Common use of Quality Metrics Clause in Contracts

Quality Metrics. 8.2.1 The PASSE must report on the quality metrics outlined in this Section of the Agreement. 8.2.2 The PASSE must meet the quality metrics to avoid recoupment or other sanctions under the Agreement, as outlined in Section 14.1. 8.2.3 The quality metrics are as follows: a. Care Coordinator caseload: Metric Target Reporting to DHS (Frequency/Content) The care coordinator’s assigned caseload will be limited to a maximum of 50 enrolled members. ≥90% of care coordinators will have a caseload of ≤50 enrolled members Quarterly/ Details of monthly caseload for each care coordinator employed, including the names of each enrolled member on the care coordinator’s caseload b. Initial Contact with Enrolled Member: c. Monthly Contact with Enrolled Member: d. Quarterly Contact with Enrolled Member: Metric Target Reporting to DHS (Frequency/Content) Care coordinators must maintain ongoing contact with each enrolled member assigned to his or her caseload, making at least one contact made in person quarterly. ≥75% of members are contacted quarterly in person by a care coordinator. Quarterly/ Details of quarterly contact with each enrolled member including, but not limited to, date of enrollment, date of initial contact, date of in person contact e. PCP Assignment Metric Target Reporting to DHS (Frequency/Content) Care coordinators must ensure that all enrolled members assigned to them have selected a Primary Care Physician (PCP), confirm that the member is seeing the PCP as needed, and if necessary, assist the member with selecting a PCP ≥80% of enrolled members will have selected a PCP and will be on the selected PCP’s caseload Quarterly/ Details on the number of enrolled members that have selected and have been assigned a PCP

Quality Metrics. 8.2.1 The PASSE must report on the quality metrics outlined in this Section of the Agreement. 8.2.2 The PASSE must meet the quality metrics to avoid recoupment or other sanctions under the Agreement, as outlined in Section 14.1. 8.2.3 The quality metrics are as follows: a. Care Coordinator caseload: Metric Target Reporting to DHS (Frequency/Content) The care coordinator’s assigned caseload will be limited to a maximum of 50 enrolled members. ≥90% of care coordinators will have a caseload of ≤50 enrolled members Quarterly/ Details of monthly caseload for each care coordinator employed, including the names of each enrolled member on the care coordinator’s caseload b. Initial Contact with Enrolled Member: c. Monthly Contact with Enrolled Member: d. Quarterly Contact with Enrolled Member: Metric Target Reporting to DHS (Frequency/Content) Care coordinators must initiate contact with each enrolled member assigned to his or her caseload within 15 business days after effective date of enrollment. ≥75% of members are contacted within 15 business days of assignment by a care coordinator. Quarterly/ Details of initial contact time frame with each enrolled member after their enrollment with the PASSE, including, but not limited to, date of enrollment, date of initial contact attempt, and date of completed initial contact Care coordinators must maintain ongoing contact with each enrolled member assigned to his or her caseload, making at least one contact monthly and at least one contact made in person quarterly. ≥75% of members are contacted quarterly monthly and in person quarterly by a care coordinator. Quarterly/ Details of monthly and quarterly contact with each enrolled member including, but not limited to, date of enrollment, date of initial contact, date of monthly contact, date of in person contact e. d. PCP Assignment Metric Target Reporting to DHS (Frequency/Content) Care coordinators must ensure that all enrolled members assigned to them have selected a Primary Care Physician (PCP), confirm that the member is seeing the PCP as needed, and if necessary, assist the member with selecting a PCP ≥80% of enrolled members will have selected a PCP and will be on the selected PCP’s caseload Quarterly/ Details on the number of enrolled members that have selected and have been assigned a PCP

Quality Metrics. 8.2.1 The PASSE must report on the quality metrics outlined in this Section of the Agreement. 8.2.2 The PASSE must meet the quality metrics to avoid recoupment Recoupment or other sanctions under the Agreement, as outlined in Section 14.1. 8.2.3 The quality metrics are as follows: a. Care Coordinator caseload: Metric Target Reporting to DHS (Frequency/Content) The care coordinator’s assigned caseload will be limited to a maximum of 50 enrolled membersEnrolled Members. ≥90% of care coordinators will have a caseload of ≤50 enrolled members Enrolled Members. Quarterly/ Details of monthly caseload for each care coordinator employed, including the names of each enrolled member Enrolled Member on the care coordinator’s caseload. b. Initial Contact with Enrolled Member:: Metric Target Reporting to DHS (Frequency/Content) Care coordinators or the appropriate PASSE team member must ≥75% of members are contacted within 15 business days of Quarterly/ Details of initial contact time frame with each initiate contact with each Enrolled Member within 15 business days after effective date of enrollment. Assignment to the PASSE. . enrolled member after their enrollment with the PASSE, including, but not limited to, date of enrollment, date of initial contact attempt, and date of completed initial contact. The member will be reported in the month the 15 days is completed. c. Monthly Contact with Enrolled Member:: Metric Target Reporting to DHS (Frequency/Content) Care coordinators must maintain ongoing contact with each Enrolled Member on their caseload, making at least one contact monthly. The monthly contact is counted if the member has been enrolled for the entire month. ≥75% of members are contacted monthly by a care coordinator. Quarterly/ Details of monthly contact with each Enrolled Member including, but not limited to, date of enrollment, date of initial contact, and date of monthly contact. d. Quarterly Contact with Enrolled Member: Metric Target Reporting to DHS (Frequency/Content) Care coordinators must maintain ongoing contact with each enrolled member Enrolled Member assigned to his or her their caseload, making at least one contact made in person quarterly. The quarterly contact is counted if the member has been enrolled for at least sixty (60) consecutive days of the quarter. ≥75% of members are contacted quarterly in person by a care coordinator. Quarterly/ Details of quarterly contact with each enrolled member Enrolled Member including, but not limited to, date of enrollment, date of initial contact, and date of in person contact contact. e. PCP Assignment Metric Target Reporting to DHS (Frequency/Content) Care coordinators or the appropriate PASSE team member must ensure that all enrolled members assigned to them have selected a Primary Care Physician (PCP), confirm that the member is seeing the PCP as needed, and if necessary, assist the member with selecting a PCP PCP. ≥80% of enrolled members will have selected a PCP and will be on the selected PCP’s caseload Quarterly/ Details on the number of enrolled members Enrolled Members that have selected and have been assigned a PCP. f. Follow-up Care: Metric Target Reporting to DHS (Frequency/Content) Care coordinators or the appropriate PASSE team member must follow up with enrolled members assigned to their caseload within seven (7) business days of: 1) a visit to an Emergency Room or 2) Discharge from Hospital or In-Patient Psychiatric Unit/Facility ≥50% of members with a visit to ER or discharge from Hospital or In- Patient Psychiatric Unit/Facility will have follow-up by a care coordinator ≤ 7 business days of visit. Quarterly/ Details of follow up visit with members after discharge from Emergency Room or discharge from Hospital or In- Patient Psychiatric Unit/Facility, including but not limited to the date of the visit, the date of the discharge, and action or treatment plan to prevent/avoid such visits in the future. g. Healthcare Effectiveness Data and Information Set (HEDIS®) measures i. The PASSE’s first HEDIS® report will be due to DHS on June 15th of the first full contract year to coincide with the submission of HEDIS® measures to the National Committee for Quality Assurance (NCQA). ii. DHS may make any HEDIS® measures or performance results public. iii. The PASSE must track and report to DHS all current HEDIS® measures for that contract year. HEDIS® measures are subject to change, therefore the PASSE has an obligation to stay abreast of the changes. HEDIS® measures should be based on the coinciding contract year HEDIS® measures set forth by the NCQA. h. PASSE created provider quality metrics i. The PASSE must have quality metrics for quality, accuracy, and timeliness that all providers in the PASSE network are held accountable for. ii. The PASSE must verify the accuracy and timeliness of the data reports submitted by providers regarding these quality metrics, regardless of whether they are Network Providers or Out-of-Network Providers or they are compensated through a capitation arrangement on or a by-service basis. iii. This information must be compiled into a narrative report and submitted to DHS quarterly. Raw data and information must be kept and made available for DHS or its agents to review.