HomeMy WebLinkAboutMINUTES - 07201999 - C191 To: BOARD OF SUPERVISORS
,} CONTRA COSTA
COUNTY
FROM; William Walker, MD
Health Services Director
DATE: Jana 24, 1999
SUBJECT- Contra Gaeta Health plan Quality Management Program Description
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
Recommendation:
Approve Contra Costa Health Plan's 1999 Quality Management Program.Description}.
Bacl and
Each year Contra Costa Health Plan(CCHP)is required to prepare an updated Quality Management
Program Description which must be approved by the Board of Supervisors. The 1999 Quality
:Management Programa Description has been approved by the CCHP's Clinical Leadership
Committee and Quality Council. The Board of Supervisors-CCHP Joint Conferer;ce Committee,
chaired by Supervisor Donna Gerber, approved the Program.Description on June 11, 1999.
Fiscal Impact-
Bore
CONTINUED ON ATTACHMENT: No SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(v)
ACTION OF BOARD ON 1u1y 2o, 1999 APPROVED AS RECOMMENDED XX OTHER
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS AND CORRECT COPY OF AN ACTION TAKEN
AND ENTERED ON THE MINUTES OF THE BOARD
AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN.
ABSENT: ABSTAIN:
Contact Person: Bobbi Baron
ATTESTED July 20. 199
CC: Milt Camhi,CCHP PHIL BATCHELOR,CLERK OF THE BOARD OF
SUPERVISPORS AND COUNTY ADMINISTRATOR
BY:
DEPUTY
CONTRA COSTA
A LTH PLAN
Quality Management
Program Description
1999
Contra Costa Health Flan
Quality Management program Description1 3
Table of Contents
Page
I. Introduction............ ...... ......... .................... ............. ............ 1
II. Mission ................................................................................................................. 1
III. Purpose................. ..........—.... ..... ................................................. 1
Ili. Scope......... .........—.................................... .......................... ............... 1
V. Objectives.............................................................................................................. 1
VI. Authority and Responsibility.................................................................................. 2
VII. Aspects of Care and Service.................................................................................. 3
VIII. Structure................................................................................................................ 3
Committees............................................................................................................ 3
A. Beard of Supervisors........................................................................................ 3
B. Joint Conference Committee............................................................................ 4
C. Quality Council................................................................................................. 5
D. Quality Council Subcommittees ...................................................................... 6
1. Credentialing Committee.......................................................o..,.........,..,,.,, 6
2. Community Provider Peer Review Committee........................................... 7
3. Grievance Committee............. .........—'--..... ......-..... ........
4. Performance Measurement Reporting Group........ ............ ........ 9
5. Benefit Interpretation Committee.............................................................. 10
6. Pharmacy and Therapeutics Committee............................... .................... 11
E, Public Advisory & Other Coordinating Committees................................... 12
I. managed Care Commission................................................................... 12
2. Cultural & Linguistic Advisory Committee............................................ 13
F. Medical Leadership................--......... ...... .......... ........... 13
1. Medical Director.................................................................................... 13
2. ,Assistant Medical Director........... ................ ...... ...... ...... ....... 14
C. Quality Management Unit. ......................................................................... 14
1. Director of Quality Management........ ............. 14
2. Quality Management Nurse...... ............. ......... ......... ....... 14
IAC. Quality Management Process and Initiatives...................................o..,...,.....,.....,, 14
A. Process............................................................................................................. 14
1. Study Topic................................................................................................. 14
2. Study Planning.......................................................................................__ 15
3. Practice Guidelines.,......... ......................... ............... ... 15
4. Quality Indicators....................................................................................... 15
5, Data Analysis Plan...................................................................................... 15
6. measurement Tool(s)................................................................................. 15
7. Validation of Collected Data....................................................................... 15
6. Data Analysis.............................................................................................. 15
-
g. Interpretation UfF;ndiOOG. ... ......... ...... — .........—.--......----... 15
10.Communication nfFindings...—.......... ................ ............. -----.. .... 15
11.Improvement Plan................ ..................... ......... ------. ...... ..—. 16
13, Quality Improvement Initiatives...... ......... ......--------- ......... ...., 16
1, Preventive.....— ..... . .............—........... ...... —.................... ............ --. 16
2, /1iniCal-/\CUte........ ...... — ...... .-......................... .................-- ........ 16
3. CliOical-Ch[OOic—......... ...... ........._-- ...... ...... --- .............. ---. 17
4. Non-Clinical.........-----........................ ............. ......--------.. 17
X. Coordination Ofr1K4Program with other Management
Functions......... ........ ...... — .................. ........................................................... 18
A. Credentia|iOg......-----.---.......... ......... ...... —.................. ............... 18
B. Member Grievance and Appeal Process.......................................... ...........—. 18
C. Utilization Management.............................................................. ........ ......... . 18
D. Telephone Triage Program................................................. ............. ...... —... 19
E. Cooperative Care Management Program......... ......................................... .... 19
XL (]M Delegation.............................................................................. ..................... 19
XIT. Quality Management Work Plan................................. .......................................... 19
XIII. Effectiveness Ofthe F\K4Program ....... ............................................................... 19
XIV. Disciplinary Action................................................................................................ 19
X\/ Confidentiality,.,,,,,..,.,...................................................................................... 20
XVI. Conflict nfInterest...................... ............ ......... .................................................. 20
X/TT. Annual ...... ............ .............. . ............. ........... .............. ... 20
CCHPQuality Management Department Organizational Ch@rf—.--......... 21
CCHP14gqQMProgram Description Committee Structure----..--..... 22
1999Quality Management Work Plan.................. ........ ....... — ...... ................. 23
Contra Costa Health flan
Quality Management Program Description
1999
I< INTRODUCTION
Contra Costa Health Plan(CCHP)is the Contra Costa County operated Heap
Maintenance Orgwiization{HMO); the first Federally qualified HMC in the country
operated by local government. CCHP contracts with individual providers, Contra Costa
Regional Medical Center and Health Centers(CCR.MC&HC)and Kaiser Permanente to
provide or arrange comprehensive health care services.
CCHP provides health care for public and private employee groups,private individuals,
Medi-Cal and Medicare beneficiaries, and low income county residents. CCHP's overall
commitment is serving the County's most vulnerable populations.
IIn MISSION
The goal of CCHP's Quality Management Program(QMP)is to erasure that quality,
appropriate health care and related services provided meet or exceed members' and other
customers' expectations. The QMP mission is carried out in accordance with CCHP's
organizational mission to provide affordable,high quality, accessible health care with
integrity and compassion to all that use our programs.
Iiia PURPOSE
The CCHP Quality Management Program description will inform internal and external
customers about how CCHP will promote,manage, and document improvement in the
duality of health care and other related services provided to its members,through a
continuous systema of planning,monitoring, assessing, and improving.
IV. SCOPE
The scope of CCHP's QM Program activities will include the quality of clinical care and
the quality of service for all services including but not limited to preventive,primary,
specialty,emergency, and ancillary care services. The scope of activities will reflect the
Plan population in terms of age groups,disease categories and special risk status. The
scope of activities will include,but not be limited to, services provided in institutional
settings, ambulatory care, home care and mental health.
V. OBJECTIVES
A. Identify opportunities for improvement through a system of monitoring which
includes member satisfaction surveys, complaints, focused studies, facility
inspections,medical record audits and analysis of HEDIS and administrative
data. Implement change as appropriate in the range of health care services
provided by CCHP to its members.
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P. Establish priorities for ongoing monitors and focused-review studies with
emphasis on access,preventive services,high volume,high risk, or problem-
prone care or services.
C. Confirm that CCHP delegated providers' Quality Assessment and Improvement
Program structure, staff, and processes are in compliance with all provisions of
CCHP QM Plan, QM policies and procedures and meet professionally
recognized standards.
D. Comply with internal and extema1 standards and requirements related to quality
improvement activities.
E. Assure that members can achieve resolution to problems or perceived problems
relating to access to care or other quality issues through Member Services and
Quality Management grievance and appeal procedures.
P. Monitor processes related to the movement of members along the continuum of
care and to ensure continuity of care that meets the members needs and
expectations.
G. Maintain policies and procedures for quality management, credentialing and re-
credentialing of delegated health partners.
V1. AUTHORITY AND RESPONSIBILITY
Though CCHP retains ultimate accountability for quality oversight, quality management
is a shared responsibility between CCHP and its delegated, contracted providers.
CCHP's;primary delegated providers are CCP.MC&HC and Kaiser Permanente.
The Contra Costa CountyBoard of Soervisors is ultimately responsible for the
quality of care and services provided to the members of Contra Costa Health Plan.
The Board of Supervisors delegates this responsibility and authority to the CCHP
Executive Director, who, in turd,has empowered the Joint Conference Committee and
Quality Council to carry out this responsibility-.
The Quality Council has the authority and responsibility for implementing and
directing the Quality Management Program. It is responsible for setting the quality
management standards, determining criteria by which care will be meass._red, setting
priorities for which aspects of care will be monitored, and analyzing quality of care
studies, indicators,utilization reports, grievances, and survey data.
The Clinical Leadership Co-mmittee is responsible to provide direction and oversight
of CCHP's clinical programs and projects. It analyzes aggregate clinical data and makes
recommendations to Quality Council for focus study and disease management topics.
The CCHP_Quality Management Unit is responsible for the day to day quality
nnanagernent activities for the non-delegated Community Providers as well as oversight
of quality management activities for contracted delegated providers. The staff in the QM
Unlit are currently licensed registered nurses, supervised by a credentialed MD who acts
as the CCHP Medical Director.
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Delegated quality monitoring status is granted upon successful demonstration by
contracted delegated providers that the required scope of quality rnoriitoring activities is
taking placed
VIL ASPECTS OF CARE AND SERVICE
CCHP's Quality Management Unit, in coordination with other CCHP operations units,
will monitor specific important aspects of care and service. These aspects or activities of
care and service include,but are not limited to:
7.1 Accessibility/Availability of care
7.2 Continuity/Coordination of care
7.3 Under/Over Utilization
7.4 Mental Health Care
T5 Chronic/Acute Care
7.6 High Risk/High Volume Services
7.7 Preventive Health Care
7.8 Member Satisfaction/Dissatisfaction
7.9 Medical Quality of Care Grievance Resolution
VITT. STRUCTURE
COMMITTEES
Aa BOARD OF SUPERVISORS
Contra Costa County Board of Supervisors,which is elected through genera`elections, is
the governing board of the Contra Costa health Plan.. The Board of supervisors is
ultimately responsible for the quality of care and service provided to all Contra Costa
Health Flan members.
Activities
i. Oversees development and communication of policy direction via the Joint
Conference Committee.
2. Reviews and approves annual Quality Management Program Description and
Work PlarVvia the Joint Conference Committee.
1 Reviews and accepts annual Quality Management Reports.
4, Receives and approves credentialing and re-credentialing actions of the CCHP
Credentialing Committee as well as reports regarding credentialing activities of
delegated providers.
5. Appoints Joint Conference Committee membership.
b. Reviews, evaluates and acts upon findings ofthe Joint Conference Cor mittee.
Membership
'.There are five(5)members of the Board of supervisors. Each is elected through general
elections in one of the five districts of Contra Costa County for a term of four(4)years.
Chair
The chairmanship of the Board of Supervisors rotates among the five beard rner:bers
annually.
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Meetins
The Board of Supervisors holds weekly pudic Meetings in accordance with the Brown
Act.
B. JOINT CONFERENCE COMMITTEE
The mechanism by which the Board of Supervisors exercises oversight of the Contra
Costa Health Flan is the Joint Conference Committee(JCC)of the Board of Supervisors
and the Contra Costa Health Plan.All Meetings of the Joint Conference Committee are
open to the public because of the public nature of the Board of supervisors. This creates
a conflict for the situations when member or provider confidentiality is a concern.
Therefore,the Joint Conference Committee will discuss such matters in executive
session,when-members of the public will be excused.
Activities
1. Promotes communication among the Board of Supervisors,the Contra Costa Health
Plan administration and the Quality Council.
2. Assesses and monitors the overall performance of the Contra Costa Health Plan and
its contracted providers including,but not limited to,the quality of care and service
provided to members.
3. Receives and reviews reports and recommendations of the Quality Council from the
Medical Director.
4. At least annually reviews and approves the Annual QM Program Description,Work
Plan, Annual Quality Management Program Evaluation and other Quality
Management reports.
5. Makes recommendations to the Board regarding activities and problems of the Health
Plan.
6. Receives and reviews periodic reports from.Quality Management Director and
Medical Director.
7. Reviews, approves and authorizes provider sanctions and terminations.
8. Reviews, approves and authorizes Medical Policy Guidelines.
9. Receives and reviews quarterly reports regarding Grievance Committee activity.
10. Oversees Protection of Confidentiality of Quality information as cited it Evidence
Code 1157 and Health and Safety Code 1370.
Membership
The Joint Conference Committee shall not exceed nine(9)total Members:
1. Two(2)members from the Board of supervisors, appointed by the Board. These
two members shall have fall voting privileges.
2. Two(2)physician members appointed by the Board from among any of the
providers of the CCHP delegated and non-delegated provider networks. To fill
these positions, the Quality Management Unit will solicit nominations by
announcing the vacancy to all providers. The Medical Director will select the
candidates and present there to the Board for approval. These two members shall
each have a one year ternn. and have full voting privileges.
3. One(1)member shah.be the Medical Director. This Member shall have ex-
officio status without voting privileges.
4. One(1)member shall be the Director of Health Services of Contra Costa County.
This member shall have ex-officio status without voting privileges.
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5. One(1)member shall be the Executive Director of the Contra Costa Health Plan.
This member shall have ex-officio stars without voting privileges.
6. One (1)member shall be the Health Services Chief Financial Officer. This
member shall have ex-officio status without voting privileges.
7. One(1)member shall be the chairperson of the Managed CareCommission.
This member shall have ex-officio status without voting privileges.
Chair
The Chair of the Joint Conference Committee shall be a member of the Board of
Supervisors. T'he Chair shall be elected annually.
Meetings
Meetings of the Joint Conference Committee shall be held at least quarterly and shall be
open to the public.
C. QUALITY COUNCIL
The Quality Council is the principal committee coordinating and directing Quality
Management activities for the Contra.Costa Health Plan, including but not limited to:
utilization management, quality management,peer review and credentialing,
Activities
1. Receives,reviews,evaluates reports of subcommittees.
2. Annually reviews and evaluates the status of contracted providers to whom
quality management,utilization management, credentialing,medical records and
member rights and responsibilities activities have been delegated.
3. Receives credentialing recommendations from the Credentialing Committee by
integrating provider specific quality of care,utilization management, and other
data made available by the CCH'Credentials Committee.
4. Receives Quality Management occurrence and grievance reports regarding
potential member or provider quality issues and recommends action:regarding
quality of care issues.
5. Receives and reviews, at least quarterly,reports from the Director of Quality
Management regarding unit activities including but rot limited to: Quality
Improvement projects,Disease Management team status, occurrence and
grievance volume and trends, delegation audit scores and recommendations.
6. Receives, analyzes and reviews quarterly UM reports and recommends action
where indicated.
7. Receives and reviews monthly reports regarding Grievance Committee activity.
8. At least annually,reviews and approves the Annual Quality Management
Program Description, Wor1c Plan, Animal Quality Management Program
Evaluation and other Quality Management reports.
9. Reviews and evaluates Quality Management reports pertaining to medical,
Pharmacy and Therapeutics, and benefit interpretation policy.ssues.
10. Distributes quality management and other Health flan-information to
individually contracted providers via the Medical Director through letters,
newsletters,policies and procedures,provider manuals, and other appropriate
methods. Community Providers will also receive reports from the Community
Provider Peer Review Coimittee,which is a subcommittee of the Quality
Council.
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11. Reports to Contra Costa Health Plan senior management for the purpose of
planning and designing services and administration of the health Plan.
12. Physician Committee Members may be asked to provide additional medical
review of appeals/reconsiderations.
11 Reviews and approves clinical practice guidelines at a minimum of every two
years.
Mern'oershin
Members of the duality Council will include:
_. The medical Director of the Health Pian with full voting privileges.
2. The.Assistant Medical Director of the Health Plan with full voti ng privileges.
1 The duality Chair or designee from each of CCHP's delegated provider networks
with full voting privileges.
4, Director of CCRlVIC 'AHC duality Management Department with. full voting
privileges.
5. The CCHP duality Management Director with full voting privileges.
6. At least two(2)independent physicians mom any of the CCHP contracted
provider networks, at?east one of whom will be from the individually contracted
physician network. One of these shall be a primary care physician; the other
shall be a specialty care physician. To fill these positions,the duality
Management L;nit will solicit nominations by announcing the vacancy to all
providers. The physician members will be appointed and annually re-appointed
by the Medical Director. Interested physicians will be solicited when vacancies
occur. Both members shall serve one year terms and have full voting privileges.
7. The CCHP Administrative Director of Nursing,with full voting privileges.
8. The CCHP Clinical Programs Liaison with fall voting privileges.
9. The CCM'Patient Services Director,with full voting privileges.
Chair
The duality Council will be chaired by the Medical Director, or in his/her absence,the
Assistant Medical Director.
Meetings
The duality Council will meet monthly, a m imam of nine(9)times yearly.
D Q}ULITY COQ..NCIL SUBCOMMITTEES
1. CREDENH IALI:'G COMMITTEE
EE
The Credentialing Committee conducts the process of credentialing and re-credentialing
CCHP contracted providers. It makes approval recommendations to the duality Council
regarding credentialing and re-credentialing of CCHP providers; arbitrates credentialing
disputes;reports issues to other Subcommittees; and makes recommendations regarding
potential providers. The Committee reports to the duality Council.
Activities
1. Receives reports regarding credentialing actions and policies from the duality
Managernent Units of the contracted delegated providers.
2. Receives and reviews recommendations regarding delegation status of contracted
delegated providers.
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3. Arbitrates credentialing disputes and makes recommendations to the Joint
Conference Committee.
4. Reports issues to other subcommittees.
5. Makes recommendations regarding potential providers and reports to the Quahty
Council.
6. Reviews information from the facility site visit credentialing process.
7. Considers pertinent Quality Management Unit information, including grievances,
access data,remember satisfaction surveys,and focused studies.
S. Makes recornniendations regarding credentialing and recredentialing of CCHP
Community Providers to the Quality Council for eventual Board of Supervisors
approval.
Membership
1. The CCHP Assistant Medical Director with fall voting privileges.
2. The CCRMC&HC Credentialing Committee Chairperson or his/her
representative. This member shall have full voting privileges.
3. The CCHP Director of Provider Affairs with fall voting privileges.
4. The Chairperson or a representative of the Community Partner Peer Review
Committee. 'chis member shall have full voting privileges.
5. Two (2)independent Physicians from any of the CCT'Health Partners, at least
one of whom will be fiom the individually contracted physician network. 0n.e of
these shall be a primary care physician; the other shall be a specialty care
physician. To fill these positions,the Quality Management Unit will solicit
nominations by announcing the vacancy to all providers. The Medical Director
will select and appoint the most qualified-candidates. Both members shall:have
serve one year terrns and have full voting privileges.
6. The Quality Maragernent Unit staff who support the committee,without voting
privileges.
7. The Credentialing Unit staff who supports the committee,without voting
privileges.
Chair
The Credentials Committee will be chaired by the CCHP Assistant Medical Director.
Meetings
The Credentials Committee will meet monthly, at a minimum of nine times a year.
2. COMMUNITY PROVIDER PEER REVIEW COMMITTEE
The Co-.mmunity Provider Peer Review Committee is the forum for all contracted
providers who do not otherwise participate in peer review activities.
The Committee reports to the Quality Council.
Activities
I. Receives,reviews, evaluates reports of represented Com pity Providers.
2. Receives potential quality issues and recommends action regarding quality of
care issues from represented Community Providers.
3. Receives and reviews quality of care issues identified through the CCHP
grievance process and makes recommendations for corrective action or other
disciplinary action.
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4. Reports to all members and other represented Community Providers via the
committee chairperson,
Mennbershits
Each Cornmunity Provider who is not affiliated with a delegated provider network will be
a member of the Community Provider. Feer Review Committee.
Subcomm..ittees
Due to the potentially large number of members spread out geographically,the
Comrmanity Provider Peer Review committee may form regional subcommittees to carry
out its;-jeer review function.The Community Provider Peer Review Committee will
determine ene number of subcommittees to form-, based on the needs of the members.
Chair
The chair of the Community Provider Peer Review Committee will be the CCHP Medical
Director. The Medical Director may choose to appoint a Chair from among the members
of the Committee.
Meetings
The Committee will meet at least semi-annually.
3. GRIEVANCE COMMITTEE
The Grievance Committee is a subcommittee of the Quality Council. It provides the only
level of appeal for all requests for reconsideration of denied, modified or deferred
services, payment for denied claims, and unsatisfactory resolution of formal grievances.
The Committee also reviews complaints against Plan members for appropriate action.
Requests for Reconsideration may be received from members or their legal
representative. The voting quorum for this committee for all non-clinical issues is at least
three Committee members, with at least one Committee member from clinical staff. For
clinical issues, the Director of Quality Management shall review the case in advance,
including obtaining appropriate clinical opinions, and determine if an additional voting
quorurn is required.
Plan members and/or their appointed designees are informed of their right to attend this
meeting to present their case in advance of the meeting. In cases where there is a
potential of risk or injury to Flan employees, the Plan member will not be allowed to
present their case in person but nay designate someone to participate on their behalf,
Activities
1. reviews and makes determinations on all Requests for Reconsideration of denied
claims and/or denied,modified or deferred services.
2. Reviews and makes determinations on all appeals of grievances not resolved to a
member's satisfaction.
3. Reviews ala case review requests submitted by a third party, including Fair
Hearings, and coordinates the Health Plan's response, as appropr4.ate.
4. Reviews complaints against Plan members for appropriate action.
S. Gathers any additional information pertinent to the determinations decision.
6, Prepares response letter to member including any further appeals rights.
7. Documents file with all additional information and determination decision.
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8. Piles are confidentially maintained by the Member Services In-lit for 5 years.
9, reviews statistical reports of the Member Services Unit to ascertain trends;
makes recommendations for change/remedial action to the Quality Council.
10. Acts as avenue of Patient Advocacy within the Health Plan.
1 l. Reports all Grievance Committee activities to Quality Council monthly.
Scope of Authority
1. Males benefit review reeve mendations
2. Makes contract charge recommendations for member materials.
3. Mages Quality Improvement recomm=endations,
4. Can approve or deny an appeal based on majority vote of the committee
5, Can refer a case to Quality Council/other authoritative body
6. Can recommend action against a member, which may include plan-initiated
disenrollrnent,to the Plan's Chief Executive Officer.
Membership
Non-Clinical:
Director of Patient Services and/or Patient Services Supervisor
Deputy Executive Director and/or Contract Manager
Business Services Manager and/or Claims Supervisor
Clinical:
Medical Director and/or Assistant Medical Director
Director of Quality Management and/or Quality Management Nurse
Director of CCHP Coordinated Care Management(CCM) and/or CCM Nurse
Practicing Physician from the Quality Council
Chair
The Chair of the Grievance Committee is the Director of Patient Services or the Patient
Services Supervisor.
Meetings
The Grievance Committee meets at least monthly. Meetings may be arranged more
frequently depending on the urgency of the requests and/or issues.
Minutes
Tlie Grievance Committee beeps copies of approved minutes for 5 years_
4, PERFORMANCE MEASUREMENT REPORTING GROUP
Yhe Performance Measurement Reporting Group is an interdepartrnental,technical work
group. It is responsible for planning, analysis,and Quality Improvement initiatives as
well as performance measurement reporting. It provides collective oversight of
performance measurement reporting in the Health Plan.
Activities:
I. Analyzes NEDIS technical specifications and develops appropriate source code.
2. Participates with outside vendors to docummnt the audit of reported PIEDIS rates.
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1 Supports the Clinical Leadership Committee by providing data and performing
data analysis and recommendation.for quality initiatives.
4. Determines the necessity for hybrid data abstraction for each indicator.
5. Oversees clinical data abstraction in coordination with administrative data
reports.
6. Submits the Health Plan's annual audited, formal NEDIS reports to regulators as
well as CCHP Senior staff and Administration and all CCHP contracted
providers.
7. Cornmunicates final,audited, and non-audited NEDIS rates to contracted
providers via provider meetings,newsletters and other appropriatd methods.
Membership:
MIS/Member Services Supervisor
Director of Quality Management
Senior Systems Analyst/Statistician
Medical Director
Health Services Information Technology Supervisor
Business Services/Claims Supervisor
Deputy Executive Director
Team.Advisors:
Administrative Director of Nursing
Public Health Epidemiologist/Biostatistician
Senior Systems Analyst,Mental Health& CSAS Divisions
Director of Health Services Information Tee'hnology
Chair:
The chair of the Performance Measurement Reporting Group is the Health Plan:Special
Projects Administrator/HEDIS Compliance Manager.
Meetings
The Perform ance Measurement Reporting Group meets monthly and schedules additional
ad hoc meetings as needed.
5. BENEFIT INTERPRETATION COMMITTEE
The Benefit Interpretation Committee(BIC)is responsible to interpret benefits in
conformance with State and Federal regulations and medical necessity and to maintain
clear, concise statements defining Health Plan benefits. The BIC will facilitate consistent
understanding of existing benefits and establish a mechanism to interpret new Federal
and California State Legislation's impact on existing and new benefits. This function is
intended to maximize consistency of decision making and enhance member service. The
BIC reports to the Clinical Leadership Committee.
Activities:
1. Assure that Medi-Cal benefit interpretations are in compliance with mandatory
benefit descriptions in Title 22.
2. Develop a consistent format to document and maintain benefit interpretation
documents.
3. Distribute proposed benefit interpretations to consultant pane' for review and
comment.
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4. Develop and document concise benefit interpretations
5. Modify all existing benefit interpretations.
6. Collaborate with the CCHP Operations Council as needed.
7. Distribute completed, approved interpretations to Senior Management for
distribution to staff and inn-plementation.
Mernbershia:
Deputy Executive Director
Director of Quality Management
Authorization Unit Lead
Health.Plan Special Project's Administrator
Consultant Panel,
Medical Director
Administrative Director of'vursing
Director of Member Services
Business Services Manager
Clinical Programs Liaison
Assistant Medical Director
Director of Planning
UM Staff
Chair:
The Chair of the Benefit Interpretation Committee is the Director of Quality
Management.
Meetings:
Meetings will be held twice monthly.
6. PHARMACY AA�;D THERAPEUTICS COMMITTEE
The Pharmacy and Therapeutics Committee reports to the Clinical Leadership
Committee. It is responsible for the oversight of drug utilization trends and establishing
and updating the CCHP formulary.
Activities:
1. Review analyze and evaluate drug utilization reports
2. Analyze new drugs and determine their status for inclusion to the CCHP
formulary.
3. Review formulary and make additions and deletions as necessary.
4. Make decisions about pharmacy benefits management policies.
Member shit:
Medical Director
Assistant Medical Director
Director of Provider Affairs
Two clinicians
Health services Department Financial Officer
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Cham.
The Chair of the Pharmacy and Therapeutics Committee will be the CCHP Medical
Director.
Meetings:
Meetings will be veld at least semi-annually.
Ea PUBLIC ADVISORY& OTHER COORDINATING COMMITTEES
1. MANAGED CARE COMMISSION
The Managed Care Commission is a public advisory commission that reports directly to
the Board of Supervisors. This commission replaced the CCHP Advisory Board.
,Activities
1, Advises the Board and Health Plan on policy decisions,provides input f om the
community and members about the financial plan,rate setting,marketing and
provider relations surveys.
2. Receives appropriate plan level Quality Management Unit reports from the CCHP
Executive erector,
3. Advises the Executive Director regarding its concerns related to the quality of care
and services provided to the Health Plan members.
4. The Chairperson of the Managed Care Commission provides feedback to tae Health
Plan senior management and Medical Director by participating in the Joint
Conference Committee.
Membership.
There are fifteen(15)members,who are appointed by the Board of Supervisors. Six(6)
positions are designated seats such as'vMedi®Cal subscriber,Medicare subscriber,non-
contracting physician,person sensitive to medically indigent needs, commercial
subscriber, and other providers (e.g.,nurse). The remaining nine(9) seats are at large,
The Health Services Director,Health Plan Executive Director,and the Board of
Supervisors are ex officio members.
Subcommittees
The Commission has six(6) standing subcommittees:
1. Health Care Delivery/Quality Maintenance
2. Finance&Administration
3. Product Development&Marketing
4. Provider Issues
5. Member&Consumer Advocacy
6. Planning/Governance&Bylaws
7. Cultural and Linguistic Advisory Committee
Chair
The chair of the Managed Care Cormr6ssion will be elected from among the Commission
members and serve a one year term.
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Meetings
The Managed Care Commission will meet monthly.
For more details, seethe Managed Care Commission bylaws in section 6.2 of the DDA.
2. CULTURAL & LINGUISTIC ADVISORY COMMITTEE
The Culturral and Linguistic Advisory Committee (CAC) advises the Board of
Supervisors and the Senior Management of the Contra Costa Health Plan on the specific
needs and concerns of Contra Costa Health plan members who have a different ethnic or
cultural backgrounds or who spear a different language.
Activities
i. Deceives appropriate aggregate Quality Management repo is without confidential
provider or member specific information from the Medical Director.
2. Advises the Medical Director regarding its concerns related to the qui.ality of care
and services provided to the Health flan members.
Membership
T:.e CAC is staffed by the CCHP's Health Educator. The members ofthe CAC will
include advisory members from.the Managed Care Commission(MCC) as well as
professionals, advocates and Medi-Cal members of the public,representing tse different
language and ethnic groups served by the Contra Costa Health Plan. Nominations will be
sought from among all members of the Contra Costa Health Plan through mail and
personal contacts with community leaders. CCHP contracted providers may assist in the
search for candidates for this committee. CCHP's Health Educator will select the
Committee members and present them to the CCHP Director of Marketing and
Commrunications for approval.
Chair
The chair of the Cultural and Linguistic Advisory Committee will be appointed by the
Managed Care Commission from among the members of the Cultural and T inguistic
Advisory Committee.
Meetings
The Cultural and Linguistic Advisory Committee will meet at least semmmi-anr^ually.
F. MEDICAL LEADERSHIP
18 MEDICAL DIRECTOR
reports to the CCHP Executive Director. The Medical Director is responsible for the
administration and coordination of medical management of the Contra Costa Health Plan.
The Medical Director oversees the activities of the Quality Management Unit, the
Utilization Management U bit and the Cooperative Care Management Unit. He/she
oversees the development of medical policy as well as the medical component of the
credentialing process.
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2, ASSISTANT MEDICAL DIRECTOR
Reports to the CCHP Medical Director. The Assistant Medical Director is responsible
for oversight of the Utilization Mar�agerrent Prograrn, He/she is accountable for all
utilization review decisions and performs all denial reviews where the denial is based on
medical necessity. The Assistant Medical Director coordinates with the Administrative
Director of Nursing to conduct Utilization Management Unit staff meetings.
G. QUALITY MANAGEMENT UNIT
1. DIRECTOR OF QUALITY MANAGEMENT
A currently licensed registered nurse who reports to the CCHP Medical Director. He/she
is responsible for development and iTrplementation of the annual Quality Management
Programa. He/she oversees the day-to-day activities of the Quality Management Unit
including but not limited to:
a. Development and administration of Quality studies.
be Oversight of the QM review of grievances and occurrences.
C. Oversight of the medical review component of facility review and corrective
action,
d. Development and annual review and revision of Quality Management policies
and procedures.
e. Coordinates data abstraction for hybrid NEDIS measures.
2. QUALITY MANAGEMENT NURSE
A currently licensed registered nurse who reports to the Director of Quality Ma:agement.
The Quality Managerdent Nurse is responsible fore
a. Medical Record Audits
b. Data collection for quality measurement activities.
C. Designing quality study and chart abstraction tools.
d, Producing reports.
e. Assisting with data analysis.
_. Review of medical occurrences and grievances and development of response
letters.
g, Conducting credentialing facility review and medical record review.
Development and monitoring of corrective action plans.
h. Oversight of quality management delegation audits.
IX, QUALITY MANAGEMENT PROCESS AND INITIATIVES
Aa PROCESS
10 STUDY TOPIC
CCPD'will assess potential study topics to determine their relevance to plan population.
In addition,CCHP will determine their ability to make and/or direct improvements in
care and/or services related to the selected study topic. Each topic or Treasure selected
will have an established goal and/or a benchmark
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2e STUDY PLANNING
CCHP will consider the following issues when planning a quality study:
a. Feasibility.
b. Establis'u ent of timeliness.
C. Assessment of appropriate dates of service add/or outcome dates,
d. Adequacy of sample size.
3. PRACTICE GUIDELINES
There indicated, CCHP will develop study practice guidelines based on reasonable
medical evidence and nationally recognized guidelines. The guidelines will be submitted
to CCHP Quality Council for review and approval. CCHP will measure its perfor nance
against selected guidelines annually. The guidelines will be updated or reviewed at a
minimum of every two years, and communicated to health plan providers and appropriate
staff.
4. QUALITY INDICATORS
CCHP will develop quality indicators appropriate to the study question. The indicators
will be objective and measurable, and based on the most cut ent HEDTS version if
appropriate.
5. DATA ANALYSIS PLAID
CCHP will develop a data analysis plan prier to data collection. It will be clear and non-
contradictory, include potential data collection problems, and detail the method for
determining whether to review the whole at-risk population or a sample of the population.
6> MEASUREMENT TOOL(s)
CCHP will use measurement tool(s) appropriate for obtaining the information pertinent to
the study topic and indicators, accompanied by sufficient written instructions,and
appropriate to the level of experience of the data collection staff.
7. VALIDATION OF COLLECTED DATA
CCHP wili assess the approximate degree of correlation between the administrative data
entries and the corresponding medical record entries and the accuracy of the medical
record abstraction if applicable.
8. DATA ANALYSIS
CCHP will correctly perform the appropriate descriptive and statistical tests. The
meaningful key data and study results will be presented clearly. Appropriate personnel
will evaluate the analyzed data to identify barriers to improvement.
9, INTERPRETATION OF FINDINGS
CCM'will appropriately interpret and analyze key findings, asing a multi-disciplinary
approach that will include bio-statistical consultation.
10. COMMUNICATION OF FINDINGS
CCHP will present study results and follow-up actions to the appropriate health plan
staff, committee(s),members, and providers.
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11, IMPROVEMENT PLAN
CCHP will develop and implement a detailed improvement p'an used on the study
findings. Appropriate interventions will be selected and implemented to improve system
and/or practitioner performance.The plan will be reviewed by the Clinical Leadership
Com-.mattee prior to irriplernentation.
Ba QUALITY IMPROVEMENT INITIATIVES
1. PREVENTIVE
a. Pediatric Preventive Services: Immunizations
In 1999,CCHP will. focus on the following objectives:
1. Establishing a data linkage between the Public Health Immunization registry and
the CCHP data warehouse.
2. A member specific i:zarnunization schedule to be inc'uded with the CCHP "new
baby"mailing.
3. Orientation of CCHP clinical staff to the use of the registry computer.
4. Establishing a link to the WIC program to gather immunization inforinnation and
refer members to Public Health Clinics for immunizations.
5. Increasing home visits to children wit::0-2 immunizations.
6, Development of automated remiInder cards and chart flags from the registry.
b. Adult Preventive Services: Breast Cancer Screening
In 1999,CCHP will continue efforts that were initiated in 1998 to improve
mammography screening rates. CCI-iP's efforts will include a reminder letter that
includes low-literacy educational brochures in bath:English and Spa aish. As well, CCHP
will continue to place a cliart flag in the medical record to alert the next provider seeing
the patient that their screening is overdue. The flag will include a request to notify CCHP
by fax when the test is complete, The flag will assist CCHP in documenting patient non-
compliance for amore targeted efforts.
C. Adult Preventive Services: Cervical Cancer Screening
In 1999,CCM'will continue efforts that were initiated in 1998 to improve cervical
cancer screening rates. CCHP's efforts will include a reminder letter that includes low-
literacy educational brochures in both English and Spanish. As well,CCHP will continae
to place a chart flag in the medical record to alert the next provider seeing the patient that
their screening is overdue. The flag will include a request to notify CCHP by fax when
the test is complete. The flag will assist CCHP in documenting patient non-compliance
for more targeted efforts.
2. CLINICAL-ACUTE
a, Prenatal—first trimester visits project
In 1999,CCHP will initiate a Pren=atal Task Farce to analyze barriers to initiation of
prenatal care in the first trimester. At the completion of barrier analysis, the team will
-make recommendations to the Clinical Leadership Committee regarding any intervention
strategies that may be necessary to improve access to early prenatal care.
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3. CLINICAL-CHRONIC
a. Asthma Management Team
In 1999 CCHP will continue the asthma management project that began ire 1998. This
year's efforts will focus on analysis of member surveys and development and early
implementation of a disease management program. As part of the project, clinical
practice guidelines have been developed in draft form and will be finalized and
implemented.in 1999.
ba Diabetes Management Team
In 1999,CCHP will initiate a diabetes management team. The team will be responsible
for analysis of the data resulting from the new NEDIS diabetes measures. The team will
identify an appropriate intervention strategy and begin formal team meetings.
4. NON-CLINICAL
ao Access to appointments
1. Emergent Care: Immediate access 24 hours a day; 7 days per week.
2. Urgent Care: Within 24 hours
3. Routine Ikon-Urgent Care: Within 7 days
4. Preventive Care: Within 45 days
5. Initial telephone response: 0—90 seconds
6. "On hold"time: 30—90 seconds
7. After hours availability
b. Respect, caring and acceptability of services including:
_. Member satisfaction surveys
2. Review of member grievances and concerns
3. Telephone waiting time
4. Office.waiting roam time
5. Disenrollment questionnaire
C. Appropriateness and utilization of services including-
I. Pattern of referral authorization:requests, approvals, denials, appeals and
outcome of appeals.
2. Timeliness of decisions
3. Utilization of Emergency Room
4. Percent of visits that occur with Primary Care Physician
5. Hospital admissions/1,000
6. Utilization of ambulatory and inpatient services
7. Authorization for costly procedures
8. (:alta of plan claims
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db Environment of care and safety of the member to whore the care is
provided:
1. On site facility audits/reviews
2. Merliber complaints and grievances
3. Review of disenrollment questionnaire survey results
e. Adequacy of the medical record including organization,
documentation, legibility, continuity, specialty referral and utilization.
See Policy&Procedure
X. COORDINATION OF QM PROGRAM WITH OTHER MANAGEMENT
FUNCTIONS
QM activities may impact and require action on the part of other administrative divisions.
These activities include credentialing,member grievance and appeal process,utilization
management(Tinel), sand advice nurse telephone triage program. Management functions
with a significant hearing on quality are linked through Quality Council.
A. CREDENTIAEING
Contra Costa Health Plan has written policies and procedures for the purpose of provider
credentials review to confirm that all contracted providers possess the practice
experience,licenses, certifications,privileges,professional liability coverage, education,
and professional and other qualifications to provide a'evel of quality of care consistent
with professionally recognized standards,and that network providers meet the credential
requirements of applicable state and federal agencies. Site visits are conducted,if
applicable, for both credentialing and recredentialing.
The credentialing process, activity and decision results will be reviewed by the
CCHP Credentialing Committee. The Credentialing Committee reports monthly to
Quality Council. The Contra Costa Board of Supervisors exercise final approval of
credentiali-.ig/recred--ntialing/reappointrne-..it decisions for the Contra Costa Health Plan
contracted providers,
Be MEMBER GRIEVANCE AND APPEAL PROCESS
Member and provider grievances and appeals are received and logged in Member
Services. Grievances that raise quality-related issues are referred directly to the QM Unit
for review,tracking, and resolution. The QM Unit tracks quality of care grievances for
the purpose of identifying potential trends. Where appropriate, corrective action is
implemented. A grievance report is submitted at least quarterly to Quality Co,micil.
C. UTILIZATION MANAGEMENT
CCHP's Utilization Management(Tj'M)Program covers all aspects of care and services
provided to all members.It provides prospective,concurrent,and retrospective review of
health care services requested and received by members.
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D. TELEPHONE TRIAGE PROGRAM
CCHP's Telephone Triage program provides health care advice and education to Health
Plan members,patients utilizing the hospital and clinic system,and those county
residents lacking health care coverage.
F. COOPERATIVE CAREMATNAGEMENT PROGRAM
CCHP's Cooperative Care Management program works with the PCP to coordinate care
of Health flan members and those patients utilizing the hospital and clinic system.
. QM DELEGATION
CCHP may delegate all, or any portion, of the Quality Management program to a
contracted provider group.Delegated quality monitoring status is granted upon successf-al
demonstration by contracted delegated providers that the required scope of quality
monitoring activities is taking place. Prior to delegation,the contracted provider group's
Quality Management Program will be evaluated to assess its ability to carry out required
activities.
If CCHP delegates all oraportion of the Quality Management Program,CCH'will
develop a written description of the delegated activities,the delegates' accountability for
these activities,the frequency of reporting to the plan and the process by which oversight
will be accomplished,
X11. QUALITY MANAGEMENT WORK PLAN
The Quality Management Work Plan will be developed a-°:nually based upon the
evaluation of the effectiveness of the Quality Management Program; upon identified high
voluri e,high risk, and disease-specific categories; and upon identified employer,
provider and regulatory requirements.
The 1999 Quality Management work plan is developed and implemented by rnembers of
the Clinical Leadership Committee.
XIII. EFFECTIVENESS OF THE QM PROGRAM
CCHP's Quality Management staff and Medical Director will evaluate the overall
effectiveness of the Quality Management Program:annually, The evaluation will address
completed and ongoing QM activities;trending of quality data, and analysis of whether
the QM Program and initiatives have accomplished meaningful improvement.
XIV. DISCIPLINARY ACTION
When a quality issue or trend is identified and att--ibuted to a specific physician,and is
severe enough to warrant reportable disciplinary action,the Quality Council will take-
action
akeaction in accordance with the CCHP credentialing appeal process, in such vases,
physicians are entitled to Judicial Review. The CC11P Chief Execrative Officer will,
arrange for this review according to the Judicial Review Policy. Corrective actions will
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be reported to the Contra Costa County legal council for subsequent reporting to the
Medical Board of California(MBC)and the National Practitioners Data Bank.(NPDB).
XV. CONFIDENTIALITY
All quality files and other quality data or information are maintained in a manner that,
protects patient and provider confidentiality. CCHP's Quality Management information
is not discoverable or admissible in a court of law as specified in Section 1157 of the
California Evidence Code and Section 1370 of the Health and Safety Code.
XVI. CONFLICT OF INTEREST
Any individual who has been professionally involved in an issue or case may not
participate in the review, evaluation, or final disposition of the case.
XVII. ANNUAL REVIEW
T'he Quality Management Program will be reviewed,evaluated,and revised annually.
The revised plan and work plan will be submitted to the Clinical Leadership Committee,
Quality Council and the Board of Supervisors for necessary modification and final
approval.
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Contra. Costa Health Plan
Quality Management Program Description 1999
Approved by the Clinical Leadership Committee:
Michael van Duren,MD,Committee Chair Date
Approved by the Quality Council:
Michael van Duren,TNID,Council Chair Date
Approved by the Joint Conference Committee:
Donna.Gerber,Committee Chair Date
CCHP Quality Management Flan e January, 1999 Page 29
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