HCPF:Health Outcomes Quality Management

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Health Outcomes Quality Management

Medicaid Quality Strategy Requirements as outlined under Code of Federal Regulation 42 CFR 438.200 - 204 delineate State responsibilities for adoption of a Quality Strategy. 42 CFR 438.202(a) states that States will have a written strategy for assessing and improving the quality of managed care services offered by all [Managed Care Organizations] MCOs and [Prepaid Inpatient Health Plans] PIHPs. The 2007 State of Colorado Quality Strategy was adopted January 2007 after commentary was obtained from stakeholders and the public. 2007 Quality Strategy

HEDIS ¹ Reports HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. HEDIS also includes a standardized survey of consumers' experiences that evaluates plan performance in areas such as customer service, access to care and claims possessing. 2009 2008 2007 2006 Legislative Report on Status of Pediatric Health Care Quality Performance Measures Colorado Medicaid Clinical Standards Report Recommendations from the Performance Measure Advisory Group Behavioral Health Organization Performance Measure Validation Health Services Advisory Group (HSAG), the Department of Health Care Policy and Financing's External Quality Review Organization (EQRO), conducts validation activities outlined in the CMS Performance Measure Validation Protocol for each of the Behavioral Health Organizations (BHOs). The performance measures are calculated on an annual basis. Each BHO is subject to the same measures making it possible to compare performance measures for each health plan. 2008 Access Behavioral Care 2008 Behavioral HealthCare, Inc. 2008 Colorado Health Partnerships 2008 Foothills Behavioral Health 2008 Northeast Behavioral Health

Encounter Data Validation The Department contracted Health Services Advisory Group, Inc. (HSAG) to conduct the 2008 Behavioral Health Encounter Data Validation (EDV) study. The purpose of the EDV study was to evaluate the extent to which administrative encounters for behavioral health services are accurate and complete. FY 2008-2009 Department's Response To HSAG's EDV Recommendations Focused Studies On an annual basis, the Department of Health Care Policy & Financing collaborates with its contracted managed care organizations (MCOs), prepaid inpatient health plans (PIHPs) and the external quality review organization, Health Service Advisory Group, Inc. (HSAG), to examine a specific aspect of health care for a defined point in time. The intended purpose of these studies is to identify opportunities and meaningful interventions that will promote quality care. These projects are usually based on information extracted from medical records or MCO/PHP administrative data such as enrollment files and encounter/claims data. 2009 BHI Focused Study Abstract 2009 BHI Focused Study Abstract Attachment A 2008 Adolescent Well-Care Study 2008 Utilization of Services for Members Diagnosed with a Serious Mental Illness

Site Reviews Reviews performed on-site at the MCO/PIHP health care delivery system sites to assess the physical resources and operational practices in place to deliver health care. There are various components of a site review, such as desk audits, emergency site visits, profiling, compliance reporting requirements and other quality and program integrity review activities. The Final Report is reviewed by the Department in order to make recommendations for contract changes and for future audit process improvement.

Physical Health Plan Site Reviews Colorado Access 2009 Denver Health 2009, 2008, 2007 Rocky Mountain Health Plan 2009, 2008, 2007

Behavioral Health Plan Site Reviews Access Behavioral Care 2009, 2008, 2007 Behavioral HealthCare, Inc. 2009, 2008, 2007 Colorado Health Partnerships 2009, 2008, 2007 Foothills Behavioral Health 2009, 2008, 2007 Northeast Behavioral Care 2009,2008, 2007

Performance Improvement Projects (PIPS) Performance Improvement Projects (PIPs), are the method health plans use to improve clinical and non-clinical services. PIPs provide a structured approach to measuring performance, implementing change to improve performance, and measuring the resulting outcomes. Changes that lead to favorable sustained results become permanent standards, practices, or procedures. Changes that are not successful should be revised and re-measured so that improvements are made. MCO/BHO requirements under the Code of Federal Regulations (42 CFR 423.240) state that PIPs be designed to achieve significant improvement, sustained over time, in clinical and nonclinical areas that are expected to have a favorable effect on health outcomes and/or member satisfaction. Behavioral Health PIPS Access Behavioral Care Coordination of Care between Behavioral Health and Primary Care 2009, 2008 Coordination of Care between Psychiatrics Emergency Services and Outpatient Treatment 2009, 2008 Improving Follow-Up After an Inpatient Stay 2007 Improving Outcomes for High-Risk Youth through AFFIRM Care Management 2007 Behavioral HealthCare, Inc. Coordination of Care between Behavioral Health and Primary Care 2009, 2008 Access to Initial Medication Evaluations 2008, 2007 Screening for Bipolar Disorder 2008, 2007 Colorado Health Partnerships Coordination of Care between Behavioral Health and Primary Care 2009, 2008 Increasing Penetration Rate for Older Adult Medicaid Members Aged 60+ 2009 Use of Alternative and/or Crisis Services 2008 The Identification and Use of Alternative and/or Crisis Services to Ensure Treatment at the Least Restrictive Level of Care for Medicaid Children and Adolescents 2007 Ambulatory Follow-up within Seven Days of Hospital Discharge for Youth and Adults2007 Foothills Behavioral Health Partners Coordination of Care between Behavioral Health and Primary Care 2009, 2008 Supporting Recovery 2009, 2008, 2007 Improving Use and Documentation of Clinical Guidelines 2008, 2007 Northeast Behavioral Health Partnership Coordination of Care between Psychiatric Providers and Physical Health Providers 2009, 2008 Therapy with Children and Adolescents: Increasing Caregiver Involvement 2009 Increase NBH Center Provider Communication/Coordination with Primary Care Physicians 2008, 2007 Follow-up after Inpatient Discharge 2007 Managed Care PIPS Colorado Access Coordination of Care 2009 Denver Health Childhood Immunization 2009, 2008, 2007 Member Satisfaction with Access to Pharmacy Services Within Denver Health 2009, 2008, 2007 Rocky Mountain Health Plan Improving Well-Care Visits for Children and Adolescents 2008, 2007 Improving Postpartum Visit Rates 2008

Client Satisfaction Surveys CAHPS ² (Consumer Assessment of Health Plans Study) The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers, such as the communication skills of providers and the accessibility of services. 2009 Adult 2009 Child 2009 CHP+ 2008 National Benchmarking Adult 2008 National Benchmarking Child 2008 Adult 2008 Child

Annual Technical Reports The Balanced Budget Act of 1997, Public Law 105-33, requires states to prepare an annual technical report that describes the manner in which data from activities conducted in accordance with 42 CFR 438.358 was aggregated and analyzed. The report must describe how conclusions were drawn as to the quality and timeliness of, and access to, care furnished by the states' managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs). The report of results must also contain an assessment of the strengths and weaknesses of the plans with regard to health care quality, timeliness, and access, make recommendations for improvement, and assess the degree to which any previous recommendations were addressed by the MCOs and PIHPs. 2009 External Quality Review Technical Report 2008 Behavioral Health Organization External Quality Review Technical Report 2008 Physical Health External Quality Review Technical Report

Interventions Interventions are developed based on recommendations from the Focused Studies. The intervention audience includes Medicaid members and providers. Most interventions are available in English and Spanish. 2008 Prenatal and Postpartum

¹ HEDIS is a registered trademark of the National Committee for Quality Assurance ² CAHPS is a registered trademark of the Agency for Healthcare Research and Quality