Women’s Health

Hello and welcome to the Quality Programs webinar on Women's Health R&R.

The objectives of this webinar are; understand the measure requirement, understand criteria to meet the measure, and apply 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, our members.

The goal is to positively impact the health of women and children in New Jersey by engaging and educating OBGYN practices on the PPC, BCS, CHL, and CCS HEDIS measures, which I will go over shortly.

Early detection for any health issue has the best outcome.

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

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

These are the measures in the women's health program. There are 8 in total, but only 5 listed on the left side of the screen, are incentivized.

PPC. For the PPC measure we need 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 prenatal care visits and a postpartum visit.

To meet the measure, timeliness of prenatal care and postpartum visits must be done within certain time frames.

The exclusions for this measure is members using hospice or using hospice services anytime during the measurement year.

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

To meet the measure there must be a prenatal care visit with an OB-GYN or other prenatal care practitioner or PCP, and one of the following examples are 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 the 7th and 84th day after delivery.

To meet the criteria for this indicator there must be a postpartum care visit with the OB-GYN or other prenatal care practitioner or a PCP, and any of the noted related pelvic exam, postpartum care, cesarean incision and other examples shown here.

These are best practices for PPC.

Stressing the importance of a 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 OB-GYN to promote consistent and coordinated healthcare.

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

Consider offering extended practice hours to increase care access.

Remind patients of their appointments by making calls and sending texts.

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

PND. For this measure, it focuses on the Medicaid and Commercial populations.

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 shortly.

To be eligible, the delivery date must have occurred during the measurement period, and the screening occurred 28 days prior to the delivery date through to delivery date.

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 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 during 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 should be a visit with a diagnosis of depression or other behavioral health condition, or depression case management encounter, or behavioral health encounter, a dispensed anti-depressant 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.

PDS. For this measure, it is 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 delivery 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 also focuses on the Commercial and Medicaid populations.

To meet the measure there must be a depression screening, and if positive, a follow-up for that.

Exclusions here are deliveries in which members were in hospice or using hospice services anytime during the measurement year.

For 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 to 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 for the prenatal depression screening follow-up that was previously discussed.

Best practices for depression screening are shown here in detail.

And best practices for follow-up are also shown here in detail.

Prenatal Immunization Status.

So this measure relies on the percentage of deliveries between January 1st and December 31st of the measurement year in which women had received influenza, tetanus and Tdap vaccination.

These measures also focus on 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 pregnancy which may include the delivery date.

The exclusions here are deliveries that occurred at less than 37 weeks and members in hospice care.

And here are some best practices for prenatal screening.

Give the mom Tdap and flu shots, the mom creates antibodies. The antibodies pass onto baby. And the mom and the baby are protected.

Breast Cancer Screening.

This measures 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 the member to be compliant, a mammogram must be done anytime between October 1st, two 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 be compliant as these tests are usually for diagnostic purposes and not for screening.

Possible exclusions include a bilateral mastectomy anytime during the members' history through December 31st of the measurement year.

And here are some best practices on breast cancer screening in detail.

And now Cervical Cancer Screening.

This measure focuses on the percentage of women 21 – 64 years of age who were screened for cervical cancer.

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

This measure also has a look back period.

If one is not found we can look at the measurement year and 4 years prior for women 30- 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.

This measure focuses on the Medicaid and Commercial population.

Possible exclusions includes a hysterectomy with no cervix, an acquired absence of cervix anytime during the member's history throughout December 31st of the measurement year.

Non-compliance vs. possible exclusions.

Non-compliance would be if there were no cervical cells present or the sample was inadequate.

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

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

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

Best practices for cervical cancer screening are here in further detail.

And now chlamydia screening in women.

This measure looks at the percentage of women between 16 and 24 years of age who had at least 1 chlamydia screening in the measurement year.

This measure is also 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 contraceptive or a claim and encounter for a pregnancy test.

As we know contraceptives are prescribed for reasons other than preventing pregnancy.

However, whenever a member is actually active or not if a contraceptive is prescribed, that member may fall into this measure.

Possible exclusions are for members who qualify for this measure and based on a pregnancy test alone and who either had a prescription for isotretinoin on the date of pregnancy test or 6 days after the pregnancy test, or had an xray on the date of the pregnancy test or 6 days after the pregnancy test.

And here are some best practices for chlamydia screening.

Thank you for attending this recorded webinar.

If you have any questions please email the Quality Department at Quality_RR@horizonblue.com.

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