Together for Quality

“Quality is not an act, it is a habit” Aristotle

Clinical Workgroup

Mission: The Clinical Workgroup’s mission is to improve the care and outcomes of patients within the state of Alabama by facilitating access to the information needed to make informed healthcare decisions.

Together for Quality Clinical Workgroup

Clinical Workgroup

o Composed of 50+ members from diverse backgrounds including providers, academia, other state agencies, and public/private entities such as BCBS of AL, Alabama Quality Assurance Foundation (AQAF), and others

o Reviewed Alabama morbidity and mortality data and prioritized 6 diseases; diabetes, asthma, cardiovascular diseases, stroke, obesity and COPD

o Reviewed compilation of QI measures for chronic diseases from national sources including NCQA, AHRQ, and AMA physician Performance Measures

o Chose quality measures for diabetes (5) and asthma (5)o Continues to assist with design of electronic clinical

support tool, tools for care coordinators and other areas as identified

Grant Requirements

TFQ will develop, test, and implement a system of data and information exchange with at least one health and human service agency

TFQ will develop EHR for Medicaid recipients and work toward partnerships for development of records for the uninsured

TFQ will enhance and provide electronic clinical support tool for providers

TFQ will develop quality improvement model for chronic diseases

TFQ Logic Model

Organized grant requirements into two areas:1. Electronic Health Information System

Simplify provider access to and use of information at the point of care through the use of an electronic clinical support tool

Establish HHS Interoperability with at least one other state agency during pilot phase

2. Develop a Data-driven Quality Improvement Model Evidenced-based practices and measures Pilot chronic disease care coordination

Action/Milestone Deliverable

(if applicable)

Completion Date (target)

Comments

Quantify disease burden-Medicaid and State, review data; limit to 3 target diseases

Prioritized diseases March 9, 2007 Completed

Review literature and provide bibliography of references and discuss quality measures for chosen disease states

March 9, 2007 Completed

Determine core data elements needed for all disease

March 9, 2007 Completed

Determine disease specific quality indicators

May 31, 2007 Completed

Sample survey of medical home providers

March 2007 Completed

Action/Milestone Deliverable

(if applicable)

Completion Date (target)

Comments

Develop care coordination protocol for Asthma and determine tools for use by care coordinator’s in conjunction with ADPH

January 2008 Completed

Develop care coordination protocol for Diabetes and determine tools for use by care coordinator’s in conjunction with ADPH

February 2008 Completed

Review screens and request necessary changes for electronic health record (EHR)

April 2008

Review and finalize Clinical Rules for use in EHR for electronic clinical support tool (ECST).

April 2008

User Acceptance Testing of ECST April/May 2008

MEASURES1. Annual Influenza Vaccination – percentage of patients who received an influenza

vaccination during 12 month review period (Children and Adults)

2. Annual HbA1C – percentage of patients who have had at least one HbA1C during 12 month review period (Children and Adults)

3. Lipid Management – percentage of patients who received at least one lipid profile (or ALL component tests) during the 12 month review period (Adults and Chidren≥16 years old)

4. Annual Urine Protein Screening (or microalbumin) – percentage of patients who received screening for urine protein during the 12 month review period (Adults and Chidren≥16 years old)

5. Annual Eye Exam – percentage of patients who received a dilated eye exam by an ophthalmologist or optometrist during the 12 month review period (Adults and Chidren≥16 years old)

Diabetes QI Measures (Adult & Pediatric)

Denominator is all patients diagnosed with diabetes or on an anti-diabetic medication. The denominator will include recipients with any claims with ICD-9-CM codes 250.00-250.93, 357.2. 362.01, 362.02 or 366.41 or on any anti-diabetic medications in the AHFS class 68:20 (68:20.02, 68:20.03, etc) with the dates of service March 01, 2006-February 28, 2007 with paid dates from March 01, 2006 through May 31, 2007.

Measurement period is 12 consecutive months.

The numerator will reflect the coding required in determining the measures above.

Annual Influenza Immunization

1) The numerator is all patients who received an influenza vaccination, CPT 90655-90660 or G0008 or V04.81 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Annual HbA1C

2) The numerator is patients who received at least one HbA1C test, CPT 83036 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Diabetes Logic

Diabetes Logic - Continued

Annual Lipid Profile 3) The numerator is patients age 16 and older with at least one lipid panel, CPT 80061 or ALL Component Tests, CPT 83718 and 83721 and 82465 and 84478 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Annual Eye Exam4) The numerator is patients age 16 and older who received a dilated eye exam, CPT 92002-92014 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Annual Urine Protein Screening5) The numerator is patients age 16 and older with any test for urine protein (microalbuminuria), CPT 81000-81003, 81005, 82042, 82043, 82044, 84156, 84160 or 84166 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Diabetic Data for Pilot Counties Straight Claims

7,478Total Diabetic Straight Medicaid Recipients

Recipients That Meet Criteria

Recipients That Do Not Meet Criteria

% Actual

12 Month Goal

12 Month Actual

Benchmarka

Annual Flu Shot

1,020 6,458 13.64% 18.78% 36.3b%

HbA1C (At least One)

3,979 3,499 53.59% 58.59% 76.20%

NOTE: The numbers in this table and in those that follow it are the numbers derived from the baseline queries using a multiplicative model to achieve a 5 percentage point increase as the target goal for the 12 month pilot period. These numbers may differ slightly from the original.

a Based on NCQA Medicaid Hedis 2005 National Average except for the Annual Flu Shot

b NCQA Commercial Hedis 2005 National Average

Diabetic Data for Pilot Counties Straight Claims

7,011Total Diabetic Straight Medicaid Recipients ≥ 16 years old

Recipients That Meet Criteria

Recipients That Do Not Meet Criteria

% Actual

12 Month Goal

12 Month Actual

Benchmarka

Annual Lipid Profile*

2,961 4,050 42.23% 47.51% 80.50%

Annual Eye Exam*

1,736 5,275 24.76% 30.02% 48.60%

Annual Urine Protein*

3,496 3,515 49.86% 55.22% 48.80%

a Based on NCQA Medicaid Hedis 2005 National Average except for the Annual Flu Shot

*Changes have been made in the denominator for these three (3) measures to address issues surrounding the recommended frequency for testing in children with type 1 diabetes which prevents annual reassessment. Therefore only adults and children 16 years and older have been considered for these three (3) measures and thus the decrease in total population.

Asthma QI Measures (Adult and Pediatric)

MEASURES1. Asthma Controller Use – 1a) Percentage of patients with an asthma related ED

visit and/or hospital admission who subsequently fill <1 prescription every three months for an inhaled steroid, either alone or in combination 1b) Percentage of patients who fill >2 short acting bronchodilator prescriptions every year who subsequently fill <1 prescription every three months for an inhaled steroid, either alone or in combination, or fill < 2 prescriptions every three months for leukotriene modifiers or mast cell stabilizers.

2. Annual Influenza Immunization – Percentage of patients with an asthma diagnosis who receive an influenza immunization during each calendar year

3. Emergency Department Visits – Percentage of patients with an asthma diagnosis who have ≥1 ED visit during a calendar year

4. Hospitalization – Percentage of patients with an asthma diagnosis who have ≥1 inpatient admission for asthma treatment during a calendar year.

Asthma Logic

LOGIC

Denominator is all patients age one and older, diagnosed with asthma or on at least two short acting beta adrenergic agents during the measurement period. The denominator will include recipients with any claims with ICD-9-CM codes 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.81, 493.82, 493.90, 493.91, and 493.92 (excludes 493.20, 493.21 and 493.22) or on two or more short acting beta adrenergic agent (Short Acting Beta Adrenergic Agents-Table D) with the dates of service March 01, 2006-February 28, 2007 with paid dates from March 01, 2006 through May 31, 2007.

Asthma Logic- ContinuedMeasurement period is 12 consecutive months.

The numerator will reflect the coding necessary to obtain the specific measures chosen by the TFQ Clinical Workgroup.

1. Asthma Controller Use1a. Numerator is patients with an asthma related ED visit (procedure codes 99281-99285) or asthma related hospital admission (Claim Type S – straight and PT=05 and Provider Specialty=W6) AND fill < 1 prescription every three months for an inhaled steroid (Table A)1b. Numerator is patients with > 2 short acting bronchodilator prescriptions (Table B) during the measurement period AND fill < 1 prescription every three months for an inhaled steroid (Table A) or fill < 2 prescriptions every three months for leukotriene modifiers or mast cell stabilizers (Table C)

2. Annual Influenza ImmunizationNumerator is patients with influenza vaccination CPT 90655 - 90660 or V04.81 or G0008 during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Asthma Logic- Continued

3. Emergency Department Visits

Numerator is patients with ≥ 1 asthma related ED visits as identified via ED visit codes (procedure codes 99281-99285) AND also has an asthma diagnosis code ICD-9-CM codes 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.81, 493.82, 493.90, 493.91, and 493.92 as the primary diagnosis on the emergency room claim during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

4. HospitalizationNumerator is patients with ≥ 1 inpatient hospital admissions (Claim Type S – straight and PT=05 and Provider Specialty=W6) AND also has an asthma diagnosis code ICD-9-CM codes 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.81, 493.82, 493.90, 493.91, and 493.92 as the primary diagnosis on the inpatient hospital claim during the measurement period (dates of service March 01, 2006-February 28, 2007 with paid dates through May 31, 2007).

Asthma Data for Pilot Counties Straight Claims (Age 1 or Older)

21,699 Recipients That Meet Criteria

Recipients That Do Not Meet Criteria

% Actual

12 Month Goal

12 Month Actual

Benchmark

Asthma Controller Use (1a)

2,103 19,596 9.69% 9.28% 7.78%

Asthma Controller Use (1b)

7,557 14,142 34.83% 33.82% 30.34%

Annual Flu Shot 5,327 16,372 24.55% 29.80% 36.3%

ED Visits 1,931 19,768 8.90% 8.48% 6.98%

Hospitalizations 767 20,932 3.53% 3.07% 1.57%

PILOT COUNTIES

Tuscaloosa X X

Lamar X X

Pickens X X

Calhoun X X

Talladega X X

Montgomery X X

Bullock X

Pike X

Jefferson X

Winston X

Houston X

County Care management Electronic Clinical Support Tool (ECST)

Eleven pilot counties have been chosen to test the effectiveness of this health information exchange initiative.

Pilot Counties - Implementation Timeline

Tuscaloosa X May 2008

Lamar X X May 2008

Pickens X X May 2008

Calhoun X X April 2008

Talladega X X April 2008

Montgomery X X April 2008

Bullock X February/March 2008

Pike X February/March 2008

Jefferson X July 2008

Winston X July 2008

Houston X July 2008

County Care Management

Electronic Clinical Support Tool (ECST)

X

Eleven pilot counties have been chosen to test the effectiveness of this health information exchange initiative.

Implementation Dates

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