Provider Quality Improvement

Health Net wants members to experience the highest quality of care from the physicians and other providers in its network. To that goal, Health Net recognizes the importance of collaborating with, and supporting, providers in their efforts to improve member's health and meet Medicare's quality standards for our Medicare Advantage (MA) plans.

Quality improvement is a major initiative for the Centers for Medicare and Medicaid Services (CMS). CMS uses the Medicare Five - Star Quality Rating System to monitor the performance of MA health plans to ensure they meet quality standards. For MA members, the ratings provide a tool to compare the quality of care and customer service offered by different MA plans. Providers have a direct impact on over 60 percent of the measures that are used for these ratings.

The rating for the quality of medical services includes multiple measures that fall into the following five categories.

• Staying healthy – Measures whether members received various screening tests, vaccines and other checkups that help them stay healthy.
• Managing chronic conditions – Measures how often members with different conditions received certain tests and treatments that help them manage their condition.
• Member experience with the health plan – Includes ratings of member satisfaction with the plan.
• Member complaints and changes in the health plan's performance – Measures how often Medicare found problems with the plan and how often members had problems with the plan. Also measures the plan's performance over time.
• Health plan customer service – Measures how well the plan handles member appeals.

Provider's participation and assistance in providing the highest quality of care to Health Net members is vital to meeting CMS' expectations in the delivery of care to MA members. In an effort to accomplish this goal and meet CMS standards, Health Net has developed tools for provider's use. Please click on the links in the sections below to access these tools.

Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) and Member Experience

• Help Improve Patient Care and Quality of Life (CAHPS) Tip Sheet – Medicare (PDF)
• Help Improve Patient Care and Quality of Life (CAHPS) Tip Sheet – Cal MediConnect (PDF)

Telehealth

• Improve Access to Care for Your Patients through Telehealth – Commercial, Medicare, and Medi-Cal (PDF)
• Improve Access to Care for Your Patients through Telehealth – Cal MediConnect (PDF)

Alcohol and Other Drug Treatment

• IET Tip Sheet – Commercial, Medi-Cal, and Cal MediConnect (PDF)
• IET Tip Sheet – Medicare (PDF)

Antidepressant Medication Management (AMM)

• AMM Tip Sheet – Commercial, Medicare, and Medi-Cal (PDF)

Anxiety and Treatment Options to Improve Health Outcomes

• Learn More About Anxiety – Commercial, Medicare, and Medi-Cal (PDF)
• Learn More About Anxiety – Cal MediConnect (PDF)

Asthma (AMR/MMA)

• Culturally Competent Asthma Care Tip Sheet – Commercial (PDF)
• Culturally Competent Asthma Care Tip Sheet – Medi-Cal (PDF)

Avoidance of Antibiotics for Bronchitis (AAB)

• AAB Tip Sheet – Commercial (PDF)
• AAB Tip Sheet – Medi-Cal (PDF)

Behavioral Health (BH) Information Exchange to Help Improve Outcomes

• BH Information Exchange – Commercial, Medicare, and Medi-Cal (PDF)
• BH Information Exchange – Cal MediConnect (PDF)

Breast Cancer Screening (BCS)

• BCS Tip Sheet – Commercial, Medicare, and Medi-Cal (PDF)
• BCS Tip Sheet – Cal MediConnect (PDF)

Cervical Cancer Screening (BCS)

• CCS Tip Sheet – Medi-Cal and Commercial (PDF)

Childhood and Adolescent Immunizations (CIS, IMA)

• Child Immunization Status (CIS) Tip Sheet – Commercial and Medi-Cal (PDF)
• Immunizations for Adolescents (IMA) Tip Sheet – Commercial and Medi-Cal (PDF)

Infant, Child and Adolescent Well-Care Visit

• Infant, Child and Adolescent Well-Care Visit Tip Sheet – Commercial and Medi-Cal (PDF)

Chlamydia Screening (CHL)

• Chlamydia Screening (CHL) Tip Sheet – Commercial and Medi-Cal (PDF)

Chronic Conditions

• Colorectal Screening Tip Sheet (PDF)

Controlling Blood Pressure (CBP)

• CBP Tip Sheet – Commercial, Medicare, and Medi-Cal (PDF)
• CBP Tip Sheet – Cal MediConnect (PDF)

Congestive Heart Failure

• Help Patients Manage Their Heart Disease (Overview) – Commercial, Medicare and Cal MediConnect (PDF)
• Help Patients Manage Their Heart Disease (Overview) – Medi-Cal and CalViva Health (PDF)
• Summary of Heart Failure Guidelines – Commercial, Medicare and Cal MediConnect (PDF)
• Summary of Heart Failure Guidelines – Medi-Cal (PDF)

Depression Screening and Follow-Up (CDF, DSF)

• CDF, DSF Tip Sheet – Commercial, Medicare, and Medi-Cal (PDF)
• CDF, DSF Tip Sheet – Cal MediConnect (PDF)

Follow-Up Care for Children Prescribed ADHD Medication (ADD)

• ADD Tip Sheet – Commercial and Medi-Cal (PDF)

Follow-Up after an Emergency Department Visit for Mental Illness (FUM) / Follow-Up after an Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)

• FUM/FUA Tip Sheet – Commercial, Medi-Cal, and Cal MediConnect (PDF)
• FUM/FUA Tip Sheet – Medicare (PDF)

Health Outcomes Survey (HOS)

• HOS Tip Sheet – Medicare (PDF)
• HOS Tip Sheet – Cal MediConnect (PDF)

Learn How to Address Medical Needs for Patients with Severe and Persistent Mental Illness (SPMI)

• Address Medical Needs for Patients with SPMI – Commercial, Medi-Cal, and Cal MediConnect (PDF)
• Address Medical Needs for Patients with SPMI – Medicare (PDF)

Low Back Pain (LBP)

• LBP Tip Sheet – Commercial (PDF)
• LBP Tip Sheet – Medi-Cal (PDF)

Prenatal and Postpartum Care (PPC)

• Timeliness of Prenatal Care Tip Sheet (PDF)
• Postpartum Care Tip Sheet (PDF)
• Cultural Considerations of Postpartum Care – Medi-Cal and Commercial (PDF)

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

• WCC Tip Sheet – Commercial and Medi-Cal(PDF)

Toolkit

These resources provide education and support to clinical staff and other provider office staff for improving quality perinatal care and birth outcomes.

• See Provider Tip Sheets section on this page for more Prenatal and Postpartum Care
• Preconception and Interconception Health Care: Tips to Improve Birth Outcomes (PDF)

Supporting Safe Deliveries

Provider Webinars

March 2018 – Dr. Elliott Main, Medical Director and Executive Committee Chair of the CMQCC is the presenter. Topics include: The importance of supporting vaginal birth and reducing NTSV cesarean rates, How to get involved in CMQCC and join the Maternal Data Center, Potential collaborations with other providers to help implementation at your site.

• Best Practices to Support Vaginal Delivery and Reduce the NTSV Cesarean Section Rate (PDF)
• Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (PDF)

April 2018 – L. Jeanine Arndal, MD, FACOG, of Northern Inyo Healthcare District is the presenter. Northern Inyo was on the Smart Care Initiative Hospital C-Section Honor Roll for the past two years. Topics include: Discussion of practices to prevent the first cesarean section, Preterm premature rupture of membranes (pPROM), Unique hospital practices, Results and continued work.

Decreasing NTSV Cesarean Section Rates: Putting it into Practice (PDF)

Smart Care California Resources on Improving Maternal Care

2019 Hospital C-Section Honor Roll Recipients (PDF)

Relevant Articles and Case Studies

• 'Time's Up': Covered California To Enforce Quality And Safety Targets, May 24, 2018
• Covered California will exclude hospitals with high rates of cesareans (PDF)
• Healthy People 2020 Goal: "Reduce cesarean births among low-risk women with no prior cesarean births." (PDF)
• Q&A: Covered California's Dr. Lance Lang on the state's high C-section rates, and what's being done to curb them.
• [Case Study] Preventing the First Cesarean Delivery, Obstet Gynecol. 2012 November 120(5): 1181-1193
• [Case Study] Induction of Labor Compared with Expectant Management for Prelabor Rupture of Membranes at Term, NEJM 1996 April Vo. 334 No 16 1005-110 (PDF)

Improving Perinatal and Postpartum Care

These resources provide education and support to clinical staff and other provider office staff for improving quality perinatal care and birth outcomes.

• Prenatal Care Tip Sheet – Commercial and Medi-Cal (PDF)
• Postpartum Care Tip Sheet – Commercial and Medi-Cal (PDF)
• Cultural Considerations of Postpartum Care – Commercial and Medi-Cal (PDF)
• Prenatal Tip Sheet – CalViva Health (PDF)
• Postpartum Tip Sheet – CalViva Health (PDF)
• Cultural Considerations of Postpartum Care – CalViva Health (PDF)
• Preconception and Interconception Health Care: Tips to Improve Birth Outcomes (PDF)

Additional webinars

September 2018 – Dr. Jack Klein, Clinical Solutions Consultant and Clinical Professor of OB/GYN at Washington University School of Medicine is the presenter. Topics include: Defining Opioid Use Disorder, Effects of Opioid Use on Pregnancy and Pregnancy Outcome, Antepartum, Intrapartum, Postpartum Care and Role of the Obstetrician–Gynecologist and Other Obstetric Care Providers.

• Video - September 2018 Use and Misuse of Opioids in Pregnancy Webinar
• Use and Misuse of Opioids in Pregnancy (PDF)

Maintaining continuity in patients' medical care is critical following discharge from the hospital to ensure successful recovery. Poor coordination of care across settings can result in costly, potentially harmful, and often avoidable re-hospitalizations. Poor care transition, failures in communication between providers, lack of patient and family involvement and few standardized tools and processes can all contribute to adverse events or avoidable readmissions. Evidence suggests improving core discharge planning and transition processes out of the hospital may reduce the rate of avoidable re hospitalizations.

The materials in this toolbox outlines best practices and provides easy-to-use tools and resources to help hospitals improve or redesign care processes to reduce avoidable hospital readmissions that occur within 30 days of discharge.

Medication Self-Management Review

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (PDF)

Discharge Planning

• Factors that contribute to readmission (AHA) (PDF)
• Discharge Planning Checklist (Robert Wood Johnson Foundation) – English (PDF)
• Discharge Planning Checklist (Robert Wood Johnson Foundation) – Spanish (PDF)
• Discharge Planning Checklist (CMS) (PDF)

Patient Engagement

• Getting the Most from Your Doctor's Visits (PDF)
• Questions for Your Health Care Team (PDF)

Tools and Links

• American Heart Association guidelines and webinars
• STAAR Readmissions Diagnostic Tool (PDF)
• STARR Improving Transitions from Hospitals to the Office Practice (PDF)
• STARR Improving Transitions from Hospitals to Home Health Care (PDF)
• Teach back
• California Quality Collaborative (CQC)
• Agency for Healthcare Research and Quality

Programs for UC and CalPers Members with Prediabetes

The Omada prediabetes program is an innovative, 16-week program designed to help individuals lose weight, and has been shown to help reduce behavioral risk factors for developing type 2 diabetes. The program is based on the CDC's Diabetes Prevention Program. It focuses on guiding participants toward reaching modest weight loss and activity goals through nutrition, online coaching, exercise and an online social community. Omada brings together the individualized attention of professional health coaches with a researched curriculum and manageable but powerful goals. It has been shown to result in sustained weight loss 1 year after program completion.

Over the course of 16 weeks, positive behaviors are introduced in 4 phases: Changing Food Habits; Increasing Activity Levels; Preparing for Challenges; and Reinforcing Healthy Choices. It includes:

• Personal health coach for one-on-one advice
• Weekly online lessons to educate and inspire
• A wireless scale that tracks your success
• A small group of participants who provide support

Omada is available to people who want to lose weight, including those who have been diagnosed with prediabetes and to those who are at high risk for type 2 diabetes. To join, interested members visit the Omada website and complete a screening tool to determine eligibility. The screening tool is based on the CDC's Prediabetes Screening Test.

Participation in Omada requires 16 weeks of dedicated involvement followed by 8 months of self-paced involvement. During the first 16 weeks, participants complete weekly lessons, record what they eat, communicate regularly with their group members and health coach, and practice what they learn. This can take 2-3 hours per week on average, although it can take more time and the time spent implementing lifestyle changes is difficult to measure. The online format is easily adaptable to the participant

For UC employees: Download the Omada Prediabetes Program Flyer for UC members (PDF)

Programs for all Members with Diabetes

Health Net's program provides a health management solution to improve the health and quality of life for Health Net members. Through personalized interventions and contemporary behavior change methodologies, Health Net's experienced staff can assist members at risk and diagnosed with chronic health conditions to better manage their conditions through education, empowerment, and support. This program includes clinical management that encompasses health and wellness, disease management, case management, and women's and children's health.

The disease management program provides support to members with chronic conditions, including diabetes. Disease management helps increase the efficiency and effectiveness of care, leads to more timely actions by the member, and helps develop more personalized and actionable solutions that ultimately lead to improved health outcomes. Program information is available in the Provider Library.

• Coordination of Care Between Medical and Behavioral Health Providers Form (PDF)
• MHN Behavioral Health Services and Referrals Flyer - Commercial, Medi-Cal, and Cal MediConnect (PDF)
• MHN Behavioral Health Services and Referrals Flyer - Medicare (PDF)
• MHN Behavioral Health Services and Referrals Flyer - CalViva Health (PDF)
• PCP Tools for Coordinating Care – MHN/EPC Behavioral Health (CalViva) (PDF)
• PCP Tools for Coordinating Care – MHN/EPC Behavioral Health (All Lines of Business) (PDF)
• Provider Training and Education Course Catalog – Cal MediConnect (PDF)
• Provider Training and Education Course Catalog – Commercial/MediCal/Medicare (PDF)
• SAMHSA Opioid Overdose Prevention Toolkit (PDF)
• Screening Brief Intervention Referral to Treatment (SBIRT) for Substance Use Disorder (PDF)

Encourage the Importance of Well-Woman Screenings

Between family, work and community responsibilities, women are often so busy caring for others that they overlook their own health needs. Health Net encourages you to remind all women about the importance of regular well-woman screenings to increase early detection and treatment of disease. Physicians play a powerful role in motivating their patients to seek regular health care services.

2020 Adult Preventive Health Guidelines (PDF)

Breast Cancer

Mammograms typically should begin at age 40 for women at normal risk. According to the American Cancer Society (ASC), the following recommendations for breast cancer screening include:

• Breast examination by a health care provider every three years starting at age 20; annual clinical breast exam starting at age 40
• Annual screening mammography starting at age 40 or 50. Breast cancer experts do not all agree. When a woman reaches age 40, a mammogram is a personal decision between her and her doctor
• Women in high-risk categories should have mammograms every year and typically start at an earlier age. MRI or ultrasound screening can also be given in addition to mammograms

Cervical Cancer

The American Congress of Obstetricians and Gynecologists (ACOG) recommends that cervical cancer screening begin at age 21 (regardless of sexual history). Screening before age 21 should be avoided because it may lead to unnecessary and harmful evaluation and treatment in women who are at very low risk of cancer. The ACOG also states:

• Pap smears are recommended every two years for women between ages 21 and 29
• Women ages 30 and older who have had three consecutive negative Pap smears and have no history of cervical intraepithelial neoplasia (CIN) 2 or CIN 3, are not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero may extend the interval between examinations to every three years
• Some women at higher risk for cancer may need Pap smears more often to monitor their health

Bone-Density Testing

Bone-density testing typically should start at age 65 and be administered every two years or more frequently as determined by the physician. According to National Osteoporosis Foundation guidelines, there are several groups of people who should consider bone-density testing:

• All postmenopausal women under age 65 who have risk factors for osteoporosis
• Postmenopausal women with fractures. This is not mandatory because treatment may well be started regardless of bone density
• Women with medical conditions associated with osteoporosis. A primary care physician can assess the patient's risk profile for osteoporosis
• Women whose decisions to use medication might be aided by bone-density testing

Colorectal Cancer

Colorectal cancer screening typically should start at age 50. According to the American College of Gastroenterology, colorectal screening should continue as follows:

• Colonoscopy every 10 years
• Alternate strategy of annual stool test for blood and a flexible sigmoidoscopic exam every five years or a double-contrast barium enema every five years

Chlamydia

Chlamydia testing normally starts at age 24 or younger. The U.S. Preventive Services Task Force (USPSTF) recommends Chlamydia screening for:

• All sexually active women ages 24 or younger
• Women older than age 24 with high-risk sexual behaviors
• Pregnant women in the first trimester and again in the third trimester if high-risk sexual behaviors are reported. Treating a pregnant woman who has a Chlamydia infection can prevent an infection in her newborn
• Women with pelvic inflammatory disease (PID)
• Women with symptoms of a cervical infection (cervicitis) found in a pelvic exam
• A newborn whose mother had a Chlamydia infection at the time of delivery
• If you would like to request a hard copy of the well woman screening pad, please email your requests to the Health Net Quality Improvement Department.

Approximately one third of community dwelling adults over the age of 65 report experiencing a fall in the past 12 months. Many of these falls result in significant injuries such as fractures and head injuries, reduced quality of life and mortality. In addition, the annual direct and indirect costs of fall injuries are expected to reach 54.9 billion by 2020.

Multiple studies have validated that interventions such as encouraging physical exercise, performing medication reviews and correcting environmental hazards can have a positive impact on fall management. The American Geriatric Society has published the Clinical Practice Guideline: Prevention of Falls in Older Persons with recommendations for screening, assessment and interventions. This and additional materials on Fall Risk Management including patient education brochures from the CDC and National Council on Aging (NCOA) are provided as a resource for providers. Please use the presentation and materials below to learn more about this important public health issue and incorporate fall prevention into standard office practice.

• AGS Clinical Practice Guideline Summary: Prevention of Falls in Older Persons (PDF)
• Fall Risk Algorithm (PDF)

Patient Materials

• NCOA Brochure – 6 Steps to Prevent Falls - English (PDF)
• NCOA Brochure – 6 Steps to Prevent Falls - Spanish (PDF)
• CDC Brochure – Check for Safety: A Home Fall Prevention Checklist - English (PDF)
• CDC Brochure – Check for Safety: A Home Fall Prevention Checklist - Spanish (PDF)
• CDC Brochure – Check for Safety: A Home Fall Prevention Checklist - Chinese (PDF)
• CDC Brochure – What You Can Do to Prevent Falls - English (PDF)
• CDC Brochure – What You Can Do to Prevent Falls - Spanish (PDF)
• CDC Brochure – What You Can Do to Prevent Falls - Chinese (PDF)

Additional Resources

• The National Council on Aging (NCOA) mission is to improve the lives of millions of older adults, especially those who are struggling, through innovative community programs and services, online help and advocacy. Additional information is available at Fall Prevention Awareness Day.
• The Center for Disease Control and Prevention has multiple provider and patient educational resources in English, Spanish and Chinese that can be ordered for free at Center for Disease Control and Prevention – Older Adult Falls.
• Fall Prevention Center of Excellence – Public/private coalition dedicated to implementing fall prevention programs and providing professional and patient educational materials and resources. Some materials involve cost.
• National Institute on Aging site, where you can order free "Falls and Fractures" brochure in English and Spanish at National Institute on Aging – Prevent Falls and Fractures.

The Department of Health Care Services (DHCS) requires all new Medi-Cal members complete their comprehensive Initial Health Appointment with a provider within the primary care setting within 120 days from plan enrollment. The Initial Health Appointment (IHA) can be completed by a primary care physician (PCP), nurse practitioner, certified nurse midwife, or physician assistant. At a minimum, it must include:

• Physical, social, or mental health histories.
• Preventive care services.
• Physical examination.

The IHA is required by DHCS for all newly enrolled patients, including those with disabilities. Providers must follow DHCS requirements for completing the IHA, in accordance with DHCS Plan Letters 08-003 and 13-001.

Additional information on IHA Requirements for Medi-Cal Patients

Provider News:

• Health Net: 20-297, Complete the IHA within 120 Days to Help Manage Your Patients' Health Care Needs
• CalViva Health: 20-298, Complete the IHA within 120 Days to Help Manage Your Patients' Health Care Needs

Provider Tip Sheets:

• Medi-Cal/Cal MediConnect: 22-173 – Tips for Completing the New Member IHA – English (PDF)
• CalViva Heatlh: 22-172 – Tips for Completing the New Member IHA – English (PDF)

Provider webinar training

• Topic: Initial Health Assessment (IHA) Requirements
• Speaker: Pam Carpenter, RN, DHCS Master Trainer Quality Improvement Manager, Facility Site and Medical Record Review
• Details: In this presentation we review IHA requirements, Staying Health Assessment forms, Facility Site Review, Medical Record Review and resources
• Resources:
  IHA Provider Webinar recording – use code: IHA12345!
  Initial Health Assessment Requirements Webinar Training Slides (PDF)
  

The Department of Health Care Services (DHCS) requires that all providers who conduct periodic health assessments on Medi-Cal children provide the following:

• Verbal or written anticipatory guidance to child's legal parent or guardian of the harmful effects of lead exposure for children starting at ages six months to 72 months (6 years). At a minimum, the information should include that:
  • Children can be harmed by lead exposure from old or chipping lead-based paint and dust.
  • Children that begin to crawl until 72 months of age, are particularly at risk.
• Blood lead level testing (finger stick or venous blood draw) on children:
  • At 12 months and 24 months of age.
  • If child between ages 12-24 months have no record of lead testing.
  • If child between ages 24-72 months is missing a lead test at 24 months or after.
  • When requested by child's parent or guardian.
  • When provider conducting Periodic Health Assessment (PHA) for child 12-72 months is aware of increased risk of lead exposure/poisoning due to changes in child's circumstances.

Providers must follow the California Department of Public Health Guidelines (PDF) for interpreting blood lead levels and follow-up activities for elevated blood lead levels.

• Screening for elevated blood levels can be conducted by finger stick test or via venous blood draw.
• Confirming or retesting of blood lead levels should be conducted through the venous blood test.

Tools to help you complete lead screenings

Health Net provides the following tools to help providers identify children who need a lead test.

• Electronic care gap reports by email
• Cozeva web-based care gap reports (PDF)

If you are not receiving your care gap reports, reach out to your provider representative for information on obtaining or how to review these reports.

Submit codes as evidence of lead testing

Providers can use the following codes for submitting claims/encounters as evidence for lead testing:

Providers and labs must report all lead test results to the Childhood Lead Poisoning Prevention Branch (CLPPB). Contact EBLRSupport@cdph.ca.gov.

Exceptions to providing a lead screening

Providers are not required to perform lead screening if:

• Legal parent/guardian refuses the lead screening and signs a voluntary refusal statement.
• In provider's professional judgement, lead testing poses greater risk for child than lead poisoning.

Providers must document reasons for not providing the lead screening or not obtaining the voluntary refusal statement in the child's medical record.

Education you can share with your patients

• Krames/Health Net: The Dangers of Lead Poisoning – English
• Krames/Health Net: The Dangers of Lead Poisoning – En Español (Spanish)
• Krames/Health Net: Lead Poisoning: Test Your Home and Family – English
• Krames/Health Net: Lead Poisoning: Test Your Home and Family – En Español (Spanish)
• Krames/CalViva Health: The Dangers of Lead Poisoning – English
• Krames/CalViva Health: The Dangers of Lead Poisoning – En Español (Spanish)
• Krames/CalViva Health: Lead Poisoning: Test Your Home and Family – English
• Krames/CalViva Health: Lead Poisoning: Test Your Home and Family – En Español (Spanish)

Additional information on Lead Screening Requirements for Medi-Cal Patients

Health Net Provider News

• 22-247 – Tips for Childhood Blood Lead Level Screenings – CalViva – English (PDF)
• 22-248 – Tips for Childhood Blood Lead Level Screenings – Health Net – English (PDF)
• 20-953 – Is Your Screening of Young Children's Blood Lead Levels Compliant? (Health Net)
• 20-954 – Is Your Screening of Young Children's Blood Lead Levels Compliant? (CalViva)

Department of Health Care Services: APL 20-016 Blood Lead Screening of Young Children – English (PDF)