Increasing Timely Assessment for Case Management Services

Project Topic / Rationale / Aims

Increasing timely assessment for case management services encompassed an important component of the philosophy of the Amida Care SNP model which advocates a comprehensive care plan that provides psycho-social as well as medical care. Amida Care objectives for this project were to update the current database to reflect the medical case manager as well as the psycho-social case manager, if applicable, and have all members assigned to a case manager and collect case management assessments on 80% of the members within 60-days of effective date of enrollment.

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Methodology

This project cohort was the plan´s entire active plan population who were enrolled for at least 90 consecutive days with an anchor date of December 31, 2010 and all new enrollees with a State Roster Date between June 1, 2011 and December 31, 2011, and who were enrolled for at least 90 consecutive days with an anchor date of December 31, 2011.

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Interventions

The improvement interventions concentrated on the technical aspects of having the capability to electronically store and report vital information in order to appropriately coordinate care. The Amida Care database capabilities were updated to automatically assign a psycho-social case manager to a member based on the member´s address. Since a member must have a PCP within 30 days of the State Enrollment Date, this will ensure 100% of new enrollees will have a medical case manager assigned to them in that time frame also.

The process workflow requires that whenever a member doesn´t receive a case management assessment, the Care Coordination Department would contact the medical case manager and, if no visit is scheduled, contact the member to schedule one. If they were unsuccessful in reaching the member, they then referred the case to the Retention in Care Unit for the Amida Care Health Navigators in that unit to attempt to reestablish contact with the member.

Barriers that were encountered included the inability to contact new enrollees in a timely manner, lack of sufficient internal staffing resources given increased enrollment, and lack of cross-departmental communication in order to update internal processes.

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Results/Conclusions

The study cohort included 2,715 members. Amida Care was unable to show a statistically significant increase in the timeliness of case management data collection due to the encountered barriers.

Amida Care was unable to achieve a statistical increase in assessments due to time constraints in hiring and training new staff, obtaining approval for new system development, choosing an applicable system and database enhancements and hiring additional consultants to actualize the project. This led to the development of Part II of the PIP.

Improving Viral Load Suppression through Telephone Counseling

Project Topic / Rationale / Aims

One of the primary goals of combination antiretroviral therapy is maximal and durable plasma HIV viral load suppression. The project was designed to utilize telephone counseling to facilitate care coordination and retention in clinical care. This effort was expanded by providing adherence assessment and counseling with the goal of maintaining and possibly improving rates of viral load suppression during a period of increased enrollment related to (mandatory) managed Medicaid expansion.

MetroPlus aimed to achieve an increase of 10% or more in the rate of viral load suppression (defined as viral load <200 cps/ml) and maintain viral suppression rates of 60% or more compared to baseline in a randomly selected group of members on Highly Active Antiretroviral therapy (HAART) enrolled between September 1, 2010 and December 31, 2010.

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Methodology

A total of 287 members (Suppressed cohort: n=171 and Unsuppressed cohort: n=116) were identified. Participants with suppressed viral load were contacted once every trimester while those not suppressed were contacted monthly. Health educators conducted adherence assessment using a standardized 7-day adherence self report tool, adherence counseling and education on other topics as the need arose. Participants who were not engaged in care were referred for community outreach.

The following indicators were tracked monthly: the number of calls scheduled and completed; the proportion of participants who self report HAART adherence rates of ≥ 95%; the number of participants for whom a care coordination need is identified and referral made; and the number of participants referred for outreach. Also tracked was the proportion of participants with PCP visits, with a viral load measurement, and with suppressed/undetectable viral load in each trimester.

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Interventions

The primary intervention was monthly counseling calls to participants in the ´unsuppressed cohort´ and quarterly calls to participants in the ´suppressed cohort´. If the participant was sub- optimally adhering to HAART, the health educator worked with the member to resolve barriers (e.g., assistance with access to PCP and specialty visits, transportation, education, and adherence tools).

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Results/Conclusions

There were 116 (40.4%) participants whose baseline HIV viral load was not suppressed and 171 (59.6%) participants whose baseline viral load was suppressed. A high proportion of participants had visits with their PCPs in each trimester. The proportion of participants with suppressed viral loads was significantly higher in the suppressed cohort compared with participants in the unsuppressed cohort. A higher proportion of the suppressed cohort reported adherence to>95% of HAART doses and had more care coordination referrals.

While it appears that the proposed milestones were not achieved, there was significant success among participants in the unsuppressed cohort because for this group the intervention was conducted more frequently (monthly calls) compared with participants with virologic suppression at baseline (quarterly calls). The project demonstrated that telephonic counseling is a valuable adjunct to other tools already being used to promote adherence to HAART.

A Pilot Study to Increase Diabetic Retinopathy Screening among HIV Positive Individuals

Project Topic / Rationale / Aims

The importance of screening for diabetic retinopathy is particularly critical among HIV positive individuals due to exacerbating factors such as HIV-associated ocular disease. New York Presbyterian System (NYPS) SelectHealth´s QARR/HEDIS results for the past three (3) years have been consistently below statewide averages for dilated eye exam screenings among diabetic members enrolled in Medicaid HMOs.

As a result, the goal of the project was to increase the proportion of eligible diabetic members who have received a retinopathy screening from pre- to post-intervention from 50% (baseline: 65/130) to 75%. This study seeks to evaluate the influence of two (2) distinctive interventions (direct versus indirect). For the direct intervention, the health plan notifies the PCP that the plan will contact members to schedule the screenings unless the provider declines. For the indirect intervention the health plan notifies the primary care physician of their patients who are due for screenings and offers assistance with scheduling appointments, but allows the provider to initiate referral. SelectHealth hypothesized that the direct intervention would result in a greater increase in diabetic retinopathy screenings among the targeted members.

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Methodology

Of the 130 eligible members, 65 did not receive diabetic retinopathy screening in 2010. These 65 members were assigned to one of two groups: 35 to the Indirect Approach Group and 30 to the Direct Approach Group.

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Interventions

In June 2011 letters were mailed to the primary care physicians for members in the Direct Approach Group and Indirect Approach Group listing those individuals who had not had a diabetic retinopathy exam in 2010. From 7/1/11 to 10/31/11 up to three attempts were made to contact the members in the Direct Group to schedule retinopathy screenings.

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Results/Conclusions

An outreach effort was undertaken to schedule retinopathy screenings for 28 members in the Direct Approach group; 7 (25%) of these members were successfully contacted. Retinopathy screening appointments were scheduled for 2 (29%) of the members. A total of 1 (4%) of the 28 Direct Group members a received retinopathy screening.

Direct approach letters were mailed to the PCPs of 23 members in the Indirect Group for whom a retinopathy screening was not conducted and appointments were scheduled for 14 of these members. Of these, 5 attended their diabetic retinopathy screenings. In summary a total of 7 (28%) of the 25 Indirect Group members received retinopathy screenings.

The study did not achieve its objectives of increasing screening rates to 75%, as the percent screened increased by only 56% (73/130). The rate of screening was 4% for the Direct Group and 28% for the Indirect Group. The Indirect Approach followed by the Direct Approach yielded a larger number of successful screenings than either approach alone. This may have been in part due to a learned improvement in outreach strategies on the part of the SelectHealth staff.

The PIP was useful in demonstrating that a multi-faceted approach may be required to engage members in specialty care. The collaboration between the health plan and the primary care physician is essential to facilitating patient access to specialty services.

Improving Childhood Immunizations for Members Enrolled in Medicaid / Child Health Plus (CHP)

Project Topic / Rationale / Aims

Vaccines are among the most successful and cost-effective public health tools for preventing illness and avoidable deaths. Vaccine-preventable diseases have a costly impact, resulting in doctors´ visits, hospitalizations, and premature deaths. However, the Plan continues to fall below the NCQA 75th percentile of 76.5% for the Combo 3 measure of vaccination compliance. The Plan´s goal was to improve all childhood immunizations for Medicaid and Child Health Plus (CHP) members using Childhood Immunization Combo 3 as the marker for evaluating the success of the interventions. In keeping with the goals and priorities set forth in this plan, WellCare focused its interventions on:

• Disseminating member information regarding the importance of childhood immunizations;
• Promoting PCP outreach and engagement with their patients who are in need of immunizations;
• Educating providers on valid coding for immunizations and monitoring compliance with the Citywide Immunization Registry (CIR) and;
• An internal audit of claims systems vs. medical record review to identify gaps and issues with immunization data.

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Methodology

WellCare employed the HEDIS measure Childhood Immunization Combo 3 methodology to measure progress toward this project´s objectives. WellCare used the HEDIS 2010 technical specifications for baseline measurement, HEDIS 2011 for interim measurement and HEDIS 2012 for re-measurement. The eligible population was children who turned age two during the measurement year and were enrolled in WellCare Medicaid or CHP.

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Interventions

Interventions included the following:

• NYC DOHMH Immunization Report to PCPs
• Provider Newsletter article, email blast, and P4P Incentive Project
• Member Newsletter article and Fun Pack mailing
• Internal claims audit to review immunization reporting

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Results/Conclusions

Medicaid/FHP baseline scored at 66% which is below state wide and NCQA average. The re- measurement is reported as 57%. CHP baseline scored at 68% with the re-measurement reported at 57%. Both lines of business showed a decrease in the measure in spite of the additional interventions implemented during 2011.

An analysis of the effectiveness of the interventions was conducted to identify the changes required and new interventions implemented. Initial analysis indicated that the plan needed to focus intervention in upstate New York where the rates are lower than downstate. An analysis of WellCare´s claims systems vs. medical record review identified gaps and issues with immunization data, including provider sites, where immunization data is recovered during medical record review. WellCare will target these provider sites to help improve their reporting of immunizations via claims and the Immunization Registry thereby minimizing the need for medical record review.