2013 Chronic Respiratory. Program Description. Our mission is to improve the health and quality of life of our members

Transcription

1 2013 Chronic Respiratory Program Description Our mission is to improve the health and quality of life of our members

2 Chronic Respiratory Program Description I. Purpose Care Coordination promotes the Plan s purpose of helping Kentuckians live healthier lives in each of its special programs. Passport Health Plan (PHP) has developed disease specific approaches to the management of members chronic medical conditions. The emphasis of the Chronic Respiratory Program is to improve the health status and quality of life of members with chronic respiratory disease, such as Asthma and COPD, while decreasing unnecessary inpatient admissions and emergency room (ER) visits by members with asthma, through improved adherence of both members and clinicians utilizing the National Institutes of Health (NIH) Guidelines for the Diagnosis and Management of Asthma, and also complications of adult members with Chronic Obstructive Pulmonary Disease (COPD), through improved adherence of both members and clinicians with the NIH Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, through education and removing any possible barriers to care. The goal of the Chronic Respiratory Program is to provide tools to educate the member on promoting improved health through better detection, treatment, and education. By analyzing utilization patterns, the Plan will be able to educate members on preventable complications so that ER visits and hospital admissions/readmissions may be reduced and appropriate pharmaceutical management may be increased. The program will facilitate member understanding and responsibility of the disease process as well as coordination of care between the member and/or caregiver and clinician. II. Rationale The Center for Disease Control (CDC)/National Center for Health Statistics, in 2011, estimated that 8.2% of adult Americans have asthma (18.9 million) and that 9.5% of American children have asthma (7.1 million). 1 From 1980 to 1996, the number of Americans diagnosed with asthma more than doubled to almost 15 million. Nationally, in 2009, asthma was responsible for 2.1 million emergency department visits, 479,000 hospitalization discharges with a 4.3 average length on stay noting asthma as the primary diagnosis, and 3,404 deaths. 2 Healthy Kentuckians 2010 reports over 220,000 Kentuckians are affected by asthma with 72 percent in persons under age 45 with increasing prevalence in all ages, especially children. COPD affects an estimated 24 million Americans. 3 More than 12 million people are currently diagnosed with COPD and another 12 million may have COPD but remain undiagnosed despite recognizable symptoms. 3 COPD is the fourth leading cause of death in the United States and in Kentucky. It caused 126,005 deaths nationwide and 2,507 deaths in Kentucky in COPD typically affects people over 45, the primary cause of COPD is cigarette smoking, although second-hand smoke, occupational dust and chemicals, air pollution, and genetic factors can also cause COPD. 4 1 Centers for Disease Control, National Center for Health Statistics, Asthma Prevalence, Health Care Use and Mortality: United States, NHLBI (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 4 C.D.C., Kentucky Healthy People /1/2013 Page 1 of 21

3 III. IV. Objectives To decrease avoidable inpatient admissions and ER visits through increased adherence of both members and clinicians with the NIH Guidelines for the Diagnosis and Management of Asthma and NIH GOLD guidelines. To increase clinician adherence to the NIH Guidelines for the Diagnosis and Management of Asthma regarding members on appropriate medication for treatment of persistent asthma, specifically prescription of long-term controller medications. To increase member adherence with recommended treatment, including the use of inhaled anti-inflammatory medication for treatment of persistent asthma. Increase clinician adherence to GOLD guidelines for the use of medications, such as: o Bronchodilator o Systemic corticosteroid Increase the percentage of members who receive appropriate pharmacotherapy management of COPD exacerbation. Increase the use of Spirometry testing to confirm COPD for newly diagnosed members. Increase the percentage of members who receive flu and pneumonia vaccinations. Promote healthy lifestyle including exercise, smoking cessation, other air pollutants, and improved nutrition. Increase member s self-management skills. Population Identification Eligible members with an Asthma or COPD diagnosis are identified primarily through pharmacy/claims data and include the following: Asthma Members 2-64 years of age, AND Continuous enrollment in the health plan defined as active two of the three months of the reporting quarter AND Currently enrolled on the date the report is run At least one inpatient admission or ER claim in the past twelve months with an ICD code of 493 as the primary diagnosis, OR At least four outpatient claims with a diagnosis, not necessarily primary, of asthma within the past year AND two asthma medications within the past year, OR At least one pharmacy claim for an asthma controller and/or reliever medication within the quarter being measured, AND a cumulative total of four such pharmacy claims over the past twelve months Note: For a member identified as having persistent asthma because of at least four asthma medication dispensing events, and leukotriene modifiers were the sole asthma medication dispensed, the member must have at least one diagnosis of asthma in any setting in the measurement year or the year prior to the measurement year. COPD Age 18 years and older, AND Continuous enrollment in the health plan defined as enrolled in two of three months of the reporting quarter AND Currently enrolled on the date the report is run AND At least one claim with the primary diagnosis of COPD (ICD-496), emphysema (ICD-492), and/or chronic bronchitis (ICD-491). 6/1/2013 Page 2 of 21

4 Additionally, member referrals may be received daily from the following sources: Data collected through the Utilization Management (UM) process, examples include, but are not limited to, hospital census report, ER Utilization reports, pre-certification data, embedded UM, and concurrent review data Referrals from other PHP departments, examples include, but are not limited to, Case Management, Disease Management, or Member Services Referrals from clinicians Self-referrals from members Referrals from hospital educators/discharge planners Data collected through the Health Risk Assessment Form (HRA) Members who meet the criteria are eligible for the program. This determination of eligible members occurs on a monthly basis. In addition to identifying members on a monthly basis, members may be adjusted from low risk to high risk based on pharmacy/claims data or referrals, as needed. V. Member Participation and Opting Out of the Program Eligible members are considered enrolled in the program and receive interventions without having to specifically request it. For this reason enrollment is considered passive. Participation, however, is voluntary and the member has the right to opt out of the program or decline all or any part of it. Information on how to opt out is provided as part of the welcome packet and the member is advised verbally if questions regarding participation arise during outreach. Members who opt out may re-enter the program at any time by contacting the Chronic Respiratory Disease Manager or the Care Connection Program, either verbally or in writing. VI. Integrating Member Information PHP utilizes an integrated documentation system, JIVA, in order to allow all health plan staff access to member information. In JIVA s Member Centric view all users are able to view information that is specific to the member such as demographics, eligibility, member s PCP clinician, spoken language, and preferences on receiving educational materials or phone contact. Users also have the ability to enter additional addresses, or phone numbers, which the member may give as an alternative way to reach him/her that is not associated with the state file download that populates the basic demographic fields in JIVA. The Member Centric view may also be utilized to denote a caregiver name and phone number, as needed. In addition, JIVA utilizes widgets to provide quick reference to open authorizations, care coordination activities, and appeals. Users can view detail of each open item, or view a summary of each, depending on what information is needed. JIVA also has multiple quickaccess tabs across the top of the Member Centric view to allow a user the ability to: Edit demographic information and preferences, as needed. Add an episode or open cases. Upload documents related to the member and/or the member s care that need to be visible to all users in order to facilitate seamless care coordination. View all the documentation that has been entered as it relates to the member. View any correspondence that the member has sent to the Plan, or that the Plan has sent to the member. View the member s established care coordination assessment and plan of care. 6/1/2013 Page 3 of 21

5 View claims, both pharmacy and medical, related to the member. View results of labs/screenings, as available. Review care gaps. View a clinical summary, of the last 6 months history, of the member regarding tests and services, medical conditions, medications, ER visits, inpatient admissions, office visits, etc. View historical data or closed cases. All of this data allows everyone interacting with the member to have to most current and available data in order to make every contact count to its fullest potential and improve coordination of care by all users having the same information. VII. Member Contact Eligible members are identified monthly and receive a welcome packet including: Welcome letter (Appendix A), An age appropriate symptom assessment tool for members with Asthma (Appendix C) Disease specific assessment for members with COPD (Appendix D) Educational material related to disease and self-management. All identified members with Chronic Respiratory Disease receive quarterly educational mailings. These quarterly mailings include information on: medications, nutrition, following a treatment plan, adherence to recommended screenings/test, exercise and activity, managing other chronic conditions, lifestyle issues, advance care planning, and depression (Appendix E). Annual reminders are sent for flu/pneumonia vaccination and adherence to NIH Asthma and GOLD COPD Guidelines. All written program material sent to members includes contact information for the Chronic Respiratory Disease Manager, the Care Connection Program, and the 24/7 Nurse Advise Line. Some educational materials are available in other languages upon request. All health plan members receive information regarding the Chronic Respiratory Program and how to contact a Chronic Respiratory Disease Manager, the Care Connection Program, and the 24/7 Nurse Advise Line via the member handbook and the Plan website. All identified Chronic Respiratory members with one of the following will be considered high risk: In-patent admission(s), 23-hour observational stays with primary diagnosis of chronic respiratory disease(s) (i.e., Asthma or COPD). Intensive Care Unit (ICU) admission. All identified asthmatic members with one of the following will be considered high risk: two ER visits for members with a diagnosis of asthma OR Pregnant members with In-patient admissions for primary diagnosis of asthma OR Ratio of controller to short acting bronchodilators (<.5) OR Short acting bronchodilators filled six within a rolling 12 months All identified COPD members with one of the following will be considered high risk: COPD related complications such as respiratory failure or right sided heart failure in any combination in a rolling six month period. 6/1/2013 Page 4 of 21

6 Chronic Respiratory members identified as high risk receive all of the quarterly disease specific educational mailings in addition to outreach from the Chronic Respiratory Disease Manager. The Chronic Respiratory Disease Manager: Assesses the member s needs utilizing a disease specific assessment, depending on the member s chronic respiratory needs and develops an individualized plan of care, including the member s caregiver when possible. Performs reassessment of the member s needs utilizing a disease specific assessment, depending on the member s chronic respiratory needs, every three months and at discharge from disease management. Coordinates care with the clinician involved in the member s care and assists with follow up care with a specialist, if appropriate. Establishes and maintains contact with the member and/or caregiver to evaluate and revise the plan of care as needed. Educates the member and/or caregiver on the importance of the clinician s established treatment plan to include medication adherence, attending scheduled appointments, adherence with self-monitoring activities, and adherence with lab test ordered by the clinician. Educates the member and/or caregiver on lifestyle issues that may improve the member s disease process to include diet/weight management, medication adherence, exercise, adherence to the NIH Asthma and GOLD COPD Guidelines recommended screenings/tests, smoking cessation, and regular clinician visits. Conducts the Patient Health Questionnaire (PHQ) 2 as a depression prescreening tool and/or the PHQ-9, as appropriate, to identify members in need of referral for behavioral health services. Provides the member with assistance/information regarding available community resources. Provides the member and/or caregiver with additional written and/or verbal information targeted to the member s specific needs. If a member has ongoing complex care coordination needs after six months the member may be referred to Case Management services. VIII. Clinician Notification and Involvement Participating clinicians in the health plan are notified of the Chronic Respiratory Program by the following: New Provider Kit distributed to new clinicians with information regarding how the Chronic Respiratory Disease Manager works with members and instructions on how to access and utilize the program s services (Appendix B) The PHP Provider Manual The PHP Provider Medical Office Notes Clinicians receive the following written notification regarding their patients participation in the Chronic Respiratory Program: Notification of a Chronic Respiratory disease specific to the member, who is not following medical treatment OR is not using controller medications specific to their disease (i.e., Asthma/COPD SA bronchodilators, COPD systemic corticosteroid) so that the clinician may review the members status and determine if medication is needed. Notification of the member s non-adherence with the clinician established treatment plan. 6/1/2013 Page 5 of 21

7 Notification of high-risk member enrollment into the Chronic Respiratory Program. Notification of member discharge from the Chronic Respiratory Program. Notification of member referral to Case Management. The NIH guidelines for both Asthma and COPD are distributed to all participating clinicians as part of the Provider Manual and are available on the PHP website. Guidelines are reviewed, updated, and posted on the health plan s website at least every two years and anytime new scientific evidence or national standards are published. IX. ER Initiative In response to the high rate of ER visits due to asthma exacerbations, the Chronic Respiratory Program implemented an ER initiative with Kosair Children s Hospital and Hardin Memorial Hospital in 2004 and University of Louisville Hospital in The hospitals send an electronic list of PHP members seen in the ER with a primary diagnosis of asthma to the Chronic Respiratory Disease Manager. These members are mailed educational materials and a letter outlining the steps they should take following the ER visit which include the following: Follow-up with their clinician Talk to the clinician about asthma controller medications Take the asthma controller medication daily if one is ordered Reminder to refill their controller medication monthly Reminder to not stop taking their controller medication without talking to their clinician Clinicians are notified of their members seen in the ER and mailed a copy of the letter sent to the member (Appendix F). X. Member Satisfaction with Care Management PHP Care Management Programs have a systematic method of evaluating member satisfaction with all areas of Care Management services. The Chronic Respiratory Member Satisfaction Survey (Appendix E) is distributed to all asthmatic and COPD members after discharge from disease management. Questions address member experiences with the Chronic Respiratory Program and the Chronic Respiratory Disease Manager in the areas of: The effectiveness in helping the member understand their chronic respiratory disease. The helpfulness in assisting the member develop a self-management plan specific to their chronic respiratory disease. The helpfulness in assisting the member adhere with the established self-management plan. The usefulness of the educational materials provided. The ability of the Disease Manager to listen to the member. The helpfulness of the Disease Manager to assist the member in care coordination. Complaints regarding the Chronic Respiratory Program may also be received by the Member Services Department during routine member contacts. The Member Service staff document the complaint in EXP, a customer service software package that records, tracks, and reports all member inquiries and/or complaints. Each department has a mailbox specific to the department. Member Services forwards the EXP complaint to the Manager of Care Coordination for follow-up. The Manager of Care Coordination conducts a quantitative and qualitative analysis of complaints regarding the Chronic Respiratory Program annually. This analysis is used to 6/1/2013 Page 6 of 21

8 identify patterns of member complaints and opportunities to improve satisfaction with the Chronic Respiratory Program. Changes to Chronic Respiratory Program are made as needed. XI. Annual Evaluation The annual evaluation of the Chronic Respiratory Program is conducted by the Chronic Respiratory Disease Manager, the Manager of Care Coordination, the Director of Medical Management Care Coordination, the Chief Medical Officer, or their designee, and receiving input from the Quality Improvement Department as appropriate. Objectives, activities and outcomes are evaluated at a minimum of annually in order to: Measure participation rates. Determine whether the Chronic Respiratory Program has demonstrated improvement in the services and quality of care provided to members. Evaluate the overall effectiveness of the Chronic Respiratory Program. Allow for exploration of barriers and limitations of the Chronic Respiratory Program. Revise areas as needed to improve effectiveness of the Chronic Respiratory Program. Formal measurements are performed annually through the HEDIS reviews using HEDIS methodology. Results of the evaluation are utilized to revise the program and set the program goals for the following year. More frequent barrier analyses are performed on an ongoing basis and adjustments to the Chronic Respiratory Program are made accordingly. XII. Program Goals Increase the overall rate of members with persistent asthma who remained on their controller medication for at least 50-75% of their treatment period. Increase the percentage of members who receive appropriate pharmacotherapy management of COPD exacerbation. Increase the use of spirometry testing to confirm COPD for newly diagnosed members. Improve compliance with NIH Guidelines for both Asthma and COPD. Reduce preventable In-patient/ER admissions. Increase percentage of members in chronic respiratory population knowledgeable in selfmanagement skills. Final approval by the Quality Medical Management Committee: July 20, 2012 June 4, /1/2013 Page 7 of 21

9 Appendices A. Member Welcome Letters B. New Provider Welcome Packet C. Age Appropriate Symptom Assessment D. COPD Assessment Form E. Chronic Respiratory Member Satisfaction Survey F. Adult One-on-One Provider Letter G. Member Mailing Schedule

10 Chronic Respiratory Program Description Appendix A Member Welcome Letter <<Date>> Dear <<Member>>, Welcome to Passport Health Plan s Asthma Program! We are here to help all members with asthma stay healthy. As a member with asthma, you are already signed up in our Asthma Program. Help Us Help You! We want to identify your asthma needs, so we can help you in the best way. To help us do this, please fill out the Asthma Control Test and send it back to us in the prepaid envelope. Special Benefits Being in our Asthma Program gives you special benefits, such as: Asthma managers are here to answer your questions. You will get helpful asthma information sent to you in the mail. We will tell your provider about your asthma. Please talk to your provider at any time you think your asthma is not in control. If you have questions, please call us at , press 0, then press TDD/TTY users may call If you do not wish to be a part of our program at this time, you may also call us at the number listed above. If you chose to leave the program, you may re-join at any time. Sincerely, <<Name of Case Manager>> Asthma Disease Manager Passport Health Plan ADM02/

11 Chronic Respiratory Program Description Appendix A Member Welcome Letter <<Date>> Dear <<Member>>, Welcome to Passport Health Plan s Chronic Obstructive Pulmonary Disease (COPD) Program! We want to help all members with COPD stay healthy. You are already signed up for the program. Being a part of the COPD program gives you special benefits: 1. A COPD manager is here to: Answer questions about your disease. Answer questions about your medicines. Get the supplies and equipment you need. Find care from special providers who work with COPD. 2. You will get helpful COPD information. 3. We will let your provider know about your COPD: Your provider is an important part of your care. Please talk to him or her any time you think your COPD is out of control. To help me identify your COPD needs, please fill out the enclosed COPD Assessment Form and send it back to me. Spirometry is the best test for diagnosing and monitoring the progression of COPD. Ask your provider for a Spirometry Test, if you have not had this done. If you have questions, please call us at , press 0, then press TDD/TTY users may call If you do not wish to be a part of the program at this time, please the number listed above. You may re-enter the program at any time. Sincerely, <<Name of Case Manager>> Passport Health Plan COPD Manager

12 Chronic Respiratory Program Description Appendix B New Provider Welcome Packet

13 Chronic Respiratory Program Description Appendix C Age Appropriate Symptom Assessment Name: Phone: Birth Date: Passport #:

14 Chronic Respiratory Program Description Appendix C Age Appropriate Symptom Assessment Name: Phone: Birth Date: Passport #:

15 Chronic Respiratory Program Description Appendix D COPD Assessment Form

16 Chronic Respiratory Program Description Appendix D COPD Assessment Form

17 Chronic Respiratory Appendix E Chronic Respiratory Member Satisfaction Survey Chronic Respiratory Program Survey Our records show that [name], our [title], recently worked with you or someone in your family. At Passport, your opinions matter to us. We want to give you the best service possible and would like to hear from you! Please answer the questions below and tell us what we are doing right and how we can improve. Please check the best answer. 1.) Were you able to manage your health better with the help of [name]? Yes, they were very helpful Yes, they were somewhat helpful No, they were not helpful 2.) Did [name] listen to you and explain things so you could understand them? Always Usually Sometimes 3.) How would you rate the number of times [name] contacted you? Too many Too few Just enough 4.) Did the [fill-in] Program help you understand your health problem? Yes, it was very helpful Yes, it was somewhat helpful No, it was not helpful

18 Chronic Respiratory Appendix E Chronic Respiratory Member Satisfaction Survey 5.) Were the written materials mailed to you (brochures, letters, newsletters) helpful and easy-to-read? Yes, they were very helpful Yes, they were somewhat helpful No, they were not helpful 6.) How would you rate the overall helpfulness of the [name of program]? Excellent Good Fair 7.) Are there things that would have made the [name] Program more helpful to you? (please explain) 8.) May we call you to talk about your survey answers? Yes No NAME (optional): PHONE NUMBER: Month: Year: Please return this survey in the postage-paid envelope. Thank you again for your time! IHCC PP186 4/3/2013

19 Chronic Respiratory Program Description Appendix F Adult One-on-One Provider Letter <<Date>> [Doctor's Name] [Address] [City], [State] [Zip Code] Dear Doctor [Name], [Patient's Full Name] was referred for one-on-one Asthma Disease Management. The member has agreed to Disease Management. I will be contacting the member monthly to provide asthma education, monitor medication compliance, discuss trigger control issues, and act as a resource to assist with asthma management. This member reports using [List Controller meds], daily, for asthma control and a bronchodilator, as needed, to treat asthma symptoms. If you have questions or specific issues regarding this member s asthma management you would like to discuss, please contact us at or , press 0, then press Passport Health Plan members with a diagnosis of asthma are automatically enrolled in the Asthma Disease Management Program and are sent information about effectively managing their asthma. The one-on-one program is designed to reinforce your treatment plan or the member. Participation by the member in the one-on-one asthma education program is voluntary. We will provide progress reports to you. Thank you, Jim Legleiter RN, RRT Asthma Disease Manager Passport Health Plan

20 Chronic Respiratory Program Description Appendix G Member Mailing Schedule Asthma 1st None No 2nd JCPS School Mailing - Includes: JCPS member letter onto PHP letterhead, JCPS PCP Asthma/ Allergy Form, Finding Your Personal Best Peak Flow Number flyer, Using a Peak Flow Meter, & EPSDT general brochure; add JCPS BRE (sent via Beeline); fold, stuff, & seal IHCC /6/2013 Yes all requested items into a #10 PHP envelope with "CC ADM" under returned address on outer envelope. Non-JCPS School Mailing - Includes: Back to school member letter onto PHP letterhead, PHP student asthma card, Finding Your Personal Best Peak Flow Number flyer, Using a Peak Flow Meter, & EPSDT general brochure; fold, stuff, & seal all requested items into a #10 PHP envelope with "CC ADM" under returned address on outer envelope. IHCC /6/2013 Yes Adult Action Plan/Peak Flow Mailing - Includes: Member Action Plan Letter onto PHP letterhead, Asthma Action Plan, Using an Asthma Action Plan, Finding Your Personal Best Peak Flow Number flyer, Using a Peak Flow Meter; fold, stuff, & seal all requested items into a #10 PHP envelope with "CC ADM" under returned address on outer envelope. IHCC /6/2013 Yes 3rd All Member Mailing - Includes: Member educational letter on PHP letterhead, Be Healthy With Asthma flyer; will need to be folded, stuffed and sealed into a #10 envelope; ink jet "CC: 158 ADM" onto #10 envelope under return address. 4th All Member Mailing - Includes: Member educational letter on PHP letterhead, 5 Simple Ways to Control Your Asthma, and Yes, You Can! Program Flyer; will need to be folded, stuffed and sealed into a #10 envelope; ink jet "CC: 158 ADM" onto #10 envelope under return address.

21 Chronic Respiratory Program Description Appendix G Member Mailing Schedule COPD 1st None No 2nd All Member Mailing - Includes: Member educational letter on PHP letterhead, IHCC COPD; will need to be folded, stuffed and sealed into a #10 envelope; ink jet "CC: 158 IHCC /6/2013 Yes COPD" onto #10 envelope under return address. 3rd All Member Mailing - Includes: Member educational letter on PHP letterhead, What is Spirometry flyer, and Yes, You Can! Program Flyer; will need to be folded, stuffed and sealed into a #10 envelope; ink jet "CC: 158 COPD" onto #10 envelope under return address. 4th All Member Mailing - Includes: Member educational letter on PHP letterhead, Preventing COPD Flare-ups flyer, and Pneumonia Flyer; will need to be folded, stuffed and sealed into a #10 envelope; ink jet "CC: 158 COPD" onto #10 envelope under return address.