WellCare of Kentucky’s Quest for Quality

1. WellCare of Kentucky’s Quest for Quality

2. Why the Quest for Quality? • It’s the RIGHT thing to do for the patient/member • Helps your clinic reach targeted goals (clinical and financial) • Focuses on your clinic as the medical home for the patient, which many of you have as a goal for your facility • Stresses evidenced-based approaches to care, which improve outcomes and reduce costs 1

3. How Do We Work Together to Achieve Our Goals? Our approach to Quality is four-pronged. It is built on fostering partnerships and working collaboratively with providers, members, the community and State to improve health outcomes. 2

4. State Requirements of WellCare That Affect Providers • Impact to Providers: • Assess PCPs compliance with national standards of care as measured by submission of claims with appropriate coding and medical record chart reviews • Evaluation of claims for appropriate referral patterns and treatment • State Requirements : • Monitor PCPs adherence to clinical practice guidelines • Asthma – Use of controllers and relievers • Diabetes – Monitoring of HbA1c, LDL, Eye Exam, Nephropathy, and BP • Adult Depression – Use and continuation of antidepressant medication • ADHD – Follow-up visits • Identify patterns of over- and under-utilization 3

5. State Requirements of WellCare That Affect Providers, continued • Impact to Providers: • Conduct medical record chart reviews and claims analysis for completion of services. Use of appropriate CPT and CPT II codes will decrease chart review • Evaluation of claims for appropriate use of behavioral health medications and ED patterns • Contact by our grievance team for issue resolution • State Requirements : • Implement steps to improve the health status of Medicaid members as measured by HEDIS and State-selected performance measures (Appendix A) • Develop and implement performance improvement projects • Behavioral health medications • ED use • Investigate and resolve member grievances within 30 calendar days 4

6. State Requirements of WellCare That Affect Providers, continued • Impact to Providers: • Conduct audits by telephone assessing compliance with the appointment standards • Providers out of compliance receive a letter and are re-audited within 90 days • State Requirements : • Monitor PCP adherence to the State’s appointment waiting times • Routine and preventive care appointments within 30 days of request • Urgent care appointments within 48 hours of request • After-hours calls returned within 30 minutes 5

7. State Requirements of WellCare That Affect Providers, continued • State Requirements : • Monitor PCPs to ensure they are: • Maintaining a current medical record for the members, including documentation of all PCP and specialty care services • Documenting all care rendered in a complete and accurate medical record that meets or exceeds the State’s specifications (Appendix B) • Providing primary and preventive care, recommending or arranging for all necessary preventive health care, including EPSDT for members under 21 years of age (Appendix C) • Impact to Providers: • Conduct medical record chart audits annually to assess PCPs and OB/GYNs compliance with documentation standards • Providers out of compliance receive a letter of corrective action and are re-audited • Conduct medical record chart audits annually to assess PCPs compliance with EPSDT documentation standards 6

8. WellCare of Kentucky Offices Lexington Office 859-264-5100 Ashland Office 606-327-6200 Louisville Office 502-253-5100 Owensboro Office 270-688-7000 Hazard Office 606-436-1500 Bowling Green Office 270-793-7300 We have six offices throughout the Commonwealth staffed with Provider Relations Representatives and Case/Disease Managers that live in those communities to service the needs of members and providers. 7

9. Our Provider Focus • Provider Tools • Identification of care gaps at eligibility checks https://kentucky.wellcare.com 8

10. Provider Tools, continued Provider Profile Report 9

11. Provider Tools, continued Provider Care Gap Report 10

12. Provider Tools, continued • Member-Centered Case and Disease Management • Member and caregiver-centered model • Service Coordination • Proactive and collaborative face-to-face outreach and assessment • Discharge Planning • Matching members needs with most appropriate provider and/or setting. • Driving Interdisciplinary Care Teams • Integrating care for members • Holistic Management • Home & Community-Based • Behavioral Health • Pharmacy • Medicare and Medicaid • Culturally Competent • Services in multiple languages • Understanding and sensitivity to subcultural norms and preferences Primary Care Physician Community / Advocate Specialist and HCBS Providers Member Family Supports Whole Person Orientation Service Coordination Provider Relations 11

13. Provider Tools, continued • Provider visits and education • HEDIS toolkits and documentation resources • Identification of members in need of screenings • Support • Designated Provider Relations Representative • Case and Disease Managers • 24/7 Nurse Advise Line 12

14. Our Member Focus • Member Outreach Initiatives • Conduct targeted phone calls to members identified as needing screenings • Remind members of any gaps in care they have when calling Customer Service • Distribute targeted mailing reminders to members identified as needing screenings • Conduct health risk assessments, identifying illnesses and chronic conditions early • Offer member incentive programs to obtain specific screenings • Distribute quarterly member newsletters with information on the importance of preventive and chronic condition care • Provide member focused Case and Disease Management services • Offer $10.00 per month in over-the-counter items to members 13

15. Our Community Focus The Role of Health Factors on Health Outcomes What are the physicians saying? According to a study by the Robert Wood Johnson Foundation, 85% of surveyed physicians say unmet social needs are directly leading to worse health. In addition, 4 in 5 physicians say the problems created by unmet social needs are problems for everyone, not only for those in low-income communities. The County Health Rankings show that much of what affects health occurs outside of the doctor’s office. 14

16. Our Community Focus, continued • How do we overcome these barriers? • Educate members at community activities • Community Activity Tracker • Bring the community, community advocates, members, providers, and the Health Plan together to serve members’ needs • Regional HealthConnections Councils • Identify a network of Social Safety Net organizations • My Family Navigator • Connect members to Social Safety Net organizations that meet their specific needs • HealthConnections Log • Compile a library of community-specific data to identify potential areas of need • WellCare in the Neighborhood • Support the needs of the communities our members live in • WellCare Innovation Institute 15

17. Community Engagement in Action – A Kentucky Case Study • A family of six living in subsidized housing. • Mom and Dad work full time without health benefits. • 10-year-old son has special needs. • 19-year-old daughter is pregnant. • 73-year-old grandmother has dementia. • WellCare connected the family to the following: • Health Care (along with condition-specific healthcare) • In-home services for grandmother • Prenatal care for the daughter • Social Supports • WIC / SNAP support • Rental / Housing assistance • Adult day activity program for grandmother • CIL-based independence training for the son • Caregiver training through National Caregiver Assoc. • WellCare found and closed gaps in the following: • Utility assistance • Peer supports for the daughter • Transportation assistance for mother / daughter The Community Advocacy Response What makes us different is that WellCare has created a function to ensure that information for referrals to social programs is readily available for the interdisciplinary team (My Family Navigator) and that the programs are still available. The local community advocates: • Identified faith-based LIHEAP-related programs that required funding because utility-based LIHEAP had closed. • Created peer-support group at the local school with provider-partner to address teen pregnancy. • Connected family to local United Way for their subsidized car loan program to ensure that the daughter could get prenatal care. 16

18. Next Steps • In-depth discussion on quality with Medical Directors and Quality Staff • Contact • Ronda Warner, Director of Quality Phone: 502-253-5139 Email: ronda.warner@wellcare.com • David Bolt, Director of Network Management Phone: 859-264-5102 Email: david.bolt@wellcare.com 17

19. Questions? 18

20. Appendix A – HEDIS Measures Pediatric HEDIS Measures 19

21. Appendix A – HEDIS Measures Pediatric HEDIS Measures, continued 20

22. Appendix A – HEDIS Measures Adult HEDIS Measures 21

23. Appendix A – HEDIS Measures Adult HEDIS Measures, continued 22

24. Appendix A – HEDIS Measures Adult HEDIS Measures, continued 23

25. Appendix A – State-Selected Performance Measures 24

26. Appendix B – Medical Record Documentation Requirements • Member identification information on each page; • Personal/biographical data, including: • Date of birth • Age • Gender • Marital status for adults • Race or ethnicity • Mailing address • Home and work addresses’ as applicable • Home and work telephone numbers’ as applicable • Employer, if applicable • School name for children • Name and telephone information for emergency contact(s) • Consent forms • Language spoken • Guardianship/parent information for children 25

27. Appendix B – Medical Record Documentation Requirements, continued • Date of data entry and date of encounter; • Provider identification by name; • Allergies, adverse reactions and any known allergies are noted in a prominent location in the record; • Past medical history, including serious accidents, operations, illnesses. For children, past medical history includes prenatal care and birth information, operations, and childhood illnesses (i.e. documentation of chickenpox); • Identification of current problems; • The consultation, laboratory, and radiology reports filed in the medical record shall contain the ordering provider’s initials or other documentation indicating review; • Behavioral health summary reports as applicable, initial evaluation and routine follow-up consultations; • Documentation of immunizations pursuant to 902 KAR 2:060; 26

28. Appendix B – Medical Record Documentation Requirements, continued • Identification and history of nicotine, alcohol use or substance abuse; • Documentation of reportable diseases and conditions to the local health department serving the jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR 2:020 as applicable; • Follow-up visits provided secondary to reports of emergency room care as applicable; • Hospital discharge summaries as applicable; • Advanced medical directives for adults. PCPs have the responsibility to discuss advance medical directives with adult members at the first medical appointment and chart that discussion in the medical record of the member; • All written denials of service and the reason for the denial, as applicable; • Signature of the provider conducting the encounter; and • Record legibility to at least a peer of the writer. Records judged illegible by one reviewer are evaluated by another reviewer. 27

29. Appendix B – Medical Record Documentation Requirements, Continued • Additional Documentation Requirements for Clinical Encounters • History and physical examination for presenting complaints containing relevant psychological and social conditions affecting the member’s medical/behavioral health, including mental health, and substance abuse status; • Unresolved problems, referrals and results from diagnostic tests including results and/or status of preventive screening services (i.e. EPSDT) are addressed from previous visits; and • Plan of treatment that includes: • Medication history, medications prescribed, including the strength, amount, directions for use and refills; • Therapies and other prescribed regimen; and • Follow-up plans including consultation and referrals and directions, including time to return. 28

30. Appendix C – EPSDT Requirements 29

31. Appendix C – EPSDT Requirements, continued 30

32. Appendix C – EPSDT Requirements, continued 31

33. Appendix C – EPSDT Requirements, continued 32