ANNUAL QUALITY REPORT3b0c642hkugknal3z1xrpau1-wpengine.netdna-ssl.com/... · This report provides a...

ANNUAL QUALITY REPORTRAE Region 3

Fiscal Year 2018 - 2019

Table of ContentsExecutive Summary ................................................................................................................................................ 2

Quality Assessment and Performance Improvement Program .....................................................................2

Key Accomplishments in FY19 .................................................................................................................. 2

Key Goals Moving into FY20 ..................................................................................................................... 3

Performance Improvement Projects ........................................................................................................................ 3

Well-Visits for Members Ages 10-14 Years ................................................................................................. 3

Follow-Up Within 30 Days After Positive Depression Screening in Primary Care ...................................... 3

Performance Measurement ..................................................................................................................................... 4

Key Performance Indicators and Behavioral Health Incentive Measures ..................................................... 4

Information System (IS) Review Audit ...................................................................................................... 5

Member Experience of Care ................................................................................................................................... 5

Experience of Care and Health Outcomes (ECHO) Survey ....................................................................... 5

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey ........................................... 7

Member Grievances ................................................................................................................................... 8

Mechanisms to Detect Over- and Under-Utilization of Care .................................................................................. 9

Utilization Management ............................................................................................................................ 9

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Coordination................................... 10

Secret Shopper ......................................................................................................................................... 11

Behavioral Health Penetration Rates ........................................................................................................ 13

Network Adequacy .................................................................................................................................. 14

Telehealth ................................................................................................................................................ 14

Client Over-Utilization Program (COUP) ............................................................................................... 14

Quality and Appropriateness of Care for Members with Special Health Care Needs ............................................. 16

Behavioral Health Medical Records Review ............................................................................................. 16

Care Management for Members with Special Health Care Needs ............................................................ 16

Quality of Care Concerns Monitoring .................................................................................................................. 17

Quality of Care Concerns ........................................................................................................................ 17

Other Quality Monitoring ................................................................................................................................... 18

External Quality Review Organization (EQRO) Audit ............................................................................ 18

Internal Advisory Committees and Learning Collaboratives ................................................................................. 19

Learning Collaboratives ........................................................................................................................... 19

Provider Learning Collaboratives ............................................................................................................. 20

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Executive Summary

Quality Assessment and Performance Improvement Program

The philosophy of the Colorado Access Quality Assessment and Performance Improvement (QAPI) Program is to ensure that members receive access to high-quality care and services in an appropriate, comprehensive, and coordinated manner that meets or exceeds community standards. Emphasis is placed on community-based, individualized, culturally sensitive services designed to enhance self-management and shared decision among members, their families, and providers. The Colorado Access QAPI promotes objective and systematic measurement, monitoring, and evaluation of services and work processes. Colorado Access is committed to the ongoing improvement of the quality of care members receive through monitoring data and outcomes. The QAPI Program uses a continuous measurement and feedback paradigm with equal emphasis on internal and external services affecting the access, appropriateness, and outcomes of care.

This report provides a reflection on key QAPI as well as Regional Accountable Entity (RAE) programs and activities that Colorado Access engaged in throughout FY19, including performance against goals. It also describes intended goals, strategies, and interventions to continuously promote quality in FY20.

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Key Accomplishments in FY19

During FY19 (July 1, 2018 – June 30, 2019), the quality program at Colorado Access used an array of measures and activities to monitor and improve the quality and effectiveness of clinical care and the quality of administrative services that make up managing a health plan. Performance improvement tools, including rapid-cycle methodology, were applied to address system, service, and/or clinical areas needing improvement. Throughout the fiscal year, the quality department launched numerous initiatives to enhance and promote a data-driven culture within Colorado Access and the provider network. These included the following areas of focus:

• Performance Improvement Projects

• Performance Measurement

• Member Experience of Care

• Mechanisms to Detect Under- and Over-Utilization of Services

• Quality, Safety, and Appropriateness of Clinical Care Furnished to Members with Special Health Care Needs

• Quality of Care Concern Monitoring

• External Quality Review

• Advisory Committees and Learning Collaboratives

As FY19 was the first year of the RAE contract, the QAPI program also focused on building the internal capacity to monitor quality of care for all Colorado Access members, promoting a data-driven culture internally within Colorado Access, and aligning quality initiatives with the requirements of the contract.

The mission of the Quality Assessment and Performance Improvement program is to promote quality and performance improvement through a data-driven, systemic approach that analyzes data and trends and identifies opportunities for performance enhancements through dynamic, system-wide and integrated change to improve the health outcomes of members, enhance their experience of care and support the sustainment of a member-defined quality of life.

Our Mission

Key Goals Moving into FY20

FY20 (July 1, 2019 – June 30, 2020) will bring enhanced focus on internal Colorado Access quality measurement and performance improvement. This will include conducting a full QAPI self assessment to identify key areas of strengths and areas of opportunity for the program and building action plans to address prioritized areas of opportunity. Colorado Access will continue to monitor the quality of care provided to members using an array of data sources and indicators, and to promote performance improvement when deficiencies are noted.

Performance Improvement ProjectsColorado Access uses a comprehensive approach to identify and prioritize performance improvement projects based on relevant high volume, high risk or targeted population data. Colorado Access selects projects based on a number of criteria including: patient safety, health risk factors or co-morbidities, volume of members, contractual requirements, potential for improvement in health outcomes, project scale and ease of implementation, financial feasibility, available resources and contract requirements.

During FY19, Colorado Access launched a new, Rapid-Cycle Performance Improvement Project (PIP) methodology to address Region 3 performance on two measures and sub-populations: well-visit rates for members aged 10-14, and follow-up after positive depression screening for members aged 10-14. This methodology is designed to quickly implement and test changes in processes to determine whether the change is effective in achieving the intended performance improvement outcome.

Well-Visits for Members Ages 10-14 years

Summary:

In FY19, the quality department at Colorado Access initiated a Rapid-Cycle PIP to target well-visit rates for 10-14 year olds attributed to STRIDE CommunityHealth Center. This topic was selected because of itsalignment with other preventive health initiativespromoting well-visits and for its potential to providelearnings that could then be disseminated across theprovider network. By narrowing the focus populationto the 10-14 year old age range, Colorado Access

sought to develop interventions to increase both access to care and the likelihood of members receiving important preventive screenings and education in early adolescence.

FY19 Goals:

• Initiate Rapid-Cycle PIP and complete and submit100% of Modules 1-4 to Health Services AdvisoryGroup (HSAG) on time.

FY19 Results:

During FY19, 100% of PIP Modules 1-4 were submitted to HSAG on time, and all relevant feedback from HSAG was incorporated into the submissions and intervention designs. The quality department at Colorado Access also initiated a key partnership with STRIDE Community Health Center on this project which continues into FY20.

FY20 Strategies and Planned Interventions:

In FY20, Colorado Access will continue to collaborate with STRIDE Community Health Center to perform a Plan-Do-Study-Act cycle to test interventions to increase well-visit rates. Important components of this work include focused targeted telephone outreach to members ages 10=14 who have not received a well visit in the previous 12 months, as well as face-to-face and/or virtual training and ongoing support to STRIDE Community Health Center on best practices for increasing well visit rates. Colorado Access will monitor well visit rates for members ages 10-14 attributed to STRIDE Community Health Center on a monthly basis to determine if interventions are effective, and will pivot intervention points where necessary.

FY20 Goals:

• Work with STRIDE Community Health Center toincrease the percentage of well-child visits amongmembers 10-14 years of age, attributed to STRIDECommunity Health Center, from 33.44% to38.44%.

Follow-Up Within 30 Days After Positive Depression Screening in Primary Care

Summary:

In FY19, Colorado Access initiated a Rapid-Cycle PIP to target follow-up rates within 30 days of screening positive for depression within a primary care setting

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among 10-14 year-olds. This topic aligns with the State’s quality strategy and also aligns with other initiatives within Colorado Access targeting follow-up after a positive depression screen.

FY19 Goals:

• Initiate Rapid-Cycle PIP and complete and submit 100% of Modules 1-4 to HSAG on time.

FY19 Results:

During FY19, 100% of PIP Modules 1-4 were submitted to HSAG on time, and all relevant feedback from HSAG was incorporated into the submissions and intervention designs.

The quality department at Colorado Access also conducted thorough data review to identify key barriers and areas of opportunity to improve performance on this measure. Internally-calculated depression screening follow-up rates in Region 3 were calculated as 0.82% for the 10-14 year old population, providing much opportunity for improvement in access to behavioral health care after depression is detected in the primary care setting.

FY20 Goals:

• Increase the percentage of members age 10-14 with a positive depression screen who received at least onefollow-up service within 30 days, from 0.82% to 5%.

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Performance Measurement

The QAPI program at Colorado Access uses a wide range of data sources and measures to monitor health plan performance. Key among these include state-defined performance measures as written into the RAE contracts (key performance indicators and incentive measures) as well as information system review activities, detailed below. Colorado Access uses these measures to prioritize and drive systematic approaches to sustained quality improvement.

Key Performance Indicators and Behavioral Health Incentive Measures

Summary:

The quality assessment and performance improvement department at Colorado Access promotes objective and systematic measurement, monitoring, and evaluation of performance on state-defined performance measures. These include the seven key performance indicators (KPIs) and five behavioral health incentive measures (IMs) as defined by the Department of Health Care Policy and Financing (HCPF).

FY19 Goals:

Key Performace Indicators

Behavioral Health

Engagement

Dental Visits Well Visits Health Neighborhood

Prenatal Engagement

Emergency Department (ED) Visits

Potentially Avoidable

Costs

Behavioral Health Incentive Measures

Engagement In Outpatient

Substance Use Disorder (SUD)

Treatment

7-Day Follow-Upafter ED SUD visit

Follow-Up after Positive Depression

Screening

7-day Follow-upAfter IP Hospital

Discharge for Mental Health Condition

Behavioral Health Screening or

Assessment for Children in Foster Care

• Launch a collaborative, multi-disciplinary pay-for-performance workgroup to develop strategies, action plans, and key implementation milestones to impact initial areas of opportunity for KPIs and IMs.

FY19 Results:

FY19 was focused on understanding KPI and IM methodology, evaluating key areas of opportunity, creating specific focus groups for key measures, and developing implementation plans to create measurable impact. The quality department at Colorado Access facilitated pay-for-performance workgroups as well as task force groups with internal and external stakeholders to examine the measures and develop mutually reinforcing activities across the provider network. This effort enhanced the Colorado Access potential to create sustained performance improvement on KPIs and IMs using a data-driven, multi-disciplinary approach.


Moving into the second year of the RAE contract, the quality assessment and performance improvement department will refine strategies to create a measurable impact on the state-defined performance measures. Colorado Access intends to continue this collaborative approach to identify and implement strategies to improve performance on KPIs and IMs and to continuously monitor performance on these indicators. Internal data methodology has been finalized to calculate and track progress on outcome measures over time.

FY20 Goals:

• Execute on action plans and implementation milestones for identified KPI and IM opportunities by leveraging data, Plan-Do-Study-Act cycles, and external partnerships.

• Improve performance against baseline measurements across the KPIs and IMs.

Information System (IS) Review Audit

Summary:

Colorado Access understands that an information systems audit can provide a wide-ranging benefit to an enterprise by ensuring the effective, efficient, secure and reliable collection and storage of information critical to organizational success. With the inception of the RAEs, HCPF identified a need to initiate an information

system (IS) review audit to examine the Colorado Access claims process and data information systems.

FY19 Goals:

Complete and submit the IS Review Audit Questionnaire on time as directed by HCPF.

FY19 Results:

Colorado Access submitted the IS review audit to HCPF on time.

FY20 Strategies and Planned Interventions

Moving into FY20, Colorado Access will continue to refine information systems and data processing and collection and use end-user feedback to enhance these systems.

FY20 Goals:

• Colorado Access will determine priorities around refining and upgrading information systems as well as data storage and processing through continuous feedback from individuals consuming data and internal information.

Member Experience of CareColorado Access continuously assesses member experience of care using a combination of data sources. These include: member surveys, first-person reports of care experience, call center data, and incident tracking through grievance and appeals.

Experience of Care and Health Outcomes (ECHO) Survey

Summary:

HCPF contracted with HSAG to administer and report the results of the Adult and Child/Parent Experience of Care and Health Outcomes (ECHO) Surveys beginning in FY19. This survey was targeted toward members who received at least one behavioral health care service through a Behavioral Health Organization, a RAE, and/or a RAE-contracted community mental health center (CMHC) or specialty clinic from November 1, 2017, through October 31, 2018.

FY19 Goals:

• Monitor member perceptions of well-being, functional status, provider accessibility and adequacy of services, taking care to assess the

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Therefore, FY19 results of the ECHO survey represent a baseline assessment of members’ experiences. In FY20, Colorado Access will review the results of the ECHO survey and identify and prioritize areas for performance improvement where appropriate.

FY20 Goals:

• Monitor member perceptions of well-being, functional status, provider accessibility and adequacy of services, taking care to assess the quality and appropriateness of care furnished to members with special health care needs.

quality and appropriateness of care furnished to members with special health care needs.

FY19 Results:

Access and Availability of Services

Of the members surveyed who reported that they needed counseling or treatment “right away,” 56.17% of adults and 64.52% of child respondents “usually” or “always” received treatment as soon as they wanted. Additionally, 80.74% of adult respondents and 83.74% of child respondents reported always/usually being seen within 15 minutes of their scheduled appointment.

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Quality/Health Status

There were 66.67% of adults and 65.07% of child respondents that rated their current overall mental health as excellent, very good, or good compared to 12 months ago. Also, 91.15% of adults and 92.52% of child respondents rated their current ability to deal with daily problems as excellent/very good/good compared to 12 months ago.

The ECHO survey included a relatively small sample size (total Region 3 respondents = 176).

Therefore, Colorado Access will exercise caution when interpreting results and/or designing interventions based solely off these results. However, this survey provides a promising opportunity to better monitor member experience of behavioral health (BH) services provided through the Colorado Access network.


In FY19, members in the RAE were surveyed for the first time.

40%

30%

20%

10%

0%

In general, how would you rate your overall mental health now?

38.78% 38.36%

25.17%30.14%

20.41% 21.92%

7.48%4.79% 4.79%

8.16%

RAE 3 Adult RAE 3 Child

Excellent Very Good Good Fair Poor

40%

30%

20%

10%

0%

When you needed counseling or treatment right away, how often did you see someone as soon as you wanted?

20.55% 22.58%

35.62%

41.94%

32.88%27.42%

10.96% 8.06%

RAE 3 Adult RAE 3 Child

Never Sometimes Usually Always

• Colorado Access will determine what ECHO survey data to routinely monitor in the future to measure member experience of behavioral health care, to identify areas for performance improvement in alignment with the Quality Assessment and Performance Improvement Plan goals and objectives.

Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey

Summary:

HCPF collects data about member experience through the CAHPS survey that assesses member and caregiver satisfaction with the experience of care, including services provided by Colorado Access and network physicians. The quality department monitors CAHPS data to identify and correct deficiencies in member experience with Colorado Access and the provider network, including creating and monitoring corrective action plans as appropriate.

FY19 Goals:

• Monitor customer service performance through a quality monitoring plan and net promoter scores (NPS).

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100%

80%

60%

40%

20%

0%

Region 3 CAHPS Results FY19 - Adult

62.6% 62.5% 59.8% 61.5%

44.9%

68.6%64.9%73.4%

Rating of health plan

Rating of health care

Rating of personal doctor

Rating of specialist seen

most often

Getting care quickly

How well doctors

communicate

Customerservice

Coordination of care

100%

80%

60%

40%

20%

0%

Region 3 CAHPS Results FY19 - Child

73.9% 74.9% 74.1%68.4%

77.2%

66.2%

80.0%

Rating of health plan

Rating of personal doctor

Rating of specialist seen

most often

Getting care quickly

How well doctors

communicate

Customerservice

Coordination of care

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FY19 Results:

The customer service department continued to implement targeted interventions to address low CAHPS customer service scores. These included continuous monitoring of NPS scores and the customer service monitoring program. The NPS is a survey offered to callers post-call to gauge the customer’s overall satisfaction with Colorado Access customer service staff members.

FY19 global rating top-box results for adults and children are shown in the adjacent graphs. The ratings produced for single and composite measures mirror the scoring methodology presented in the HSAG 2019 Colorado Patient-Centered Medical Home Survey Report.


• Continue the customer service quality monitoring program, including continuous monitoring of NPS scores.

• Distribute survey results to relevant providers to promote education while exploring potential solutions to improve scores.

• Initiate focus groups between quality and care management staff members to understand member barriers to care commonly seen by care managers.

• Implement an in-house member satisfaction survey for members who call Colorado Access customer service to monitor the member’s experience with access, timeliness, and quality of care provided by Colorado Access-contracted providers.

FY20 Goals:

• Monitor CAHPS data to identify and correct deficiencies in member experience with Colorado Access and the provider network, including creating and monitoring corrective action plans as appropriate.

• Conduct at least one focus group with quality, care management, and customer service to discuss common member experience concerns.

• Launch a member satisfaction survey through customer service to capture baseline data of key drivers of member experience.

Member Grievances

A key way that Colorado Access monitors member experience is through the member grievance process. Members have the right to submit grievances to Colorado Access regarding any aspect of the operations, activities, or behavior of the health plan or the Colorado Access contracted provider network. Quality and customer service staff members monitor member grievance data to identify sources of dissatisfaction with care or service delivery, and member grievance data is aggregated quarterly.

FY19 Goals:

• 100% grievance resolution within contractual timeframes.

• Less than 2.0 grievances per 1000 members.

FY19 Results:

During FY19, a total of 47 grievances were filed by or for Region 3 members. Out of 47 grievances, 71% were resolved within 15 business days. For these 47 grievances, there were 10 extensions filed.

During FY19, Colorado Access identified an opportunity to realign focus within member grievances aimed at promoting awareness of the grievance process for members and care management staff members, in order to increase reporting of grievances and better ensure that member voices are being heard. In FY20, Colorado Access will continue focus to more effectively capture member grievances from care management staff members so that member satisfaction issues may be identified, tracked, and resolved in an efficient and timely manner.


• Pilot a program with care management to train Colorado Access care managers on the member grievance process and increase documentation of member grievances.

• Conduct meetings with customer service and quality to continuously monitor areas of member dissatisfaction.

FY20 Goals

• Train at least six care management staff members on the member grievance process in the first quarter of FY20.

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• Maintain 100% compliance for contractually required grievance timeframes.

• Provide education and out-reach to members, families, and providers to ensure they are informed of member rights and procedures to file grievances.

Mechanisms to Detect Over- and Under-Utilization of Care

Colorado Access monitors, assesses, and prevents the over- and under-utilization of services by utilizing medically necessary and appropriate levels of care. Key initiatives include utilization management decision-making and turnaround time, secret shopper activities, monitoring of behavioral health penetration rates and network adequacy, promoting telehealth services, and through implementation of the Client Over-Utilization Program.

Utilization Management

Colorado Access Utilization Management (UM) continuously monitors timeliness of UM decisions to assure that they are made according to contractual requirements and to support members’ accessibility to services according to need. Additionally, UM conducts an annual inter-rater reliability (IRR) study to objectively assess the degree to which raters answer the same questions in the same way (reliability) and to measure the level of consistency and adherence to Colorado Access-approved medical management criteria/guidelines. For any member over the age of 21 who receives denial of a non-covered benefit, UM and care management participate in creative solutions meetings to actively problem solve accessibility of services for members with complex and special health care needs.

FY19 Goals:

• Maintain turnaround time (TAT) compliance to 99% or higher.

FY19 Results:

In FY19, Colorado Access continued to monitor the timeliness of all UM decisions. The percentage of compliance with TAT for all decisions, as well as the inter-rater reliability scores by staff member type are shown in the nearby graphs.

In spring 2018, UM hired more than 20 new staff members to prepare for the addition of RAE Region 3 and to in-source 24/7 behavioral health UM coverage. This addition of staff members required extensive onboarding, training, and thorough inter-rater reliability (IRR) testing.

20

15

10

5

0

Region 3 Grievances by Type

235

7

11

19

Rights/ legal

OtherFinancial/ billing

Customer service

Clinical care

Access and availability

100%

80%

60%

40%

20%

0%

UM Turnaround Time Compliance

92.1%

7.9%

Timely Untimely

IRR Scores by Staff Type

Staff Type Average Overall Score Goal/Benchmark

Intake Specialist 97.50% 90%

Clinical Review Staff 97.60% 90%

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In FY20, Colorado Access UM will continue monthly monitoring of compliance with timeframes. In addition, UM will develop individualized reporting for all staff to increase transparency and accountability for turnaround time compliance and denial rates. Staff members will receive ongoing education and coaching around TAT standards.

FY20 Goals:

• Achieve TAT compliance at 99% or higher.

• All UM staff meet the 90% or greater benchmarkfor IRR.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Coordination

Colorado Access care management helps to coordinate the provision of EPSDT benefits for children and adolescents under the age of 21.

FY19 Goals:

• Provide/coordinate any medically necessary serviceto children and adolescents under age 21 within thecapitated behavioral health benefit.

• Assist members in accessing EPSDT benefits,including those covered by fee-for-service, suchas respite and residential services for membersdiagnosed with intellectual or developmentaldisabilities (IDD).

• Educate members about the benefits they haveaccess to under EPSDT.

• Educate providers about EPSDT services, processes,and their obligations for coordinating the provisionof EPSDT services.

• Educate Colorado Access clinical staff membersabout EPSDT benefits and the process for accessingthe different services under EPSDT.

FY19 Results and Analysis:

During FY19, the following EPSDT services were provided under the capitated behavioral health benefit in Region 3:

• Vocational Services: 50 members received 381services

• Prevention/Early Intervention Services: 7,532members received 16,541 services

• Clubhouse and Drop In Center Services: 304members received 646 services

• Recovery Services: 122 members received 530services

• Respite Services: 9 members received 66 services

During FY19, Colorado Access prioritized educating members, providers, and staff about EPSDT benefits and procedures:

• All Colorado Access clinical staff (utilizationmanagement and care management staff members)completed an EPSDT webinar published by theDepartment of Health Care Policy and Financing,and received an in-person training from GinaRobinson, the EPSDT subject matter expert withHCPF.

• Colorado Access made significant revisions to theEPSDT section of the provider manual, includingadding more content around provider expectations,links to training materials, and fact sheets that canbe distributed to their patients through revisions tothe EPSDT section of the provider manual.

• Added a new section on the Colorado Accesswebsite for members to learn more about thebenefits they can access through EPSDT – boththose in the capitated behavioral health benefit andthose that are paid by fee-for-service.


Colorado Access will revise and improve training materials for training staff members and providers about EPSDT benefits.

FY20 Goals:

• Continue to provide medically necessary services tochildren and adolescents under age 21 within thecapitated behavioral health benefit.

• Assist members in accessing EPSDT benefits,including those covered by fee-for-service, suchas respite and residential services for membersdiagnosed with intellectual or developmentaldisabilities (IDD).

• Continue to educate staff, members, and providers

about EPSDT benefits.

Secret Shopper

Summary:

The quality management department maintains a systematic process to monitor and fulfill access to care standards and metrics for contractual requirements. Colorado Access monitors various provider categories including physical health and behavioral health services to assure timely and appropriate routine and urgent services.

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Physical Heath Appointment Standards

Type of Care StandardRoutine care (non-symptomatic, well care physical exam, preventive care)

Scheduled within 4 weeks of request

Non-urgent care (symptomatic) Scheduled within 1 week of request Urgent care Scheduled within 24 hours of request Behavioral Health Appointment Standards

Type of Care StandardRoutine care (non-urgent, symptomatic behavioral health services)

Within 7 days of member’s request

Urgent care Within 24 hours of initial contact by member Emergency services (face-to-face) Urban/suburban: within 1 hour of contact

Rural/frontier: within 2 hours of contact Emergency services (phone) Within 15 minutes of initial contact Outpatient follow-up appointments after hospital (behavioral health & physical health)

Within 7 days after discharge from a hospitalization

Access to Care Standards, Colorado Access Provider Manual

FY19 Goals:

• Educate providers on access to care standards.

• Monitor access to care data per contractual requirements.

• Collaborate with Mental Health Center of Denver to obtain data around urgent and emergency face-to-face services (mobile and walk-in).

FY19 Results:

The quality department updated information about access to care standards in the provider manual and circulated information in the monthly provider newsletter. Additionally, 67 total secret shopper calls were conducted in FY19, doubling the 32 total calls made in FY18. The quality department also increased monitoring by shifting from behavioral health data being self-reported to being tested by Colorado Access quality staff members.

Region 3 providers met the performance goals of 80% compliant secret shopper calls for the physical health access to care standards. However, overall behavioral health access needs further development and training to inform providers about access standards. In particular, many providers offer walk-in appointments and do not always provide a scheduled appointment against which Colorado Access can measure timely access. Members have reported long

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wait times for walk-in appointments limiting a member’s ability to get timely care. Colorado Access experienced difficulties in the first year of testing behavioral health providers due to not being able to provide a “fictitious” Medicaid ID which many providers requested in order to enter information into a system and provide an estimated appointment.

The below graph describes compliance with access to care standards by provider and appointment type. Please note that historical scores are based on former metropolitan region estimates and are not an apples to apples comparison with Region 3 counties/populations:

FY17 FY18 FY19

Physical HealthRoutine 60% 60% 92%

Non-Urgent Symptomatic 100% 100% 100%

Urgent 100% 100% 83%

Behavioral Health

Routine 98% 100% 38%Outpatient Follow-up N/A N/A N/AUrgent 100% 100% 100%Emergency face-to-face 100% 100% N/AEmergency phone 99% 100% N/A

Note: FY17 & 18 BH scores are self-reported

The quality department updated provider manual information with new contract access to care standards. Reporting tools were updated from a flat Excel file to a more dynamic Access database, and auto-reporting is currently being piloted. Both physical health and behavioral health calls were entered into the system, whereas previously behavioral health data was collected through provider self-report.

The quality department continues to increase efforts on providing education related to the standards through updating the provider manual, distributing updated information in provider newsletters, and attending the quarterly provider face-to-face meetings.

The quality department conducted a targeted examination of access to care with Aurora Mental Health Center in fall of 2018. Results showed long hold times on the telephone and also that the provider was offering walk-in appointments, but not scheduled appointments. This information was communicated back to the provider in a timely manner and has been utilized to create additional monitoring practices within the Colorado Access care management team.


• Continue educating providers on access to care standards, as evidenced by provider newsletter communicationsand/or face to face provider quarterly forums.

• Implement corrective action plans (CAPs) when compliance falls below 80%.

• Continue to monitor access to care data per contractual requirements, as evidenced by completing at least 30calls annually, increasing monitoring from the eight calls made in FY19.

• Collaborate with other internal Colorado Access workgroups to monitor data and target any providers whoneed support or monitoring. For example, in partnership with the business intelligence team, quality willanalyze data and increase monitoring gaps for providers who have large attribution but small claim volume.

FY20 Goals:

• Conduct at least 15 secret shopper calls for physical health providers, and 15 secret shopper calls for behavioral health providers (for a total of 30 calls throughout the fiscal year).

Behavioral Health Penetration Rates

Summary:

Behavioral health penetration rates are calculated annually in order to measure the percentage of members who have received one or more behavioral health service. These rates are an important indicator of utilization of behavioral health services and help to ensure that members are accessing needed services.

FY19 Goals:

• Establish baseline penetration rate in Region 3 and continuously monitoring penetration rates.

FY19 Results:

With the advent of the RAE structure in FY19, Colorado Access sought to establish baseline Region 3 penetration rates in alignment with the Region 3 service area. Colorado Access also continued to monitor behavioral health penetration rates in alignment with the RAE key performance indicator of behavioral health engagement. During FY19 in Region 3, 12.9% of members received one or more behavioral health service.


Under the structure of the RAE, Colorado Access will work with county partners to address barriers in accessing behavioral health care facing foster care members; this will be accomplished through targeted performance improvement around the behavioral health screen and assessment incentive measure. Additionally, Colorado Access will seek to enhance access and increase behavioral health penetration rates in alignment with the IMs as set forth by the state.

FY20 Goals:

• Maintain or increase the overall behavioral health penetration and utilization rates across the RAE region.

Network Adequacy

Summary

Member access to primary and specialty care is an important component of timely medical care and member satisfaction. Colorado Access continuously monitors network adequacy and develops comprehensive plans to monitor and grow the physical and behavioral health provider network to ensure access to timely and appropriate health care and comprehensive choice to RAE Region 3 members.

FY19 Goals:

Meet the geographical needs of members by assuring provider availability for the following provider types:

• PCMPs

• Hospitals

• Psychiatrists

• Mental health providers and psychiatrists

• Substance use disorder providers

FY19 Results:

Colorado Access achieved a 100% success rate in re-contracting all targeted PCMPs last year for Region 3. In addition, Colorado Access increased total PCMP contracts this past year, and will continue to add new PCMPs to its Region 3 network.

Colorado Access has a long standing statewide behavioral health network. This network continued uninterrupted into the RAE implementation and includes contracted relationships with every community mental health center in the state, hospital systems, institutes for mental disease (IMDs), behavioral health providers who are integrated with PCMPs, and independent behavioral health providers, statewide. Colorado Access continues to receive requests from behavioral health providers to join its network. Colorado Access adds any provider who is validated, submits a completed application, meets Colorado Access credentialing criteria standards, and signs a Professional Provider Agreement.

FY20 Strategies and Planned Interventions

Colorado Access will continue building relationships with specialty, ancillary, hospital, behavioral health, and primary care providers throughout the state to ensure the needs of our members are met with an adequately-sized network. The quality department at Colorado Access will continue to assess network adequacy and

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monitor provider to member ratios to maintain adequate access and choice for members when determining a provider.

FY20 Goals:

• Continue to monitor potential gaps in the networkand find opportunities to decrease access to carebarriers for targeted populations, including fostercare members and refugee populations.

Telehealth

Summary

Colorado Access, through its subsidiary, AccessCare Services, has developed new programs and services to increase access to behavioral health care for members through telemedicine technology. These innovative solutions provide enhanced capabilities for both members and providers. The goal of this program is to develop and implement innovative clinical delivery models and services that leverage technology to facilitate real-time access to care and care coordination between members, providers, and systems.

AccessCare Services offers telehealth through the Virtual Care Collaboration Integration (VCCI) program, which provides both provider-to-provider consultations between the AccessCare Services behavioral health team and primary care, as well as direct encounters with patients within the primary care setting. The VCCI program provides services to 25 practices within the Colorado Access network, 17 of which are in Region 3, working with both primary care/family medicine and pediatric practices.

FY19 Goals:

• Increase utilization with current VCCI practices.

• Ensure telehealth programs align with ColoradoAccess RAE KPIs and IMs.

FY19 Results:

In FY19, the VCCI program expanded its reach to 25 sites across the state. In CY2018, AccessCare Services provided 829 discrete services to members through telehealth.


Colorado Access will launch a second phase of VCCI perinatal support program, engaging OB/GYN practices

and developing a “direct-to-consumer” workflow to offer services in a convenient setting outside of their physician’s office. In addition, Colorado Access will develop a plan to offer VCCI Medically Assisted Treatment (MAT) services, adding addiction medicine to the specialties offered through telehealth by AccessCare Services.

FY20 Goal:

• Expand the number of practices participating in theVCCI program throughout the provider network to35 practices.

Client Over-Utilization Program (COUP)

Summary:

The Client Overutilization Program (COUP, also known as “Lock-In”) is a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of care or services by Health First Colorado members. The Colorado Access care management department outreaches members who have been identified in the client over-utilization program to provide appropriate care coordination services. Colorado Access also conducts digital outreach and engagement to those members to educate them on their overutilization status and Colorado Access resources to help address their needs.

FY19 Goals:

• Outreach at least 90% of identified members tolink them to appropriate and available services.

• Partner with HCPF to administer the COUPprogram for members who meet criteria forinappropriate or over-utilization of health careservices.

FY19 Results:

The adjacent table provides full FY19 data for COUP activities at Colorado Access, as reported in the Region 3 COUP Report for Q4.


Colorado Access will address the needs of members identified as having high utilization through two main strategies: digital engagement and care management.

Digital Engagement

Colorado Access has launched a COUP digital

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engagement initiative designed to provide RAE members (21 and older) with emergency department (ED) and high-risk pharmacy overutilization with information about their service usage and Colorado Access resources to address their needs. Members are identified by the quarterly HCPF COUP list and receive one outbound IVR describing their overutilization and the Colorado Access care coordinator number for further support.

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Care Management

The Colorado Access care management COUP intervention strategy is designed to assist members by addressing overutilization patterns. Members who appear on the quarterly COUP list are outreached by phone, mail, or in person.

Once members are reached, care managers will communicate with members over the phone or in person to complete a comprehensive health assessments to identify the root of the member’s ED/high risk prescription utilization, identify gaps in care, and determine social needs that may be driving their behavior. Care managers work with members to connect them back to their primary care and/or specialty care provider and work with the member to develop care plans to address their needs.

FY20 Goals:

• Provide appropriate digital engagement messaging and resources for members identified on the HCPF COUP list.

• Outreach members who have been identified on the HCPF COUP list through appropriate channel(s) (i.e. care coordination or digital engagement IVR).

• Recruit providers to serve as lock-in providers. Colorado Access is working to recruit lock-in providers with particular discussion focusing on federally qualified provider groups and individual providers on a case-by-case basis.

Activities Q1 Q2 Q3 Q4 Total

# of Members on list from EQ Health 3,206 1,057 969 561 5,793 # of Outreaches attempted 231 1,940 2,013 1,864 6,048# of Members successfully contacted 119 134 177 234 664# of Members connected to care coordination 119 123 55 137 434# of Members connected to other services 28 8 21 22 79# of Members connected to PCMPs 2,251 1,057 0 13 3,321# of Members in Lock-In status N/A N/A N/A N/A N/A# of Lock-In Providers 0 0 0 0 0# of Appeals for Lock-In N/A N/A N/A N/A N/A

overview of the audit process during a one hour training session at the quarterly in-person provider meeting on June 20, 2019. Additionally, the quality department collaborated with provider relations staff members to roll out a robust documentation training webinar available on a monthly basis to the provider network.


In FY20, Colorado Access will continue to refine the documentation audit tool as needed to ensure continued high inter-rater reliability. Colorado Access will conduct quarterly, random or targeted chart audits on providers billing for assessment, psychotherapy, and/or case management services to ensure the quality and appropriateness of care for those members and services.

FY20 Goals:

• Audit 25 Region 3 records per quarter during each quarter of the fiscal year (for a total of 100 record reviews) and develop corrective action plans as necessary with participating providers.

• Implement corrective action plan for providers who do not meet the 80% passing threshold for services rendered during FY20.

Care Management for Members with Special Health Care Needs

Summary:

The Colorado Access care management department operates numerous programs aimed to address the unique needs of members with special health care needs. Populations who are targeted include, but are not limited to: adults and children with chronic conditions, populations in the criminal justice system, foster care/child welfare children, members transitioning from hospital to home for physical or behavioral health conditions, and pregnant women.

FY19 Goals:

• Establish work flows integrating UM and care management to best serve members.

• Support members access services at appropriate levels of care through care coordination, education on disease management and guidance on community resources.

FY19 Results:

Quality and Appropriateness of Care for Members with Special Health Care Needs

Colorado Access uses a variety of activities and mechanisms to monitor the appropriateness of care received by the membership, including members with special health care needs, counting individuals with physical and developmental disabilities, chronic conditions, substance use disorders, severe mental illness, and traumatic brain injuries. Additionally, Colorado Access monitors the quality and appropriateness of care through medical record reviews for claims validation, examining the completeness of clinical documentation, and evaluating the appropriateness of treatment plans.

Behavioral Health Medical Records Review

Summary:

One way Colorado Access identifies a special health care need (SCHN) is through behavioral health diagnoses. Colorado Access assesses the quality and appropriateness of care for these members by reviewing the medical record to ensure high-quality services are delivered and properly documented for this population.

FY19 Goals:

• Develop a validated audit review tool for behavioral health assessments, treatment plans, psychotherapy progress notes, and case management services.

• Train providers on updated quality behavioral health documentation standards.

FY19 Results:

During the second half of FY19, the behavioral health documentation audit tool was finalized and validated by inter-rater reliability with seven total staff members. This tool provides comprehensive scoring criteria across five categories: General Documentation, Assessment, Treatment Plan, Psychotherapy Progress Notes, and Case Management Progress Notes. The quality department also built out a full audit database to conduct audits and track audit scores across time and providers.

Colorado Access educated providers on behavioral health documentation standards and provided an

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• This year, Colorado Access has continued to integrate UM into the work care management does. The work UM has assisted care management with has included, but is not limited to: assisting with identification/notification of members who have been authorized for an inpatient psychiatric stay for a covered behavioral health condition, identification/notification of members who have been denied a behavioral health service due to a non-covered benefit, and notification for members needing assistance identifying appropriate providers to best meet the member’s needs. UM and care management have also collaborated on several creative solutions calls to support and coordinate care for highly complex behavioral health cases.

• Conducted phone and in-person outreach to identified members to complete comprehensive health assessments, connect them with resources, and coordinate care with their primary/specialty care providers.

• Refined care management workflows to serve members in a comprehensive, timely manner. This has included, but not limited to: continuing to build relationships with community partners, such as Delores Project, parole/probation offices, and local hospitals to serve members with special health care needs.

• Developed clinical programs for potentially avoidable costs (PAC) to provide targeted care management interventions to members with asthma, diabetes and Chronic Obstructive Pulmonary Disease (COPD).

• Refined the grievance process and trained all care management staff members to better capture any member concerns regarding care management services provided. This has allowed for better tracking of issues and will inform future refinements to the processes.


In FY20, Colorado Access will continue to meet the needs of members with special health care needs through targeted care management services.

• Work to more accurately identify member’s needs based on health and disease conditions.

• Enhance risk stratification models that identify members for outreach to ensure appropriate interventions are provided and to promote appropriate levels of care.

FY20 Goals:

• Identify and incorporate best practices into care management workflows to increase effectiveness of disease management.

• Refine data entry accuracy and create data quality assurance processes in order to enhance deliverables quality and data reporting capabilities.

• Inventory all data sources and derive insights to inform the development of clinical programs and risk stratification models.

• Collaborate with the population health department to refine stratification models and care management interventions.

• Continue to identify measurement metrics to assist in monitoring effectiveness of care management interventions.

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Quality of Care Concerns MonitoringQuality of Care Concerns

Summary:

The Colorado Access quality of care (QOC) process identifies, investigates, and addresses potential quality of care concerns, including those involving physician providers. QOCs can be raised by the State, providers or Colorado Access staff members and are defined as evidence of harm to a member. These categories may include all potential problems, concerns, or complaints regarding access to urgent or emergent care, delay or denial of care or services, after-hours services, professional conduct or competence, coordination of care, medication issues, diagnosis issues, and service plan or delivery issues. QOC investigations are also triggered by care resulting in unexpected death, suicide attempts requiring medical attention, or adverse medication effects or errors requiring medical attention, preventable complication requiring medical attention, assault or accident related injuries requiring medical attention, or an at-risk client missing from a 24-hour facility. These more substantial investigations are categorized as critical incidents when they meet a more severe threshold.

Potential QOCs are forwarded to the quality improvement department for initial investigation and are then reviewed with a medical director for determination. Findings are confidential under peer review statutes. A QOC submission may be determined not to meet QOC thresholds, may be trended, may trigger an educational letter to the provider, a corrective action plan (CAP), or in more serious cases be referred to the credentialing committee for consideration for provider termination.

FY19 Goals

• < 2.0 QOCs per 1000 members

FY19 Results

There were 94 total QOCs filed for Region 3 in FY19, bringing QOCs well below the goal of two QOCs per 1,000 members. In FY19, there was a spike in QOC submissions from care managers regarding post-psychiatric hospital discharge in relation to quality follow-up appointments. This information has been tracked in more detail in the care management department and distributed to approriate teams within Colorado Access to promote accountability amongst providers.

In FY19, the quality department at Colorado Access determined there was opportunity to refine program goals to better capture meaningful measures for QOCs as quality placed more emphasis on thorough and timely investigation of QOCs submitted.


• Continue to investigate and resolve quality of care concerns. Utilize the more detailed QOC log to identify trends, engage providers in educational and improvement opportunities, and execute CAPs in a timely manner.

• Use a combination of sources to aid in data collection, investigations and recommendations such as the QOC log, the post-psychiatric hospital follow-up log, and provider relations database.

• Quality improvement staff members will continue to work with customer service and care management staff members to ensure that all quality of care concerns are correctly identified and forwarded to quality for investigation.

FY20 Goals:

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• < 2% substantiated QOCs per 1,000 members.

• Increase provider as well as Colorado Access staff member awareness of QOC process through educational materials to promote communication of possible concerns in order to promote quality services.

• 90% of QOCs closed within 90 days of submission to the quality department.

Other Quality Monitoring

External Quality Review Organization (EQRO) Audit

Colorado Access participates in an annual external independent review of quality outcomes, timeliness of, and access to services covered under its RAE contracts. This review was conducted by Health Services Advisory Group (HSAG).

FY19 Goal

• Perform at or above previous year’s performance.

FY19 Results

Based on conclusions drawn from the review activities, HSAG assigned each requirement in the compliance monitoring tool a score of Met, Partially Met, Not Met, or Not Applicable. HSAG assigned required actions to any requirement receiving a score of Partially Met or Not Met. HSAG also identified opportunities for improvement with associated recommendations for some elements, regardless of the score.

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Colorado Access is implementing additional checks and safeguards to ensure the organization is compliant with contract requirements through inter-departmental mock audit trials.

FY20 Goals

• Use learnings from the EQRO activity to drive business practices to maintain quality improvement in identified areas.

Internal Advisory Committees and Learning CollaborativesLearning Collaboratives

Colorado Access participates in multiple learning collaboratives with HCPF, community partners, other RAE regions, Denver Health, and members. During FY19, Colorado Access participated in 11 RAE learning collaborative meetings, ranging in topics from population health plans, the hospital transitions of care program, potentially avoidable costs, member engagement, and value-based payment, among others.

FY19 Goals:

• Ensure Colorado Access is effectively serving members and providers by participating in multi-disciplinary statewide learning collaboratives.

FY19 Results:

During FY19, Colorado Access participated in 11 RAE learning collaborative meetings, ranging in topics from population health plans, the hospital transitions of care program, potentially avoidable costs, member engagement, and value-based payment, among others.


Colorado Access participates in multi-disciplinary statewide learning collaboratives by actively contributing to agenda topics, helping facilitate meaningful discussion and collaborating with HCPF and other participating partners to identify meaningful topics of discussion.

FY20 Goals:

Summary of Scores for the Standards

Standard # of Elements

# of Applicable Elements

# Met # Partially Met

# Not Met # Not Applicable

Score (% of Met Elements)

III. Coordination and Continuity of Care

12 11 11 0 0 0 100%

IV. Member Rights and Protections

7 7 7 0 0 0 100%

V. Member Information

19 17 16 1 0 2 94%

X. Quality Assessment and Performance Improvement

8 8 7 1 0 0 88%

Totals 46 43 41 2 0 3 95%

• Attend learning collaborative meetings with appropriate Colorado Access representation.

• Working with HCPF to identify topics and facilitate sessions of the collaborative on a rotating basis.

Provider Learning Collaboratives

The Colorado Access provider relations department conducts multiple face-to-face learning opportunities for providers throughout the fiscal year, including quarterly in-person provider meetings, monthly webinars, and ad-hoc support as needed and requested by the provider network. These forums provide enhanced opportunities for Colorado Access and the provider network to collaborate and share best practices.

FY19 Goals:

• Educate providers through learning collaborative on clinical, administrative and other functions to increase provider resources.

FY19 Results:

The Colorado Access provider relations team managed 55,859 individual contacts with providers in FY19, including outreaches to providers to educate them on topics such as alternative payment model (APM) measures, adoption of the Data Analytics Portal (DAP), RAE panel sizes, among others. These activities have increased the number of provider contacts and strengthened connections with contracted providers, offering a more proactive approach to issue resolution. AccessCare Services, practice support, and provider relations conduct joint in-person meetings with providers to maximize sharing of information, streamline points of contact, and increase internal coordination. Additionally, Colorado Access expanded the reach of the Navigator provider newsletter to more than 6,000 providers/staff in the network. During FY19, Colorado Access also hosted three provider forums and one provider networking opportunity with attendance between 80 and 150 providers and/or clinic staff members.


Leveraging multiple avenues of reaching providers including face-to-face meetings, electronic newsletters and ad-hoc support Colorado Access will support providers by providing pertinent education and guest

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speakers/writers to ensure the provider network is promoting quality and best practices as well as up to date on trends and changes happening within Colorado and the network.

FY20 Goal

• Educate providers through learning opportunities on clinical, administrative and other functions to increase provider resources.

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