Information for Health Care Improvement
Florida Agency for Health Care Administration (AHCA)
HMO/PSN
Well-Child Visits in the First 15 Months of Life—Six or More Visits
Statewide Collaborative Performance Improvement Project
Designing Quality Initiatives Worksheet Results
Identification /What tools do you use to identify children in need of preventive services? / We query age groups and then bump it up against Internal claims/encounter data. The no hits go on a list for outreach. Additionally, our corporate office sends a letter to the provider requesting that they do a medical record check and fill in encounters if they find one.
In mid-year, we run claim data against the potential denominator member based on HEDIS guideline.
Given the relatively small size of the plan member population (N=1479), the entire population (n=90) of individuals 0-15 months of age are targeted.
Utilize both claims data and chart audits to gain understanding of our member population and their rate of compliance with recommended well-child visits during the first 15 months of life. Our intervention is more proactive than retrospective. We target all members in the age range and intervene before the well-child visit is due.
Use the following tools to identify children who have not received preventative services: Claims data; Florida Shots registry; Health Risk Assessment; lab data.
Discrepancy report sent to PCPs monthly identifies members with eight months of eligibility who are due for identified services and there is no claim.
Quarterly non-compliant member reports based on claims/encounters
Annual random chart audits (HEDIS, child health check-up audit)
Claims run quarterly
834 File; Claims Data; -Immunization Registry; -Medical Record Review; -Individual HRA performed with welcome calls
We currently use Medical Record Review, Case Management, and Claims/encounter data to identify children in need of the preventative services.
Children in need of preventive services can be found through many sources. The individual identification occurs in Case and Disease Management, through Member Service Department, Grievance/Appeal unit, and other contact points. Population reports are pulled monthly between February and December to determine children in need of services, as it relates to the HEDIS measure for WC15 and other HEDIS measures. CHCUP (EPSDT) reports are also pulled routinely, which impacts all children who may need preventive services. Additionally, a report is pulled quarterly from claims/enrollment files of children who have not had any claims, who are presumed to be in need of well visits and/or other preventive services.
Health Analytics reviews laboratory data during the 3rd week of each month and reports any blood lead screen results 5 or greater to the Director of Care Integration or designee. This information is used to enter the member into Case Management for follow-up.
Pull a list of children per PCP, quarterly, who have not had a CHCUP completed within the last 13 months.
We run a mid-year HEDIS report using the licensing software on potential denominator members.
Stratification /
Once you have identified children in need of preventive services how do you prioritize your outreach to those children’s caregivers?
Examples of data sources may include:
— Claims
— Immunization Registry
— Chart audits
— Lab data / We have an outreach cycle that all state approved health promotion activities are scheduled on in rotation based upon staffing levels, We adjust the rotation cycle based upon the organizations projects and the impact to the health plan. HEDIS; PIPs, PMAPs; vs. routine outreach.
Once the plan has identified children in need of preventive services, we determine which services members have already received and what they currently need through claims data first; then the hospital’s EMR for lab tests; and last immunization registry.
We produce a monthly well-child report that lists all children who are due for a well-child check-up in the upcoming month and then lists separately all of those children who are overdue for a visit. This report is based on claims data in the ERV file. We send this report monthly to PCP’s (listing their pediatric members) and also to our Out Reach Coordinators who use this list to place outbound calls to parents. We also use claims data to identify which children are overdue for a well-child visit when we generate the quarterly reminder letters to parents. We also generate a quarterly dental report that lists all pediatric members who have not had an annual dental visit per claims data.
Newborns
Discrepancy Report to PCPs
Time sensitivity i.e. Summer Blitz mailing is sent in the spring, Birthday cards are sent timely, Case Management letters at 45 and 180 days of enrollment, episode of care review for preventive Service/care.
The Plan partners with providers by sharing member non compliant lists for their review and outreach to members as appropriate. Prioritization of outreach is based on the provider’s clinical judgment and assessment of the child’s prevention needs.
Sending providers a list of the members that need their CHCU
Provider record review (have the QI Analyst go out to doctor offices to review charts)
Quarterly mailing list updates from claims run
Case managed children
Frequent users of ER without established relationship with PCP
Categorized by provider and type of service – 1) claims; 2) immunization registry; 3) lab data; 4) chart audits
Prioritization is given based on the latency period of the preventative service and the lack thereof.
Data Sources may include but are not limited to:
· Claims
· Chart Audits
· Immunization Registry- Florida Shots
We target the 0-15 month group of children first using claims data that produces reports the PCPs use to reach out to the members.
Outreach to children is prioritized by several different means. This minimally includes the number of family members also needing outreach, the number of measures/preventive care needed by the member, and the timing of the preventive care needed (how close to due date of service needed). Claims and encounters are the primary source of the data used. Key PCPs are given lists of members eligible for services with contact information so the provider can outreach directly to the member, or if the member is seen, knows what services need to occur.
Send a list quarterly to all PCPs of children assigned, who have not had a CHCUP completed within the last 13 months so they can attempt to get an appointment scheduled.
Once the plan has identified children in need of preventative services, we determine which services members have already received and what they currently need through claims data first; then the hospital’s EMR for lab tests; and last immunization registry.
Outreach /
How does your plan outreach the child’s family?
For example:
— Regular calls to members
— School or community presence / Live telephone calls; Automated telephone calls; Mailings; Incentives
Our health plan takes a proactive approach by sending monthly birthday reminder to parent/guardian and a list of members who are due for check up based on birthday to their assigned providers. Also, we sent out monthly list to provider who is newly assigned to their practice.
In addition, our health plan will conduct outbound call to parent/guardian to remind them to schedule the check up after the mid-year report of the non-compliant members. The nurse coordinators at the CMS local office also remind the members’ care giver on preventive service.
We send letters to remind providers of the correct CPT code for well visit. We send out flyers to remind about lead screening.
Send postcard reminders to member families every three months during the first 15 months of life. The member is also sent a birthday card at their 1st birthday containing a well-child visit reminder and information. In addition, calls are also placed the month before the child’s birthday to remind parents to schedule a well-child visit. This process addresses communicative and organizational barriers relevant to parents’ needs to handle the various medical and other responsibilities associated with caring for very young children with special health care needs.
We have hired two Out Reach Coordinators to place out bound calls to all parents of children who have not received preventive care. We place calls to children who have not received a well-child check-up visit or annual dental visit. We educate them about transportation available and AHCA’s Enhanced Benefit Program. We let them know that they will be rewarded with a $25.00 healthy behavior credit if they take their child for a well-child check-up or dental visit. We also send out quarterly reminder letters with a colorful coupon advising them about the $25.00 healthy behavior credit from AHCA. We also inform them about the plans dental bus and school schedule. The biggest barrier we have identified is incorrect/disconnected phone numbers and incorrect addresses.
First health assessment educational letter in new member packets
Welcome calls to members with valid phone numbers
Resending undeliverable mail when updated address is received
Targeted mailings
Birthday cards
Satisfaction Surveys
Dedicated sections in Member Newsletters
Website
AHCA’s ‘CHCUP – A Formula for Success’ in mailings from Case Management
Case Management contact during episodes of care
New member welcome calls to all members
Birthday Wellness calls to all members/caregivers (follow up 6 months after the child’s birthday wellness call if the child remains non compliant with wellness visit)
Member educational newsletter to all member households (3 newsletters per year)
Quarterly, age appropriate Well Child mailers to all children 0-15 months of age
Sending reminder letters on a monthly basis to members
Schedule CHCU Screening Events quarterly
Incentives to PCPs and members
“Congratulations! Happy first birthday to your baby!” educational birthday card
Annual Birthday card reminder in month of child’s birth
Health Fairs
Possible Connections Representative Home Visit if child not seen by an PCP
Information on Web site
Regular calls to the members and follow-up calls assuring preventive appointments were kept.
Educate members through Enrollee Manual and the Member Newsletter.
Reinforce with Customer Service representatives who are conducting member outreach calls to all new members within 30 days of joining the emphasize to follow-up with PCP to ensure they are getting the care needed for their children.
Our health plan takes a proactive approach by sending monthly birthday reminder to parent/guardian and a list of members who are due for check up based on birthday to their assigned providers. Also, we sent out monthly list to provider who is newly assigned to their practice.
In addition, our health plan will conduct outbound calls or letters to parent/guardian to remind them to schedule the check up once the mid-year report of non-compliant members generated.
We send letter to remind providers the correct CPT code for well visit. We send out flyer to remind about lead screening. Also, we send out quarterly Provider Newsletter informing providers on new guideline or changes.
Mothers who deliver on the plan are sent letters instructing them to get the newborns into the PCP for a check-up.
Mailing reminders to the family
Routine outreach is completed to all members in the form of welcome calls and birthday wellness calls. This activity intends to support our providers’ efforts and encouragement for annual wellness exams.
Provider panel reports (provided to PCPs with children who require preventive health visits
Send a list quarterly to all PCPs of children assigned, who have not had a CHCUP completed within the last 13 months so they can attempt to get an appointment scheduled.
A total of 17 plans responded.
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