AmeriHealth annually monitors the continuity and coordination of care that members receive to promote the appropriate diagnosis, treatment, and follow-up for medical care. Today, patients' health care needs are rarely met by a single professional. More often, it occurs through coordination and sharing of information by different providers.¹ 

Continuity and coordination of medical care services is the facilitation – across transitions and settings of care – of patients getting the care or services they need and practitioners or providers getting the information they need to provide that care.

Care transitions refer to members moving between health care practitioners and across settings as their conditions and care needs change during the course of a chronic or acute illness. Settings of care are either inpatient (hospital, skilled care, extended care facility or inpatient hospice) or outpatient (home health, emergency room visits, urgent care, physician office, etc.). ²

AmeriHealth utilizes the following data sources to evaluate continuity and coordination of care:

• Medical record review:
  • referrals to specialist and initial consultation notes
  • documentation of ongoing coordination of care from primary care physician (PCP) to specialist
  • documentation of ongoing coordination of care from specialist to PCP
• Data from the Healthcare Effectiveness Data and Information Set (HEDIS^?)
  • comprehensive Diabetes Care: eye exam for retinopathy
• Complex case management metrics for readmission rates
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey
  • members who received care from a doctor or other health care provider besides their personal doctor
  • members who stated that their personal doctor seemed informed and up-to-date about care received from these doctors and other health providers
• Qualified Health Plan Enrollee Experience Survey (EES)
  • members who saw a specialist
  • members who stated that their personal doctor seemed informed and up-to-date about the care received by the specialist

Methodology

Data is collected and analyzed per product in both Pennsylvania and New Jersey: HMO/POS, PPO/EPO, HMO Marketplace, POS Marketplace, and EPO Marketplace. Where applicable, HEDIS, CAHPS, and EES benchmarks were utilized as the Plan goal.

Medical record review: AmeriHealth utilized HEDIS criteria and framework to select a random sample. The sample is large enough to estimate plan-wide percentages with 95 percent confidence and 10 percent oversampling. The Plan goal for these indicators is 90 percent.

Complex case management metrics: The following criteria were applied for calculating readmission rates:

• all members enrolled in Complex Case Management between January 2016 and December 2016                              
• baseline measurement period: January 2015 to December 2015   
• re-measurement period: January 2017 to December 2017

The Plan goal for this indicator is a 10 percent improvement (or reduction) in readmission rates.

Results

Data review from medical record review demonstrates a gap with a PCP’s involvement with transitions and coordination of care. None of the plans met the goal for initial consultation summaries in the medical record or documentation of PCP review of the consult summaries. Rates reported were below the 90 percent goal across all products. Results for coordination of care also reported gaps as documentation of ongoing coordination of care from specialist to PCP reported below 90 percent results for all products. In addition, documentation of ongoing coordination of care from PCP to specialist reported rates below 15 percent. 

Overall results for readmission rates for members enrolled in Complex Case Management report that fluctuations to these results may be related to lower member populations enrolled in Complex Case Management. It was identified that adult Commercial results were driven by four members who account for 100 percent of the readmissions (four readmissions post-period compared to three readmissions pre-period); two readmissions were the same member. Pediatrics reports similar results with the readmission rate being driven by two members with cancer, who accounted for 45 percent of the readmissions. Therefore, true analysis of effectiveness for these two-member populations is not measured. Readmission rates for Marketplace products far exceeded the goal with a 58 percent improvement.

Review of CAHPS data reports mixed results. AHNJ PPO met the CAHPS benchmark, but AHNJ HMO, AHNJ POS, and AHPA did not. EES rates for AHNJ HMO Marketplace met EES benchmark; EES rates for AHNJ POS and EPO Marketplace did not.

AmeriHealth acknowledges certain barriers that influence coordination of care, including, but not limited to, the following:

• facility discharge practices;
• access to electronic records utilized by different health care systems;
• members not keeping health care providers informed of changes in care (e.g., hospital admissions, emergency or urgent care);
• PCPs and specialists not informed of all providers involved in the member’s care (i.e., other specialists);
• for members with multiple complex conditions, lack of identification of a PCP.

Recommendations

To achieve optimal outcomes for members, AmeriHealth expects practitioners to work with other health care providers to facilitate coordination of care. This can be accomplished through:

• educating patients on the importance of collaboration in care and requesting consent to discuss medical and/or behavioral health care;
• following up on referrals to specialty or behavioral health care;
• communicating with other health care practitioners and documenting outcomes in the medical record;
• obtaining access to electronic health records for other health care systems so you can review inpatient/ outpatient information for patients who receive care at facilities outside of your network;
• utilizing Plan resources for information and coordination of care.

Resources

Our goal is to assist providers in facilitating the coordination and collaboration of care to achieve optimal outcomes. AmeriHealth offers the following resources to network providers:

• Clinical Practice Guidelines
• NaviNet^? web portal
• HealthShare Exchange of Southeastern Pennsylvania
• Care Management programs

Providers are also encouraged to utilize the Clinician Collaboration Form located on the Resources for Patient Management web page for AmeriHealth New Jersey and Worksheets, Forms, and Guides web page for AmeriHealth Pennsylvania.

¹Gulliford, M., Naitani, S., Morgan, M. “What is ‘continuity of care’?” J Health Serv Res Policy. 2006 Oct;11(4):248-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17018200.

²NCQA Standards 2018; QI 5

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

NaviNet is a registered trademark of NaviNet, Inc.