Women’s Health

Hello and welcome to the Quality Program’s presentation on the Women’s Health Results & Recognition Program.

Results and Recognition is also referred to as R & R.

The objectives of this presentation is to understand the HEDIS requirements and criteria to meet those measures, as well as applying suggested best practices.

Horizon launched the Women's Health R&R Program to improve clinical outcomes performance on HEDIS measures and promote the quality of care rendered to your patients, which are our members.

The goal is to positively impact the health of women and children in New Jersey by engaging and educating OB/GYN practices on the PPC, BCS, CHL and CCS HEDIS measures, which will be reviewed in this presentation. Early detection for any health issue has the best outcome.

We're focusing on early detection by encouraging and educating our members to have their prenatal and postpartum care visit, as well as being screened for breast cancer, cervical cancer, and chlamydia.

The Women's Health R&R program offers additional financial incentives to providers that are tied to improved performance for specific HEDIS measures through high touch collaboration with Horizon BCBSNJ.

These are the HEDIS measures in the Women’s Health R&R Program.

There are 8 in total, but only the 5 listed on the left side of the screen are incentivized.

Horizon Mommy’s Health Choice and Horizon Healthy Journey programs offers incentives for women who have completed their mammograms and for women who have their prenatal visit, postpartum visit and were screened for postpartum depression.

The first measure I’ll review is Prenatal and Postpartum Care.

For this, we're looking at the percentage of deliveries of live births on, or between October 8th of the year prior to the measurement year and October 7th of the measurement year who had a prenatal care visit and a postpartum care visit.

This measure focuses on only the Medicaid and Commercial populations.

To meet the measure timeliness of prenatal care and a postpartum visit must be done within certain timeframes and we'll look at both areas shortly. The only exclusion to this measure are members who are using hospice services at any time during the measurement year.

The first indicator for the PPC measure is timeliness of prenatal care.

We need to see the percentage of deliveries that received a prenatal care visit in the first trimester on or before the enrollment start date, or, within 42 days of enrollment, in the organization.

To be eligible for the measure, a live birth should have occurred on, or between October 8th of the year prior to the measurement year and October 7th of the measurement year, and delivered in any setting.

To meet the measure, there must be a prenatal care visit with an OBGYN or other prenatal care practitioner, or PCP AND one of the following, which can be documentation in a standardized prenatal flow sheet, documentation of last menstrual period, a positive pregnancy test result, a basic physical OB exam with OB observations, evidence that a prenatal care procedure was performed, such as an OB panel, or other examples as noted here.

For the postpartum care visit indicator we need to see the percentage of deliveries that received a postpartum care visit on or between 7 and 84 days after delivery.

To meet criteria for this indicator, there must be a postpartum care visit with an OBGYN or other prenatal care practitioner or PCP and any other notation related to a pelvic exam, postpartum care, cesarean incision or wound check, screening for tobacco or substance use or mental health disorders, glucose screening for women with gestational diabetes, or documentation of topics related to areas, such as infant care, breastfeeding, family planning, or resumption of physical activity or attainment of healthy weight.

Some suggested best practices for the PPC measure.

Stress the importance of the prenatal initial visit.

Review the visit schedule with the patient, connect patients to resources for family assistance programs in New Jersey.

Encourage patients to maintain the relationship with an OBGYN to promote consistent and coordinated health care.

Educate patients on the importance of keeping each prenatal and postpartum visit.

Consider offering extended practice hours to increase care access.

Remind patients of their appointment by making calls or sending texts.

Make outreach calls and or send letters to advise members of the need for a visit.

And lastly, partner with Horizon Healthy Journey Program to assist with targeted outreach activities.

The next measure is Prenatal Depression Screening and Follow-Up.

We're focusing on the percentage of deliveries in which,1, members were screened for clinical depression while pregnant, and 2, if screened positive received follow-up care.

We'll look at both indicators in a bit. To be eligible, the delivery date must have occurred during the measurement period, and the screening, 28 days prior to the delivery date through the delivery date.

This measure also focuses on the Medicaid and Commercial populations.

Exclusions for this measure are deliveries that occurred at less than 37 weeks gestation and members in hospice, or using hospice services anytime during the measurement year.

So, to meet the criteria for the first indicator of Prenatal Depression Screening, we need to see deliveries in which members had a documented result for depression screening, using an age-appropriate, standardized screening instrument, performed during pregnancy.

For deliveries between January 1st and December 1st of the measurement period, the screening should be performed between the pregnancy start date and or on the delivery date.

For deliveries between December 2nd and December 31st of the measurement period, the screening should be performed between the pregnancy start date and December 1st of the measurement period.

For the second indicator of Positive Depression Screening Follow-Up, again, we need to see the percentage of deliveries in which members were screened for clinical depression while pregnant and if screened positive, received follow-up care.

To meet criteria for this, within 30 days after the first positive screen, there must be a visit with a diagnosis of depression or other behavioral health condition, a depression case management encounter or behavioral health encounter, a dispensed antidepressant medication or documentation of additional depression screening, on a full length instrument.

And each bullet noted here provides a little extra detail about the criteria.

The next measure is Postpartum Depression Screening and Follow-Up.

For this, we're focusing on the percentage of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, received follow-up care.

The measure focuses on deliveries during September 8th of the year prior to the measurement year, through September 7th of the measurement year and through 60 days following the date of delivery.

This measure focuses on the Commercial and Medicaid populations as well.

To meet the measure there must be a depression screening, and if positive, a follow up for that, and we'll look at both indicators.

The exclusion here is for deliveries in which members were in hospice, or using hospice services any time during the measurement year.

For the Postpartum Depression Screening, this indicator focuses on the percentage of deliveries in which members were screened for clinical depression during the postpartum period.

Those members must have had a documented result for depression screening, using an age-appropriate standardized instrument, performed during the 7-84 days, following the date of delivery, to meet compliance.

If members do have a positive depression screening, they should receive follow-up care within 30 days of that positive finding.

The criteria to meet this measure is the exact same as that for the Prenatal Depression Screen Follow-Up, that was previously discussed.

Some suggested best practices for Depression Screening

Educate the members about the importance of early detection and encourage screening.

Engage patients to discuss their fears. Set alerts in your electronic medical record.

Screening should occur with or without symptoms.

Review the visit schedule with the patient and make outreach calls and or send letters to advise members of the need for a visit.

Some suggested best practices for follow up set alerts in your electronic medical record, connect patients to resources.

Encourage patients to maintain the relationship with an OB/GYN to promote consistent and coordinated health care.

Educate patients on the importance of keeping the visit and consider offering extended practice hours to increase care access.

Remind patients of their appointment by making calls or sending texts.

Make outreach calls and or send letters to advise members of the need for a visit and also partner with Horizon Healthy Journey program to assist with targeted outreach activities.

The next measure is Prenatal Immunization Status.

We're focusing on the percentage of deliveries between January 1st, to December 31st of the measurement year in which women have received influenza and tetanus, diphtheria toxoids and acellular pertussis, known as Tdap, vaccinations.

And the measure focuses on only the Medicaid and Commercial populations.

To meet the measure, members must have received an adult influenza vaccine on or between July of the year prior to the measurement year and the delivery date, and at least one Tdap vaccine during the pregnancy, which may include the delivery date.

The exclusion here are for those deliveries that occurred at less than 37 weeks gestation, as well as members in hospice care.

Some suggested best practices to meet this measure.

Schedule appointments to coincide with required timeframes for immunization administration.

Use your electronic medical record system to set reminder flags.

During visits talk about the importance of having the immunizations, and ensure that the members' medical record includes the immunization history.

The next measure is Breast Cancer Screening.

This measure focuses on the percentage of women, 50 to 74 years of age, who had a mammogram to screen for breast cancer.

However, the eligible population is for women, 52 to 74 years old by December 31st of the measurement year.

This is due to a look back timeframe. The measure focuses on the Medicaid, Medicare and Commercial populations.

For a member to be compliant a mammogram must be done any time between October 1st, 2 years prior to the measurement year through December 31st of the measurement year.

3D mammograms will meet compliance.

However, MRIs, ultrasounds or biopsies will not meet compliance, as these tests are usually for diagnostic purposes and not for screenings.

A unilateral mastectomy is not an exclusion, however a bilateral mastectomy may be an exclusion at any time during the member’s history through December 31 of the measurement year.

Some suggested best practices for this measure is to educate members about the importance of early detection and encourage screening.

Engage patients to discuss their fears about mammograms and let them know that the test is less uncomfortable and uses less radiation than it did in the past.

Establish a standing order to obtain annual mammogram for eligible population and also document the month and year of the most recent mammogram and mastectomy status in the medical record.

Cervical Cancer Screening. This measure focuses on the percentage of women, 21 to 64 years of age who was screened for cervical cancer.

However, for a member to be compliant, we look for women who are 24 to 64 years of age and had a screening done in the measurement year or 2 years prior.

This measure also has a lookback period. If one is not found, we can look at the measurement year and 4 years prior for women, 30 to 64 years of age for cervical high-risk HPV testing.

However, the age of the member must be 30 years or older on the date the test was performed.

We're focusing on the Medicaid and Commercial populations.

Possible exclusions include hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during the member's history through December 31st of the measurement year.

Let's talk a moment about noncompliance versus optional exclusions.

Noncompliance would be if there are no cervical cells present, or the sample was inadequate.

Again, biopsies are diagnostic and not considered a screening, so they would not be eligible for this measure.

Documentation of hysterectomy alone does not meet the criteria for a possible exclusion and that's because we need to have significant evidence that the cervix was removed.

Any one of these optional exclusions noted here may be used to exclude the member from this measure.

Lab results that indicate the sample contained no endocervical cells may be used if a valid result was reported for the test.

Some suggested best practices for this measure.

Average-risk women younger than 21 years of age should not be screened.

Cervical cancer is rare in adolescence and screening does not appear to lower that risk.

Average-risk women, younger than 30 years of age should not be tested for HPV.

Frequently the test will be positive because it's spread through sexual contact and is very common in young people.

But the infection often clears on its own within a year or two.

Assess existing barriers to regular cervical cancer screenings, such as access to care cost, anxiety, embarrassment or fear, and try to implement a policy or procedural change to increase the rate of cervical cancer screenings.

Increase community demand to promote cervical cancer screening through patient reminders, group and 1 on 1 education.

Request to have cervical cytology results sent to you from an OB/GYN office.

Chlamydia Screening in Women. For this measure, we look at the percentage of women between 16 to 24 years of age who had at least one chlamydia screening in the measurement year.

This measure is for the Medicaid and Commercial populations.

The eligible population are those women who turned 16 to 24 years of age by December 31st of the measurement year and who have been identified as being sexually active, either by pharmacy data for a contraceptive or a claim or an encounter for a pregnancy test.

So, as we all know, contraceptives are prescribed for reasons, other than preventing pregnancy.

However, whether the member is sexually active or not, if the contraceptive is prescribed that member may fall into this measure.

A possible exclusion are for those members who qualified for the measure based on a pregnancy test alone AND who either had a prescription for isotretinoin on the date of the pregnancy test or the 6 days after the pregnancy test OR who had an X-ray on the date of the pregnancy test for the 6 days afterwards.

Some suggested best practices for this measure.

Adopt urine screening of all women in this age range to eliminate the need for a pelvic exam.

Screening should occur with, or without symptoms.

Screenings should also occur at any visit where oral contraceptives, STDs, or urinary symptoms are discussed.

Create an environment conducive to sexual history taking and develop a tool for taking that history.

Establish a process for obtaining chlamydia screening results from OBGYN providers participating in the member’s care.

This is the conclusion of this presentation. Thank you for listening.

If you have any questions, please email them to the email noted here.

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Thank you so much.

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