Substance Use Disorder HEDIS Measures

Thank you for attending the Behavioral Health Quality Program’s presentation, an overview of Substance Use Disorder related HEDIS measures. My name is Kerry Bennett and I'm a Licensed Clinical Social Worker, and one of the Behavioral Health Clinical Quality Improvement Liaisons also known as a CQIL. This presentation is provided in part by Horizon's Behavioral Health Department HEDIS Team. We thank you for joining, and we hope you will attend future presentations. If you would like more information, please reach out to your assigned Behavioral Health Clinical Quality Improvement Liaison, or you can utilize the general Behavioral Health HEDIS Team email. Contact information will be provided at the end of this presentation.

To begin, I'm going to review the agenda for today's call. Our objectives are, that at the conclusion of this training, you will have an improved understanding of Horizon's goals, NCQA and HEDIS, define the measure requirements and understand the criteria to meet each measure, be able to apply best practice recommendations and finally access the additional resources from Horizon to help you improve the quality of care provided to our members.

Horizon's goal for the quality programs is to improve clinical outcomes and performance on HEDIS measures and promote the care our members receive.

The National Committee for Quality Assurance, also known as NCQA, is a private nonprofit organization focused on quality of care. NCQA provides accreditation to a wide range of healthcare organizations and helps Horizon meet the goal of accreditation requirements in promoting supportive care that keeps members at optimum levels of health, while controlling costs and meeting government and purchaser requirements.

When you see the NCQA seal on a health plans materials that indicates that the plan has met the set guidelines for the standardized quality performance measures. NCQA is committed to providing consumers with the information needed to find high quality healthcare providers and plans.

If you are not already familiar with HEDIS it is an acronym that stands for Healthcare Effectiveness Data and Information Set. HEDIS was developed by the National Committee for Quality Assurance and is a set of standardized performance measures. It ensures the public has the information it needs to compare organization performance. HEDIS is not exclusive to Horizon. 90% of America's health plans use HEDIS to measure performance and there are 95 HEDIS measures categorized under six domains of care. Those domains of care include: effectiveness of care, access/availability of care, experience of care, utilization and risk adjusted utilization, health plan descriptive information and measures collected using electronic clinical data systems.

Not all of the Behavioral Health HEDIS measures apply to every line of business. This slide lists the 11 measures and indicates which product line the data is collected either Medicaid, Medicare or Commercial.

Even though every measure may not apply to every line of business or plan we should still adhere to the best practice suggestions, regardless if we are monitoring these measures or not, as we want to ensure we are providing the highest quality of care to our members. It is important to note that the two measures highlighted at the bottom in red are not current behavioral health owned measures. While the Behavioral Health HEDIS Team is not tasked with the performance rates for SMC or SMD they do relate to our members, so we monitor their performance. Highlighted in green are the three HEDIS measures that are specific to the treatment of Substance Use Disorders, or SUD and will be the focus of today's presentation.

The first measure we will be reviewing is Follow-Up After Emergency Department Visit for Substance Use, or FUA.

For this HEDIS measure, we are examining the percentage of emergency department visits for members 13 years of age and older with a principal diagnosis of substance use disorder or any diagnosis of drug overdose who had a follow-up. Members who fall into the eligible population are age 13 years and older and have a principal diagnosis of substance use disorder, or any diagnosis of drug overdose, on or between January 1st and December 1st of the measurement year. For this measure, a member must be age 13 or older on the date of the emergency department visit. The lines of business reported are Medicaid, Medicare and Commercial. In order to meet compliance for this HEDIS measure members with a principal diagnosis of a substance use disorder, or any diagnosis of drug overdose, had a follow up visit for either rates reported. First, a 7 day follow-up. A follow up visit or a pharmacotherapy dispensing event within 7 days after the emergency department visit, which is actually 8 total days because as per NCQA you are able to include visits and pharmacotherapy dispensing events that occur on the date of the emergency department visit. And second, a 30 day follow-up. A follow up visit or a pharmacotherapy dispensing event within 30 days after the emergency department visit, which is 31 total days, as you are able to include visits and pharmacotherapy dispensing events that occur on the date of the emergency department visit. Exclusions for this measure include members in hospice or using hospice services any time during the measurement year. Members who died any time during the measurement year. Emergency department visits that result in an inpatient stay and emergency department visits followed by an admission to an acute or non-acute inpatient care setting on the date of the emergency department visit, or within 30 days after the emergency department visit regardless of the principal diagnosis for the admission.

Here are several recommended best practices for the FUA measure. Schedule follow up appointments as soon as possible, particularly those patients recently discharged from the emergency department. Train patients and staff on the teach back method to ensure patients and caregivers review and understand discharge instructions and the next steps in their care. Encourage the patient to bring their discharge paperwork to their first appointment. Educate the patient about the importance of follow-up and adherence to treatment recommendations. Outreach patients who cancel appointments and assist them with rescheduling as soon as possible. Set flags if available in the electronic health record or develop a tracking method for patients due or past due for follow-up after discharge.

Use the same diagnosis for substance use disorder abuse or dependence at each follow-up visit. A non-mental illness diagnosis code will not fulfil this measure. Coordinate care with behavioral health practitioners by sharing progress notes and updates. Select culturally appropriate screening and assessment tools. Incorporate cultural factors into discharge planning. Consider social determinants of health factors as possible barriers to care.

The next measure we will be reviewing is Follow-Up After High-Intensity Care for Substance Use Disorder, or FUI.

For this HEDIS measure, we are examining the percentage of acute inpatient hospitalizations, residential treatment or withdrawal management visits for a diagnosis of substance use disorder among members 13 years of age and older that result in a follow-up visit or service for substance use disorder. There are two rates that are reported. Members who fall into the eligible population are age 13 years and older as of the date of discharge, stay or event from an acute inpatient discharge,

residential treatment or withdrawal management for a principal diagnosis of substance use disorder on or between January 1st and December 1st of the measurement year. The lines of business reported are Medicaid, Medicare and Commercial. In order to meet compliance for this HEDIS measure, members age 13 years and older as of the date of discharge, stay or event from an acute inpatient discharge, residential treatment or withdrawal management with a principal diagnosis of substance use disorder must have had a follow-up visit or service for either of the two rates reported. First, a 7 day follow up. A follow up visit or event with any practitioner for a principal diagnosis of substance use disorder

within the 7 days after the visit or discharge. Or second, a 30 day follow up. A follow up visit or event with any practitioner for principal diagnosis of substance use disorder within the 30 days after the visit or discharge. Please note, for this HEDIS measure, these are a true 7 or 30 day follow-up which begins after the visit or discharge.

Members are excluded if they are in hospice are using hospice services any time during the measurement year. Members who died any time during the measurement year. Initial discharge and direct transfer discharge if the last discharge occurs after December 1st of the measurement year.

Once again, this slide reviews some recommended best practices for the FUI measure. Discuss the importance of timely, recommended follow-up visits. Use the same diagnosis for substance use at each follow up. Coordinate care between behavioral health and primary care physicians.

Reach out to patients who cancel appointments and assist them with rescheduling as soon as possible. Consider telemedicine visits when in person visits are not available.

The last measure we are reviewing today is Initiation and Engagement of Substance Use Disorder Treatment, abbreviated IET.

Before we review IET, let's take a closer look at some of the HEDIS terminology pertaining to this measure. SUD Episode Date is the date of service for an encounter during the intake period with a diagnosis of substance use disorder. Initiation of SUD treatment is the percentage of new substance use disorder episodes that result in treatment initiation through an inpatient substance use disorder admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth visit

or medication treatment within 14 days. And Engagement of SUD Treatment is the percentage of new substance use disorder episodes that have evidence of treatment engagement within 34 days of initiation.

For this HEDIS measure, we are examining the percentage of adolescent and adult members with a new substance use disorder episodes that result in treatment initiation and engagement. There are two rates reported for this measure. Members who fall into the eligible population have a new episode of substance use disorder and are 13 years of age and older as of the SUD episode date and received Initiation of SUD Treatment and Engagement of SUD Treatment. The intake period is used to capture new substance use disorder episodes from November 15th of the year prior to the measurement year to November 14th of the measurement year. The lines of business reported are Medicaid, Medicare and Commercial. In order to meet compliance for this HEDIS measure adolescent and adult members with a new substance use disorder episode must have received the following:

Initiation of SUD treatment. Initiation of substance use disorder treatment within 14 days of the SUD Episode Date. And Engagement of SUD Treatment. Evidence of on-going treatment engagement within 34 days of initiation of substance use disorder treatment. Members are excluded if they are in hospice or using hospice services any time during the measurement year. Members who died any time during the measurement year.

Members with a history of diagnosis of substance use disorder or substance use disorder medication administration or dispensing event 194 days prior to the SUD Episode Date. Members who had an inpatient stay with a discharge date after November 27th of the measurement year.

The next few slides are going to look at different ways providers can meet compliance for the IET HEDIS measure. We want to reiterate that substance use disorder episodes that were not compliant for the Initiation of SUD Treatment rate, which again are visits that occur within 14 days of the SUD Episode Date, will not be considered compliant for the second rate reported Engagement of SUD Treatment. This information is per the NCQA HEDIS 2023 technical specifications.

This first example we are going to look at shows how to meet compliance when a member has been in an inpatient setting. John is 13 years old with a new onset SUD episode. He was admitted to an inpatient setting with a new diagnosis of substance use disorder on June 29th during the HEDIS measurement year. He was discharged on July 1st, with a diagnosis of opioid use disorder. Since his admission resulted in an inpatient stay

the discharge date is considered compliant for meeting initiation of treatment within 14 days. John was seen in an outpatient setting on July 15th. John is compliant for engagement of SUD treatment within the 34 day period after discharge and John would be compliant for meeting the IET HEDIS measure.

This next example shows how to meet measure compliance when a member is being seen in an outpatient setting. Jane is 13 years old with a new onset SUD episode. She was seen in an outpatient setting with a new diagnosis of substance use disorder on June 29th during the HEDIS measurement year. June 29th is now the SUD Episode Date. Jane was seen on July 1st, meeting numerator compliance for Initiation of SUD Treatment within 14 days. Jane was seen for an appointment on July 15th. Jane is compliant for engagement of SUD Treatment within the 34 day initiation event. And Jane would be compliant for meeting the IET HEDIS measure.

Best practices for providers that are applicable to the IET measure could include scheduling follow up appointments as soon as possible, particularly those patients recently discharged from the hospital. Encourage patient to bring their discharge paperwork to their first appointment. Discuss the importance of timely, recommended follow-up visits. Use the same diagnosis for substance use at each follow up. Coordinate care between the Behavioral Health and Primary Care Physician.

Reach out to patients who cancel appointments and assist them with rescheduling as soon as possible. Consider telemedicine visits when in person visits are not available. Select culturally appropriate screening and assessment tools. Incorporate cultural factors into treatment planning. Consider social determinants of health factors as possible barriers to care.

Now that we've reviewed the three substance use disorder specific behavioral health HEDIS measures and how to better support members who fall into these populations, we are going to discuss why HEDIS is important at Horizon. HEDIS helps Horizon obtain and maintain accreditation requirements. Information improves health plan delivery and services. Quality measures reduces gaps in care. Evaluates clinical quality performance. Improves outcomes for members, which reduces cost of care. Enables data to identify at risk populations. Information from HEDIS reports help create the annual State of Health Care Quality report from NCQA.

Horizon understands that as a provider in our network, your role is crucial in improving patient outcomes. The next few slides will detail some of the resources available to our members and network providers to assist with closing gaps in care for all HEDIS measures.

The Behavioral Health Quality Team at Horizon include several Behavioral Health specific, Clinical Quality Improvement Liaisons or CQILs. As an in network behavioral health provider you have access to a dedicated CQIL team who will collaborate with your practice by supporting the goal of improving HEDIS quality performance and care provided to our members.

CQILs assist providers with a comprehensive variety of tools including resources, education, data and practice transformation with the objective to enhance treatment delivery. CQILs can help with meeting HEDIS measures by acting as the single point of contact within Horizon to assist with navigating NCQA HEDIS. Providing a variety of resources tools and webinars to improve HEDIS knowledge. Assisting to analyze quality performance reports and address barriers to care. On-going collaboration to promote best practices.

This slide contains the names of the five CQILs on the Behavioral Health HEDIS Team along with their email and phone number. We also have an email set up for general behavioral health HEDIS related inquiries that we check regularly, which is noted at the bottom of this slide. If you have not been assigned to work with a specific Behavioral Health CQIL, we encourage you to use the general HEDIS email and someone from the team will respond timely to your outreach.

Horizon's online Quality Resource Center contains various supports designed to assist providers on-going efforts in delivering quality services to their patients. The Quality Resource Center web address is located at the top of this slide. Here you can find links to resources including the provider tips for optimizing HEDIS results booklet, the HEDIS and quality management programs manual, the HEDIS measure guidelines, interactive HEDIS guidelines, information regarding the results and recognition program as well as previously recorded provider educational webinars.

Our network providers have the ability to access Horizon's HEDIS measure guidelines for behavioral health via the Horizon Blue dot com website.

Each link provides summarized NCQA HEDIS best practice recommendations along with a link to access the provider tips for optimizing HEDIS results booklet.

Another resource available to our members is Horizon's Care Management Teams. Care Management is a unique opportunity for members to collaborate with our clinical team in efforts to educate and coordinate care. Members with an assigned Care Manager may receive updates on various programs and vendors. Members who qualify for Care Management and have agreed to engage in the program need to complete assessments based on the program criteria. The risk level scoring will indicate the level of care management interventions. If the member is enrolled, they will be assessed through additional outreach and receive assistance from our Care Management Teams. If you think someone may benefit from one of our Care Management Teams, please feel free to use the numbers located on the right side of the screen and let them know our member would like to be assessed.

This slide details some additional resources available to our members and network providers. Listed are important phone numbers, emails and websites for member and provider assistance.

Additional resources for providers can also be found on the HNJH website.

Once again, we thank you for attending today's webinar. If you have any questions, please contact us at BH_HEDISTeam@horizonblue.com This concludes our presentation. We thank you for your participation and look forward to you joining us in future HEDIS trainings.