Quality Improvement & Utilization Management Program Evaluation

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2012

Quality Improvement & Utilization

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1. Introduction

1.1. Executive Summary

The goal of the San Francisco Health Plan (SFHP) Quality Improvement Program is to assure high-quality care and services for our members by aggressively seeking opportunities to improve the performance of our health care delivery system. This report is a summary of 2012 activities to monitor and improve both the health status and experience of our members. It highlights our successes, examines lessons learned, and outlines next steps.

The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP’s health care delivery system. It reviews and approves SFHP policies and procedures, clinical guidelines and studies, and the activities of all entities delegated for utilization management services. During 2012, the QIC met bimonthly. SFHP maintains minutes of each QIC meeting and submits them to the California Department of Health Care Services (DHCS) on a quarterly basis. SFHP also relies on its Pharmacy and Therapeutics Committee and Physician Advisory/Peer Review/Credentialing Committee to oversee its QI and UM programs.

Improving Member Health - SFHP manages several interventions to encourage members to

seek recommended care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). We continue to look for ways to make interventions more effective and find new opportunities for improvement. We offer preventive health programs for infants and toddlers, children, adolescents, and women. Our chronic disease programs focus on improving the care of members, including diabetes and asthma. A 24-hour Nurse Help Line ensures access to timely clinical advice for our members. These efforts have been successful, as measured by HEDIS results on key preventive care measures. In 2011, 16 out of 19 publicly reported Medi-Cal

measures were above the 90th percentile benchmark of Medicaid plans nationwide.

Health Education and Cultural and Linguistic Services - These principles are actively integrated

into quality improvement activities. In making decisions about quality improvement interventions, we examine the demographic characteristics of our member population to ensure delivery of culturally appropriate materials. We believe that health education is better for the member when provided by his or her primary care provider or the provider care team. For this reason, our Health Education Compensation Program reimburses health education provided to members in one-on-one and group settings. SFHP also maintains a library of health education materials in a wide range of topic areas. We make the materials available in both paper and online formats. Upon request, we also make materials available in alternative formats including large print, audio, or Braille. Our website includes an easy-to-navigate repository of educational materials that providers, members, and visitors can access and print. We continuously improve the website by uploading newly developed and revised materials.

Improving Health Systems - To support improved quality, SFHP continually explores new ways

to collaborate with its providers to move from a visit-based model to a population health-based model. In 2012, two pay-for-performance programs incentivized providers to improve their systems and services, Strength in Numbers and the Practice Improvement Program (PIP). Where

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the Strength in Numbers program focuses on the population health efforts of front‐line staff in safety net clinics, and is a joint program of SFHP and Healthy San Francisco (our health access program for the uninsured), PIP focuses on the whole primary care network, targeting clinical quality, data quality, patient experience and key system improvements needed for high

performance. Beyond incentive programs, SFHP also supports San Francisco safety net clinics in patient-centered medical home improvement efforts in preparation for healthcare reform. Two specific programs include Coleman’s Rapid Dramatic Process Improvement and the San Francisco Quality Culture Series.

Ensuring Member Satisfaction - One of SFHP’s top four organizational goals is to offer

“exemplary service” to our members and providers. Each year, SFHP monitors member satisfaction through member experience surveys (CG-CAHPS). Based on survey results, SFHP implements programs aimed at improving satisfaction. For 2012, this included three action series on improving patient access, customer service, and patient-provider communication. SFHP’s Customer Service Department helps members understand and take full advantage of their health plan benefits. Additionally, SFHP monitors grievances on a quarterly basis to identify trends and problems, as well as to gauge timeliness and regulatory compliance. Our goal is to provide excellent service and, at a minimum, meet the California Department of Managed Health Care (DMHC) standards for responding to and resolving grievances.

Provider Relations - SFHP closely monitors the adequacy of its provider network to ensure that

members have access to the care they need in a timely manner. We measure network access in a variety of ways, including language capacity and availability of specialists. SFHP participated in the Industry Collaboration Effort (ICE) Timely Access Workgroup to develop a standard

methodology and survey tool for monitoring appointment availability. Clinical quality

monitoring is also critical to SFHP’s success. We have a Memorandum of Understanding (MOU) with Anthem Blue Cross of California to review all jointly contracted primary care providers and sites, in order to ensure compliance with criteria from the California Department of Health Care Services (DHCS). In addition, SFHP delegates and oversees the facility site reviews, medical record reviews, and interim monitoring activities with its medical groups. Lastly, SFHP measured provider satisfaction in 2012, indicating that 78% of providers report high satisfaction with SFHP.

Care Management Services - SFHP’s Utilization Management Program uses a set of policies to

ensure that effective and appropriate health care services are delivered to members. SFHP complies with strict standards for issuing denials and responding to appeals to assure member rights are protected. SFHP assures the quality of its pharmacy services by offering a generous formulary, maintaining good relationships with pharmacy providers, and overseeing the pharmacy credentialing process. Our pharmacy services and formulary are reviewed and updated by our Pharmacy and Therapeutics Committee. We monitor pharmacy usage monthly through cost and utilization reports.

At San Francisco Health Plan, we take pride in the many ways we partner with our members and our provider network to improve quality and access to care. We follow the Model for

Improvement; since it is not always clear what is the best way to achieve a goal, we frequently pilot interventions, measure the outcomes, and then revise our approach accordingly.

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1.2. Quality Leadership

The SFHP Quality Improvement Committee (QIC) is the main forum for oversight of SFHP’s Quality Improvement and Utilization Management programs. QIC meets six times a year and contains physician and administrative representatives from our broad network. The QIC reviews and approves SFHP Medical Management Department’s policies and procedures (Health Improvement, Utilization Management, Health Education and Cultural and Linguistic Services, Care Support, and Pharmacy), Provider Relations policies, clinical guidelines, the Health Improvement and Utilization Management Programs, and the activities of all entities delegated for utilization management services.

All SFHP policies and procedures are reviewed biannually; however, clinical guidelines require an annual, or more frequent, review if necessary. SFHP maintains minutes of each QIC meeting and submits them to DHCS on a quarterly basis. In addition, SFHP relies on its Pharmacy and Therapeutics Committee (P&T) for formulary and pharmacy criteria review, and the Physician Advisory Committee (PAC) for peer review, review of quality incidents, and credentialing. Both committees report up to the QIC.

QIC Membership

Governing Board representative o Dale Butler

Member Advisory Committee representatives o Irene Conway

o Edward Evans Provider Network

o Daniel Chan, MD – North East Medical Services o Hali Hammer, MD – Family Health Center o Claire Horton, MD – General Medical Center o Shawna Lamb – Hill Physicians Medical Group

o Dexter Louie, MD – Chinese Community Health Care Association o Todd May, MD – San Francisco General Hospital

o Carol Miller, MD – UCSF Medical Center

o Jaime Ruiz, MD – Mission Neighborhood Health Center and SF Community Clinic Consortium

o Kenneth Tai, MD – North East Medical Services o Ning Tang, MD – UCSF Medical Center

o Albert Yu, MD – Chinatown Public Health Center and DPH Community Oriented Primary Care

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2. Improving Member Health

Our goal is to be among the top ten percent of Medicaid health plans nationwide for getting the right care at the right time, as determined by the HEDIS measures required by the State of California for Medi-Cal plans. SFHP has multiple programs to encourage members to seek care, and every year we continue to look for ways to make our interventions more effective. For example, we have member outreach and incentive programs, and we support population health at the provider practices through two pay-for-performance programs, to encourage provider adherence to quality care measures.

In addition, we are highly committed to improving the health of members with chronic conditions. To that end, SFHP started work in 2012 to enhance its offerings of chronic disease self-management resources to members. We recently updated our low-literacy, multilingual health education fact sheets and web resources on the SFHP website, and launched two new programs: a diabetes health text messaging program called DMTxt, and an evidence-based peer education program called Healthier Living. These and other programs are described at length below.

2.1. Preventive Care for Infants and Toddlers

Members receive a $50 gift card for completing all immunizations by age two. An offer is mailed to families with children turning 13 and 17 months of age. In 2012, 14% (630) of members who were offered the incentive successfully participated in the program. To support members with achieving the incentive, families with children turning five and eight months of age receive an Immunization Reminder Card with educational information about vaccinations. Reminder cards include needed immunizations to receive the incentive. SFHP mailed 4,022 reminder cards in 2012.

Additionally, families receive four recorded telephone calls when their child turns 12, 13, 17, and 22 months of age, reminding them of upcoming well-visits and immunizations. Families with children under the age of two who are assigned either to the Department of Public Health clinics or to clinics using the California Immunization Registry receive reminder calls for well child checks and immunizations.

2.2. Annual Check-ups for Children and Adolescents

Families with a child between the ages of three and six years old receive a birthday card from SFHP, offering them a $25 gift card for bringing their child to an annual check-up. Along with the birthday card, families also receive a recorded telephone message

encouraging them to take their child to their provider and take advantage of the well-child incentive. The messages were recorded in English, Spanish, Chinese and Vietnamese. Also, SFHP is in partnership with North East Medical Services (NEMS) to help promote this

incentive. In 2012, 2,348 (27%) members who were offered the incentive participated in the program.

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8 In 2012, SFHP began a new raffle for members ages 0-19 who receive a well visit in the measurement year or the year prior for members age 7-19. Brochures explaining the raffle and encouraging them to see their provider for a well visit were sent to members age 0-7 who have not received a well visit in 2012 and members ages 7-19 who have not received a well visit in 2011 or 2012. Raffle winners receive an Apple iPad.

2.3. Preventive Health for Women

Well-Woman Preventive Health Mailing

Upon enrollment and then once per year, female members 27 years and older receive a brochure with preventive health care guidelines for women such as recommended

frequency for mammograms as well as other health education messages. The mailer also includes a promotion for our prenatal and postpartum incentive programs for members who may be pregnant or who have recently given birth.

Your Body, Your Baby Incentive Program

In 2011, SFHP initiated a member incentive program for postpartum care. The Timely

Prenatal Care Incentive Program was incorporated into this new program. Together, the

two perinatal incentive programs became the Your Body, Your Baby program. This program offers a $25 gift card for receiving timely prenatal care and a $25 gift card for receiving timely postpartum care per HEDIS specifications. SFHP makes live calls to members who are identified as having recently given birth or newly enrolled in SFHP due to pregnancy. The member is informed of the program and asked if she would like to participate. If the member decides to participate, she receives health education materials in the appropriate language along with an incentive voucher. In 2012, we sent 365 vouchers and received 84 back; of those members who returned an incentive voucher, 87% completed the visit as required.

Cervical Cancer Screening

In October 2012, all providers who had at least one SFHP member who was due for a Pap test received an outreach list with contact information for these patients. In order to drive utilization of the outreach lists, SFHP offered an incentive to providers of $25 for each member on the list who received a PAP test prior to December 31, 2012 SFHP hired a nurse practitioner contractor to work as a liaison to providers, answering questions about the program and encouraging participation.

In November 2012, SFHP used an automated call service to send prerecorded messages to members due for a Pap test, encouraging them to schedule an appointment for the test. Additionally, SFHP offered $25 gift cards as an incentive for members to receive the Pap test. The gift cards were distributed to clinics participating in the provider incentive program according to the number of patients on their respective outreach lists.

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2.4. Nutrition and Physical Activity

SFHP’s 2011 Health Education Group Needs Assessment (completed every five years) indicated that the top health education needs of SFHP members and providers are in the area of nutrition and physical activity, as well as in chronic disease management. In 2012, we continued our focus on improving health education resources.

To support the SFHP provider network in providing tools for maintaining a healthy weight, SFHP has materials such as cookbooks, educational placemats, and measuring cups and spoons, which are available to providers upon request. These materials are

disseminated to clinic sites and are used for health education and as incentives in targeted campaigns such as a Diabetes Days and Nutrition Classes. Additionally, SFHP supported its provider network in caring for new Seniors and Persons with Disabilities by financing and distributing 35 wheelchair-accessible bariatric scales and 25 wheelchair-accessible exam tables to 34 sites across its network.

Addressing the obesity epidemic is a top priority for SFHP. In spring 2012, SFHP

distributed Weight Assessment Toolkits at 54 provider and clinic sites through mailings and at meetings. The toolkits contained:

BMI wheels

Information about documenting BMI, nutrition and physical activity counseling in the patient’s chart (following HEDIS specifications)

Tips for communicating with patients Sample member educational materials San Francisco Childhood Obesity Taskforce

In 2012, SFHP continued to participate in a citywide coalition of health care providers and managed care organizations focused on childhood obesity. The taskforce aimed to identify low-cost resources for PCPs and families to support healthy eating and physical activity. In March 2012, the coalition hosted a leadership roundtable entitled: Managing

Pediatric Overweight among Medi-Cal Patients. This summit aimed to promote

communication, collaboration, and the sharing of best practices. A total of seven presenters shared highlights of their various programs related to managing childhood weight and obesity. The rest of the session was devoted to group discussion and ideas for approaching collaboration.

2.5. Initial Health Assessment (IHA)

SFHP sends monthly reports to its providers with demographic information about their new patients. SFHP asks providers to reach out to those members to receive an Initial Health Assessment within 120 days, as mandated by DHCS (60 days for members 0-18 months old). New members receive a mailer in their primary language encouraging them to call their providers and make an appointment to receive this service.

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10 SFHP monitors performance against this requirement by reviewing administrative claims and encounter data and calculating the percentage of new members who receive an IHA visit within the DHCS-recommended periods. Below are the IHA rates for SFHP members.

Rate Measure

67.98% New patients over 18 months old receiving IHA within 120 days 70.17% New patients under 18 months old receiving IHA within 60 days

According to the DHCS requirement, the following exceptions apply to the expectation of a completed IHA for each new member. These reasons for not doing an IHA help to explain why member completion rate is lower than expected:

The new member is assigned to a PCP who completed an IHA with the member prior to the member’s enrollment at SFHP,

The elements of the IHA were completed within 12 months prior to member’s effective date of enrollment,

The PCP has documented in the medical record that all findings have been reviewed and updated accordingly,

The new member was not continuously enrolled in the plan for the required number of days,

The new member disenrolled from SFHP during the IHA period,

The new member or a member’s parent/guardian refused to complete an IHA and this refusal is documented in the chart,

The new member missed a scheduled appointment with the PCP and at least two additional documented attempts were made to reschedule the appointment, without success.

In spite of the above exceptions, SFHP continuously makes every effort to assess member needs and provide them with appropriate care. Beginning with the enrollment of SPD members in 2011, SFHP contracted with Nurse Response to conduct Health Risk

Assessments to SPD members. After the completion of mandatory enrollment in mid-2012, SFHP’s customer service department began completing the HRAs. SFHP Care Support staff uses the information from these assessments to provide appropriate care coordination services to the members who need it most.

2.6. Nurse Help Line

SFHP contracts with Nurse Response, a Nurse Help Line that is available 24 hours per day, 7 days per week. SFHP advises members to use the Nurse Help Line in the following situations:

If member is unable to reach their doctor during the day or after hours

If member desires to speak with a registered nurse to answer health questions, give advice, and instruct them to go to the emergency room, urgent care center, or contact their provider after being triaged with standardized McKesson protocols.

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11 Members assigned to Kaiser Permanente or to a clinic with its own call center/Nurse Help Line are transferred through a live voice-to-voice connection from the SFHP Nurse Help Line to the advice line operated by their provider organization.

SFHP has marketed the Nurse Help Line in a variety of ways, including: Including the phone number on the back of member’s SFHP ID card

Mailing postcards and magnets to new members (available in 5 languages)

Listing the phone number on 2012-2013 Evidence of Coverage document, mailed to all enrollees annually.

The most frequent reasons adult members call the Nurse Help Line include basic medical questions, non-clinical questions (e.g. clinic hours, pharmacy info, provider info, etc.), and common symptoms such as diarrhea. The most common questions for pediatric members relate to vomiting, colds, and fevers.

SFHP receives and reviews monthly statistics from Nurse Response that are reported annually to the SFHP Quality Committee (QIC) and to the Department of Managed Health Care (DMHC). DMHC’s Timely Access Standard Report requires triage or screening by phone within 30 minutes of the call. Only 0.64% of calls exceeded the 30 minute threshold. The table below shows the Nurse Help Line’s performance relative to this standard. In 2012, the number of abandoned calls remained extremely low, only 16 in 2012. Our 0.6% abandoned call rate is well below the 5% NCQA standard.

Total # Calls Average Time to Answer (seconds) Abandon Calls ≥ 30 Seconds Abandon Rate Outlier Calls ≥ 30 min Outlier Call Rate January 134 20 0 0.00% 1 0.75% February 173 24 6 3.47% 0 0.00% March 256 28 9 3.52% 0 0.00% April 232 11 4 1.72% 2 0.86% May 282 13 3 1.06% 2 0.71% June 195 9 5 2.56% 0 0.00% July 193 8 1 0.52% 1 0.52% August 181 13 1 0.55% 3 1.66% September 204 7 0 0.00% 1 0.49% October 197 13 3 1.52% 0 0.00% November 175 7 1 0.57% 3 1.71% December 264 12 5 1.89% 3 1.14% Total/Average 2,486 14 38 1.53% 16 0.64%

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2.7. Asthma

The San Francisco Health Plan provides medical homes and health education centers serving our members with free asthma supplies. In 2012, SFHP donated over $5,690 worth of free spacers, peak flow meters, hypoallergenic pillowcases and mattress cover sets to distribute to SFHP members with asthma. Additionally, health education materials related to asthma are available in the member and provider sections of our website in English, Chinese, Spanish, Russian, and Vietnamese.

SFHP is a member of the San Francisco Asthma Task Force Clinical Committee, and participates in the planning of programs and provider trainings aimed at improving the management of asthma among San Francisco residents. On October 5, 2012, The Task Force hosted its annual Networking Forum, “Motivational Interviewing and Asthma Self

Management,” which was advertised to providers in San Francisco and included a full day of training on Motivational Interviewing by expert Steve Berg-Smith.

2.8. Diabetes

Member Incentives

In 2012, we continued to offer a $25 gift card incentive for completing the following six recommended services within the calendar year:

HbA1c LDL Eye exam Foot exam Blood pressure

Monitoring for Nephropathy (Urine micro albumin screening, prescription for ACE/ARB, or other evidence of medical attention for nephropathy)

Marketing the Diabetes Incentive Program

Annually, all members with diabetes are sent a diabetes reminder card with information about our incentive program.

In September 2012, a contracted call center made live calls to 2,050 members with diabetes who had not yet completed all necessary exams in 2012, an increase from 2011 (1,728 live calls). The calls encouraged members to complete their regular screening tests. After the calls in September, the number of incentive vouchers returned jumped from 27 in September to 96 in October and 53 in November.

Lastly, SFHP worked with our contracted eye vendor, VSP, to send letters to members with diabetes who had not received an eye exam in the past 12 months. SFHP regularly sent VSP a list of SFHP members with diabetes to ensure the most accurate outreach lists.

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13 Incentive Program Results

In 2012, 12% (444) of members who received cards returned them, compared to 19% (308) in 2011. Of the members who returned cards, 62% (280) of the members turning in a card qualified for the incentive. We attribute the decrease in participation to the following: 1) A decrease in outreach efforts and panel management by providers who are transitioning to electronic medical records, and 2) an increase in the number of new members with diabetes (specifically SPDs) who are not familiar with our incentive program.

Health Texting Pilot: DMTxt

In early 2012, SFHP started planning for the launch of a health texting program for members with diabetes, with the goal of encouraging members to get their annual

diabetes-related screenings and improve self-management skills. Many studies have shown evidence for the effectiveness of using text messages to deliver health interventions. SFHP partnered with a health-focused technology startup, HealthCrowd. Members were invited to opt in to the program, DMTxt, and to expect to receive three to four texts per week, containing diabetes and general health-related messages. Many of the messages are interactive and invite a response, as a way to further engage members. As of December 2012, 175 members had enrolled in the program, which launched in early 2013. The pilot is planned to run for six months after the launch, at which point SFHP and HealthCrowd will review data to evaluate the success of the pilot phase and to make improvements to the program.

Healthier Living Program

In 2012 SFHP joined the San Francisco Healthier Living Coalition, a group of San

Francisco agencies that have joined together to schedule, promote, and lead workshops in the Healthier Living program, an evidence-based peer education program developed by Stanford University. The program is designed to empower people with chronic conditions to self-manage their care. The six-week program builds knowledge and self-management skills in order to increase participants’ self-efficacy, and is taught by peers who also have chronic conditions. The classes are available in multiple languages, in locations across the city.

2.9. HEDIS Results

Our quality improvement programs have been successful, as measured by our strong HEDIS results for reporting year 2012.

Preventive Care Measures

SFHP demonstrated improvements in most Medi-Cal measures during the 2012 reporting year (measurement year 2011). Sixteen out of 19 publicly-reported Medi-Cal measures were in NCQA’s 90th percentile benchmark for Medicaid plans, as highlighted in yellow below. By comparison, last year only had 14 out of 21 measures above the 90th percentile. The table below shows our Medi-Cal results reported in 2012, compared to the prior year’s results. Measures highlighted in pink are used by the California Department of Health Care Services to calculate the percentage of Medi-Cal enrollees assigned to SFHP when they do not choose a health plan. Based on the 2012 scores, as well as the percent of

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14 members receiving services in the safety net, our default assignment rate for 2013

increased to 89%, adjusted to 84% due to a new cost factor (awarding points for the lower-cost county plan). This is an improvement from the 71% auto-assignment rate for the previous year.

HEDIS Measure

2011 2010 2011 Medicaid 90th Percentile

Avoidance of Inappropriate Antibiotic Treatment

in Adults 45.45% 44.5% 31.6%

Adolescent Well-Care Visits 65.20% 64.4% 64.1%

Cervical Cancer Screening 80.19% 79.4% 78.7%

Childhood Immunization Status (Combination 3) 87.04% 87.3% 82.6% Comprehensive Diabetes Care BP <140/90 78.64% 73.7% 76.0% Comprehensive Diabetes Care Eye Exam 69.72% 70.1% 70.6% Comprehensive Diabetes Care HbA1c Control <8 63.38% 64.1% 59.1% Comprehensive Diabetes Care HbA1c Testing 91.08% 90.4% 90.9% Comprehensive Diabetes Care LDL Testing 83.33% 83.2% 83.2% Comprehensive Diabetes Care LDL Control <100 48.83% 47.9% 45.9% Comprehensive Diabetes Care Monitoring for

Nephropathy 83.57% 85.1% 86.9%

Comprehensive Diabetes Care Poor Control >9

(lower rate is better) 26.53% 26.3% 29.1%

Postpartum Care 75.64% 63.6% 75.2%

Prenatal Care 93.44% 90.3% 93.2%

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents - BMI Percentile

76.16% 60.7% 69.8% Weight Assessment and Counseling for

Children/Adolescents – Nutrition 80.56% 78.5% 72.0% Weight Assessment and Counseling

Children/Adolescents – Physical Activity 72.69% 70.4% 60.6% Well-Child Visits in the Third, Fourth, Fifth and

Sixth Years of Life 84.95% 85.2% 82.9%

Use of Imaging Studies for Low Back Pain 82.98% 82.2% 82.3% Auto Assignment Measure

SFHP above NCQA’s Medicaid 90th Percentile for that year

We had significant increases in our rates for postpartum care and blood pressure control. In 2012 we began sending out health education materials in the appropriate language along with an incentive voucher to all women who had recently given birth, regardless of whether we were able to reach them via phone. This caused a spike in the number of members who participated in our incentive program and were compliant for this measure. Blood pressure control rate increased in 2012. This may be due in part to the

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15 introduction of a new measure in the Strength in Numbers program, incentivizing clinics to raise their blood pressure control rates. Prior to 2012, Strength in Numbers only

incentivized blood pressure documentation. Chronic Care Measures

SFHP reached the national HEDIS 90th percentile in all diabetes measures with the exception of LDL testing, monitoring for nephropathy, and eye exams. Although SFHP did not reach the 90th percentile for LDL testing, we improved upon our 2011 scores from measurement year 2010. Measure 2011 2010 2011 Medicaid 90th Percentile Eye Exam 69.72% 70.1% 70.6% HbA1c Testing 91.08% 90.4% 90.9% LDL Testing 83.33% 83.2% 83.2%

Monitoring for Nephropathy 83.57% 85.1% 86.9% Blood Pressure Control (<140/90) 78.64% 73.7% 76.0% HbA1c Poor Control (>9) 26.53% 26.3% 29.1% HbA1c Good Control (<8) 63.38% 64.1% 59.1% LDL Good Control (<100) 48.83% 47.9% 45.9%

Eye Exams HbA1c Testing LDL Testing Monitoring for Nephropathy

MY2010 67.5% 89.4% 82.6% 85.8% MY2011 70.1% 90.4% 83.2% 85.1% MY2012 69.7% 91.1% 83.3% 83.6% MY2012 90th %ile 70.6% 90.9% 84.2% 86.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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16 Healthy Families

In measurement year 2011, 6 out of 14 Healthy Families measures were in the 90th percentile, whereas in 2010, 9 Healthy Families measures were in the 90th percentile. SFHP attributes this decrease to the change in the Childhood Immunization measure and also possibly to decreased appointment access at provider offices due to the implementation of electronic health records in many San Francisco safety net clinics in 2011.

In our Healthy Families measures, we had a significant increase in our rate for Childhood Immunization Status. Childhood Immunization Status has continued to improve; we believe this may be attributed to our strong HEDIS incentive program for Childhood Immunizations.

Measure 2011 2010 2011 Medicaid 90th%

Adolescent Well-Care Visits 80.32% 69.7% 64.1%

Childhood Immunization Status - Combination 10

(New indicator) 43.86% 19.51% 23.6%

Well-Child Visits in the First 15 Months of Life 75.86% 81.1% 77.1% Well-Child Visits in the Third, Fourth, Fifth and Sixth

Years of Life 87.27% 87.7% 82.9%

Children and Adolescents’ Access to PCP (12-24

months) 97.30% 96.2% 98.6%

Children and Adolescents’ Access to PCP (25

months to 6 years) 92.44% 94.1% 92.7%

Children and Adolescents’ Access to PCP (7 to 11

years) 94.14% 96.1% 94.7%

Children and Adolescents’ Access to PCP (12-18

years) 94.86% 94.0% 93.4%

Use of Appropriate Medication for Asthma (all

ages) 87.23% 95.2% 93.2%

Appropriate Testing for Children with Upper

Respiratory Infection 95.67% 95.8% 94.8%

Appropriate Testing for Children with Pharyngitis 50.37% 25.2% 83.3%

Lead Screening in Children 70.18% 77.2% 87.6%

Chlamydia Screening in Women 17.00% 19.2% 69.1%

Immunizations for Adolescents 80.30% 66.4% 75.5%

2.10. Strength in Numbers Program

The Strength in Numbers program engages primary care clinics in the SFHP and Healthy San Francisco (HSF) provider networks to share quality data and improve performance in population health and access to care. Strength in Numbers rewards clinics with financial incentives for improvement in key chronic care and access measures. The program also provides technical assistance in the form of trainings to support population management

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17 activities. Supplemental practice coaching is provided through a collaboration with the UCSF Center for Excellence in Primary Care. Strength in Numbers tracks population health performance for over 13,000 patients with diabetes. Clinics continue to value the

opportunity to report measures and share performance results for all their patients, not just SFHP members. Community results are shared through a newsletter that highlights best practices.

During the 2012 program year, Strength in Numbers underwent significant changes. The expansion of the measurement set placed increased emphasis on clinical outcomes. For example, more than half of the participating Strength in Numbers medical homes reported on blood pressure control (< 140/90), instead of reporting solely on blood pressure

electronic documentation. The program also offered a number of optional measures, including preventive health screening measures such as cervical cancer screening and Hepatitis B vaccination rates.

Another big change in 2012 included incentives for clinics that care for children.

Pediatric practices and family medicine practices chose to participate and report on an adult health measure set, a children’s health measure set, or both. The new children’s measure set targets BMI documentation, anemia screening, and improved access to primary care. In addition, clinics were given the option of reporting on adolescent immunizations and clinic show rate.

Data became more transparent in 2012, as clinic-specific program results were shared across all participating organizations on a quarterly basis. These unblinded data allowed sites to monitor both their internal progress as well as their improvement compared to their peer organizations. Also, by highlighting a clinic’s individual highest and lowest performance within a measure, the program’s comparative data built awareness of opportunities to standardize clinical practice.

Looking at the Strength in Numbers program population as a whole, two measures saw significant improvement in 2012. Interestingly enough, the measures added in 2011 and 2012 saw the most improvement, likely due to clinics focusing their efforts to the new measures. The overall colorectal cancer screening rate rose steadily over the course of the year to finish at 20% above baseline in Quarter Four (October – December). Smoking status documentation also improved; the average rate rose every quarter in 2012 to finish at 13% above baseline. Increased smoking status documentation is a particularly good sign as Strength in Numbers looks forward to the 2013 program year when all participants will build on this foundation to report on Smoking Cessation Counseling.

Overall performance in the four core diabetes measures (A1c Testing, A1c > 9, LDL Testing, and LDL < 100) was slightly lower in late 2012 than the initial scores in 2010. This is a huge disappointment after two years of aggregate improvement in these measures. The main factor that may account for this is the loss of clinic capacity to do proactive population management during a time of electronic records implementation. This loss of capacity was

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18 both a loss of primary care appointments available during the months following go-live in many sites, as well as the loss of staff time to do proactive panel management outreach. The following charts show the aggregate rates of 6 clinics, 3 of which implemented electronic health records in 2012 and 3 of which did not. In the two screening measures (HbA1c Testing and LDL Testing), the clinics that implemented EHR in 2012 saw a

progressive decline in performance, where the three clinics that did not implement EHR maintained performance. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012

Diabetic Measures

for All Participating Medical Homes

HbA1c Testing HbA1c > 9* LDL Testing LDL < 100

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19 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012

HbA1c Testing

Implemented EHR Did not Implement EHR

50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012

LDL Testing

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20 Additionally, one noteworthy subset of Strength in Numbers participants has shown progress during this time. Medical homes performing in the bottom 20% during their first quarter in the program have all achieved significant improvement over baseline.

0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2010 2011 2012

Overall Improvement of Medical Homes with

Lowest Initial Rates

HbA1c Testing HbA1c > 9 LDL Testing LDL < 100

28.9%

23.0%

80.7%

11.4%

0% 20% 40% 60% 80% 100%

HbA1c Testing HbA1c > 9 LDL Testing LDL < 100

Relative Improvement of Medical Homes with

Lowest Initial Rates

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21

2.11. Health Coaching & Panel Management Training

A key component of Strength in Numbers is technical assistance. In 2012, a six-part training on health coaching and panel management trainings was made available to all participating medical homes. 25 attendees representing 10 medical homes and 3 other health providers participated in this six-week training.

The San Francisco Health Plan partnered with the UCSF Center for Excellence in Primary Care (CEPC) in facilitating and coordinating a six-part (12 hour) training focused on the practices and procedures of health coaching, including a brief introduction of panel management.

Training utilized a classroom style, highly-interactive approach to introducing the skills, strategies, and knowledge in working collaboratively with patients with diabetes,

hyperlipidemia and hypertension. Training content included self-management skills,

medication reconciliation, action planning, reading a registry report, panel risk stratification, and inreach and outreach techniques. Participants demonstrated the core competencies of health coaching using role-plays with partners.

The graph below shows the improvement of participant confidence in using the ask-tell-ask method to engage patients in talking about their health from session 1 to session 6. The mean values are shown based on a 1-10 scale.

6.8

8.1

0 1 2 3 4 5 6 7 8 9 10 Session 1 Session 6

Participant Confidence to Use

"Ask-Tell-Ask" Intervention

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22

How much do you agree or disagree with the following statements? (n=12)

Participants found the trainings to be very useful, rating the training an average of 4.4 out of 5.0. Participants made the following comments, with regards to the training:

“I learned a lot about how to talk to patients and potential problems that may arise. I think the scenarios definitely helped me in understanding the benefits of the ask-tell-ask method.”

“Diabetes is a common disease among the patients in our clinic. This training provides very helpful scenarios about coaching patients about their diabetes management.”

2.12. Reducing Avoidable Emergency Department Visits QIP

The Reducing Avoidable Emergency Room Visits Quality Improvement Project (ER QIP) was a DHCS-led project that started in 2008 and closed in October of 2011. SFHP continued the project through the end of 2012 because there continued to be worthwhile progress, particularly with regards to operational improvements at the clinic sites that partnered with SFHP in this project.

As the formal QIP began, SFHP analysis showed that St. Luke’s Hospital had the highest emergency visit rates for SFHP members when compared with other SFHP network

hospitals. In addition, the majority of members with emergency visits at St. Luke’s belonged to the Hill Physicians Medical Group. For the QIP, SFHP initiated a partnership with these two organizations. At St. Luke’s, the two primary care clinics at the hospital were the main partners, with productive participation by the Emergency Department as well.

The results for the project through 2011 follow; St. Luke’s hospital changed affiliations and information systems in the middle of the project, making it too difficult to see the results from the 2012 activities (specifically, it was impossible to distinguish the location of the visits, as the reporting blended the sites of affiliated hospitals).

Decreased overall emergency visit rates for SFHP members utilizing the St. Luke’s Emergency department by 2% compared to baseline (from 24% CY2009 to 23.52% CY2012)

Decreased avoidable emergency visit rates for SFHP members utilizing St. Luke’s ER by 10% from baseline (from 5% CY2009 to 4.5% CY2012).

4.3 4.3 4.4 4.4

1 2 3 4 5

I enjoyed Format of the training I learned what I hoped to learn The materials were helpful This training met my expectations

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23 In 2012, the following activities continued:

Emergency visit data from St. Luke’s Hospital was reviewed weekly for project monitoring and for creation of outreach lists.

A SFHP health navigator phoned patients who had a recent emergency visit to review alternatives and to promote the SFHP Nurse Help Line; health education materials were offered for parents, to help them know when to use primary care instead of the emergency department. Phone calls by SFHP ended in June 2012, as St. Luke’s started outreach calls to these same members about accessing

appointments in the future for urgent needs.

Health education materials such as the book “What to Do When Your Child Gets Sick” and marketing materials for the Nurse Help Line were mailed to interested members after the phone call from the SFHP health navigator.

Hill Physicians Medical Group offered case management services to members with three or more emergency visits within six months.

SFHP sent an Emergency History report to the St. Luke’s providers for patients who had three or more emergency visits within six months. St. Luke’s clinic staff used these lists to reach out to these patients.

St. Luke’s clinic staff engaged the providers and staff at the St. Luke’s emergency department to contact the clinic to schedule a follow-up primary care visit for the patient after an emergency visit, as necessary for the patient’s care and follow-up.

2.13. Reducing All Cause Readmissions QIP

The All Cause Readmission QIP is a DHCS-led project that started in 2012. This is a statewide collaborative that provides an opportunity to collect data, share knowledge and best practices, and implement changes that will help reduce readmission rates for the Medi-Cal population. In preparation for the QIP, SFHP collaborated with other health plans to develop a study proposal, including appropriate technical assistance from HSAG, California’s designated external quality review organization. DHCS has mandated that each plan

evaluate the readmission rate and address any disparities through barrier analysis and targeted interventions. SFHP spent much of 2012 working with outside agencies to develop effective interventions. Initially, SFHP met with San Francisco’s Department of Aging and Adult Services to explore offering a care transitions program to SFHP members. SFHP also joined the Avoiding Readmissions through Collaboration Network (ARC) in order to learn best practices for decreasing readmissions utilized by other health plans, hospitals, and other health care agencies. In 2013, SFHP will implement a new measure (as part of its pay for performance program) that targets members that have been recently discharged from the hospital. Our goal is to engage our entire network of medical groups and clinics to promptly contact patients on discharge from the hospital, and ensure they get needed follow-up care.

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24

3. Health Education, Cultural, & Linguistic

Services

Health education and cultural and linguistic competency principles are actively integrated into SFHP’s quality improvement activities. In order to make decisions about quality improvement interventions, SFHP examines the demographic characteristics of its member population. Many existing projects were continued in 2012 and SFHP developed two other large-scale pilots in response to provider recommendations and member input.

3.1. Health Education Compensation Program (HECP)

The Health Education Compensation Program (HECP) provides financial support for medical homes and health education centers offering health education services free of charge to SFHP members. HECP has two funding structures. The first one covers medical homes with assigned SFHP members, in which 19 PCP sites participated in 2012.

The second structure covers both health education centers without an assigned SFHP membership, in addition to PCP sites providing health education services to SFHP members assigned to other medical homes. This funding supports clinics providing unique course offerings and services in SFHP’s five threshold languages (Chinese, Russian, Vietnamese, Spanish, and English) that are not offered in the patient’s home clinic. A total of 8 health education centers and PCP sites enrolled in this second funding structure.

The 2012 participating sites provided health education classes and individual counseling on the following topics:

Health Education Topics

Diabetes Asthma

Perinatal Care Nutrition and weight management

Hyperlipidemia Hypertension

Smoking Cessation Behavioral Counseling

Dental hygiene/fluoride varnish Parenting/family wellness Infant/adult CPR and first aid Healthy Aging

Pain Management Yoga

Acupuncture Chronic disease management

Walking groups

=New in 2012

3.2. Health Education Products & Services

SFHP maintains a library of health education materials in a wide range of topic areas. Upon request, materials are also available in alternative formats including large print, audio, or Braille. In 2012, SFHP also started work on two new projects: a health text messaging program and a collaboration to promote a chronic disease self-management program.

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25 Social Media-Based Health Education

The SFHP website includes an easy-to-navigate repository of educational materials that providers, members, and visitors can access and print. In response to the State’s policy letter requiring English-language written health education materials to be certified at or below a sixth grade reading level (APL 11-018), SFHP developed a new library of low-literacy health education fact sheets. Starting in October 2012, they are available in English,

Chinese, and Spanish. All materials are available in both paper and online formats. These online materials addressed almost 30 topics including asthma, diabetes, breastfeeding, back pain, sleep, and weight management. To assess website use, SFHP tracks the frequency of hits to the Health and Wellness pages of the website. In 2012, the provider, member, and visitor sections of the SFHP website were accessed 8,740 times, more than double the hits from 2011.

Health & Wellness Web Hits to Provider Section – 2012

Health Education Material for Members 2,398 Health Education Material for Providers 256

Health Education Classes 1,039

HECP 300

Total 3,993

Targeted Health Education Mailings

As part of quality improvement initiatives to promote preventive care and management of chronic conditions, SFHP mails health education materials to members. In 2012, SFHP mailed information and health reminders on the following health topics:

Immunizations for 0-2 year-olds Well-checks for 3-6 year-olds Cervical cancer screening Breast cancer screening Women’s health

Diabetes management Diabetic eye exams Initial health assessments Pregnancy education books

“What To Do When Your Child Gets Sick” parent/caregiver education book

Health & Wellness Web Hits by Language

Member Section Visitor Section

English 2,097 1,862

Spanish 108 104

Chinese 218 358

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26 SFHP’s quarterly member newsletter continues to be an important means for

communicating health education messages to members. The newsletter, Your Health

Matters, regularly includes articles on topics such as nutrition and physical activity ideas,

child safety, member rights pertaining to language access services, stress reduction tips, and SFHP’s community partnerships. Topics are chosen based on a myriad of factors, including regular input from the Member Advisory Committee, as well as relevant local and national health priorities.

Group Health Education

In 2012, SFHP joined the San Francisco Healthier Living Coalition, a group of San Francisco agencies that have joined together to schedule, promote, and lead workshops in the Healthier Living program, an evidence-based curriculum developed by Stanford

University designed to empower people with chronic conditions to self manage their care. The six-week peer education program builds knowledge and self-management skills in order to increase participants’ self-efficacy. In conjunction with the Healthier Living Coalition, SFHP members were offered this free workshop eight times and in four languages (English, Spanish, Cantonese, and Russian) over the course of several months. SFHP and coalition partners conducted extensive outreach to the community and SFHP members in particular through targeted mailings, phone calls, and tabling at events. Despite high interest from members, follow-through proved challenging. Of 39 members who enrolled in the workshops, 21 graduated (meaning they completed four of six weeks). Those who

graduated reported highly positive experiences with the program. Since this time, SFHP has strengthened recruitment efforts at key locations as well as trained internal leaders to increase member participation.

Community Events

In May 2012, two SFHP staff members led a “Finding Reliable Health Information Online” workshop at the Aging and Disability Technology Summit, and about 50 people attended this interactive session. The aim of this conference is to connect seniors and persons with disabilities to technology. SFHP plans to present again at the 2013 summit and continue to build a relationship with the Community Living Campaign, which organized the summit.

In June 2012, three SFHP staff members led a workshop called “Health Inequities – How to be Part of the Solution” at the Stronger Bridges to Health Forum, which is an information and resource fair for community advocates who connect the uninsured to health

coverage. The event is sponsored by SFHP and is made available to participants at no cost. The 2012 theme, “Bringing the Pieces Together,” focusesd on harnessing community-based services to create healthier communities and complement health care coverage.

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3.3 Promoting Cultural Competency and Language Access

Cultural Awareness Training

In 2012, SFHP conducted or sponsored several Cultural Awareness Trainings open to SFHP staff and contracted medical groups and providers; examples of differing trainings and their outcomes are described below.

The Cultural Awareness and Humility training was held on November 19, 2012 and targeted SFHP staff; the training was conducted by Lee Mun Wah, MS, MA, Founder of StirFry Seminars & Consulting, Inc. The objectives included the following:

Define culture, and why it matters for our work with members and each other Discuss how cultural factors affect health care delivery

Practice noticing the intent and impact in all cross-cultural communications Learn and practice techniques on how to listen and respond to intercultural communications

96% of SFHP staff attended. Of those who completed the evaluation, 85% agreed that their cultural awareness knowledge/tools improved as a result of this seminar. In addition, 78% agree that as a result of this training, they are more confident in their ability to

effectively deal with diversity issues. Some staff members felt there should be much more time spent on this topic, while others felt that this was sufficient.

Reducing African-American Infant Mortality in San Francisco: A Cultural Competency Training for Providers, was held May 9, 2012 and was open to SFHP’s provider network. This training was jointly conducted by Gene Ramos, Expert Consultant, and Dr. Carol Miller, UCSF pediatric faculty. The objectives included the following:

Discuss infant mortality rates and disparities in San Francisco Improve culturally competent patient care

Strengthen advocacy to eliminate disparities in African-American infant mortality in San Francisco

A total of forty-four people attended, with a mix of case managers, counselors, nurses, and social workers. Of these participants, 98% reported they would recommend this training to others, while 97% learned new strategies, ideas, and resources and agreed that the materials covered would be useful in their jobs.

Language Access

SFHP monitors language access through medical group oversight audits, grievances, and provider network monitoring. The examples below better illustrate such processes, and include Medical Group Joint Administrative Meetings and our analysis of HEDIS Rates by race/ethnicity and language with the goal of reducing disparities in care.

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28 Several times throughout the year, SFHP held Joint Administrative Meetings with the following contracted medical groups: Kaiser Foundation Health Plan – San Francisco, Chinese Community Health Care Association, North East Medical Services, Hill Physicians Medical Group, and Brown and Toland Medical Group.

At the meetings, SFHP staff educated medical group contacts on resources and

requirements for complying with State mandates. These resources are available to medical groups at any time and include the following:

Cultural and Linguistic Services Requirements Tips for Communicating Across Language Barriers Tips for Working with Interpreters

Employee Language Skills Self-Assessment Tool

Issues related to adding on members who are Seniors and Persons with Disability While we continued to make progress in improving our overall rates for almost all HEDIS measures in 2012, an analysis of HEDIS data from measurement year 2011 by race/ethnicity and language showed continued disparities in the rates for some measures. SFHP is

currently working with our Quality Improvement Committee and Member Advisory Committee to determine areas for targeted interventions. Some initial findings by focus area are summarized in the chart below.

Access African Americans had lowest rates for children’s access measures.

Prevention

African Americans had the lowest rates across obesity prevention measures (BMI, Physical Activity, and Nutrition Counseling). Chinese speakers had the best rates of childhood immunizations.

Women’s Health

Cervical cancer screening rates were lowest for African-American women.

Prenatal rates were lowest for African Americans and highest for Chinese women. Among language groups, rates were predictably lowest for English speakers and highest for Chinese speakers.

Diabetes Across almost every diabetes measure, African Americans and

Latinos fared poorest.

With these disparities identified, SFHP staff worked in 2012 to identify and engage potential partners in the predominantly African-American neighborhoods of San Francisco. Community organizations and primary care providers in these neighborhoods led SFHP to conclude that door-to-door outreach was the main way to reach particularly low-income women who were most in need of support for improved health related to pregnancy and childbirth.

Based on the disparities identified, and building on community partnership efforts made in 2012, SFHP is targeting outreach for the following three health education and health

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29 status improvement initiatives: community collaboration, Healthier Living workshops, diabetes texting program, and health education materials development and dissemination.

Community collaboration includes outreach to and collaboration with community agencies, health care providers, and allied personnel regarding these findings in order to increase understanding of member needs and identify strategies for addressing identified gaps. Examples of community organizations and collaboratives where SFHP is building capacity to address disparities include On Lok/30th Street Senior Center, the Bayview Child Health Center, the Centering Pregnancy Program at San Francisco General Hospital, the Adolescent Health Working Group, the San Francisco Childhood Obesity Task Force, Black Infant Health, the Chinese Community Health Resource Center, the San Francisco

Department of Public Health, the San Francisco Chronic Pain Workgroup, and more. Each of these collaboration initiatives focuses on a specific population facing significant health disparity.

The second initiative, Healthier Living workshops and the texting program, will focus on expanding outreach and increasing the capacity of existing self-management workshops to increase members’ health-related self-efficacy and health behaviors. In conjunction, SFHP is launching a pilot DMTxt health text messaging program and will analyze results after six months to determine any necessary improvements.

Lastly, health education materials development and dissemination, involves continually increasing the outreach and promotion of culturally-matched educational materials

regarding well-baby visits, chronic conditions, overweight/obesity, heart health, and member use of emergency department for acute symptoms. Part of this effort will include expanding the SFHP website to include broader health information, tools, and community resources.

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4. Improving Health Systems

4.1. Practice Improvement Program

In 2012, SFHP rolled out the second year of its pay for performance program, the Practice Improvement Program (PIP). The overall goal of PIP is to reward system improvements and drive better outcomes in clinical care and patient experience by providing financial incentives and technical assistance. Each measure selected allows for improvement opportunities.

An advisory board governs PIP, with member representatives from our entire provider network. This board meets several times per year to develop and approve measurement sets and advise on issues of both feasibility and clinical relevance of each proposed measure. SFHP’s Governing Board and Executive Team determine funding streams for the PIP program on an annual basis. Incentive payments were provided to PIP participants on a semi-annual basis. Each medical group and clinic’s potential earnings in the program were based on capitation rates and enrolled membership. In 2012, payments were based on 18.5% of Medi-Cal capitation, 7.5% of Healthy Families capitation, and 5% of Healthy Kids capitation. The incentive pool was set to be sufficiently generous to truly drive system improvements in the delivery system.

The second year of PIP continued to focus on measures in four main domains: Clinical Quality, Data Quality, Patient Experience, and Systems Improvement. The table below lists some examples of measures within each domain.

Domain Example of a Measure within Domain

Clinical Quality

Demonstrate relative improvement on a QI Project focused on one of the participant’s three lowest scoring HEDIS measures.

Data Quality Submit 90% of encounter data within 90 days of the service date.

Patient Experience Conduct a project for improving patient experience.

Systems Improvement

Select at least three members of the staff, including a senior leader to participate in SF Quality Culture Series, or a similar leadership-training program; adopt meaningful use standards for electronic health records

implementation.

Participants in the second year of the program included 20 community health centers, six medical groups, and three individual providers. A few highlights of the 2012 program year’s success include:

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31 All eligible sites (n=28) submitted a QI project plan related to a clinical area of focus, chosen from clinical quality indicators where the most improvement is needed 89% of eligible sites (n=26) engaged in a patient experience improvement project, which targeted improving either patient-provider communication, clinic staff customer service, or reducing wait times for primary care appointments

89% of eligible sites (n=17) adopted or made plans to adopt at least five meaningful use measures to better use electronic health record technology to achieve health, quality and efficiency goals

4.2 Provider Incentive Pilot to Support Patients on Persistent Medications

In September 2012, SFHP piloted a provider incentive program targeting the HEDIS measure, Annual Monitoring for Patients on Persistent Medications. The eligible population for this measure is all members over 18 years of age who have received at least 180 days of treatment with an ACE inhibitor or ARB, digoxin, or a diuretic. To be compliant in this measure, a member must receive at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test each year.

Providers who participated in the pilot received an outreach list of their patients who were not compliant in the measure. In order to receive the incentive, providers scheduled the appropriate screening test for their patients and documented the date that the test results were received and reviewed.

The goal of this intervention was to increase screening rates for patients with persistent medications while raising provider awareness of the intervention. Participation in the pilot incentive program was very low. However, we believe that by targeting different providers and increasing our communication efforts, future iterations of the incentive would see higher participation rates.

4.3. SF Quality Culture Series

San Francisco clinics face major challenges in preparation for healthcare reform:

ensuring timely access to care despite a primary care shortage, developing patient-centered medical homes in order to improve quality and patient experience, and implementing Electronic Health Records (EHR).

Studies on high-performing organizations frequently name leadership commitment and alignment as the foundation for success. Redwood Community Health Coalition, a

consortium of clinics in four North Bay counties, created the Quality Culture Series and saw a dramatic acceleration of improvements in the areas of chronic care, access, EHR, and patient experience, after 100% of their clinic leadership teams went through the training together. They attribute their success to the fact that the entire leadership team attended all sessions, then spread the training to their clinic staff.

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32 San Francisco’s Quality Culture Series was based on this model. The initial year-long program consisted of 8 full-day interactive sessions, focusing on leadership and

management skills, quality improvement, and project management. Each clinic was assigned a practice coach, and all clinics participated with their senior leadership teams. The series has been credited with increasing the pace of improvement in safety net clinics related to access, chronic care, and patient experience. In addition, clinic leaders had the opportunity to network and share best practices.

The series has been so successful that San Francisco Health Plan continues to sponsor the SF Quality Culture Series on an ongoing basis. In 2012, three follow-up sessions were sponsored for clinic leadership teams. The January session was focused on leading and managing change, and sharing data. 90 attendees from 22 clinics attended. In May 2012, the session featured Kumar Rajarum, Ph.D., from the UCLA Anderson School of

Management, who taught clinic leaders on key strategies to improve operations

management. Clinic leaders learned how to improve and manage processes, and explored tools to measure and analyze wait times, productivity, as well as decrease variations. 120 attendees from 27 clinics attended the session. The September 2012 session focused mostly on team-based care, and included topics such as creating teamlets (consistent provider-medical assistant pairs), defining the role of a nurse, legal scope of provider-medical assistants, and standing orders. 100 attendees from 26 clinics attended the session.

The SF Quality Culture Series has proved to be a transformative experience for clinic leadership teams. The excellent attendance rate, active engagement and program ratings across clinic participants demonstrate the high value they place on their experience. People cannot drive quality improvements without being able to manage people, change, and conflict, among other leadership, teamwork, and management skills. Thus, the fusion of the learning session content (management training, leadership development, quality

improvement basics) with training (learning skills to teach adult learners) was particularly effective.

4.4. Safety Net Quarterly Quality Meetings

The Safety Net Care Teams Quarterly Quality Meeting is collaboratively hosted by the San Francisco Health Plan, The San Francisco Community Clinic Consortium, and San

Francisco Department of Public Health clinics, both those at San Francisco General Hospital, and off-campus clinics. This meeting brings together clinic staff of all levels including

medical assistants, clinic managers, providers, and medical directors from safety net clinics across the city. This is a unique forum where all clinics are welcomed to come together to learn as a group and network, as well as share best practices.

Examples of Topics from Quarterly Quality Meetings

Implementing Huddles Standing Orders

Safety in the Ambulatory Setting Effective Communication

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4.5 Coleman Rapid DPI Program

In 2012, SFHP sponsored nine clinics in its provider network to participate in Coleman Associates' Rapid DPI (Dramatic Performance Improvement) program. In this intense program, 3 to 5 consultants work side-by-side with clinic staff for one week, redesigning clinic processes to improve teamwork, patient access, and visit efficiency. This week is followed by two months of coaching, monitoring and reporting of performance measures, and continuous quality improvement.

The Coleman Rapid DPI program led to measurable operational improvements. For example, one clinic cut its new patient first-visit waitlist down by 67% (from 300 patients to 100) in three months and decreased its no-show rate from 30% to 24% over the same period. Another clinic made so much progress that it reset its goal of achieving NCQA Level I Patient-Centered Medical Home certification to achieving the Level III certification.

The Coleman Rapid DPI program also led to improvements in teamwork and patient centeredness. One clinic noted that tensions between front and back office staff faded away as their roles became more integrated and they started using walkie-talkies to communicate. Another clinic greatly appreciated Coleman's suggestion of using small gestures in order to make patients feel cared for during their visit and improve the overall patient experience.

To ensure that the changes implemented during the Rapid DPI process are sustained, SFHP is sponsoring a data reporting and improvement incentive program, as well as quarterly webinars for clinics to share best practices and compare their progress.

Quality Improvement & Utilization Management Program Evaluation

2012