Together For Quality

Alabama Medicaid Agency

Pilot Project Counties

What is Q4U? Component of Together for Quality that provides

for comprehensive chronic care management program

Asthma and Diabetes are Targeted Diseases Protocols Designed to Affect all Disease Facets Accomplished through Alabama Dept. of Public

Health Care Coordinators (aka Care Managers) Care Managers Provide Patient Training,

Education, and Reinforcement

Measures

Diabetes Influenza Immunization Annual HbA1C Annual Lipid Profile Annual Eye Exam Annual Urine Protein

Screening

Asthma Asthma Controller Use Influenza Immunization Emergency Department

Visits Hospitalizations

Developed by the Clinical WorkgroupTarget Goals

Q4U Patients

From RMEDE Patient 1st Recipients Five, four, etc. Missed Opportunities Stratified by High, Medium and Low Patient 1st PMP Agrees to Participate Strive to Enroll 120% of Target Minimum Six Months Enrollment

Q4U PMP Recruitment

Significant Number of Patients with Missed Opportunities

Face-to-FaceProvider NotebookProvider AgreementList of Patients Referred to Care

ManagementOngoing Reporting Through RMEDE

Patient Enrollment

Online Referral System through State ADPH Demographics are Provided to County Level

Care Managers Patient Contact Enrollment Accomplished Through Home

Visit Patient has Ability to Refuse

Once Enrolled

Schedule of Monthly Follow-Up Ongoing Contact with PMP/Nurse ADPH Monthly Survey RMEDE Reporting Appropriate Coordination with Other

Caregivers and Schools Disease Specific Educational Material Works With Entire Family

Patient Example

Bullock County Resident Four Missed Opportunities Not Very Compliant Enrolled in the Program Initial Home Visit Subsequent Visits/Contacts Coordination with PMP Ongoing Intervention

Q4U Implementation

Pilot Providers February/March

Bullock – 3 sites, 4 providers Pike – 7 sites, 18 providers

April Montgomery – 11 sites, 23

providers Calhoun – 16 sites, 31

providers Talladega – 5 sites, 14

providers May – recruitment underway

Patients Enrolled To Date

Bullock Asthma – 25 Diabetes – 0

Pike Asthma – 59 Diabetes – 9

Together for Quality

Clinical Workgroup Update

April 9, 2008Mary G. McIntyre, M.D., M.P.H

TFQ

Quality Improvement Performance Measures

County Specific

Targets Chosen

Review of NCQA “The Plan” Provider driven versus consumer driven Establishment of 12 month change

Asthma 0.5 to 1.0 percentage point reduction from baseline for all but Annual Influenza Immunization(Lower is Best)

Diabetes – 5 percentage point increase from the baseline(Higher is Best)

Overall Pilot County

Percentages

Measure Baseline Goal 1 (4 months)

Goal 2(8 months)

Target(12 months)

Annual Influenza Vaccine

13.64% 14.93% 17.50% 18.78%

Annual HbA1C

53.21% 54.56% 57.25% 58.59%

Lipid Management

42.23% 43.55% 46.19% 47.51%

Annual Eye Exam

24.76% 26.08% 28.71% 30.02%

Annual Urine Protein Screening

49.86% 51.20% 53.88% 55.22%

Diabetes (Overall Pilot Co.

Percentages)

Asthma (Overall Pilot Co.

Percentages)Measure Baseline Goal 1 (4 months)

Goal 2 (8 months)

Target (12 months)

Asthma Controller (Service) 1a

9.69% 9.59% 9.38% 9.28%

Asthma Controller (Rx) 1b

34.83% 34.58% 34.07% 33.82%

Annual Influenza Immunization

24.55% 25.86% 27.93% 29.80%

ED Visit 8.90% 8.80% 8.59% 8.48%

Hospitalization

3.53% 3.42% 3.19% 3.07%

Individual County

Results

BULLOCK

County - Specific Targets: BULLOCK County

Additional Straight Recipients Who Numbers Needed

Recipients Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal(Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 108 8 7.41% 8.11% 9.50% 10.20% 3HBA1C 108 71 65.74% 67.40% 70.73% 72.39% 7Annual Lipid 100 51 51.00% 52.59% 55.78% 57.38% 6Eye Exam 100 31 31.00% 32.65% 35.94% 37.59% 7Urine Protein 100 34 34.00% 34.91% 36.74% 37.66% 4Asthma: Contoller Use, 1a 358 39 10.89% 10.78% 10.55% 10.43% -2Controller Use, 1b 358 116 32.40% 32.17% 31.70% 31.46% -3Annual Flu Shot 358 92 25.70% 27.07% 29.82% 31.19% 20ED Visits 358 18 5.03% 4.97% 4.85% 4.79% -1Hospitilizations 358 35 9.78% 9.46% 8.82% 8.50% -5

Total: 2306 495 21.47% 23.49% 27.53% 29.55% 36

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

CALHOUN

County - Specific Targets: CALHOUN County

Additional Straight Recipients Who Numbers Needed

Recipients Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal(Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 692 58 8.38% 9.17% 10.75% 11.54% 22HBA1C 692 334 48.27% 49.49% 51.93% 53.15% 34Annual Lipid 645 235 36.43% 37.57% 39.85% 40.99% 29Eye Exam 645 177 27.44% 28.90% 31.81% 33.27% 38Urine Protein 645 314 48.68% 49.99% 52.61% 53.92% 34Asthma: Contoller Use, 1a 2200 177 8.05% 7.96% 7.79% 7.71% -7Controller Use, 1b 2200 571 25.95% 25.77% 25.39% 25.20% -17Annual Flu Shot 2200 324 14.73% 15.51% 17.09% 17.88% 69ED Visits 2200 164 7.45% 7.37% 7.19% 7.10% -8Hospitilizations 2200 46 2.09% 2.02% 1.89% 1.82% -6 Total 14319 2400 16.76% 17.18% 18.03% 18.46% 188

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

HOUSTON

County - Specific Targets: HOUSTON County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 498 99 19.88% 21.75% 25.50% 27.37% 37HBA1C 498 315 63.25% 64.85% 68.05% 69.65% 32Annual Lipid 466 210 45.06% 46.47% 49.29% 50.70% 26Eye Exam 466 99 21.24% 22.37% 24.63% 25.76% 21Urine Protein 466 239 51.29% 52.67% 55.42% 56.80% 26Asthma: Contoller Use, 1a 1510 166 10.99% 10.88% 10.64% 10.53% -7Controller Use, 1b 1510 444 29.40% 29.19% 28.76% 28.55% -13Annual Flu Shot 1510 378 25.03% 26.37% 29.05% 30.39% 81ED Visits 1510 137 9.07% 8.97% 8.75% 8.64% -6Hospitilizations 1510 69 4.57% 4.42% 4.12% 3.97% -9

Total 9944 2156 21.68% 22.36% 23.71% 24.39% 188

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

JEFFERSON

County - Specific Targets: JEFFERSON County

Additional Recipients Who Numbers Needed Straight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes: FluShots 2690 436 16.21% 17.74% 20.79% 22.32% 164 HBA1C 2690 1446 53.75% 55.11% 57.83% 59.19% 146 Annual Lipid 2545 1047 41.14% 42.43% 45.00% 46.28% 131 Eye Exam 2545 516 20.28% 21.35% 23.51% 24.58% 110 Urine Protein 2545 1266 49.74% 51.08% 53.76% 55.09% 136 Asthma: Contoller Use, 1a 8739 933 10.68% 10.56% 10.34% 10.22% -39 Controller Use, 1b 8739 2924 33.46% 33.22% 32.73% 32.49% -85 Annual Flu Shot 8739 2617 29.95% 31.55% 34.75% 36.35% 560 ED Visits 8739 904 10.34% 10.22% 9.98% 9.86% -43 Hospitilizations 8739 351 4.02% 3.89% 3.62% 3.49% -46

Total: 56710 12440 21.94% 23.10% 25.43% 26.60% 1034

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

LAMAR

County - Specific Targets: LAMAR County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 113 10 8.85% 9.68% 11.35% 12.18% 10HBA1C 113 56 49.56% 50.81% 53.32% 54.57% 13Annual Lipid 103 46 44.66% 46.06% 48.85% 50.24% 16Eye Exam 103 30 29.13% 30.67% 33.77% 35.31% 20Urine Protein 103 43 41.75% 42.87% 45.11% 46.24% 12Asthma: Contoller Use, 1a 147 7 4.76% 4.71% 4.61% 4.56% -1Controller Use, 1b 147 56 38.10% 37.82% 37.27% 36.99% -27Annual Flu Shot 147 26 17.69% 18.63% 20.52% 21.47% 77ED Visits 147 7 4.76% 4.71% 4.59% 4.54% -1Hospitilizations 147 1 0.68% 0.66% 0.61% 0.59% -2

Total 1270 282 22.20% 22.80% 23.99% 24.59% 117

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

MONTGOMERY

County - Specific Targets: MONTGOMERY County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 1289 145 11.25% 12.31% 14.43% 15.49% 55HBA1C 1289 471 36.54% 37.46% 39.31% 40.23% 48Annual Lipid 1214 406 33.44% 34.49% 36.58% 37.62% 51Eye Exam 1214 284 23.39% 24.64% 27.12% 28.36% 60Urine Protein 1214 613 50.49% 51.85% 54.57% 55.92% 66Asthma: Contoller Use, 1a 3483 276 7.92% 7.84% 7.67% 7.59% -12Controller Use, 1b 3483 1140 32.73% 32.49% 32.02% 31.78% -33Annual Flu Shot 3483 772 22.16% 23.35% 25.72% 26.90% 165ED Visits 3483 222 6.37% 6.30% 6.15% 6.07% -10Hospitilizations 3483 114 3.27% 3.17% 2.95% 2.85% -15

Total 23635 4443 18.80% 19.30% 20.31% 20.82% 375

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

PICKENS

County - Specific Targets: PICKENS County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 193 31 16.06% 17.58% 20.60% 22.11% 12HBA1C 193 140 72.54% 74.37% 78.04% 79.87% 14Annual Lipid 172 119 69.19% 71.35% 75.67% 77.83% 15Eye Exam 172 74 43.02% 45.31% 49.88% 52.16% 16Urine Protein 172 58 33.72% 34.63% 36.44% 37.35% 6Asthma: Contoller Use, 1a 263 32 12.17% 12.04% 11.78% 11.65% -1Controller Use, 1b 263 99 37.64% 37.37% 36.82% 36.55% -3Annual Flu Shot 263 51 19.39% 20.43% 22.50% 23.54% 11ED Visits 263 37 14.07% 13.90% 13.57% 13.40% -2Hospitilizations 263 8 3.04% 2.94% 2.74% 2.65% -1

Total 2217 649 29.27% 30.06% 31.63% 32.42% 67

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

PIKE

County - Specific Targets: PIKE County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 255 26 10.20% 11.16% 13.08% 14.04% 10HBA1C 255 131 51.37% 52.67% 55.27% 56.57% 13Annual Lipid 240 128 53.33% 55.00% 58.33% 60.00% 16Eye Exam 240 95 39.58% 41.69% 45.89% 47.99% 20Urine Protein 240 112 46.67% 47.92% 50.43% 51.68% 12Asthma: Contoller Use, 1a 1216 28 2.30% 2.28% 2.23% 2.21% -1Controller Use, 1b 1216 942 77.47% 76.91% 75.78% 75.22% -27Annual Flu Shot 1216 362 29.77% 31.36% 34.54% 36.14% 77ED Visits 1216 26 2.14% 2.11% 2.06% 2.04% -1Hospitilizations 1216 15 1.23% 1.19% 1.11% 1.07% -2

Total 7310 1865 25.51% 26.20% 27.57% 28.26% 117

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

TALLADEGA

County - Specific Targets: TALLADEGA County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 661 58 8.77% 9.60% 11.25% 12.08% 22HBA1C 661 424 64.15% 65.77% 69.01% 70.63% 43Annual Lipid 626 259 41.37% 42.67% 45.25% 46.55% 32Eye Exam 626 196 31.31% 32.97% 36.30% 37.96% 42Urine Protein 626 357 57.03% 58.56% 61.63% 63.16% 38Asthma: Contoller Use, 1a 1544 193 12.50% 12.37% 12.10% 11.97% -8Controller Use, 1b 1544 531 34.39% 34.14% 33.64% 33.39% -15Annual Flu Shot 1544 221 14.31% 15.08% 16.61% 17.37% 47ED Visits 1544 171 11.08% 10.94% 10.68% 10.55% -8Hospitilizations 1544 56 3.63% 3.51% 3.27% 3.16% -7

Total 10920 2466 22.58% 23.19% 24.40% 25.01% 186

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

TUSCALOOSA

County - Specific Targets: TUSCALOOSA County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 785 121 15.41% 16.87% 19.77% 21.22% 46HBA1C 785 485 61.78% 63.35% 66.47% 68.03% 49Annual Lipid 721 381 52.84% 54.49% 57.80% 59.45% 48Eye Exam 721 190 26.35% 27.75% 30.55% 31.95% 40Urine Protein 721 356 49.38% 50.70% 53.36% 54.68% 38Asthma: Contoller Use, 1a 1888 222 11.76% 11.63% 11.39% 11.26% -9Controller Use, 1b 1888 604 31.99% 31.76% 31.30% 31.06% -18Annual Flu Shot 1888 452 23.94% 25.22% 27.78% 29.06% 97ED Visits 1888 221 11.71% 11.57% 11.29% 11.15% -10Hospitilizations 1888 63 3.34% 3.23% 3.01% 2.90% -8

Total 13173 3095 23.50% 24.13% 25.39% 26.02% 273

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

WINSTON

County - Specific Targets: WINSTON County

Additional Recipients Who Numbers NeededStraight Meet the Criterion Percent Actual 4-Month Goal 8-Month Goal 12-Month Goal to Meet Goal

Recipients (Baseline) (Baseline) (Percent) { 1.} (Percent) { 1.} (Percent) { 1.} {2}

Diabetes:FluShots 194 28 14.43% 15.79% 18.51% 19.87% 11HBA1C 194 106 54.64% 56.02% 58.78% 60.16% 11Annual Lipid 179 79 44.13% 45.51% 48.27% 49.65% 10Eye Exam 179 44 24.58% 25.89% 28.50% 29.80% 9Urine Protein 179 104 58.10% 59.66% 62.78% 64.35% 11Asthma: Contoller Use, 1a 351 30 8.55% 8.46% 8.28% 8.19% -1Controller Use, 1b 351 130 37.04% 36.77% 36.23% 35.96% -4Annual Flu Shot 351 32 9.12% 9.60% 10.58% 11.07% 7ED Visits 351 24 6.84% 6.76% 6.60% 6.51% -1Hospitilizations 351 9 2.56% 2.48% 2.31% 2.23% -1

Total 2680 586 21.87% 22.45% 23.63% 24.22% 52

{1} Multiplicative factor applied to Entire Pilot Area "Percent Actual" figures to achieve absolute overall growth of (roughly) five percentage points.Individual Pilot County growth targets are rendered summative to Area growth target for overall Pilot Area.{2} Incremental change in target criterion recipients at individual county-level, overall Pilot Area-level.

Clinical Rules

CLINICAL RULES

Initial focus on TFQ performance measures Asthma Diabetes

Alerts and Flags – Actionable Additional “flags” for some labs and

depression screening Immunizations – IMMPrint

Next Steps

Inch by Inch, Step by StepUser Acceptance Testing of Q toolContinued Pilot Provider RecruitmentFollow-up and Monitoring

Measure progress providers, care managers, county

Feedback, Review and Modifications Chronic Care Management Process Issue Identification and Resolution

Finalization of External Evaluation Process