PROVIDER Newsletter. Reducing the Risk for Cardiovascular Disease. Screening for Depression JULY 2015

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1 PROVIDER Newsletter Reducing the Risk for Cardiovascular Disease Tufts Health Plan has implemented a chronic care improvement program to identify members with congestive heart failure, to monitor and reduce hospital admission and readmission rates for CHF, and to reduce the risk for cardiovascular disease in this population. The program emphasizes educating members with CHF and their caregivers about how to better self-manage their disease. A comprehensive educational program emphasizes preventive measures, medication compliance, and early recognition of cardiac decompensation. The program aims to reduce CHF admission and readmission rates through ongoing assessments of health risk factors, and the development of individualized care plans for targeted interventions to reduce hospitalizations. The program also includes the following interventions: } Coordinating and implementing assistance for members with activities of daily living (ADLs) needs who are admitted to an acute hospital facility for CHF } Connecting members who are identified as having caregiver support needs and who have an acute admission/readmission to appropriate community support/services } Providing members who are admitted to an acute hospital facility for CHF with a post-hospital discharge assessment. This assessment will help to remind members of CHF early warning signs, as well as identify potential barriers to medication adherence and PCP follow-up. Members also will be provided with tools and education to meet their specific needs. } Assessing behavioral health concerns, such as memory problems and depression, and developing an appropriate plan to address those issues Providers can help achieve the program s outcomes by: } Defining clear goal weight and diuretic titration parameters. Clear communication of target weight and titration parameters, as well as dose of diuretics are of paramount importance to prevent readmissions. } Ensuring that hospitalized patients are stable prior to discharge. Proposed criteria for discharge include: Stability on oral dose of diuretics for at least 24 hours prior to discharge Stable and acceptable oxygenation with activity } Emphasizing the importance of prevention and disease self-management } Providing collaborative care through participation in the member s structured interdisciplinary team } Routine reporting and feedback to keep all care team members and patients informed JULY 2015 Screening for Depression Many patients who suffer from depression often do not complain of a depressed mood, but instead complain of multiple unexplained physical ailments such as fatigue, pain, sleep disturbances or eating disturbances. The risk of depression is higher in individuals with serious medical conditions such as diabetes and cancer, and in survivors of heart attacks and strokes. Routine depression screening is recommended for all seniors at the time of their medical office visit. Generally, yearly depression screening is recommended unless there are clinical indications that additional screenings are necessary. The evaluation and screening for risk factors for depression is required for the initial Annual Wellness Visit (AWV). If depression screening is done outside of the AWV, providers can use code G0444 (annual depression screening, 15 min.). Clinicians can use a variety of tools to screen patients for depression. One example, PHQ-2, is a two-question screener used to begin screening for depression. If a patient answers yes to one or both of the questions, then it is recommended that it should be followed by the PHQ-9 questionnaire to further assess the patient s risk for depression. The PHQ-9 screener is used to help determine the severity of depression and next steps for treatment. For another alternative in screening depression in seniors, refer to the Geriatric Depression Scale (GDS). Depression can have a serious impact on one s health and quality of life. With proper screening, depression can be effectively treated. A Guide for Treating Depression in the Primary Care Setting can be found in the Clinical Practice Guidelines section of our website at tuftshealthplan.com/providers.

2 Important HEDIS Measure Information Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options use the Healthcare Effectiveness Data and Information Set (HEDIS ) as one mechanism to assess performance against established benchmarks and to identify areas of focus to improve the health of our members. We would like to make you aware of important information for select performance measures, including what you need to report to be compliant with these measures, as well as specific patient activities around each measure that will contribute to the improved health and well-being of your patients. HEDIS Measures for Tufts Medicare Preferred HMO and Tufts Health Plan SCO (HMO SNP) Controlling High Blood Pressure (CBP) Patients age 60 and over are considered to have adequate control of hypertension when their blood pressure reading is <150/90 mmhg. For patients with diabetes, regardless of age, adequate control is considered to be a blood pressure of <140/90 mmhg. Actual blood pressure readings should be maintained as part of the patient s medical record. Important Changes to Annual Monitoring for Patients on Persistent Medication (MPM) Measure The revised MPM measure no longer allows a blood urea nitrogen test to count as evidence of annual monitoring for ACE inhibitors and ARB, digoxin and diuretics. A lab panel test or a serum creatinine and a serum potassium test are required. For patients on digoxin, a serum digoxin test is also required. HEDIS Measures for Tufts Health Plan SCO (HMO SNP) Only In addition to the standard HEDIS measures for Medicare Advantage plans, as a Special Needs Plan (SNP), there are two additional SNP-only measures for Tufts Health Plan SCO (HMO SNP) members: Care of Older Adults (COA) and Medication Reconciliation Post-Discharge (MRP). Care for Older Adults (COA) This measure is intended to verify that members age 66 and older have had each of the following four items occur during the measurement year. All must be dated and present in the medical record during the measurement year (January 1 to December 31). Note that measures 2 4 below are CMS Star Measures. } Advanced Care Planning: Advanced care planning is defined as discussions about preferences for resuscitation, life-sustaining treatment and end-of-life care. The medical record must contain an actual advanced care plan (such as an advance directive or a living will) or evidence of an advanced care planning discussion. } Medication Review: The medical record must contain a medication list and a medication review should be conducted by a prescribing practitioner or clinical pharmacist. If a patient is not taking any medication, a dated notation that a medication review has been conducted by a prescribing practitioner or clinical pharmacist stating such must be present in the medical record. } Functional Status Assessment: Evidence of a complete functional status assessment must be present in the medical record. Examples include results from a standardized functional status assessment tool or notation that activities of daily living (ADL) were assessed. } Pain Assessment: Evidence of a pain assessment must be present in the medical record. This may be in the form of a standardized pain assessment tool or other documentation that the member was assessed for pain. The CPT and HCPCS codes listed below can be submitted on claims to substantiate that medication review or medication reconciliation were performed during an office visit. Using these codes can alleviate the need to provide medical record documentation in the future. You should always use the code that is most appropriate for the individual situation. Activity Advanced Care Planning Medication List (must be dated same as Medication Review) Provider Medication Review (must be dated same as Medication List) Medication Review (via Transitional Care Management) Functional Status Assessment Pain Assessment Codes Accepted 1157F, 1158F, S F, G , 99605, 99606, 1160F 99495, F 1125F, 1126F Medication Reconciliation Post-Discharge (MRP) The MRP measure requires that any Tufts Health Plan SCO member with an inpatient discharge (acute or nonacute) from January 1 to December 1 of the measurement year have his or her discharge medications reconciled with their current medication list within 30 days of the discharge. The reconciliation needs to be done by a prescribing practitioner, clinical pharmacist or registered nurse. Providers can document this activity to Tufts Health Plan on their claims using the following codes: CPT codes and 99496, CPT Cat. II: 1111F. 2

3 Expanded Care and Support for Members With Dementia In collaboration with the Alzheimer s Association of Massachusetts and New Hampshire, Tufts Health Plan has developed a free program that is open to plan members and their families. The dementia care consultation program is an in-depth personalized service for individuals and families who are facing decisions and challenges associated with Alzheimer s disease and related dementias. This free program began as a 10-month pilot study of 100 members and their families in 2013, and is now fully integrated with more than 450 referrals. The goal of the program is for each family to develop an understanding of a dementia diagnosis, create a collaborative care plan which maximizes the independence of the affected individual, secure needed resources, and develop strategies for the best possible symptom management and communication. Once a member is referred to the program, the dementia care consultant makes outreach to the identified caregiver for a needs-based assessment. An individualized care plan outlining personalized recommendations and resources is then sent to the caregiver. Feedback is then shared with the care manager and PCP. Follow-up with the caregiver and clinical staff is provided until the identified needs and goals have been met. The caregiver is also connected to the Alzheimer s Association, which provides ongoing educational programs, support groups and a 24/7 helpline. This program is open to all Tufts Health Plan members who have or care for someone with Alzheimer s disease or other dementia, or who have concerns with a member s memory or cognition. No formal diagnosis is required. A referral form and Inclusion Criteria for Alzheimer s Association Consultation are available in the Medical Management Toolbox in the Tufts Medicare Preferred HMO section at tuftshealthplan.com/providers. For more information, please contact Elyse Rokos, LICSW, Dementia Care Consultant, at , ext. 2384, or elyse_rokos@tufts-health.com. Reducing Readmissions Tufts Health Plan has implemented a quality improvement project to reduce all-cause readmission rates for its members. The project aims to promote the following outcomes for members: } Reduce inpatient admissions and improve quality of life } Reduce mortality, morbidity and complications } Improve patient-centered care and satisfaction with health care delivery } Improve members well-being, including health status, functional status, mental health and social support systems } Reduce unnecessary health care utilization and cost Tufts Health Plan members who have been discharged from an acute facility receive coaching and education on early recognition of symptoms, medication adherence, the importance of PCP follow-up, and preventive measures. The project also includes the following activities: } Connecting members with community support services where there is lack of caregiver assistance } Coordinating and implementing assistance with activities of daily living needs } Providing guidance before, during and after an inpatient admission to minimize negative outcomes of hospitalization How you can help reduce readmissions: } Educate your patients on early recognition and timely reporting of symptoms, medication adherence, and preventive measures. } Engage with your patients, their caregivers and the Tufts Health Plan SCO Primary Care Team (if applicable) at each point along the care continuum in efforts to improve communication, coordination and discharge planning. } Reinforce the importance of post-acute follow-up in a timely manner. Tufts Health Plan recommends having a PCP follow-up visit within seven days of the member s being discharged from an acute facility. Zostavax Vaccine For Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options members, Zostavax is covered under the Medicare Part D prescription drug benefit and can be obtained through retail pharmacies. Certified pharmacists at many retail pharmacies can administer Zostavax. The member will pay the appropriate copay, and the pharmacist will process the claim through the pharmacy benefit manager claim system. A Vaccine Locator to find pharmacies that administer Zostavax is available at 3 If you have a supply of vaccine on hand and prefer to administer the vaccine yourself, you can bill CVS Caremark directly by submitting a paper CMS 1500 claim form for the vaccine and/or administration to Caremark Medicare Vaccine Processing, PO Box 52193, Phoenix, AZ SilverScript, the CVS Caremark subsidiary that contracts with Tufts Health Plan Medicare Preferred for all vaccines covered under Part D, processes the claim (usually within 30 days) and returns reimbursement to the doctor s office with an explanation of payment, including the member s cost share.

4 Preventing Secondary Fractures in Older Women Statistics indicate that one in two women has a fragility fracture after the age of 50. According to clinical literature, having a prior fracture, regardless of a confirmed fragility fracture, is a significant predictor of a future fracture. Older adults, particularly females who have had a fracture, are at increased risk of hospital stays, admission to long-term care facilities and mortality. Tufts Health Plan strongly encourages providers to carefully evaluate all patients with a fragility fracture for bone density testing, osteoporosis treatment and falls prevention counselling. A bone mineral density (BMD) test may be appropriate for the following individuals: } Adults who have a fracture after age 50 } Women age 65 and older and men age 70 and older, regardless of clinical risk factors } Younger postmenopausal women, women in the menopausal transition and men age with clinical risk for fracture } Adults with certain conditions, such as rheumatoid arthritis, or who are taking certain medications (for example, glucocorticoids in a daily dose 5mg prednisone or equivalent for three months or longer) For those at risk, BMD scans should be repeated at least every two years. Tufts Health Plan recommends that all female members aged who suffer a new fracture obtain a BMD scan or appropriate medication within six months of that fracture if a BMD scan was not previously performed within the past two years or a medication to treat osteoporosis was not prescribed within the past year. Tufts Health Plan provides coverage for an at-home BMD scan for all Tufts Medicare Preferred HMO or Tufts Health Plan Senior Care Options members who are home-bound or who lack transportation to a provider office. (Certain locations within Massachusetts may be excluded.) There is no cost share to members for either method. Therapy is also a key component for secondary fracture risk reduction and includes bisphosphonates, antiresorptives and anabolic agents. Patients should also be counseled on the importance of incorporating calcium, vitamin D and exercise as part of any fracture prevention plan. All patients being considered for treatment of osteoporosis should also be counseled on risk factor reduction, including preventing falls. Potential areas of assessment for providers and care management may include dehydration, malnutrition, exercise, impaired transfer and mobility, home living situations (e.g., low lighting and throw rugs), and lack of assistive devices. Tufts Medicare Preferred HMO and Tufts Health Plan SCO care managers are available to collaborate with medical staff regarding further education, assistance and care coordination. For further information, contact Derek J. McFerran, Pharm. D., CGP, FASCP, Manager of Clinical Specialties, at , ext. 8552, or derek_mcferran@tufts-health.com. Tufts Health Plan SCO Disease Management Program In the fall of 2014, Tufts Health Plan Senior Care Options initiated a disease management program for Tufts Health Plan SCO members with chronic heart failure, COPD, dementia, depression and/or diabetes. The goal of the program is to help members who have these conditions better understand and manage their disease. Under the guidance of our care management team, this program is designed to provide education and coaching to members and to support their plan of care. The disease management program provides the following services: } Educational and informational materials that can assist members in understanding and managing their disease } Disease-specific health assessments } Support from our care managers to ensure that members understand how to best manage their disease } Member-centric plans of care that define and review disease-specific goals and interventions } Ongoing evaluation of health status } Identification of gaps in care to assess opportunities for early intervention Tufts Health Plan SCO members with CHF, COPD and diabetes are automatically enrolled in the program once identified as having the condition through a combination of claims data and self-reported information. Members with dementia or depression are identified using the same information; however, members are enrolled in the program once they have agreed to participate. The disease management program is provided at no additional cost to Tufts Health Plan SCO members. If you have questions about the Tufts Health Plan SCO Disease Management Program, would like to discuss enrolling a member in the program, or would like to know if a member has been enrolled, please contact Tufts Health Plan SCO Care Management at

5 Tufts Medicare Preferred HMO Care Management The Tufts Health Plan Medicare Preferred integrated care management model has multiple core guiding principles. The cornerstone of the model consists of the primary care provider, care manager and member working as a unified team. Our care management team integrates principles of care management, disease management, member selfmanagement, transitional care, and caregiver support into the primary care model to promote improved care for our members. Integrated care management helps members across the continuum of care through inpatient management, transition management and ambulatory care management. Inpatient management allows care managers to work with inpatient providers to create evidence-based, standardized care for the cross-continuum management of highest risk members. Transition management is a key opportunity to prevent complications and avoidable admissions and readmissions. It relies on front-loaded home health with care paths, medication adherence and chronic disease management. Ambulatory care management of members with both chronic and complex conditions allows care managers to integrate with PCP practices to facilitate comprehensive member engagement. All levels of care management allow for early and actionable identification of high-risk members through predictive modeling and clinician referrals while focusing on community resources and face-to-face member interaction. Regardless of where a member falls on the care continuum, multidisciplinary collaboration with pharmacists and behavioral health, palliative and hospice providers, when appropriate, is imperative. In addition, standardized education, behavior modification techniques, and patient engagement and activation are all incorporated into member-centric action plans for member and caregiver selfmanagement. Referrals to the chronic care management program may be appropriate for members with one or more chronic conditions (e.g., COPD, CHF, DM) with self-management deficits such as IADL or 1 ADL deficit or medication adherence or exercise/ diet needs. A referral to the program may be appropriate for members with one or more chronic conditions and two or more of the following risks: one or more admissions in the past six months, medication adherence issues, altered mental status with a teachable caregiver, living alone, one or two falls in the past six months, community resource needs, or is age 85 years or older. A referral to the complex care management program may be appropriate for individuals with a catastrophic/traumatic injury (e.g., stroke, brain injury) or two or more chronic conditions (e.g., COPD, CHF) with IADL and multiple ADL deficits, cognitive impairment and living alone, or a new oncology diagnosis. A referral may also be appropriate for those who have two or more chronic conditions and two or more of the following: two or more admissions in the previous six months, three or more falls in the past six months, 10 or more medications, psychosocial needs, community resource needs, altered mental status, is age 85 years or older, living alone, or medication adherence concerns. To refer a patient to the care management program, contact your Tufts Medicare Preferred HMO care manager. If you need assistance in identifying the appropriate Tufts Medicare Preferred HMO care manager, please call Tufts Health Plan Medicare Preferred Provider Relations at Tufts Medicare Preferred HMO All-Member Survey Update In January 2015, Tufts Medicare Preferred HMO launched its annual member survey. The goal of the survey is to understand members perspectives on different aspects of their physical and mental health. Members survey responses trigger a variety of Tufts Medicare Preferred HMO clinical outreach and member education programs. Also, as in past years, we shared reports at the group and PCP level on their performance relative to the network and peers respectively, as well as recommendations related to their members. Please contact your Tufts Medicare Preferred HMO Group Medical Director to receive your data. However, please note that we need sufficient sample size to report data at the PCP level. Tufts Health Plan Senior Care Options Annual Care Model Training Requirement The Centers for Medicare & Medicaid Services requires Tufts Health Plan Senior Care Options to provide care model training to its provider network on provider enrollment and annually thereafter. To facilitate your completing this training, we have developed an online educational webcast specifically for Tufts Health Plan SCO providers that includes the following topics: } An overview of the plan } Care model information } Provider roles and resources 5 continued on page 6

6 Tufts Health Plan Senior Care Options Annual Care Model Training Requirement (Continued) This online training, which can be completed in approximately 30 minutes, is available on our website. To access the training, go the Tufts Health Plan SCO section of the public Provider website at tuftshealthplan.com/providers: } From the left navigation menu, select Plans and then Tufts Health Plan Senior Care Options, or } Under Plans and Products click Tufts Health Plan Senior Care Options. } The Care Model Training webcast can be accessed by selecting Training and Education. Once you have completed the webcast, please complete the evaluation survey at the end of the training and attest that you have reviewed the information to document your participation. If you have any questions about the training or how to access the webcast, or should you wish to have an on-site training delivered by a Tufts Health Plan SCO clinical team member, please call Provider Relations at PROVIDER Newsletter Tufts Health Plan 705 Mount Auburn Street Watertown, MA tuftshealthplan.com/providers Presorted Standard U.S. Postage PAID Brockton, MA Permit No. 301? For More Information ADDRESS SERVICE REQUESTED } tuftshealthplan.com/providers } Tufts Health Plan Medicare Preferred Provider Relations WHAT S INSIDE Reducing the Risk for Cardiovascular Disease...1 Screening for Depression...1 Important HEDIS Measure Information...2 Expanded Care and Support for Members with Dementia...3 Reducing Readmissions...3 Zostavax Vaccine...3 Preventing Secondary Fractures in Older Women...4 Tufts Health Plan SCO Disease Management Program...4 Tufts Preferred HMO Care Management...5 Tufts Medicare Preferred HMO All-Member Survey Update...5 Tufts Health Plan Senior Care Options Annual Care Model Training Requirement