fiscal year 2015 quality improvement work plan 2015 work plan final.pdf · under the direction of...

Fiscal Year 2015 Quality Improvement Work Plan

FY 2015 Work Plan

Table of Contents

Administration and Leadership ................................................................................................. 3

Quality Assessment and Performance Improvement ............................................................... 3

Enrollee Rights and Responsibilities ......................................................................................... 9

Access and Availability ............................................................................................................ 10

Coordination and Continuity of Care ...................................................................................... 11

Utilization Management ......................................................................................................... 12

Provider Participation ............................................................................................................. 13

Program Integrity .................................................................................................................... 14

Information Systems ............................................................................................................... 14

Adequate Resources ............................................................................................................... 16

Financial Solvency ................................................................................................................... 17

Quality Improvement Updates/Program Evaluation .............................................................. 17

FY 2015 Work Plan

1. Administration and Leadership Under the direction of the Governing Body and, with its support, University of Utah Health Plans leadership is responsible to adopt and support an Accountable Care Organization (ACO) business model. To meet this obligation requires a shift from episodic care with fee for service payment, to population management with payment methodologies aligned to achieve value-based payment. The overall outcome is intended to be improved population health, improved experience of care (quality and satisfaction), and reduced costs.

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Goal Methods Target Date Project Lead

Ongoing ACO development: Implementation of new payment methodologies.

X X Continue to expand value-based payment to other network providers. Explore value-based payment for disease managed populations.

1. Strengthen payment models with Community Clinics, UPC, and South Main Clinics.

2. Risk stratification to identify high priority populations for care management.

3. Incorporate currently defined (HEDIS) quality measures into the model.

1Q2015 and ongoing

Wilson/ Dorius/ Borer

2. Quality Assessment and Performance Improvement University of Utah Health Plans employs a systematic quality assessment and performance improvement process based on the Nolan model, Plan-Do-Study-Act, and the HIVQUAL interdependent project/program model. The process applies to all aspects of the health plans and the associated contractual requirements. Addressed here are measures of the experience of care (quality and satisfaction) captured through HEDIS and the CAHPS survey.

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Collaborate with the UUMG data warehouse initiative.

X Improve the timeliness, accuracy, and efficiency of HEDIS data collection.

1. Provide EDW staff with HEDIS measures.

2. Validate results obtained from EDW.

September 2014 and ongoing

Johnson

Wellness X X Engage members as active partners in their health and wellness.

1. Publish member focused, timely information, on our website and in member newsletters.

2. Expand the All About U pilot wellness program and

Ongoing Dorius

FY 2015 Work Plan

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associated activities to Health Plan and Healthy U members

Improve chronic disease care for children and adults

X Increase A1c testing rates for people with diabetes to 90% (Baseline 82.39%) Increase annual eye exam rates for people with diabetes to 55% (Baseline 44.23%) Improve the Asthma Medication Ratio to 65% (Baseline 61.69%) Improve appropriate asthma medications for children age 5 – 11 to 90% (Baseline 88.6%)8

1. Provider office outreach - documentation, coding, and billing.

1. Reminders via MyChart and

ActiveCare app. 2. Engage Moran Eye Center. 3. Segment American Academy of

Ophthalmology DVD to be useful to providers and members.

4. Consider offering education sessions for members using the DVD.

5. Member incentives. 6. Work with Community

Clinics/Moran to arrange back-to-back appointments.

1. Collaborate with Community

Clinics pharmacy. 2. Symptom.ly pilot implemented

July 2014. Pilot of 50 in first 90 days, then expand.

3. Monitor asthma medication use and medication ratio data.

4. Partner with UPIQ. 5. Engage providers through

UUMG, newsletters, and outreach.

6. Use Department of Health resources currently under

December 2014 and Ongoing

Dorius/ Johnson/ Armour-Roth

FY 2015 Work Plan

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Physician champions: Tim Graham, MD Chuck Norlin, MD Julie Day, MD

Improve blood pressure control for patients with hypertension. Baseline 58.39%

development (Rebecca Giles). 7. Implement Home visit folder

that includes a home assessment tool designed to surface needs for asthma education.

8. Implement the Asthma Education Booklet and children’s coloring book.

9. Magnetic folders will house the Asthma Action Plan to be posted on the home refrigerator.

1. Continue participation in the

Health Plan Partnership hypertension initiative.

2. Partner with HealthInsight on Million Hearts.

3. Member outreach related to hypertension.

Improve care for children with pharyngitis Physician champions: Chuck Norlin, MD Julie Day, MD

X Improve Appropriate Testing for Children with Pharyngitis to 70%. (Baseline 67.89%) Maintain Appropriate Treatment for Children with URI at 95%.

1. Provider office outreach - documentation, coding, and billing.

2. Incorporate performance into UPC value based payment.

3. Engage with UPIQ to create messaging and drive antibiotic stewardship

1. Incorporate performance into UPC value based payment.

2. Engage with UPIQ to create messaging and drive antibiotic stewardship



FY 2015 Work Plan

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Decrease the incidence of vaccine preventable conditions Physician champions: Ellie Brownstein, MD Julie Day, MD

X Maintain childhood immunization Combo 3 compliance at 75% or improve to 80%. Increase adolescent immunization compliance rate (Combo 1) to 70%. (Baseline 63.65%) Increase the HPV vaccination rate to 20%. (Baseline 13.38%) Promote adult immunizations.

1. Continue to promote and educate regarding immunizations for all ages, with an emphasis on children and adolescents.

2. Pair immunization reminders with CHEC reminders.

3. Engage the Patient Advisory Group to understand barriers.

4. MyChart reminders. 5. Children’s health infographic. 6. Partner with UPIQ and the

Vaccine Advisory Committee 1. Measure using hybrid method. 2. Age appropriate member

outreach through member newsletters and our website.

1. Link to the Department of

Health HPV Awareness Campaign.

2. Targeted outreach to parents of 11 - 12 year olds.

3. Link to adolescent immunizations.

4. Educate the pediatric care managers and our partner pediatric providers, i.e., Community Clinics, UPC, South Main Clinic using the Invisible Threat video.

1. Continue active participation in



FY 2015 Work Plan

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Tamara Sheffield, MD (UAIC) UAIC and the Vaccine Advisory Committee.

2. Promote adult immunizations in August.

3. Targeted outreach to pregnant women for Tdap.

Increase women’s health screening rates Physician champion: Julie Day, MD

X Increase mammography screening rate to 55% and cervical cancer screening rate to 65% (Mammography baseline 45.49%) (Cervical baseline 42.82%) Increase the overall chlamydia screening rate to 57% (Baseline 25%)

1. Implement recommendations from the cancer screening stakeholder group, e.g., MyChart, social media, infographic.

2. Partner with Community Clinics to improve or spread their processes and practices.

3. Partner with Strong Start. 4. Engage physician champions in

impacting provider performance.

5. Institute directed provider feedback.

6. Work with Community Clinics to adapt methods successful in previous cancer screening initiatives.

1. Targeted outreach to 16 - 24

year olds. 2. Engage UPC and South Main

Clinic, CHCs.



Continued reduction in preterm births Physician champion: Erin Clark, MD

X X Maintain the rate of preterm births <36 weeks to < 5%. Reduce total preterm births by 1%.

1. Continued participation in Strong Start.

2. Emphasize contraception and 17P

Ongoing Dorius/ Johnson/ Armour-Roth

FY 2015 Work Plan

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Continued improvement in prenatal and postpartum care Physician champion: Erin Clark, MD Karen Buchi, MD

X Continue to increase the expected number of prenatal visits by 5% (Baseline 56.93%) Increase prenatal care in the 1st trimester or w/in 42 days of enrollment to 25% (Baseline 72.26%) Increase postpartum visits between 21 and 56 days post-delivery to 65% (Baseline 60.1%)

1. Encourage the use of telehealth in low risk populations.

2. Provider outreach to encourage telehealth and implement reminders.

3. Develop a prenatal infographic. 1. Validate administrative data and

review MRR method for this measure.

2. Work with providers to complete a prenatal visit on enrollment.

1. Work with providers using

cocoon visits to work within the date parameters.

2. Track appropriate care that falls outside the HEDIS time frame.

December 2014 and ongoing


Continued improvement in well child care Physician champion: Karen Buchi, MD

X Increase well child visits at 0 – 15 months to 65% (Baseline 58.64%) Increase well child visits at 3 – 6 years to 72% (Baseline 62.04%)

1. Combine CHEC and well child visits, as well as immunizations into a targeted, ongoing program.

2. Consider using social media to reach families more timely.

3. Create and post an infographic related to childhood wellness.

1. Adapt the above for this age

group.

December 2014


Reduce resource utilization, cost, and radiation exposure by eliminating imaging for low back pain

X X Improve the percentage of members with a primary diagnosis of low back pain who did not have an imaging

1. Link with the Radiology Department initiative.

2. Support hard stop in Epic.

December 2014


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Physician champion: XXXXX, MD

study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis to 80%. (Baseline 71.72%)

Annual CAHPS Survey Physician champion: Michael Magill, MD Julie Day, MD UUMG

X X Improve CAHPS scores to the level of the national average or above for:

Getting needed care (Baseline76.0%) Getting care quickly (Baseline 87.0%) Customer service rating (Baseline 84.9%)

1. Continue customer service focus.

2. Outreach to specialty groups through CAC and the UUMG to improve timeliness.

3. Attempt to increase response rate.

December 2014 and ongoing

Peterson/ Muhlestein/ Harkness/ Dorius

3. Enrollee Rights and Responsibilities University of Utah Health Plans have established functions, operating under established policies and procedures, which are designed to provide safe, effective, efficient, timely, equitable and patient-centered services to our members. Those functions include member and community education and outreach, an efficient enrollment process, accurate and timely claims processing, avenues to communicate appeals and grievances, and mechanisms to assist members to make informed decisions about their care.

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Member and Community Outreach X X Increase effectiveness of communications by leveraging technology to reach members and providers.

1. Increase the number of MyChart accounts.

2. Engage more members with social media.

2Q2015 Peterson/ Dorius

Continue to decrease the total number of adjusted claims

X X Decrease overall claims adjustments by 2%

1. Organize recurring meeting. 2. Review reason for adjustments

and identify areas of improvement.

3. Implement identified changes.

3Q2014 4Q2014 1Q2015

Harkness/Smi

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FY 2015 Work Plan

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Increase member engagement X Increase member engagement through various member touch points.

1. Implement online chat functionality

2. Reach out to members for welcome call

3. Implement phone survey option in customer service

2Q2015 Harkness

4. Access and Availability University of Utah Health Plans ensures that all services are available, accessible, and provided to members in a culturally and linguistically appropriate manner. We utilize primary language information in the claims system to provide member materials for all languages making up 3% or more of the enrolled population and provide translation services for all situations. We continually strive to increase access to and availability of services to all members through scheduling, technology, expanded service hours and expanded services within those hours

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Increase access to services X X Improve the availability and use of after-hours, Saturday, and remote services. Direct scheduling by care managers.

1. Identify patients utilizing the ED on Saturdays and after hours.

2. Outreach mailer and care manager notification of urgent care services within their geographic locations.

3. Communicate the availability and location of after-hours and Saturday service to members.

4. Utilize telehealth, Project ECHO.

2Q2015 Dorius/ Day

FY 2015 Work Plan

5. Coordination and Continuity of Care University of Utah Health Plans is committed to providing coordinated care across the continuum. Strengthening the care management team with physician leaders, using technology to expand the care managers’ reach, engaging members in self-management of chronic illnesses, and improving the potential and quality of life for tech dependent children are key strategies to achieve coordinated care across the continuum. The outcomes will include increased member satisfaction, higher quality care, improved member health, increased access to care, and lower overall cost.

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Ongoing development of the care management program

X X Continue to advance care management teams in the population management approach.

1. Compile ROI for each team using process mapping and the Harvard methods.

2. Identify outcomes for each team and monitor progress.

3. Increase focus on high cost, high risk pharmacy.

4. Implement programs for: a. Palliative care b. Pain management c. Disease management

1Q2015 Dorius/ Armour-Roth/ Johnson

Access to Care Management services X X Outreach to our members so they are aware of the range of our care management services. Encourage enrollment in MyChart, CM telephone outreach and home visits, text messaging, telehealth visits.

1. Encourage member enrollment in MyChart.

2. Care manager outreach: a. Telephone and text

messaging b. MyChart communication c. Home visits d. Telehealth visits

1Q2015 Dorius/ Armour-Roth

Self-management programs for diabetes, heart disease, and asthma Physician champion: Tim Graham, MD Christopher McGann, MD Chuck Norlin, MD

X X Engage and empower patients in self-management programs using community services and technology.

1. Enroll members in ActiveCare. 2. Promote the Living Well

Program. 3. Partner with the Million Hearts

initiative. 4. Enroll members in Symptom.ly 5. Monitor outcomes and ROI.


Improved quality of life for ventilator X Better align the needs of these 1. Implement telehealth visits. 4Q2014 Dorius/

FY 2015 Work Plan

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dependent children and their families Physician champion: Nancy Murphy, MD

children and their families through effective collaboration among specialty providers, PCP, and health plan.

2. Monitor parent stress scores. 3. Measure patient and family

satisfaction.

Armour-Roth/ Johnson

Improve care coordination for members requiring both medical and psychiatric care Physician champions: Kristi Kleinschmidt, MD

X Increase the number of Community Clinics with integrated medical and mental health services to 10. Increase use of GATE Utah.

1. Continue participation in the BHP Care Coordination Partnership.

2. Monitor GATE Utah referrals. 3. Assess patient and provider

satisfaction.


6. Utilization Management In order to provide evidence-based, efficient, and equitable care and services to our members. University of Utah Health Plans is committed to a utilization management program based on nationally recognized criteria that are accurately and appropriately applied in all cases.

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Encourage and enforce appropriate utilization of services. Physician champions: Dean Smart, MD Nate Wanner, MD Scott Junkins, MD

X X

Implement programs to address high risk, high cost drugs. Evaluate new and/or high cost procedures. Better use the palliative and pain management services.

1. Establish a Utilization Management Team.

2. Train staff on palliative care resources.

3. Better utilize the Pain Clinic. 4. Adopt drug protocols.


Complete the redesign of the DME process.

X X

Streamline DME approval processes and reduce expenditures.

1. Implement process changes identified in process mapping.

2. Complete fee schedule changes. 3. Review DME rentals.

3Q2014 Dorius/ Muhlestein/ Smith

FY 2015 Work Plan

7. Provider Participation University of Utah Health Plans engages providers through newsletters, updates and performance feedback. Providers are active participants on all Health Plans committees; advise care managers; and lead population-based care management teams. Implementing a provider portal adds another level of engagement. Increasing performance feedback on all quality measures will provide additional opportunities for engagement and collaboration.

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Physician Connection (formerly Plan Link) implementation

X X Recruit additional Physician Connection participating providers.

1. Epic 2014 upgrade will be completed in Q1 2015 and will have several changes that will need to be tested and communicated to providers.

2. Provider groups who use both the clinical and health plan features will be implemented in Q3 2014.

3. Enhance training environment and roll out to additional pilot practices.

4. Solicit feedback from additional pilot practices.

5. Develop criteria for additional offices.

6. Implement with minimum 20 offices.

2Q2015 Muhlestein/ Smith

Provider feedback for continuous improvement in compliance with CHEC guidelines.

X Achieve 90% compliance with CHEC physical exam component guidelines.

1. Continue to improve the CHEC audit process: a. Conduct quarterly audits b. Redesign the audit tool and

methodology 2. Reinstitute member letters. 3. Establish a provider outreach

program.

December 2014

Dorius/ Johnson

FY 2015 Work Plan

8. Program Integrity The Fraud, Waste and Abuse Program is designed to prevent and detect fraudulent and/or abusive behavior by providers, members, and other individuals or organizations associated with the operations of the University of Utah Health Plans. The program is linked to the re-credentialing process through regular reviews of the Fraud and Abuse audit log prior to credentialing/re-credentialing meetings.

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Continued refinement of the Fraud, Waste, and Abuse Program

X X Provide training to providers (internal and external) identified through the fraud/waste/abuse program.

1. Set up random quarterly audits with provider types that abuse trends are more prevalent, i.e., Home Health, DME.

2. Monthly audits. 3. Develop process for reporting

identified substance abuse to the OIG/MFCU.

Ongoing Peterson/ Muhlestein

9. Information Systems Information systems supports the University of Utah Health Plans overall improvement strategy by facilitating the collection, aggregation, analysis, tracking, and

reporting of utilization, cost, quality, and service data. Information systems include claims, registries, databases, electronic medical records, and analytical

programs. Two important focus areas are the CMS mandated ICD-10 and an improved Provider Database which serves as a resource for claims processing, customer

service, and provider directories, among other uses. Increasing the accuracy of the Provider Database will result in more accurate provider directories, better customer service to

members and providers, a decreased number of misdirected payments, and increased efficiency during the credentialing process.

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ICD-10 Implementation X X Continue to prepare and test systems to achieve successful ICD-10 implementation.

1. Additional testing of EDI claims with internal providers.

2. Testing of EDI claims with external providers.

3. Review of build completed by coding auditor position.

4. iCES upgrade to version 5.2.1 for additional remediation of

1/15-3/15 3/15-6/15 10/14-12/14 1/15

Smith

FY 2015 Work Plan

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ICD10. 5. Testing with other outside

vendors (Crimson, Verisk, etc.). 6. Actuarial analysis of ICD10

conversion on inpatient claims.

3/15-6/15 TBD

Continued improvement in the setup and population of the provider database

X X Achieve 80% accuracy of the

database.

1. Complete redesign of provider database.

2. Continue new process. 3. Audit 5% of delegated

credentialing audits. 4. Hire additional coordinator

position by 10/14. New executive position starts 7/7/14.

3Q2014 Muhlestein/ Smith

Use available technology to reduce workload and improve turnaround time.

X X Expand cHIE access for facility documentation. MyChart access for plan/member communication and documentation review.

1. Expand included populations. 2. Begin looking at hospital

admissions and discharges. 1. Obtain MyChart security access

to communicate with members. 2. Review electronic

documentation before requesting additional records.

3. Monitor workload and workflow.


FY 2015 Work Plan

10. Adequate Resources University of Utah Health Plans’ administrative team is aware and fully supportive of quality improvement initiatives as evidenced by encouraging innovative ideas and solutions, use of technology, and use of resources that will better serve members, providers, staff, and the University community.

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Administrative and leadership support for quality improvement initiatives Physician champions: Mike Magill, MD John Bohnsack, MD Rachel Hess, MD

X X Inform leadership of current and planned QI activities and projects. Establish a link to University Healthcare committees approving lean projects. Increase awareness of health plan activities within the University community.

1. Restructure the Population Management Committee.

2. Partner with the Health System Innovation and Research (HSIR) Department.

3. Continue to design lean projects within Health Plans.

4Q2104 and Ongoing

Wilson/ Magill

Expand the program to curb non-emergent, non-urgent use of the Emergency Department Physician champion: Scott Youngquist, MD

X X Continue to reduce ED utilization for non-emergent, non-urgent care.

1. Continue to work with the ED High Utilizer Committee to identify patients that have high ED utilization for non- emergent care.

2. Implement a program incorporating linkage to primary care, community-based services, telehealth technology, member and provider engagement and follow up.

3. Align payment with the appropriate/desired levels of care.

1Q2015 Dorius

FY 2015 Work Plan

11. Financial Solvency University of Utah Health Plans uses sound financial management and accounting best practices to ensure financial solvency. A key marker of success is the ability to manage the Medical Loss Ratio.

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Manage Medical Loss Ratio (MLR) X X Healthy U MLR 92.1% UHCP MLR 86.1%

Continued emphasis on Care management OB & ED diversion initiatives, as well as other programs. 1. Revamp deductible, copay

benefit structure 2. Care management for OB and

other programs

June 2015 Finlinson

12. Quality Improvement Program Updates/Program Evaluation University of Utah Health Plans is contractually obligated to maintain a Quality Improvement Program. The Quality Improvement program is organized through the Quality Improvement Program Description, Quality Improvement Work Plan, and Quality Improvement Program Evaluation.

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QI Program Description and Work Plan

X X Monitor, improve, and document the quality of care and service provided to our members

Continue to update the program annually and maintain quarterly accountability to the Work Plan

Ongoing Johnson

QI Program Evaluation X X Evaluate and document the quality of care and service provided to our members

Continue to evaluate progress at least quarterly. For goals that are no longer applicable or not feasible, consider finalizing evaluation of those goals at the time they are determined to be non-operational.

Ongoing Johnson

fiscal year 2015 quality improvement work plan 2015 work plan final.pdf · under the direction of...

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