Welcome to the Results and Recognition Quality Programs of 2021. This webinar will be a review of the Adult Measures in the R&R program and suggested best practices.
Welcome to the Results and Recognition Quality Programs of 2021. This webinar will be your review of the Pediatric HEDIS Measures in the R&R program and suggested best practices.
The objectives for this webinar are to: Understand the measure requirements, Understand criteria to meet the measure, Identify possible exclusions, and Offer best practices that you may utilize.
These are the Pediatric Medicaid Measures in the R&R Program. There are 12 measures in this program including the sub-measures. Each sub-measure is independent of one another for the incentives. We will talk about each of these measures in more detail as we move along in the presentation. You will hear the term “Measurement year.” This refers to the year in which we are collecting data from. The measurement year starts January 1st and ends December 31st. Some of the pediatric measures are for services and/or treatments that must be completed within a specific age time span, for example, childhood immunizations have a specific age to and from date for the administration of the vaccines. Before we get started, I just want to talk a little bit about exclusions. There are some exclusions specific only to a specific measure. The exception is members in Hospice care. This applies to all measures. Members who use hospice service at any time during the measurement year will be excluded from the measure. However, if there is documentation that a member is nearing the end of life or is receiving palliative care that would not meet the hospice exclusion requirements.
Please remember that any exclusion must be clearly documented in the medical record and occur on or before a specific age or on or before December 31st of the measurement year. Let’s start reviewing the measures.
Childhood immunization Status. HEDIS requires this measure to be reported out in 10 different combinations. For the R&R program, we incentive on 2 of these, the Combo 10 and the Combo 4.
Combo 10 is the percentage of children 2 year of age who had all 10 immunizations on or before their second birthday.
The eligible population are members who turn 2 years of age during the measurement year. For the member to be compliant they must receive all the 10 different vaccines noted here, or documented history of the illness on or before their 2nd birthday. Also, all dates of service must be a least 14 days apart. So let’s review each vaccine and the age specifications. 3 Hepatitis B vaccines are to be administered from birth and on or before their 2nd birthday. One of these can be given from date of birth to 7 days after. Documentation of history is very important to capture this immunization, as many times as it is administered in the hospital. 4 DTaPs, 3 IPV’s or Polio, 3 HIBs, 3 PCVs or Pneumococcal, and either a 2 or 3-dose Rotavirus series; these are to be administered no sooner than 42 days of age and on or before their 2nd birthday. For Rotavirus it should specify on the immunization record if the 2 or 3 dose series being given. RotaTeq we know is the 3 dose whereas Rotarix, we also know is the 2 dose. If this is not specified by name or dose, it is assumed to be a 3-dose series. 2 flu vaccines administered between 6 months of age and on or before their 2nd birthday. If one of the two flu vaccinations is the LAIV vaccination, which is the intranasal vaccine, this one has to be administered exactly on the child’s second birthday and not a day before. 1 MMR or Measles, 1 Varicella, & 1 Hepatitis A vaccines, these are to be administered between the child’s 1st and on or before their 2nd birthday. Exclusions - Contraindication for a specific vaccine documented in the medical record on or before the 2nd birthday. The exclusions have to be clearly documented in the medical record and have to had occurred on or before the child’s 2nd birthday. The documentation must clearly indicate which vaccine, when it occurred and what the contraindication was.
Another important thing to note is that parental refusal is not an exclusion. This would simply make the member non-compliant.
Combo 4. This measure is almost identical to Combo 10. What makes them different is that Combo 4 does not include the Flu or Rotavirus vaccines. If the child is compliant for Combo 10, it’s a given the child will be compliant for Combo 4 as well. Your office will receive compliancy for both measures and if over the NCQA’s 50th percentile benchmark, the incentives for both measures will be paid.
Immunizations for Adolescents also has 2 sub-measures: Combo 1 and HPV
Combo 1 is the percentage of adolescents who had one does of meningococcal and pap on or before their 13th birthday and HPV the percentage of adolescent who had 2 or 3 doses of HPV on or before their 13th birthday. The eligible population are members who turn 13 years of age during the measurement year. For Combo 1 to be compliant the member must receive the following immunizations: 1 Meningococcal between their 11th and on or before their 13th birthday AND 1 pap between their 10th and on or before their 13th birthday. Just to be clear DTaP does not count towards pap. These are two separate vaccines, DTaP is for the pediatric population under the age of 7 and pap is for adolescents starting at age 11.
For HPV to be complaint the member receive 2 or 3 vaccines with different dates of service on between the 9th and 13th birthday and there must be at least 146 days between the first & second dose, if using the 2-dose vaccine. There has been some taboo around the administration of the HPV vaccine such as it will encourage sexual activity, which is something we all know is not accurate. It’s all about education to parents and members as to the need of the vaccine to help prevent cervical cancer. The exclusions are the same as Combo 10 and Combo 4, however for the adolescents it must be on or before their 13th birthdate. Exclusions have to be clearly documented in the medical record that it occurred on or before the 13th birthday. Again, the documentation must clearly indicate which vaccine, when it occurred and what the contraindications were. Again, parental refusal is not an exclusion. It would make the member non-compliant.
So let’s look at some best practices for the immunizations.
Schedule appointments to coincide with required timeframes for the immunization. Use your electronic medical record system to set reminders and flags. During every visit, talk to parents about the importance of having their children get all of the immunizations. Be sure that your medical record includes immunization history from all sources. If the child received vaccines from another provider, please be sure to add these as history with the dates and the name of the vaccine being given. This will count towards your compliance of this measure even if the vaccines were given elsewhere. Utilize the HEDIS recommended codes to ensure these gaps are closed. Update the New Jersey Immunization Information System or NJIIS registry. This is the official Immunization Registry per the Statewide Immunization Registry Act; It consolidates immunization information from all providers into one record. Please note, if you document “All immunizations are up-to-date,” this will not meet compliancy. We must see the name and the dose of every dose being administered. If you have a seropositive test result for MMR, Hep B, Varicella or Hep A, this too will meet compliancy as long as it was done on or before the second birthday.
Chlamydia Screening in Woman
So this is the percentage of woman between the ages of 16-24 who’ve been identified as sexually active and has had at least one chlamydia test during the measurement year. The eligible population are woman 16 to 24 years of age as of December 31st in the measurement year and who have been determined to be sexually active by either pharmacy data dispensing event for a contraceptive or a claim for a pregnancy test. To be compliant the member must have at least one chlamydia test during the measurement year. This test can be done by either urine or a vaginal swab. If the test was done at another office, for example at an OB/GYN office, and the lab was submitted and processed, or if you have the documentation with the date of the test and the test results in your medical record you can submit that information, then you will obtain compliancy for that member. We know that contraceptives are prescribed for reasons other than preventing pregnancy. However, whether the member is actually sexually active or not, if a contraceptive is prescribed, the member will fall into the measure. One of the exclusions is for those members in the eligible population based on the pregnancy test alone. They may be excluded if they were prescribed isotretinoin on the date of the pregnancy test or the 6 days after the pregnancy test or if they had an X-ray on the date of the pregnancy test or 6 days after the pregnancy test. Both of these have a mandate that a member must have a pregnancy test prior to either the prescription or for certain x-rays.
So let’s look at some best practices. Adopt urine screening of all women in this age range to eliminate need for a pelvic exam. Many offices have already adopted a process of universal screening of all boys and girls in this age range through a basic urine test, especially in pediatric offices starting at their well visits at 16 years – so that may be something to consider doing.
Screening should occur with or without symptoms.
Screenings should also occur at any visit where oral contraceptives, sexually transmitted disease or urinary symptoms are discussed.
Create an environment conducive to sexual history taking and develop a tool for taking this history.
Establish a process for obtaining chlamydia-screening results from an OB/GYN provider that is participating in the member’s care.
Lead Screening in Children
This is the percentage of children 2 years of age during the measurement year who has had one or more capillary or venous blood test for lead poisoning on or before their 2nd birthday.
The eligible population are children who turn 2 years of age during the measurement year. Lead screening is a required test by Medicaid, HEDIS & the State of NJ. The target ages for having a blood lead test completed are 12 months & 24 months of age.
For a member to meet compliance they must have one blood lead level test on or before their 2nd birthday. If a lab claim is not received, then a note or a lab report from the medical record indicating the date the test was reported or collected and the results, can be submitted to make the member compliant for tests done on or before the member’s second birthday.
For the collection and reported dates, they cannot be more than 7 days apart. For example, if a child had a lead screening sample collected on December 28 of the measurement year and a lead screening was resulted on January 2 of the following year, the dates are within seven days and can be considered the same test. Results can be documented as a numerical value or quantitative value such as WNL, Negative or None detected.
The lead screening questionnaire, which again is not part of the R&R incentives, which should be completed starting at 6 months and continue through 6 years of age at every well visit. If the member is at high risk based on the questions answered, the provider may opt to have the child tested before the age of 12 months. That test will also be compliant for this measure. But again please remember the questionnaire does not count towards this measure, only the blood lead level test.
So MedTox is a great resource and it’s free to you at your office to use. It is an in-office collection of blood sample by a finger stick. MedTox is Clinical Laboratory Improvement Amendments or CLIA certified. There is a Point-of-care testing reimbursement by Horizon NJ Health of $10 per test
And again, the kits are free and can be obtained from LabCorp.
If you have any information pertaining to these tests, you can reach out to Joe Huffer at 1-877-725-7241 or you can reach out to you Clinical Quality Improvement Liaison.
So let’s talk about some best practices. A lot of parents don’t realize that lead is still out there. Some of the best practices we have seen for lead screening are: To educate parents on the importance of screening for lead poisoning. Perform the Verbal Lead Risk Assessment at every well visit from 6 months to 6 years of age, Order the test at the appropriate age and ensure it is completed. And also, Follow up on open lab orders for lead screening before the child’s second birthday. Provide in-office testing, Be sure chart documentation includes the date the test was performed AND the results or findings. Utilize the HEDIS recommended codes to ensure these gaps close. Again, please remember the target date for testing is 12 and 24 months, unless the provider feels the member is at a high risk based on the answers received from the lead questionnaire or if there is no documented test. If the test is done after the member’s 2nd birthday, they will not be compliant. We have a WebEx presentation that goes into further detail about lead screening. Again, please contact your CQIL for additional information on that WebEx.
Weight Assessment and Counseling also has three sub-measures.
It is the percentage of member 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and have documentation of a body mass index percentile, counseling for nutrition and counseling for physical activity. The eligible population are members who are 3 – 17 years of age by December 31st of the measurement year. The 3 sub-measures are independent of the other for compliancy and incentives earned. BMI Percentile – for the member to be compliant, a BMI percentile or evidence of BMI percentile plotted on a growth chart specific for BMI percentiles during the measurement year.
Counseling for nutrition - for the member to be compliant, there has to be documentation of nutrition counseling done during the measurement year.
In Counseling for physical activity, there has to be documentation of physical activity counseling done during the measurement year.
So we’re going to review each of these sub-measures in more detail to review what is compliant and what is not compliant. Also please note, the exclusion of diagnosis of pregnancy, it must be occurring in the measurement year.
So let’s look at some examples of compliant documentation.
BMI: BMI percentiles plotted on a BMI percentile age-growth chart, Documentation of a distinct BMI percentile
Documentation of the BMI percentile being noted as >99% or <1% will meet the criteria
Also member-reported biometric values (height, weight, BMI percentile) are compliant if provided during a telehealth visit. The information must be recorded, dated and maintained in the member’s medical record as part of the history being taken during the telehealth visit by the provider.
NUTRITION: Discussion of current nutritional behaviors (eating habits, dieting behaviors), A Checklist indicating nutrition was addressed, Counseling or referral for nutritional education, Educational materials distributed during an in-person visit on nutrition, And Anticipatory guidance for nutrition. Also, Referral to WIC which is a Special Supplemental Nutrition Program for Women, Infants and Children may be use.
Discussion of current physical activity behaviors such as exercise routine, participation in sports activities, and even an exam for sports participation is acceptable. One thing to note here, even if it’s documented that the member does not participate in any sports activity that can also be considered a discussion of their physical activity and would meet compliancy. A checklist indicating physical activity was addressed, Counseling or referral for physical activity. Educational materials distributed during an in-patient visit on physical activity, and Anticipatory guidance specific for physical activity or exercise. Please note, for Nutrition and Physical Activity – if you give the member educational materials, the name of the materials must be noted in the medical record. Ok, so let’s review some examples of what would make a member non-compliant.
So these are just a few examples of what we have seen in documentation that makes the member non-compliant.
BMI: Documentation of height, weight and BMI percentile ranges or thresholds. So for example, 70-75% is not compliant, also BMI values are not acceptable, we need the BMI percentiles.
For NUTRITION AND PHYSICAL ACTIVITY:
If any of the counseling or education was done before or after the measurement year,
Notation of “health education” or “anticipatory guidance” alone without specific mention of nutrition or physical activity is not compliant, also Documentation related to an acute or chronic illness.
So for NUTRITION also:
If the physical exam findings alone, such as “well-nourished” or “well-developed,”
Documentation related to a member’s appetite, such as, “appetite fair or poor” or “picky eater or little appetite,” and
Notation that the BRAT diet, banana, rice, applesauce and toast was discussed and the member is being seen for diarrhea. These are all non-compliant examples.
Being “cleared for gym class” alone without any further discussion, Notation of anticipatory guidance related solely to safety – such as using a helmet when skateboarding,
Notation related to screen time without specific mention of any physical activity, Notation that member with a chronic or acute condition, such as knee pain is unable to run without limping, and Notation that member has exercise-induced asthma. Please remember any counseling for chronic or acute conditions is not compliant.
So let’s look at some best practices. Take advantage at every visit, including sick visits, to capture the BMI percentile, nutrition and physical activity assessments and anticipatory guidance. Remember, as long as it is not specifically related to the acute reason they are being seen or treated, it can be used. Document weight and obesity counseling, if applicable, to comply for both Nutrition and Physical Activity sub-measures, Use standardized templates in charts and EMRs that allow checkboxes for counseling activities. Please remember the standardized templates with check boxes must be specific for nutrition and physical activity. Simply stating “anticipatory guidance given” will not make the member compliant, Utilize the HEDIS recommended codes to ensure these gaps are closed. A couple things to note here: Services rendered for eating disorders may be used to meet criteria for the Counseling for Nutrition and Counseling for Physical Activity, if the documentation is specified and present. Again, referral to WIC, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) may meet the criteria for Counseling for Nutrition. And members who report biometric values during a telehealth visit and are documented in the medical record by the provider at the time of the visit are acceptable.
Well Child in the First 30 Months of Life
Well Child in the First 30 month of life is the percentage of children who turn 30 months of age during the measurement year, who had 6 or more visits by 15 months of age and 2 additional visits between 15 months 1 day and 30 months of age. The eligible population for this measure is broken down into 2 rates: Rate 1 is members turning 15 months of age during the measurement year, and Rate 2 are members turning 30 months of age during the measurement year.
So to meet compliance for Rate 1 the member must have at least 6 well visits on or before 15 months of life. Based on the well visit schedule, there are actual 7 opportunities of capture these visits: Newborn (as long as it is not just for weight check) then again at their 1st, 2nd, 3rd, 4th, 6th, 9th 12th and 15 months of life. To meet compliance for Rate 2, the member must have 2 well visits that occurs at 15 months 1 day and on or before 30 months of life. The visits must contain documentation of a health history, physical & mental developmental history, a physical exam, and health education – and we’re going to look at these components a bit more in detail in the following slides. Visits to school-based clinics, with practitioners whom the organization would consider a PCP, may be counted as well visits if all the components are present and documented in the medical record.
So what will make a visit compliant? We’ll talk about a visit, we’ll first look at the components performed on one date; however, please note that they do not all have to come from the same date.
Components can be taken from sick as well as well visits as long as it does not apply to acute or chronic condition.
Health History: For Health History if the note contains medications, allergies, immunizations this is compliant, however please remember the note must contain all 3 of these components. We would also accept any type of past medical history, any surgical history and also any type of birth history. We can also accept any type of family history.
Physical Developmental History: So this goes according to the gross and fine motor skills. This also goes according to the age of the child. So depending on the age of the child is what we’ll be looking for.
Mental Developmental History: Cognitive development. Again, this is based on the age of the child so that would determine exactly what we’re looking for at that time.
Physical Exam: It’s the assessment of the body system that must be a hands-on. So the assessment must have at least five bodily systems.
Health Education and Anticipatory Guidance:
Advice and counseling.
These are just a few examples of what we have seen in documentation that will make the member non-compliant.
Health History: The notation of allergies, medications, or immunization status alone,
As stated on the previous slide, for health history, allergies, medications and immunization is compliant as long as all 3 are noted. If the note only contains allergies or medications or immunizations, it cannot be considered compliant.
Physical Developmental History:
Notation of Tanner Scale or Stage - this is because the Tanner stage or scale starts at age 8 and this measure focuses on well visits during the first 30 months of life,
Any notation of “age-appropriate” or “appropriate for age” without specific mention of development, Notation of “well-developed/nourished/appearing” is non-compliant for physical development.
Mental Developmental History:
Notation of “appropriately responsive for age” or “neurological exam” is non-compliant.
Physical Exam: Vital signs alone will not be considered compliant.
Health Education/Anticipatory Guidance: If it is just information regarding medications or immunizations or even side effects, this is not considered anticipatory guidance.
So these are just a few examples of what we have seen in documentation that will make the member non-compliant.
Let’s talk about Child and Adolescent Well-Care Visits.
So Child and Adolescent Well Care Visits is the percentage of members ages 3 to 21 years who had at least 1 well visit in the measurement year with a PCP or OB/GYN. The eligible population are members 3 to 21 years as of December 31st in the measurement year. For the member to be compliant, they need to have one well visit in the measurement year. This a new measure this year and it combines the well child visits in the 3rd, 4th, 5th and 6th year of life with the previously standalone adolescent well care visits. This is very straightforward. The only exception and exclusion is members in hospice.
So let’s take a look at some best practices for the well visits. Take advantage of every visit, including sick visits, to capture the different components,
Schedule visits within the recommended time frames,
Use standardized templates in charts and EMRs to allow checkboxes for standard counseling activities, and again,
Utilize the HEDIS recommended codes to ensure these gaps are closed.
A few important reminders for the past three measures we just reviewed. Services may be rendered during a visit other than a well-child, Services rendered in an Emergency Department or during an inpatient visit do not count,
Services specific to the assessment or treatment of an acute or chronic condition do not count, Services rendered during a consultation or with a specialist will not count for the W30 measure, Visits must be at least 14 days apart; however, the 14-day threshold does not apply when capturing different components from well and sick visits, The well-child visit must occur with a PCP or OB/GYN for the Well Child Visits and the PCP does not have to be the practitioner assigned to the child.
This is the last measure we have in the pediatric Results & Recognition Program, Asthma Medication Ratio.
So Asthma Medication Ratio is the percentage of members 5 to 64 years of age, who were identified as having persistent asthma and had a ratio controller of medication of total asthma medications of 0.50 or greater during the measurement year.
The eligible population are members who have persistent asthma, a true diagnosis of being asthmatic and not seasonal or allergic asthma. In addition to this, they must meet at least one of the following criteria during both the measurement year AND the year prior: At least one ED visit with a principal diagnosis of asthma - At least one acute inpatient encounter, with a principal diagnosis of asthma without telehealth - At least one acute inpatient discharge with the principal diagnosis of asthma on discharge - At least four outpatient visits, observation visits, telephone visits, or online assessments, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events for any controller or reliever medications, or At least four asthma medication-dispensing events for any controller or reliever medication. So members must meet a medication ratio of 0.50 or greater in the measurement year. We’re going to show you how this is calculated in the following slide.
Please remember this measure is strictly pharmacy driven, however, education from the PCP is the most important aspect of this measure. Educating on the importance of staying on their controller meds is the key to success with this measure.
Let’s look at how this calculation is done. When identifying medication units, count each individual medication, defined as an amount lasting 30 days or less, as one medication unit. One medication unit equals one inhaler, one canister, one injection, one infusion, or a 30-day or less supply of an oral medication. So just for example, if two inhaler canisters of the same medication dispensed on the same day that is counted as two medication units but only one dispensing event. And again please remember this is all pharmacy-driven and all the calculations are done for you.
So let’s talk about the asthma medication ratio or AMR equation. This would be units of controller medications divided by units of total asthma medications. So in this example, our member filled one-month supply of asthma medications for a controller and a rescuer. They also had an additional prescription for three refills of both the controller and the medication for the rescuer.
Our claims data shows that within the measurement year, the controller meds were filled twice and the rescue meds were filled four times. So the total asthma medication would be the 2 plus the 4 which is six. So looking at out AMR equation, we would take units of controllers, which was 2 filled divided by units of total asthma medication which is 6, which only gives us a medication ratio of 0.33. So unfortunately, this member is Non-Compliant for this measure because their Asthma Medication Ratio is under 0.50 compliance ratio.
So let’s talk about some best practices. Develop an Asthma Action Plan, Educate members on the importance of adhering to medications and reducing asthma triggers, Advise members to incorporate inhalers into their daily routine, and Reach out to members to schedule follow-up visits for the conditions.
We have many different tools and resources available and this is just one of that contains a lot of information pertaining to the pediatric population. Please reach out to your Clinical Quality Improvement Liaison for additional tools and resources.
Use your member gap list, this contains a lot of information to assist you in identifying non-compliant members, it also contains a lot of contact information on member -
Keep in contact with your patients and remind them to schedule their appointments, you may want to implement a process of either calling them or even sending them mailings or even sending them text messages - Considers some of the barriers your patients have, maybe offer them telehealth visits or even possibly offering extended hours - Utilize your electronic medical record to develop standing orders and review your current codes and set alerts - You can refer to the Provider Tips for Optimizing HEDIS Results booklet. If you need a copy of this booklet, please reach out to your CQIL. Please note, that we cannot tell you what or how to code, this booklet offers you suggested codes for closing gaps of care administratively. Any codes you use must be reflective of the services and/or treatments you have rendered and that is clearly documented in the member’s medical record.
Thank you for listening, if you have any questions, please email them to Quality_RR@HorizonBlue.com.
This is for the FIDE-SNP and Medicare population only.
For a member to be compliant, they need to have either a nephropathy screening or monitoring or evidence of nephropathy during the measurement year, as documented through either administrative data or medical record review. The next slide will show how the member can meet compliance
The member is compliant if they meet one of the following:
Nephropathy screening test – to meet this criteria, the member needs to have a urine test for albumin or protein in the measurement year. There are several different urine tests that will be accepted for compliance. We need the date of the test or the reported date and the results. The simplest way to meet compliance for a provider’s office is a spot test or a dipstick, which is the urine test done in the office at the time of the visit. Evidence of Nephropathy – to meet this criteria the member needs to have one of the following:
Documentation of a visit to a nephrologist in the measurement year,
Evidence of nephrectomy or kidney transplant,
Documentation of medical attention to any of the following diagnosis noted.
There are not any restrictions on provider type, as far as whose following or monitoring the patient for the illness, it does not have to be the PCP. As long as there is documentation in the medical record stating the member is receiving care for any of these that will meet criteria for this sub-measure. Nephropathy Monitoring – to meet this criteria the member needs to have an ace or an arb prescribed, filled or documented in the measurement year.
Controlling High Blood Pressure
So again, Blood Pressure Control – this sub-measure and criteria is the same as Controlling High Blood Pressure previously discussed.
This, again, is for the Medicaid population only. For members to be compliant, their last blood pressure of the measurement year must be below 140/90.
Some best practices for CDC:
Order labs prior to the members’ appointment.
Coordinate lab testing prior to the office visit so that results can be reviewed and treatment plans adjusted as needed.
Ensure documentation in the medical record includes the date when the HbA1c test was done and/or nephropathy screening was performed, and the results. Document the date of most recent diabetic eye exam, with results, the name and title of eye care provider in the medical record.
Document blood pressure readings at every visit and re-take if greater than 140/90.
As previously discussed, all know some members get a little nervous just walking into a provider’s office. If the first reading is greater than 140/90, allow the member to rest or even talk to them to distract them then re-take it. Just like CBP, we can take the lower of the systolic and diastolic reading on the same day.
Statin Therapy for Patients with Diabetes
Statin Therapy for Patients with Diabetes is the percentage of members ages 40-75 years of age during the measurement year with diabetes, who do not have clinical atherosclerotic cardiovascular disease AND received statin therapy and have a compliance of 80% or greater adherence. The eligible population for members 40-75 years of age as of December 31st of the measurement year.
This, again, is for the Medicaid population only. For a member to be compliant, the member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on the medication for at least 80% of the treatment period. This measure is also pharmacy driven but again education is the key component. Some possible exclusions: Again, members who do not have a diagnosis of diabetes AND who have had a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year may be excluded.
These are the medications at the different intensity levels that will meet compliance. Please remember this is only a guide as to what is in the NCQA specifications state. We cannot tell you how to treat your patients that would be up to you.
This measure has the same exclusions as the CDC measure with a few additional components. Members with cardiovascular disease identified by either an event or a diagnosis as noted here may be excluded. Some other exclusions that may apply is a diagnosis again of pregnancy, in-vitro fertilization, cirrhosis, palliative care during the measurement year, and these are just to name a few as noted on the bottom of this slide.
Statin Therapy for Patients with Cardiovascular Disease
Statin Therapy for Patients with Cardiovascular Disease is the percentage of males 21-75 years of age and female’s 40-75 years of age during the measurement year, who have clinical atherosclerotic cardiovascular disease AND received statin therapy and an adherence of 80% or greater.
This differs from the previous measure in that the member does not have diabetes but DOES have heart disease.
Also the eligible population differs in ages for males and females. Again, for the males, it’s 21 to 75 years of age by December 31st of the measurement year and for females, it’s ages 40 to 75 years of age by December 31st of the measurement year. This is for the Medicaid population only. For a member to be compliant, it is the same as the previous statin measure for diabetes. The member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on that medication for at least 80% of the treatment period. Again, this measure is pharmacy driven but education is the key component.
Here again, we’re offering you a list of medications at different intensity levels that will meet compliance. Again, please remember this is only a guide as to what is in the NCQA specifications, we cannot tell you how to treat your patients.
Some exclusions, so the exclusions are the same as the one previously discussed with the statin therapy for diabetes.
Let’s talk about some best practices. Educate on the importance of complying with statin therapy during every communication. Simplify the medication regime by using once-daily dosing, if possible.
Listen to the members’ concerns and make them an active part of sharing decision making. Routinely arrange the next appointment for consistent follow-up and monitoring during the current visit.
Colorectal Screening – the percentage of members 50 to 75 years of age who had colorectal screening.
The eligible population is for member’s 50 to 75 years of age by December 31st of the measurement year. This is for the FIDE-SNP and Medicare population only. For a member to be compliant, any of the following screenings completed in the specified time frames are acceptable: A fecal occult blood test during the measurement year, Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year, A colonoscopy during the measurement year or the nine years prior to the measurement year, CT done during the measurement year or the four years prior to the measurement year, A FIT-DNA test during the measurement year or the two years prior to the measurement year. Please note that a digital rectal exam done in the office for a FOBT test in an office setting or to obtain a sample from any test, or for any test, is not acceptable; the member will be non-compliant.
Again, the exclusions are the same as the CDC exclusions. There is an exceptional exclusion for this specific measure and that would be colorectal cancer or a total colectomy at any time during the member’s history through December 31 of the measurement year.
Let’s talk about some best practices.
Again, ask the member if they’ve had a colorectal screening and update this in their history on an annual basis; document the type and date the test was performed.
Emphasize personal choice and various modalities, especially for those members who may have a fear of having a colonoscopy. You can distribute the FOBT or the FIT test to members who need to be screened. You can also have an FOBT kit on hand to utilize for member teaching. Please remember to act quickly for members who have had a positive stool result. Also, Horizon has partnered with a vendor called BioIQ to send FIT tests to all the non-compliant Medicare members. The vendor will reach out to the PCP first to receive consent to send the members these in-home screenings.
This is the last measure we’re going to review that’s in the Adult R&R Program, Care of Older Adults.
So for Care of Older Adults, we are looking for Medication Review and this is the percentage of adults age 66 years and older who had a medication review completed in the measurement year.
The eligible population are members ages 66 years or older by December 31st of the measurement year. This measure is for the FIDE-SNP population only. So for a member to be compliant there needs to be one medication review in the measurement year. It can be done by either the prescribing physician or a clinical pharmacist. If the medication list is in the progress note and the provider signs the note, this is an indication they have reviewed the list during that visit. Also the member does not need to be physically present when the review is being conducted. So again, if the member is not taking any medications, that will also make the member compliant as long as it’s clearly documented in the medical record. One thing I do need to note, that if the review if for a side effect of a medication at the time it’s being prescribed this is not considered compliant. That is not a medication review.
So let’s just take a look at some best practices. Again, ensure the medication list is in medical record and evidence of the medication review by the prescribing practitioner or clinical pharmacist and the date it was performed. So please remember if the medication list in the in the progress note and the provider signs that note, that is considered a compliant medication review. If the member is not taking any medications clear documentation should be in the medical record with a date of the notation.
Incorporate a standardized template to capture this measure for members 66 years of age or older, if you’re using an EMR system.
That concludes the review of the Adult HEDIS measures for the 2021 Results & Recognition Program. Let’s quickly discuss how you can be successful in closing the gaps. So you can use your gap list, this contains a lot of information to assist you in identifying non-compliant members, it also contains contact information for the members. Calling or mailing to keep in contact with your patients and remind them to schedule their appointments.
Considers some barriers to your patients – offer telehealth visits or even possibly offer extended hours. Utilize your electronic health record – develop standing orders, review your current codes, and also set alerts. You can also refer to the Provider Tips for Optimizing HEDIS Results booklet. If you do not have a copy of that, that can be obtained through your CQIL.
Thank you for listening, if you have any questions, please e-mail them to Quality_RR@HorizonBlue.com.
Review of the Pediatric HEDIS Measures that includes suggested next practices and appropriate documentation requirements.