Download health maintenance form - Medica Healthcare Plans

Patient ID#:
HEALTH MAINTENANCE FORM
Name:
Member ID:
D.O.B.:
PREVENTIVE
Breast Cancer Screening
(27 months: October 1, 2013 December 31, 2015)
FOBT Testing (Annually)
Flexible Sigmoidoscopy
(every 5 years)
Colonoscopy (every 10 years)
Adult BMI Assessment (Annually)
Flu Vaccine (Annually)
Pneumonia Vaccine (every 10 years)
Monitor/Maintain Physical Activity
(Annually)
Maintaining Mental Health
(Annually)
CONDITION MANAGEMENT
SOURCE
HEDIS
®
HEDIS
®
HEDIS
®
DATE
Rx
DATE
Rx
DATE
DATE
Rx
DATE
Rx
DATE
Rx
DATE
®
CAHPS
HOS
HOS
SOURCE
HEDIS
®
Diabetes Care / HbA1c (Annually)
Diabetes Care / Nephropathy
(Annually)
Blood Pressure Controlled
(Annually)
Rheumatoid Arthritis Management
(Annually)
Osteoporosis Mgmt. for Women
who have had a fracture
Improving Bladder Control
(Annually)
HEDIS
®
HEDIS
®
HEDIS
®
HEDIS
®
HEDIS
®
Reducing Risk of Falling (Annually)
HOS
HOS
®
Advanced Care Planning (Annually)
Medication Review (Annually)
Functional Status Assessment
(Annually)
Pain Management Screening
(Annually)
HEDIS /SNP
®
HEDIS /SNP
High Risk Medications
Blood Pressure Medications for
People with Diabetes
PDE
®
HEDIS /SNP
®
HEDIS /SNP
PHARMACY
Medication Adherence
1) Oral Diabetes Mediations
2) Hypertension (ACEI &
ARBS)
3) Cholesterol (Statins)
Rx
HEDIS
®
HEDIS
CAHPS
Diabetes Care / Eye Exam (Annually)
CARE FOR OLDER ADULTS (COA)
DATE
PDE
PDE
Breast Cancer Screening (BCS)
Mammography Screening performed during
October 1, 2013 - December 31, 2015
Females age 50-74
With or without clinical Breast
Examination every 1-2 years for
women age 40 and older
Provider to send member for Mammography.
Ultrasound and MRI -- DO NOT COUNT
The percentage of members 50-75 years of
age who have had appropriate screening for
colorectal cancer
FOBT Testing
Flexible Sigmoidoscopy
Colonoscopy
Annually (2015)
Every 5 years (2011-2015)
Every 10 years (2006-2015)
Colorectal Cancer Screening (COL)
Osteoporosis Mgmt. of Fracture (OMW)
Women ages 67 and older who have suffered
a fracture and who have had either a BMD
test or Rx. Drug to treat or prevent
osteoporosis within 180 days after the
fracture
Treatment within 180 days after the
fracture
The percentage of members 18-74 years of
age who have had an outpatient visit and
whose BMI was documented during the
measurement year or the year prior
BMI documented
during current year (2015) or
prior measurement year (2014)
ALL diabetic patients ages 18-75 - testing
performed during 2015 for each of the
following:
Dilated Eye Exam
Nephropathy Screening Test
HbA1c Screening HbA1c (<9.0%)
Rx. to treat osteoporosis or A BMD within 180 days
after the fracture
Adult BMI Assessment (ABA)
Formula for Body Mass Index:
2
Weight (lb) / [height (in)] X 703
Comprehensive Diabetes Care (CDC)
Dilated Eye Exam, Nephropathy,
LDL-C and HbA1c Screening
(at a minimum Annually)
Annually
Provider orders Lab-Urine that
includes microalbumin test
Annually (or Q/4 months for
Diabetic patients)
For Diabetic Retinal Eye screening, in order to detect
Retinopathy, the provider must refer to an
ophthalmologist and/or optometrist. Providers should
ensure that the eye exam is DILATED.
Ophthalmologist/Optometrist will code the exam
Vital Signs to be done with
EVERY visit, BP must be <140/90 to
be compliant
Providers will be compliant if they send a claim with
diagnosis of Hypertension and a blood pressure
reading during each visit
Controlling High Blood Pressure (CBP) | for [HTN – DIABETES]
Patients ages 18-85 who have had a
diagnosis of Hypertension (HTN) / (< 140 /
90) during the Measurement year (2015)
18 and older who received DMARD Rx
(disease modifying anti-rheumatic drug)
with diagnosis of rheumatoid arthritis
The Percentage of adults 66 years and older
who had each of the following during the
measurement year. (See Right Column) ►
The percentage of members 50-75 years of
age who had appropriate screening for
colorectal cancer
Rheumatoid Arthritis Management (ART)
18 and older who received DMARD Rx (disease modifying anti- rheumatic drug)
with diagnosis of rheumatoid arthritis
Care for Older Adults (COA)
Advance Care Planning
Medication Review
Functional Status Assessment
Pain Screening
Annually during (2015)
66 years and older as of Dec. 31
Annually during (2015)
Annually during (2015)
Pharmacy (Part D) Measures
High Risk Medications: The percentage of plan
members who got prescriptions for certain drugs
See High Risk Medication Pocket Guide
with a high risk of serious side effects, when
there may be safer drugs choices.
Blood Pressure Medications for People with Diabetes: The percentage of plan members with diabetes and hypertension who were prescribed an
angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or renin inhibitor medication.
Medication adherence: Percentage of plan
Members taking oral diabetes medications
members with an oral diabetes and/or
in the following therapeutic classes:
hypertension and/or cholesterol prescription
Oral Diabetes Medication
Biguanides, sulfonylureas,
who fill their prescription to cover 80% or more
thiazolidinediones, and DiPeptidyl
Peptidase (DPP) - IV inhibitors
of the time they are supposed to be taking the
medication.
Members taking hypertension medications
in the following therapeutic classes: ACE
Hypertension (ACEI & ARBs)
(Angiotensin Converting Enzyme) or ARB
(Angiotensin Receptor Blocker)
Members taking a cholesterol medication
Cholesterol (Statins)
in the following therapeutic class: Statin
PCPMHP00026_20150316