Provider Manual  

Section 5
Case Management / Reporting Responsibilities

Table of Contents
5.
Case Management/Reporting Responsibilities
5.1
Case Management Definition, Objectives, Responsibilities (Including Health Assessment and Screening)
5.2
Plan Utilization Management Program
5.3 Quality Management Plan/Quality Assurance and Improvement
5.4 Coordination of Care Policies
5.5 Long Term Care, Discharge Planning
5.6 Emergency Services Notification
5.7 Records and Reporting Responsibilities
5.8 Member Delete Procedure
5.9 Appointment No-Show Follow-Up Procedures
5.10 Administrative Member Request
Attachment A 
Adult Preventive Care and Childhood Preventive Care
Attachment B 
Quality Management Plan / Quality Assurance and Improvement
Attachment C 
Quality Based Incentives and Definitions
   
5. Case Management/Reporting Responsibilities

5.1 Case Management Definition, Objectives, Responsibilities
         (Including Health Assessment and Screening)

5.1.a Definition of Case Management                               top

The California Department of Health Services defines case management as “Guiding the course of resolution of a personal medical problem (including the ‘problem’ of the need for health education, screening or preventive services) so that the recipient is brought together with the most appropriate provider at the most appropriate times, in the most appropriate setting.”

Five requirements are necessary for the case management system to function.  These are as follows:

5.1.b Objectives                                         top

The objectives of physician case management of Member medical care are as follows:

5.1.c Primary Care Physician Responsibilities                   top

The responsibilities of Primary Care Physicians are as follows:

5.2 Plan Utilization Management Program                    top

Policy Objective:

Provide an overview of the Central Coast Alliance for Health Utilization Management Program.  All Alliance utilization management policies are included in this manual on compact disc, located in the binder pocket of this manual.

5.2.1 Purpose

Central Coast Alliance for Health’s Utilization Management (UM) Program oversees the delivery of health care services rendered to its member population.  The program is designed to ensure that utilization issues are identified, documented, and reviewed and that appropriate improvement plans are initiated to address utilization problems in a consistent and timely manner.  The Program implements measures to monitor the health care services delivered to members, identify issues which impact service and quality, improve health care outcomes, and resolve problems and recommend action plans.  The UM Program will:

5.2.2 Goals and Objectives                                               top

5.2.3 Scope                                                                     top

The Utilization Management Program is comprehensive, systematic and ongoing.  It includes all aspects of health care, encompassing all services and practitioners who have direct impact on patient care.  It includes reviews of health care services in the inpatient, outpatient, skilled nursing, and pharmacy settings.

5.2.4 Functions                                                                top

5.2.5 Authority and Responsibility                                   top

Central Coast Alliance for Health’s Medical Director and Associate Medical Director have the authority and responsibility to ensure that an effective UM Program is established, supported and maintained.  The Medical Director or Associate Medical Director are the only individuals who may deny service authorization requests. Authorization decisions are based upon nationally recognized standards including:

5.2.6 Utilization Management Process                              top

5.2.7 Review Activities                                                     top

5.3 Quality Management Plan/Quality Assurance and Improvement   top

The Central Coast Alliance for Health (the Alliance) is a public agency established to enter into contracts with:

The Alliance is dedicated to improving the health and well being of the residents of our region.
Our mission is to:

The Alliance has established a comprehensive Quality Management Program (QMP) for all of its quality assurance and quality improvement activities.  The Health Services Policy Quality Management Program (QMP) provides a more detailed description of the QMP, including: Program Oversight and Implementation Reviews and Approvals QMP Goals and Objectives Scope of Care Systematic Processes Quality Improvement (QI) Staff Role Definitions 

The Annual Quality Improvement Plan (AQIP) outlines activities for the year and provides a key element in implementing our overall QMP to both assure and improve quality.

Please see Attachment B of this section for an outline of our 2005 Annual Quality Improvement Program (AQIP).

5.4 Coordination of Care Policies                                   top

5.4.1 Mental Health and California Children’s Services

A Memorandum of Understanding (MOU) is an agreement between the Alliance and a division of the County Health Services Agency that delineates how the two entities will coordinate provision of covered services (for both Medi-Cal and Healthy Families recipients) and/or public health services, as appropriate, and which delineates the roles and responsibilities of each agency related to specific public health services.

Public Health Services with MOUs

The Alliance maintains MOUs with the following divisions of the Santa Cruz County Health Services Agency and Monterey County Health Services Department.

5.4.2  Members with Developmental Disabilities               top

In accordance with MMCD Letter 97-03, the health plan provides medically appropriate services to members who have or are suspected of having a developmental disability and members who are at high risk of parenting a child with a developmental disability.  The plan also collaborates with the San Andreas Regional Center and Local Education Agencies for delivery of services to members with developmental disabilities.

The Alliance provides members identified or suspected of having developmental disabilities with all medically necessary and appropriate developmental screenings, primary preventive care, diagnostic and treatment.  The plan has the authority to determine medical necessity for covered services.  Members requiring medically necessary but “carved out” services are referred to the appropriately funded agency, such as the Local Education Agencies (LEA) and the San Andreas Regional Center (SARC). 

Members with developmental disabilities are linked to Primary Care Providers (PCP).  PCPs provide members with all appropriate preventive services and care including necessary EPSDT services.  Preventive care is provided per the current guidelines of American Academy of Pediatrics and the United States Preventive Services Task Force for Adults.

Referrals

Specialty Referrals

Case Management 

Dispute Resolution

5.5 Long Term Care, Discharge Planning                       top

When a provider is discharging a member to a Long Term Care (LTC) facility the Discharge Planner should:

The admitting LTC needs to notify the Alliance by submitting the MC 171 (LTC Admission and Discharge Notification Form).  Depending on the date of notification, one of the following will occur:

When a member is admitted and discharged from long term care, the facility will send the Alliance the MC 171 form.  Member Services Department Staff will relink the member to a Primary Care Provider, who will assist the member in selecting or continuing care with a PCP.

LTC facilities are state mandated to inform the Alliance of admissions to a nursing facility on an MC-171 form and through a LTC Treatment Authorization Request (TAR).

Discharges from Mental Health Units to State licensed Skilled Nursing Facilities require prior authorization.  Discharges to IMDs or locked facilities will need authorization from the member’s county Mental Health Agency.

5.6 Emergency Service Notification                               top

5.7 Records and Reporting Responsibilities                   top

Maintenance of Records

The Alliance requires that you maintain records regarding services that you provide to Alliance members.  Records should be maintained in accordance with applicable state and federal privacy laws.  The Alliance has the right to review your records for claims authorization, service authorization and when we are performing medical audits.

Records should be maintained in a manner consistent with professional practices and prevailing community standards.

You are to maintain records for the shorter of seven (7) years after termination of your agreement with the Alliance and, the period of time required by state and federal law and Membership Contracts, including the period required by the Knox Keene Act and Regulations, and by the Medicare and Medi-Cal programs.

Access To and Copies of Records

Health Services staff from Central Coast Alliance for Health may request records from your office for one of our covered members for a number of reasons:

For the above purposes, The Alliance may obtain medical records for our covered members without a signed release of information pursuant to the following legal authority:  Title 22, Section 51009, adopted from the Welfare and Institutions Code Section 14100.2.

Your contract indicates that the Alliance, government officials and accrediting organization shall have access to your records.  The first copy of records provided to the Alliance is to be provided at no cost.  Each copy provided thereafter will be reimbursed at five cents (.05) per page.

In addition, you are contractually required to provide access to and copies of records to various government officials as stated in your agreement.  Such information shall be available for inspection, examination and copying at all reasonable times at your office or at some other mutually agreeable location in California.  Copies of such information shall be provided to Grover Officials promptly upon request.  The disclosure requirement includes, but is not limited to, the provision of information up request by DHS relating to any pending litigation.  

Copies of Clinical Information

When you see a member who is not linked to your practice you are required to forward a copy of the initial consultation report and summary of patient care to the Member’s Primary Care Physician, at no cost.  You may do this by mail or by fax.

Reporting Encounter Data

Encounter Data are detailed data about individual services provided by a capitated managed care entity.  The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims".

Confidentiality of Information

The names of Members receiving public social services are confidential and are to be protected from unauthorized disclosure.  This includes all information, records and data collected and maintained for the operation of the Agreement.

Alliance contracted providers are not to use any such information for any purpose other than carrying out the terms of their agreement.  In compliance with the HIPAA regulations, Members are entitled to an accounting of any disclosure of information.

5.8 Member Delete Procedure                                       top

Please review the following Alliance guidelines prior to submitting your Request For Deletion of Patient From Case Management List form:

5.8.1 Make Sure You Have An Appropriate Reason To Request A Deletion

Appropriate reasons to delete a patient:

The most common problems that lead a physician to need to delete a patient from Case Management are listed below:

Inappropriate Reason to Delete a Patient

Physicians cannot delete patients simply because they are very sick and have a diagnosed condition which would be difficult to manage or would adversely affect the PCP risk pools.  To allow such shifting of patients is neither good medicine nor in the interests of any participating physician.  It also defeats the goal of the Alliance Plan to spread actuarial risk across all PCPs and provide continuity of care to Alliance members.

5.8.2 Filling out the Delete Request Form                         top

A Deletion Request Form must be completed for each member you are deleting (deleting one person from a family does not automatically delete the entire family).  The Deletion Request Form is designed to allow a narrative description of the events leading to your request.  Be sure to give the specific information (e.g., dates of missed appointments or an explanation of a patient’s abusive behavior) as well as your efforts to correct the problem with the patient.  Your request may be delayed or denied without specific information and/or documentation about the circumstances which led to the request.

In Section 7 - Forms, of this manual, you will find a copy of the Deletion Request Procedure and forms to be used when requesting the deletion of an Alliance Member from your Case Management List.

5.8.3 Where to Send the Delete Request Form                 top

Facilitation of the Delete Request Form is the responsibility of the Provider Services Department at the Alliance.  Please send your Delete Requests to:

For Santa Cruz County For Monterey County
Provider Services Department Provider Services Department
Central Coast Alliance for Health Central Coast Alliance for Health
1600 Green Hills Road, Suite 101 1000 S. Main St., Suite 313
Scotts Valley, CA  95066 Salinas, CA  93901
or FAX to Provider Services at (831) 430-5857 or FAX to Provider Services at (831) 755-8226

5.8.4 Effective Date of Deletion                                        top

If your request is approved, typically the effective date of the member deletion is the first day of the month following the date your request is approved and processed by the Alliance.  However, the Alliance may determine a later effective date to allow adequate time for internal processing and for contacting the member so that he/she may select another Primary Care Provider:

5.8.5 Processing of your Request                                     top

Processing of your Delete Request involves the following basic steps at the Alliance:

5.8.6 What To Do While You’re Waiting For The Deletion To Become Effective    top

The member will remain linked to your practice until the effective date indicated in the letter you receive from Provider Services.  Until that date, you are required to ensure access to care either by providing it yourself or referring the member out to another provider via the Referral Authorization Form (RAF).  In addition, you are responsible for authorizing any specialty care services that the member may require until the effective date of the delete.  

Important Note: The Alliance is accountable to State and Federal regulatory agencies to ensure that physicians do not terminate care to patients inappropriately.  Alliance members have the right to file a formal complaint or grievance if they perceive they were treated unfairly.

5.9 Appointment No-Show Follow-Up Procedures        top

The purpose of the form, found in Section 7 of this Provider Manual, is to provide a mechanism for physicians to notify the Alliance of missed appointments in an effort to preserve the physician/patient relationship; assist physicians with patient compliance and empower members to be responsible and to participate in their own health care.

When an Alliance member misses an appointment with your office, without calling to cancel or reschedule, complete the form and forward it to the Alliance by fax or mail to:

For Santa Cruz County For Monterey County
Provider Services Department Provider Services Department
Central Coast Alliance for Health Central Coast Alliance for Health
1600 Green Hills Road, Suite 101 1000 S. Main St., Suite 313
Scotts Valley, CA  95066 Salinas, CA  93901
or FAX to Provider Services at (831) 430-5857 or FAX to Provider Services at (831) 755-8226

The Alliance Member Services staff will attempt to contact the patient and educate them about the importance of keeping their scheduled physician appointments.

The Alliance will document their efforts on the form and return it to your office to file in the patient’s chart.

Important Note: This procedure is intended to be used in conjunction with, not in place of, your current office policy for missed appointments.  The Alliance contract requires that the Primary Care Physician establish procedures to contact members when they miss appointments which require rescheduling.

In Section 7 - Forms, of this manual, you will find a copy of the form to be used when reporting that an Alliance Member from your Case Management List has missed an appointment.

5.10 Administrative Member Request                            top

The Alliance assigns Administrative Member status to Medi-Cal members whose service needs are such that inclusion in the Alliance capitated case management system would be inappropriate.  Assignments to administrative member status may be based on either the members’ medical condition or administrative eligibility status.  To maximize the patient-provider relationship and to coordinate care, administrative members are encouraged to select and identify a Primary Care Provider (PCP).  Services for administrative members will be paid on a fee-for-service basis based upon prevailing Medi-Cal rates.  The TAR system is in place for all Alliance services that require the use of a TAR.

In Section 7 - Forms, of this manual, you will find a copy of the form to be used when requesting the Administrative classification of an Alliance Member from your Case Management List.

Attachment A                                                               top

Adult Preventive Care
Childhood Preventive Care

I. Adult Preventive Care Policy Objective

To establish guidelines for Adult Preventive Care Screening.

To specify and define the Alliance guidelines for adult health screening and preventive services provided by primary care physicians, as recommended by:

II. Definitions:

1. These guidelines address periodic health and behavioral risk screening and preventive services for asymptomatic adults.

2.  Individuals identified as being at high risk for a given condition may require screening at intervals that are more frequent or performing additional screening tests specific to the condition.  High-risk individuals are defined as those individuals whose risk behaviors:  family history, socioeconomic status, ethnic background, or lifestyle are associated with a higher tendency towards a specific disease.

3. Any required interventions are considered to be an integral component of primary care, and consequently, the compliance of each PCP in performing these may be audited by the Alliance annually.  These required interventions are in bold (see below).  All other interventions are considered recommended and constitute good clinical care, but not required by the Alliance and are not considered an audit criteria.

III. Content of Screening Visits:

A. PCPs must complete a comprehensive health assessment including a health history, health behavior risk assessment, and physical examination for each new member linked to their practice within 120 days of enrollment.

1. The member’s health history must include information concerning: current and past medical conditions and medications; allergies; tobacco, alcohol, and street drug use; adult immunizations; past hospitalizations and family health history.
2. The health behavior risk assessment must include at least those items contained within the age-specific recommendations of the USPSTF.
3. The physical examination should be comprehensive and include determination of height, weight, blood pressure, dental screening, and other age and risk-specific interventions.
4. The comprehensive health assessment should include documentation of WIC referral for all WIC eligible members (pregnant, breastfeeding, or postpartum women).

B. If a member has not been seen for an initial health assessment visit or for periodic health screening visits, the PCP should either perform the indicated screening, behavioral risk assessment, and preventive interventions during episodic visits, or recommend that the member schedule a visit for the purpose of health screening.

C. If a new member to a PCP’s practice has received health-screening services from another provider within the past 3 years, medical records should be requested and transferred to the new PCP.

D. If the member is an already established patient of a PCP before becoming a member AND has had a screening examination within the past 12 months, no initial health assessment is required. 

IV. Documentation:                                                              top

Preventive services offered and/or performed as well as health education provided either verbally or in writing must be documented in the member’s medical record.  Optimally, this information should be entered on an age-specific summary sheet, so that completed and still needed services can be monitored efficiently.

V. Monitoring and Quality Improvement:

As part of the ongoing audit of medical records and state and federally required quality improvement initiatives, documentation of adult preventive health services is periodically reviewed.

PREVENTIVE Health Screen Items

INTERVENTIONS/RECOMMENDATIONS

REFERENCE

Health/Risk Assessment Database

Initial entry into the health plan
Schedule health assessment within 120-days of enrollment) 

USPSTF
DHS

     
History and Physical, Dental Screening Age 18-21:  every year
Age 22-39:  every 3-5 years
Age 40-64:  every 3 years
Age >65:  at the discretion of the clinician

USPSTF

     

Height/Weight

Initial entry into health plan periodic height and weight measurements are recommended for all patients, e.g. use BM
Frequency for measuring height and weight is at the discretion of clinician.

USPSTF

     

Dental Screening

Documentation of Dental Screening (and dental referral if indicated)
Dental screening is a required component of the comprehensive exam at the Initial Health Assessments and all subsequent preventive care examinations.

DHS

     

TB Testing

Initial entry into health plan, and repeat testing at regular intervals depending on the degree of risk of exposure, as determined by locally generated data.  

DHS

     

Blood Pressure

Initial Entry into Health Plan
Routine Adult Patients – blood pressure should be measured every 1 to 2 years.
Normotensive patients should have blood pressure measurements at least yearly if any of the following pertains:

1. Diastolic blood pressure between 85* and 89 mmHg
2. African-American heritage
3. Moderate or extreme obesity
4. A first-degree relative with hypertension
5. A personal history of HTN.

*JN VII recommends annual BP measurement for diastolic BP between 80 and 89 mmHg and systolic BP 120-139 mm Hg.  USPSTF has not yet adopted these guidelines.  Use of JN VII is at the provider’s discretion.

ACP
JNC VI
JN V II

 

FEMALE PATIENTS

 
Clinical Breast Exam

Clinical Breast Exam:  Annually for women age >19yrs per clinician discretion   There is insufficient evidence to recommend annual CBE alone to screen for breast cancer.

Self Breast Exam teaching and review:  Annually for women >19yrs per clinician discretion.  There is insufficient evidence to recommend annual BSE alone to screen for breast cancer.

USPSTF 

     

Mammography

Routine patients: Ages >40 yrs: every 1 to 2 years 

High-Risk Women: Women with a family history of premenopausally diagnosed breast cancer in a first-degree relative should have mammography regularly beginning at clinician’s discretion.

USPSTF

     

Pap Smears

Routine patients:  all women should begin having Pap tests every 1-3 years within 3 years of onset of sexual activity or at 21 years of age, whichever occurs first. 

Because sensitivity of a single Pap test for high-grade lesions may only be 60% to 80%, most organizations in the U.S. recommend that annual Pap smears be performed until a specified number (usually 2-3) are cytologically normal before lengthening the screening interval.

Older Women: The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer.

Women at increased risk for cervical cancer:  Screen every 2 years with initial screening tests done as frequently as annually for two or three examinations to ensure diagnostic accuracy.

Post-hysterectomy:  The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.

USPSTF

     

Chlamydia Screening

Annual screening for sexually active females age <26 years and other asymptomatic women at increased risk for infection.

USPSTF

     

Osteoporosis Screening

All women aged 65 years and older should be screened routinely for osteoporosis.

Routine screening should begin at age 60 for women at risk for osteoporotic fracture.

Among different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites.  Other technologies for measuring peripheral sites include quantitative ultrasonography (QUS), radiographic absorptiometry, single energy x-ray absorptiometry, peripheral dual-energy x-ray absorptiometry, and peripheral quantitative computed tomography.

No studies have evaluated the optimal intervals for repeated screening.  Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeated screening to identify new cases of osteoporosis.  Yield of repeated screening will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture. 

There are no data to determine the appropriate age to stop screening and few data on osteoporosis treatment in women older than 85.  Patients who receive a diagnosis of osteoporosis fall outside the context of screening but may require additional testing for diagnostic purposes or to monitor response to treatment.

 
  MALE PATIENTS  
PSA PSA testing is at the discretion of the clinician. USPSTF
     
Abdominal Aortic Aneurysm (AAA) A one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography is recommended for all men aged 65 to 75 who have ever smoked. USPSTF
  ALL PATIENTS  
Cholesterol

Routine:  Periodic screening for lipid disorders is recommended for all men >35 years of age and women >45 years of age. The appropriate interval for periodic screening is not known.  Screening for lipid disorders should include measurement of total cholesterol and HDL.

Young Adults (men aged 20-35 and women aged 20-45): These young adults should be screened if at high-risk for coronary heart disease. Risk factors include:

  • Family history of very high cholesterol
  • Premature CHD in a first-degree relative (before age 50 in men or age 60 in women)
  • Diabetes
  • Smoking
  • Hypertension
USPSTF
     
Stool Occult
Blood/
Endoscopic
Evaluation of
Colon

All men and women 50 years of age or older should be screened for colorectal cancer.  Potential screening options for colorectal cancer include home FOBT, flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema.  The choice of specific screening strategy should be based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up.  The optimal interval for screening depends on the test.  Annual FOBT offers greater reductions in mortality rates than biennial screening but produces more false-positive results.  A 10-year interval has been recommended for colonoscopy on the basis of evidence regarding the natural history of adenomatous polyps.  Shorter intervals (5 years) have been recommended for flexible sigmoidoscopy and double-contrast barium enema because of their lower sensitivity, but there is no direct evidence with which to determine the optimal interval for tests other than FOBT.  Case-control studies have suggested that sigmoidoscopy every 10 years may be as effective as sigmoidoscopy performed at shorter intervals.  

Expert guidelines exist for screening very high-risk patients, including those with a history suggestive of familial polyposis or hereditary nonpolyposis colorectal cancer, or those with a personal history of ulcerative colitis.  Early screening with colonoscopy may be appropriate, and genetic counseling or testing may be indicated for patients with genetic syndromes.

1There is insufficient evidence to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal exam (DRE).

AAFP USPSTF
     
Depression

Adults should be screened for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.

Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]). 

There is little evidence to recommend one screening method over another, so clinicians can choose the method that best fits their personal preference, the patient population served, and the practice setting.

The optimal interval for screening is unknown.  Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (e.g., panic disorder or generalized anxiety), substance abuse, or chronic pain

USPSTF
     
Diabetes Mellitus, Type II All patients with hypertension or hyperlipidemia should be screened for diabetes mellitus.  The optimal screening interval is not known. USPSTF
     
Patients with stable Diabetes Mellitus (Juevenile or Adult Onset)
  • Foot examination annually (using visual examination and a Semmes-Weinstein monofilament)
  • Hemoglobin A1C

Perform the A1C test at least two times a year in patients who are meeting treatment goals ( and who have stable glycemic control) and quarterly in patients whose therapy has changed or who are not meeting glycemic goal.

  • Urine micro albumin
    • Type 1:  5 years post diagnosis, then every year
    • Type 2:  begin at diagnosis, then every year
  • Dilated Retinal examination by a trained expert
    • Type 1:  Initial dilated and comprehensive eye exam by a trained expert within 3-5 years after the onset of diabetes and annually thereafter.
    • Type 2:  Initial dilated and comprehensive eye examination by trained expert shortly after the diagnosis of diabetes and annually thereafter.
  • Test for lipid disorders at least annually and more often if needed to achieve goals
ADA

VI. Childhood Preventive Care Policy Objective                       top

To establish guidelines for Childhood Preventive Care Screening.

To specify and define the Alliance guidelines for periodic health screening and preventive health services for members up to 21 years old provided by primary care providers. The Alliance uses the current American Academy of Pediatrics (AAP) preventive health care recommendations and well care periodicity schedule, as well as the ACIP/AAP immunization schedule, in formulating plan specific standards and guidelines. Since all Alliance primary care providers who care for Medi-Cal children are expected to be enrolled as CHDP providers, all other CHDP policies related to the provision of pediatric preventive services are applicable as well.

A. The following standards and guidelines address periodic health screening  and preventive services for low risk, asymptomatic children and adolescents. Individuals identified as being at high risk for a given condition may require screening at intervals that are more frequent or the performance of additional screening tests specific to the condition. High-risk individuals are defined as those individuals whose risk behaviors, family history, socioeconomic status, ethnic background, or life style is associated with a higher tendency towards a specific disease.

B. PCPs who provide periodic health screening to members under the age of 21 years old must adhere to the periodicity and content of the current AAP “Periodicity Schedule for Health Assessment Requirements by Age Groups”, as included in attachment 1.

C. In addition to the content of the AAP guidelines, certain CHDP required interventions must be provided as well. At each periodic health-screening visit, these include:

a. Comprehensive health and developmental history, including assessment of both physical and mental health development.
b. Assessment of nutritional status and screening for obesity.
c. Dental screening, including inspection of the mouth, teeth, and gums. PCPs must refer children to a dentist annually, starting at age three.
d.Tobacco smoking history or exposure:

D. PCPs must endeavor to complete an initial health assessment within 90 days of assignment to the practice (and within 120 days of enrollment as an Alliance member) unless it has been determined by the PCP practice that the member’s medical records contain complete and current information consistent with the health assessment criteria stated above. 

E. Immunizations must be provided according to the current schedule of the Advisory Committee on Immunization Practices (ACIP), AAP, and the American Academy of Family Physicians (AAFP), as provided in “Recommended Childhood Immunization Schedule,” attachment 2.

a. When immunizations are provided at sites other than the PCP’s office, the provider should notify the PCP’s office of the immunization given and the date.
b. If this is not possible, the member or parent/guardian of the member must be advised to provide this information to the PCP at the next visit. 
c. PCP office should be requesting previous medical record(s) to show a complete history.

F. Unless the member has received a periodic health screening (well visit) within the periodicity schedule, in attachment 1, the member, or the member’s parent/guardian, must be informed at the time of each non-emergency primary care visit of the availability of  well visits available through the PCP’s practice, or at another site offering  well visits .

a. This requirement may be met through the provision of the Alliance document Recommendation’s for Preventive Pediatric Health Care” in attachment 1, or by providing a document of equivalent content.
b. Should the member not receive periodic health screening services according to the attached schedule, either:
1. The voluntary refusal of the member (or the parent/guardian) regarding the use of  well visits should be documented in the member’s medical record, or:
2. There should be documentation of an outbound phone call or written communication from the provider to the member advising of the need to schedule a periodic health screening appointment.
c. In the case where a child scheduled for a periodic health screening visit is not seen as scheduled, the PCP’s staff should contact the member (or parent/guardian) to reschedule the visit, and document same in the medical record.

G. PCPs must schedule appointments for preventive services no later than 6 weeks from the point that the member or parent/guardian, or the County CHDP office, requests the appointment.

H. Diagnosis and treatment of any medical conditions identified through the periodic health screening process, either by the PCP or through referral to a specialist, must be initiated within 60 days of identifying health assessment appointment.  Justification for delays beyond 60 days must be entered into the member’s medical record. 

I. Providers must enter their findings in the member’s medical record and complete the CHDP PM 160 Form (for Medi-Cal members) It is not acceptable to use the PM-160 form as the sole medical record of the visit.

a. For CHDP clients, a copy of the PM 160 form must be given to the member or parent/guardian after completion of the visit. Upon request by the member, or the parent/guardian of the member, the PCP must provide additional discussion or consultation regarding the results of the health assessment.
b. Completed PM-160 forms must be submitted to the Alliance within 60 calendar days of the member’s visit. 

J. Parents of children found to have conditions which could constitute eligibility for the California Children’s Services (CCS) Program should be so informed. The PCP’s staff should initiate a referral to the county CCS office, regarding the finding of a potentially eligible child.

K. Documentation of Women, Infant and Children Program (WIC) referral or participation must be made for all eligible children (i.e. children under the age of five years) at the initial IHA and at subsequent well visits.

L. Monitoring and Quality management

a. Reports of encounter data will be reviewed periodically by the Alliance Quality Management staff for appropriateness and timeliness of child and adolescent preventive care services.
b. As a component of the ongoing audit of medical records in each PCP’s practice, documentation of children’s preventive services will be reviewed periodically.

Central Coast Alliance for Health
Guidelines for Pediatric Preventive Care
                                                         top

 

AGE IN YEARS

REFERENCE

Initial Health Assessment

Schedule within 120 days of Alliance enrollment

DHS

     

Well Baby Care

PHN post-partum mother-baby home visit (week 1)
Well Visit at 2-4 weeks, months 2, 4, 6, 9, 12, 15, 18
Well visit includes documentation of:

  • Full physical exam (with ht, wt, and OFC)
  • Health and Developmental history
  • Anticipatory Guidance

Breastfeeding support svcs. (rec. up to 1 year of age)

DHS
AAP

     

Well Child and Adolescent Care

Annual Well Visit for ages 2-20 years: document:
1. Full physical exam
2. Health and Development/Risk Behaviors
3. Anticipatory Guidance and Education

AAP

     

Dental Health

Dental Screening at each Well Visit.
Address preventive dental care as part of anticipatory guidance.  Document of dental screening at each well visit, and dental referral if indicated.

AAP

     

Obesity Prevention

Calculate and plot BMI annually in all children and adolescents.  See http://www.cdc.gov/growthcharts.  Screen for excessive weight gain relative to linear growth.
Address dietary behavior and exercise.

AAP

     

Immunizations

Per current CDC guidelines www.cdc.gov/nip/recs/child-schedule.htm#printable

AAP
ACIP

Lead Test

Blood lead test for all member at 12 and 24 months.
Lead prevention education, including nutrition.

DHS
AAP

     

Blood Pressure

At age 3, at each subsequent well child visit or at least annually. 

AAP

     

Pelvic Exam

Offer for all females at well visits beginning at age 18.  Annual screen for sexually active teens beginning at onset of sexual activity.

USPSTF
AAP

     

STD Screening

Annual STD screen for sexually active teens.

USPTF
AAP

     

Vision

Subjective screening at well visits 0-35 months
Objective screening at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years.

AAP

     

Hearing

Neonatal Hearing Assessment
Subjective screening at well visits 0-47 months
Objective Screening at 3, 4, 5, 6, 8, 10, 12, 15, and 18 years.

AAP

     

TB Skin Test

TB Risk assessment at all well visits.
PPD screen at 4-5 years, 13-16 years, or if indicated by TB risk screening.
Children for whom immediate TST is indicated:

  • Contacts of people with confirmed or suspected contagious tuberculosis (contact investigation)
  • Children with radiographic or clinical findings suggesting tuberculosis disease.
  • Children immigrating from endemic countries (eg, Asia, Middle East, Africa, Latin America)
  • Children with travel histories to endemic countries and/or significant contact with indigenous people form such countries.

Children who should have annual TST:

  • Children infected with HIV
  • Incarcerated adolescents

Some experts recommend that children should be tested every 2-3 years:

  • Children with ongoing exposure to the following people: HIV infected people, homeless people, residents of nursing homes, institutionalized adolescents or adults, users of illicit drugs, incarcerated adolescents or adults, and migrant farm workers; foster children with exposure to adults in the preceding high-risk groups are included.

Some experts recommend that children should be considered for TST at 4-6 and 11-16 years of age:

  • Children whose parents immigrated (unknown TST status) form regions of the world with high prevalence of tuberculosis; continued potential exposure by travel to the endemic areas and/or household contact with people from the endemic areas (with unknown TST status) should be an indication for a repeated TST.
  • Children at increased risk of progression of infection to disease.

CHDP
AAP

     

Anemia Test

Age 9-12 months, 6 months later, annually ages 2-5 years, and annually for menstruating teens.  

AAP
CHDP

     

Cholesterol

Children and adolescents who have a family history of premature cardiovascular disease or have at least one parent with a high blood cholesterol level.

USPSTF
AAP

PREVENTIVE

 

REFERENCE

Anticipatory Guidance; Patient Counseling

At all well visits. Development, nutrition, physical activity, dental health, safety, unintentional injuries and poisonings, violent behaviors and firearms, STDs and HIV, family planning, alcohol use, tobacco use, drug use, obesity prevention. For Medi-Cal patients, use the DHS Staying Healthy assessment.

USPSTF
AAP
DHS

CDC Immunization Schedule

Late Immunization Schedule

Attachment B                                                                                                          top

Quality Management Plan/Quality Assurance and Improvement

2006 ANNUAL QUALITY IMPROVEMENT PLAN (AQIP)

1. Introduction

The Central Coast Alliance for Health (the Alliance) is the local managed care health plan serving Medi-Cal and Healthy Families members in Santa Cruz and Monterey Counties, and Healthy Kids in Santa Cruz County.

The Alliance is dedicated to improving the health and well being of the residents of our region. Our mission is to:

The Alliance has established a comprehensive Quality Management Program (QMP) for all of its quality assurance and quality improvement activities.  The Health Services Policy Quality Management Program (QMP) provides a more detailed description of the QMP, including:

The Annual Quality Improvement Plan (AQIP) outlines activities for the year and provides a key element in implementing our overall QMP to both assure and improve quality.

1.1 AQIP Purpose

The 2006 Annual Quality Improvement Plan (AQIP) outlines the activities intended to assure and improve the quality of care for all Alliance members within the limits of the resources available to the Alliance and its participating providers.  Additionally, we intend the AQIP to meet the requirements of state and federal agencies and standards, such as the National Committee for Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS®), and Quality Improvement System for Managed Care (QISMC). 

1.2 AQIP Scope

We have designed the AQIP to provide a structured and organized activity schedule that outlines the aspects of care we intend to review throughout the year.  Systematic, comprehensive, and ongoing, the AQIP includes a review of important aspects of the delivery of health care services.  It encompasses all services, physicians, and vendors who have direct or indirect impact on the medical care of Alliance members in inpatient, outpatient, skilled nursing, ancillary, care management, and pharmacy settings. It also includes development of clinical protocols and standards. 

We have set up our data systems to separately identify and track different lines of business, namely Healthy Families and Medi-Cal for each county, Healthy Kids for Santa Cruz County only, and In-Home Support Services for Monterey County only. Although these programs are monitored separately, we hold them to the same quality standards.

1.3 AQIP Goals and Objectives

The AQIP objectives parallel the Quality Management Program (QMP) objectives:

2. Planned Activities for 2006                                                top

Although AQIP activities frequently overlap the following categories, we have grouped them as follows:

2.1 Continual Quality Assurance Activities

The following activities form much of the regular day-to-day work within the Health Services Department that assures the on-going quality of care delivered to Alliance members.

2.1.1 Physician/Vendor Credentialing/Recredentialing

The Alliance Credentialing/Recredentialing process meets NCQA standards, including the credentialing of mid-level practitioners.  Recredentialing occurs every 3 years and includes a site review by a plan Utilization/Onsite Review Nurse.

Information Management (Medical Records):  Each newly credentialed and recredentialed Alliance primary care provider has ten of his/her Alliance medical records reviewed as part of the facility review and credentialing process. Depending on the scope of the physician’s practice, records are reviewed for five adults and five children, or all ten are adults or children. Medical records are reviewed for documentation, organization and completeness of the medical record in relation to medical history, current treatment, and preventive measures. Confidentiality of medical records is always a prime consideration. All medical records reviewed at the Alliance or at a provider facility are maintained according to regulations to maintain strict confidentiality.

The Physician Peer Review/Credentialing Committee (PRC) presents regular confidential reports (usually quarterly) to the Board regarding credentialed and recredentialed providers.

2.1.2 120-Day Initial Health Assessments

The Alliance continues to identify new members on provider eligibility lists and to provide ongoing feedback to providers regarding their compliance with the 120-Day Initial Health Assessment mandate. We have implemented the Individual Behavior Risk Assessment requirement as part of the initial health assessment and ongoing preventive health visits.  Compliance with the 120-Day Initial Health Assessment requirement is tracked and analyzed as part of the annual HEDIS® audit (see below, under Regulatory Compliance Activities, for more information).

2.1.3 Utilization Review

The Alliance Utilization Review (UR) Team is comprised of the Medical Director, the Associate Medical Director, and the plan’s Utilization Review Nurses. UR meets three or more times each week to ensure the delivery of quality medical healthcare at the most appropriate level of care, in a timely, effective, and efficient manner for Alliance members.

Reporting takes place as part of the quarterly Data Book that includes monitoring of Use of Services.

2.1.4 Case Management

The Alliance currently uses five different kinds of case managers:

The Alliance tracks and analyzes the volume and outcomes of case management activities.  The specific indicators to be monitored in 2005 include the following:

The Health Services Operations Manager and the Health Programs Manager report these results periodically to the Board.

2.1.5 Health and Disease Management

During 2006, the Alliance Health Services department will continue to implement components of important health and disease management programs for members with diabetes and asthma. These programs will affect all areas of the Alliance service region, and will be reviewed for access, quality, and outcomes.

Reporting on these activities occurs as part of the Quality Improvement Project responsibilities.

2.1.6 Risk Management

Wheelchair Timeliness Report:  The Alliance Utilization Review Team tracks the timeliness of all wheelchair purchases and repairs and reports this to the Board each calendar quarter.  The specific indicators monitored include the following:

2.1.7 Potential Quality Issues and Verified Quality Issues

Potential Quality Issues (PQIs) are documented on a standardized form.  The Medical Director then reviews the PQI and the accompanying information to make a determination whether a Verified Quality Issue (VQI) does in fact exist.  
If the PQI is not a quality issue, it will be logged, closed, and filed.  Closed PQI logs will be monitored annually for trends.  

Cases determined to be VQIs by the Medical Director may be presented to the Physician Peer Review/Credentialing Committee (PRC) for review.  The PRC will make recommendations for corrective actions as appropriate.  Each VQI will be assigned a Quality of Care Classification and an Adverse Effect Rating by the Medical Director to give an indication of the impact of the problem upon the patient.

Where appropriate, the Medical Director or PRC will develop a Corrective Action Plan (CAP) that includes recommendations, planned follow-up, the time frame for completing the action, and the person(s) responsible for implementing the plan.  

For more information on PQIs, VQIs, and CAPs, please consult the Health Services Policies and Procedures Manual sections regarding these areas.

The Medical Director or Quality Improvement Manager reports status and trends of PQIs/VQIs as a standing agenda item at QMC meetings.

2.1.8 Education

Clinical Practice Guidelines:  The following care guidelines are regularly reviewed, approved, and distributed to providers:

Perinatal Outreach:  To promote early prenatal care, the Alliance sends a letter about health education services to all new female members of childbearing years, and all members who fill a prenatal vitamin prescription.  The letter urges early entry into prenatal care for pregnant members and offers information and support on having a healthy pregnancy, on request.  Providers also refer members who need transportation assistance to attend prenatal appointments, or referrals to other support services.  A Health Programs Coordinator calls the member, helps with access to appointments and services, and sends low-literacy health education materials.  Health Programs staff also provide phone follow-up with new mothers to encourage compliance with the recommended postpartum visit, breastfeeding, immunization of the newborn, and enrollment of the newborn.  The Alliance offers an incentive gift for mothers who have their postpartum check-up within 21 to 56 days.  The effectiveness of these activities is measured both through HEDIS® perinatal measures and regular reports by the Health Programs Manager.

Immunization:  In addition to the postpartum phone reminder, the Alliance mails immunization reminders to families when infants are 3 and 9 months of age.  Using claims data, the Alliance sends monthly notices to providers of their members who are overdue at 9 or 18 months of age.  With the help of grant funding for Santa Cruz County members, a Health Programs Coordinator calls the families whose children are overdue.  The effectiveness of these activities is measured through HEDIS® immunization measures and quarterly reporting.

Adolescent Well-Care:  The Alliance “Teen Tune-Up!” program sends members age 12 to 18 a birthday well-care reminder and incentive offer. Teens who complete the exam receive movie tickets once the examination has been verified.  Additionally the Alliance obtained grant funding to raffle mountain bikes to teens who have their well care exams.  The bikes along with helmets are raffled every two months.  At this point it is unknown if this program will extend to 2006.  The Alliance also sends providers a monthly list of teen members who have not had a well-care exam in the last 12 months.  The effectiveness of these activities is measured through the HEDIS® adolescent well-care measure.

Breast and Cervical Cancer Screening:  Twice a year, the Alliance sends a reminder notice to members who are overdue for mammography or pap smears.  Providers also receive a list of their overdue members.  The effectiveness of these activities is measured through HEDIS® breast and cervical cancer screening measures.

Chlamydia Action lists:  Twice a year, the Alliance sends providers action lists of their members who may need chlamydia screening.  The effectiveness of these activities is measured through HEDIS® chlamydia screening measure.

Diabetes and Asthma Education:  The Alliance covers comprehensive self-management education for diabetes and asthma.  The Alliance sends educational materials to members with diabetes and asthma, encouraging them to get appropriate medical care and manage self-care.  The Alliance promotes the Diabetes Control Network (DCN) to this end.  It also distributes semi-annual Action Lists to providers regarding their members with asthma or diabetes, and various reminders directly to affected members.  The Alliance began investigating various options to move toward electronic clinical data sharing with providers for diabetes and chronic illness in 2005, and hopes to begin some form of implementation during 2006. The effectiveness of all these activities is measured through HEDIS® diabetes and asthma measures.

Other Health Education Efforts:  The Alliance also sends an annual flu shot reminder to high risk members, refers members to smoking cessation services, offers general health education through the member newsletter and other print materials, and conducts health outreach through a local farmers’ market and Spanish language radio.  The Alliance collaborates with community partners on primary prevention activities for diabetes, asthma, obesity, and other chronic diseases.

Medical Director Meetings:  The Alliance Medical Director continues to attend the statewide meetings to discuss quality improvement initiatives and activities.

Memoranda of Understanding (MOUs):  The Alliance continues to work with health departments and local agencies and coalitions on the delivery and coordination of quality health care to Alliance members, and ongoing review and education of network providers.

Cultural and Linguistic and Health Education Group Needs Assessment:  During CY 2001, the Alliance completed an initial Group Needs Assessment report for DHS and MRMIB.  The report included findings and recommendations for improvement of services in these areas.  The next comprehensive Needs Assessment is scheduled for 2005.

2.1.9 Quality-Based Incentives for Providers

The Alliance launched a test run of its first Quality-Based Incentives (QBI) Plan for Providers in 2005. Providers were shown how many quality points they could have earned through meeting pre-established goals based on 2004 claims/encounter data, and the Alliance was able to better approximate the effectiveness of such a program. One more test run report is scheduled for 2006 (based on 2005 claims/encounter data). The first real QBI reports and payments are set to occur in 2007, based on 2006 claims/encounter data.

2.2 Regulatory Compliance Activities                                        top

The Alliance will continue to meet regulatory requirements and strive toward meeting NCQA standards.  The following activities measure the effectiveness of the quality of care delivered to Alliance members.

2.2.1 Member Satisfaction Consumer Assessment of Health Plans (CAHPS®) Survey

In 2003, DHS contracted with Widener-Burrows & Associates, Inc. (WB&A) to perform the HEDIS®/CAHPS® 3.0H Adult and Child Surveys (the Medi-Cal Member Satisfaction Survey). WB&A administered the CAHPS® mail and phone surveys in English and Spanish to randomly selected Alliance members in 2004.  This member satisfaction survey was performed in collaboration with the other DHS Medi-Cal Managed Care Division (MMCD) contracted Health Plans.   As of this writing, DHS is still in the process of preparing the cross-plan results from the 2004 surveys.

The CAHPS will not be performed for DHS during 2006. DHS has not scheduled the next Medi-Cal CAHPS survey.  

As of this writing, MRMIB has funded CAHPS surveys for 2006 but has yet to select a survey vendor.

2.2.2 Statistical Measures: HEDIS® and State-Mandated Measures

The Alliance 2006 HEDIS® measures are drawn from the following HEDIS® domains: Effectiveness of Care, Access and Availability of Care, Use of Services, and Utilization Measures. Reporting on these measures provides the Alliance an opportunity to improve its preventive health care delivery practices through the analysis of study results and implementation of appropriate quality improvement interventions.  

These measures integrate contractual obligations under the Department of Health Services (DHS), the California Managed Risk Medical Insurance Board (MRMIB), Healthy Kids (HK), and In-Home Support Services (IHSS). For 2006, MRMIB has also mandated a 120-Day Initial Health Assessment measure of its own.

The following table indicates Domain of Care, Measure, whether the measure is required by DHS, MRMIB, or HK, and whether the measure is Administrative (A) or Hybrid (H). (Administrative measures are based only on claims and encounter data; Hybrid measures also include data from chart reviews.)  

2006 HEDIS® and State-Mandated Measures by DHS, MRMIB, and HK top

Domain of Care Measure

DHS

MRMIB

HK

IHSS*

Effectiveness of Care

Childhood Immunization Status

H

H

   

Breast Cancer Screening

A

     

Cervical Cancer Screening

H

     

Chlamydia Screening in Women

A

     

Comprehensive Diabetes Care (Eye Exam Only)

H

     

Use of Appropriate Medications for People with Asthma

A

 A

A

 

Follow-Up after Hospitalization for Mental Illness

 

 A

A

 

Access and Availability of Care

Children's Access to Primary Care Practitioners

 

 A

 A

 

Prenatal and Postpartum Care
•Timeliness of Prenatal Care
•Postpartum Care

 H

     

Use of Services

Well-Child Visits in the First 15 Months of Life

H

     

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life

H

H

A

 

Adolescent Well-Care Visits

H

H

A

 

Chemical Dependency Utilization

 

A

   

State-Mandated Measures

120-Day Initial Health Assessment

 

 

HEDIS®Utilization Measures:

  Frequency of Selected Procedures:

Myringotomy

A

 

A

 

Tonsillectomy

A

 

A

 

Non-obstetric dilation and curettage

A

     

Hysterectomy, abdominal

A

     

Hysterectomy, vaginal

A

     

  Inpatient Utilization -- General Hospital/Acute Care:

Discharges

A

 

A

 

Discharges/1000 member months

A

 

A

 

Days

A

 

A

 

Days/1000 member months

A

 

A

 

Average length of stay

A

 

A

 

  Ambulatory Care:

Outpatient Visits

A

 

A

 

Emergency Department Visits

A

 

A

 

Ambulatory surgery/procedures performed in hospital
outpatient facilities or freestanding surgical centers

A

 

A

 

  Outpatient Drug Utilization:

Total Cost of Prescriptions

A

 

A

 

Average Cost of Prescriptions per Member per Month

A

 

A

 
Total Number of Prescriptions A   A  
Average Number of Prescriptions per Member per Year A   A  

* Due to the newness of IHSS Care, data is insufficient to report on quality measures in 2006. Quality reporting for IHSS Care will begin 2007, based on services delivered in 2005-06.

These measures will be audited by Medstat (except for the Utilization Measures) and reported to DHS, MRMIB, HK, and all other interested parties.

2.2.3 Other Regulatory Quality Reports

The following table details other quality reports mandated by state agencies.

Other State-Mandated Quality Reports for 2006

Report

Frequency

DHS

MRMIB

CCS & Mental Health

Annually 

  X

Utilization and Fiscal

Quarterly 

X  

Utilization and Fiscal

Annually 

X  

Chemical Dependency Utilization

Annually  

  X

2.3 Quality Improvement Projects (QIPs)                                 top

The following special activities seek to measure and improve the quality of care delivered to Alliance members. 

2.3.1 Quality Improvement Activities

The Alliance has developed and implemented on-going interventions and data capture activities to address issues identified by HEDIS® and QIP studies:

2.3.2 Quality Profiling Reports

The Alliance uses the CRMS data system to capture, analyze, and report data related to quality measures.  The Alliance also uses the CRMS database to produce two types of reports for providers:

2.3.3 Quality Detailing Visits

The Medical Director and Quality Improvement Manager intend to make approximately four on-site quality detailing visits to key providers during 2006 to review results and share best practices.

2.3.4 Quality Improvement Projects (QIPs)

DHS requires plans to conduct and/or participate in four Quality Improvement Projects (QIPs).  Among those four QIPs:

Under these guidelines, the Alliance will be participating in the following QIPs:

The Medical Director and Quality Improvement Manager provide QIP quarterly progress reports to the QMC.

2.3.5 Quality Improvement Focus: Long Term Care

The majority of verified quality issues in 2005 related to care in skilled nursing facilities. In response to identified concerns, the QI department recommends the following strategies to improve care to Alliance members in skilled facilities, to be implemented in 2006:

2.3.6 Quality Based Incentives (QBI)

The Alliance’s Quality Based Incentives (QBI) Program provides an opportunity for all physicians to benefit by rewarding high quality care and effective systems of care. QBI clinical measures are based on Health Plan Employer Data & Information Set (HEDIS) measures. Physician performance is assessed based on claims and encounter data. QBI will begin in 2006, with the first quality awards to be given out in early 2007.

3. Program Accountability                                                      top

The Quality Management Program (QMP) makes provisions for the following forms of review, appeals, and approvals.

3.1 External Review

The Alliance provides for an external independent review according to the regulations set forth by DHS and DMHC for the purpose of impartial review of appeals and disputed level of care decisions.

3.2 AQIP Review and Approval

The AQIP outlines the related Health Services activities for the year and the proposed aspects of care to be reviewed. 

The Quality Improvement Manager revises and updates the AQIP for the coming year at least annually, for subsequent review by the Medical Director and Health Services Director, and final review and approval by the Quality Management Committee (QMC). 

The QMC reviews and recommends the Alliance’s Quality Improvement Program (QIP) to the Commission for approval annually.  The QMC may also make recommendations for revision of the plan at any time deemed necessary.  The Commission review and approval are documented in the minutes of the Governing Board. 

The minutes of the QMC reflect AQIP progress at least quarterly. 

3.3 Report on the Annual Quality Improvement Plan (RAQIP)

The Quality Improvement Manager prepares a year-end evaluation of the AQIP in the form of the Report on the Annual Quality Improvement Plan (RAQIP).  This report summarizes the activities for the year, and identifies areas where actual improvements in quality and outcomes of care have been accomplished through the efforts of the Quality Management Program.  It also identifies any deficiencies with suggested actions for improvements for the following year.

The Medical Director and Health Services Director subsequently review the RAQIP before final review and approval by the Quality Management Committee (QMC).  The Medical Director will forward the RAQIP to the Commission for its approval. 

Attachment C                                                                top
Quality-Based Incentives and Definitions

Medi-Cal Quality Based Incentives:
HEDIS-Based Clinical Measure Descriptions

The Alliance’s Quality Based Incentives (QBI) Program provides an opportunity for all physicians to benefit by rewarding high quality care and effective systems of care for Medi-Cal members.  QBI clinical criteria are based on Health Plan Employer Data & Information Set (HEDIS®) measures.  A brief description of each measure follows below, highlighting eligibility and compliance criteria.  Physician performance is assessed based on claims and encounter data for services to Medi-Cal prime members.  Awards will be distributed annually four (4) months after the end of the Fiscal Year.  Contact the Quality Improvement Manager at (831) 430-5571 for more detailed information.

Well-Child Visits in the First 15 Months of Life

Description:  The percentage of members who turned 15 months of age during the measurement year, who were continuously enrolled in the plan from 31 days of age, and who received six or more well-child visits with a primary care practitioner by age 15 months.

Well-Care Visits 3-6 Years 

Description:  The percentage of members who were three, four, five, or six years old during the measurement year, who were continuously enrolled during measurement year, and who received a well-child visit with a primary care provider. 

Adolescent Well-Care Visits 

Description:  The percentage of members who were age 12-21 during the measurement year, who were continuously enrolled during the measurement year, and who had a comprehensive well-care visit with a primary care provider or an OB/GYN provider.  

Appropriate Treatment of Upper Respiratory Infection (URI)

Description:  The percentage of children 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the Episode Date. 

Appropriate Use of Medications for Asthma, Age 5-9, 10-17, 18-56, and 5-56 Years 

Description:  The percentage of members 5-56 (also broken down 5-9, 10-17, and 18-56) who were identified with persistent asthma, and who were prescribed medications acceptable as primary therapy for long-term control of asthma (controller medication).

Breast Cancer Screening 

Description:  The percentage of women 50-69 who were continuously enrolled during the measurement year and the year prior to the measurement year, and who had a mammogram during the measurement year or the year prior to the measurement year.

Cervical Cancer Screening 

Description:  The percentage of women age 21 through 64 years who were continuously enrolled during the measurement year and who received one or more cervical cancer screening tests (i.e., Pap smears) during the measurement year or the two years prior to the measurement year.

Chlamydia Screening in Women, Age 16-20, 21-25, and 16-25 Years 

Description:  The percentage of women age 16-25 (also broken down 16-20 and 21-25) who were identified as sexually active, who were continuously enrolled during the measurement year, and who had at least one test for chlamydia during the measurement year.

Comprehensive Diabetes Care (LDL-C Screening) 

Description:  The percentage of members with diabetes (Type I or Type 2) age 18 through 75 years, who were continuously enrolled during the measurement year, and who had an LDL-C test using claim/encounter or automated laboratory data.  The LDL-C test must have a service date during the measurement year of the year prior to the measurement year.

Comprehensive Diabetes Care (HbA1c Screening) 

Description:  The percentage of members with diabetes (Type I or Type 2) age 18 through 75 years, who were continuously enrolled during the measurement year, and who had one or more HbA1c tests conducted during the measurement year identified through administrative data.  The HbA1c test must have a service date during the measurement year.

Medi-Cal Quality Based Incentives:                                          top

Family Practice/General Practice

Quality Based Incentives are awarded annually based on the following key areas of performance:

Performance is based on services for Medi-Cal prime patients, excluding patients with other health coverage including Medicare 

Quality Category

Data Collection

Measures

Performance Criteria

Points

Clinical Measures

Claims and encounter data (No chart review)
All measures use NCQA HEDIS methodology and are audited by an external NCQA certified auditor for accuracy.
Minimum Denominator of 10 members per measure.

1.Well Child 0-15 month
2. Well Child 3-6 years
3. Well Adolescent
4. Appropriate Treatment of URI
5. Asthma Controller Medication 
6. Breast Cancer Screening
7. Cervical Cancer Screening
8. Chlamydia Screening
9. Diabetes LDL-C Screening
10. Diabetes HbA1c Screening

For each measure*:
Rate >75% = 8 points
Rate 50-75% = 4 points
Rate <50% = 0 points

*Compared to overall Family Practice/General Practice performance.

80

Access to Care:
Acceptance of Medi-Cal Members

Linkage data

1. Level of Access (Medi-Cal prime)

Open to Auto Assignment for 10 or more months in 2006 =10 pts
Open to Auto Assignment < 10 months, with average members linked per month (for calendar year 2006):
1-99 1 point
100-199 2 points
200-299 3 points
300-399 4 points
400-499  5 points
500-599 6 points
600-699 7 points
700-799 8 points
800-899 9 points
900 or more 10 points

10

Access to Care:
Emergency Department Utilization

Administrative Data Only**

1. Provider ED utilization rates for non-emergent care (ED Visits Levels 1-3).

Rate < -1 SD = 10 points
Rate –1 to +1 SD = 5 points
Rate > +1SD = 0 points
Compared to mean ED Level 1-3 utilization rates for Family Practice/General Practice

10

Total Points

100

Quality Point Calculation to Determine Quality Award

  • Possible Quality Award Points = 100
  • A separate Quality Pool will be established for each calendar year.
  • The Quality Award will be distributed annually four (4) months after the conclusion of each Fiscal Year.
  • The formula for distribution of the dollars in the Quality Pool is as follows:
  • Determine the number of quality points earned by the provider
  • Multiply total quality points earned times the provider’s linked member months for 2006 to determine “weighted points”
  • Determine the percent of “weighted points” the provider earned as compared to the total “weighted points” for all providers
  • Multiply that amount by the total amount of dollars being distributed in the Family Practice Quality Pool
  • Result is the provider’s Quality Award 

**ED Utilization Rates will be calculated for those practice sites with a minimum of 1200 member months in 2006 (minimum average of 100 members per month).

Best Practice Implementation

Data Collection

Indicator

Reimbursement

1. Asthma Management

Childhood Asthma Action Plan (age 0-18 years)

1.Submission of Asthma Action Plan (Member must have controller RX.)

1.Pay $20 FFS per submitted Asthma Action Plan (reimbursement limited to the first plan submitted for each patient during the calendar year)

2. Chronic Pain Management

Pain Contract

2. Submission of pain contract

2. Pay $20 per submitted Pain Contract (reimbursement limited to the first contract submitted for each patient during the calendar year)

Medi-Cal Quality Based Incentives:                                        top

Internal Medicine

Quality Based Incentives are awarded annually based on the following key areas of performance:

Quality Category

Data Collection

Measures

Performance Criteria

Points

Clinical Measures

Claims and encounter data
(No chart review)
All measures use NCQA HEDIS methodology and are audited by an external NCQA certified auditor for accuracy.
Minimum Denominator of 10 members per measure.

1. Breast Cancer Screening
2. Cervical Cancer Screening
3. Diabetes LDL-C Screening
4. Diabetes HbA1c Screening
5. Asthma Controller Medication

For each measure*:
Rank >75% = 16 points
Rank 50-75% = 8 points
Rank <50% = 0 points

*Compared to performance of Alliance Internal Medicine providers.

80

Access to Care:

Acceptance of Medi-Cal Members

Linkage data

1. Level of Access (Medi-Cal prime)

Open to Auto Assignment for 10 or more months in 2006           =10 points
Open to Auto Assignment < 10 months, with average members linked per month (for calendar year 2006):
1-99  1 point
100-199 2 points
200-299 3 points
300-399 4 points
00-499 5 points
500-599 6 points
00-699 7 points
700-799 8 points
800-899 9 points
00 or more 10 points

10

Access to Care:

Emergency Department Utilization

Administrative Data Only**

1. Provider ED utilization rates per 1000 member months for non-emergent care (ED Visits Levels 1-3)

Rate* < -1 SD = 10 point
Rate* –1 to +1 SD = 5 points
Rate* > +1SD = 0 points
Compared to mean ED Level 1-3 utilization rates for Internal Medicine Providers

10

     

Total Points Available

100

Quality Point Calculation to Determine Quality Award 

  • Possible Quality Award Points Total = 100
  • A separate Quality Pool will be established for each calendar year.
  • The Quality Award will be distributed annually four (4) months after the conclusion of each Fiscal Year.
  • The formula for distribution of the dollars in the Quality Pool is as follows:
  • Determine the number of quality points earned by the provider
  • Multiply total quality points earned times the provider’s linked member months for 2006 to determine “weighted points”
  • Determine the percent of “weighted points” the provider earned as compared to the total “weighted points” for all providers
  • Multiply that amount by the total amount of dollars being distributed in the Internal Medicine Quality Pool
  • Result is the provider’s Quality Award

**ED Utilization Rates will be calculated for those practice sites with a minimum of 1200 member months in 2006 (minimum average of 100 members per month).

Best Practice Implementation

Data Collection

Indicator

Reimbursement

1. Chronic Pain Management

Pain Contract

1. Submission of pain contract

1. Pay $20 FFS per submitted Pain Contract (reimbursement limited to the first contract submitted for each patient during the calendar year)

Medi-Cal Quality Based Incentives:                                           top

Pediatrics 

Quality Based Incentives are awarded annually based on the following key areas of performance:

Performance is based on services for Medi-Cal prime patients, excluding patients with other health coverage including Medicare.

Quality Category

Data Collection

Measures

Performance Criteria

Points

Clinical Measures

Claims and encounter data (No chart review)
All measures use NCQA HEDIS methodology and are audited by an external NCQA certified auditor for accuracy.
Minimum Denominator of 10 members per measure.

1.Well Child Visit 0-15 months 
2. Well Child Visit 3-6 years
3. Well Adolescent 12-21 years 
4. Asthma Controller Medication 
5. Appropriate Treatment of URI 

For each measure*
Rate >75% = 16 points
Rate 50-75% = 8 points
Rate <50% = 0 points

* Compared to overall Pediatrician performance

80

Quality Category

Data Collection

Measures

Performance Criteria

Points

Access to Care:

Acceptance of Medi-Cal Members

Linkage data

1. Level of Access (Medi-Cal prime)

Open to Auto Assignment for 10 or more months in 2006 =10 points

Open to Auto Assignment < 10 months, with average members linked per month (for calendar year 2006):

 1-99 1 point
100-199 2 points
200-299 3 points
300-399 4 points
400-499 5 points
500-599 6 points
600-699 7 points
700-799 8 points
800-899 9 points
900 or more 10 points

10

Access to Care: Emergency Department Utilization

Administrative Data Only**

1. Provider ED utilization rates for non-emergent care (ED Visits Levels 1-3) 

Rate < -1 SD = 10 points 
Rate –1 to +1 SD = 5 points 
Rate > +1SD = 0 points
Compared to mean ED Level 1-3 utilization rates for Pediatricians

10

Total Points

100

Quality Point Calculation to Determine Quality Award

  • Possible Quality Points = 100
  • A separate Quality Pool will be established for each calendar year.
  • The Quality Award will be distributed annually four (4) months after the conclusion of each Fiscal year.
  • Determine the number of quality points earned by the provider
  • Multiply total quality points earned times the provider’s linked member months for 2006 to determine “weighted points”
  • Determine the percent of “weighted points” the provider earned as compared to the total “weighted points” for all providers
  • Multiply that amount by the total amount of dollars being distributed in the Pediatric Quality Pool
  • Result is the provider’s Quality Award

**ED Utilization Rates will be calculated for those practice sites with a minimum of 1200 member months in 2006 (minimum average of 100 members per month).


Best Practice Implementation

Data Collection

Indicator

Reimbursement

Asthma Management

Childhood Asthma Action Plan (age 0-18 yrs.)

1. Submission of Asthma Action Plan (Member must have controller RX.)

 1.Pay $20 FFS per submitted Asthma Action Plan (reimbursement limited to the first plan submitted for each patient during the calendar year)

 

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