2019 coronary artery disease program evaluation · (91.03%) received monitoring for ace inhibitors...

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2019 Coronary Artery Disease

Program Evaluation

2019 Coronary Artery Disease Program Evaluation

Table of Contents

Program Purpose Page 1

Program Goals Page 1

Program Objectives Pages 1-2

Measurements

Evaluation Annual Participation Rates Page 2

Coronary Artery Disease Member Engagement Page 3

Coronary Artery Disease Management HEDIS® Results Pages 3-7

Healthy Kentuckians Results Page 8

Analysis of Findings Page 9

Number of Referrals by Source Page 10

Member Discharge Status Page 11

Emergency, Admission and Readmission Utilization Page 12

Coronary Artery Disease Cost Trends Page 13

Overall Financial Impact for Identified Sample of Coronary Artery Disease Members Page 14

Goals Met/Not Met Page 15

Coronary Artery Disease Care Gaps Pages 16-17

Member Satisfaction Survey Results with Services Received Pages 17-18

Member Satisfaction Survey Results for Improvement of Health or Quality of Life Page 18

Barriers/Opportunities Page 19

Activities Pages 20-22

3/3/20 FINAL Page 1 of 22

2019 Coronary Artery Disease Program Evaluation

Program Title: Coronary Artery Disease (CAD) Program

Evaluation Period: January1, 2019 – December 31, 2019

Program Purpose: The CAD Program is a system of coordinated healthcare interventions and communications for a population with a condition in which patient self-care efforts are significant. Adherence to evidence-based medicine combined with a team approach assist in: • Empowering members

• Supporting behavior modification

• Reducing incidence of complications

• Improving physical functioning

• Improving emotional well-being

• Supporting the clinician/patient relationship

• Emphasizing and reinforcing use of clinical practice guidelines

Program Goals: The goal of the CAD Program is to effectively identify members with potentially avoidable healthcare needs and intervene to positively impact the health outcomes and quality of life for patients with CAD. By using a multi-faceted approach to achieve the best possible outcomes the program can lower costs through preventing avoidable episodes of care and better coordination of care. Program goals include: • Partner with member, their caregiver and their primary and specialty care

clinicians to develop a plan of care or action plan by a CAD Health Educator

• Improve medication adherence

• Facilitate appropriate communication across the entire care team

• Optimize CAD management and close relevant gaps in evidence-based care

• Educate patients on CAD diagnosis and self-management

Program Objectives: • Increase adherence to American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Guidelines medication management protocols for coronary vascular disease.

• Increase the percentage of members receiving angiotensin-converting enzyme (ACE) inhibitors post-myocardial infarction (MI).

• Increase the percentage of members receiving beta-blocker treatment in all post-MI patients unless contraindicated.


• Increase the percentage of all adult members receiving (Lipid) LDL-C screening.

• Increase adherence to LDL-C monitoring in patients with coronary vascular disease or hypocholesteremia.

• Increase member adherence to the use of LDL-C lowering and anti-hypertensive drug therapy.

• Increase member awareness of those risk factors that increase the risk of heart disease and stroke.

• Promote healthy lifestyle-diet and nutrition, weight management, physical activity, smoking cessation, routine physician office visits, screenings, and treatment.

Measurements: Overall effectiveness of the CAD Program is measured through annual

participation rates and audited HEDIS®1 results.

Annual Participation Rate Eligible members are identified and passively enrolled in the CAD Program. Members may “opt out” of the Program and elect not to receive services, by notifying a CAD Health Educator or the Care Connector Program, either telephonically or in writing. Participation Rates are tracked and reported annually.

Graph 1.

1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)

18 22 25

36

25 22 26 2217

2919 22

27

51 54

134

21

127

70

5

93

165

50

9

3 8 515

010 6 0

1017

6 0January February March April May June July August September October November December

Members Engaged Members Identified Declined Participation

35.11% Participation


Member Engagement

CAD Health Educators engaged 283 members in 2019. This represents a 15% increase from 2018. Members appropriate for this program have a CAD diagnosis. CAD Health Educators work with the members to decrease readmissions and ER utilization and to increase utilization of outpatient services and compliance with treatment and care plans.

Graph 2.

CAD Management

HEDIS® Results

The 2019 HEDIS® Results are based on measurement year 2018 data. 1. Controlling High Blood Pressure (CBP)

The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year.

Findings: In measurement year 2018, a total of 33,064 members were identified with high BP. In a sample of 411 members, 198 (48.18%) had a controlled BP.

1714

21

31

22

1614

18

23

2926

1518

2225

36

2522

26

22

17

29

1922

January February March April May June July August September October November December

Member Engagement for Coronary Artery Disease Program2018 vs. 2019 (January through December)

2018 2019


Graph 3.

The goal to meet or exceed the 2019 Quality Compass® 90th Percentile for CBP (72.26%) was not met. For measurement year 2018, CBP met the 2019 Quality Compass® 10th Percentile.

2. Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)

The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.

Findings: In measurement year 2018, a total of 327 members were identified and 241 (73.70%) received treatment.

Graph 4.

23.00%

33.00%

43.00%

53.00%

63.00%

73.00%

MY 2015 MY 2016 MY 2017 MY 2018

53.76%

59.95%

33.42%

48.18%

Controlling High Blood Pressure

Goal 72.26%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

MY 2015 MY 2016 MY 2017 MY 2018

85.31%

69.41%

82.43%

73.70%

Persistence of Beta-Blocker Treatment After a Heart Attack

Goal 85.00%


The goal to meet or exceed the 2019 Quality Compass®2 90th Percentile for PBH (85.00%) was not met. For measurement year 2018, PBH met the 2019 Quality Compass® 33.33rd Percentile.

3. Annual Monitoring for Patients on Persistent Medications (MPM)

The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Three rates are reported:

• Annual monitoring for members on ACE inhibitors or angiotensin receptor blockers (ARB).

• Annual monitoring for members on diuretics.

• Total rate (the sum of the two numerators divided by the sum of the two denominators).

Findings: In measurement year 2018, a total of 25,137 members were identified and 13,136 (91.03%) received monitoring for ACE Inhibitors or ARBs, 9,726 (90.85%) received monitoring for Diuretics with a total of 22,862 (90.95%) that received monitoring. Graph 5.

2The source for data contained in this publication is Quality Compass® 2019 (Medicaid) and is used with the permission of the NCQA. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass® is a registered trademark of NCQA.

84.00%

85.00%

86.00%

87.00%

88.00%

89.00%

90.00%

91.00%

92.00%

93.00%

ACE INHIBITORS OR ARBS

90.33%

89.22% 89.29%

91.03%

Annual Monitoring for Patients on Persistent Medications

MY 2015 MY 2016 MY 2017 MY 2018

Goal 92.55%


Graph 6. Graph 7. The goals to meet or exceed the 2019 Quality Compass® 90th Percentile for MPM ACE/ARB (92.55%), MPM Diuretics (92.51%) and MPM Total Rate (92.55%) were not met.

For measurement year 2018, all three MPM measures met the 2019 Quality Compass® 75th Percentile.

84.00%

85.00%

86.00%

87.00%

88.00%

89.00%

90.00%

91.00%

92.00%

93.00%

DIURETICS

90.71%90.02%

89.44%

90.85%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 92.51%

84.00%

85.00%

86.00%

87.00%

88.00%

89.00%

90.00%

91.00%

92.00%

93.00%

TOTAL RATE FOR ANNUAL MONITORING

90.33%

89.48% 89.35%

90.95%


MY 2015 MY 2016 MY 2017 MY 2018

Goal 92.55%


4. Statin Therapy for Patients with Cardiovascular Disease (SPC)

The percentage of males 21–75 years of age and females 40–75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria:

• Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.

• Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.

Findings: In measurement year 2018, a total of 2,762 members were identified as needing a statin medication. Of those members, 1,801 (65.21%) received a statin therapy and 1,081 (60.02%) of the 1,801 members had 80% adherence.

Graph 8. Graph 9. The goals to meet or exceed the 2019 Quality Compass® 90th Percentile for SPC Received Statin Therapy (70.19%) and SPC Statin Adherence 80% (71.00%) were not met. SPC Received Statin Therapy met the 2019 Quality Compass® 50th Percentile and SPC Statin Adherence 80% met the 2019 Quality Compass® 33.33rd Percentile.

48.00%

53.00%

58.00%

63.00%

68.00%

73.00%

78.00%

RECEIVED STATIN THERAPY

75.43% 75.32%73.61%

65.21%

Statin Therapy for Patients with Cardiovascular Disease

MY 2015 MY 2016 MY 2017 MY 2018

Goal 70.19%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

STATIN ADHERENCE 80%

82.22%

47.15%

70.91%

60.02%

Statin Therapy for Patientswith Cardiovascular Disease

MY 2015 MY 2016 MY 2017 MY 2018

Goal 71.00%


Healthy Kentuckians (HK) Results

The 2019 HK Results are based on measurement year 2018 data.

1. Cholesterol Screening The percentage of male members ≥ 35 years of age and female members ≥ 45 years of age who had an outpatient office visit and had LDL-C screening in the measurement year or during the four years prior.

Findings: In measurement year 2018, a total of 51,875 members were identified in the appropriate age range, of those members 40,928 (78.90%) received an LDL-C Screening. Graph 10. • Specific results include:

o LDL-C Screening had a decrease by 1.15 percentage points

32.00%

42.00%

52.00%

62.00%

72.00%

82.00%

MY 2015 MY 2016 MY 2017 MY 2018

59.62%

77.95%80.05% 78.90%

LDL-C Screening


Analysis

HEDIS®: Passport aspires to be in the Quality Compass® 90th Percentile for each measure. Results for HEDIS® 2019 (MY 2018) for CBP indicator indicated a significant increase of 14.76 percentage points which met the 2019 Quality Compass® 10th Percentile. Results for PBH indicator indicated a decrease of 8.73 percentage points from MY 2018 and achieved the 2019 Quality Compass® 33.33rd Percentile. Results for MPM ACE Inhibitors or ARBs indicator indicated an increase 1.74 percentage points, MPM Diuretics had an increase of 1.41 percentage points, and MPM Total Rate for Annual Monitoring had an increase of 1.60 percentage points. All three MPM measures achieved the 2019 Quality Compass® 75th Percentile. Results for SPC indicator for Received Statin Therapy had a significant decrease of 8.40 percentage points and SPC Statin Adherence 80% had a significant decrease of 10.89 percentage points. SPC Received Statin Therapy met the 2019 Quality Compass® 50th Percentile and SPC Statin Adherence 80% met the 2019 Quality Compass® 33.33rd Percentile. Member Engagement: Multiple member interventions were conducted to educate the member on the importance of screenings/tests needed based on the ACCF/AHA Guidelines. Providers are notified of members in need of screenings and provided with resources to track members with cardiovascular conditions. Members receive a new member packet upon enrollment in the Condition Care CAD program. Members engaged in the Condition Care CAD program participate in health coaching sessions to assist in learning better condition self-management skills. Community and Clinician Engagement: Providers received status updates on members enrolled in the CAD Program and provided reference information on the ACCF/AHA Guidelines on Passport’s website. Community activity involvement included collaboration with the AHA, including Have Faith in Heart Event, Go Red for Women, Stroke Association, American Red Cross and community and health fairs around Kentucky. Risk Stratification: During 2019, an average of 855 members were identified via the Passport’s risk stratification tool as appropriate for the Condition Care CAD Program. Of those members, 545 received one-on-one telephonic outreach by a CAD Health Educator. Three separate attempts are made to contact the member. All enrolled members receive an initial mailing, followed by health coaching sessions with a CAD Health Educator. Because members with a cardiovascular diagnosis typically have multiple comorbid conditions, some members will continue to be stratified in the Complex Care Management Program versus the CAD Program. Member Complaints: During 2019, there were no complaints received regarding the CAD Program or a CAD Health Educator.


Referral Sources

Graph 11.

Passport proactively identifies CAD members through multiple resource avenues. Findings: Graph 11 represents referrals by source. The top three sources were:

1) Stratification 2) Utilization Management 3) Physician/Provider

Multiple avenues are used to proactively identify members for the CAD Program. Education and information are distributed via the Member and Provider Handbooks, Member Newsletter, New Member Packets, and Member and Provider Program brochures. Provider Request for Care Management Forms are available as well on the Passport website. Education is provided through internal department meetings and internal referrals between Care Management and Behavioral Health (BH) is encouraged. A daily report is obtained from the 24-Hour Nurse Advice Line of identified members. Health Risk Assessments (HRA) are utilized as a means of risk screening for the member. An attempt is made to obtain an HRA for all new members and again when health status changes.

Health Risk Assessment (HRA)

1

PROGRAM: Medically Frail

1Member Services

2Patient/Family

2

PROGRAM: Transition Care

5

Physician/Provider8

Utilization Management11

Stratification253

n = 283


Member Discharge Status

Graph 12.

Passport aims to reduce the inability to sustain engagement for CAD members by identifying barriers and trends. Findings: Graph 12 represents reasons for member discharge from the CAD Program during 2019. The top three reasons were:

1) Closed – Problem Resolved/Goals Met 2) Closed – Lost Contact 3) Closed – Insurance Terminated

There were 146 (60%) members discharged/closed due to problem resolved/goals met; 77 (32%) members lost contact and 14 (6%) members discharged due to insurance terminated. Discharge reasons remain consistent with 2018.

1 1 1 1 1 1

14

77

146

n = 243

Closed-Externally Managed

On Hold-Patient in Transition Care

Closed-Discontinued/Patient

Closed-Deceased

Closed-Unable to Reach

Closed-Not Appropriate for Program

Closed-Insurance Terminated

Closed-Lost Contact

Closed-Problem Resolved/Goals Met


Emergency Department and Inpatient Utilization

Graph 13. Graph 14.

Graph 15. Passport aims to reduce the rates of inappropriate emergency department (ED) utilization, avoidable inpatient admissions, and 30-day readmissions. Findings: Graphs 13, 14, and 15 represent a sample of CAD members and are a comparison of ED/inpatient utilization six months prior to and six months following engagement. After program involvement during 2019, the data indicates: • A decrease in the number of members accessing the ED (-33.33%), experiencing inpatient stays

(-61.76%) and being readmitted (-40.00%). • A decrease in the number of visits to the ED (-43.98%), inpatient stays (-59.79%) and

readmissions (-50.00%).

216

121 108

72

38%25%

Prior Post

ED Utilizationn = 283

ED Visits # Members Percentage of Total Members

97

39

68

26

24% 9%

Prior Post

Inpatient Utilizationn = 283

IP Visits # Members Percentage of Total Members

6

3

5

3

2% 1%

Prior Post

Readmissions within 30 Daysn = 283

Readmission Visits # Members Percentage of Total Members


CAD Cost Trends

Graph 16. Passport aims to reduce costs related to ED utilization, Inpatient Admission, and 30-day Readmissions. Findings: Graph 16 represents a sample of CAD members comparing utilization six months prior to and six months following engagement. After program involvement during 2019, the data demonstrates: • A decrease of $65,954.95 in ED costs. • A decrease of $585,729.01 in inpatient costs. • A decrease of $57,402.02 in readmission costs.


Overall Financial Impact for Identified Sample of CAD Members

Graph 17. Summary: Graph 17 represents the overall financial impact for the identified sample of CAD members comparting utilization six months prior to and six months following engagement. After program involvement during 2019, the data demonstrates a potential cost savings of $709,085.98. This is not representative of the entire program, but instead only the sample for analysis. This represents what is a potentially significantly higher amount for the entire program population.

Total Cost Post CM$472,147.53

Total Cost Prior to CM$1,181,233.51

n = 283


Goals Met/Not Met

Graph 18.

Passport aims to meet or exceed a rate of 90% of care plan goals partially or completely met for members enrolled in the CAD Program.

Findings: Graph 18 represents the status of care plan goals for members enrolled in the CAD Program. In 2019, 657 goals were “completely met/partially met.” There was a total of one (1) goal that was not met due to the members could not complete. There was a goal completion rate of 99.85% for 2019; which remains consistent from 2018 (98.78%). The goal to meet or exceed the target of 90% of care plan goals partially or completely met for members enrolled in the CAD Program was exceeded.

2

181

475

0%

28%

72%

Not Met Partially Met Completely Met

2019 Total Goals 2019 Percentage


CAD Care Gaps

Graph 19.

Passport aims to close gaps in care for members enrolled in the CAD Program. Findings: Graph 19 represents the total number of care gaps for members enrolled in the CAD Program. In 2019, a total of 1,738 care gaps were identified. Of those, 1,054 were closed (60.64%) and 684 (39.36%) were still active. Below is a list of the Top 10 Closed and Active care gaps identified for members in the CAD Program: Top 10 Closed Care Gaps Total 1,054 Patient with cardiovascular disease: statin therapy may be indicated 221 21% Patient may be nonadherent to medications for cholesterol (statins) 143 14% Patient with diabetes: greater HbA1c control may be indicated 99 9% Patient with depression may not have remained on antidepressant for at least 6 months 75 7% Patient may be nonadherent to medications for hypertension (ACE/ARB) 74 7% Patient with depression may not have remained on antidepressant for at least 12 weeks 71 7% Patient with diabetes: statin therapy may be indicated 64 6% Patient with persistent asthma may be nonadherent to controller medications 46 4% Preventive/ambulatory care visit may be indicated 39 4% Cervical cancer screening may be indicated 37 4%

Active684

Closed1,054

n = 1,738


Top 10 Active Care Gaps Total 684 Patient with hypertension: greater blood pressure control may be indicated 163 24% Patient with diabetes: greater blood pressure control may be indicated 75 11% Colorectal cancer screening may be indicated 69 10% Patient with diabetes: greater HbA1c control may be indicated 65 10% Cervical cancer screening may be indicated 61 9% BMI assessment may be indicated 61 9% Patient with diabetes: statin therapy may be indicated 41 6% Patient with diabetes: eye exam may be indicated 38 6% Patient with cardiovascular disease may be nonadherent to statins 28 4% Breast cancer screening may be indicated 24 4%

CAD Member Satisfaction Results for Services Received

Graph 20. Passport aims to achieve or exceed a score of 90% or above in all areas of member satisfaction for the CAD Program. Findings: Graph 20 represents the members’ satisfaction regarding services received. The areas surveyed include: 1) Understand Health Condition 2) Professional and Courteous Manner 3) Value of Written Materials 4) Help with Making Decisions The goal was to achieve 90% satisfaction for each area. For 2019, 227 telephonic member surveys were conducted, of which 38 were completed (17% response rate). The target was met in all but one area.

100%92% 92% 89%

93%

0%

20%

40%

60%

80%

100%

120%

UnderstandHealth Condition

Professional andCourteous Manner

Value ofWritten Materials

Help withMaking Decisions

Total

Goal 90%

n = 38


Interventions: • Upon closure of the CAD Program, members are encouraged to participate/provide feedback to the

survey. • Outreach is done to members who indicate via the satisfaction survey that they would like to be

contacted.

CAD Member Satisfaction Results for Improvement of Health and Quality of Life

Graph 21. Passport aims to maintain or exceed the goal of 75% or above in member's perception of improved overall health status and quality of life. Findings: Graph 21 represents the members’ satisfaction regarding improvement in health or quality of life. The areas surveyed include: 1) Deal with Health Condition 2) Quality of Life 3) Overall Health

The goal was to achieve 75% satisfaction/agreement for each topic. The target was exceeded in all areas. Interventions: • Upon closure of the CAD Program, members are encouraged to participate/provide feedback to the

survey. • Follow up outreach is done by Management to members who indicate via the satisfaction survey that

they would like to be contacted.

87%84%

79%83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Deal with Health Condition Overall Quality of Life Overall Health Total

Goal 75%

n = 38


Barriers and Opportunities

Barrier: Lack of clinician awareness regarding ACCF/AHA Guidelines the diagnosis and treatment of cardiovascular disease.

Opportunity: • Increase clinician awareness of the appropriate treatment for persons with cardiovascular disease

by posting current ACCF/AHA Guidelines on Passport’s website. Barrier: Member lack of knowledge regarding cardiovascular disease. Opportunity: • Increase members’ and caregivers’ knowledge regarding the appropriate treatment and

appropriate self-management skills for persons with cardiovascular disease. • Increase member and caregiver awareness regarding the appropriate treatment and appropriate

self-management skills for persons with cardiovascular disease through: o Face-to-face outreach o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport’s website o Member educational materials

Barrier: Member lack of knowledge related to risk factors for cardiovascular disease. Opportunity: • Identify members with risk factors for cardiovascular disease to provide targeted member

educational outreach.

• Collaborate with community agencies and statewide initiatives to increase awareness and management of risk factors for cardiovascular disease.

• Utilize the CAD Program to educate members regarding risk factors for cardiovascular disease.

Barrier: Limited member engagement in Condition Care CAD program compared to overall CAD population limits reach of care management interventions. Opportunity:

• Targeted member education campaign to increase understanding and education about appropriate care.

• Targeted provider education campaign to address key HEDIS® measures.


Interventions completed in 2019: Provider Education: • Increase provider awareness of the appropriate treatment for persons with cardiovascular

conditions by posting current ACCF/AHA Guidelines on Passport’s website and through Provider Relations site visits.

Member Education: • Educated members/caregivers regarding cardiovascular conditions through face-to-face outreach,

telephonic outreach, member newsletters, on-hold SoundCare messages, Passport’s website, and member educational material.

• Collaborated with CareMessage to provide information on preventive care to members with

Passport sponsored cell phones.

• Continued efforts to educate members and/or caregivers regarding cardiovascular disease, and smoking cessation.

• Collaborated with community partners to provide supportive services to members/families who need advance illness management services without the requirement of discontinuing active treatments.

Screening Activities: • Administered the Patient Health Questionnaire (PHQ) 2 with 280 members with 25% of the

members with a positive screening. Further depression screenings (PHQ-9 for adults) were conducted with those members. There were 29 members referred for Behavioral Health (BH) services.

• Administered the Member Satisfaction Survey telephonically to members enrolled in the CAD

Program, reviewed surveys as received and conducted outreach to those members who indicate “disagree” or “strongly disagree” responses on their survey. Passport monitored surveys for trends, none were identified. Provided feedback to individual staff when appropriate and addressed any identified areas that needed improvement, none identified.

Identification Activities: • Leveraged the Care Connector Program to engage members in need of assistance making

appointments. • Leveraged the use of Dietician and Social Worker for additional member support. • Continued to improve integration and collaboration to improve overall coordination of care for

members with co-existing medical and BH diagnoses/conditions.


Community Activities: • Increased community initiatives related to the diagnosis and treatment of cardiovascular disease

through: o Collaboration with community partners, providers, and specialists to promote treatment of

cardiovascular conditions. o Collaboration with community partners to continue to raise awareness of cardiovascular

conditions within the community through local departments of health. o Collaboration with community agencies and statewide initiatives to increase awareness of

cardiovascular conditions and cardiovascular management. o Continued distribution of educational materials at health fairs and special events.

• Participated in community forums to determine additional community resources and best practices

related to a healthy lifestyle for our members including: o Health and Wellness Fairs o Prevention Workshops

Planned Interventions for 2020: Continued Interventions: • Increase clinician awareness of the appropriate treatment for persons with cardiovascular

conditions by posting current ACCF/AHA Guidelines on Passport’s website and through Provider Relations site visits.

• Educate members/caregivers regarding cardiovascular disease through:

o Face-to-face outreach o Telephonic outreach o Member newsletters o On-hold SoundCare messages o Passport’s website o Member educational materials

• Continue efforts to educate members and/or caregivers regarding cardiovascular disease, and

smoking cessation.

• Evaluate all new member materials to ensure each piece is clear and concise. Materials continued to be utilized for member mailings; in addition to face-to-face education with the members at the clinician’s office.

• Administer the Patient Health Questionnaire PHQ-2 and PHQ-9 for prescreening and screening for

depression in identified members with cardiovascular conditions and refer to the BH team as needed.


• Review surveys as received and conduct outreach to those members who indicate “disagree” or “strongly disagree” responses on their survey.

• Monitor surveys for trends, provide feedback to individual staff and address any identified areas that needed improvement.

• Continue to improve integration and collaboration to improve overall coordination of care for members with co-existing medical and BH diagnoses/conditions.

• Continue collaboration with CareMessage vendor to provide information on preventive care to

members with Passport sponsored cell phones.

• Increase community initiatives related to the diagnosis and treatment of cardiovascular disease through: o Continue collaboration efforts with community partners, providers, and specialists to promote

treatment of cardiovascular conditions. o Continue collaboration with community partners to continue to raise awareness of

cardiovascular conditions within the community through local departments of health. o Targeted member education campaign to increase awareness of appropriate self-management

for CAD as well as availability of Passport CM programs. o Targeted provider education campaign related to key HEDIS® measures.

Overall the CAD Program noted improvements in 2019, particularly in the reduction of visits to the emergency room and inpatient stays. Based upon the 2019 evaluation, Passport developed new initiatives to strive towards the overall goal of improving the health and quality of life for our members with cardiovascular conditions.

2019 coronary artery disease program evaluation · (91.03%) received monitoring for ace inhibitors...

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