Based on its review of the MassHealth Senior Care Organization performance improvement projects, KEPRO did not discern any issues related to any plan’s quality of care or the timeliness of or access to care. MassHealth Senior Care Organizations used a wide variety of approaches to reduce the 30-day readmission rate. These interventions are described in more detail in this report’s section on Performance Improvement Project Validation, as are plan strengths and opportunities to improve quality, timeliness, and access to health care. A summary of 2016 plan interventions follows. Care Management BMCHP established a Transition of Care Program in which a Care Manager was focused specifically on ensuring that members experience a seamless transition through the continuum of care including the emergency department, acute inpatient, post-acute rehabilitation hospitals, skilled nursing facilities, nursing homes, and home. The Care Manager for Transitions of Care conducted admission assessments; collaborated with Geriatric Support Services Coordinators; conducted pre-discharge and inpatient risk assessments; collaborated with the member’s primary care provider, inpatient utilization management staff, and the discharge case manager; and conducted face-to-face visits at the member’s home or facility to complete the post-discharge assessment. The Care Manager for Transitions of Care was a member of the Primary Care Team. (Boston Medical Center HealthNet) To proactively prevent ED admissions, care managers huddled on a weekly basis to review patients transitioning from one of care to another. Clinical Managers also performed weekly audits to ensure that Transition of Care Assessments and Care Plans were completed within two days of plan notification of discharge. (Fallon Health) Members identified as high-utilizers were contacted by a nurse care manager for follow-up and education. A monthly report contained detailed information about the reason for the member’s ER visit. The Nurse Case Manager (NCM) was responsible for contacting the
Based on its review of the MassHealth Senior Care Organization performance improvement projects, KEPRO did not discern any issues related to any plan’s quality of care or the timeliness of or access to care. MassHealth Senior Care Organizations used a wide variety of approaches to reduce the 30-day readmission rate. These interventions are described in more detail in this report’s section on Performance Improvement Project Validation, as are plan strengths and opportunities to improve quality, timeliness, and access to health care. A summary of 2016 plan interventions follows. Care Management BMCHP established a Transition of Care Program in which a Care Manager was focused specifically on ensuring that members experience a seamless transition through the continuum of care including the emergency department, acute inpatient, post-acute rehabilitation hospitals, skilled nursing facilities, nursing homes, and home. The Care Manager for Transitions of Care conducted admission assessments; collaborated with Geriatric Support Services Coordinators; conducted pre-discharge and inpatient risk assessments; collaborated with the member’s primary care provider, inpatient utilization management staff, and the discharge case manager; and conducted face-to-face visits at the member’s home or facility to complete the post-discharge assessment. The Care Manager for Transitions of Care was a member of the Primary Care Team. (Boston Medical Center HealthNet) To proactively prevent ED admissions, care managers huddled on a weekly basis to review patients transitioning from one of care to another. Clinical Managers also performed weekly audits to ensure that Transition of Care Assessments and Care Plans were completed within two days of plan notification of discharge. (Fallon Health) Members identified as high-utilizers were contacted by a nurse care manager for follow-up and education. A monthly report contained detailed information about the reason for the member’s ER visit. The Nurse Case Manager (NCM) was responsible for contacting the
2017-sco-eqr-technical-report.docx