Embed Size (px)
Citation preview
2nd Quarter MSHO/MSC+ Care Coordination Training
2018
June 13th-Care Systems and Internal Care Coordinators
June 14th-Recorded WebEx
Agenda
• Opioid Management
• STARS
• Advanced Directives
• Care Coordination Updates
• Q & A
Opioid Management
Current and Future Opioid Management Initiatives
Overview Formulary Management
– Excluded Medications
– Utilization Management Strategies
– Point of Sale Claim Edits
Overutilization Monitoring and Outreach
– Monitoring
– Outreach and Case Management
Other Programs
– Restricted Recipient Program
– Medication Assisted Treatment Clinical Protocol
Formulary Management
Excluded Medications
MSHO
– 2018• Brand name opioids, oxycodone ER
– 2019• Brand name opioids, oxycodone ER, oxymorphone IR and
ER, tramadol ER
MSC+
– 2018• Brand name opioids
– 2019• TBD - Potentially brand name opioids, oxymorphone IR and
ER, and tramadol ER
Utilization Management Strategies: MSHO
Prior Authorization
– 2018 and 2019
• Long acting opioids
• Transmucosal fentanyl
• > 200 MME cumulative
Quantity Limits
– 2018 and 2019
• All opioids have CMS approved quantity limits
Utilization Management Strategies: MSC+
Prior Authorization
– 2018
• Oxycodone ER– Must try morphine ER first
– 2019
• TBD – potentially adding long acting opioid and/or transmucosal fentanyl
Quantity Limits
– 2018
• 120 MME for all opioid medications
– 2019
• 90 MME for all opioid medication
Point of Sale Claim Edits
Claim edit – Drug utilization review message through claims processing which trigger message to pharmacist
– Pharmacist will review message and override as necessary
MSHO and MSC+
– 2018 and 2019
• Drug interactions
• Therapy duplication
• Drug age
• Excessive dosing
Overutilization Monitoring and Outreach
Overutilization Monitoring Process
Monthly report of all UCare members taking opioid medications
Threshold for review (CMS definition)
– ≥ 90 MME and;
– > 3 prescribers and > 3 pharmacies or;
– > 5 prescribers
Other reasons for review
– Very high MME
– High MME with dangerous concomitant medications
Exclusions for cancer and hospice
Reviews occur each quarter with outreach and care management for appropriate members
Overutilization Outreach and Case Management
The following occurs for each member identified for opioid overutilization
– Written communications are sent to prescribers
• Appropriateness of opioid dose, number of prescribers, and concomitant medications
– Phone call to prescriber if no response occurs
If necessary, beneficiary level claim edits may be implemented to restrict opioid prescriptions.
Members may be recommended for further care management
Other Programs
Restricted Recipient Program
Program for Minnesota Health Care Program (MHCP) members
Use services at a frequency or amount that is not medically necessary and/or who have used health services that resulted in unnecessary costs
Upon enrollment, the recipient is restricted to one physician, one clinic, one pharmacy and one hospital for health care services.
The designated primary care provider manages referrals to non-designated providers
Placement in the restricted recipient program lasts for a period of twenty-four (24) months.
Medication Assisted Treatment (MAT) Clinical Protocol
The MAT Protocol is a member-centric, voluntary program, focused on building trusting relationships with participating members through telephonic case management
UCare’s MAT Protocol goals align with those of the State of Minnesota’s Opioid Action plan– Remove barriers to successful Medicine Assisted Treatment
– Refer members to resources to maintain a healthy lifestyle
– Monitor & support strict adherence to MAT requirements
– Educate members on safety/risks for use of other controlled substances
– Promote prevention of overdose and death by overdose among MAT population
– Prevent Relapse
Stars Update
Quarterly – June, 2018
Preliminary HEDIS
• Showing some great improvement in MSHO Clinical rates for preventive care.
• Areas that don’t improve but stay same, are
still areas for focus.
Where we need focus
• Breast Cancer Screening Overall appears to only be about 1% increase ( 2 Star ).
• Diabetes Eye Exam. Stayed at 81% 81% is the 5 Star cut off, need some improvement to stay.
• Diabetes Care – Kidney Disease Monitoring 93% but cut points are really tight, this is only a 2 Star.
Did actually come up 2% so went from 1 to a 2! 94% is 3 Star, 96% is 4 star, 98% is 5 star.
Where showing progress
• Colon Cancer Screening Shows about a 4% improvement. At about 68%, still 3 star. 73% is 4 star.
• Osteoporosis screening From 11% to 33%. Up to a 2 Star rating
• Plan all cause readmissions 1% improvement 3 Star
• Functional Status assessments and Pain screenings 2% increase in functional status (4 star) 1% in pain screenings (5 Star)
• Diabetes Care – Blood Sugar Controlled From 77% to 81% 4 Star to 5 Star potentially!
What is UCare doing?
• Partnership with vendor doing in home osteoporosis testing.
• Mailing to members in birth month to address specific gaps in care.
• Will conduct in home CRC mailing again tentatively in June.
• Expanding partnerships with clinics to work on measures.
• Working on expanding ways to reach members:
Social media
Newsletter articles
Additional live/automated engagement
• Auto calls in other languages
What can you do?
• Focus on ways to improve Breast Cancer Screening! Remind members of incentive- $50.00
Any Breast Cancer events?
Education to members! No need for PCP visit, assist to schedule!
• Ensure Diabetic members are getting all 3 preventive care needs addressed! Potential for $75.00 for Eye Exam-A1c-Nephropathy
testing!
• Any member stories?
A Royal THANK YOU!
• Great appreciation for the quick turn around times for the file requests on our MDH Care Plan Audit and our CMS Data Validation audit!
Part C Assessment Reporting
• This also feeds into a Star measure- SNP Assessment reporting!
• Important to report accurately.
• Do Not include 6 month assessments.
• Ensure you are conducting and reporting product changes.
• Examples of common clarifications we need.
Common clarifications
Tips • Only indicate what did happen, not what was supposed to
happen.
• If you miss an assessment on the log one month, just add to the next month’s log.
• Schedule your Annuals well in advance of the 365 day to avoid going over.
• Don’t forget to complete product changes!
• If indicate a refusal, ensure you have documentation.
• If indicate an Unable to reach, ensure you have 4 documented attempts.
Again a Royal THANK YOU!!!
Therese’s Story
• Her Story
Advanced Directives
Why Are Advance Directives Needed?
• Population is aging.• People are seeking health care alone.• Health crises are unpredictable.• Not appropriate to educate on advance
directives in midst of crisis.• Eases burden for family members/providers.• Reduces fear and worry about health care
decisions.• Communicates your wishes when you are not
able to.
Defining Advance Directives• Legal documents that allow patients to put
healthcare wishes in writing, or to appoint someone they trust to make decisions for them, if they become incapacitated.
• Two types – Living will. Durable power of attorney for healthcare.
• In Minnesota, an Advance Directive is called a Health Care Directive. Combines living will (medical instructions) and
durable power of attorney for health care (someone to act as your agent).
Why Don’t People Have Advance Directives
• Only 18-32% complete the form. Low health literacy rates. Language barriers. Healthy people don’t see the need. Discomfort/superstition with discussion. Just don’t get around to it.
History
• Advance Directives created in response to increasing medical technology.
• 80% of deaths occur in health care facilities.
• Developed to help avoid suffering and costs associated with unwanted treatment.
• Living will proposed in 1969 – provided directives about course of treatment.
• Durable power of attorney added next.
• Wishes and values added later.
History
• 1998 – Minnesota introduced the Health Care Directive tool to help members put wishes into writing.
• Combines living will (1989) and Durable Power of Attorney for Health Care (1993).
• Makes it easier to complete an advance directive.
Did You Know?
• It is just as important for individual who wants to initiate or continue treatment to leave written instructions, as it is for those who have other preferences.
• A health care directive does not require an attorney to complete.
• Once written, a health care directive can be changed or revoked as long as you have the capacity to do so.
What’s in a Health Care Directive?
• Many choices, including: Personal info- name, address, etc. Agent duties – describes them. Agent notes- choose how agent can act, Act alone, together, primary agent,
secondary, etc. Powers of agent- extended or limited. You don’t need to answer every
question.
What’s in a Health Care Directive?
Health care instructions To describe views, beliefs, care preferences,
organ donation. May add your own instructions.
Signatures and dates Notary public or witness signatures.
Records Master list of who has copies. Review and updates.
Required Elements of Health Care Directives
• Must be in writing.• Must be dated.• Must state person’s name.• Must be executed by a person with capacity to do so. • Must be signed by you or someone authorized to sign
for you, when you can understand and communicate your health care wishes.
• Must be verified by a notary or two witnesses.• Must include either health instructions OR a health
care power of attorney, or both.
What to Do with a Health Care Directive
Inform others that it exists.• Inform others of the content, who the
decision makers are, etc.• Give others a copy, especially health care
providers, keep record of who has copies.• Review and update as health care needs
change.• Keep in a safe place, where easily found, not
in safe deposit box.• Copies of the form are valid.
What to Do with a Health Care Directive
Review and update it when there are changes in:• Health status.• State of residence.
An advance directive from another state must meet requirements of each state.
Requests for assisted suicide will not be followed- regardless of state.
• The availability of individuals named as health care agent or alternative agents.
How Long Does It Last?
Until you change or cancel it.
• You can change it by.. Writing a statement saying you want to
cancel it. Destroying it. Telling at least two people you want to
cancel it. Writing a new health care directive.
Advance Directives Will Not Be Honored
When..• The request for treatment is outside of
reasonable medical practice.
• The request is for assisted suicide, euthanasia, mercy killing.
Did You Know?
• It is illegal for health care providers to require patients to complete an advance directive.
• Health care providers are required to tell patients about advance directive laws in Minnesota and note whether or not the patient has one.
• Laws regarding advance directives are not the same in all fifty states in the U.S.
POLST• Provider Orders for Life Sustaining Treatment (POLST)
Is a portable medical order› Is one part of advance care planning, does NOT
replace health care directive.› Identifies what types of treatment a pt. wishes to
receive at end of life or in medical emergency.› Helps convey those wishes to emergency services and
other medical providers.› Used and recognized by hospitals, LTC facilities,
medical professionals, and EMS throughout MN.› Must be signed by a licensed provider to be valid.› Standardized form in MN.› EMS can only follow signed medical orders, thus they
can follow a POLST but not a health care directive.
Care Coordinator’s Role
• Review member record for advance directive information.
• Ask member if they have an advance directive If yes, document the discussion, what
they have, etc. If no, ask if they want to discuss.
Care Coordinator’s Role
• If member wishes to discuss advance directive: Describe advance directive. Ask if they want help completing one- locate
forms, etc. Give ideas or suggestions for talking with
family, etc. Support their ideas or wishes. Follow up on any planned discussion. Give resources for advance directives.
Care Coordinator’s Role
• If member does NOT wish to discuss advance directive: Document that the member does not
want to discuss. Assure members that they will still have
coverage if they choose to have an advance directive, or not.
• Address advance directives annually with all members, and document.
Care Coordinator’s Role
• May assist member in filling out advance directive.
• May not act as witness or authorized agent.
Cultural Considerations
• Approach carefully.
• Respect cultural beliefs about death and dying.
• Do not require member to discuss.
• Document if member does not want to discuss.
• Act as a resource when possible.
Additional Resources
• UCare product overviews on Care Manager’s tab on UCare website. Click on Questions and Answers about
Health Care Directives. Senior Linkage Line.
For More Information
• The Minnesota Health Care Directive: Available in English and Large Print Minnesota Health Care Directive
Planning Toolkit can be printed online at: http://z.umn.edu/mnhcdirective/.
For More Information
• Five Wishes- U.S. Advance Directive Created by Aging with Dignity. Document available in other languages. Discusses individual’s personal,
emotional and spiritual needs as well as their medical wishes.
Available online at http://www.agingwithdignity.org/fivewishes.
Care Coordination Updates
Annual Wellness Visit incentive
• MSHO Members who complete an Annual Wellness Visit and have the doctor/provider complete the voucher will receive a $25 gift card.
• UCare mails out the voucher to all members who have not had an Annual Wellness Visit in the last 12 months.
• An online version is available along with all incentive vouchers at www.ucare.org/rewards.
• The visit must be with a Primary Care Physician
Care Coordination Letters
• UCare’s letters that are posted to the UCare website have been approved by CMS/DHS, meaning: Verbiage cannot be altered The approval on the bottom can not be
taken off i.e.› MSC+ H2456_020918 DHS Approved
(02092018) U7724 (02/18)
• Care Coordinators can alter: Verbiage in <>’s (carrots)
PCA Appeals Outcomes
• Care Coordinators have asked UCare to notify them when a member appeal is overturned for PCA services, so they can account for additional hours in the member’s waiver budget.
• When a decision is made to overturn a DTR of PCA services, UCare will issue the care coordinator a copy of the adjusted authorization letter via fax. Please note that the member and provider will
receive a mailed copy of the adjusted authorization based on the appeal determination.
Waiver Service Approval Form (WSAF)
• Waiver Service Approval Forms are required for approval of any EW service. Please note the following reminders when submitting Waiver Service Approval Forms to UCare:
Elderly Waiver (EW) providers must be registered with DHS.
The EW provider must also be registered with UCare and have a UCare EW provider ID number in order to bill for services. When completing the provider section of the WSAF, please document the EW provider ID number.
› Note, some providers have more than one UCare provider ID based on the line of service. Obtaining and documenting the correct EW provider ID will help prevent delays or claim denials.
If the provider is registered with DHS but not with UCare, they are required to complete the “Provider Add/Update Form” located on UCare’s website and must obtain the created provider ID prior to claims submission.
› https://www.ucare.org/providers/Provider-Profile/Pages/FacilityAdd.aspx
EW Reminders
• All EW services require an authorization via the WSAF.
• Members must access and exhaust medical benefits before accessing EW benefits.
• Due to safety reasons mobility devices such as wheelchairs, scooters and lift chairs maybe subject to review. i.e. CMS and DHS require that recipients are
able to safely operate (demonstrated based assessment) or transfer (lift chair) from these items.
2018 Care Coordination Satisfaction Survey
• All UCare care coordinators will receive the 2018 Care Coordination Satisfaction Survey in July through Survey Monkey.
• Every response is confidential and helps UCare identify potential improvements in our processes.
• Please take a few moments to complete the survey, as we value your feedback.
• Results will be shared at the 3rd quarterly.
UCare Secure Email Site
• UCare cannot open 3rd party secure emails.
• When sending member PHI to UCare Care Coordinators must send it via UCare’s Secure email site: https://web1.zixmail.net/s/e?b=ucare_minnesota&
• If you do not have an account you will need to register.
UCare Website
UCare recently introduced some changes to the provider web pages. With these enhancements, the Care Manager site has been redesigned with a more intuitive look and feel.• Here are some things to keep in mind when visiting
the website: Check and update your bookmarks to the new
URLs showing in the address line. Everything on the current website will be on the
new site, but it may be in a new location. Look for information “drawers” that open when
clicked to expose additional information on a particular subject.
• This is the first of several improvements we will be introducing to support your online experience. We will keep you informed along the way.
