Guest Column | March 1, 2019

3 Insights From Our Journey To NCQA Accreditation

By Jennifer Greene and Onika Wilson, Cardinal Innovations Healthcare

Unlocking The Potential Of Real-World Data: Tapping Into Today’s Data To Improve Healthcare Tomorrow

Healthcare organizations serving complex populations — such as those with intellectual and developmental disabilities (IDD), mental health concerns, and substance use disorders — have some unique challenges. Key among them is ensuring that these individuals receive comprehensive care that aligns their behavioral health and physical health needs. That includes accounting for specific issues related to housing, transportation and other social determinants of health.

That’s why we’ve built an integrated care strategy at Cardinal Innovations Healthcare. It’s centered on a holistic and person-centered care planning approach, as well as a community-based model of care management. Both are instrumental to our ability to positively impact the health and wellness of the complex Medicaid and indigent populations that we serve throughout North Carolina.

As part of our commitment to person-centered care, we were the first Local Management Entity-Managed Care Organization (LME/MCO) in the state to achieve accreditation from the National Committee for Quality Assurance (NCQA). It’s a designation we’ve steadfastly maintained since 2009. Specifically, we’ve focused on achieving Full Accreditation for Medicaid Managed Behavioral Health Organizations (MBHO), plus the Long Term Services and Supports (LTSS) Distinction which we added in 2018.

MHBO Accreditation through NCQA evaluates how well a health plan manages all parts of its delivery system — including physicians, hospitals, other providers and administrative services — in order to continuously improve care for its members.

The LTSS distinction takes care quality to the next level. It’s based on an organization’s ability to demonstrate how well it coordinates services between caregivers, individuals, LTSS providers, and clinicians. In addition to implementing best practices for person-centered care planning and effective care transitions, organizations must be able to measure quality improvement. The ultimate goal is to support people so they can live their best lives in their preferred settings.

Like many organizations, we believe these NCQA designations are important markers of our commitment to improving the health and lives of our members. At the same time, we recognize that getting there is a journey. So, we’d like to share three key insights that have helped us on our path to achieving NCQA accreditation:

  1. It Takes Data To Create A Truly Person-Centered Model

Health plans and healthcare providers are challenged in their efforts to collect, review, and use data to support continuous improvement. Even when the right data is available, the level of infrastructure needed to put it to use building more person-centered, integrated care can hinder progress.

That’s even more true in behavioral health, where traditionally it’s been difficult to obtain data around the physical cost of healthcare for members — let alone combine it with behavioral healthcare data. Fortunately, we’ve seen improvements over the past couple of years, and it’s starting to make a big impact.

When it comes to improving member engagement rates, for example, we put significant effort toward reviewing claims data, and problem-solving at the member level to make sure individuals get the preventative and diagnostic care they need. For instance: We’ve used that information to ensure that children on antipsychotic medications have the financial and support resources they need to get metabolic monitoring. Another example involves helping members with bipolar disorder follow through with their treatment. We review their medication management plan, and drill into data to identify ways to keep them engaged in their treatment, while removing any barriers to care they may face.

Care transitions are another high-risk area that benefit from data analysis and improved data integration. Within our organization, we use data to reduce unplanned transitions and identify triggers that indicate a member may be headed toward crisis. Specifically, we want members to be involved with their treatment teams in the decisions about changes in service. We don’t want them to be subjected to a change they find problematic, and subsequently find themselves facing an emergency that requires a higher level of care.

Using data, we can flag and combine identifiers that may indicate an escalating concern, such as when a member has an increase in incidents, or multiple grievances filed. With this insight, we step in with community resources to try to avoid an emergent situation.

We also use data analysis to improve follow-up for members who visit the ER or the hospital. Our best practice is to check with the member within seven days to make sure they receive support services, so they do not cycle back through the system in crisis.

In short: Data is crucial. We believe that better member outcomes result from what we can plan for, and what we can measure.

  1. A Community-Based Model Surrounds Members With The Right Resources At The Right Time To Make A Difference In Their Lives

In a person-centered planning model, care coordinators work to encircle members with services that reflect their wants and needs. They identify steps members can take to realize more complete lives, and coordinate with organizations that can support them along the way. The success of an integrated care model relies on understanding and maximizing the use of community services to address members’ care plans.

Consequently, we employ care coordinators who work together with population health specialists, research and data scientists, clinicians, and utilization management specialists. Our care coordinators also are deeply engaged with their local communities — including housing agencies, workforce resources centers, community activity centers, and public service agencies — so they can help give members the community support they need to lead healthier, more fulfilling lives.

Additionally, care coordinators serve as member advocates, ensuring that members remain in charge of their own plan and team. Their needs must remain front-and-center, even as plans are put in place to manage any potential challenges that occur. We see this as an important element of truly person-centered care.

  1. Empowering Members With Tools To Manage Their Own Health Improves Their Engagement

Offering self-management tools is an additional way we keep members engaged in managing their physical and mental health. (It also happens to be one of the NCQA standards.)

Members can use a number of interactive tools on our website at any time, day or night. They can review their BMI levels, for instance, or assess whether they’re getting enough physical activity. They can get stress management information, and other similar evaluations. Since our member populations often don’t have or can’t use smartphones, we make user-friendly tools accessible at the public library.

We also provide an online search tool on our website that delivers region-specific listings of support resources, including things like housing mediation services, credit counseling, and other items that technically are outside of the domain of behavioral health — but that directly impact members’ lives.

The Right Resources At The Right Time To Improve Quality Of Life
Ultimately, improving the health and wellness of complex member populations takes an unwavering focus on members, providers, and communities. This is well aligned with the tenants and performance improvement measurements laid out by accreditation bodies like NCQA. We know that our accreditation efforts are just one more way to ensure we’re making a significant impact in the communities we serve.   

About The Author

Jennifer Greene is Accreditation and Performance Improvement Manager, and Onika Wilson is a Director of Quality Management at Cardinal Innovations Healthcare.