We work closely with network PCPs to ensure Peoples Health patients receive quality care that meets regulatory guidelines and that aligns with our care coordination model (see the Introduction – Contact and General Information section of this guide for more about this). Our care coordination model places plan members at the center of their care. Our care coordinators support network PCPs in coordinating patient services and assisting in meeting quality and performance benchmarks.
PCPs are required to see their Peoples Health patients on a regular schedule to help them manage conditions and avoid emergency visits and hospital admissions. We encourage PCPs to proactively conduct checkups on their highest risk patients to properly manage chronic conditions and improve health outcomes.
PCP Performance Goals
Peoples Health encourages PCPs to meet the following goals:
- Coordinate care with specialists and ancillary providers as appropriate for patients’ needs
- Examine all patients at least once within a six-month period
- Conduct follow-up visits within seven days of discharge for recently hospitalized patients
- Conduct preventive screenings in accordance with CMS quality measures
- Monitor patients’ medication use and adherence
- Refer patients for Peoples Health care management services as appropriate; reference Section B.8 (Medical Management Programs) for more about this
- Participate in CMS quality improvement and Peoples Health administrative initiatives
- Periodically review utilization metrics with Peoples Health clinical staff as requested
PCP Performance Standards
Our initiatives, as well as CMS and NCQA initiatives, require the cooperation of network providers to actively work toward common goals, including meeting or exceeding CMS quality measures, providing the highest quality of coordinated care to Peoples Health patients, and improving health outcomes for Peoples Health patients.
The following standards are a supplement to your Peoples Health provider agreement.
Administration and Coordination of Covered Services:
- Participate, as appropriate, in trainings led by Peoples Health staff on elements related to the Peoples Health care coordination model, including the Complex Case Management Program; risk score education; medication management; care coordination for high-risk patients and patients confined to the home or a skilled nursing facility; utilization management; quality reporting; and case management.
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- Coordinate patient care with specialists and ancillary providers as appropriate.
- Coordinate and manage the care of patients confined to the home or a custodial care setting.
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Patient Access:
- Schedule follow-up visits within seven days of a patient’s discharge from an inpatient setting.
- Schedule checkups for patients at least twice during a 12-month period. Request and review stratification reports from Peoples Health to determine patient needs.
- Reserve slots for same-day appointments as appropriate.
Medicare Annual Wellness Visits and Peoples Health Comprehensive Wellness Assessments:
- Schedule and perform patient Medicare annual wellness visits, develop a plan of care, and perform medication reconciliation.
- Encourage patients to schedule comprehensive wellness assessments with a contracted vendor that performs house calls when available in a patient’s area
- Appropriately document and code quality indicators, such as HCC (hierarchical condition category) and HEDIS (Healthcare Effectiveness Data and Information Set) indicators.
- Schedule a follow-up visit within 30 days of a comprehensive wellness assessment as appropriate, and share information with Peoples Health medical management staff as appropriate.
- Allow Peoples Health to perform or arrange Peoples Health comprehensive wellness assessments as needed.
Plan of Care:
- Complete a health risk assessment for all patients and work with Peoples Health to develop a plan of care for D-SNP patients.
- Provide all information that Peoples Health needs to create a patient’s plan of care and support such efforts as appropriate.
Quality Measures:
- Schedule and perform HEDIS screenings and tests, or sign standing orders for the administration of screenings and tests.
- Provide timely documentation of compliance with HEDIS screenings and tests.
- Schedule appointments to complete necessary screenings and tests for patients who are not in compliance with HEDIS requirements.
- Comply with quality initiatives including but not limited to those related to:
- Completing appropriate screenings timely.
- Improving quality scores and patient health outcomes, including meeting all Medicare Advantage program requirements related to CMS’ quality measures for health care processes, outcomes, patient perceptions and organizational structure associated with the ability to provide high-quality health care.
- Permitting Peoples Health case managers to accompany patients to office visits at the patient’s request.
- Documenting advance directives and body mass index; coding all prior diseases and surgical history relevant to current monitoring and treatment; using CPT II codes to capture in-office test and assessment results; using Member Viewer to determine HEDIS and quality screening or test needs during each office visit; and documenting compliance and completion of screenings and tests.
- Documenting complete and accurate diagnoses in the medical record to substantiate the severity of illness for which the patient is being treated.
- Documenting complete and accurate treatment plans for known conditions.
Complex Case Management Program:
- Adhere to evidence-based practice guidelines.
- Cooperate with patient participation in Peoples Health high risk model related to diabetes; heart failure; chronic kidney disease, including end-stage renal disease; chronic obstructive pulmonary disease; or other chronic disease states.
- Encourage and support participation in the Complex Case Management Program, implement a case management care plan for affected patients, and coordinate regular communication with the care management team.
Customizable Provider Reports
Peoples Health can deliver periodic reports that may help you track your patients in need of a checkup, as well as gauge your progress in meeting various quality and performance standards.
These reports are customizable and can help identify:
- Patients needing lab work (this resource works well in conjunction with Member Viewer, which provides snapshots of patients’ clinical histories)
- Percentage of patients seen within a certain time period
- CMS star rating performance
Providers can also request patient profile summaries for an upcoming week’s scheduled appointments. These summaries can help identify important factors, such as missing diagnoses and HEDIS tests or results, so that patients and physicians get the most out of every office visit.
Contact your Peoples Health representative to discuss these resources, which may assist your office in working within our care delivery model.