Friday, May 18, 2012
   
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Quality Measurements & Guidelines

HEDIS

HEDIS® (Healthcare Effectiveness Data and Information Set) is a widely used set of performance measures developed by the National Committee for Quality Assurance (NCQA®). The information gathered during HEDIS® reviews is used to compare the performance of managed care plans nationally. 

Each spring, The Health Plan QI department nurses review physician office records and complete a set of audited HEDIS reports on preventive services such as immunizations, cancer screening, and prenatal/postpartum care. In addition, we also record the effectiveness of care for members with hypertension and diabetes.

 The “Controlling High Blood Pressure (CBP)” review consists of confirmation of a hypertension diagnosis on a dated problem list or office note, and the subsequent visits to ensure adequate blood pressure control (<140/90).  

Diabetic charts are reviewed for an HBA1c, lipid screening and micro/macro-albumin as well as for blood pressure control and retinopathy screening.

For the diabetes measure, Category II codes may be used for LDL (3048F,3049F, 3050F),nephropathy (3060F,3061F), HbA1c (3044F,3045F,3046F,3047F), and eye exams (2022F,2024F,2026F and 3072F). Use of these codes may decrease the number of charts that we have to request in the future.

For more information on Category II codes as well as other areas that are surveyed administratively, refer to the HEDIS® Coding Guide  and the HEDIS® Overview

While most of our HEDIS® rates remain in the higher percentiles when compared with managed care plans nationally, we are always trying to identify ways to improve. We appreciate you accommodating our staff in this process and for continuing to provide quality of care to our members. 

 

Disease Management

The Health Plan’s Disease Management and Health Promotion Programs are multi-disciplinary and continuum-based systems developed to proactively identify populations with, or at risk for, chronic medical conditions. Populations currently being managed include members with diabetes, chronic heart failure, and chronic obstructive pulmonary disease. The Health Plan’s pregnant members are also monitored with the intent to identify those at high risk for premature delivery.  

The guidelines above are updated every two years or with changes and mailed to providers. Please call 1.800.624.6961, ext. 7659 or 740.695.7659 if you require another set of guidelines and we will mail them out to you. If you have additional questions about the Disease Management Guidelines, you can call 740.699.6110.

 

Advance Directives

The following resources are here to assist you in helping your patients with advance care planning and discussing end of life issues.

  • Respecting Choices 
    Website aimed at professional healthcare providers and designed to help them implment effective, patient-centered systems within their community or organization.
  • National Hospice and Pallative Care Organization 
    Organization that advocates for the terminally ill and their families. It also develops public and professional educational programs and materials to enhance understanding and availability of hospice and pallative care.
  • Caring Connections 
    Website provides  resources, as well as free advance directives and instructions for each state, for you and your patient.
  • Advance Directive Handout
    Patient education handout explaining the importance of Advance Directives.
  • Advance Directive Poster
    Advance Directive 11x14 poster to hang in your office to begin the conversation of the importance of Advance Directives.
  • Advance Directives Flow Chart
    This algorithm can be used to record patients education on advance directives and advance care planning.
  • West Virginia Center for End-of-Life Care
    Ensuring West Virginians have their wishes respected and pain controlled at the end of life.
   

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Ohio Valley/Mountaineer Region
TF: 1.800.624.6961
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:30 am to 5:00 pm

HomeTown Region
TF: 1.800.426.9013
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:00 am to 5:00 pm