partnership healthplan of california …...donna barton, rn, regional team manager/um nancy steffen,...

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

QUALITY/UTILIZATION ADVISORY COMMITTEE MEETING NOTICE

DATE: Friday, September 11, 2015

FROM: Jennifer Secretaria, QI Administrative Assistant

SUBJECT: Quality/Utilization Advisory Committee (Q/UAC) Meeting

In preparation for the upcoming Q/UAC meeting, please carefully review the agenda topics and corresponding materials.

In addition, please be informed that due to the size of our meeting packets, PHC’s Green Committee has respectfully asked

that we reduce our environmental impact, so we encourage you to use your electronic device (ex. iPad, laptop, etc.) during

the meeting. However, a few hard copy packets will be available for the external Committee Members only.

PHC Staff: You will be responsible for printing your own copy, if you feel you need it.

If you are calling-in to the meeting, please dial 1 (888) 240-2560. Meeting ID: 870356221 Passcode: 0671

Date: Wednesday, September 16, 2015

Time: 7:30 a.m. - 9:00 a.m.

Place: Partnership HealthPlan of California

4665 Business Center Drive, Solano/Napa Conference Room – 1st Floor

Fairfield, CA 94534

Physicians and Consumer Members:

Jennifer Wilson, MD Robert Quon, MD

Kali Stanger, MD Rodrigo Manalo, MD

Madhusudan Borde, MD Sara Choudhry, MD

Michael Pirruccello, MD Steven Gwiazdowski, MD, FAAP

Michael Strain, PHC Consumer Member Steven Namihas, MD

Randolph Thomas, MD Thomas Paukert, MD

PHC Staff Members:

Debra McAllister, Associate Director, UM Nadine Harris, RN, MBA, Quality Compliance Manager

James Cotter, MD, Associate Medical Director Peggy Hoover, RN, Health Services Senior Director

Jessica Thacher, MPH, Quality & PI Assoc. Director Rachael French, Interim Quality & PI Assoc. Director

Hanten Day, Quality, PI, & Health Analytics Sr. Director Richard Fleming, MD, Regional Medical Director

Mark Glickstein, MD, Associate Medical Director Robert Moore, MD, MPH, CMO - Chairman

Mary Kerlin, Provider Relations Senior Director Scott Endsley, MD, Associate Medical Director

Michael Vovakes, MD, Northern Region Medical Director

Cc:

Andy Jensen, Regional Manager Karen Stephen, PhD, HS Mental Health Director

Betsy Campbell, MPH, Senior Health Educator Kelley Sewell, Northern Region Director of MS & PR

Carly Fronefield, Assoc. Director of Health Svcs (R) Lynn Scuri, Associate Regional Director

Cristina Lauck, Manager, General Case Management Margaret Kisliuk, MPP, JD, Executive Director

Darryl Crowder, Provider Contracts Manager Margarita Garcia-Hernandez, Mgr., Health Analytics

David Crawford, MD, Associate Medical Director Marshall Kubota, MD, Regional Medical Director

Gary Louie, PharmD, Director, Pharmacy Services Sonia Tatney, QI Project Coordinator

Heather Brandeburg, Assoc. Dir., Provider Relations Sulinsa Lee-McMurray, QI Project Manager

Jeff Ribordy, MD, Northern Regional Medical Director

PHC Offices: Please use the “Q/UAC Meeting” directory entry on your video conference unit. If you need assistance please contact IT a

minimum of one (1) day prior to the meeting so that they can provide instructions and testing.

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QUALITY/UTILIZATION ADVISORY COMMITTEE

MEETING AGENDA

Date: September 16, 2015 Time: 7:30 – 9:00 a.m. Location: Napa/Solano Room (1st Floor)

I. Approval of Minutes Lead Time Page #

1 Quality/Utilization Advisory Committee (QUAC_08.19.15) (attachment)

Internal Quality Improvement (IQI_08.11.15) (attachment) Robert Moore, MD 7:30 4-17

II. Standing Agenda Items (Full Committee)

1 Status of open action items (none) Robert Moore, MD/

Rachael French 7:33 ---

2 Quality Improvement Update (attachment) Rachael French/

Nancy Steffen 7:35 18-21

3 Health Plan Update (discussion) Robert Moore, MD 7:40 ---

III. Old Business (Committee Members as Applicable)

None. --- ---

IV. New Business (Committee Members as Applicable)

1 Consent Calendar (attachments)

Quality Improvement, no substantive changes

MPQP1008 Conflict of Interest

All 7:45 22-59

23-24

MPQP1019 Quality Improvement/Utilization Management Delegation 25-27

Utilization Management, no substantive changes

HKUP3077 PCP to Specialty Care Referral Process (RAF) 28-32

MPCP2006 Coordination of Services for Children with Special Health Care Needs

(CSHCNs) and Persons with Developmental Disabilities 33-37

MCUG3043 Transportation Guidelines ARCHIVE 38-40

MCUP3041 TAR Review Process 41-56

MCUP3124 Referral to Specialists (RAF) 57-59

2 Social Determinants of Health (attachment) Danielle Niculescu 7:50 60-72

3 PHC Stars Program (attachment) Robert Moore, MD 8:10 73-81

4 Long Term Care Quality Improvement Program (attachment) Robert Moore, MD 8:15 82-88

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New Business, continued Lead Time Page #

5 HEDIS Preliminary Results (attachment)

Megan Wilson/

Nancy Steffen/

Sue Lee

8:20 89-111

6 3NA Analysis (attachment) Sue Lee/

Liat Vaisenberg 8:40 112-135

7 Policy Disclaimer (attachment) Peggy Hoover 9:00 136

V. Additional Business

VI. Adjournment

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MEETING MINUTES

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Committee: Quality and Utilization Advisory Committee (QUAC)

Date/Time: August 19, 2015 7:30 – 9:00am

Members Present: Kali Stanger, M.D. Rodrigo Manalo, M.D.

Madhusudan Borde, M.D Sara Choudhry, M.D.

Michael Strain, PHC Consumer Member Steven Gwiazdowski, M.D., FAAP

Randolph Thomas, M.D. Steven Namihas, M.D.

Robert Quon, M.D.

Members Absent: Jennifer Wilson, M.D. Thomas Paukert, M.D.

Michael Pirruccello, M.D.

PHC Members Present: Debra McAllister, RN, Associate Director, UM Richard Fleming, M.D., Regional Medical Director

Mark Glickstein, M.D., Associate Medical Director Robert Moore, M.D., MPH - Chairman

Peggy Hoover, RN, Health Services Director Scott Endsley, MD, Associate Medical Director

Rachael French, Interim Associate Director, Quality and PI

PHC Members Absent: James Cotter, M.D., Associate Medical Director Mary Kerlin, Provider Relations Director

Jessica Thacher, Assoc. Director, Quality and PI Michael Vovakes, M.D., Northern Reg. Medical Director

Kelley Sewell, Northern Region Director of MS & PR Nadine Harris, RN, MBA, Manager of Quality Compliance

Guests: Carly Fronefield, Assoc. Director of Health Services (R) Jenna Trask, RN, PICS I

Cristina Lauck, RN, General Case Management Manager Katherine Barresi, RN, Care Coordination Manager

Danielle Niculescu, MPH, QI Project Coordinator II Lauri Stevenson, RN, PICS II

Donna Barton, RN, Regional Team Manager/UM Nancy Steffen, Manager, Quality Improvement Programs

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS/

ACTION

TARGET

DATE

DATE

RESOLVED

Call to Order and

Approval of Minutes

The meeting was called to order at 7:36 am.

Minutes from the 6/17/2015 QUAC meeting were reviewed.

Minutes from the 6/9/2015 IQI meeting were reviewed.

QUAC Minutes: Approved

without changes.

IQI Minutes: Accepted.

8/19/2015

I. Standing Agenda Items

1. Status of open

action items

There were no open action items discussed. None.

2. QI Update

Rachael French, Interim Associate Director of Quality and Performance Improvement, pro-

vided an update on key activities occurring in the Quality Improvement (QI) Department.

HEDIS – The HEDIS team is working closely with Partnership HealthPlan of California’s

(PHC) Analytics team to summarize the 2015 HEDIS performance at the regional, county,

and provider level. Final regional and county level performance has been completed and will

be shared with Committees starting in September. The HEDIS team is currently working on

strengthening our internal HEDIS processes and working with our provider partners on small

improvements to impact performance in measurement year 2015.

None. 8/19/2015

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MEETING MINUTES



ACTION

TARGET

DATE

DATE

RESOLVED

QI Update,

Continued

Primary Care Provider (PCP) Quality Improvement Program (QIP) – The PCP QIP meas-

urement year closed at the end of June. Providers still have a grace period until August 15th

to upload data onto eReports (online clinical portal) to improve their overall scores. Final

payment for PCP QIP, along with the score card, will be sent out to the sites by Oct 31st.

The new PCP QIP 2015-16 measurement year (MY) started July 1st. The team is working

diligently with the IT department to get eReports up and running for the new year. The ex-

pected launch date for 2015-2016 eReports is in October.

Hospital QIP – The 2014-15 MY ended on June 30th. Submission forms for hospital-

reported measures are due August 31st and final payments are expected to be released by

October 31st. The new Hospital QIP 2015-16 MY has started and PHC held the first webinar

on June 22nd. A training webinar is scheduled for August 5th to guide hospitals who are

planning to participate in the California Maternal Quality Care Collaborative (CMQCC),

which is a new measure added in the 2015-16 MY.

PHC has four new Hospital QIP participants in the 2015-16 MY; Petaluma Valley, Santa

Rosa Memorial, Healdsburg District, and Mendocino Coast District.

Quality “Stars” Dashboard – PHC’s Board of Commissioners requested a separate “dash-

board” including measures to help the plan specifically evaluate the quality of care provided

to our members. The goal is to give PHC an overall score across measurement areas, similar

to the Medicare Stars Quality Bonus Program. Measures and targets will be presented at the

September Committee meetings.

ABCs of QI – PHC is offering, for the first time, a five-week ABCs of Quality Improvement

(QI) webinar series in partnership with the community clinic consortia in Northern CA—

Health Alliance of Northern California and North Coast Clinics Network – for their clinic

members. The series began on July 17, 2015 and will conclude on August 14, 2015. Early

feedback from participants revealed high satisfaction with this training. We will conduct a

more thorough evaluation at the end of the program.

ADVANCE – The application deadline for the 2015-16 was July 31st. Fifteen practices will

be selected by August 11th to participate in this next iteration of Improvement Advisor train-

ing. The program will run from August 2015 through June 2016.

Coleman – Three of the five Coleman Rapid Dramatic Performance Improvement teams

(Solano County Family Health Services, Alexander Valley Healthcare, and Mountain Valleys

Health Centers) have begun their eight-week long intensive change session with Coleman

Associates. After completing the eight week sessions, they will develop sustainability plans

with a sustainability and spread consultant. On July 20, there was a Leadership Visioning

meeting for Offering and Honoring Choices, the initiative that encompasses PHC’s advance

care planning and palliative care activities. The group developed the following draft vision

statement: “Through Offering and Honoring Choices, PHC members, staff, and our commu-

nities will easily and comfortably access advance care planning and palliative care services

when, where, and how they want and need support.”

Managing Pain Safely (MPS) – The MPS project convened the first PHC Oversight Commit-

tee on June 10th, reviewing the case of one member on chronic high-dose opioids. On June

of 136


MEETING MINUTES



ACTION

TARGET

DATE

DATE

RESOLVED

QI Update,

continued 20th, PHC hosted a peer-sharing webinar regarding setting up oversight committees at the

clinic level. Additionally, the MPS Steering Committee has developed outcome measures for

the project and is currently working to collect data to determine the project’s impact. Lastly,

the MPS team has uploaded a provider tool kit to the MPS Website. This toolkit consists of

key tools and critical reading documents as resource for providers treating patients with

chronic pain.

Upcoming Opportunities – Clinicians, pharmacists, and other staff who are interested in

learning more about chronic opioid use are invited to participate in a MPS forum in Eureka

on August 27th, at the Wharfinger Building, 1 Marina Way, Eureka, from 12-6pm. PHC will

be hosting a webinar entitled “Making the Right Diagnosis and Providing the Best Treat-

ment” on August 3rd. The discussion will be focused on using mindfulness as a best practice

for treating chronic pain. The 4th Annual Palliative Care Conference: Aligning Treatment

and Goals of Care, hosted by Napa Valley Hospice Adult Day Services and sponsored by

PHC, will be held October 29-30, 2015, at the Doubletree hotel in American Canyon. Clini-

cians and other staff who want to learn more about best practices and innovations in advance

care planning and palliative care are encouraged to attend. There is no registration fee for

PHC staff. An in-person ABCs of QI training is planned for November 12th, in Santa Rosa.

Registration information will soon be posted on PHC’s website.

3. Health Plan

Update

Robert Moore, MD, MPH, Chief Medical Officer, highlighted the following:

Michael Strain and Margaret Sager, Consumer Members, joined the Board of Commis-

sioners in August 2015.

Scott Endsley, MD is the new Quality Associate Medical Director.

The transition of Regional Medical Directors for Yolo County will begin in Septem-

ber/October 2015.

The new Senior Director of Quality and Performance Improvement will be announced on

September 1, 2015.

PHC’s pilot on palliative care was featured on PBS’ NewsHour.

None. 8/19/2015

II. Old Business

There was no old business discussed.

III. New Business

1. Consent

Calendar

The following items were on the consent calendar this month:


MPQP1018 Preventive Health Guidelines

MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines


HKCP2015 Continuity of Care (HK Only)

HKUG3120 Prenatal & Perinatal Care for Commercial Members

HKUP3069 Emergency Services (HK Only)

HKUP3070 External Independent Medical Review

HKUP3073 Mastectomy and Breast Reconstruction

Approved without changes. 8/19/2015

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MEETING MINUTES



ACTION

TARGET

DATE

DATE

RESOLVED

Consent

Calendar,

continued

HKUP3074 Medical Transportation

HKUP3076 Health Services Review of Non-admission In-hospital Obstetrical Evaluations

HKUP3078 Second Medical Opinions

HKUP3082 Continuity of Care ARCHIVE

MCUP3108 BRCA – Gene Sequence Analysis ARCHIVE

See MCUP3131 Genetic Testing

2. Facility Site Re-

view (FSR) Bi-

Annual Report

Lauri Stevenson, Performance Improvement Clinical Specialist I, discussed the bi-annual

report on Facility Site Review (FSR) compliance. FSRs are conducted for credentialing and

re-credentialing purposes. It is a state mandate that PCP sites meet patient safety and access

standards in order to see PHC members. There are two components, FSR and Medical Rec-

ord Review (MRR), each with six domains. FSR and MRR data is gathered by Site Review

Nurses at PCP sites. The FSR portion looks at areas ranging from Access and Safety to In-

fection Control with an overall passing score of 80%. For the MRR, a random sample of

members’ records is selected. The sample can range from 10 to 30 records depending on the

number of PCPs at the site. An 80% overall score is required to pass. If any of the MRR

domains fall below 80%, a Corrective Action Plan (CAP) is required for the entire review.

The results for FSR are as follows: we saw a significant improvement in Access and Safety

and Infection control for the Southeast Region; there were no significant changes noted

across all domains for the Southwest Region; there was a significant improvement noted in

Clinical Services for the Northeast Region; and there were no significant changes noted

across all domains for the Northwest Region. The results for MRR are as follows: we saw an

overall improvement in facility site scores with notable improvement in documentation and

pediatric preventive for the Southeast Region; there was a significant decrease in documenta-

tion scores with improvement seen in pediatric preventive screening for the Southwest Re-

gion; there was improvement seen in the adult preventive screening scores for the Northeast

Region; and there was no December 2014 data to compare for the Northwest Region. A few

ideas to explore: continue to monitor and report trended data to IQI and QUAC semi-

annually; use an electronic tool to allow PHC to report data to assist in other initiatives, such

as advance care planning (ACP) and immunizations; and strengthen the standardization of the

review process and explore the feasibility of an annual Inter-rater Reliability (IRR) for the

site.

None. 8/19/2015

3. Grievance Report

w/ State Hearing

Richard Fleming, MD, Regional Medical Director, provided a brief report as follows: as of

June 2015, there were 76 complaints, 105 appeals, and 47 state hearings. The top reasons for

complaints to be filed were quality of care, access to care, denial of care, rudeness, and mis-

communication. The top reasons for filing an appeal were Harvoni, referral to Stanford, am-

phetamine salts, oxycodone HCL, and Strattera. The top reasons for filing a state hearing

were Harvoni, physical therapy, and direct member reimbursement.

None. 8/19/2015

4. Managing Pain

Safely

Danielle Niculescu, MPH, CPH, QI Project Coordinator II, presented on the Managing Pain

Safely (MPS) initiative. This initiative is working to improve the health of PHC members by

ensuring that prescribed opioids are for appropriate indications, at safe doses, and in conjunc-

tion with other treatment modalities. In 2010, the Centers for Disease Control and Prevention

None. 8/19/2015

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MEETING MINUTES



ACTION

TARGET

DATE

DATE

RESOLVED

Managing Pain

Safely, continued

(CDC) released findings depicting the dangers of long term opioid use, and government or-

ganizations began recommending limiting the use of opioids in chronic, non-cancer, terminal

pain. Based on this research and findings, PHC is working with our communities to increase

awareness of the importance of safe prescribing of opioid medicine. We have instituted new

prescribing guidelines with the help of those in the community to safeguard the health and

well-being of our members. Our overall goal is to improve the health of PHC members by

ensuring that prescribed opioids are for appropriate indications, at safe doses, and in conjunc-

tion with other treatment modalities as measured by a: decrease in total number of inappro-

priate initial prescriptions by 75%, decrease in total number of inappropriate prescription

escalations by 90%, and decrease in total number of patients on inappropriate high-dose opi-

oids by 75%. High-dose of opioids is defined as greater than 120mg morphine equivalent

dose (MED).

5. MCCP2014

Continuity of

Care

Katherine Barresi, RN, Care Coordination Manager, discussed this new policy. The pur-

pose of this policy is to define the process by which a member may request to be allowed

to continue to receive services by an out-of-network provider in the event that the mem-

ber has an established relationship with the provider who is providing ongoing care to the

member prior to his/her enrollment or re-enrollment into PHC.


6. MCUG3024

Inpatient

Utilization

Management

Debra McAllister, RN, Associate Director of Utilization Management, discussed the changes

to this policy. The purpose of this guideline is to provide guidelines for PHC’s inpatient uti-

lization management activities not delegated to other entities. These activities are performed

by the Utilization Management Department under the direction of the Chief Medical Officer

or Physician Designee.


7. MCUP3131

Genetic Testing

Peggy Hoover, RN, Senior Director of Health Services, discussed this new policy. The pur-

pose of this policy is to describe the criteria for evaluating requests for genetic testing and to

cite the external professional resources on which we will rely to make coverage determina-

tion. Genetic testing is a rapidly expanding aspect of medical care which can be useful for

diagnosing disease, guiding treatment, and/or identifying possible genetic risks for develop-

ment of disease. Given the rapid evolution of this field, it is impossible to establish guide-

lines to reliably inform when genetic testing is appropriate, which will remain valid for a sig-

nificant time frame.


8. MPUP3048

Dental Services Ms. Hoover discussed the changes to this policy. The purpose of this policy is to define the

coverage under which PHC authorizes and reimburses for dental anesthesia for all lines

of business and dental services for MediCal and Healthy Kids Programs.


9. MPUP3126

Autism Spectrum

Disorder

Behavioral

Health Treatment

Ms. Hoover discussed this new policy. The purpose of this policy is to define PHC’s finan-

cial responsibility to provide for Behavioral Health Treatment (BHT) services to PHC Medi-

Cal eligible beneficiaries under the age of 21 diagnosed with Autism Spectrum Disorder

(ASD) under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) Supple-

mental Services benefit.


10. MCUG3002

Acupuncture

Services

Ms. Hoover discussed the changes to this guideline. The purpose of this guideline is to de-

scribe the conditions under which acupuncture services are authorized and the procedure pro-

viders follow to obtain such authorization.


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MEETING MINUTES



ACTION

TARGET

DATE

DATE

RESOLVED

Guidelines

11. MPXG5003

Major

Depression in

Adults Clinical

Practice

Guidelines

Dr. Moore discussed the changes to this guideline. The purpose of this guideline is to define

the appropriate diagnostic criteria and therapy for patients with major depression. This

guideline is meant to be a basic guideline, not an enforceable standard, and is intended to

assist the primary care professional in caring for PHC adult members with major depression.

Recommendations are not intended to replace sound clinical judgment in caring for individu-

al patients.



There was no additional business discussed.

The meeting was adjourned at 9:09 am.

Respectfully submitted by Jennifer Secretaria, QI Administrative Assistant

Signature of Approval: ____________________________________ Date: ______________________________

Robert Moore, MD, Chairman

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MEETING MINUTES

Committee: INTERNAL QUALITY IMPROVEMENT [IQI] MEETING

Date/Time: August 11, 2015_Tuesday_1:30PM – 3:30PM_Board Room, 3rd Floor

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS

/ ACTION

TARGET

DATE

DATE

RESOLVED

I. Call to Order and

Approval of Minutes

The meeting was called to order at 1:32 pm.

Minutes from the 6/9/2015 IQI meeting were reviewed.


II. Standing Agenda Items (Full Committee)

1. Status of Open Action

Items

There was no open action item discussed at this meeting. None.

2. QI Update

Rachael French, Interim Associate Director of Quality and Performance Improvement,

provided an update on key activities occurring in the Quality Improvement (QI) Department.

HEDIS – The HEDIS team is working closely with Partnership HealthPlan of California’s

(PHC) Analytics team to summarize the 2015 HEDIS performance at the regional, county,

and provider level. Final regional and county level performance has been completed and will

be shared with Committees starting in September. The HEDIS team is currently working on

strengthening our internal HEDIS processes and working with our provider partners on small

improvements to impact performance in measurement year 2015.

None. 8/11/2015

Standing Members Present:

Campbell, Betsy, MPH, Senior Health Educator Jensen, Andy, Regional Manager (E)

Cotter, James, MD, MPH, Associate Medical Director Kerlin, Mary, Senior Director, PR

Endsley, Scott, MD, Associate Medical Director Kubota, Marshall, MD, Regional Medical Director

French, Rachael, Interim Assoc. Director, Quality & PI Layne, Robert, Government and Public Affairs Director

Fronefield, Carly, Interim Associate Director/UM (R) Louie, Gary, PharmD, Pharmacy Services Director

Hoover, Peggy, RN, Senior Health Services Director McAllister, Debra, RN, Associate Director of UM

Standing Members Absent:

Barton, Donna, RN, Regional Team Manager/UM (R) Shafer, Debbie, Sr. Dir. of Member Services/Enrollment/Marketing

Fleming, Richard, MD, Regional Medical Director Moore, Robert, MD, MPH, Chief Medical Officer, Chairman

Gibboney, Liz, Chief Executive Officer Scuri, Lynn, Regional Director

Harris, Nadine, RN, MBA, QI Compliance Manager Smith, Lyle, Manager, Operations Excellence & PMO

Lauck, Cristina, Manager, General Case Management Vovakes, Michael, MD, Northern Regional Medical Director (R)

Guests:

Bjork, Sonja, Deputy COO Leslie, Chad, Provider Relations Coordinator II

Barresi, Katherine, Case Management Manager Santos, Daniel, Provider Services Supervisor

Gale, Sue, Regional Team Manager/UM Stevenson, Lauri, RN, PICS I

Haynes, Dina, Associate Director, Pharmacy Operations Turnipseed, Amy, Policy & Program Development Director

Lee, Heidi, Lead Credentialing Specialist

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QI Update, continued

Primary Care Provider (PCP) Quality Improvement Program (QIP) – The PCP QIP

measurement year closed at the end of June. Providers still have a grace period until August

15th to upload data onto eReports (online clinical portal) to improve their overall scores.

Final payment for PCP QIP, along with the score card, will be sent out to the sites by Oct

31st. The new PCP QIP 2015-16 measurement year (MY) started July 1st. The team is

working diligently with the IT department to get eReports up and running for the new year.

The expected launch date for 2015-2016 eReports is in October.

Hospital QIP – The 2014-15 MY ended on June 30th. Submission forms for hospital-

reported measures are due August 31st and final payments are expected to be released by

October 31st. The new Hospital QIP 2015-16 MY has started and PHC held the first webinar

on June 22nd. A training webinar is scheduled for August 5th to guide hospitals who are

planning to participate in the California Maternal Quality Care Collaborative (CMQCC),

which is a new measure added in the 2015-16 MY.

PHC has four new Hospital QIP participants in the 2015-16 MY; Petaluma Valley, Santa

Rosa Memorial, Healdsburg District, and Mendocino Coast District.

Quality “Stars” Dashboard – PHC’s Board of Commissioners requested a separate

“dashboard” including measures to help the plan specifically evaluate the quality of care

provided to our members. The goal is to give PHC an overall score across measurement

areas, similar to the Medicare Stars Quality Bonus Program. Measures and targets will be

presented at the September Committee meetings.

ABCs of QI – PHC is offering, for the first time, a five-week ABCs of Quality Improvement

(QI) webinar series in partnership with the community clinic consortia in Northern CA—

Health Alliance of Northern California and North Coast Clinics Network – for their clinic

members. The series began on July 17, 2015 and will conclude on August 14, 2015. Early

feedback from participants revealed high satisfaction with this training. We will conduct a

more thorough evaluation at the end of the program.

ADVANCE – The application deadline for the 2015-16 was July 31st. Fifteen practices will

be selected by August 11th to participate in this next iteration of Improvement Advisor

training. The program will run from August 2015 through June 2016.

Coleman – Three of the five Coleman Rapid Dramatic Performance Improvement teams

(Solano County Family Health Services, Alexander Valley Healthcare, and Mountain Valleys

Health Centers) have begun their eight-week long intensive change session with Coleman

Associates. After completing the eight week sessions, they will develop sustainability plans

with a sustainability and spread consultant. On July 20, there was a Leadership Visioning

meeting for Offering and Honoring Choices, the initiative that encompasses PHC’s advance

care planning and palliative care activities. The group developed the following draft vision

statement: “Through Offering and Honoring Choices, PHC members, staff, and our

communities will easily and comfortably access advance care planning and palliative care

services when, where, and how they want and need support.”

Managing Pain Safely (MPS) – The MPS project convened the first PHC Oversight

Committee on June 10th, reviewing the case of one member on chronic high-dose opioids.

On June 20th, PHC hosted a peer-sharing webinar regarding setting up oversight committees

at the clinic level. Additionally, the MPS Steering Committee has developed outcome

measures for the project and is currently working to collect data to determine the project’s

of 136


QI Update, continued impact. Lastly, the MPS team has uploaded a provider tool kit to the MPS Website. This

toolkit consists of key tools and critical reading documents as resource for providers treating

patients with chronic pain.

Upcoming Opportunities – Clinicians, pharmacists, and other staff who are interested in

learning more about chronic opioid use are invited to participate in a MPS forum in Eureka

on August 27th, at the Wharfinger Building, 1 Marina Way, Eureka, from 12-6pm. PHC will

be hosting a webinar entitled “Making the Right Diagnosis and Providing the Best

Treatment” on August 3rd. The discussion will be focused on using mindfulness as a best

practice for treating chronic pain. The 4th Annual Palliative Care Conference: Aligning

Treatment and Goals of Care, hosted by Napa Valley Hospice Adult Day Services and

sponsored by PHC, will be held October 29-30, 2015, at the Doubletree hotel in American

Canyon. Clinicians and other staff who want to learn more about best practices and

innovations in advance care planning and palliative care are encouraged to attend. There is

no registration fee for PHC staff. An in-person ABCs of QI training is planned for November

12th, in Santa Rosa. Registration information will soon be posted on PHC’s website.

III. Old Business (Committee Members as Applicable)

There was no old business discussed at this meeting

IV. New Business (Committee Members as Applicable)

1. Consent Calendar

The following items were on the consent calendar this month:

Delegation Reports

Lucile Packard Children’s Hospital Credentialing/Re-credentialing 2015 Qtr 1

Sutter Medical Foundation – Solano Credentialing/Re-credentialing 2015 Qtr 2

Sutter Medical Foundation – Sutter West Credentialing/Re-credentialing 2015 Qtr 2

Sutter Pacific Medical Group – Redwoods & Marin Highlands Credentialing/

Re-credentialing 2015 Qtr 2

University of California, San Francisco Credentialing/Re-credentialing 2015 Qtr 2

Woodland Clinic Medical Group Credentialing/Re-credentialing 2015 Qtr 2

Pharmacy, no substantive changes

MCRP4060 340B Compliance Program

MPRP4061 Enteral Nutrition Products

Provider Relations, no substantive changes

CR #12 Credentialing of Independent Nurses under EPSDT

MP CR #2 Credentialing and Re-credentialing Committee Authority and Responsibility

MP CR #7 Re-credentialing Requirements

MP CR #7A Re-credentialing Criteria, Application/Attestation, and Monitoring of

Sanctions for Behavioral Health Practitioners

MP CR #10 Organizational Providers Assessment

MP CR #11A Review of Delegated Credentialing and Re-credentialing Policies

MP CR #13B Buprenorphine Prescriber Credentialing

MP CR #14 Pharmacy Provider Assessment Criteria

MP PR #200 PHC Provider Contracts


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Consent Calendar,

continued MP PR #207 Annual Physician Satisfaction Survey

MP PR #208 PHC Provider Termination or Change in Location Information

MP PR-GR #210 Provider Grievance

MP PR-PL-CR #201 Credentials Committee Review


MPQP1018 Preventive Health Guidelines

MPQP1026 OB/GYN Facility Site Review Requirements and Guidelines


HKCP2015 Continuity of Care (HK Only)

HKUG3120 Prenatal & Perinatal Care for Commercial Members

HKUP3069 Emergency Services (HK Only)

HKUP3070 External Independent Medical Review

HKUP3073 Mastectomy and Breast Reconstruction

HKUP3074 Medical Transportation

HKUP3076 Health Services Review of Non-admission In-hospital Obstetrical Evaluations

HKUP3078 Second Medical Opinions

HKUP3082 Continuity of Care ARCHIVE

MCUP3108 BRCA – Gene Sequence Analysis See MCUP3131 Genetic Testing

ARCHIVE

2. Grievance Report w/

State Hearing

James Cotter, MD, Associate Medical Director, provided a brief report as follows: as of June

2015, there were 76 complaints, 105 appeals, and 47 state hearings. The top reasons for

complaints to be filed were quality of care, access to care, denial of care, rudeness, and

miscommunication. The top reasons for filing an appeal were Harvoni, referral to Stanford,

amphetamine salts, oxycodone HCL, and Strattera. The top reasons for filing a state hearing

were Harvoni, physical therapy, and direct member reimbursement.

None. 8/11/2015

3. Beacon Corrective

Action Plan Summary

Heidi Lee, Lead Credentialing Specialist, discussed Beacon’s corrective action plan (CAP).

PHC conducted the annual audit for delegation of credentialing and re-credentialing activities

on May 19, 2015. The audit was conducted by Daniel Santos, PHC Credentialing Supervisor,

and deficiencies were found in Beacon’s Ongoing Monitoring of Sanctions. PHC notified

Beacon that it would require corrections and Beacon submitted a Corrective Action Plan that

detailed their plan to address the deficiencies noted.


4. Facility Site Review

(FSR) Bi-Annual Report

Lauri Stevenson, Performance Improvement Clinical Specialist I, discussed the bi-annual

report on Facility Site Review (FSR) compliance. FSRs are conducted for credentialing and

re-credentialing purposes. It is a state mandate that PCP sites meet patient safety and access

standards in order to see PHC members. There are two components, FSR and Medical

Record Review (MRR), each with six domains. FSR and MRR data is gathered by Site

Review Nurses at PCP sites. The FSR portion looks at areas ranging from Access and Safety

to Infection Control with an overall passing score of 80%. For the MRR, a random sample of

members’ records is selected. The sample can range from 10 to 30 records depending on the

number of PCPs at the site. An 80% overall score is required to pass. If any of the MRR

domains fall below 80%, a Corrective Action Plan (CAP) is required for the entire review.

The results for FSR are as follows: we saw a significant improvement in Access and Safety

and Infection control for the Southeast Region; there were no significant changes noted

None. 8/11/2015

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Facility Site Review

(FSR) Bi-Annual Report,

continued

across all domains for the Southwest Region; there was a significant improvement noted in

Clinical Services for the Northeast Region; and there were no significant changes noted

across all domains for the Northwest Region. The results for MRR are as follows: we saw an

overall improvement in facility site scores with notable improvement in documentation and

pediatric preventive for the Southeast Region; there was a significant decrease in

documentation scores with improvement seen in pediatric preventive screening for the

Southwest Region; there was improvement seen in the adult preventive screening scores for

the Northeast Region; and there was no December 2014 data to compare for the Northwest

Region. A few ideas to explore: continue to monitor and report trended data to IQI and

QUAC semi-annually; use an electronic tool to allow PHC to report data to assist in other

initiatives, such as advance care planning (ACP) and immunizations; and strengthen the

standardization of the review process and explore the feasibility of an annual Inter-rater

Reliability (IRR) for the site.

5. Primary Care Access Mary Kerlin, Senior Director of Provider Relations, provided an update from the Primary

Care Access Workgroup. The workgroup was developed in April 2015 by Mary Kerlin,

Kelley Sewell, and Liz Gibboney. Jessica Thacher, Associate Director of Quality and

Performance Improvement, was asked to lead this group, under the direction of our Chief

Executive Officer. However, since Ms. Thacher is currently on maternity leave, Jess Liu,

Senior Project Manager, has been providing support on this project. The Primary Care

Access Workgroup’s intent is to ensure our members have access to timely and high-quality

primary care. There have been numerous challenges with primary care access in all of our 14

counties. Due to the increased patient demand as a result of the Affordable Care Act (ACA),

we are working on ways to support the primary care clinicians/providers in addressing this

need. Under the direction of Ms. Gibboney, the workgroup created a primary care dashboard

and Chad Leslie, Provider Relations Coordinator II, reviewed key examples.

None. 8/11/2015

6. Managing Pain Safely Danielle Niculescu, MPH, CPH, QI Project Coordinator II, presented on the Managing Pain

Safely (MPS) initiative. This initiative is working to improve the health of PHC members by

ensuring that prescribed opioids are for appropriate indications, at safe doses, and in

conjunction with other treatment modalities. In 2010, the Centers for Disease Control and

Prevention (CDC) released findings depicting the dangers of long term opioid use, and

government organizations began recommending limiting the use of opioids in chronic, non-

cancer, terminal pain. Based on this research and findings, PHC is working with our

communities to increase awareness of the importance of safe prescribing of opioid medicine.

We have instituted new prescribing guidelines with the help of those in the community to

safeguard the health and well-being of our members. Our overall goal is to improve the

health of PHC members by ensuring that prescribed opioids are for appropriate indications, at

safe doses, and in conjunction with other treatment modalities as measured by a: decrease in

total number of inappropriate initial prescriptions by 75%, decrease in total number of

inappropriate prescription escalations by 90%, and decrease in total number of patients on

inappropriate high-dose opioids by 75%. High-dose of opioids is defined as greater than

120mg morphine equivalent dose (MED).

None. 8/11/2015

7. Pharmacy Network

Credentialing Summary

Dina Haynes, Associate Director of Pharmacy Operations, discussed the summary of the

MedImpact Network Credentialing Report from January to June 2015. MedImpact’s entire

network has 303 operating pharmacies in PHC’s 14 counties. 100% of the pharmacies were

None. 8/11/2015

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Pharmacy Network

Summary, continued

licensed by both DEA and the state during January - June 2015. All had liability coverage

and pharmacist in charge (PIC) with current licensure.

8. MPRP4056 Pediatric

Enteral Nutrition

Ms. Haynes discussed the changes to this policy. The purpose of this policy is to define

criteria for coverage of enteral nutrition products in children under 21 years of age served by

Partnership HealthPlan of California.


9. MPXG5003 Major

Depression in Adults

Dr. Moore discussed the changes to this guideline. The purpose of this guideline is to define

the appropriate diagnostic criteria and therapy for patients with major depression. This

guideline is meant to be a basic guideline, not an enforceable standard, and is intended to

assist the primary care professional in caring for PHC adult members with major depression.

Recommendations are not intended to replace sound clinical judgment in caring for

individual patients.


10. MP CR #18 Applied

Behavioral Health

Provider

Ms. Kerlin, discussed this new policy. The purpose of this policy is to detail the process for

credentialing of Applied Behavior Analysis (ABA) providers who meet the criteria of the

PHC Credentials Committee. PHC only credentials Licensed Medical Professionals or

BACB® certified providers; not all ABA providers fall within the current credentialing scope

since many of the ABA providers per definition of California SB 946 (2012) are not licensed.

Providers who are not licensed or Behavioral Analyst Certification Board (BACB) certified

may only provide ABA services while under the supervision of a PHC credentialed provider.

Autism Spectrum Disorder treatment requires a prescription from a physician or referral by a

psychologist pursuant to Chapter 6.6 of, Division 2 of the Business and Professions code.


11. MP CR #19 Skilled

Nursing Facility

Providers (SNFists)

Credentialing

Ms. Kerlin discussed this new policy. The purpose of this policy is to detail the credentialing

criteria for Skilled Nursing Facility providers by PHC Credentials Committee. The

Committee suggested combining lines b and c in section, VI, A.

Approved with changes to

Section VI, A, b-c

8/11/2015

12. MP CR #5 Review

Standards for

Credentials, Re-

Credentials Process

Ms. Kerlin discussed the changes to this policy. The purpose of this policy is to define the

standards used and handling of issues identified during the credentialing or re-credentialing

of a practitioner. Each practitioner’s credentialing file is reviewed by the PHC Provider

Relations Department for accuracy based on Credentialing Criteria prior to presentation to the

PHC Credentialing Committee. Any file identified with exceptions or potential exceptions is

referred to the Chief Medical Officer or designee. Subsequently the Credentialing Committee

reviews each file. The Committee suggested reformatting section III, B.


Section III, B.

8/11/2015

13. MP PR-PL-CR #701

Re-credentialing

Document Collection,

Review, Verification,

and Ongoing

Monitoring of Sanctions

and Complaints

Ms. Kerlin discussed the changes to this policy. The purpose of this policy is to describe the

procedure for practitioner re-credentials document review and processing for presentation to

the Credentials Committee. As part of the re-credentialing review the Credentials Committee

may use the performance monitoring criteria including, Quality Management, Utilization

Management and or Member issues.


14. MP PR-PL-CR #701A

Re-credentialing for

Behavioral Health

Practitioners

Ms. Kerlin discussed the changes to this policy. The purpose of this policy is to describe the

procedure for practitioner re-credentials document review and processing for presentation to

the Credentials Committee. As part of the re-credentialing review the Credentials Committee

may use the performance monitoring criteria including, Quality Management, Utilization

Management and or Member issues.


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15. MCCP2014 Continuity

of Care Katherine Barresi, RN, Care Coordination Manager, discussed this new policy. The

purpose of this policy is to define the process by which a member may request to be

allowed to continue to receive services by an out-of-network provider in the event that

the member has an established relationship with the provider who is providing ongoing

care to the member prior to his/her enrollment or re-enrollment into PHC.


16. MP316 Provider

Request to Discharge

Member & Assistance

with Inappropriate

Member Behavior

This policy was removed from the agenda. None. 8/11/2015

17. MCUG3024 Inpatient

Utilization Management

Debra McAllister, RN, Associate Director of Utilization Management, discussed the changes

to this policy. The purpose of this guideline is to provide guidelines for PHC’s inpatient

utilization management activities not delegated to other entities. These activities are

performed by the Utilization Management Department under the direction of the Chief

Medical Officer or Physician Designee.


18. MCUP3131 Genetic

Testing

Peggy Hoover, RN, Senior Director of Health Services, discussed this new policy. The

purpose of this policy is to describe the criteria for evaluating requests for genetic testing and

to cite the external professional resources on which we will rely to make coverage

determination. Genetic testing is a rapidly expanding aspect of medical care which can be

useful for diagnosing disease, guiding treatment, and/or identifying possible genetic risks for

development of disease. Given the rapid evolution of this field, it is impossible to establish

guidelines to reliably inform when genetic testing is appropriate, which will remain valid for

a significant time frame.


19. MPUP3048 Dental

Services (including

Dental Anesthesia)

Ms. Hoover discussed the changes to this policy. The purpose of this policy is to define the

coverage under which PHC authorizes and reimburses for dental anesthesia for all lines

of business and dental services for MediCal and Healthy Kids Programs. Section VI, G,

3, should read as “If the provider documents both A and B below, then the…” per the

suggestion of the Committee.


Section VI, G, 3.

8/11/2015

20. MPUP3126 Autism

Spectrum Disorder

Behavioral Health

Treatment

Ms. Hoover discussed this new policy. The purpose of this policy is to define PHC’s

financial responsibility to provide for Behavioral Health Treatment (BHT) services to PHC

Medi-Cal eligible beneficiaries under the age of 21 diagnosed with Autism Spectrum

Disorder (ASD) under the Early and Periodic Screening Diagnosis and Treatment (EPSDT)

Supplemental Services benefit.


21. MCUG3002

Acupuncture Services

Guidelines

Ms. Hoover discussed the changes to this guideline. The purpose of this guideline is to

describe the conditions under which acupuncture services are authorized and the procedure

providers follow to obtain such authorization. The Committee suggested updating the review

dates.


the review dates.

8/11/2015


There was no additional business discussed at this meeting.

VI. Adjournment

The meeting was adjourned at 3:12 pm.

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Respectfully submitted by Jennifer Secretaria, QI Administrative Assistant

Signature of Approval: ____________________________________ Date: ______________________________

Robert Moore, MD, MPH, Chairman

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4665 Business Center Drive

Fairfield, CA 94534

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September 19, 2015

To: The Quality/Utilization Advisory Committee

From: Rachael French, Interim Associate Director of Quality & Performance Improvement

Re: QI Department Update

The purpose of this memo is to provide an update on key activities occurring in the QI Department

over the past month.

Staffing:

Senior Director of Quality and Performance Improvement – We are pleased to announce that

Hanten Day has joined Partnership HealthPlan as Senior Managing Director of Quality,

Performance Improvement and Health Analytics. Hanten comes to us from Moda Health in

Oregon, a health plan providing medical, dental and pharmacy coverage to Medicaid, Medicare

and Commercial populations in several western states. He has extensive background in healthcare,

health policy, and analytics. We are extremely excited to have him on the QI leadership team.

Northern Region Quality Analyst- We are pleased to announce Cody West who has joined the

Northern Region QI team! Cody is an Analyst, formerly assigned to the Admin team in Redding.

He brings a wealth of Data Warehouse knowledge and reporting expertise to the team. He will

continue to support all of the teams in the Northern Region but his primary focus will now be in

supporting QI projects and reporting needs.

Performance Measurement Activities:

HEDIS: All Hands on Deck for the HEDIS 2016 Reporting year. To address our first year

performance in the Northeast and Northwest, our Northern Region QI team in collaboration with

Northeastern Rural Health Center and Fairchild Medical Clinic, are leading rapid cycle

improvement projects focused on improving the Quality of Care in Children and Adolescents. This

work has been spear headed by our Northern Region team all-stars Tegan, Sandra, Laurie, Marya

and Jena. Partnership will also be performing member outreach through pre-recorded messages

across a subset of HEDIS measures encouraging members to follow up with primary care for

preventative care services across all counties in which PHC serves. We continue to work on

strengthening our internal HEDIS processes and summarizing our 2015 HEDIS performance at

the Provider Level with an estimated release date late October.

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Fairfield, CA 94534


Primary Care Provider QIP.

The QIP team is currently wrapping up the 2014-2015 measurement year and preparing for final

payment along with the score card will be sent out to the sites by Oct 31st.

The Northern Region QIP team in partnership with the Southern Region IT and QIP team has been

leading efforts to validate reports for the 2015-2016 measurement year. eReports testing is

underway and expected to conclude early September. A pilot testing period with a small group of

providers will follow through the end of the month. The expected launch date for 2015-2016

eReports is still anticipated for early October.

Hospital QIP.

A web page for the Hospital QIP went live in July. The webpage includes a description of the

Hospital QIP program and other information including access to HQIP webinars, measurement

specifications, submission forms, and program timelines. We also created a Hospital QIP help

desk email.

Contracts have been executed with all four non-capitated hospitals. These include Healdsburg

District Hospital, Mendocino Coast District Hospital, St. Joseph Petaluma and Santa Rosa

Hospitals.

The deadline for final data submission for 2014-15 Hospital-reported data was August 31st. Some

of the hospitals have had difficulties extracting OB data and were given an extension to submit

this data by September 18th.

Quality “Stars” Dashboard. PHC’s Board of Commissioners requested a separate “dashboard”

including measures to help the plan specifically evaluate the quality of care provided to our

members. The goal is to give PHC an overall score across measurement areas, similar to the

Medicare Stars Quality Bonus Program. Measures and targets will be presented at today’s

committee meeting.

Performance Improvement Activities:

ABCs of QI: PHC partnered with the community clinic consortia in Northern CA—Health Alliance of

Northern California and North Coast Clinics Network – to provide a five-week webinar series on

the ABCs of Quality Improvement for their clinic members between July 17, 2015 and August

14, 2015. The training was very well received and served as a valuable test of offering webinar

training over a period of several weeks.

ADVANCE: The 2015-16 ADVANCE cohort kicked-off with an orientation webinar on August

25, 2015. Fifteen practices were selected to participate and have begun meeting with their assigned

PHC coaches to select the area of focus for the 10-month program.

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Fairfield, CA 94534


COLEMAN:

During the latter half of August, the final two of five Coleman Rapid Dramatic

Performance Improvement (RDPI) teams (Ole Health Women’s Health Services and

Community Medical Center – Vacaville) began their eight-week long intensive change

session with Coleman Associates.

On September 2, 2015, PHC facilitated a leadership webinar on sustainability and spread

for the five RDPI teams. The teams are in the process of developing their sustainability

work plans. After completing the eight-week RDPIs, each team will have two leadership

coaching calls with a consultant with expertise in sustainability and spread and PHC.

MANAGING PAIN SAFELY:

In August, the Managing Pain Safely project provided two CME educational opportunities,

participated in community workgroups, and worked to validate data collected related to

specific outcome measures. On August 3rd PHC hosted a “Mindfulness and Beyond:

Changing the brain through mind-body discipline” webinar, which was attended by 58

participants.

On August 27, over 100 providers and key stakeholders attended a very successful Managing

Pain Safely Forum in Eureka which included clinicians, pharmacists and other staff

interested in learning more about chronic opioid use. This forum was spear headed and

coordinated by our Northern Region Team Marya Choudry, Andy Jensen, Sandra McMasters

and Shelby Franklin. The MPS team is busy planning additional educational opportunities,

which will be offered in the coming months.

UPCOMING OPPORTUNITIES:

Please visit the Managing Pain Safely website to learn more about these upcoming

events:

o PHC will be hosting a webinar entitled “Making the Right Diagnosis and

Providing the Best Treatment” on September 25, 2015. In this webinar, Dr.

David Green will provide education to providers to understand the neurologic

basis for this improving function in individuals with chronic pain through using

the mind-body discipline. Dr. Green will also discuss how providers’

communities can leverage this treatment modality to improve the health outcomes

of their chronic pain patients.

o PHC will be hosting a webinar entitled “Urine Toxicology Screening for

Patients Using Chronic Daily Opioid Therapy” on October 27, 2015. In this

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Fairfield, CA 94534


webinar, Dr. Andrea Rubinstein will discuss the purpose and limits of urine drug

monitoring and how to use the results to make rational therapeutic changes for

patients using chronic daily opioid therapy.

The 4th Annual Palliative Care Conference: Aligning Treatment and Goals of Care,

hosted by Napa Valley Hospice Adult Day Services and sponsored by PHC, will be held

October 29-30, 2015, at the Double Tree in American Canyon. Clinicians and other staff

who want to learn more about best practices and innovations in advance care planning

and palliative care are encouraged to attend. For more information, go to

www.nvhads.org.

We will offer a day-long, in-person ABCs of QI training in Santa Rosa on Thursday,

November 12. The California Improvement Network is sponsoring this training, and it

will be open to participants external to the PHC network.

ACEs which stands for, Adverse Childhood Experiences conferences in collaboration

with the Northern Consortia, Shasta County Public Health, and other community partners

are planned for September 11th in Redding and September 19th in Eureka, to increase

awareness of ACEs in the primary care setting. These conferences will provide avenues

for discussion on the impact of trauma on patient health, identification of local resources,

and the application of screening tools.

Regulatory Activities:

Electronic Site Review Tool:

Exciting work has begun on the development of an electronic site review tool. This has long

been in the making. The QI Site Review and IT staff have established a work group and

meetings have begun. The electronic tool will allow for capture of the primary care provider

facility site and medical record review findings at the sub-domain level. With this enriched

information, in addition to work efficiency concerns, PHC will be able to better identify

progress of providers meeting state standards and health care service areas that may need

more attention. Completion of the project is forecast for January 2016.

Initial Health Assessment Project:

Work has begun on improving the rates of our newly enrolled members in coming in to their

primary care physician’s office for a comprehensive visit to assess and diagnose acute and

chronic conditions. This visit should occur within 120 days of the member’s enrollment to

the health plan. We have established a workgroup to review claims data and identify high

and low performing providers and are in the process of recruiting providers to participate in

a pilot, looking at data, root cause analysis and intervention ideas.

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http://www.nvhads.org/

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QUALITY/UTILIZATION ADVISORY COMMITTEE

CONSENT CALENDAR

Items on the Consent Calendar have minor or no changes and are recommended by staff for approval.


MPQP1008 Conflict of Interest

MPQP1019 Quality Improvement/Utilization Management Delegation


HKUP3077 PCP to Specialty Care Referral Process (RAF)

MPCP2006 Coordination of Services for Children with Special Health Care Needs (CSHCNs) and

Persons with Developmental Disabilities

MCUG3043 Transportation Guidelines ARCHIVE

MCUP3041 TAR Review Process

MCUP3124 Referral to Specialists (RAF)

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POLICY/ PROCEDURE

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Policy/Procedure Number: MPQP1008 (previously QP100108 &

KK QI201) Lead Department: Health Services

Policy/Procedure Title: Conflict of Interest Policy for QI Activities ☒External Policy

☐ Internal Policy

Original Date: 04/25/1994 - Medi-Cal

11/16/2005 (KK QI201) – Healthy Kids Next Review Date: 09/16/2016

Last Review Date: 09/16/2015

Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☐ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH Approval Date: 09/16/2015

I. RELATED POLICIES:

A. CMP-10 – Confidentiality

II. IMPACTED DEPTS:

A. Quality Department

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. Conflict of Interest Agreement

V. PURPOSE: To describe the mechanism to ensure that a conflict of interest does not exist when contracted physicians

who are members of PHC committees perform peer review or quality improvement activities.

VI. POLICY / PROCEDURE:

A. All persons involved in peer review activities or committees shall sign a conflict of interest statement

annually.

B. Conflict of interest is defined as any involvement in the care of the member involved in the review, any

fiduciary interest or fiduciary relationship with the provider under review, or any other involvement in

the case that may impact objectivity in performing the review. Note – a provider is a broad term that

could include physicians or other direct care providers and vendors.

C. Committee members or peer reviewers with a conflict of interest in a particular case will notify the

Director of Quality or the Committee Chair, and excuse themselves from receiving related materials and

from participating in the review.

D. Should a situation arise in which this policy is not followed, the appropriate Committee and/or its Chair

will determine appropriate action and notify the individuals(s) verbally and in writing.

VII. REFERENCES: A. N/A

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

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Policy/Procedure Number: MPQP1008 (previously QP100108

& KK QI201) Lead Department: Health Services

Policy/Procedure Title: Conflict of Interest Policy for QI

Activities

☒ External Policy

☐ Internal Policy

Original Date: 04/25/1994 - Medi-Cal

11/16/2005 (KK QI201) – Healthy Kids Next Review Date: 09/16/2016



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IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Chief Medical Officer

X. REVISION DATES: Medi-Cal

01/27/95; 10/10/97 (name change only); 12/98; 6/21/00; 05/16/01; 08/20/03; 09/15/04; 04/19/06; 04/18/07;

02/20/08; 03/18/09; 04/21/10; 08/15/12; 08/20/14; 09/16/15

Healthy Kids

04/18/07; 02/20/08; 03/18/09; 04/21/10; 08/15/12; 08/20/14; 09/16/15

PREVIOUSLY APPLIED TO:

PartnershipAdvantage:

MPQP1008 - 04/18/2007 to 01/01/2015

Healthy Families:

MPQP1008 - 08/15/2012 to 03/01/2013

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Policy/Procedure Number: MPQP1019 (previously QP100119 &

KK QI204) Lead Department: Health Services

Policy/Procedure Title: Quality Improvement / Utilization

Management Delegation

☒External Policy

☐ Internal Policy

Original Date: 04/03/1997 Medi-Cal

11/16/2005 Healthy Kids (KKQI204) Next Review Date: 09/16/2016



Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☐ PAC



I. RELATED POLICIES:

A. N/A

II. IMPACTED DEPTS:

A. Delegation: PHC is accountable for and has appropriate structures and mechanisms to oversee the

delegated activities. PHC has the responsibility of performing oversight of a delegated entity's QI or UM

delegated activities to ensure full compliance with PHC's policies/established standards and to make

recommendations for improvement and monitor corrective actions.

III. DEFINITIONS:

A. N/A

IV. ATTACHMENTS:

A. Specific Delegation Agreements for NCQA Standards

B. PHC Audit Findings Tool Activities

V. PURPOSE:

To ensure that delegated entities have a comprehensive and systematic program for ascertaining that

Partnership HealthPlan of California (PHC) members have access and may obtain quality and cost-effective

healthcare services consistent with the standards established and recognized by PHC for all covered services

that are obtained through delegated service agreements.

To ensure that delegated utilization management (UM) and quality improvement (QI) activities are in

compliance with policies and procedures of PHC and professionally recognized standards and requirements.


A. Prior to delegation, PHC reviews the entity’s submitted written policies, procedures and program

descriptions for the activities under consideration.

B. Collaboratively with the potential delegate, PHC evaluates the delegate’s capability to perform the

activities within standards and ensures understanding of the delegated tasks. Results are reviewed by

PHC’s Internal Quality Improvement Committee (IQI). Recommendations are forwarded to the Quality/Utilization Advisory Committee (Q/UAC) for determination of delegation status. Evaluations

are done either remotely or onsite with the potential delegate.

C. PHC must have documentation, dated before delegation began, showing that it evaluated the entity

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☒ External Policy

☐ Internal Policy





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before implementing delegation.

D. A mutually agreed-upon delegation agreement should identify the responsibilities of PHC and the

delegated identity, the delegated activities, the process by which PHC evaluates the delegated entity’s

performance, and the remedies available to PHC if the delegated entity does not fulfill its obligations.

E. PHC reviews, evaluates and approves, on an annual basis, the delegated entity's QI and/or UM programs

and related policies for consistency with PHC policies and with DHCS, and CMS contractual obligations

of PHC. The content of the delegates’ work plan must reflect the needs of the health plan’s membership

covered by the delegated entity. PHC must ensure that its members receive quality and equitable access

to care and service throughout its network. Any substantive revisions to the delegated entity's QI and/or

UM programs and/or related policies are submitted to PHC within 30 days of the date changes were

made.

F. Reporting frequencies for each delegated activity is included in the delegation agreement grid.

Evaluation should occur when the reports are received. Feedback will be forwarded to the delegated

entity in the event deficiencies are identified and a Corrective Action Plan (CAP) may be needed to

correct or improve performance. Failure to improve can result in revocation of the delegation

agreement.

G. QI/UM reports are reviewed by PHC’s IQI and recommendations are forwarded to the Q/UAC for

evaluation and determination of continued delegation status.

H. PHC reports recommendations made by the IQI and Q/UAC to the delegate and works collaboratively to

develop action plans for improvement, if necessary.

I. PHC has responsibility to monitor the status of action plans by reporting progress to the IQI and Q/UAC.

J. If the delegate is not an NCQA accredited organization, PHC audits the delegate's QI/UM Program

Description/Evaluation at least annually to ensure:

1. Compliance with the approved QI/UM Program and related policies and procedures.

2. Adequate monitoring of potential under/over utilization of services.

3. Consistency of utilization review practices with PHC member benefit package and utilization review

criteria.

4. Materials to be evaluated during the audit process may include, but are not limited to:

a. Current delegated entity’s QI/UM Program and related policies and procedures.

b. Delegated entity’s QI/UM Committee meeting minutes.

c. Documentation of utilization management program implementation (e.g. records regarding

treatment authorization requests and reviews, referral authorization requests and review,

utilization review criteria utilized in decision making, and actions taken-- including but not

limited to denials of care, member and provider notification, appeals report, turnaround times,

and consistency of reviewers)

d. Review of utilization decision-makers’ credentials and licensure.

e. Reports of utilization trending and analysis.

5. The results of this audit are reported to the IQI and Q/UAC for consideration and recommendations

regarding continuation of delegation.

K. For NCQA accredited organizations, PHC may opt to waive the requirement for an annual onsite audit of

the QI/UM Program. PHC retains the right to reinstate onsite reviews.

L. Revocation of Delegation

1. If the delegated entity fails to fulfill its obligations under the delegation agreement in place, PHC

retains the right to revoke delegation.

VII. REFERENCES: A. N/A

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☒ External Policy

☐ Internal Policy





I:\QUALITY\QI Assistant\QUAC\2015 Meetings\09.16.2015\Policies on Consent\MPQ1019 Quality Improvement_Utilization Management Delegation 09.16.2015 .docx Page 3 of 3

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Associate Director of Regulatory

Affairs

X. REVISION DATES: Medi-Cal

10/10/97 [name change only]; 06/21/00; 01/17/01; 04/17/02; 09/15/04; 03/15/06; 06/20/07; 07/16/08;

10/21/09; 04/20/11; 12/19/12; 10/16/13; 09/16/15

Healthy Kids

06/20/07; 07/16/08; 10/21/09; 04/20/11; 12/19/12; 10/16/13; 09/16/15

PREVIOUSLY APPLIED TO: PartnershipAdvantage:

MPQP1019 - 06/20/2007 TO 01/01/2015

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POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Healthy Kids\UM\UM Poliicies for 09-08-15 IQI\HKUP3077\HKUP3077 PCP to Specialty Care Referral Process 09-16-15.docx Page 1 of 4

Policy/Procedure Number: HKUP3077 (previously MPUP3077 & KK UM 114) Lead Department: Health Services

Policy/Procedure Title: PCP to Specialty Care Referral Process (RAF)

External Policy Internal Policy

Original Date: 11/16/2005 Next Review Date: 09/16/2016 Last Review Date: 09/16/2015

Applies to: Medi-Cal Healthy Kids Employees

Reviewing Entities:

IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT

Approving Entities:

BOARD COMPLIANCE FINANCE PAC

CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH Approval Date: 01/16/201309/16/2015

I. RELATED POLICIES: A. …MPUP3004 Advice Nurse Program B. HKUP3069 Emergency Services A.C. MPCP2002 California Children’s Services

II. IMPACTED DEPTS: A. Health Services B. Claims A.C. Member Services…

III. DEFINITIONS: A. …N/A

IV. ATTACHMENTS: A. Referral Authorization Form (RAF) (Healthy Kids) Referral Authorization Form (RAF) (Healthy Families)

V. PURPOSE: To define the procedure used for PHC members to obtain specialty referral. ALL members who have a Primary Care Physician (PCP) assignment must obtain a RAF for specialty referrals EXCEPT for the indications outlined in Section VI. BII of this policy.

VI. POLICY / PROCEDURE: A. The Referral Process-PCP to-Specialist

1. The primary care physician shall initiate the referral process for specialty care 2. The authorizing PCP completes the RAF after making a determination of either the number of visits

or timeframe of services to be rendered. The preferred method is for the E-RAF to be completed. This will expedite processing time and will automatically send a copy of the request to the specialty provider. PCP should be sure to provide the clinical information that the specialty provider will need to make an accurate assessment of the situation and make recommendations for on-going care and treatment if needed.

3. The PCP is expected to keep a copy of the RAF, along with the specialists’ written follow-up report(s) and or recommendation(s) in the patient’s medical record.

4. A copy of the RAF is also sent to the Specialist by the PCP office if a paper form is used or will automatically be system generated if the E-RAF system is used.

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☒External Policy ☐Internal Policy


Applies to: ☐ Medi-Cal ☒ Healthy Kids ☐ Employees


5. A copy of the RAF should be given to the member so that they he/she will have the information about the specialist to whom he/she is that they are being referred to. This is to be doneshould be provided by the Primary Care Provider.

6. Upon completion of the initial evaluation and subsequent treatment (if indicated), the referral provider shall: a. Notify the PCP of the member’s condition, proposed treatments and prognosis though the

timeframe of treatment b. Provide the PCP with a written, or other oral reports as appropriate in regard to the diagnosis

and prognosis of the member’s treatment 7. If the request is for a non-contracted/non-network provider, a determination of the request will be

rendered within the timeframes outlined under section VI. E. 8. Out of Network referrals will be approved when there is a compelling medical reason for why the

service cannot be performed by an in-plan provider. Also, if there is non-availability of the service within the network, the referral will be approved.

B. Services EXCLUDED from the Referral Process

1. Emergency Service Referrals: a. Emergency services are defined as those services necessary to evaluate or stabilize an

Emergency Medical Condition that is found to exist using a prudent layperson definition b. Emergency Medical Condition is defined as a medical condition, which is manifested by acute

symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) Placing the health of the individual (or, in the case of a pregnant woman, the health of the

woman and her unborn child) in serious jeopardy OR 2) Serious impairment to bodily functions OR 3) Serious dysfunction of nay any bodily organ or part 4) PCPs are required to maintain 24 hour/ X7 days a week access for members, which includes

availability for response to Emergency Services and urgent requests of members. When possible, the PCP is to triage members and direct to the most appropriate level of service based on the needs of the member.

5) When the above is NOT possible, members may self- refer to the Emergency Room Department (ED) based on the members’ belief that there is an emergency situation occurring. or are taken by a third party.

6) Members may be referred to the EDR by the PHC Advice Nurse. 7) Members who have requested specialty referral from their PCP, but the request has been

declined by the PCP, may appeal directly to the health plan. 2. Family Planning Services

a. Health education and counseling necessary to understand contraceptive methods and make informed choices.

b. History and physical examination as indicated. c. Laboratory tests, if medically indicated, as part of decision making process for choice of

contraceptive methods. (e.g., Pap smear at appropriate intervals) d. Diagnosis and treatment of sexually transmitted diseases (STDs), if medically indicated. e. Screening, testing and counseling of individuals at risk for human immunodeficiency virus

(HIV) and referral for treatment. f. Provision of contraceptive pills/devices/supplies. g. Tubal ligation

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h. Vasectomy i. Pregnancy testing and counseling.

3. Routine Obstetrical and Gynecological Services

a. Female members have the right to self-refer to any contracted/in-network OB/GYN, family practitioner and/or certified nurse midwife who provides OB/GYN services without a referral from the member’s PCP.

b. The selected provider shall communicate with the member’s PCP regarding services provided and the need for additional or follow-up care.

4. Termination of Pregnancy a. PHC permits members to obtain termination of pregnancy services, without prior authorization,

from any in-network/contracted provider of their choice. 5. Mental Health Services

a. Members may self-refer to contracted in-plan providers or the County Mental Health Department

6. Routine vision care services a. Members may self-refer to contracted in-plan providers of Vision Care Services

7. Dental Services a. Members may self-refer to contracted in-plan providers of Dental Care. Certain specialty care

may require a referral from your dentist. 8. Native American Indians seeking care at an Indian Health Center 9. Urgent Care Services when traveling outside of the service area

C. Extended Referral Authorizations

1. Members with chronic conditions may require repeated specialty visits over an extended period of time, in order to sustain the appropriate level of medical supervision. In instances where there is a recurring need that is predictable, the PCP may initiate the referral for a period of up to a one-year time frame. If after that time, the need still exists for continued care, a new referral can be generated.

2. Members who have requested a long term referral from their PCP, but the request has been declined by the PCP, may appeal directly to the health plan.

D. CCS Conditions

1. For member with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), or any other condition as defined in California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS< Chapter 4 Medical Eligibility, Sections 41800-41872, these are eligible for coverage under the CCS program for the specialty services related to those conditions. CCS shall approve for and pay for all services in these instances.

2. The PCP, or other treating provider, is responsible to refer the individual to the local CCS office in the county in which the member resides. This shall include providing CCS with the needed documentation to make an eligibility determination.

3. PHC’s benefits are exclusive of services for CCS conditions and will not pay providers who render those services.

E. Turn Around Times

1. For in-plan contracted specialist, there is not an approval process from the health plan. The function performed is to enter the RAF into the PHC system so that the claim is paid when it is received in the claims department.t. These are put into the system within five (5) business days of receipt.

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2. For non-contracted specialty referrals, the plan will determine the medical necessity using InterQual established criteria and render a determination to either as to whether or not the referral is approved approve the referral and if so, make arrangements for payment within 1 business day on Emergent or Urgent requests and five (5) business days for routine requests.

3. If care can be rendered by a contracted specialist, the member will be redirected to a contracted provider.

VII. REFERENCES:

A. California Health and Safety Code Section 1367.695 AND 1374.16 B. Title 28, Division 1, Chapter 2, Article 7 Section 1300.67 B.C. InterQual Criteria

VIII. DISTRIBUTION:

A. PHC Directors B. Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health

Services X.IX. XI.X. REVISION DATES: 11/21/07; 11/19/08; 07/21/10; 10/01/10; 01/16/13; 09/16/15

PREVIOUSLY APPLIED TO: Healthy Families: MPUP3077 – 10/01/2010 to 03/01/2013

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Referred to:

Address:

Telephone:

Services requested:[ ] Consult and / or Continuing Care [ ] Please call me when you have seen patient.

[ ] 2 months [ ] 4 months [ ] up to 12 mos. [ ] I would like to receive periodic status report.[ ] Call me if procedures or admission planned.

Is requested provider contracted with PHC. This referral is:[ ] Urgent: potentially life-threatening condition.[ ] Indicated: important to health; not life-threatening.

Reason for referral:

Work-up and treatment to date: (Include copies of lab reports, imaging studies, etc.):

Questions I need answered:

Provisional Diagnosis:

Date of Issue: Clinician Signature:

Print Name

Send consult report to:

Final Report (please check all that apply) [ ] Typed consultation note will be sent to you.[ ] My medical record note will be sent to you. [ ] I will call you to discuss case.

[ ] Patient was not seen as schedulted on

Preliminary Report:

Plan:

Distribution Copies: Consultant, PCP, PHCFax No.Signature / Print Name Date Seen Phone No.

Date of Birth:

TO BE COMPLETED BY THE REFERRING CLINICIAN

ID#:

Referral Authorization Form (RAF)

Member Name:

City, Zip:

(from date of issue)

TO BE COMPLETED BY CONSULTANT

Primary ICD-9 /Dx:

The consultant name must be the same as that used to bill for these services.

Consultants should verify PCPPayment subject to member eligibility.Approval of consultation limited to covered benefits.

If Non-Contracted provider, RAF must be approved by PHC before given to member.

Consults must be initiated < 30 days of date below.

Phone FaxCityAddress

4665 Business Center DriveFarifield, CA 94534(707) 863-4133 or (800) 863-4144(707) 863-4118 FAX

PARTNERSHIP HEALTHPLAN OF CALIFORNIA RAF NUMBER

Member Phone:

PHC Determination: Approved Redirected to Contracted Provider Denied Signature____________________Date_______

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POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Multi-Program\Care Coord\IQI in September\MPCP2006 Coord. of Services for Mbrs with Special Health Care Needs & Persons with Developmental Disabilities 09-16-15.docx Page 1 of 4

Policy/Procedure Number: MPCP2006 (previously CP100206) Lead Department: Health Services Policy/Procedure Title: Coordination of Services for Members with Special Health Care Needs (MSHCNs) and Persons with Developmental Disabilities

External Policy Internal Policy

Original Date: 06/20/2001 Medi-Cal 01/16/2008 Healthy Kids

Next Review Date: 10/15/2015 09/16/2016 Last Review Date: 10/15/201409/16/2015


Reviewing Entities:


Approving Entities:




I. RELATED POLICIES: A. Regional Center Memorandums of Understandings B. MPCP2002 - California Children’s Services

II. IMPACTED DEPTS:

A. Health Services B. Claims C. Member Services

III. DEFINITIONS:

A. Members with Special Health Care Needs (MSHCNs) are those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by members generally.

IV. ATTACHMENTS:

A. PCP Notification Letter V. PURPOSE:

To outline a process for the identification, assessment, case management and coordination of care for Members with Special Health Care Needs and Persons with Developmental Disabilities that encourage access to specialties, sub specialties, ancillary providers, and community resources.


Partnership HealthPlan of California (PHC) has a process for the identification, assessment, case management and coordination of care for members with Special Health Care Needs and Persons with Developmental Disabilities. PHC encourages timely access to specialties, sub specialties, ancillary providers, and community resources. The effectiveness of PHC’s processes in serving MSHCNs is monitored on an annual basis to ensure best practices and identify opportunities for improvement. This quality review may be accomplished by utilizing HEDIS measures, member satisfaction surveys, response to complaints and grievances, input from community agencies, and data-driven measures that analyze clinical trends, access to care and specific utilization questions. A. Identification

1. PHC identifies MSHCNs in multiple ways including, but not limited to the following: a. Primary Care Physicians (PCP) may identify children with special needs, including California

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http://eshare/sites/PoliciesnProcedures/_layouts/15/WopiFrame.aspx?sourcedoc=/sites/PoliciesnProcedures/Care%20Coordination/MPCP2006%20Attachments/MPCP2006-A.docx&action=default




Next Review Date: 10/15/201509/16/2016 Last Review Date: 10/15/201409/16/2015

Applies to: ☒ Medi-Cal ☒ Healthy Kids ☐ Employees


Children Services (CCS) eligible conditions, and facilitate timely referrals to appropriate services/agencies.

b. UM team screens Treatment Authorization Requests (TARs) and may confer with Care Coordination Special Programs Liaison(s) on select TARs where special needs may need consideration such as deferring to for CCS review.

c. UM Nurses review all hospitalizations concurrently for early interventional opportunities. d. Health Services Care Coordination staff respond to requests from providers, families, and other

agencies for case coordination assistance, and/or other intended departments. e. PHC downloads the list of Regional Center enrollees from DHCS monthly.State downloads of

regional center enrollees. 2. Assessment

Primary Care Physicians (PCPs) are trained by PHC’s Provider Relations Department for the identification of MSHCN when they contract with PHC. Our review concerns the following assessment: a. A History & Physical (H&P) is completed within 120 days of the member’s effective date of

enrollment into the HealthPlan, or documented within the 12 months prior to the plan enrollment. The H&P will assess and diagnose acute and chronic conditions.

b. Health assessments containing Child Health and Disability Program (CHDP) age-appropriate content requirements are provided according to the most recent American Academy of Pediatrics (AAP) periodicity schedule for pediatric preventive health care. Assessments and identified problems are documented in the progress notes. Follow-up care or referral is provided for identified physical health problems as appropriate.

3. Direct Access to Specialists PHC allows certain populations of MSHCNs to be placed in a special member category, which allows direct access to care without requiring a referral from a primary care physician. These include but are not limited to clients of CCS, youth in Foster Care and GHPP. Members identified as MSHCNs are otherwise assigned to a Primary Care Physician with referrals to specialty and ancillary care as needed.

B. Case Management and Care Coordination PHC coordinates care with other agencies that provide services for MSHCNs: 1. California Children Services (CCS) Birth to age 21 years

a. PHC has established a relationship with the CCS programs in all counties served by PHC. 2. PHC’s Care Coordination Department, upon receiving a referral, contacts the member’s

representative, resulting in either referring the member to appropriate community-based services or state programs and/or opening a case for PHC Care Coordination members not otherwise eligible but with other identified special needs. a. The Special Programs team works closely with the outside agencies and the primary care

provider to encourage all necessary documentation regarding the member’s diagnosis, treatments, and services are placed in a member’s health record. All interventions are documented in PHC’s case management record to track the flow of the case.

b. The Special Programs case managers receive monthly caseload reports in order to track and monitor the new enrollments.

c. PHC ensures Medi-Cal coverage for medically necessary eligible services for the member’s CCS eligible condition continues until CCS eligibility is confirmed. To ensure continuity and prevent any gaps in care during this time the member is reviewed for entry in PHC’s episodic case management level of care.

d. If CCS program eligibility is established for a member, PHC continues to provide all medically

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necessary Medi-Cal covered services that are unrelated to the CCS eligible condition. e. If the local CCS program does not approve eligibility, PHC remains responsible for the

provision of all medically necessary covered services to the Member. f. If the local CCS program denies authorization for any services, PHC remains responsible for

obtaining the services, if they were medically necessary, and paying for all the services that were provided.

3. Early Intervention (EI) Services - Birth to age 3 years a. The PHC provider network has primary responsibility for the identification of children less than

3 years of age who may be eligible to receive services from the Early Start Program and to make the referral to the Regional Center which coordinates those services. These include children where a developmental delay in either cognitive, communication, social, emotional, adaptive, physical or motor development is suspected, or whose early health history places them at risk for delay.

b. A PHC Perinatal Enrollment Specialist (PES) working in the high risk pregnancy/ Growing Together Perinatal Program (GTPP) may identify children qualifying for Early Start Program due to certain conditions found in-utero. The PES notifies the Special Programs team of the case and documents in the expectant mother’s case management record that Special Programs is aware. The Special Programs team will work with the appropriate providers to ensure early intervention services are accessed.

PHC collaborates with the providers and the local Regional Center or Early Start Program in resolving problems, determining medically necessary services including diagnostic and preventive services and provides input to be considered in the treatment plans for members participating in the Early Start Program. Children under age 21 with an actual or provisional diagnosis of Autism Spectrum Disorder (ASD) may be eligible for behavioral health treatment (BHT) services. Please see PHC policy #MPUP3126 , “Autism Spectrum Disorder Behavioral Health Treatment” for details.

c. d. PHC’s Care Coordination Department and primary care physicians provide case management

and care coordination to the member to ensure the provision of all medically necessary covered diagnostic, preventive and treatment services that are identified in the Individual Family Service Plan developed by the Early Start Program.

4. Services for Persons with Developmental Disabilities and/or ASD- Age 3 years through adulthood PHC provides all screening, preventive, medically necessary, and therapeutic covered Medi-Cal

services to Members with developmental disabilities. Children under 21 with a diagnosis of Autism Spectrum Disorder (ASD) may be eligible for behavioral health treatment (BHT) services. Please see PHC policy #MPUP3126 , “Autism Spectrum Disorder Behavioral Health Treatment ”for details.

a. b. PHC members who are also clients of a Regional Center are advised to contact the Regional

Center for evaluation and access to those non-Medi-Cal services provided through the Regional Centers such as; but not limited to, respite, day care, out-of-home placement and supportive living.

c. PHC members who are not clients of Regional Center but who may meet their eligibility criteria for developmental disability are advised to contact the Regional Center for assessment and evaluation PHC is not able to make direct referral to Regional Center without written consent of the member or legal representative

d. Upon request to PHC by the member, Regional Center staff or other entities, PHC Special Programs staff will assist with identification and coordination of appropriate services for the

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member. 5. Local Education Agency Services (LEA)

a. PHC assures a PCP is available to provide primary care management and care coordination to the member to ensure the provision of all medically necessary Medi Cal covered diagnostic, preventive and treatment services. Local Education Agency assessment services are services specified in Title 22 CCR Section 51360(b) and provided to students who qualify based on Title 22 CCR Section 51190.1. LEA services are provided pursuant to an Individual Educational Plan as set forth in Education Code, Section 56340 et seq. or Individual Family Service Plan as set forth in Government Code, Section 95020, are not covered under the contract.

6. School Linked Children’s Health and Disability Prevention (CHDP) Services. PHC does not currently have a school linked CHDP program in its county service area. If a school linked CHDP program site establishes within its county service area PHC will do the following: a. Maintain a “medical home” and ensure the overall coordination of care and case management of

members who obtain CHDP services through the local school districts or school sites. b. Establish guidelines for the following:

1) Sharing of critical medical information. 2) Coordination of services 3) Reporting requirements 4) Quality standards 5) Processes to ensure services are not duplicated 6) Processes for notification to Member/student /parent on where to receive initial and follow-

up services 7) Referral protocols/guidelines for the school sites which conduct CHDP screening only, to

assure those Members who are identified at the school site as being in need of CHDP services receive those services within the required state and federal time frames

8) Assure processes for appropriate follow-up and documentation of services provided to the member

9) Provide resources to support the provision of school linked CHDP services VII. REFERENCES:

A. DHCS Contract 2009 Section A11.7-11.11 VIII. DISTRIBUTION:

A. PHC Department Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services X. REVISION DATES:

Medi-Cal 08/20/03; 04/20/05; 01/16/08; 05/19/10; 10/01/10; 09/19/12; 10/15/14; 09/16/15 Healthy Kids 01/16/08; 05/19/10; 10/01/10; 09/19/12; 10/15/14; 09/16/15 PREVIOUSLY APPLIED TO: Healthy Families: MPCP2006 - 10/01/2010 to 03/01/2013

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Fairfield, CA 94534

I:\POLICIES\Draft policies for review\Multi-Program\Care Coord\IQI in September\MP2006A Special program PCP letter for CCS Regional Center 10-15-14 NO CHANGE.docx

Date <Name> <Address> <Address> <Address> Attention: Medical Records Please place into patient file Patient Name: <member name> Dear <PCP>: Partnership HealthPlan would like you to know that < member name > has managed care benefits coordinated through Partnership HealthPlan. We are aware that this person has special needs and receives services through California Children Services and/or Regional Center. The Partnership HealthPlan Care Coordination Department has special program case managers available to assist you in the coordination of medical care for this member. We work together with you well as other agencies including Regional Centers and California Children Services toward ensuring case management medical needs are being met. If you would like to discuss this member’s benefits or the special case management program please call me at 1-800-809-1350 ext XXXX, 8am to 5pm Monday through Friday. We look forward to hearing from you. Sincerely, <Name> Case Manager Special Programs Care Coordination Department Partnership HealthPlan of California 4665 Business Center Drive, Fairfield, CA 94534 Phone (707) 555-5555 | Fax (707) 863-4502 Email: Our Website: www.partnershiphp.org

ATTACHMENT A

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http://www.partnershiphp.org/


GUIDELINE / PROCEDURE

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 09-08-15 IQI\ARCHIVE MCUG3043\MCUG3043 Transportation Gdlns- ARCHIVE 09-16-15.docx Page 1 of 4

Guideline/Procedure Number: MCUG3043 (previously UG100343) Lead Department: Health Services

Policy/Procedure Title: Transportation Guidelines ☒External Policy ☐ Internal Policy



Reviewing Entities:

☒ IQI ☐ P & T ☒ QUAC ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC



I. RELATED POLICIES: A. Member Services’ Guidelines for Transportation - MP 315

II. IMPACTED DEPTS:

III. DEFINITIONS: N/A

IV. ATTACHMENTS: N/A

V. PURPOSE:

The following guidelines will be used by the transportation specialist when reviewing TAR requests for transportation services.

VI. GUIDELINE / PROCEDURE:

A. EMERGENCY TRANSPORT 1. EMERGENCY transport is provided for emergency medical conditions as defined in the Federal

Statute (420.5.C.S 1396b[V]). The term “emergency medical condition” is defined in federal statute to mean a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: a. Placing the patient’s health in serious jeopardy. b. Serious impairment to bodily functions. c. Serious dysfunction of any bodily organ or part.

AIR emergency transportation is covered when medically necessary and when other forms of transportation are not practical or feasible for the patient’s condition. GROUND emergency transportation is covered when ordinary public or private medical transportation is medically contraindicated and transportation is needed to obtain care. 2. TAR is not required for emergency air or ground transportation. 3. Emergency transportation must be to the nearest hospital capable of meeting the medical needs of

the patient.

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Policy/Procedure Title: Transportation Guidelines ☒ External Policy ☐ Internal Policy




4. Medical transportation which represents a continuation of an original emergency transport (such as

transfer from an emergency room of one hospital to an emergency room of another hospital for treatment or admission) is considered a continuation of the initial emergency transport. The transfer is not considered a continuation of the initial transport if the provider vehicle leaves the facility to return to its place of business or accepts another call prior to completing the transfer and can be billed separately and does not require a TAR.

5. Emergency transportation provided for the purposes of evaluating a psychiatric crisis and/or for admission to a psychiatric facility is a covered service without a TAR. Counties directly performing this service are eligible providers, and the mode of transportation should be appropriate to the patient’s medical and psychiatric needs. The continuation of an original emergency transport from an emergency room to another facility that can meet the medical and psychiatric needs of the patient is an appropriate emergency transport.

B. NON-EMERGENCY TRANSPORT 1. Non-emergency transportation is covered when the member’s medical and physical condition is such

that transport by ordinary means of public or private conveyance is contraindicated, and transportation is required for the purpose of obtaining needed medical care that is a covered benefit of the Medi-Cal program.

2. TAR is required for all non-emergency transportation except for transport, upon discharge, from an acute care facility, inpatient bed or Emergency Department directly to a LTC facility or to another acute care facility.

3. The TAR needs to indicate the nature of the medical condition and verification that the attending physician ordered the service. a. The provider has 15 business days from date of service to submit a TAR. b. PHC reviews the TAR request to determine the appropriate level of transport based on medical

necessity and reviews the case with the physician as indicated. 4. AIR non-emergency transportation is covered only when clearly medically necessary and when

other forms of transportation are not practical or feasible for the member’s condition. 5. Transportation is covered from a medical facility to the same or lower level of care, including the

member’s place of residence. 6. Transportation is covered when the member’s needs are such that SNF/LTC must obtain specialty

medical services not outlined as the responsibility of the facility as per CCR Title 22 Section 72301 and the service to be obtained is a Medi-Cal benefit.

C. TYPES OF NON-EMERGENCY TRANSPORTATION

1. AMBULANCE service may be used for: a. Transport from hospital to long-term care facility or to home when the medical/physical

condition requires recumbency and the use of medical supportive devices (such as IV fluids, suction, oxygen).

b. Chronic respiratory distress patient who requires continuous oxygen and cannot utilize self-portable oxygen or who cannot otherwise sit upright.

c. Chronic cardiac conditions which requires monitoring during transport. 2. LITTER VAN service may be used for:

a. Medically necessary transport of member for special testing, radiation therapy or transfer to a lower level of care or to home when a member’s medical/physical condition is stable but requires recumbency and does not require medical supportive devices.

b. Cases where a medical/physical condition precludes sitting upright for any period of time but no

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Policy/Procedure Title: Transportation Guidelines ☒ External Policy ☐ Internal Policy




medical supportive devices are required. c. Hospital transfer to a long-term care facility or home when the medical/physical condition

requires recumbency but no supportive medical devices are required. 3. WHEELCHAIR VAN service may be used for:

a. Members who are wheelchair bound and unable to travel by public or private conveyance. Members who require attendant supervision door-to-door while ambulating, even with the assistance of a walker or crutches.

b. Members who are mentally challenged where transport requires attendant supervision. 4. PHC reserves the right to review any TAR or claims for non-emergency transport and based on

medical necessity will pay for the appropriate type of transport if that service is available within the county.

5. For members not meeting the above criteria see Member Services’ Transportation policy.

D. BILLING 1. The cost of an ambulance, litter van, or wheelchair transport of an inpatient between acute care

facilities for services that cannot be performed at the facility such as; special testing, diagnostic procedures or radiation therapy; is included in the hospital per diem rate and the provider is to bill the hospital directly.

2. Services included in the base rate and not separately reimbursable are: backboards, flat/scoop stretcher, long boards, disposable O2 masks/tubing, disposable IV tubing, childbirth, assistance, restraints, suction/suction equipment, resuscitations respirator/IPPB, crew of 3 (air) or 2 (ground), pick-up off paved road, or overweight or difficult patients, linens/blankets.

3. Wait time up to six units is reimbursable (1 unit equals 15 minutes). 4. The provider must bill Medicare and/or private insurance payers first for all emergency transports of

PHC members who have other coverage. 5. It is PHC policy to cover all transportation services per Medi-Cal guidelines. See Medi-Cal

Guidelines for more specific information and rates. Medi-Cal References 200-53 and 55, 300-84, 300-111 Manual of Medi-Cal Criteria 6.1

6. Kaiser keeps risk on transportation. E.

VII. REFERENCES:

A. Title 22 CCR §51323 VIII. DISTRIBUTION:

A. PHC Departmental Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:

X. REVISION DATES: 04/28/00; 10/17/01, 02/19/03; 02/16/05; 01/18/06, 08/20/08; 11/18/09; 10/16/13

PREVIOUSLY APPLIED TO:

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POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 09-08-15 IQI\MCUP3041\MCUP3041 TAR Review Process 09-16-15.docx Page 1 of 8

Policy/Procedure Number: MCUP3041 (previously UP100341) Lead Department: Health Services

Policy/Procedure Title: TAR Review Process ☒External Policy ☐ Internal Policy

Original Date: (UM-2) 04/25/1994 (Effective 06/19/2013 - TAR/RAF Review Policy split)



Reviewing Entities:

☒ IQI ☐ P & T ☒ QUAC ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC



I. RELATED POLICIES: A. MCUP3124 – Referral to Specialists (RAF) Policy B. MCUP3033 – Out of Area Emergency Admissions

II. IMPACTED DEPTS:


III. DEFINITIONS:

A. Medical Necessity – Medical Necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

IV. ATTACHMENTS:

A. PHC TAR Requirements list (including Outpatient Surgical Procedures CPTs Requiring TAR list and Pain Management CPTs Requiring TAR list

V. PURPOSE:

To describe the procedure used by the PHC Utilization Management (UM) Department to process Referral Authorization Forms (RAFs) and Treatment Authorization Requests (TARs) based upon the medical necessity of the request.


A. TAR REVIEW PROCESS 1. General Procedures

a. Partnership HealthPlan of California (PHC) pays for authorized services according to the specific terms of each physician, hospital, or other provider contract. PHC will reimburse only if individuals are eligible at the time the service is rendered.

b. Resources necessary to help in determining review decisions, include, but are not limited to the published, current, InterQual criteria; Medi-Cal (State of California) criteria, Medicare criteria, and PHC internally developed and approved guidelines. Determinations also take into account individual member needs and characteristics of the local delivery system. 1) The Provider of service must verify eligibility of the member via PHC systems at the time

of service. This verification is necessary for all service authorizations.

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Policy/Procedure Title: TAR Review Process ☒ External Policy ☐ Internal Policy


Next Review Date: 09/16/201606/17/201606/17/2016 Last Review Date: 06/17/201509/16/2015



2) PHC’s eEligibility and Interactive Voice Response (IVR) Systems are available to verify

eligibility and determine the member’s assigned PCP. Information required to verify the eligibility of an individual is as follows: a) Name b) Date of Birth c) Sex d) Social Security Number e) Medi-Cal number/CIN f) PHC member number g) Address and name of parent may be necessary in some cases.

2. Services Requiring Treatment Authorization a. Certain procedures, services, and medications require prior authorization from PHC before

reimbursement is made. Those services requiring a Treatment Authorization Request (TAR) are listed as attachments to this policy. The attachment consists of: 1) PHC TAR Requirements List 2) Outpatient Surgical Procedures Requiring TAR 3) Pain Management CPTs Requiring TAR

b. All elective inpatient hospital admissions require prior authorization except anticipated two (2) day post vaginal delivery stays and four (4) day post C-Section stay (Please see section for the inpatient TAR process). A service being provided that is not pregnancy related requires the admitting physician to submit the TAR for the elective procedure prior to the actual hospital admission. Although an approved TAR will assign a specified number of initial days approved, the hospital is required to notify PHC within one working day of the actual date of admission.

c. All Skilled Nursing or Long Term Care facility admissions require approval prior to the admission, and throughout the length of stay.

d. For those providers contracting with PHC, if a member has primary coverage through Medicare Part A, a TAR is not required until the member exhausts the benefits available under Medicare. Once benefits have been exhausted, the TAR must be submitted along with written verification from Medicare that the benefits have been exhausted. The TAR must be submitted within 15 days of the date the benefits exhausted or within 60 days of retrospective eligibility.

e. Exception: If the provider receives a denial from Medicare or any other primary payor source, they must submit a TAR to PHC’s Health Services Department, along with a copy of the Medicare denial and the medical record documentation. The TAR must be received by PHC within 60 days of the issue date of the denial from Medicare or the other payor source.

f. TARs are not required for services related to emergency services, minor consent, family planning and preventive services, basic prenatal care, sexually transmitted disease services and HIV testing.

3. Outpatient Service TAR Submission Process a. TARs should be submitted electronically via PHC’s Online Services portal. Electronic

submission will allow for more expedient processing. If online submission is not possible, the TAR may be submitted via fax or mail.

b. Expedited Process 1) Expedited processing is available for requests in which the provider indicates or PHC

determines that the standard timeframe could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function. Under these circumstances PHC will expedite the review determination and provide notice as expeditiously as the

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member’s health condition requires, but no later than three (3) business days after receipt of the request for services.

2) Requests for an expedited determination should be submitted via e-TAR or fax, and be clearly marked “Urgent” or “Expedited” and should indicate the reason there is an urgent need for authorization. A TAR for elective (non-emergent) surgery submitted urgently due only to an imminent date of service is NOT considered to be urgent. TARs submitted under these circumstances will be processed as a routine TAR.

3) The Nurse Coordinator will process the expedited request and will notify the provider within one calendar day of the determination.

4) Members will be notified of all adverse determinations in writing. c. Routine Outpatient TARs

1) TARs for members who require services should be submitted electronically via PHC’s Online Services. If electronic submission is not available, the TAR may be faxed or mailed to PHC’s Health Services Department for review.

1)2) If the TAR is received without sufficient information to render a determination, the Provider and Member will be notified in writing requesting the information required. In addition to sending a letter, the UM Staff will contact the Provider and/or designated office staff member to remind him/her of the specific information requested and the regulatory timeframe for submission.

2)3) Routine TARs will be processed within 5 business days of receipt of all required documentation, but no longer than within 14 calendar days from receipt of the request.

3)4) A decision may be deferred and the time limit extended an additional 14 calendar days only where the Member or the Member’s provider requests an extension, or PHC can provide justification upon request by the State for the need for additional information and how it is in the Member’s interest. Any decision delayed beyond the time limits is considered a denial and will be immediately processed as such.

4)5) The provider will be notified of the decision to approve, modify, defer, or deny the TAR in writing within one (1) working day.

5)6) Members or their authorized representative will be notified of denials, deferrals, and modifications in writing within two (2) working days of the determination.

4. Inpatient Prior Authorization TARs a. The TAR procedure for elective services is as follows:

1) Authorization for elective hospital admissions must be submitted by the admitting physician and include the following: a. Procedure code or service being performed b. Facility where procedure will be performed c. Anticipated date of procedure d. Number of days being requested if inpatient admission e. Diagnosis

2) Please note that PHC will assign a number of initially approved days however, it is the hospital’s responsibility to notify PHC within one working day of the date of the actual admission.

3) If the patient’s condition necessitates hospitalization beyond the pre-approved time frame, PHC will perform concurrent review on the remainder of the stay.

4) The Nurse Coordinator reviews the information received from the provider utilizing PHC approved review guidelines. The Nurse Coordinator approves the request if it meets medically necessary criteria. Requests that do not meet review guidelines are referred to the

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Chief Medical Officer (CMO) or Physician Designee for further evaluation. 5) PHC’s Chief Medical Officer or Physician Designee reviews all TARs referred to him/her,

taking the action deemed appropriate. He/She may contact the requesting provider for further information. Once the Chief Medical Officer or Physician Designee approves or modifies the request, the TAR will be returned to the Nurse Coordinator for completion. Denials for medical necessity are made only by the Chief Medical Officer or Physician Designee.

b. Emergency admissions 1) For all emergency and obstetrical admissions, the hospital or LTC facility must notify PHC

and the member’s PCP of the admission as soon as possible, but not later than the first working day following the date of admission.

2) The preferred method of notification is electronically using PHC’s Online Services Portal. If a facility is not contracting with PHC, or if online submission is not possible, the TAR may be submitted via fax or mail. It is recommended that the provider maintain documentation of successful transmission and receipt.

3) The case is reviewed by the Nurse Coordinator and a decision on length of stay is authorized based on PHC established criteria within one calendar day.

4) The provider is notified of decision within one calendar day. c. Obstetrical delivery services

1) Obstetrical admissions do not require a TAR prior to admission, for obstetrical delivery. 2) PHC will approve two (2) consecutive days for both mother and baby for post vaginal

deliveries and four (4) days for a Caesarean Section delivery. 3) The hospital must notify PHC if the mother and/or baby require additional days of acute

care. The Nurse Coordinator reviews the case for medical necessity during the next UM review.

5. Nurse Coordinator/UM Review Process a. A Nurse Coordinator can approve, modify, defer (pend) the TAR, or deny the TAR for

administrative reasons. b. TARs that require clinician review due to questions of medical necessity are pended to the Chief

Medical Officer / Physician Designee. The Nurse Coordinator attaches all relevant documentation and the Medical Director Worksheet.

c. TARs can be denied, for reasons of medical necessity, ONLY by the Chief Medical Officer or Physician Designee.

6. TARs with Special Processing Requirements a. Dialysis TAR Process

Initial TAR requests for Dialysis services for members who have no other insurance will be authorized for a 90 day period only.

1) Per CCR Title 22 section 50763 “Medi-Cal beneficiaries must apply for any available health care coverage when no cost is involved.” All members receiving dialysis must submit an application to Social Security for Medicare benefits. The provider must submit a denial from Medicare for PHC to approve services beyond the initial 90 days.

2) Once a Medicare determination of denial of coverage is received, PHC will issue a TAR that will remain valid for the member’s lifetime or until the member receives a kidney transplant.

b. Hospice Services 1) Hospice services require a TAR ONLY for inpatient services (i.e. acute or SNF/LTC

facility). However, a Hospice election form signed by the member or his/her legal

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representative must accompany any initial claim for hospice services (all outpatient and inpatient services).

7. Chief Medical Officer / Physician Designee Review a. The Chief Medical Officer or Physician Designee must be available physically or by telephone

during business hours to assist with evaluating TAR requests. b. The Chief Medical Officer or Physician Designee review is done in all cases of potential denial

due to medical necessity, interpretation issues, or other issues as requested by the UM staff. c. The Chief Medical Officer or Physician Designee may contact involved providers or consultants

for additional information as required to assist him/her in rendering a decision about the case. The Chief Medical Officer or Physician Designee documents the rationale for any decision on the Medical Director Worksheet.

d. The Chief Medical Officer or Physician Designee is the only person authorized to sign denials for medical necessity or to make any exceptions or modifications to the established PHC medical criteria.

e. PHC makes available to physicians a physician reviewer (Chief Medical Officer or Physician Designee) to discuss by telephone determinations based on medical necessity.

8. Finalization of TARs a. TARs are not processed by PHC until the TAR is completely filled out with all the information

on the member and all attachments noted on the TAR are received. For the provider of service and service(s) being requested - this includes the requirement that correct and valid codes be utilized.

b. Authorizations are only valid for the timeframe approved by PHC. If the timeframe is exceeded due to an unforeseen delay, the Provider may submit a request for an extension of the time period, noting the reason for the delay

c. All TARs s including worksheets, letters, and other documentation are kept on site for 12 months and archived off site for 10 years or until member reaches age 21.

9. Administrative Denials a. Health Services staff designee may process denials based on administrative criteria.

Administrative denial criteria shall include: TAR not required, member not eligible with PHC on date of service, member has other insurance, duplicate request, TAR or service line not accepted due to coding issue, TAR not submitted on a timely basis and additional information not received by PHC within 14 days of request. Each month a report of all administrative denials is reviewed and signed by the Chief Medical Officer or Physician Designee. Administrative denials are not subject to the Provider Appeals process.

10. Delegated Entities a. Kaiser and Woodland Healthcare are delegated to perform some aspects of utilization

management for members assigned to them and will make determinations on service requests for their assigned members. PHC’s Senior Health Services Director is responsible for monitoring the Utilization Management activities and receives biannual reports from the delegated entities.

b. Multi-specialty medical groups do not require pre-authorization from PHC for services for which they are delegated. All elective hospital admissions must be pre-authorized by the medical group and reported to PHC at the time of admission.

11. Non-Contracting Hospital Review a. Elective admissions to non-contracted hospitals require approval of a TAR, which is subject to

PHC’s timeline policies. Since most admissions to non-contracted hospitals are for emergency conditions, the procedure for non-contracting hospital review is as follows:

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1) PHC electronically notifies the member's assigned PCP or medical group of the admission to the non-contracted hospital, and assigns an initial length of stay (LOS) if the admission is an emergency as set forth in Title 22, California Code of Regulations.

2) If the admission does not meet admission criteria, it is referred to the Chief Medical Officer or Physician Designee for review. The Nurse Coordinator notifies the non-contracting hospital of the Chief Medical Officer or Physician Designee's decision and provides the process for appeal or the opportunity to discuss the determination with the CMO/Physician Designee.

3) If the member is not medically stable for discharge or transfer to a lower level of care by the last certified day, the admitting hospital must obtain telephone authorization for extensions of stay from PHC's Nurse Coordinator.

4) For a member capitated to an in-plan hospital who is admitted to a non-capitated hospital, please refer to the MCUP3033 Out of Area Emergency Admissions policy.

b. When the admission is elective and has been given prior authorization, no further communication is required until the approved number of days is nearing expiration and the member is expected to remain hospitalized beyond the days previously approved. The facility is required to provide to the Nurse Coordinator appropriate clinical information supporting the medical necessity of continued stay.

12. Retrospective Review for TAR Required Services a. Retrospective (Retro) TARs must be received by PHC within fifteen (15) business days of the

date of service or within 60 days of a denial from the primary insurance carrier. Retro TARs received after that timeframe are considered for review only under the following conditions: 1) When a member does not identify himself/herself to the provider as a PHC member by

deliberate concealment or because of physical or mental incapacity to so identify himself/herself.

2) If a member has obtained retroactive eligibility. The TAR must be received by PHC within 60 days of the members obtaining Medi-Cal eligibility.

b. For retrospective medical review, the decision for authorization is made within 30 days of obtaining all the necessary information.

c. Members and providers are notified in writing within 5 working days of the determination. 13. Correction TARS

a. The provider has up to 6 months from the approved date of the ORIGINAL authorized TAR to submit modifications of approved services. A new TAR must be submitted with the requested modifications and MUST reference the ORIGINAL TAR number and code(s) or date(s) to be modified. Modifications will be accepted or made only on approved TARS for the following: 1) Types of service. For example, only similar items or procedures may be modified (e.g.

micropore tape versus paper tape, right wheels versus left wheels, etc.). 2) Minor extension or change of dates may be requested (e.g. start of service May 15 versus

May 20). 3) Units of service (e.g. 9 visits versus 6 visits). This usually coincides with a change of, or

extension of, dates of service requested. 14. UM Decision Timelines

a. For precertification of nonurgent care, PHC makes decisions within five working days of obtaining all the necessary information.

b. For precertification of nonurgent care, PHC notifies practitioners of the decisions within one working day of making the decision.

c. For precertification of nonurgent care that result in a denial, PHC gives members and

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practitioners written or electronic confirmation of the decisions within two working days of making the decision.

d. Post Stabilization Services 1) Upon receipt of an authorization request from an emergency services provider, UM shall

render a decision within 30 minutes or the request is deemed approved, pursuant to Title 28 CCR Section 1300.71.4.

e. For precertification of urgent care, PHC makes decisions and notify practitioners of the decisions within one calendar day.

f. For precertification of urgent care that results in a denial, PHC notifies both members and practitioners of how to initiate an expedited appeal at the time they are notified of the denial.

g. For precertification of urgent care that results in a denial, PHC gives members and practitioners written or electronic confirmation of the decisions within two working days of making the decision.

h. For concurrent review, PHC makes decisions within one working day of obtaining all the necessary information.

i. For concurrent review, PHC notifies practitioners of decisions within one working day of making the decision.

j. For concurrent review decisions that result in a denial, PHC gives members and practitioners written or electronic confirmation within one working day of the original notification.

k. For concurrent review decisions that result in a denial, PHC notifies both members and practitioners of how to initiate an expedited appeal at the time they are notified of the denial.

l. For retrospective review, PHC makes the decision within 30 working days of obtaining all the necessary information.

m. For retrospective review, PHC notifies practitioners and members of denials in writing within five working days of making the decision.

15. Monitoring of the TAR Process a. Aggregate TAR data is subject to retrospective analysis by PHC’s UM Department. This review

is designed to: 1) Identify individual provider practice patterns relative to standards of medical practice. 2) Evaluate over and under-utilization of services.

b. PHC monitors turnaround times of internal processing for compliance with standards. b.c. Denials or modifications for medical necessity are monitored weekly to ensure accuracy in

regulatory requirements, review processes, and correspondence. c.d. PHC performs inter-rater reliability audits as outlined in the policy at least annually on both

physician and nurse reviewers. d.e. Member & provider grievances, as well as PHC’s member and provider satisfaction survey

responses, serve as an evaluation tool. f. Administrative denials are monitored quarterly to identify trends and/or the need for additional

provider education, outreach, or other intervention. A summary is presented to the Internal Quality Improvement Committee every six months.

VII. REFERENCES:

A. Medicare Home Health Agency Manual B. U.S. Department of Health and Human Services C. HCFA - Pub 11 (2/84) thru Rev. 149 ICN 403750

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VIII. DISTRIBUTION: A. PHC Departmental Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: TAR Procedure [UM-2]: 11/19/96; 12/15/99; 01/12/00 – RAF Procedure [UM-1]:

12/27/95; 05/27/99); (TAR/RAF [UP100341] - 06/21/00; 04/18/01; 03/20/02, 05/21/03 attachments revised 10/01/03; 04/21/04; 01/19/05; 04/20/05; 09/21/05, 10/18/06, 08/20/08, 07/15/09; 05/19/10; 07/20/11); 06/19/13; 06/17/15; 09/16/2015 PREVIOUSLY APPLIED TO:

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Attachment A - MCUP3041 Attachment A - MCUP3049 Attachment A - HKUP3080 Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised 04/15/2015

Page 1 of 8

PHC TAR REQUIREMENTS

A. Hospitalization 1. The hospital must notify PHC of any admission within 24 hours of the admission. 2. Authorization for elective admission must be requested by the admitting physician prior to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or change in payor status within one working day. (Examples include Medicare non-coverage or exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs and injectable drugs (including drugs compounded for IV infusion therapy) not onthe PHC formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans ♦ MRI ♦ MRA ♦ PET scan ♦ Transcranial Doppler ♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits requested including initial visit.

♦ Acupuncturist

� Speech Therapy

♦ Chiropractor � Occupational Therapy ♦ Faith Healer � Home Infusion Therapy (Nursing Component Only) ♦ Physical Therapy � Home Health Care

I. Hospice Care (Inpatient Only)

J. Pulmonary Rehabilitation K. Hyperbaric Oxygen Pressurization

L. Non-Emergency Medical Transportation

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Page 2 of 8


M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s). Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item ♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including: - L0999 Addition to spinal orthosis, not otherwise specified - L1499 Spinal orthosis, not otherwise specified - L2999 Lower extremity orthosis, not otherwise specified - L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified - L3999 Upper limb orthosis, not otherwise specified - L5999 Lower extremity prosthesis, not otherwise specified - L7499 Upper extremity prosthesis, not otherwise specified - L8039 Breast prosthesis, not otherwise specified - L8499 Unlisted procedure for miscellaneous prosthetic services - L8699 Prosthetic implant, not otherwise specified ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150 ♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is required)

♦ Oxygen and related supplies ♦ Diabetic Supplies are to be provided by Pharmacies ONLY ♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary) ♦ Any unlisted or miscellaneous code ♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will NOT be allowed for parts or labor during a guarantee period if due to a defect in material or workmanship)

- Purchase items over $100.00 / item (Vendor to guarantee for a MINIMUM of six (6) months from the date of purchase)

- Rental items over $50.00 / month / item (Rental rate includes equipment related supplies.)

- Any unlisted or miscellaneous code - Purchase of any wheelchairs for Medi-Medi members

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Page 3 of 8


♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds $125.00

AND any unlisted or miscellaneous code - Washes and creams for members with incontinence will only be authorized if the

physician justifies medical necessity

♦ Nutritional Supplements (Submit TAR to Pharmacy)

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Page 4 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR CPT Code Description

10040 Acne Surgery 15788 Thru 15793 Chemical Peel, Facial Et Al

15810-11 Salabrasion 15820 Thru 15823 Revision Of Lower Or Upper Eyelid

15845 Skin And Muscle Repair, Face 17360 Skin Peel Therapy 17999 Skin Tissue Procedure 19140 Mastectomy For Gynecomastia 19300 Mastectomy For Gynecomastia 19316 Mastopexy 19318 Reduction Mammoplasty

19324/25 Breast Augment; W/O Prosthetic Implant

19355 Correction Of Inverted Nipples

19380 Revise Breast Reconstruction

19396

Design Custom Breast Implant 19499 Unlisted Procedure, Breast 20999 Musculoskeletal Surgery 21208 Augmentation Of Facial Bones 22899 Spine Surgery Procedure 22999 Abdomen Surgery Procedure

28290 Thru 28299 Correction Of Bunion

28300 Thru 28345 Osteotomy / Repair / Reconstruction

30400 Thru 30520 Reconstruct Of Nose 30520 Repair Nasal Septum 32999 Chest Surgery Procedure 36299 Vessel Injection Procedure

37700

Ligation And Division Of Long Saphenous Vein At Saphenofemoral Junction, Or Distal Interruptions

37718 Ligation, Division, And Stripping, Short Saphenous Vein

37722 Ligation, Division, And Stripping, Long (Greater) Saphenous Veins From Saphenofemoral Junction To Knee Or Below

37735

Ligation And Division And Complete Stripping Of Long Or Short Saphenous Veins With Radical Excision Of Ulcer And Skin Graft And/or Interruption Of Communicating Veins Of Lower Leg, With Excision Of Deep Fascia

37760

Ligation Of Perforator Veins, Subfascial, Radical (Linton Type) Including Skin Graft, When Performed, Open, 1 Leg

37761

Ligation Of Perforator Vein(S), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg

37765 Stab Phlebectomy Of Varicose Veins, 1 Extremity; 10-20 Stab Incisions

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Page 5 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued) CPT Code Description

37766 More Than 20 Incisions

37780

Ligation And Division Of Short Saphenous Vein At Saphenopopliteal Junction (Separate Procedure)

37785 Ligation, Division, And/or Excision Of Varicose Vein Cluster(S) 1 Leg 38206, 38231 Stem Cell Harvesting

38230 Bone Marrow Harvesting 36511 Therapeutic Apheresis Of WBC ‘s 36512 Therapeutic Apheresis Of RBCs 38204 Unrelated Harvesting Of Cells 38205 Stem Cell Harvesting From Siblings 38207 Stem Cell Storage 41899 Gum Surgery Procedure 43770 Laparoscopy, Surgical, Gastric Restrictive Procedure

43771 Laparoscopy, Surgical, Revision Of Adjust Gastric Band

43772 Laparoscopy, Surgical, Removal Of Adjustable Gastric Band

43773 Laparoscopy, Surgical, Removal & Placement Of Adj Gastric Band

43774 Laparoscopy, Surgical, Removal Of Adjustable Gastric Band

43842 Gastroplasty, Vertical Banded, For Morbid Obesity

43843 Gastroplasty, Other Than Vertical-Banded, For Morbid Obesity

43845 Gastroplasty 43846 Gastric Bypass For Obesity

43847 Gastric Restrictive Procedure With Gastric Bypass

43848 Revision Of Gastric Restrictive

43886 Gastric Restrictive Procedure

43887 Gastric Restrictive Procedure, Removal Of Subcutaneous Port Component

43888 Gastric Restrictive Proc, Removal & Replacement Of Subcutaneous Port

49999 Abdomen Surgery Procedure 54161 Circumcision –TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision

54360 Penis Plastic Surgery 54400 Thru 54440 Penile Prosthesis / Plastic Procedure For Penis

55175/80 Revision Of Scrotum 55200 Incision Of Sperm Duct 56800 Repair Of Vagina

58150 Thru 58294 Hysterectomy 58350 Reopen Fallopian Tube

58550 Thru 58554 Laparoscopy, Surgical; With Vaginal Hysterectomy With Or Without Removal Of Tube(S), With Or Without Removal Of Ovary(S) (Laparoscopic Assisted Vaginal Hysterectomy)

58578/79 Unlisted Procedure, Uterus

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Page 6 of 8


Outpatient Surgical Procedures - CPTs Requiring TAR (Continued)

CPT Code Description

58750 Thru 58770 Tubal Repair 61850 Thru 61888 Insertion, Revision Or Removal Of Cranial Neurostimulator 62290 thru 62291 Discography, Lumbar (62290) and Cervical/Thoracic (62291) 63650 Thru 63688 Insertion, Revision Or Removal Of Spinal Neurostimulator 67900 Thru 67924 Repair Brow, Ptosis, Blepharoptosis, Lid

67950 Thru-66 Revision Of Eyelid 67971-75 Reconstruction Of Eyelid

67999 Unlisted Eyelid Procedure 69300 Revise External Ear 69399 Outer Ear Surgery Procedure 72285 Cervical and Thoracic Discography

72295 Lumbar discography

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Page 7 of 8


Pain Management CPTs Requiring TAR

CPT CODE DESCRIPTION 27096 Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

0027T Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline) including radiologic localization and epidurography

0062T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level

0063T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels

22521 thru 22525

Percutaneous vertebroplasty and percutaneous vertebral augmentation

62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or automated percutaneous discectomy, percutaneous laser discectomy)

62263 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days

62264 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day

62360 thru 62362

Implantable or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

63650 thru 63688

Insertion, revision or removal of spinal neurostimulator

64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

64480 Cervical or thoracic, each additional level

64483 Lumbar or sacral, single level

64484 Lumbar or sacral, each additional level

64490 Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; single level.

64491 Second level (List separately in addition to code for primary procedure)

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Page 8 of 8


Pain Management CPTs Requiring TAR (Continued)

* TARs generated by the Pharmacy Department

64492 Third level (List separately in addition to code for primary procedure

64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral; single level)

64494 Second level (List separately in addition to code for primary procedure)

64495 Third level (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic, single level

64634 Cervical or thoracic, each additional level

64635 Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or sacral

64636 Lumbar or sacral, each additional level

*J0585 (If billed with 64612 & 64613) Botulinum A Toxin – 1 unit extraocular

*J0587 (If billed with 64612 & 64613) Botulinum B Toxin – 10 units facial

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POLICY / PROCEDURE

I:\POLICIES\Draft policies for review\Medi-Cal\U MGMT\UM Policies for 09-08-15 IQI\MCUP3124\MCUP3124 RAF Policy 09-16-15.docx Page 1 of 3

Policy/Procedure Number: MCUP3124 Lead Department: Health Services

Policy/Procedure Title: Referral to Specialists (RAF) Policy External Policy Internal Policy

Original Date: (UM-1) 12/27/1995 (Effective 08/21/2013 - RAF Review Policy split from TAR/RAF Review)



Reviewing Entities:


Approving Entities:




I. RELATED POLICIES: A. MCUP3041 - TAR Review Process

II. IMPACTED DEPTS:


III. DEFINITIONS:

A. Referral Authorization Form (aka: RAF) is defined as the process by which the primary care physician submits a request to Partnership HealthPlan of California (PHC) to refer a PHC enrollee to a specialist for evaluation and/or treatment

B. Tertiary Medical Care is specialized consultative care, usually on referral from primary or secondary medical care personnel, by specialists working in a center that has personnel and facilities for special investigation and treatment.

IV. ATTACHMENTS: N/A V. PURPOSE:

To describe the procedure used by the PHC Utilization Management Department to process Referral Authorization Forms (RAFs) based upon the medical necessity of the request.


A. Members assigned to a primary care physician must have an approved RAF on file for the PHC Claims Department to reimburse the specialist for elective/scheduled services rendered. RAFs are not required for members who have another insurance plan as the primary carrier or are assigned a PHC special member status.

B. Specialist to Specialist Referral 1. A specialist may request a referral to another specialist from the primary care physician ONLY

under the following circumstances: a. Referral must be within the same specialty field as the specialist. b. Referrals must be for emergent or urgent conditions only. c. Referral must be sent to the member’s PCP to submit to PHC.

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Policy/Procedure Title: Referral to Specialists (RAF) Policy ☒External Policy ☐Internal Policy





C. Obstetric/Gynecological Services (OB/GYN) 1. OB/GYN services do not require a RAF. During obstetrical care the member may be referred to

another provider for medically necessary obstetrical subspecialty services (e.g. amniocentesis, perinatology services, etc.)

D. Referral to Tertiary Care Center 1. PHC has a number of tertiary care centers (TCC) within our provider network. If a referral to a non-

contracting tertiary care center is received, PHC clinical staff will review the request to determine if the services are available from one of the contracting facilities. If the services are available within the contracting network, PHC’s Chief Medical Officer or Physician Designee will review the request to determine if there are medical reasons the member should be referred to the non-contracting facility. If the CMO or Physician Designee determines the member may receive services within the contracting network, a letter of denial of the referral to the non-contracting TCC will be issued to the PCP, Member and facility. The Notice of Action letter will include the member’s right to appeal and all grievance and appeal rights will apply.

E. Standing Referrals

1. A member with a condition or disease that requires an extended access referral for specialized medical care may receive an extended referral to a specialist or specialty care center that has expertise in treating the condition or disease.

2. The PCP should refer the member to a specialist within the PHC provider network. Referrals to out of network providers may occur only when the specialty care required is not available within the PHC network of providers.

F. Referral Authorization Process

1. A PCP should submit the Referral Authorization Request electronically using PHC’s On Line Services system. Paper RAFs will be accepted if electronic submission is not possible, however, for appropriate tracking and to expedite the request, electronic submission is preferred.

2. RAFs submitted electronically allow completion of most RAFs within one to two business days, however those submitted on paper may take up to 5 business days for processing.

3. An electronic copy of the RAF determination is sent via electronic fax to both the referring PCP and the receiving specialist.

4. In general there are no limits to the number of visits, but in certain circumstances such as transitioning care back to local specialist or if a pattern of over utilization is noted on retrospective review, then PHC may impose limits on number of visits or time period covered by the RAF. At the end of one year period a new RAF from the PCP will be required.

G. Treatment Authorization Requirements

1. If the services to be rendered require a Treatment Authorization Request (TAR) from PHC it is the responsibility of the rendering provider (specialist and/or facility) to submit a TAR to PHC for review.

H. Monitoring Referrals 1. PHC monitors referrals to specialists including open or unused referrals using data from PHC’s

electronic Referral System and claims. This information is submitted to the Internal Quality Improvement Committee every six months.

2. PHC requires its high volume providers to submit an annual report of their referral completion rate for review by the specialty access workgroup and by the Internal Quality Improvement Committee.

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Policy/Procedure Title: Referral to Specialists (RAF) Policy ☒External Policy ☐Internal Policy





VII. REFERENCES: A. InterQual Criteria B. Medi-Cal Guidelines

VIII. DISTRIBUTION: A. Department Directors B. Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services X. REVISION DATES: : RAF Procedure [UM-1]: 12/27/95; 05/27/99; (TAR/RAF [UP100341] - 06/21/00;

04/18/01; 03/20/02, 05/21/03 attachments revised 10/01/03; 04/21/04; 01/19/05; 04/20/05; 09/21/05, 10/18/06, 08/20/08, 07/15/09; 5/19/10; 07/20/11, 08/21/13; 03/19/14; 04/15/15; 09/16/15 PREVIOUSLY APPLIED TO:

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Social Determinants of Health (SDOH)

Presenter:

Danielle Niculescu, MPH

QI Project Coordinator II

September 16, 2015

SDOH are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” -World Health Organization

Defining Social Determinants of Health

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1) Economic Stability- Poverty, Employment, Food Security, Housing Stability

2) Education- High School Graduation, Enrollment in Higher Education, Language and Literacy, Early Childhood Education and Development

3) Social and Community Context- Social Cohesion, Civic Participation, Perceptions of Discrimination and Equity, Incarceration/ Institutionalization

4) Health and Healthcare- Access to Health Care, Access to Primary Care, Health Literacy

5) Neighborhood and Build Environment- Access to Healthy Foods, Quality of Housing, Crime and Violence, Environmental Conditions

5 Key Areas of SDOH

IHI/KP study of SDOH

2014

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IHI/KP Study

IHI/KP Study

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Initiative Services Outcomes Strength of

Evaluation

Programs with Quantified Cost Benefits Arkansas Community Connector Program

Social services navigation for low-income

ROI of $2.92 per dollar invested in program

3

Buurtzorg Netherland Integrated home-basedcare

40% cost savings projected 3

CHOICE Regional Access Program

Social services navigation for low-income

• $4.5 million savings in uncompensated care

• 14% reduction in hospital bad debt and charity care

3

Programs with Quantified Health BenefitsFirst Diabetes (England) Integrated home-based

diabetes care• 75% reduction in insulin doses• 1.25kg average weight loss

4

Joined-Up Care: Kent,England

Integrated health and social care

• 75% of patients improved functional quality

• 86% of patients no longer anxious about condition (from baseline of 46%)

3

Newquay Pathfinder Project (England)

Integrated long-term care • 23% improvement in self-reportedwell being (compared to 8-11%)

• 10% are providing peer support (compared to 0% prior)

4

IHI/KP Key Findings

IHI/ KP Key Findings

Initiative Services Outcomes Strength of Evaluation

Programs with Quantified Utilization Benefits

Camden Link2Care Hotspotting, health care and social services

40-50% reduction in hospital cost and use

3

CareOregon Targeted intensive care management

50% reduction in re-hospitalization

4

Joined-Up Care: Hampshire, England

Integrated, home-based health and social care

21% reduction inadmission (vs. 9% reduction in surrounding county practices)

4

Programs with Quantified Quality/ Service Benefits

Jonkoping City Council & “The Esther Project”

(Sweden)

Integrated, streamlined care

• Wait time reduction: 85 days to 14 days

• 30% increase flue vaccination

3

Midhurst MacmillanService (England)

Community- based palliative care service

99% of patients died in their place of choosing

3/1

Newquay Pathfinder Project (England)

Integrated long-term care 87% of practitioners say integration is working very well and their work is meaningful

4

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Finding: The role of health care typically falls into one of these three categories:

• Navigation• Collaboration• Provision

Implications• Navigate when services are already available• Collaborate when there is synergy in the collaboration• Provide when the services are not available or accessible

in the community but necessary to improve health

Navigate, Collaborate, Provide

Integrating Interventions

• Integrate into Electronic Health Record

• Service Navigators

• Other Local Resources (example: 211.org)

• PHC Website

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PHC Social Determinants of Health Project

5 Key Areas of SDOH

Improved health equity and the health outcomes of

patients in the communities we serve.

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To review health indicators for our counties, please refer to the PHC County Level Data on page 72 of your packet.

Health Indicators- PHC Counties

Data Compiled from County Health Ranking and Roadmaps- funded by RWJ

Healthy Communities

Participant

Convener/

Catalyst

Partner

Advocate

Funder

Leader

Potential Roles of PHC

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• What is the investment?

• What change is expected?

• How will change be measured?

• Who are the other partners working to address the issue?

• What is PHC’s role?

• How are PHC’s resources leveraged?

Questions to Consider

PHC Social Determinants of Health Project

Policy

EnvironmentalSystems

Sustainable

Change

PHC SDOH

Project

PHC SDOH

Project

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• PHC advocates for policies which address SDOH, leading to comprehensive change

• Examples from PHC 2015 Legislative Platform• Supporting measures funding transitional housing

providing post-acute care• Health Homes

SDOH Project: PHC Support of Policy Change

PHC supports Environmental Change projects and initiatives• Hope Rising Initiative in Lake County• Live Healthy Napa County Initiative in Napa County• Solano Coalition for Better Health

SDOH Projects: PHC Support Environmental Change

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• Upstream Medicine Institute- October 2014

• Proposed SDOH RFP

• IOPCM Project

• PHC Internal Care Coordination Program

• PCP Access

• QIP Incentives• PCMH Certification• Peer-Led Self Management Support Groups• Access/ Extended Office Hours

SDOH Projects: PHC Support of System Change

The Low-Hanging Fruit AnalogyLevels of Change and ROI Impact

Early childhood education

Accountable Communities for health

Homeless outreach

Living wage laws

Community Gardens

Integrated Data

Collection

Activation level of

individual

Access to higher

education

Community Advocate

Warm handoffs

Targeted Initiatives at the Health

Center

Norm shifts

Referrals to social services

Prevention Advocacy

Worksite wellness policies

Environ-mental safety laws

Mental Health Parity

Community based

nutrition programs

Increased civic

participation programs

Domestic violence support groups

Targeted Programs-

MPS, IOPCM

PHC

Nurturing Family

Environ-ments

System Reform-Short Term Measurable ROI

Policy Change and Shift in Culture-Medium/ Long Term Measurable ROI

Environmental Change-Medium/ Long Term Measurable ROI- Long Term Effort Needed

Leader/ Convener/Participant/

Partner

Advocate

Funder

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Structure of PHC SDOH Project

SDOH Steering Committee

Environ-

mental

Initiatives

System

Initiatives

Policy

Initiatives

Project Management Team

Sustainable Community Wide

Change

• PHC will work on all three intervention levels to tackle social determinants that effects our members

• PHC will continue to partner/ participate/ convene community initiatives

• PHC has allocated $1.5 Million to be used to fund SDOH projects

• PHC will advocate for SDOH related policies

SDOH: The future of healthcare

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Questions or Comments?

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County Health Rankings - 2015

PHC Region: State Del Norte Humboldt Lassen Modoc Shasta Siskiyou Trinity Lake Marin Mendocino Napa Solano Sonoma Yolo

2015

Health Outcomes: 52 34 36 53 50 55 54 56 1 35 13 32 8 6

Length of Life:

Premature Death (Lost Yrs of Life) 5,295 9,082 8,140 6,821 9,307 8,990 8,761 9,952 10,269 3,501 7,323 4,739 6,229 4,942 4,923

Health Factors:

Health Behaviors:

Adult smoking 13% 20% 19% 18% 25% 24% 23% 25% 10% 18% 9% 14% 14% 8%

Adult obesity 23% 26% 26% 24% 24% 28% 22% 25% 27% 16% 24% 24% 27% 22% 21%

Food Environ. Index 7.5 6 6.5 4.3 5.8 6.4 6 6.4 6 8.5 6.8 8.3 7.4 7.8 7.2

Physical Inactivity 17% 18% 15% 17% 21% 19% 19% 19% 22% 11% 18% 13% 20% 12% 14%

Access to exercise opp. 93% 78% 86% 51% 57% 79% 71% 89% 87% 97% 75% 94% 97% 94% 92%

Excessive drinking 17% 22% 21% 20% 20% 21% 22% 24% 24% 18% 22% 19%

Alcohol-impaired driving deaths 31% 23% 33% 21% 23% 38% 31% 48% 38% 32% 27% 36% 32% 31% 40%

Sexually transmitted infections 441 127 297 172 64 328 145 104 266 190 403 247 507 316 317

Teen Births 34 54 26 34 38 35 41 34 44 12 39 25 29 23 19

Clinical Care:

Uninsured 20% 18% 21% 13% 22% 19% 19% 20% 21% 12% 22% 18% 15% 18% 16%

Percent covered by PHC 38% 34% 21% 32% 33% 35% 32% 42% 13% 39% 19% 25% 21% 24%

Primary Care Physicians 1,294:1 1,286:1 1,390:1 2,104:1 3,109:1 1,294:1 1,424:1 2,254:1 1,777:1 700:1 1,053:1 1,015:1 1,287:1 1,031:1 891:1

Primary Care Physicians 1326 1433 1348 2138 3172 1307 1648 2745 1693 716 1042 1160 1322 1062 878

Dentists 1,291:1 1<394:1 1,281:1 919:1 1,307:1 1,432:1 1,251:1 2,690:1 2,456:1 943:1 1,301:1 1,299:1 1,170:1 1,165:1 1,930:1

Mental Health Providers 376:1 293:1 291:1 346:1 538:1 422:1 320:1 320:1 324:1 160:1 238:1 249:1 353:1 293:1 318:1

Preventable Hospital Days 45 56 39 63 46 43 42 32 54 30 36 46 41 31 28

Diabetic screening 81% 85% 86% 77% 82% 85% 81% 79% 81% 84% 84% 80% 73% 82% 81%

Mammography 59.3% 51.5% 66.4% 51.7% 48.4% 65.0% 61.5% 57.2% 54.5% 65.0% 58.4% 63.5% 45.8% 64.5% 61.5%

Social & Economic Factors:

High school graduation 83% 90% 89% 86% 91% 90% 90% 94% 91% 93% 84% 88% 81% 85% 89%

Some college 61.7% 41.5% 66.2% 42.6% 65.9% 64.5% 62.2% 63.7% 55.2% 73.7% 53.8% 57.7% 62.4% 61.6% 68.9%

Unemployment 8.9% 11.6% 8.8% 10.8% 11.7% 10.9% 13.0% 12.8% 12% 5.0% 7.7% 6.3% 8.4% 6.7% 9.4%

Children in poverty 24% 33% 26% 20% 33% 28% 28% 35% 34% 10% 29% 14% 18% 16% 18%

Income Inequality 5.1 5.8 4.7 4.3 4.8 4.6 4.7 4.7 4.9 5.5 4.9 4.3 4.3 4.5 5.4

Children in single-parent household 32% 42% 39% 35% 31% 35% 36% 42% 42% 24% 37% 28% 35% 29% 28%

Violent crime 425 493 334 353 440 757 294 214 512 203 501 384 446 366 269

Injury deaths 46 97 103 84 119 96 110 118 128 52 89 50 51 50 40

Physical Environment:

Air pollution - particulate matter 9.3 8 8.2 11.1 10 9.6 8.7 8.7 7.2 7.5 7.3 7.6 8.1 7.2 7.9

Drinking water violations 3% 0% 0% 1% 0% 0% 6% 5% 1% 1% 7% 40% 0% 0% 0%

Severe housing problems 29% 24% 25% 22% 21% 23% 25% 15% 26% 24% 28% 25% 24% 25% 25%

Driving alone to work 73% 75% 72% 75% 65% 81% 71% 69% 74% 66% 72% 76% 76% 76% 67%

Long Commute - driving alone 37% 8% 15% 15% 19% 15% 20% 19% 34% 40% 20% 32% 38% 31% 27%

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September, 2015

To: Quality/Utilization Advisory Committee

From: Robert Moore, MD MPH, CMO

Topic: PHC Stars Update

September 2015 Update

Background: The first of our PHC-wide goals is to ensure our members receive high quality care, as

reflected in our PHC Stars program. PHC stars includes the following 13 measures. The table below lists

each with its weight, the 2015 Stars performance and the proposed plan to maintain/improve these

measures.

97.5 Total Points: Note that the total adds up to 97.5 points, as one measure worth 2.5 points was

dropped because we were unable to obtain valid rates with our current systems/data sources.

Our Challenge: The HEDIS scores of our Southwest, Northeast and Northwest regions were low for

the first year (2014 measurement year, 2015 reporting year (see HEDIS report for details). While the

data for the Northeast and Northwest will not count for official reporting this reporting year (2015), so

won’t affect our 2016 Stars, however the Southwest performance may affect our comparative ranking

with the state. There is substantial risk of continued poor performance in the Northern Regions during

measurement year 2015 (which we are in the middle of), which will affect HEDIS reporting year 2016

(including state-wide ranking and reputation of PHC) and PHC stars in 2017. HEDIS scores are

responsible for 30% of the overall patient outcome scores, so this will have a significant effect on the

2017 PHC stars.

Strategy: There are 4 months of activity left in 2015 which will impact 2016 HEDIS measurement, so

certain focused activity now, can potentially impact these scores. Maintaining current activities that

impact HEDIS measures is also important. Finally, longer term strategies to achieve higher scores are

needed.

Another way to mitigate the reduction of HEDIS scores is to boost scores in other STARS areas. Where

short-term interventions can impact these measures, these should also be a focus in the next few

months.

Tactics: The QI team has identified current activities, long term and short term tactics which can be

expected to improve performance if implemented quickly, in the next couple of months. These are

listed briefly in the appendix. For the next two months, our focus should be on short term measures

that required changes at the front-line, PCP level. Some of these efforts will be optimized with inter-

departmental efforts.

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Concurrently, our focus must be on planning for optimizing HEDIS data collection, developing a plan that

will have sufficient time to implement. This plan will be brought to the Executive Leadership Team and

Finance Committee in September.

Finally, we must also think about the longer term improvement of quality of care provided in our

network on HEDIS metrics, using a combination of

1. Pay for performance

2. Sharing comparative data

3. Performance improvement efforts

4. Building capacity to support improvement efforts in our provider network

This is especially important to position ourselves to be ready for NCQA accreditation in a few years.

Priorities through the end of September

HEDIS Measures:

1. Overall HEDIS process improvement: additional resources:

More staffing for re-pursuit, HEDIS project management, over-reading, over-sampling: plan being

drafted, will present to Liz week of 8/22.

2. See attached list of options for each measure.

a. System wide interventions recommended:

i. Member notification across our Southwest, Northeast and Northwest Regions

through care calls for members needing labs to satisfy MPM, cervical cancer

screening, Adolescent Immunization and DM eye exam

ii. Ask GTPP in North and South to help with notification/coordination of post-

partum visits for all patients, not just those enrolled in GTPP

b. Northern Regional interventions

i. See HEDIS presentation.

Non-HEDIS Measure PHC Stars Short Term Interventions:

Stars category Intervention Responsible Department

Leadership Team Sponsor

Next steps/Timeline

Avoidable ED Visit

HS Analytics team to review data at hospital level to look for drivers

-HS Analytics -North and South Region Provider Relations/Regional Medical Directors

Dr. Moore Pediatric URI and OM visits driving rates; Healdsburg and Santa Rosa Driving Rates: Plan Sharing of Info with key stakeholders. (See Data)

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Medication Adherence measures

Med-impact off-the-shelf medication adherence intervention program

Pharmacy Dr. Moore/Gary Louie

Pharmacy has requested meeting with Med-Impact to review program description and cost

CAHPS: Health Plan Score

Develop plan for more frequent systematic outreach to members

Communications and North and South Member Services

Margaret/ Sonja/Robb

Company wide: Set up meeting to decide on plan for quick intervention, and for longer term communication plan development Northern Region to pursue some local efforts to increase member engagement

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Appendix: PHC Quality Outcome Measures (PHC Stars) with Improvement Options

Priorities for August/September in Red

Measure Name Weight 2015 Stars

Proposed Plan

Avoidable ED visits

10% 3 1. Current efforts: PCP QIP measure; IOPCM 2. Long term: All efforts to Improve PCP Access;

advocacy around small co-pay; HIE to alert practices of ED visits; HHPCN; Partners in Palliative care

3. Short term: Expand IOPCM before HHPCN; Analyze data by hospital to ID hotspots/abnormal coding patterns; Engagement of ED physician leaders

Readmission Rate 10% 3 1. Current efforts: In-house and contracted care transition program; Online services notification of Admission; PCP QIP measure; Hospital QIP; CCM program

2. Long term: HIE to notify PCP of admission and discharge; Better ACP/Palliative care through 14 projects in Offering and Honoring Choices Initiatives; HHPCN

3. Short term: Engagement of hospital CMOs, Hospitalist group leaders

Cost effective prescribing

10% 5 1. Current efforts: Entire TAR process; PCP QIP; Pharmacy QIP; 340B agreement structure; Managing Pain Safely

2. Long term: PARx phases 3 and 4 3. Short term: (Already 5 STARS, no short term focus

needed)

HEDIS composite 25% 4 1. Current efforts: PCP QIP 2. Long term: Provider level analytics; HIE to capture

HEDIS data 3. Short term: EHR configuration for better HEDIS at

largest sites; Provider education for better HEDIS in North; Implement as many Lab Data feeds for HEDIS in North as possible; Analyze 2015-2016 HEDIS staffing plans and adjust to ensure optimum data capture; evaluate potential member incentives to help with some HEDIS measures; member notification/reminders about need for labs by letter and/or by phone (see separate document for more detail)

HEDIS below MPL 5% 4 Same as above.

High risk meds (opioids and others)

2.5% 3 1. Current efforts: Managing Pain Safely; formulary management, TAR processing

2. Long term: As MPS winds down, evaluate strategies for benzodiazepines next.

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Measure Name Weight 2015 Stars

Proposed Plan

3. Short term: Maintain effort in MPS

Med adherence: ACE/ARB

2.5% 2 1. Current efforts: None 2. Long term: Provider level analytics 3. Short term: Pharmacy intervention program with

Med-Impact

Med adherence: statins

2.5% 3 Same as above

CAHPS: Health Plan

10% 4 1. Current efforts: Added benefits; member newsletter; customer service focus; new website; Operational Excellence in member services

2. Long term: Build/buy member portal 3. Short term: Short term increase in member

communication.

CAHPS: customer service

5% 4 1. Current efforts: Operational Excellence in member services; Customer Service focus; new QIP measure

2. Long term: Build/buy member portal 3. Short term:

CAHPS: Rating of doctor

5% 5 1. Current efforts: Engagement of PCP leaders; ADVANCE; Coleman; PCP QIP

2. Long term: Payment reform; More organized and sustained recognition program

3. Short term: Current 5 star, not short term focus

Getting needed care composite

5% 4 1. Current efforts: PCP access work; specialty access work; mental health access work; recruitment support; ADVANCE; Coleman

2. Long term: 3. Short term:

Getting care quickly composite

5% 5 Same as above

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Data on Avoidable ED visits: Plan wide, by county and diagnosis

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Which hospitals are driving this?

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August, 2015 PHC membership distribution: (Includes Duals)

0-19: 40%

20-64: 52%

65+: 8%

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Which PCP sites are driving avoidable ED visits?

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Partnership Health Plan of California

Long Term Care Quality Improvement Program

Background

Partnership HealthPlan of California has value-based purchasing programs in the areas of

primary care, hospital care, specialty care, community pharmacy, and mental health.

This proposal sets out the parameters for a Long Term Care pay for performance

program.

Partnership Health Plan Long Term Care Quality Improvement Program (LTC

QIP)

Given the increasing visibility of SNF measurement at the Federal level, and the

expanding Medicare population, PHC is exploring the implementation of a LTC QIP. An

initial assessment of existing LTC measures and programs was completed, and the

measures are included in this document.

As in the existing QIP, a LTC QIP will adhere to the following principles:

1. Where possible, pay for outcomes instead of processes.

2. Distribute 100% of Funds [develop formula for distribution]

3. Actionable Measures

4. Feasible data collection

5. Collaboration with providers (in QIP development)

6. Simplicity in the number of measures

7. Measurement set represents different domains of care

8. Align measures that are meaningful

9. Stable measures (they don't change every year)

Eligibility Criteria: LTC must have a PHC contract to be eligible. All contracted LTC

are automatically eligible. LTC facilities must be in good standing with state and federal

regulators as of the month the payment is to be disbursed. Good standing means that the

LTC is open, solvent, not under sanctions from the state of California or CMS.

Financing details: A pool of money will be allocated for the LTC QIP, approximately

equal to approximately 2% of the total reimbursement for all LTC services. This pool

will be distributed based on points earned. Detailed methodology will be finalized after

board approval.

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Timeline

Milestone Timing

Research pay for performance and quality programs in existence for SNFs. July 18, 2015

Meeting #1 with LTC QIP Technical Workgroup to develop an initial draft set of

measures.

July 22

Review measures with high-performing LTC stakeholders. July 31

Meeting #2 with LTC QIP Technical Workgroup to review updated draft of measures. August 18

Send draft of measures to California Association of Health Facilities for any comments. August 24

Review draft measure set at Internal Quality Improvement Meeting. September 8

Review draft measure set at Quality Utilization Advisory Committee Meeting. September 16

Comment period for LTC stakeholders to provide final feedback on measures

- Kick off comment period with webinar

September 19-29

Meeting #3 with LTC QIP Technical Workgroup to review final recommendations Approx October 1

Present the potential measures at the Physician Advisory Committee (PAC) Meeting. October 14

Obtain PHC Board approval of LTC QIP. October 28

Begin building the infrastructure of the LTC QIP on the PHC website

- Designated person from Finance on payment

- Designated person (from QI, or CMO’s office, or consultant) to draft specifications

document and submission templates

- Build in two weeks for Communications to review materials for external use

- Develop a communication strategy for recruitment and data submission

November, 2015

Implement LTC QIP pilot program.

- A 60-day grace period for sites to become contracted

January 1, 2016

Webinars to roll out program Early January, 2016

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Measure Definitions & Thresholds1

Measure Measure Source Threshold Points Measure Specifications

CLINICAL

% of high-risk residents

with pressure ulcers

NQF 0679 Lower is better

Pay for performance based on

being better than the average US

performance of 5.9% for year 12

10% Submit to PHC a copy of the

summary measure from the

MDS reports sent to CMS, for

all patients in facility, regardless

of payer.

% of residents who lose

too much weight




performance of 7.0% for year 1.





of payer.

FUNCTIONAL

STATUS

% of residents

experiencing one or more

falls with major injury









of payer.

% of residents who

have/had a catheter

inserted and left in their

bladder









of payer.

RESOURCE USE

1 Detailed measure specifications for clinical and functional measures at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User’s-Manual-V80.pdf 2 Source-All clinical and functional measure thresholds from: http://www.medicare.gov/NursingHomeCompare/compare.html#cmprTab=3&cmprID=555227%2C555694&cmprDist=1.7%2C3.6&loc=94960&lat=37.9885355&lng=-122.5655549

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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User's-Manual-V80.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User's-Manual-V80.pdf

http://www.medicare.gov/NursingHomeCompare/compare.html#cmprTab=3&cmprID=555227%2C555694&cmprDist=1.7%2C3.6&loc=94960&lat=37.9885355&lng=-122.5655549

http://www.medicare.gov/NursingHomeCompare/compare.html#cmprTab=3&cmprID=555227%2C555694&cmprDist=1.7%2C3.6&loc=94960&lat=37.9885355&lng=-122.5655549



Measure Measure Source Threshold Points Measure Specifications

Transfers resulting in

admission to hospital as

an inpatient

None, pay for reporting, year 1 10% Pay for reporting for inpatient

admissions, reported semi-

annually.3

Transfers resulting in ED

visit only

INTERACT None, pay for reporting, year 1 10% Pay for reporting for ED visits,

reported semi-annually.

OPERATIONAL/

SATISFACTION

Results of last state audit Most recent CMS stars rating

with 4 and above for full credit,

3 or 3.5 for half credit.

15% PHC will check Stars score on

Nursing Home Compare in on

the month prior to the least

month of the measurement year

(eg. November if the

measurement year ends in

December).

INTERACT 4 or

Advancing Excellence

program participation

None, pay for completing

process milestones

25% Year 1, Process measures

Submit implementation plan

(10%)

Attend PHC sponsored

training (15%)

3 PHC to compare the data from the first semi-annual report with internal ability to report on this data. After the first year, the data will be generated by PHC analytics department directly for the LTC QIP.

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Pilot Measure

Measure Measure Source Measure Specifications

PHC staff annual facility

visit

PHC Brief checklist that the UM or Provider Relations staff evaluate when they do an

annual visit?

Items such as:

Overall appearance of building

Friendliness of staff to patients and visitors

Aroma/cleanliness of the building

Patient call lights off and answered promptly

Patients in wheelchairs in the hallway are sitting upright and safely

Dining room patients are being attended to – upright in their chairs

Dignity, privacy issues

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Appendix

Other Quality Programs for LTC: CMS Initiatives

In 2009, in an effort to improve the quality and efficiency of care for Medicare

beneficiaries CMS conducted a Nursing Home Value-Based Purchasing (NHVBP)

Demonstration.4 Nursing homes in Arizona, New York and Wisconsin participated

addressing quality in four measure domains: nurse staffing, quality outcomes, survey

deficiencies, and potentially avoidable hospitalization rates.

Results from the demonstration suggest that there are no major pre-post performance

differences across the treatment and comparison groups, although it is believed some

program design modifications could lead to increased savings and improved outcomes.

On September 18, 2014, Congress passed the Improving Medicare Post-Acute Care

Transformation Act of 2014 (the IMPACT Act).5 The Act requires the submission of

standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities

(SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs).

The IMPACT Act requires standardized reporting of quality measures, resource use, and

other measures, with a portion of future revenue tied to adherence to reporting

requirements.

Outside Measurement of Quality in LTC

Nursing Home Compare6 is a publicly reported data set, with the intent of providing

consumers comparative SNF data. Nursing Home Compare reports self-reported quality

of care information on every Medicare- and Medicaid-certified nursing home in the

country, including information about residents' health, physical functioning, mental

status, and general well-being.

Per the California Association of Health Facilities (CAHF)7 California SNFs score well

on a number of these metrics, including:

Preventing a decline in activities #1

Preventing depression #1

Preventing urinary tract infections #1

Preventing weight loss #2

Preventing falls with injury #2

Use of antipsychotic medications in short stay residents #3

Controlling pain in long-stay residents #4

4 Source: http://innovation.cms.gov/Files/reports/NursingHomeVBP_EvalReport.pdf 5 Source: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html 6 Source: http://www.medicare.gov/NursingHomeCompare/About/What-Is-NHC.html 7 Source: http://www.cahf.org

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http://innovation.cms.gov/Files/reports/NursingHomeVBP_EvalReport.pdf

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html

http://www.medicare.gov/NursingHomeCompare/About/What-Is-NHC.html

http://www.cahf.org/



Resources

California Association of Health Facilities: quality section refers to Nursing Home

Compare measures, data

(http://cahfdownload.com/cahf/quality/QualityReport2015forWeb.pdf)

Interact 4.0 quality improvement program: focus on resident transfers, efficiency

(https://interact.fau.edu/ )

Advancing Excellence in Long Term Care Collaborative for quality improvement:

(https://www.nhqualitycampaign.org/ )

American Health Care Association: nation’s largest association of long term and

post-acute care providers; quality section refers to Nursing Home Compare data

(http://www.ahcancal.org)

CMS Nursing Home VBP Demonstration: Evaluation Report, 8/26/13

(http://innovation.cms.gov/Files/reports/NursingHomeVBP_EvalReport.pdf)

Nursing Home Compare

(http://www.medicare.gov/NursingHomeCompare/About/What-Is-NHC.html).

The Effect of Pay-for-Performance in Nursing Homes: Evidence from State

Medicaid Programs (2013)

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657568/)

Pay-for-Performance in Nursing Homes: 2009 literature review; conducted prior to

CMS VBP nursing home pilot (https://www.cms.gov/Research-Statistics-Data-and-

Systems/Research/HealthCareFinancingReview/downloads/09Springpg1.pdf

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http://cahfdownload.com/cahf/quality/QualityReport2015forWeb.pdf

https://interact.fau.edu/

https://www.nhqualitycampaign.org/

http://www.ahcancal.org/

http://innovation.cms.gov/Files/reports/NursingHomeVBP_EvalReport.pdf

http://www.medicare.gov/NursingHomeCompare/About/What-Is-NHC.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657568/

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/09Springpg1.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/09Springpg1.pdf

HEDIS 2015

Performance

IQI Meeting, September 2015

Presented by:

Megan Wilson

Project Coordinator II, HEDIS

Sue Lee Project Manager

Nancy Steffen Manager of Quality Improvement Programs, Northern Region

PHC Internal Use Only

Objectives


• HEDIS Overview

• 2015 HEDIS Results

• Drivers of HEDIS Performance

• Administrative Data

• Medical Record Project

• Care Quality

• 2015 Changes/Next Steps

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HEDIS Overview


• What is HEDIS?• Healthcare Effectiveness Data Information Set

• Administrative vs. Hybrid Measures

• Why is HEDIS Important?• Evaluates clinical quality in a standardized way

• Identifies opportunities for improvement

• Regional-level performance is publicly reported

• Regional-level reporting is required by the State

HEDIS 2015 Reporting Regions

PHC Internal Use OnlyHEDIS 2014 Reporting Regions

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HEDIS 2015 Goals


1. Maintain our global rating on HEDIS from 2014 to

be at or above 75th percentile in our Southeast

Region (Yolo, Napa, Solano)

2. 100% of measures where DHCS holds health plans

accountable perform above the minimum

performance level (MPL) across all four reporting

regions

DHCS Quality Award Scoring Methodology-MCAL


The score for each measure set by DHCS is:

• 4 points for the 90th percentile

• 3 points for the 75th-89th percentile

• 2 points for the 50th-74th percentile

• 1 point for the 25th-49th percentile

• NO points for a HEDIS score below the 25th percentile

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Goal 1: Maintain Global HEDIS Rating for Southeast Region


59.09%

48.86%

22.50%27.50%

40.18%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Southeast

(N=22)

Southwest

(N=22)

Northeast

(N=20)

Northwest

(N=20)

Composite HEDIS Performance 2015

Composite Score Aggregate Performance

HEDIS 2015 Regional Performance

2

1011

4

5

52

7

10

3

310

2

1

2

13

12

0%

20%

40%

60%

80%

100%

Southeast (N= 22) Southwest (N=22) Northeast (N=20) Northwest (N=20)

HEDIS 2015 Regional Level PerformanceDistribution of Measures by Percentiles

At or above 90th Percentile

≥75th- <90th Percentile

≥50th-<75th Percentile

≥25th-<50th Percentile

<25th Percentile

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Goal 1: Maintain Global HEDIS Rating for Southeast Region


69.74%

51.14%

62.50%59.09%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

2012 (N=19) 2013 (N=22) 2014 (N=22) 2015 (N=22)

2 Reporting Units-

Southeast and Sonoma

4 Reporting Units- Southeast,

Sonoma, Marin and Mendocino

4 Reporting Regions- Southeast,

Southwest, Northeast, Northwest

Composite HEDIS Performance – TRENDED

Southeast Region

Trended Data

11

5

4 4

8

9

97

4

4

510

6

34

1

0%

20%

40%

60%

80%

100%

2012 (N=19) 2013 (N=22) 2014 (N= 22) 2015 (N= 22)

HEDIS Percentiles Distribution- TRENDEDSoutheast Region

At or above 90th Percentile

75th-89th Percentile



<25th Percentile

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Goal 2: Measures below the Minimum Performance Level


Reflecting on the Drivers of HEDIS Performance


Care Quality

Medical Record Project

Administrative Data

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Administrative Data Highlights


• Transition of PHC’s Data Quality Workgroup

from QI to IT.

1. Lab data in the Northern Region

2. Internal QA process for Quest encounter data

3. Data sources, data quality and timely data

submission

*CAIR data request from QI to IT showed

huge improvement in overall immunization

rates

Care Quality


Administrative Data

• Obtained and created supplemental data sources

*The eReport data was not incorporated for HEDIS 2015

Administrative Data Highlights

• Partner with IT to improve data files loaded to

HEDIS certified software:

1. Develop BRD and validation processes

2. Understand PHC’s data sources

3. Incorporate the identified data sources

4. Assure proper mapping

5. Committed resources from IT


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Admin Data Impact on Overall Performance

Measures Details Southeast Southwest Northeast Northwest

Measure Name Submeasure Name

Admin Rate

2015 Percentile Ranking

Admin Rate


Admin Rate


Admin Rate


Cervical Cancer Screening 46.61% 25th 41.36% 25th 24.33% <MPL 28.95% <MPL

Childhood Immunization Status-Combo 3 54.93% 25th 50.61% 50th 49.15% <MPL 40.15% <MPL

Comprehensive Diabetes Care

HbA1c Testing 84.39% 75th 81.75% 50th 84.43% 50th 88.56% 90th

HbA1c Poor Control >9.0% (Lower is better) 28.78% 75th 31.87% 50th 30.17% 50th 13.63% 75thHbA1c Control <8.0% 32.93% 75th 14.11% 50th 0.00% 50th 0.24% 75thEye Exam Performed 46.10% 25th 37.47% 25th 29.20% <MPL 29.44% <MPL

Medical Attention for Nephropathy82.20% 75th 72.51% 25th 71.78% 25th 84.67% 50th

Blood Pressure Control <140/90mm Hg 0.00% 50th 0.00% 50th 0.00% 25th 0.00% 25th

Controlling High Blood Pressure 0.00% 50th 0.00% 25th 0.00% <MPL 0.00% <MPL

Immunization for Adolescents-Combo #1 64.47% 25th 58.64% 25th 33.58% <MPL 45.53% <MPL

Prenatal and Postpartum Care

Timeliness of Prenatal Care 68.06% 50th 81.75% 50th 64.25% 25th 68.86% 25thPost Partum Care 55.00% 50th 59.85% 50th 45.97% <MPL 36.25% <MPL

Well Child Visits in the Third, Fourth, Fifth, and Sixth 72.26% 50th 69.59% 50th 58.39% <MPL 61.07% <MPL

Weight Assessment and Counseling for Nutrition and Physical Activity

BMI Percentile 8.56% 75th 6.08% 90th 1.95% 90th 2.68% 50thCounseling for Nutrition 28.36% 75th 14.60% 50th 0.97% 25th 0.24% <MPL

Counseling for Physical Activity15.40% 75th 9.73% 50th 0.24% <MPL 0.00% <MPL

Admin Data Impact on Hybrid Measures

Measure NameSubmeasureName

2014 Adm Rate

2015 Adm Rate

Admin Rate Diff

2014 MR Rate

2015 MR Rate

MR Rate Differen

ce

Final Rate Diff

2014 to 2015



Percentile Change

Impact by eReport File

in HEDIS 2014

Cervical Cancer Screening

55.47% 46.61% -8.86% 14.36% 11.58% -2.77% -11.64% 50th 25th ↓ 2.93%

Comprehensive Diabetes Care

HbA1c Control <8.0% 41.85% 32.93% -8.92% 10.46% 20.73% 10.27% 1.35% 50th 75th ↑ 0.44%

Blood Pressure Control <140/90mm Hg

4.38% 0.00% -4.38% 60.83% 61.95% 1.12% -3.26% 50th 50th - 4.60%

Weight Assessment and Counseling for Nutrition and Physical Activity

BMI Percentile

31.22% 8.56% -22.66% 38.54% 68.46% 29.92% 7.26% 75th 75th - 8.82%

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• Successfully collected data across 14 counties

• Retrieved and reviewed over 17,000 medical

records in 13 weeks

• 70 provider sites had an onsite visit by our

vendor

• Increased Provider HEDIS Satisfaction from

2014

• Firsts:

• Reporting in Expansion Counties

• Regional-Level reporting

• HEDIS operations in two offices

• New Medical Record Collection Vendor,

Enterprise Consulting Solutions (ECS)

Care Quality


Administrative Data



Challenges:• Resources

• Learning new systems

• Provider Communication in the Northern Region

• Billing Error impacting PPC measure in Northeast Region

Next Steps:

• Increasing Resources

• Fully Utilize Vendor’s MR Portal

• Ongoing Provider Education

• Follow up work on Billing Error

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Medical Record Review Validation


Measures Selected Results

Cervical Cancer Screening (CCS) First Sample-Passed

Immunizations for Adolescents (IMA-1)-

Combo 1

Second Sample-Passed

Prenatal and Postpartum Care (PPC)-

Timeliness of Prenatal Care

First Sample-Passed

Weight Assessment and Counseling for

Nutrition & Physical Activity (WCC)-

Nutrition

First Sample-Passed

Measure Selected Results

Childhood Immunization Status (CIS) –

Combo 3

Passed

MRRV Measure Selection:

Additional Measure Selected during Second Sample Selection:

Care Quality


QI Department engages in a number of

activities designed to improve Care Quality:

• PCP Quality Improvement Program

(PCP QIP)

• Hospital Quality Improvement Program

• Partnership Improvement Academy –i.e. ADVANCE,

Coleman, ABC’s of QI

• Quality Improvement Projects and Improvement Plan

Submissions

Care Quality


Administrative Data

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2015 Northern Region Improvement Plan

Partner with select providers to conduct Rapid Cycle

Improvement Projects and using PDSAs to document small

tests of change:

Shasta Community Health Center—Childhood

Immunization Status –Combo 3

• Northeastern Rural Health Center—Adolescent

Immunizations Status—Combo 1

• Fairchild Medical Center—Weight Assessment and

Counseling for Nutrition and Physical Activity

*Results and Best Practices shared at Northern Region Consortia

QI Peer Network

Upcoming Events

Improving the Quality of Care in Children and

Adolescents

Webinar focused on:

Adolescent and Childhood Immunizations

Well Child Visits

Weight Assessment and Counseling for

Nutrition and Physical ActivityREGISTER:

https://attendee.gotowebinar.com/register/5007550155465409282

Date: Wednesday, September 16th

Time: 12:00-1:00pm

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https://attendee.gotowebinar.com/register/5007550155465409282

Northern Region Next Steps

Improving the Quality of Care in Women

Webinar focused on:

Cervical Cancer Screening (CCS)

Prenatal/Postpartum Care (PPC)

Date: October 21, 2015

Time: 12:00-1:00pm

• Outreach to the Northern Region provider network to

partner in new PDSAs focused on Controlling High

Blood Pressure (CBP)

Questions?


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Healthcare Effectiveness Data Information Set (HEDIS)

2015 Summary of Performance

Measuring quality of care and services provided to our members.

Presented By:

Sue Lee, Project Manager, HEDIS Admin Data

Megan Wilson, Project Coordinator II, HEDIS

Nancy Steffen, Northern Region Manager of Quality Improvement Programs

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Percentile Northeast Northwest Southeast Southwest

90th (HPL)

75th

50th

25th

Below MPL 2

5

10

2

3

4

7

10

1

11

2

3

2

2

10

5

3

1

1

Measure Northeast Northwest Southeast Southwest

Avoidance of Antibiotic Treatment in Adults withAcute Bronchitis (AAB)*

Comprehensive Diabetes Care (CDC)- HBA1CTesting**

Use of Imaging Studies for Low Back Pain (LBP)*

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- BMI Percentiles**

Measures At or Above the High Performance Level (90th Percentile)


Annual Monitoring for Patients on PersistentMedications (MPM) ACE or ARB*,**

Annual Monitoring for Patients on PersistentMedications (MPM) Diuretics*,**

Cervical Cancer Screening (CCS)**

Childhood Immunization Status (CIS-3)- Combo 3Immunizations**,***

Comprehensive Diabetes Care (CDC)- Eye Exam**

Controlling High Blood Pressure (CBP)**

Immunizations for Adolescents (IMA-1)- Combo 1Immunizations**

Prenatal and Postpartum Care (PPC)- PostpartumCare

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC) - Physical Activity**

Weight Assessment and Counseling for Nutrition &Physical Activity (WCC)- Nutrition**

Well-Child Visits in the Third, Fourth, Fifth, andSixth Years of Life (W34 )**

Measures Below the Minimum Performance Level (25th Percentile)

Partnership HealthPlan of CA HEDIS 2015 PerformanceDistribution of Percentile Rankings by Region Across All Measures

Sonoma

HumboldtTrinity

Mendocino

Marin

Lake

Yolo

SolanoNapa

Del Norte Siskiyou

Shasta

Modoc

Lassen

*Administrative measure. Entire eligible population is used in calculating performance. **Measure included in QIP (pay for performance program). Note: Excludes measures where DHCS does not hold Medicaid Managed Care Plans accountable (All-Cause Readmissions, Ambulatory Care, Annual Monitoring for Pa-tients on Persistent Medications-Digoxin, Children & Adolescents’ Access to Primary Care Practitioners).

Northeast

Northwest

Southeast

Southwest

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Comprehensive Diabetes Care (CDC)- Blood PressureControl (<140/90)**


Comprehensive Diabetes Care (CDC)- HbA1cAdequate Control (<8)**

Comprehensive Diabetes Care (CDC)- HbA1c PoorControl (>9)**


Comprehensive Diabetes Care (CDC)- MedicalAttention for Nephropathy**



Medication Management for People with Asthma(MMA-50) Total Population 50%*



Prenatal and Postpartum Care (PPC)- Timeliness ofprenatal care





Well-Child Visits in the Third, Fourth, Fifth, and SixthYears of Life (W34 )**

72.02%

62.77%

53.77%

86.13%

68.37%

37.94%

59.39%

68.86%

54.01%

76.64%

87.10%

43.31%

46.72%

49.15%

64.48%

73.72%

56.20%

75.30%

73.11%

77.02%

67.97%

87.50%

69.17%

40.13%

58.96%

71.05%

58.52%

84.88%

88.05%

35.37%

53.66%

54.15%

61.95%

68.66%

58.19%

35.00%

88.88%

88.26%

66.91%

82.97%

85.89%

31.14%

56.20%

58.39%

29.00%

55.96%

80.00%

78.83%

76.16%

87.35%

42.58%

48.91%

56.69%

22.00%

83.30%

83.20%

62.53%

46.47%

36.25%

50.36%

57.98%

47.45%

39.17%

56.13%

49.64%

83.65%

80.41%

62.04%

40.39%

52.80%

39.17%

48.42%

34.79%

58.64%

45.99%

83.23%

82.11%

86.62%

88.00%

41.00%

87.00%84.00%

92.21%

86.13%

25th (MPL) 50th 75th 90th (HPL)

85.76% 88.04% 89.97% 92.01%

85.69% 87.91% 90.58% 92.07%

20.20% 24.33% 30.45% 38.66%

54.50% 64.34% 71.30% 75.96%

66.67% 72.33% 77.78% 80.86%

53.28% 61.31% 70.07% 75.18%

46.25% 54.18% 63.14% 68.04%

38.20% 46.17% 52.89% 59.37%

53.76% 44.77% 36.52% 30.28%

80.18% 83.87% 87.59% 91.73%

75.67% 80.10% 83.11% 86.86%

48.53% 56.20% 63.76% 69.79%

61.70% 71.29% 80.90% 86.46%

47.88% 54.07% 58.94% 66.96%

24.55% 30.19% 35.37% 43.08%

56.18% 62.84% 69.47% 74.03%

77.80% 84.30% 89.62% 93.10%

72.15% 75.29% 78.57% 84.03%

41.67% 51.16% 60.82% 69.76%

41.85% 57.40% 73.72% 82.46%

50.00% 60.58% 69.21% 77.47%

65.97% 71.76% 77.26% 82.69%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Partnership HealthPlan of CA HEDIS 2015 Performance Regional Rates and Benchmarks

*Administrative Measures. Entire eligible population used in calculating performance. **Measures are included in the QIP (pay for performance program). ***Only forDTap (QIP year 2013-2014 and 2014-2015) and Hep B (QIP year 2013-2014) vaccines.

NA NA

BenchmarksRegional Rates

Below MPL (minimum performance level, based on NCQA's national Medicaid 25th percentile)

Above HPL (high performance level, based on NCQA's national Medicaid 90th percentile)

Notes: For the CDC HbA1c Poor Control >9% measure, the HPL is based on the national Medicaid 10th percentile because a lower rate indicates better performance. Measures with a denominator of less than 30 are reported as NA. Excludes measures where DHCS does not hold Medicaid Managed Care Plans accountable (All-Cause Readmissions, Ambulatory Care, Annual Monitoring for Patients onPersistent Medications-Digoxin, Children & Adolescents’ Access to Primary Care Practitioners).

NA NA

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Solano

Mendocino

Humboldt

Del Norte

Sonoma

Siskiyou

Lassen

Shasta

Modoc

Trinity Marin

Napa

Lake

Yolo

Percentile

Southeast

Solano

Yolo

Napa

Southwest

Sonoma

Mendocino

Marin

Lake

Northeast

Shasta

Siskiyou

Lassen

Trinity

Modoc

Northwest

Humboldt

Del Norte

90th

75th

50th

25th

Below MPL

43654

15871

3892

15311

24726

57343

25654

9441

7542

94123

72631

114221

11323

111323

Distribution of Percentile Rankings by County

Partnership Healthplan of CA : HEDIS 2015 County Level Performance

of 136

Measure Solano Yolo Napa Sono..Mend..Marin Lake ShastaSiskiy..LassenTrinityModocHumb..Del N..

Avoidance of Antibiotic Treatment in Adultswith Acute Bronchitis (AAB)*



Comprehensive Diabetes Care (CDC)- HbA1cPoor Control (>9)**




Prenatal and Postpartum Care (PPC)-Postpartum Care


Weight Assessment and Counseling for Nutrition& Physical Activity (WCC) - Physical Activity**

Weight Assessment and Counseling for Nutrition& Physical Activity (WCC)- BMI Percentiles**

Weight Assessment and Counseling for Nutrition& Physical Activity (WCC)- Nutrition**

County Level Measures At or Above the High Performance Level (90th Percentile)

Measure Solano Yolo Napa Sono..Mend..Marin Lake ShastaSiskiy..LassenTrinityModocHumb..Del N..



Avoidance of Antibiotic Treatment in Adultswith Acute Bronchitis (AAB)*



Comprehensive Diabetes Care (CDC)- BloodPressure Control (<140/90)**

Comprehensive Diabetes Care (CDC)- EyeExam**








Prenatal and Postpartum Care (PPC)-Postpartum Care

Prenatal and Postpartum Care (PPC)- Timelinessof prenatal care




County Level Measures Below the Minimum Performance Level (Below 25th Percentile)

HEDIS 2015 Partnership Healthplan of California

of 136

Measure Solano Yolo Napa



Avoidance of Antibiotic Treatment in Adults with AcuteBronchitis (AAB)*





Comprehensive Diabetes Care (CDC)- HbA1c AdequateControl (<8)**


Comprehensive Diabetes Care (CDC)- HBA1C Testing**

Comprehensive Diabetes Care (CDC)- Medical Attentionfor Nephropathy**





Prenatal and Postpartum Care (PPC)- Postpartum Care







78.00%

17.31%

86.36%

85.34%

61.80%

77.50%

87.50%

75.00%

86.92%85.27%87.98%

39.35%

81.13%

90.00%

64.00%

29.37%

55.56%

71.19%

64.00%

86.00%

44.00%

48.00%

56.00%

68.00%

76.56%

58.00%

79.38%

67.92%

59.43%

64.15%

91.46%

73.17%

37.77%

54.68%

66.95%

61.26%

84.26%

84.26%

38.89%

50.00%

53.70%

58.33%

57.00%

31.90%

88.69%

86.61%

71.35%

73.99%

81.61%

67.26%

85.78%

68.97%

42.63%

60.97%

73.40%

56.28%

85.38%

91.30%

32.81%

55.34%

52.96%

62.06%

69.23%

59.05%

89.44%

89.60%


85.76% 88.04% 89.97% 92.01%

85.69% 87.91% 90.58% 92.07%

20.20% 24.33% 30.45% 38.66%

54.50% 64.34% 71.30% 75.96%

66.67% 72.33% 77.78% 80.86%

53.28% 61.31% 70.07% 75.18%

46.25% 54.18% 63.14% 68.04%

38.20% 46.17% 52.89% 59.37%

53.76% 44.77% 36.52% 30.28%

80.18% 83.87% 87.59% 91.73%

75.67% 80.10% 83.11% 86.86%

48.53% 56.20% 63.76% 69.79%

61.70% 71.29% 80.90% 86.46%

47.88% 54.07% 58.94% 66.96%

24.55% 30.19% 35.37% 43.08%

56.18% 62.84% 69.47% 74.03%

77.80% 84.30% 89.62% 93.10%

72.15% 75.29% 78.57% 84.03%

41.67% 51.16% 60.82% 69.76%

41.85% 57.40% 73.72% 82.46%

50.00% 60.58% 69.21% 77.47%

65.97% 71.76% 77.26% 82.69%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Partnership HealthPlan of CA HEDIS 2015 Performance Southeast Region Rates and Benchmarks


BenchmarksSoutheast Rates




of 136

Measure Sonoma Mendocino Marin Lake



Avoidance of Antibiotic Treatment in Adults with AcuteBronchitis (AAB)*





Comprehensive Diabetes Care (CDC)- HbA1c AdequateControl (<8)**


Comprehensive Diabetes Care (CDC)- HBA1C Testing**

Comprehensive Diabetes Care (CDC)- Medical Attentionfor Nephropathy**





Prenatal and Postpartum Care (PPC)- Postpartum Care







58.00%

46.00%

28.00%

71.23%

42.47%

71.43%

74.29%

67.14%

30.00%

37.14%

52.86%

58.00%

26.98%

79.52%

78.25%

64.52%

73.02%

34.33%

24.10%

39.71%

80.63%

83.33%

84.49%

84.03%

84.08%92.50%

78.00%

95.24%

25.40%

63.49%

84.62%

89.55%

77.88%

88.24%

88.99%

91.08%

44.79%

50.37%

78.00%

70.00%

52.33%

20.45%

71.62%

82.43%

54.05%

86.00%

29.85%

52.24%

79.10%

56.90%

61.90%

69.84%

69.84%

86.63%

86.05%

72.31%

55.22%

82.41%

90.27%

50.60%

65.06%

54.44%

88.24%

44.12%

44.12%

55.88%

72.92%

53.09%

32.63%

75.73%

65.64%

64.76%

90.27%

70.81%

64.09%

67.08%

53.67%

75.71%

88.57%

40.48%

48.10%

52.38%

69.52%

73.02%

62.25%


85.76% 88.04% 89.97% 92.01%

85.69% 87.91% 90.58% 92.07%

20.20% 24.33% 30.45% 38.66%

54.50% 64.34% 71.30% 75.96%

66.67% 72.33% 77.78% 80.86%

53.28% 61.31% 70.07% 75.18%

46.25% 54.18% 63.14% 68.04%

38.20% 46.17% 52.89% 59.37%

53.76% 44.77% 36.52% 30.28%

80.18% 83.87% 87.59% 91.73%

75.67% 80.10% 83.11% 86.86%

48.53% 56.20% 63.76% 69.79%

61.70% 71.29% 80.90% 86.46%

47.88% 54.07% 58.94% 66.96%

24.55% 30.19% 35.37% 43.08%

56.18% 62.84% 69.47% 74.03%

77.80% 84.30% 89.62% 93.10%

72.15% 75.29% 78.57% 84.03%

41.67% 51.16% 60.82% 69.76%

41.85% 57.40% 73.72% 82.46%

50.00% 60.58% 69.21% 77.47%

65.97% 71.76% 77.26% 82.69%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Partnership HealthPlan of CA HEDIS 2015 Performance Southwest Region Rates and Benchmarks


BenchmarksSouthwest Rates




NA

NA

NA

of 136

Measure Shasta Siskiyou Lassen Trinity Modoc





Childhood Immunization Status (CIS-3)- Combo3 Immunizations**,***








Immunizations for Adolescents (IMA-1)- Combo1 Immunizations**

Medication Management for People withAsthma (MMA-50) Total Population 50%*

Medication Management for People withAsthma (MMA-75) Total Population 75%*


Prenatal and Postpartum Care (PPC)- Timelinessof prenatal care



Weight Assessment and Counseling for Nutrition& Physical Activity (WCC)- BMI Percentiles**



62.00%

44.00%

42.42%

40.00%

30.00%

52.00%

34.00%

80.00%

54.00%

55.56%

26.00%

40.00%

82.24%

48.00%

40.00%

13.89%

44.00%

26.00%

58.54%

44.00%

74.12%

71.63%

64.94%

36.51%

23.81%

50.00%

38.82%

85.25%

82.85%

62.80%

38.21%

74.54%

54.24%

43.51%

47.72%

39.45%

61.71%

48.66%

83.41%

83.11%

96.00%

86.49%

94.00%95.24%

87.14% 66.00%

42.00%

87.88%

76.00%

86.00%

50.00%

48.00%

86.79%

60.00%

82.00%

44.00%

80.00%

52.00%

76.00%

90.00%

42.00%

46.00%

66.00%

83.05%

52.00%

46.00%

78.00%

82.00%

32.00%

54.00%

58.00%

60.27%

82.19%

52.05%

75.29%

92.65%

58.82%

59.68%

80.95%

42.86%

52.38%

61.90%

55.36%

81.94%

76.47%

85.81%

41.87%

49.48%

55.71%

20.45%


85.76% 88.04% 89.97% 92.01%

85.69% 87.91% 90.58% 92.07%

20.20% 24.33% 30.45% 38.66%

54.50% 64.34% 71.30% 75.96%

66.67% 72.33% 77.78% 80.86%

53.28% 61.31% 70.07% 75.18%

46.25% 54.18% 63.14% 68.04%

38.20% 46.17% 52.89% 59.37%

53.76% 44.77% 36.52% 30.28%

80.18% 83.87% 87.59% 91.73%

75.67% 80.10% 83.11% 86.86%

48.53% 56.20% 63.76% 69.79%

61.70% 71.29% 80.90% 86.46%

47.88% 54.07% 58.94% 66.96%

24.55% 30.19% 35.37% 43.08%

56.18% 62.84% 69.47% 74.03%

77.80% 84.30% 89.62% 93.10%

72.15% 75.29% 78.57% 84.03%

41.67% 51.16% 60.82% 69.76%

41.85% 57.40% 73.72% 82.46%

50.00% 60.58% 69.21% 77.47%

65.97% 71.76% 77.26% 82.69%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Partnership HealthPlan of CA HEDIS 2015 Performance Northeast Region Rates and Benchmarks


NA NA NA NA

BenchmarksNortheast Rates



Notes: For the CDC HbA1c Poor Control >9% measure, the HPL is based on the national Medicaid 10th percentile because a lower rate indicates better performance.Measures with a denominator of less than 30 are reported as NA.Excludes measures where DHCS does not hold Medicaid Managed Care Plans accountable (All-Cause Readmissions, Ambulatory Care, Annual Monitoring for Patients onPersistent Medications-Digoxin, Children & Adolescents’ Access to Primary Care Practitioners).

NA NA NA NA

NA NA NA NA

NA

NA

NA NA

NA NA

NA NA

of 136

Measure Humboldt Del Norte























63.86%

42.86%

22.08%

71.84%

46.60%

50.91%

39.64%

53.15%

54.72%

83.04%

78.88%

62.20%

47.31%

39.52%

51.62%

59.90%

46.67%

39.00%

56.48%

47.91%

83.88%

80.99%

92.79%

27.93%

61.26%

86.34%

88.33%

92.00%

59.74%

78.21%

49.21%

79.28%

55.00%

68.56%

86.69%

32.33%

54.33%

60.33%

25.00%


85.76% 88.04% 89.97% 92.01%

85.69% 87.91% 90.58% 92.07%

20.20% 24.33% 30.45% 38.66%

54.50% 64.34% 71.30% 75.96%

66.67% 72.33% 77.78% 80.86%

53.28% 61.31% 70.07% 75.18%

46.25% 54.18% 63.14% 68.04%

38.20% 46.17% 52.89% 59.37%

53.76% 44.77% 36.52% 30.28%

80.18% 83.87% 87.59% 91.73%

75.67% 80.10% 83.11% 86.86%

48.53% 56.20% 63.76% 69.79%

61.70% 71.29% 80.90% 86.46%

47.88% 54.07% 58.94% 66.96%

24.55% 30.19% 35.37% 43.08%

56.18% 62.84% 69.47% 74.03%

77.80% 84.30% 89.62% 93.10%

72.15% 75.29% 78.57% 84.03%

41.67% 51.16% 60.82% 69.76%

41.85% 57.40% 73.72% 82.46%

50.00% 60.58% 69.21% 77.47%

65.97% 71.76% 77.26% 82.69%

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Abc

Partnership HealthPlan of CA HEDIS 2015 Performance Northwest Region Rates and Benchmarks


NA NA

BenchmarksNorthwest Rates




NA NA

NA

of 136

HED

IS 2

015

Adm

inis

trat

ive

Dat

a Im

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Per

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Rat

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Per

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ile

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Cerv

ical

Can

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cree

ning

46.6

1%25

th56

.20%

41.3

6%25

th45

.99%

24.3

3%<M

PL49

.64%

28.9

5%<M

PLCh

ildho

od Im

mun

izatio

n St

atus

-Co

mbo

354

.93%

25th

73.7

2%50

.61%

50th

58.6

4%49

.15%

<MPL

56.1

3%40

.15%

<MPL

HbA1

c Te

stin

g84

.39%

75th

87.1

0%81

.75%

50th

87.3

5%84

.43%

50th

92.2

1%88

.56%

90th

HbA1

c Po

or C

ontr

ol >

9.0%

(L

ower

is b

ette

r)28

.78%

75th

43.3

1%31

.87%

50th

42.5

8%30

.17%

50th

31.1

4%13

.63%

75th

HbA1

c Co

ntro

l <8.

0%32

.93%

75th

46.7

2%14

.11%

50th

48.9

1%0.

00%

50th

56.2

0%0.

24%

75th

Eye

Exam

Per

form

ed46

.10%

25th

49.1

5%37

.47%

25th

34.7

9%29

.20%

<MPL

39.1

7%29

.44%

<MPL

Med

ical

Att

entio

n fo

r N

ephr

opat

hy82

.20%

75th

76.6

4%72

.51%

25th

76.1

6%71

.78%

25th

85.8

9%84

.67%

50th

Bloo

d Pr

essu

re C

ontr

ol

<140

/90m

m H

g0.

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50th

64.4

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50th

56.6

9%0.

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25th

58.3

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25th

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re0.

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50th

54.0

1%0.

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25th

48.4

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<MPL

47.4

5%0.

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<MPL

Imm

uniza

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for A

dole

scen

ts-

Com

bo #

164

.47%

25th

68.8

6%58

.64%

25th

39.1

7%33

.58%

<MPL

57.9

8%45

.53%

<MPL

Tim

elin

ess o

f Pre

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l Car

e68

.06%

50th

86.1

3%81

.75%

50th

79.8

4%64

.25%

25th

82.9

7%68

.86%

25th

Post

Par

tum

Car

e55

.00%

50th

68.3

7%59

.85%

50th

52.4

2%45

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<MPL

50.3

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.25%

<MPL

Wel

l Chi

ld V

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in th

e Th

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Four

th, F

ifth,

and

Six

th72

.26%

50th

72.0

2%69

.59%

50th

62.0

4%58

.39%

<MPL

62.5

3%61

.07%

<MPL

BMI P

erce

ntile

8.56

%75

th86

.62%

6.08

%90

th86

.13%

1.95

%90

th66

.91%

2.68

%50

thCo

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ling

for N

utrit

ion

28.3

6%75

th62

.77%

14.6

0%50

th55

.96%

0.97

%25

th46

.47%

0.24

%<M

PL

Coun

selin

g fo

r Phy

sical

Act

ivity

15.4

0%75

th53

.77%

9.73

%50

th40

.39%

0.24

%<M

PL36

.25%

0.00

%<M

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Pren

atal

and

Pos

tpar

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Wei

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and

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Nor

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Cerv

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.47%

46.6

1%-8

.86%

14.3

6%11

.58%

-2.7

7%-1

1.64

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2.93

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A1c

Cont

rol

<8.0

%41

.85%

32.9

3%-8

.92%

10.4

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10.2

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75th

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38%

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60.8

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31.2

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38.5

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29.9

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Com

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are

of 136

PCP AND SPECIALTY ACCESS SURVEY

2015 Results

CONTENTS

Background Survey methodology Results

Overall Primary Care Specialty Care Prenatal Care

Limitations & Challenges Discussion – Activities for Improvement

2

of 136

BACKGROUND

PHC assesses compliance with the Accessibility standards annually. The survey monitors appointment availability, telephone access and appointment wait time among network primary care providers and high volume specialists

Standards set forth by DHCS, to ensure access to and availability of services for our members. Completing an access survey annually is required by DHCS

Survey Objectives: Assess compliance with PHC access standards Review trends and identify opportunities to improve Assist providers to ensure standards are met

3

SURVEY METHODOLOGY

Survey instrument and training: designed and coordinated by PHC’s Provider Relations (PR) and

Quality Improvement (QI) departments

Surveyed providers: PCPs (Family Practice, Internal Medicine and Pediatrics) and High-Volume Specialists

The survey is administered by PHC’s PR staff (cross-sectional; one-time call to provider offices to request access data; some surveys taken in-person)

Data Entry: Sugar Database with fields constructed to align with the survey questions which allows uniformity of data entry across interviewers.

4

of 136

SURVEY METHODOLOGY, CONT.

Telephonic survey administration: Telephonic survey during business hours in June 2015, asking specific appointment availability using the “third next

available appointment” methodology

Data Validation and Analysis: completed by QI and Analytics using Tableau

5

SAMPLE SELECTION: WHO WE SURVEYED

PCPs: all PCP’s in each of the fourteen counties served by the plan. No sampling of PCP’s will be conducted Southern Region: Solano, Napa, Yolo, Lake, Marin,

Mendocino and Sonoma Northern Region: Del Norte, Humboldt, Lassen,

Modoc, Shasta, Siskiyou and Trinity

Specialists: Multi-Step Process Step 1: Use claims data to ID which specialists

served the largest volume of unique PHC members (1/1/14 – 12/31/14)

Step 2: Compile list of 10 “highest volume” specialists in each county across the network

Step 3: Generate list of all specialty types identified; ensure that any specialty type in top 10 in any single county is surveyed across all counties 6

of 136

SURVEY MEASURES

7

ALL REGIONSPRIMARY CARE PROVIDERS

Standard

Days to 3NA Adult New Pt Appt <= 14 days (10 business days)

Days to 3NA Adult Estab Pt Appt <= 14 days (10 business days)

Days to 3NA Pediatric New Pt Appt <= 14 days (10 business days)

Days to 3NA Ped Estab Pt Appt <= 14 days (10 business days)

Newborn Appt <= 48 hours

Urgent Appt <= 48 hours

# rings before phone answered <= 5 rings

Minutes on hold <=5 minutes

Average wait time before seeing provider <=30 minutes

Return call within 30 minutes <=30 minutes

HIGH-VOLUME SPECIALISTS Standard

Days to 3NA Routine Specialty appt New Pt 21 days (15 business days)

Days to 3NA Routine Specialty appt Established Pt 21 days (15 business days)

Time to Next Available Urgent Appt 48 hours

# rings before phone answered 5




PRENATAL CARE Standard

Days to 3NA Prenatal Care (PCP & Specialists) <= 14 days (10 business days)

SUMMARY RESULTS

8

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PCP RESULTS

9

PCP-TRENDED PERFORMANCE 2014-2015

10

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PCP BY COUNTY 2015

11

PCP REGIONAL AND OVERALL PERFORMANCE

Overall, the data showed worse access in Adult New Pt (60.3%) and Newborn (69.1%) appointment. Less than 70% of our network met the compliance standard in both areas

The average days to 3NA are above the standard in Adult New Pt (18.1 days) and Newborn (2.8 days). Access is worse in the North when comparing with the South

We experienced the same access issue in 2014 where both Adult New Pt (56%) and Newborn (71%) had the worse performance. In 2014, the average scheduled time to Adult New Pt was 15 days but remained the same for Newborn (2.9 days)

Overall, higher days to 3NA for PCPs and less percentage compliance in 2015 than 2014

As a consequence of membership growth, primary care and specialty appointment access for new patients may be compromised (relative to established patients). The data showed worse access for new versus established patients 12

of 136

SPECIALTY RESULTS

13

SPEC-TRENDED PERFORMANCE 2014-2015

14

of 136

15

SPEC REGIONAL AND OVERALL PERFORMANCE

Greater accessibility for ESTABLISHED patients vs NEW Overall, poor performance in specialty access in 2015 than 2014 Access is worse in the North when comparing with the South Poor specialty access in the worse performing counties

16

COUNTY SPECIALTY

Del Norte Orthopedic Surgery, OphthalmologyHumboldt Nephrology, Pain ManagementShasta Neurology, GastroenterologyLake Neurology, NephrologyMendocino Ophthalmology, Podiatry

of 136

SPEC REGIONAL AND OVERALL PERFORMANCE

Specialties with worst access across the network (EST PT)

17

SPECIALTY COUNTY

Neurology (avg 46.6 days) Lake, Shasta*

Nephrology (avg 40.5 days) Yolo, Lake

Dermatology (avg 31.4 days) Humboldt, Shasta*

Ophthalmology (avg 27.4 days) Humboldt, Siskiyou

Pulmonary (avg 27.0 days) Shasta*, Solano

PRENATAL RESULTS

18

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PRENATAL CARE BY COUNTY

19

PCPS WITH ACCESS CHALLENGES

CANDIDATES FOR FUTURE ACCESS PROJECTS

Sites with >10% of the member volume assigned in a county, and non-compliance on 3 or more 3NA measures

Northern

Stevens Parkview Healthcare, Modoc (24%) Northeastern Rural Health Clinic, Lassen (80%)

Southern

SCHSS Vallejo, Solano (12%) La Clinica, Solano (11%) Ukiah Valley Rural, Mendocino (14%) Vista Family Health Center (20%) Marin Community Clinic, Novato (25%) 20

(%) – percent of county membership assigned to practice

Note: Only collected data at one point in time. To really understand access at these sites, need more data.

of 136

LIMITATIONS & CHALLENGES

Methodological Cross-sectional analysis Variation in survey style/script Small sample sizes of some specialty providers

Not all data are actionable Self-reported data: Cycle time Not representative at site or clinician level Specialty access – difficult to quantify

Weighting: No “capitation” to weight by Not accounting for volume of specialists relative to

membership Provider frustration – over-surveyed, measuring Access via QIP,

PR Reps, Consortium surveys, etc.21

CURRENT ACTIVITIES FOR ACCESS IMPROVEMENT

Activities to Build Network Capacity: 2015

TelemedicineE-ConsultsPrimary Care Access WorkgroupSpecialist QIPRegional efforts to improve specialty referral agreementsPHC Coleman Collaborative – Primary Care Practice RedesignPHC Provider Recruitment InitiativeMarin Ortho Improvement ProjectPrimary Care Access Pilot – Northern Region – allow during business hours access to urgent careExtended hours QIP pilotACA payment for open access 22

of 136

CREDITS

PR - South

Chad Leslie Necole Montgomery Jill Tarap Jean Levato Stephanie Phipps Judy Paul Gloria Turner Melissa Perez Mary Kerlin Heather Brandeburg Ledra Guillory

PR - North

Tami Spliethof Sharon McFarlin Ray Phillips Jennifer Chancellor Michele Swift Kelley Sewell Tara Brumley

Finance

Melanie Lam Liat Vaisenberg

QI

Sue Lee Rachel Joseph Jessica Thacher

23

QUESTIONS?

24

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3rd Next Available Survey, 2015Review











Primary Care Providers Standards

Days to 3NA New Pt Appt 21 days (15 business days)

Days to 3NA Established Pt Appt 21 days (15 business days)





High Volume Specialists Standards

North South Grand Total

97.8%

99.6%

99.3%

100.0%

93.1%

69.1%

79.5%

76.3%

76.0%

60.3%

99.5%

99.5%

98.9%

100.0%

96.8%

69.3%

74.8%

75.2%

70.3%

64.1%

94.2%

100.0%

100.0%

100.0%

85.4%

68.7%

87.9%

78.3%

87.2%

52.8%

% Compliant with Standard


92.8%

99.3%

99.8%

100.0%

70.7%

60.1%

99.1%

99.7%

99.7%

100.0%

75.3%

64.4%

78.7%

98.6%

100.0%

100.0%

60.3%

50.4%



76.5%80.0%70.0%



12.8

0.7

1.5

0.5

2.8

7.6

9.9

10.0

18.1

12.7

0.8

1.5

0.3

1.8

7.9

10.0

11.2

15.7

13.0

0.5

1.7

0.9

4.9

7.2

9.6

7.6

22.9

Average


12.8

0.4

1.6

19.5

25.1

11.7

0.4

1.7

16.2

21.5

15.2

0.3

1.5

27.0

33.3

Average


10.910.112.5

Average

Days to 3NA Prenatal Care <= 14 days (10 business days)

Prenatal Care Standards

of 136

3rd Next Avaialbe Survey, 2015Primary Care Appointment Access

Adult New Days

Adult Established Days

Ped New Days

Ped Established Days

Average Days to 3NA, by Measure and Year All

0 2 4 6 8 10 12 14 16 18Avg. Days

Newborn DAYS

Urgent DAYS

North South

99.5%

99.5%

98.9%

100.0%

96.8%

69.3%

74.8%

75.2%

70.3%

64.1%

94.2%

100.0%

100.0%

100.0%

85.4%

68.7%

87.9%

78.3%

87.2%

52.8%


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% Compliant

Adult New

Adult Established

Ped New

Ped Established

Newborn

Urgent

Percent Compliant with Standard by Measure and Year, All











Primary Care Providers Standards

60.3%

76.0%

76.3%

79.5%

69.1%

93.1%

100.0%

99.3%

99.6%

97.8%

OverallNorth South

12.7

0.8

1.5

0.3

1.8

7.9

10.0

11.2

15.7

13.0

0.5

1.7

0.9

4.9

7.2

9.6

7.6

22.9

Average

2.8

0.5

1.5

18.1

10.0

9.9

7.6

Overall

0.7

12.8

Year 2014 2015

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0 5 10 15 20

New Adult DAYS

0 5 10

Est Adult DAYS

0 5 10

New Peds DAYS

0 5 10

Est Ped DAYS

0 1 2 3 4 5

Newborn DAYS

0.0 0.5 1.0 1.5 2.0

Urgent DAYS

North

South

Average Days to 3NA by Measure, Region and Year

0% 20% 40% 60% 80% 100%Adult New

0% 20% 40% 60% 80% 100%Adult est

0% 20% 40% 60% 80% 100%Ped New

0% 20% 40% 60% 80% 100% Ped Est

0% 20% 40% 60% 80% 100%Newborn

0% 20% 40% 60% 80% 100%Urgent

North

South

Percent Compliance with Standards by Measure, Region and Year

Year of Conducted Date2014

2015

of 136


Year2015

Press on desired County, and then on "Provider Level Data" to view provider level data at the county level. Select Year to see difference over time.

Days 3NA New Adults Days 3NA Est Adults Days 3NA New Peds Days 3NA Est Peds Days 3NA Newborn Days 3NA Urgent

DelNorte

Lake

Siskiyou

Modoc

Humboldt

Lassen

Shasta

Solano

Napa

Mendocino

Sonoma

Trinity

Marin

Yolo

51.5 1.7 16.0 2.4 1.0 0.1

43.5 22.7 23.1 12.6 2.0 0.4

30.0 15.9 11.0 7.8 2.6 2.0

22.3 13.4 20.2 16.2 0.7 5.4

22.2 4.3 6.7 3.8 3.6 0.9

18.6 1.7 18.6 18.7 1.9 1.0

17.5 8.7 8.9 8.7 8.3 0.5

17.4 15.3 10.3 9.0 1.8 0.8

14.4 7.3 11.0 10.5 2.7 0.0

12.6 8.8 11.4 5.8 1.1 0.1

12.4 10.0 6.6 6.9 1.7 0.1

11.1 11.8 9.4 9.6 13.5 0.6

8.7 8.0 9.7 8.2 3.3 0.1

7.2 2.7 8.5 5.6 0.9 0.0

Weighted Avg Days to 3NA by County, 2015

Mendocino0

Humboldt2

DelNorte2

Siskiyou4

Sonoma0

Lassen3

Shasta2

Solano2

Modoc4

Trinity1

Lake3

Yolo0

Number of Compliance Violoations by County, Primary Care

0% 20% 40% 60% 80% 100%Adult New

0% 20% 40% 60% 80% 100%Adult est

0% 20% 40% 60% 80% 100%Ped New

0% 20% 40% 60% 80% 100% Ped Est

0% 20% 40% 60% 80% 100%Newborn

0% 20% 40% 60% 80% 100%Urgent

LakeSolanoMarin

MendocinoModocTrinitySonomaShastaSiskiyouHumboldtDelNorteLassenNapaYolo 60.3% 76.0% 76.3% 79.5% 69.1% 93.1%

Percent Compliance with Standard, 2015

of 136


Year2014

Press on desired County, and then on "Provider Level Data" to view provider level data at the county level. Select Year to see difference over time.

Days 3NA New Adults Days 3NA Est Adults Days 3NA New Peds Days 3NA Est Peds Days 3NA Newborn Days 3NA Urgent

Lassen

Siskiyou

Shasta

DelNorte

Sonoma

Solano

Napa

Humboldt

Mendocino

Lake

Marin

Yolo

Trinity

Modoc

32.0 5.7 32.0 7.5 7.1 0.3

25.0 16.4 9.7 8.2 5.3 1.0

19.7 14.8 8.7 8.0 1.8 0.0

17.4 2.5 1.5 1.2 2.0 0.0

16.7 6.2 10.2 7.7 3.7 0.0

15.2 8.2 7.4 2.7 0.9 0.6

14.5 13.5 12.1 12.2 1.2 0.8

13.8 6.4 8.7 2.9 8.4 0.5

11.9 3.2 8.2 3.1 0.3 0.1

9.5 3.9 6.4 2.3 3.1 0.3

7.5 7.4 7.4 4.9 2.4 0.4

6.1 5.5 2.9 3.0 1.5 0.7

5.9 4.1 5.9 2.3 3.7 0.0

5.8 4.8 4.1 5.0 1.5 1.1

Weighted Avg Days to 3NA by County, 2014

Mendocino0

Humboldt1

DelNorte1

Siskiyou3

Sonoma2

Lassen3

Shasta2

Solano1

Modoc0

Trinity1

Lake1

Yolo0

Number of Compliance Violoations by County, Primary Care

0% 20% 40% 60% 80% 100%Adult New

0% 20% 40% 60% 80% 100%Adult est

0% 20% 40% 60% 80% 100%Ped New

0% 20% 40% 60% 80% 100% Ped Est

0% 20% 40% 60% 80% 100%Newborn

0% 50% 100%Urgent

NapaSiskiyouHumboldtSolanoShastaModocSonomaYolo

DelNorteMarinLakeLassen

MendocinoTrinity 55.8% 81.1% 79.5% 88.6% 70.8% 96.0%

Percent Compliance with Standard, 2015

of 136

3rd Next Avaialbe Survey, 2015Specialty Care Appointment Access

North South

11.7

0.4

1.7

16.2

21.5

15.2

0.3

1.5

27.0

33.3

Average

Days to 3NA New Pt Appt 21 days (15 business days)

Days to 3NA Established Pt Appt 21 days (15 business days)





High Volume Specialists Standards

SpecialtyAll

25.1

19.5

Overall North South

99.1%

99.7%

99.7%

100.0%

75.3%

64.4%

78.7%

98.6%

100.0%

100.0%

60.3%

50.4%


60.1%

70.7%

100.0%

99.8%

99.3%

92.8%

Overall

1.6

0.4

12.8

Select Specialty to View Results by Specialty

0% 10% 20% 30% 40% 50% 60% 70% 80%% Compliant

New Patient

Estab Patient

Percent Compliant with Standard by Measure and Year, All

0 5 10 15 20 25Value

New Patients Days

Estab Patient Days

Weighted Average Days to 3NA, by Year, All

Year 2014 2015

of 136

3rd Next Avaialbe Survey, 2015

Specialty Care Appointment Access, 2015

0% 20% 40% 60% 80%% Compliant

New Patient North

South

Estab PatientNorth

South

Compliance by Region and Year, All

SpecialtyAll

0 10 20 30Days

New Patients Days North

South

Estab Patient Days North

South

Days to 3NA by Region and Year, All

20142015

NorthSouth

Estab Patient New Patient

ENDOCRINOLOGY - MD

NEUROLOGY

NEPHROLOGY - MD

GASTROENTEROLOGY

DERMATOLOGY - MD

PULMONARY DISEASE

PAIN MANAGEMENT

OPHTHALMOLOGY - MD

UROLOGY

PHYSICAL MEDICINE AND RE.. 33.3%

52.9%

52.2%

25.0%

43.8%

40.0%

45.0%

29.4%

20.0%

0.0%

66.7%

64.7%

58.7%

55.0%

50.0%

48.0%

45.0%

41.2%

33.3%

0.0%

10 Worst Performing Specialties by Region

Select Specialty or Click on specialty view provider specific data ("Specialty Providers").

0 20 40 60 80 100 120 140 160 180Avg. Measures

ENDOCRINOLOGY - MD SouthNEUROLOGY North

SouthNEPHROLOGY - MD North

SouthDERMATOLOGY - MD North

SouthOPHTHALMOLOGY - MD North

SouthPULMONARY DISEASE North

SouthGASTROENTEROLOGY North

SouthPAIN MANAGEMENT North

SouthCARDIOVASCULARDISEASE/INTERNAL MEDICI..

NorthSouth

UROLOGIC ONCOLOGY SouthORTHOPEDIC SURGERY North

SouthUROLOGY North

SouthPHYSICAL MEDICINE ANDREHABILITATION

NorthSouth

PODIATRY NorthSouth

INFECTIOUS DISEASES - MD SouthPLASTIC/RECONSTRUCTIVESURGERY

NorthSouth

OTOLARYNGOLOGY - MD NorthSouth

NEUROSURGERY NorthSouth

GENERAL SURGERY - MD NorthSouth

OBSTETRICS/GYNECOLOGY

NorthSouth

CARDIAC SURGERY SouthONCOLOGY/HEMATOLOGY -MD

NorthSouth

ALLERGY/ IMMUNOLOGY NorthBARIATRIC SURGERY SouthRADIATION THERAPY (D.O.ONLY)

NorthSouth

OPTOMETRY SouthCPSP SERVICES South

Avg. Number of Days, Established Patients

Patient TypeEstablished Patients

of 136

3rd Next Avaialbe Survey, 2015Specialty Care Appointment Access

Patient TypeEstablished Patients Click on desired Type of Patient. Click on County to view County ("Provider Breakdown") specific providers.

Mendocino20.9

Humboldt28.6

DelNorte26.9

Siskiyou22.2

Sonoma15.1

Lassen3.0

Shasta28.1

Solano15.0

Modoc33.5

Trinity5.0

Lake24.8

Yolo17.4

Avg Number of Days, Established Patients

CountyNumber ofProviders

Lassen 4

Trinity 2

Sonoma 111

Marin 42

Solano 43

Napa 46

Yolo 39

Lake 31

Shasta 80

Mendocino 29

Humboldt 40

Siskiyou 9

Modoc 2

DelNorte 7

100.0%

100.0%

81.6%

81.0%

76.7%

73.9%

71.4%

61.3%

60.0%

58.6%

57.5%

55.6%

50.0%

42.9%

% Compliant, Established Patients

SpecialtyNumber ofProviders

Avg Days NewPatients

Avg DaysEstablsihed Patients

ALLERGY/ IMMUNOLOGY 1

BARIATRIC SURGERY 1

CARDIAC SURGERY 1

CARDIOVASCULAR DISEASE/INTERNAL MEDICINE - MD 48

CPSP SERVICES 7

DERMATOLOGY - MD 25

ENDOCRINOLOGY - MD 1

GASTROENTEROLOGY 20

GENERAL SURGERY - MD 54

INFECTIOUS DISEASES - MD 1

NEPHROLOGY - MD 17

NEUROLOGY 15

NEUROSURGERY 2

OBSTETRICS/ GYNECOLOGY 61

ONCOLOGY/HEMATOLOGY - MD 15

OPHTHALMOLOGY - MD 46

OPTOMETRY 1

ORTHOPEDIC SURGERY 52

OTOLARYNGOLOGY - MD 17

PAIN MANAGEMENT 20

PHYSICAL MEDICINE AND REHABILITATION 3

PLASTIC/RECONSTRUCTIVE SURGERY 3

PODIATRY 38

PULMONARY DISEASE 16

RADIATION THERAPY (D.O. ONLY) 2

UROLOGIC ONCOLOGY 1

UROLOGY 17

6

18 6

7 7

27 21

4 2

37 31

183

36 26

13 11

21 14

51 40

44 47

12 12

12 8

10 7

31 27

2 2

22 18

25 12

46 25

27 17

14 14

23 17

33 27

9 3

19 19

19 18

Average Number of Days to 3NA, by Specialty and Type of Patient, All

of 136

3rd Next Avaialbe Survey, 2015Prenatal Care Appointment Access

Yolo85.7%

Trinity100.0%

Sonoma80.8%

Solano100.0%

Siskiyou87.5%

Shasta75.0%

Napa100.0%

Modoc50.0%

Mendocino81.8%

Marin85.7%

Lassen80.0%

Lake54.5%

Humboldt66.7%

DelNorte0.0%

% Compliant with Standards by County

0 2 4 6 8 10 12 14Avg. Days to App

10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%% Compliant

North

South

GrandTotal

Prenatal Care Acceess by Year and Region

YoloAvg Days5.9

TrinityAvg Days11.0

SonomaAvg Days7.7 Solano

Avg Days5.0

SiskiyouAvg Days9.3

ShastaAvg Days14.5

NapaAvg Days2.7

ModocAvg Days16.0

MendocinoAvg Days10.7

MarinAvg Days7.7

LassenAvg Days6.6Lake

Avg Days24.5

HumboldtAvg Days9.7

DelNorteAvg Days29.0

Average Number of Days to Appointment by County

Days to 3NA Prenatal Care <= 14 days (10 business days)

Prenatal Care Standards

Year 2014 2015

AverageNorth South

% CompliantNorth South

AverageTotal

% CompliantTotal

10.112.5 80.0%70.0% 10.9 76.5%

1 39Clinic Count

of 136


Provider Name PCP MemberCount

% of TotalCounty PCPMemberCount

AdultEstablishedDays

Adult NewDays

PedEstablishedDays

Ped NewDays

NewbornDAYS Urgent DAYS

Fairchild Medical Clinic

Mercy Community Clinic Mount Shasta

Karuk Tribal Health Clinic

Siskiyou Medical Group - Mt Shasta 824 Pi..

Tulelake Health Center

Swenson Medical Group

Butte Valley Health Center

Shasta Family Care

Dignity Health Pine Street Clinic

Karuk Community Health Clinic - Happy C..

Dunsmuir Community Health Center

Scott Valley Rural Health Clinic

Mercy Lake Shastina Community Clinic

McCloud Healthcare Clinic Inc.

Siskiyou Medical Group - Weed

Anav Tribal Health Clinic

Siskiyou Medical Group - Mt Shasta 822 Pi..

Danny Drew MD 2

0

0

1

0

7

0

0

0

29

1

0

0

0

6

0

1

0

0

1

2

21

1

7

1

7

1

10

0

1

4

3

2

0

0

7

2

92

4

3

6

39

2

10

4

1

5

30

4

0

4

1

92

1

3

6

39

1

7

1

1

3

14

1

14

0

8

2

124

4

3

6

52

80

10

1

7

5

121

19

14

7

0

4

2

124

1

3

6

39

1

7

1

1

5

3

61

11

1%

1%

2%

3%

3%

3%

3%

4%

4%

4%

5%

5%

5%

5%

6%

6%

9%

32%

90

154

290

373

382

424

490

537

585

644

660

669

686

793

892

900

1,261

4,650

Primary Care Providers, Siskiyou

of 136


Region County Provider Name SpecialtyEstab Patient

DaysNew PatientsDays Urgent Days

North Humboldt Humboldt Neurological Medical Group NEUROLOGY

Shasta Hamid Rabiee, MD NEUROLOGY

Harvinder Birk, MD NEUROLOGY

South Lake St Helena Family Health Center-Clearlake-15230 Lakeshore Dr NEUROLOGY

Marin Ilkcan Cokgor, MD NEUROLOGY

Napa St Helena Medical Specialties-Neph/Neuro 821 S St Helena Hwy NEUROLOGY

Margaret A. Schlatter, MD NEUROLOGY

Solano Albert M. Mitchell, DO - Fairfield NEUROLOGY

Sonoma Sutter Medical Group Of The Redwoods- 3883 Airway Ste 201 NEUROLOGY

Gravenstein Community Health Center NEUROLOGY

Healdsburg Specialty Medical Services NEUROLOGY

Yolo Woodland Healthcare-2440 W Covell Blvd NEUROLOGY

Harbor Medical Clinic NEUROLOGY

Woodland Healthcare-515 Fairchild Neurology NEUROLOGY

Sutter West Medical Group-2030 Sutter Pl Ste 1000 Neuro NEUROLOGY

0296

221112

36666

3115115

14962

45952

03016

13434

06955

04646

01919

04457

323232

03515

21512

Specialty Providers, NEUROLOGY

of 136


Provider Name County SpecialtyEstab Patient

DaysNew PatientsDays Urgent Days

Big Valley Health Center Lassen GENERAL SURGERY - MD

Westwood Family Practice Lassen OBSTETRICS/GYNECOLOGY

Banner Health Lassen GENERAL SURGERY - MD

Northeastern Rural Health Clinic Lassen OBSTETRICS/GYNECOLOGY

377

133

011

121

Specialty Providers, Lassen

of 136

Suggested wording for new policy disclaimer

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

• Consistent with sound clinical principles and processes • Evaluated and updated at least annually • If used as the basis of a decision to modify, delay or deny services in a specific case, the

criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

of 136

partnership healthplan of california …...donna barton, rn, regional team manager/um nancy steffen,...

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