Evercare Select monitors the quality of care provided to our members by our contracted providers. QM monitoring and evaluation activities are a continuous ongoing process. Whenever possible, Evercare Select will align QM activities with those of AHCCCS, CMS ADHS, and other Program Contractors. This is done to focus our providers’ quality improvement activities on areas of state and nationwide importance and to reduce duplication of service.
There are several steps used by Evercare Select in the QM Provider profiling process. They are as follows:
Step One: Data Collection for Provider QM Profiling
There are four methods used to evaluate contracted providers.
• provision of care monitoring (i.e. mortality reviews, site reviews, acute care review, member satisfaction surveys, and grievances/concerns trending).
• regulatory agency findings, when applicable • disease management compliance rates, when
applicable
• member trust fund monitoring, when applicable • medical records monitoring, when applicable
Provisions of Care Monitoring
Documentation reviews and/or onsite visits are coordinated to assure member issues are dealt with in a time appropriate manner based upon the nature of the issue and the geographical location of the provider. For some provision of care reviews there are selection criterion. Not every case triggered for review by the selection criteria will prove to be a problem. These reviews also give Evercare Select
9 Quality ManagementProcess for QM Provider Profiling
UnitedHealthcare Community Plan monitors the quality of care provided to our members by our contracted providers. QM monitoring and evaluation activities are a continuous ongoing process.
Whenever possible, UnitedHealthcare Community Plan will align QM activities with those of AHCCCS, CMS, ADHS, and other program contractors. This is done to focus our providers’ quality improvement activities on areas of state and nationwide
importance and to reduce duplication of service. There are several steps used by UnitedHealthcare Community Plan in the QM provider profiling process. They are as follows:
Step One: Data Collection for Provider QM Profiling
There are four methods used to evaluate contracted providers:
• Provision of care monitoring (e.g. mortality reviews, site reviews, acute care review, member satisfaction surveys, and grievances/ concerns trending).
• Regulatory agency findings, when applicable. • Disease management compliance rates,
when applicable.
• Member trust fund monitoring, when applicable. • Medical records monitoring, when applicable.
Provisions of Care Monitoring:
Documentation reviews and/or onsite visits are coordinated to assure member issues are dealt with in a time-appropriate manner based upon the nature of the issue and the geographical location of the provider. For some provision of care reviews there are selection criterion. Not every case triggered for review by the selected criteria will prove to be a problem. These reviews also give UnitedHealthcare Community Plan an opportunity to identify areas of good performance.
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Each provision of care review has a data collection tool to evaluate key indicators of the care. Each key indicator of care has points attached. The points are totaled and a final score is given, the best possible score being 100 points.
Upon completion of onsite investigations, identified problems are shared with the facility director/ manager. UnitedHealthcare Community Plan will attempt to resolve problems through education and technical support whenever possible.
• Mortalities
Mortalities review selection criteria includes: relative expectation of death and discretion of the Medical Director. Reviews for facilities and attending physicians are conducted by licensed professionals and results reviewed with the medical director.
• Acute Care Site Reviews
This review is specific to home health agencies and is done by the UnitedHealthcare Community Plan QM Specialist every three years. Please refer to the Home Health Monitoring Section of this document and the QM Manual.
• QM Site Monitoring Service
Sites are monitored at least annually to collect data indicative of quality and/or delivery of service. Depending upon the provider type and nature of the review, the reviews can be conducted by UnitedHealthcare Community Plan QM Specialists, other UnitedHealthcare Community Plan staff as appropriate or
delegated to an external agency (e.g. Foundation for Senior Living).
If significant problems are identified, or a provider and/or service site scores 85 percent or lower on an audit an Improvement Action Plan (IAP)) will be requested of the service provider. The action plan should address the following:
• Specify the type of problem(s) that require action.
• Person(s) or body (e.g., committee) responsible for making the final determination regarding quality issues. • Type(s) of member/provider actions to be taken (e.g., education, monitoring, process changes, etc).
• How the effectiveness of the plan will be evaluated.
• Method(s) of communication of findings and resulting changes to staff and providers.
• Method(s) of communication of pertinent information to AHCCCS and/or other agencies.
The effectiveness of the improvement actions taken by providers is determined during subsequent monitoring visits by the QM and/ or CM staff. Intensive monitoring reviews can occur weekly, monthly or quarterly depending on the pattern and scope of the deficiencies noted during an onsite review.
It is the goal of the QM staff to provide education and support to providers to develop changes in their policies, procedures and internal monitoring to effect lasting improvement in areas found to be deficient. If a pattern of deficiency is noted that impacts several members, a decision can be made within the health plan to limit future admissions or referrals to the provider until corrective action has been completed and the provider has demonstrated that identified issues have all been resolved.
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• Member Satisfaction
Periodically a survey may be mailed by Member Services to the members/family. Member satisfaction with the care being provided by our network providers affords feedback. From this feedback, areas for improvement can be determined. Should the survey be provider- specific, the results of the surveys will be shared with the provider for inclusion in their QM efforts.
• Complaints and Concerns (QOC)
Concern reports are received as problems are identified. All concern reports are investigated. Clinical quality of care issues will be investigated by licensed personnel. Aggregating concerns and complaints help to identify problems within the provider network. A quarterly summary by provider is run for all complaints. This aggregated complaint data is reviewed for trends by the QM Specialist and QM Committee. If a trend is noted, the QM Committee will determine what further actions are needed to address the trend.
Regulatory Agency Findings
• ADHS Annual Survey and ADHS Deficiency Reports
The annual ADHS survey and deficiency report results are compared to issues identified by our provision of care monitoring.
• Medicare Compare
CMS’ website www.cms.gov posts quarterly reports showing the CMS Nursing Home Quality Initiatives. Selected quality measure rates will be ranked by provider. Reports are run by the facility along with the contracted providers’ state and federal survey results to use in identification of trends.
Disease Management Compliance Rates
• Provider Specific
The annual objective/goal for measures, established by AHCCCS, will be used as the benchmark. Those providers falling below the goal may require intervention by the medical director, EPSDT coordinator or QM Nurse as indicated.
Flu Vaccine Compliance Rate:
• Nursing Facility...75% • HCBS...50% Diabetic Care Compliance Rate:
• Annual HgA1c...80% • Annual Lipids...72% • Annual Dilated Eye...60% • EPSDT Participation...55%
Medical Records Monitoring
Primary Care Providers and Obstetricians/ Gynecologist will have a medical record audit at least every three years in conjunction with the re-credentialing process. Specialists with 50 or more referrals per contract year will also have a medical record audit at least every three years.