Adult Measures

Thank you for taking time out of your day to attend the Quality R&R Programs Adult Measures WebEx recording.

This webinar will be a review of the adult measures in the R&R program and suggested best practices.

We'll review the adult measures in the R&R program, the criteria to meet compliance for those measures, discuss the possible exclusions, and also review some suggested best practices that can help you be successful in closing those gaps in care.

These are the HEDIS measures in the Adult R&R Program.

They are broken down according to the different lines of business or specific populations they apply to; Medicaid, Fully Integrated Dual Eligible Special Needs Plans, also referred to as FIDE-SNP, Medicare Advantage/Braven.

Note, for COA, all three sub-measures must be compliant to close the gap of care.

We will talk about each of these measures in more detail as we move along in the presentation.

There are some exclusions that may apply to certain measures and some that may apply to every measure. A required exclusion for every measure pertains to hospice. Added this year for all measures is a required exclusion for members who died during the measurement year.

If a member is to be excluded from a measure there has to be clear documentation in the member's medical record as to the reason why, as well as the date of the occurrence.

As we review the measures we will talk about the measure, the eligible population for each measure, the specific line of business it applies to, what specifically meets the measure for compliance, and if any the required exclusions that may apply.

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.

Adult Access to Care.

For a member to be compliant they need just one visit with the PCP, sick or well, in the measurement year. There are no applicable exclusions here. It's very simple and straightforward.

Best practices for AAP.

Encourage PCP patient relationship resulting in more consistent, comprehensive healthcare. Educate patients to come in for annual outpatient visits.

Consider providing office hours conducive to varying schedules. Telehealth visits meet compliance.

Reminder texts or calls for appointments.

Asthma Medication Ratio, AMR.

Asthma Medication Ratio is the percentage of members 5 to 64 years of age who are identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

The eligible population are members who have persistent asthma and 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.

There are some exclusions. Some exclusions can be emphysema, COPD, chronic respiratory conditions due to fumes or vapes, to just name a few.

Members who had no asthma controller or reliever medications dispensed during the measurement year, may also be excluded.

Best practices for AMR.

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.

Reach out to members to schedule follow-up visits for their condition.

Breast Cancer Screening, BCS-E.

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.

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

3D mammograms will meet compliance, however, MRIs 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. It must be a bilateral mastectomy.

Best practices for BCS-E.

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

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

Establish a standing order to obtain annual mammograms for eligible populations.

Document month and year of most recent mammogram or mastectomy status in the medical record.

Cervical Cancer Screening, CCS.

Eligibility of the population is women 24 to 64 years of age as of December 31st of the measurement year.

This measure also has a look back period and for a member to be compliant we look for women who are 24 to 64 years of age and had a screen done in the measurement year or 2 years prior.

If one is not found, we can look at the measurement year and four 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 of the test was performed.

Noncompliance. No cervical cells present, sample was inadequate, biopsies. Possible exclusions. Total or radical hysterectomy, vaginal hysterectomy, documentation of vaginal Pap smear in conjunction with documentation of hysterectomy. Documentation of hysterectomy and the member no longer needs PAP testing or cervical cancer screening.

Best practices for CCS.

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

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

Assess existing barriers to regular cervical cancer screenings, examples; access to care, costs, anxiety, embarrassment or fear. To implement policies and procedural changes to increase the rate of cervical cancer screenings.

Increase community demand to promote cervical cancer screening through patient reminders and education.

Request to have cervical cytology results sent to you if done by an OBGYN office.

Chlamydia Screening.

Eligible population is 16 to 24 years of age as of December 31st of the measurement year.

Chlamydia screening compliance is met with at least one chlamydia test during the measurement year.

Best practices for CHL.

Adopt urine screens for all women in this age range to eliminate the need for pelvic exams.

Screening should occur with or without symptoms.

Screenings should also occur at any visit where oral contraceptives, sexually transmitted diseases 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 screen results from OBGYN providers participating in the member's care.

Care for Older Adults, COA.

The eligible population is 66 years of age and older as of December 31st of the measurement year.

Note, member must be compliant for all three sub-measures to close the gap: medication review, functional status, and pain assessment.

COA medication review. Documentation must come from the same medical record and must include one of the following: a medication list, or a notation of medication changes in an outpatient office.

COA functional status assessment. Notation of five ADLs being assessed, notation of four IADLs being assessed. Use a functional status assessment tool, for example, Bayer ADL or Barthel index.

COA pain assessment. Documentation in the medical record must include evidence of a pain assessment and the date when it was performed.

Notations for pain assessment must include one of the following; documentation that the patient was assessed for pain, which may include positive or negative findings for pain, result of assessment using a standardized pain assessment tool, for example, a numeric rating scale or FLACC scale.

Best practices for COA.

Complete the medication review, functional status assessment, and pain assessment during the same visit.

Ensure a medication list is present in the medical record. Document in the medical record if the member is not taking any medication.

Incorporate a standardized template to capture these measures for members 66 years of age and older.

Complete a functional status assessment and pain assessment at every face-to-face visit.

Complete a functional status assessment and pain assessment during every telehealth visit.

Colorectal Cancer Screening, COL.

Eligible populations are 45 to 75 years of age as of December 31st the measurement year. The percentage of members 45 to 75 years of age who had appropriate screening for colorectal cancer.

Fecal occult blood test during the measurement year. Flexible sigmoidoscopy during the measurement year or four years prior to the measurement year. Colonoscopy during the measurement year or nine years prior to the measurement year.

CT colongraphy during the measurement year or four years prior to the measurement year. FIT-DNA tests during the measurement year or two years prior to the measurement year.

Best practices for COL.

Ask members if they had a colorectal cancer screening and update this history on an annual basis.

Document test and date in the medical record.

Emphasize personal choice and various modalities, especially for those who may fear having a colonoscopy.

Distribute FOBT and FIT test kits to members who need to be screened. Have an FOBT kit on hand to utilize for member teaching. Act quickly for members who have positive stool test results.

Controlling High Blood Pressure, CBP.

Members 18 to 85 years of age on December 31st of the measurement year. The percentage of members 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled, less than 140 over 90, during the measurement year.

For compliant telehealth visits, documentation must include used digital device to capture BP and include the reading.

Non-compliance for CBP. BP was greater than or equal to 140 over 90 or missing/incomplete reading.

Taken in an acute setting, like an ER. Taken by the member using a non-digital device, for example, a manual blood pressure cuff and stethoscope.

Taken the same day as a diagnostic test or procedure that requires a change in diet or medication, with the exception to fasting for a blood test.

Best practices for CBP.

Document BP readings at every visit, and, if the BP reading is 140 over 90 or greater at the time of the visit, retake it.

Schedule follow up visits for blood pressure control after diagnosis or medication adjustments.

Consider referral to cardiologists for those BP goals that cannot be attained, or for complicated patients.

Primary care provider obtain visit notes from specialist.

Blood Pressure Control for Patients with Diabetes, BPD.

The next few measures focus on diabetes.

They were previously grouped together as a comprehensive diabetes care measure, which was known as CDC. However, the sub measures for CDC are now independent of one another and have different acronyms.

The eligible population is 18 to 85 years of age as of December 31st of the measurement year.

For this measure the criteria is identical to controlling high blood pressure. The difference is that one focuses on diabetics and CBP focuses on those with hypertension.

So, for this measure the criteria is identical to controlling high blood pressure.

The difference is that this one focuses on diabetics and CBP focuses on those with hypertension.

In addition, the possible exclusions for both measures are different.

Possible exclusions. Members who do not have a diagnosis of diabetes during the measurement year or the year prior to the measurement year and who have a diagnosis of polycystic ovarian syndrome or gestational diabetes, or steroid induced diabetes in any setting during the measurement year or the year prior to the measurement year.

Hemoglobin A1C Control for Patients with Diabetes, HBD.

The eligible population is 18 to 75 years of age as of December 31st of the measurement year.

We are looking at the percentage of members 18 to 75 years of age with diabetes type 1 and type 2 who had A1C control of less than 8% for Medicaid members and HBA1C poor control of greater than 9% for FIDE-SNP Medicare and Braven members.

The latter, which is A1C control of greater than 9%, is known as an inverted measure, which means the lower rate indicates better performance for this indicator. And member's diabetic status is determined by claims or pharmacy data.

Eye Exam for Patients with Diabetes, EED.

Members 18 to 75 years of age as of December 31st the measurement year.

The percentage of members 18 to 75 years of age with type 1 or type 2 diabetes who had a retinal eye exam by an optometrist or ophthalmologist.

Possible exclusions, members who do not have a diagnosis of diabetes during the measurement year or prior to the measurement year.

This is the measurement criteria for EED.

Letter by an eye care professional.

A chart or a photograph when fundus photography was performed.

Bilateral eye enucleation.

Exam must be performed in an outpatient setting.

Documentation does not have to say, no diabetic retinopathy.

Documentation of a negative retinal or dilated exam by eye care professional.

Kidney Health Evaluation for patients with Diabetes, KED.

Members must have both tests to meet compliance regardless of the result.

For uACR, we can take either a ratio or both, quantitative urine albumin and a urine creatinine if those service dates are 4 days or less apart.

For example, if the service date for the quantitative urine albumin test was December 1st of the measurement year, then the urine creatinine test must have a service date on or between November 27th and December 5th of the measurement year.

Statin Therapy for Patients with Diabetes, SPD.

Eligible population is 40 to 75 years of age as of December 31st of the measurement year. Possible exclusions are the same as the previous measures related to diabetes.

These are the medications at different intensity levels that will meet compliance.

Please remember this is only a guide as to what NCQA specification states. We cannot tell you how to treat your patients. That would be up to you.

These are medications at different intensity levels that will meet compliance. Please remember this is only a guide.

Again, as NCQA specifies, we cannot tell you how to treat your patients, that is up to you.

Best practices for diabetic measures.

Order labs prior to member's appointments and ensure documentation in the medical record includes the date and result of most recent HbA1C test.

Ensure documentation in the medical record includes a kidney health evaluation.

Document date of most recent diabetic eye exam with results, name and title of the eye care provider in the medical record.

Document BP readings at every visit and retake if greater than 140 over 90.

Educate on the importance of complying with statin therapy during every communication.

Statin Therapy for Patients with Cardiovascular Disease, SPC.

The difference between this and the SPD measure, which was just discussed, is that SPD focuses on members who do not have these conditions and this one focuses on those who do.

Meets criteria. Members who were dispensed at least one high intensity or moderate intensity statin medication during the measurement year. Statin adherence 80%, members who remained on a high intensity or moderate intensity statin medication for at least 80% of the treatment period.

Eligible populations. Males is 21 to 75 years of age as December 31st of the measurement year, females, 40 years to 75 years of age on December 31st of the measurement year.

Here again we're offering you a list of medications at different intensity levels that will meet compliance.

Again, please remember this is only guide as you decide what is best for how to treat your patients.

Another difference between this measure and SPD, is that SPD includes low intensity statin medications and this measure only includes high and moderate intensity statins.

Best practices for SPD and SPC.

Educate on the importance of complying with statin therapy during every communication.

Simplify the medication regimen with using once-daily dosing if possible. Listen to members' concerns and make them an active part of your shared decision making.

Routinely arrange the next appointment for consistent follow up and monitoring.

Suggestions for success with closing gaps.

Accurate claim submission.

Utilize gap lists available on Horizon Docs, or with your EMR system.

Submitting ECDS/EHR templates.

Access to Quality Resource Center for strategies and tools to providing quality service to your patients.

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