ISSUE 1 | 2012 PROVIDERPROVIDER CONNECTION

ISSUE 1 | 2012

PROVIDER+CONNECTION

Produced by Kaiser Foundation Health Plan of Ohio

providers.oh

FOR NETWORK PROVIDERS OF KAISER PERMANENTE

KAISER PERMANENTE'S

COMPLEX CASE MANAGEMENT PROGRAM

The Kaiser Permanente Ohio Complex Case Management (CCM) program began on November 1, 2011, and consists of focused, high intensity case management and care coordination services to positively affect the health outcomes of vulnerable, at risk, and high utilization member populations through the use of clinical systems, streamlined evidence-based care pathways, and processes.

The CCM program is designed to ensure that members at high risk for hospital re-admissions due to catastrophic events or select chronic conditions receive evidence-based, comprehensive assessments, detailed care plans, and posthospitalization follow-up. The goal is to quickly reconnect members with primary, specialty, and/or population management teams. This collaborative program integrates catastrophic case management, resource stewardship

(utilization management), and chronic care coordination for service areas within Kaiser Permanente.

The CCM program is staffed by Registered Nurses and Licensed Independent Social Workers that provide both admission and post-hospital discharge case management and coordination. Case managers (from the catastrophic case management team) continuously evaluate the quality of care provided as well as outcomes of treatments and services during and immediately following acute admission as members and their families require focused management and support.

Case managers (from the chronic care coordination team) provide post-hospital discharge care to members with

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INSIDE THIS ISSUE:

New Look and Feel at the Community Provider Portal . . . . . . . . . . . . . . . . . . . . . . . . 3 Kaiser Permanente's Quality Management Program . . . 4 Speech Language Pathology and Occupational Therapy Referrals . . . . . . . . . . . . . . . . 6 Lower Prices on Generic Drugs in 2012 . . . . . . . . . . . . . . 7 Wellness Coaching by Phone . . . . . . . . . . . . . . . . . . . . . 8 Customer Relations Is Here To Help Our Members . . . 9

Clinical Guidelines Updates . . . . . . . . . . . . . . . . . . . . . . 9

Medical Management: Utilization Department Contacts . . . . . . . . . . . . . . . . . . 10

New CMS Required Preventive Services for Medicare Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . 10

Kaiser Permanente Online Affiliate . . . . . . . . . . . . . . . . 11

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Kaiser Permanente's Complex Case Management Program

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newly diagnosed or complex Heart Failure or HIV diagnosis to facilitate transitions and ensure members are able to self-manage conditions. Both teams work together so our members are successfully supported as they move across the care continuum. As additional resources to support the CCM program become available, the overall goal of the program will be to expand criteria to include other conditions that utilize the top 1% of all resources.

Objectives

? Assist members in regaining an optimal health status; ? Improved functional status of chronic conditions; ? Proactively identify and attain members for the CCM

program; ? Develop effective case management care plans that

match the members' health needs with timely, evidencebased care and services; ? Promote improved quality of life in a cost effective setting; ? Provide timely access to services; and ? Provide case managers tools to positively impact the target population.

? Multiple trauma due to motor vehicle accident or significant burn injury

? Traumatic spine injuries ? Traumatic brain injuries ? High risk pregnancy ? Complex wounds requiring specialized care ? NICU babies with anticipated prolonged length of stay ? Members in need of chronic pain medication management ? Cerebrovascular accident with extensive functional deficit ? Long term ventilator management ? Advanced illness planning: pilot program Advanced

Illness Coordinated Care Program began June 2011 ? Geriatric consultation clinic referrals

Kaiser Permanente members can request a case manager to help members or their caregiver coordinate their health care. Case management services are designed for people who have a complex medical condition or a newly diagnosed medical problem such as Heart Failure or HIV or a health condition that has required multiple hospital or emergency department admissions.

Goals

? Decrease inpatient re-admission rates; ? Decrease emergency department and clinical decision

unit admissions; and ? Promote member satisfaction with Kaiser Permanente.

Identifying Members for Complex Case Management

Target populations that require complex case management fall into one of the following groups:

? Members with complex chronic illnesses; ? Members with multiple co-morbidities; ? Members who experience catastrophic health episodes; ? Members who require intense interaction with the health

care system; and ? Members predicted to have high costs associated with

their care.

Specific member populations that will benefit from Complex Case Management include members stratified as high risk in one or more of the following populations:

? Heart Failure with qualifiers ? HIV with qualifiers ? Post solid organ transplant ? End stage renal disease/dialysis ? Late stage COPD ? Late stage cancers ? Asthma

Kaiser Permanente case managers are highly experienced registered nurses and licensed social workers who will help members access care and coordinate the services they need to achieve wellness. They will work closely with members to make certain they know how to best care for themselves. In addition, they will monitor care and make recommendations and/or referrals, as needed.

To see if one of your Kaiser Permanente members meet the criteria for case management services, call 888-953-5794.

? Members will be prompted to leave a message with their name, phone number, Kaiser Permanente medical record number, and the main reason why they would like to have their own case manager.

? Within three business days, a member of the Case Management team will contact the member about their past medical history, current medical condition, where they live, and their family/social support system.

? If the member meets the criteria for case management, they will be assigned a case manager. They can choose not to participate in, or opt to discontinue case management services at any time.

? If a member does not qualify for case management or chooses not to participate, Kaiser Permanente's case managers can discuss other ways to manage their care.

Case management services are one more way that we at Kaiser Permanente are helping our members Thrive.

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ISSUE 1 | 2012

NEW LOOK AND FEEL AT THE

COMMUNITY PROVIDER PORTAL

We are pleased to announce the debut of a new look and feel to the Community Provider Portal. The same great information is still found on the site but is presented in a crisp, clean, and easy to navigate site. You can access the website at: . oh/index.html You will see that navigational links can be found along the left-hand side of the page, providing a clear gateway to information such as the Provider Manual, Ohio Clinical Guidelines, and Referral Information. Providers can still access Online Affiliate in the same fashion and once inside the secured site, it will still look the same to them.

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KAISER PERMANENTE'S QUALITY MANAGEMENT PROGRAM

The Kaiser Permanente Quality Management Program was designed to improve the quality and safety of clinical care and the quality of services provided to our members. The Quality Improvement (QI) program prioritizes quality activities aligned with the region's strategic plan and provides resources in support of achieving the QI work plan. This complies with applicable regulatory and accrediting body requirements. Kaiser Permanente's QI work plan must address:

? Quality and safety of clinical care ? Quality of service ? Program scope ? Yearly objectives ? Yearly planned activities

? Timeframe within which each activity is to be achieved

? The staff member responsible for each activity

? Monitoring of previously identified issues ? Evaluation of the QI program

The Quality, Service, and Resource Stewardship Committee is the official quality committee for Kaiser Permanente. It establishes annual quality priorities, approves and evaluates progress and outcomes of the quality work plan, identifies major organizational quality initiatives, provides resources, reviews and recommends policy decisions, institutes needed actions, and ensures followup. Every year, a Program Description (PD) and a Program Evaluation (PE) is completed to provide the `big picture' of why a program description is needed, an overview of all the programs, and a summary of progress towards meeting planned goals.

PROGRAM DESCRIPTION

The 2012 PD encompasses the Ohio Permanente Medical Group (OPMG) clinical departments including Behavioral Health, ancillary departments, affiliated practitioners and providers, and oversight of delegated activities. It also provides a link to Medical Management, Risk Management and Patient Safety, Legal Counsel, Compliance, Accreditation, Customer Relations, Population Care Management and Prevention, the Medical Group, and the Care Experience initiatives.

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PROGRAM EVALUATION

The PE describes completed and ongoing QI initiatives, as well as program development, actions that were taken, metrics, trends, and comparative analysis, barriers to progress, and opportunities for improvement.

KAISER PERMANENTE'S QUALITY MANAGEMENT PROGRAM QI PROGRESS

Kaiser Permanente's Accreditation department oversees survey readiness, Healthcare Effectiveness Data and Information Set (HEDIS?) measurement, and improvement activities. Kaiser Permanente's HEDIS audit took place in March 2011, and our last National Committee for Quality Assurance (NCQA) onsite audit was conducted in August 2009. Based on the findings of the NCQA surveyors, Kaiser Permanente received an `Excellent' status for both the commercial and Medicare product lines. Any activity that was not completed in 2011 is reassessed and carried over

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Kaiser Permanente's Quality Management Program

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ISSUE 1 | 2012

to the 2012 work plan if appropriate. OPMG providers and staff track their assigned QI initiatives on a regular basis.

ABOUT THE NATIONAL COMMITTEE ON QUALITY ASSURANCE

The National Committee on Quality Assurance (NCQA) evaluates all resources the organization devotes to the QI program and the associated activities including staff, data sources, analytic resources, and evidence that Kaiser Permanente is completing QI activities in a competent and timely manner. To meet NCQA's Quality Improvement Standards, Kaiser Permanente must demonstrate that we are designing sound studies, applying statistical analysis to data, and deriving meaning from the statistical analysis.

NCQA also oversights the annual Healthcare Effectiveness Data and Information Set (HEDIS?) for clinical effectiveness of care measures of performance. Several HEDIS measures of focus improved in 2011. Kaiser Permanente exceeded our goals for cancer screening and caring for our diabetic and cardiac patients. Electronic medical record tools, such as the Proactive Office Encounter and Best Practice Alerts,

were instituted and provided clinical staff with the ability to easily identify which tests are needed and then order and advise the member to schedule screenings such as a mammogram, pap test, or blood work.

Health plan member satisfaction is measured at least annually with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (Commercial HMO members) and the Member Experience: Tracking, Evaluation, and Opinion Research (METEOR) survey (Commercial and Medicare HMO members). NCQA uses nine CAHPS measures to determine accreditation points. Ohio's scores continue to improve each year for CAHPS and METEOR. More details, including competitor comparisons can be found in the 2011 CAHPS report.

To request a printed hard copy of the `Quality/Medical Management Annual Program Description' and the `Quality Program Annual Evaluation,' contact your Network Associate or the Network Development department at 800-441-9742.

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