Members were 66 years of age or older as of December 31 of the measurement year. Reporting not required - small denominator Met Met Met Met Met Geographic Area Includes only Medicaid enrollees served in the SCO’s reporting area. Reporting not required - small denominator Met Met Met Met Met NUMERATORS Administrative Data: Counting Clinical Events Standard codes listed in state specifications or properly mapped internally developed codes were used. Reporting not required - small denominator Met Met Met Met Met Data sources used to calculate the numerators (e.g., claims files, medical records, provider files, and pharmacy records, including those for members who received the services outside the plan’s network, as well as any supplemental data sources) were complete and accurate. Reporting not required - small denominator Met Met Met Met Met Members had evidence of advanced care planning as documented through either administrative data or medical record review. Reporting not required - denominator Met Met Met Met Met Data Quality Based on the IS assessment findings, the data sources used were accurate. Reporting not required - small denominator Met Met Met Met Met Appropriate and complete measurement plans and programming specifications exist that include data sources, programming logic, and computer source code. Reporting not required - small denominator Met Met Met Met Met Proper Exclusion Methodology in Administrative Data (if no exclusions were mark as N/A) There are no exclusions for this measure. Reporting not required - small denominator Met Met Met Met Met Medical Record Review Documentation Standards
If the discharge is followed by readmission or direct transfer to an acute or non-acute facility within the 30 day follow up period, only the readmission or transfer discharge is counted. Exclude if the readmission/direct transfer discharge occurs after December 1 of the measurement year or if the member remains in the facility through December 1 of the measurement year. Met Met Met Met Met Met Medical Record Review Documentation Standards Record abstraction tool requires notation of the date of medication reconciliation. Met Met Met Met Met Met Data Quality The eligible population was properly identified. Met Met Met Met Met Met on the IS assessment findings, data sources used for this numerator were accurate. Met Met Met Met Met Met Hybrid Measure If hybrid measure was used, the integration of administrative and medical record data was adequate. Met Met Met Met Met Met If hybrid method or solely MRR was used, the results of the MRR validation substantiated the reported numerator. Met Met Met Met Met Met SAMPLING Unbiased Sample As specified in the state specifications, systematic sampling method was utilized. Met Met Met Met Met Met Sample Size exclusions, the sample size was equal to 1) 411, 2) the appropriately reduced sample size, which used the current year’s administrative rate or preceding year’s reported rate, or 3) the total population. Met Met Met Met Met Met Sample treated all measures independently. Met Met Met Met Met Met Proper Substitution Methodology in Medical Record Review (if no exclusions were taken, mark as N/A) Excluded only members for whom MRR revealed 1) contraindications that correspond to the listed in appropriate specifications as defined by state, or 2) data errors. Met Met Met Met Met Met Substitutions were made for properly excluded records and the percentage of substituted records was documented. Met Met Met Met Met Met
through an encounter data system or other methods. The system must be able to ensure that data received from providers are accurate and complete and verify the accuracy and timeliness of reported data; screen the data for completeness, logic, and consistency; and collect service information in standardized formats to the extent feasible and appropriate. The findings of this assessment follow. Exhibit 9: Information Systems Capability Assessment Findings BMCHP CCA Fallon SWH Tufts UHC Adequate documentation; data integration, data control and performance measure development Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Claims systems and process adequacy; no non-standard used for claims Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable All primary and secondary coding schemes captured Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Appropriate membership and enrollment file processing Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Appropriate appeals data systems and accurate classification of appeal types and appeal reasons Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Adequate call center systems and processes Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Required measures received a “Reportable” designation Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable & KEPRO did not identify any significant issues resulting from PMV. In fact, no issues at all were identified for two of the six plans. The few recommendations made related to source code, medical record review, and supplemental data. (BMCHP)
Based on its review of the MassHealth Senior Care Organization performance improvement projects, KEPRO did not discern any issues related to any plan’s quality of care or the timeliness of or access to care. MassHealth Senior Care Organizations used a wide variety of approaches to reduce the 30-day readmission rate. These interventions are described in more detail in this report’s section on Performance Improvement Project Validation, as are plan strengths and opportunities to improve quality, timeliness, and access to health care. A summary of 2016 plan interventions follows. Care Management BMCHP established a Transition of Care Program in which a Care Manager was focused specifically on ensuring that members experience a seamless transition through the continuum of care including the emergency department, acute inpatient, post-acute rehabilitation hospitals, skilled nursing facilities, nursing homes, and home. The Care Manager for Transitions of Care conducted admission assessments; collaborated with Geriatric Support Services Coordinators; conducted pre-discharge and inpatient risk assessments; collaborated with the member’s primary care provider, inpatient utilization management staff, and the discharge case manager; and conducted face-to-face visits at the member’s home or facility to complete the post-discharge assessment. The Care Manager for Transitions of Care was a member of the Primary Care Team. (Boston Medical Center HealthNet) To proactively prevent ED admissions, care managers huddled on a weekly basis to review patients transitioning from one of care to another. Clinical Managers also performed weekly audits to ensure that Transition of Care Assessments and Care Plans were completed within two days of plan notification of discharge. (Fallon Health) Members identified as high-utilizers were contacted by a nurse care manager for follow-up and education. A monthly report contained detailed information about the reason for the member’s ER visit. The Nurse Case Manager (NCM) was responsible for contacting the
Results of Validation Ratings for Y/N Values Number of Items Total Available Points Points Scored Rating Averages General Information 1 1 1 100% Reassessing Intervention Parameters & Strategies 3 3 3 100% Performance Indicator Data Collection 3 3 3 100% Validation Rating Score for Y/N Values 7 7 7 100% Summary Results of Validation Ratings for 3, 2, or 1 Values Number of Items Total Available Points Points Scored Rating Averages Reassessing PIP Goals & Barriers 4 12 12 100% Reassessing Intervention Parameters & Strategies 4 12 12 100% Performance Indicator Parameters 1 3 3 100% Performance Indicator Data Analysis 4 12 12 100% Performance Indicator Results 1 3 3 100% Member Population Analysis 2 6 6 100% Conclusions & Future PIP Improvements 4 12 11 92% Validation Rating Score for 3, 2, or 1 Values 20 60 59 98% Overall Validation Rating 27 67 66 98% Update on Calendar Year 2016 Recommendations is required by CMS to determine the status of recommendations made in the previous reporting year. An update on recommendations made in 2016 to Senior Whole Health follows.
Reassessing Intervention Parameters & Strategies 4 12 9.7 81% Performance Indicator Parameters 1 3 3 100% Performance Indicator Data Analysis 4 12 12 100% Performance Indicator Results 1 3 3 100% Member Population Analysis 2 6 3 50% Conclusions & Future PIP Improvements 3 9 7 78% Validation Rating Score for 3, 2, or 1 Values 19 57 48.7 85% Overall Validation Rating Score 26 64 55.7 87% Update on 2016 Recommendations KEPRO is required by CMS to determine the status of recommendations made in the previous reporting year. An update on recommendations made in 2016 to UnitedHealthcare follows. Calendar Year 2016 Recommendation 2017 Update Care managers telephone members at the first and second levels of risk within seven days of discharge. There may be a subpopulation that needs more intensive outreach because of literacy needs or language barriers. KEPRO recommends a review of data to determine any possible opportunities that might exist. UHC reports, “Due to the nature of SCO members having a number of health, literacy, language, co-morbidity, frailty or socioeconomic factors, it is difficult to assess which interventions yielded the highest effectiveness.” UHC did not provide related data. UHC is to use its data to drill-down on the population factors (demographic, clinical, REL, hospital utilization) to identify key barriers and their component parts. With these assessments, UHC quality committees will have better information about how to prioritize interventions that will have maximum impact on the key barriers driving readmission rates. UHC reports, “A Plan Performance Improvement Project on Health Disparities showed no difference in readmission by language or geographic location across a Massachusetts county adjacent to Boston.” Plan & Project Strengths UHC is commended for including members and pharmacists in the review of its barriers.