2013 Congestive Heart Failure. Program Description. Our mission is to improve the health and quality of life of our members - PDF

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2013 Congestive Heart Failure Program Description Our mission is to improve the health and quality of life of our members I. Purpose Care Coordination promotes the Plan s purpose of helping Kentuckians
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2013 Congestive Heart Failure Program Description Our mission is to improve the health and quality of life of our members I. Purpose Care Coordination promotes the Plan s purpose of helping Kentuckians live healthier lives in each of its special programs. PHP has developed disease specific approaches to the management of members chronic medical conditions. The emphasis of the program is disease prevention or limiting complications of an existing condition and wellness education for targeted members and clinicians to improve the overall health, wellness, and quality of the member s life. The goal of the Congestive Heart Failure (CHF) Program is to provide tools to educate the member on promoting improved health through better prevention, detection, treatment, and education. By analyzing utilization patterns, the Plan will be able to educate members on preventable complications so that emergency department visits and hospital admissions/readmissions may be reduced and appropriate pharmaceutical management may be increased. The program will facilitate member understanding and responsibility of the disease process as well as coordination of care between the member and/or caregiver and clinician. In addition, by analyzing utilization and pharmacy patterns, the Plan will be able to educate clinicians on adherence with the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guidelines for the Diagnosis and Management of Heart Failure in Adults. 1 II. Rationale According to the Center for Disease Control and Prevention (CDC) Heart Failure Fact Sheet for 2010, 5.8 million Americans have heart failure with approximately 670,000 newly diagnosed every year. One in 5 diagnosed with heart failure will die within one year of diagnosis. In 2010, heart failure cost the United States $39.2 billion dollars, which includes health care services, medications and lost productivity. The CDC sites the most common causes of heart failure as coronary artery disease, high blood pressure, and diabetes. 2 According to the Kentucky Cabinet for Health and Family Services (CHFS), Kentucky ranked 5 th for heart failure related deaths in The hospitalization rate for heart failure was 45.2 per 100,000 in 2005, an increase of 13% from Based on the CDC-Behavioral Risk Factor Surveillance System Survey (BRFSS) Data in 2009 and 2010, Kentucky ranked second in the nation for having high cholesterol, third in the nation for smoking, fourth in the nation for hypertension, ninth in the nation for no physical activity in the last months, fourteenth for diabetes, and seventeenth in eating less than 5 fruits and vegetables per day. In addition, the BRFSS notes that 67.5 percent of Kentuckians have been told by their doctor that they are overweight or obese. 4 In 2012, PHP noted a total membership of approximately 170,000 with 4,296 members diagnosed with CHF age 18 years and older (2.5% of the total population). In 2012, the 1 Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics 2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010; 121:e1-e Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data /19/2013 Page 1 of 17 members experienced 386 ER visits, 3,291 outpatient visits, and 1,909 inpatient stays related to a primary diagnosis of CHF. Early diagnosis and treatment can improve the quality of life and life expectancy for people with heart failure. Treatment usually includes taking medication, reducing sodium in the diet, tracking daily symptoms and weight, and getting daily physical activity. 1 III. IV. Objectives Increase clinician and member adherence to ACCF/AHA CHF Guidelines regarding the use angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), diuretics, and/or beta-blockers unless contraindicated. Increase member adherence with medications, sodium intake, and weight monitoring and management. Decrease the frequency of CHF inpatient admissions, readmissions within 30 days, and emergency room (ER) visits. Promote healthy lifestyle-diet and nutrition, daily measurement of weight, physical activity, and smoking cessation. Population Identification Eligible members for the CHF Program are identified primarily through claims/encounter data and include the following: Age 18 years and older AND Continuous enrollment in the health plan, defined as active two of the three months of the reporting quarter AND Currently enrolled on the date the claims report is run AND At least one claim with the primary or secondary diagnosis of heart failure (ICD ) within a rolling 12 month period OR a claim with the diagnosis of heart failure and a determination of ejection fraction. Additionally, member referrals may be received daily from the following sources: Data collected through the Utilization Management (UM) process, examples include, but are not limited to, hospital census report, ER Utilization reports, pre-certification data, embedded UM, and concurrent review data Referrals from other PHP departments, examples include, but are not limited to, Case Management, Disease Management, or Member Services Data collected through the Care Connection How info Program is used health 1 B this and is the wellness same for outreach all representatives Disease Programs- Chronic Respiratory, Referrals from clinicians Diabetes, and Obesity Self-referrals from members Referrals from hospital educators/discharge planners Data collected through the Health Risk Assessment Form (HRA) Members who meet the criteria are eligible for the program. This determination of eligible members occurs on a monthly basis. In addition to identifying members on a monthly basis, members may be adjusted from low risk to high risk based on claims/encounter data or referrals, as needed. 7/19/2013 Page 2 of 17 V. Member Participation and Opting Out of the Program Eligible members are considered enrolled in the program and receive interventions without having to specifically request it. For this reason, enrollment is considered passive. Participation, however, is voluntary and the member has the right to opt out of the program or decline all or any part of it. Information on how to opt out is provided as part of the welcome packet and the member is advised verbally if questions regarding participation arise during outreach. Members who opt out may re-enter the program at any time by contacting the CHF Disease Manager or the Care Connection Program, either verbally or in writing. VI. Member Contact Eligible members are identified monthly and receive a welcome packet including: Welcome letter (Appendix A), CHF disease specific assessment (Appendix B), and Educational material related to CHF and self-management. All identified CHF members receive quarterly educational mailings. These quarterly mailings include information on: medications, monitoring weight, nutrition, following a treatment plan, exercise and activity, managing other chronic conditions, lifestyle issues, advance care planning, and depression (Appendix C). Annual reminders are sent for flu/pneumonia vaccination and monitoring for persistent medications. All written program material sent to members includes contact information for the CHF Disease Manager, the Care Connection Program, and the 24/7 Nurse Advise Line. Some educational materials are available in other languages, upon request. All health plan members receive information regarding the CHF Program and how to contact the CHF Disease Manager, the Care Connection Program, and the 24/7 Nurse Advise Line via the member handbook and Plan website. All identified CHF members with one of the following will be considered high risk: Not on an ACE Inhibitor/ARB/ or beta blocker. Non-adherence with prescribed medication regimen. Inpatient admission, ER visit, or 23 hour observation with a primary diagnosis of CHF in a rolling 12 months. Inpatient admission, ER visit, or 23 hour observation with a primary diagnosis of CHF and related complication such as COPD, Diabetes, or Hypertension in a rolling 12 months. Two or more inpatient admissions, ER visits, or 23 hour observation stays for a secondary diagnosis of CHF. CHF members identified as high risk receive all of the quarterly CHF educational mailings in addition to outreach from the CHF Disease Manager. The CHF Disease Manager: Assesses the member s needs, utilizing a CHF specific assessment, and develops an individualized plan of care, including the member s caregiver, when possible. Performs reassessment of the member s needs, utilizing a CHF specific assessment, every three months and at discharge from disease management. 7/19/2013 Page 3 of 17 Coordinates care with the clinician involved in the member s care and assists with follow up care with a specialist, if appropriate. Establishes and maintains contact with the member and/or caregiver to evaluate and revise the plan of care, as needed. Educates the member and/or caregiver how to assess how well the member is managing their care, including medications, and when to call the clinician to prevent an admission related to CHF. Educates the member and/or caregiver on the importance of the clinician s established treatment plan to include medication adherence, attending scheduled appointments, adherence with self-monitoring activities, and adherence with lab test ordered by the clinician. Educates the member and/or caregiver on lifestyle issues that may improve the member s symptoms of CHF to include diet/weight management, medication adherence, smoking cessation, when to call the clinician with symptoms to prevent an exacerbation, and regular clinician visits. Conducts the Patient Health Questionnaire (PHQ) 2 as a depression prescreening tool and/or the PHQ-9, as appropriate, to identify members in need of referral for behavioral health services. Provides the member with assistance/information regarding available community resources. Provides the member and/or caregiver with additional written and/or verbal information targeted to the member s specific needs. If a member has ongoing complex care coordination needs after six months, the member may be referred to Case Management services. VII. Clinician Notification and Involvement Participating clinicians in the health plan are notified of the CHF Program by the following: New Provider Kit distributed to new clinicians with information regarding how the CHF Disease Manager works with CHF members and instructions on how to access and utilize the program s services (Appendix D) The PHP Provider Manual The PHP Provider Medical Office Notes Face-to-Face encounters with the CHF disease manager Clinicians receive the following written notification regarding their patients participation in the CHF Program: Notification of CHF identification without an ACE inhibitor/arb/ or beta blocker so that the clinician may review the member s status and determine if one of the medications if needed. Notification of the member s non-adherence with the clinician established treatment plan. Notification of high-risk member enrollment into the CHF Program. Notification of member discharge from the CHF Program. Notification of member referral to Case Management. 7/19/2013 Page 4 of 17 The ACCF/AHA CHF Guidelines are distributed to all participating clinicians as part of the Provider Manual and are available on the PHP website. Guidelines are reviewed, updated, and posted on the health plan s website at least every two years and anytime new scientific evidence is published. VIII. Integrating Member Information PHP utilizes an integrated documentation system, JIVA, in order to allow all health plan staff access to member information. In JIVA s Member Centric view all users are able to view information that is specific to the member such as demographics, eligibility, member s PCP clinician, spoken language, and preferences on receiving educational materials or phone contact. Users also have the ability to enter additional addresses, or phone numbers, which the member may give as an alternative way to reach him/her that is not associated with the state file download that populates the basic demographic fields in JIVA. The Member Centric view may also be utilized to denote a caregiver name and phone number, as needed. In addition, JIVA utilizes widgets to provide quick reference to open authorizations, care coordination activities, and appeals. Users can view detail of each open item, or view a summary of each, depending on what information is needed. JIVA also has multiple quick-access tabs across the top of the Member Centric view to allow a user the ability to: Edit demographic information and preferences, as needed. Add an episode or open cases. Upload documents related to the member and/or the member s care that need to be visible to all users in order to facilitate seamless care coordination. View all the documentation that has been entered as it relates to the member. View any correspondence that the member has sent to the Plan, or that the Plan has sent to the member. View the member s established care coordination assessment and plan of care. View claims, both pharmacy and medical, related to the member. View results of labs/screenings, as available. Review care gaps. View a clinical summary, of the last six months history, of the member regarding tests and services, medical conditions, medications, ER visits, inpatient admissions, office visits, etc. View historical data or closed cases. All of this data allows everyone interacting with the member to have to most current and available data in order to make every contact count to its fullest potential and improve coordination of care by all users having the same information. IX. Member Satisfaction with the CHF Program PHP Care Management Programs have a systematic method of evaluating member satisfaction with all areas of Care Management services. The CHF Member Satisfaction Survey (Appendix E) is distributed to all CHF member s after discharge from disease management. Questions address member experiences with the CHF Program and the CHF Disease Manager in the areas of: 7/19/2013 Page 5 of 17 The effectiveness in helping the member understand CHF The helpfulness in assisting the member develop a self-management plan The helpfulness in assisting the member adhere with the established selfmanagement plan The usefulness of the educational materials provided The ability of the CHF Disease Manager to listen to the member The helpfulness of the CHF Disease Manager to assist the member in care coordination Complaints regarding the CHF Program may also be received by the Member Services Department during routine member contacts. The Member Service staff document the complaint in EXP, a customer service software package that records, tracks, and reports all member inquiries and/or complaints. Each department has a mailbox specific to the department. Member Services forwards the EXP complaint to the Manager of Care Coordination for follow-up. The Manager of Care Coordination conducts a quantitative and qualitative analysis of complaints regarding the CHF Program, annually. This analysis is used to identify patterns of member complaints and opportunities to improve satisfaction with the CHF Programs. Changes to CHF Program are made as needed. X. Annual Evaluation The annual evaluation of the CHF Program is conducted by the CHF Disease Manager, the Manager of Care Coordination, the Director of Medical Management Care Coordination, the Chief Medical Officer or their designee, and receiving input from the Quality Improvement Department, as appropriate. Objectives, activities, and outcomes are evaluated at a minimum of annually in order to: Measure participation rates. Determine whether the CHF Program has demonstrated improvement in the services and quality of care provided to members. Evaluate the overall effectiveness of the CHF Program. Allow for exploration of barriers and limitations of the CHF Program. Revise areas as needed to improve effectiveness of the CHF Program. Results of the evaluation are utilized to revise the program and set the program goals for the following year. More frequent barrier analyses are performed on an ongoing basis and adjustments to the CHF Program are made accordingly. XI. Program Goals Increase clinician adherence to ACCF/AHA CHF Guidelines regarding the use ACE inhibitors, ARB, diuretics, or beta blockers unless contraindicated as evidenced by fewer members diagnosed with CHF that are not on the above medications. Increase member adherence with medications, sodium intake, and weight monitoring and management. Decrease the frequency of CHF inpatient admissions, readmissions within 30 days, and ER visits. 7/19/2013 Page 6 of 17 Promote healthy lifestyle-diet and nutrition, daily measurement of weight, physical activity, and smoking cessation. Final approval by the Quality Medical Management Committee: February 5, /19/2013 Page 7 of 17 Appendices A. Member Welcome Letter B. CHF Assessment Form C. CHF Reassessment Form D. Member Educational Material Mailing Schedule E. CHF Member Satisfaction Survey Appendix A Member Welcome Letter Dear Member, Welcome to Passport Health Plan s Congestive Heart Failure (CHF) Program! The CHF Program is here to help you stay as healthy as possible. As a member of the program, you get special benefits such as: A CHF Manager is here to answer your questions about: Your condition, CHF. Your medicines. Doctors who work with CHF. We ll mail you information to help you manage your CHF. We ll let your doctor know about your CHF. Your doctor is an important part of your care. Please talk to him or her any time you think your CHF is getting worse. To help us meet your needs, please fill out the enclosed CHF Assessment Form and send it back in the postage-paid envelope. If you have questions, please call me at , press 0, then press If you are TDD/TTY user, please call If you do not wish to be a part of our program at this time, you may also call the number listed above. If you choose to leave the program, you may rejoin at any time. Sincerely, Margot French, RRT CHF Disease Manager Passport Health Plan PP58 10/19/2012 Appendix B CHF Assessment Form Appendix B Member CHF Assessment Form Appendix C CHF Reassessment Form Appendix C CHF Reassessment Form Appendix D Member Educational Material Mailing Schedule CHF 1st CHF Initial All New Member Mailing - Includes: New member letter on PHP letterhead, CHF Assessment, AHA What is Heart Failure flyer and BRE with CC: 158 CHF ink jetted onto envelope; to be stuffed and sealed into a #10 envelope, ink jetted CC: 158 CHF . 2nd All Member Mailing - Includes: Member educational letter on PHP letterhead, Sodium and Fluids Brochure; will need to be folded in half, stuffed and sealed into a 6x9 envelope; ink jet CC: 158 CHF onto 6x9 envelope under return address. 3rd All Member Mailing - Includes: Member educational letter on PHP letterhead, Stay Active with Heart Failure flyer; will need to be folded, stuffed and sealed into a #10 envelope; ink jet CC: 158 CHF onto #10 envelope under return address. 4th All Member Mailing - Includes: Member educational letter on PHP letterhead, 3 Heart Failure Zones flyer, and Track My Symptoms Chart; will need to be folded in half, stuffed and sealed into a 6x9 envelope; ink jet CC: 158 CHF onto #10 envelope under return address. RROT /11/2013 Yes IHCC /10/2013 Yes 7/18/2013 Appendix E CHF Member Satisfaction Survey Congestive Heart Failure Program Survey Our records show that [name], our [title], recently worked with you or someone in your family. At Passport, your opinions matter to us. We want to give you the best service possible and would like to hear from you! Please answer the questions below and tell us what we are doing right and how we can improve. Please check the best an
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