NCQA quality of care
measures for prenatal and postpartum care?
• Set up an appointment reminder system for prenatal and postpartum
visits.
• Remind patients to return for their prenatal and postpartum
appointments.
• Take extra measures to remind patients who had a cesarean
section to return for their postpartum visit.
• Contact Member Services to refer members who miss appointments
to the member advocate for intervention: 877-877-8159
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HEDIS Guidelines for Chronic
Disease Populations Overview
HEDIS Guidelines for Chronic Disease Populations
• Comprehensive Diabetes Care
• Controlling High Blood Pressure
• Medication Management for Individuals with Asthma
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Comprehensive Diabetes Care
Adults ages 18-75 with Type 1
Event/Diagnosis
and 2 Diabetes
Individual identified as diabetic during
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Hemoglobin A1c (HbA1c) testing
or prior to the measurement year:
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HbA1c poor control (>9.0%)
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At least two outpatient visits
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HbA1c control (<8.0%)
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At least one acute inpatient
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HbA1c control (<7.0%) for a
selected population
encounter
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HEDIS data collection methods:
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Eye exam (retinal) performed
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Medical attention for nephropathy
• Insulin
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Blood Pressure control (<140/90
• Hypoglycemics/
mm Hg)
antihyperglycemics
Pharmacy data
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Controlling High Blood Pressure
Overview
Controlling High Blood Pressure
• Percentage of adult enrollees ages 18 to 85 who had a diagnosis of
hypertension and whose blood pressure was adequately controlled
(< 140/90) during the measurement year
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For the Medicaid Adult Core Set, states calculate and report this measure
for two age groups:
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Ages 18 to 64
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Ages 65 to 85
HEDIS data collection methods: Hybrid only
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Medication Management
for Individuals with Asthma
Members ages 5 to 85 years who:
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were diagnosed with persistent
asthma
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were dispensed appropriate
medications
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Event/Diagnosis
• Primary diagnosis of asthma
• At least one acute inpatient
remained on appropriate dispensed
encounter
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two asthma medication dispensing
medications during the treatment
period.
Two rates are reported:
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events
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At least four asthma medication
dispensing events
Percentage of members remaining
on an asthma controller for 50% of
At least four outpatient visits and
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HEDIS data collection methods:
their treatment period
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Pharmacy
Percentage of members remaining
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Encounter data
on an asthma controller medication
75% of their treatment period
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Monitoring and Improving
Quality of Care
The Quality Improvement program tracks certain plan of performance to
assess the quality, adequacy and appropriateness of health care resources.
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Accessibility of providers
Provider availability
Member and provider satisfaction with plan services
Credentialing/re-credentialing standards
Provider adherence to clinical practice guidelines
Preventive health services
Continuity and coordination of care process
Access to member services
Quality of care issues
Patient safety
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Quality Initiatives: Member Health Education
Adults, Children and Teen Wellness Visits
Reminders Including:
• EPSDT Screening Communication
• Immunization and Lead Screening Reminder
Cards
• Flu Shot Campaign
• Diabetes Mailers and Education
• Pregnancy and Postpartum Mailers, Outreach
Calls
• Provider and UnitedHealthcare Cobrand
Collaborative Initiative
• Outreach calls
• Letters
• Case Management
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Quality Initiatives: Healthy Rewards
Healthy Rewards
• Individuals with diabetes can earn gift
cards for taking steps to control their
disease by getting:
• HbA1c and LDL tests
• A dilated retinopathy exam
• Attending diabetic education classes
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Quality Initiatives: Clinic Day Program
Clinic Day Program
• A high-touch member outreach and
intervention program to help:
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Increase HEDIS rates for all
members receiving annual
preventive care services;
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Decrease member no-show
appointments; and
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Increase compliance with HEDIS
measures.
• Pre-scheduled days with provider office
for preventive pediatric and adult visits.
• Members receive incentives to complete
preventive visits and screenings.
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