Abstract:
In Federal fiscal year (FFY) 2004, Oklahoma's Medicaid and SCHIP covered children under the age of 21 received only 62 percent of the number of Child Health Checkups expected based on the State's periodicity schedule. Five multi-faceted strategies have been initiated in recent years to engage members and providers in improving both screening rates and quality. Beneficiary - oriented efforts include a Newborn Outreach Initiative, Care Management Initiatives, and Foster Care Queries. Provider Oriented Efforts include Practice Facilitators, as well as Provider Information and Inducements. The percentage of expected Child Health Checkups received by all Oklahoma Medicaid and SCHIP children under the age of 21 increased by more than 10 percentage points from FFY 2004 through FFY 2006. Problem:
In FFY 2004, Oklahoma's Medicaid and SCHIP covered children under the age of 21 received only 62 percent of the number of Child Health Checkups expected based on the State's periodicity schedule. (In Oklahoma, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) health screens are called Child Health Checkups). At 31 percent, members between the ages of 15 and 18 had the lowest rate of any age group. State agency personnel, external advocates, the State Legislature, and the Governor have all sought to boost these screening rates.
Approach:
The Oklahoma Health Care Authority (OHCA), the State agency that administers both Medicaid and SCHIP, implemented its SCHIP program as a Medicaid expansion of the SoonerCare section 1115 demonstration project. Under SoonerCare, SCHIP-enrolled children receive the same benefits through the same provider network as Medicaid eligibles, and a member's eligibility is not differentiated as to Title XXI or XIX in correspondence or outreach. This makes coverage appear seamless to the member and family.
For a number of years, OHCA has attempted to improve both Child Health Checkup screening rates and quality for Medicaid and SCHIP eligible children through five multi-faceted strategies that engage members and providers: Beneficiary Oriented Efforts
1. Newborn Outreach Initiative: OHCA launched this effort to educate parents about the importance of child health screens, the range of under which benefits available to the entire family, and how to navigate the health care system. The initiative was implemented in January 2006 as a small pilot project in which selected households with newborns were contacted. By October 2006, the effort expanded to target all households identified with newborns born the previous month who had a telephone number on file. Between July 2006 and June 2007, the State attempted to call 17,649 households - both Medicaid and SCHIP - to provide educational outreach.
2. Care Management Initiatives:
(a) Evaluations of Children Receiving Private Duty Nursing (PDN): In 2004, OHCA began making home visits to each Medicaid and SCHIP child currently receiving PDN or for whom PDN is requested. Comprehensive initial assessments are administered by OHCA-employed Care Management Registered Nurses to determine if and at what level private duty nursing care is warranted. Follow-up assessments are completed for each child on a three-to six-month time frame. Initial evaluations can take up to an hour and a half each, while follow-up reviews generally take about one hour. During the in-home evaluation process, the importance of child health screenings is emphasized. More than 470 in- home evaluations for 156 Medicaid and SCHIP children were completed from July 2006 through June 2007.
(b) Education of Identified High Risk Obstetrical (OB) Members: Effective December 2007 each Medicaid or SCHIP woman identified as a high-risk OB member is enrolled automatically in Care Management. One distinct component of the care management process is education about the importance of child health screenings. Through May 2008, some 300 high risk OB women had been enrolled in active care management. 3. Foster Care Queries: The OHCA Child Health Unit has been collaborating with the Oklahoma Department of Human Services (DHS) to improve access to information on health status and service history for foster parents, physicians, and others who are attempting to care for children entering DHS custody or who are involved in the adoption process. Sharing data allows case workers and physicians to have access to vital information quickly about the health of these at-risk Medicaid and SCHIP children. As a child enters DHS custody, a request is submitted to OHCA. The OHCA claims database, which includes all Medicaid and SCHIP claims, is reviewed and pertinent healthcare information is returned to DHS within two business days. Oklahoma Health Care Authority (OHCA) Child Health staff searches the claims data to determine whether the children have had their required immunizations, and to establish a record of past health care services, including surgeries and mental health treatment. The claims information also can tell providers and foster/adoptive parents about past and current medications, known diagnoses, hospitalizations, the most recent dental visit, and the most recent vision and hearing screenings. The Child Health staff sends this information to DHS, where it is entered into the Child Welfare computer system and follows the child if a placement changes. OHCA is able to supply information for 85 percent of the 500 to 600 Medicaid and SCHIP children for whom requests for medical histories are received each month. What began as a quality improvement initiative is now part of routine efforts to assure greater continuity of care. Provider Oriented Efforts
4. Practice Facilitators: OHCA has worked with the Oklahoma University Health Sciences Center (OUHSC) to implement a pilot project to determine if practice facilitators (PFs) can help practices improve the quality and quantity of Medicaid and SCHIP Child Health Checkups for all SoonerCare children. The PFs have master's-level training and experience in primary health care settings and have been trained to help practices make changes in their processes of care. Ten participating practices in two different counties have each agreed to generate patient lists for chart reviews and to meet with a practice facilitator once weekly to discuss any necessary changes in care processes. The PFs provide feedback on their findings to participating practices and help them make changes in their processes of care. Providers have learned how to better document and claim for child health screening services. The enhancement of outreach and scheduling procedures at the practices is also expected to contribute to improved screening rates.
5. Provider Information and Inducements:
(a) Provider Education- In recent years, the importance of child health screening has been emphasized in regular on-site new provider training and in regional semi- annual provider training sessions. Provider education is also available through the OHCA Provider Services Department via telephone consultation, on-site training, and other forms of assistance.
(b) Provider Profiling-The date of the child's most recent health screen is indicated in the monthly provider roster and on OHCA's secure provider web-based eligibility verification system. In 2007, a new profile focusing on child health screens was launched and distributed to PCPs. Since all providers serve Medicaid and SCHIP children without any differentiation in the child's eligibility or benefits, this profile incorporates an analysis of data for both programs for all covered members. Produced twice every year, each profile examines a 12-month period of claims data. Quality Assurance on - site PCP audits also address provider screening rates.
(c) Provider Incentive Payments " Oklahoma makes an incentive payment to each Medicaid/SCHIP primary care provider contractor whose Child Health Checkup screening rate exceeds a benchmark for any or all of five age groups based on the state periodicity schedule. As of June 2008, the threshold for receiving an incentive payment was 65 percent. This threshold has increased over time as overall statewide rates have improved. . Next Steps: The State plans to send letters to all Medicaid and SCHIP households identified under the Newborn Outreach Initiative to ensure that at least one form of educational contact is attempted for every household with a newborn. Based on this project, a new initiative is planned to provide education to expectant mothers receiving SoonerCare benefits. An Oklahoma State Department of Health/OHCA Child Health Advisory Task Force has been formed to address issues such as improving the quality and quantity of Child Health Checkups and follow- up care, and identifying better ways to address common children's health problems in Oklahoma's combined Medicaid and SCHIP program. The top three priority areas addressed in the Task Force recommendations are utilization of primary care, mental health services for children, and childhood obesity. Results:
The percentage of expected Child Health Checkups received by all Oklahoma Medicaid and SCHIP children under the age of 21 increased by more than 10 percentage points from FFY 2004 through FFY 2006. This rate reached 67 percent in FFY 2005 and 72 percent in FFY 2006. Even the screening rates for those least likely to obtain Child Health Checkups " Medicaid and SCHIP members ages 15 to 18 years old " increased, by nine percentage points to 40 percent in FFY 2006. While no one strategy can be singled out as the sole source of these improvements, OHCA believes that the combination of efforts listed above have contributed to the observed results.
Parents of newborns have given positive feedback on the outreach efforts conducted under the Newborn Outreach Initiative. While results of the Practice Facilitator pilot project are being formally evaluated to assess the potential for expanding this approach statewide, preliminary evaluation data are very encouraging. Further Information: Contact: Terrie Fritz
Director of Child Health
Oklahoma Health Care Authority
(405) 522 7377
Terrie.fritz@okhca.org
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