Pregnancy Care 2020 Program Description - Passport · 2020. 4. 23. · impact pregnancy outcomes • Encourage self-management support by assisting and educating the patient on navigating

Our mission is to improve the health and quality of life of our members

Pregnancy Care

2020 Program Description

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TABLE OF CONTENTS I. Introduction ..........................................................................................................1 II. Program Philosophy .............................................................................................1 III. Clinical Evidence and Guidelines Used to Develop the Program .........................4 IV. Identifying Patients for Pregnancy Care ...............................................................6 V. Care Planning Processes ................................................................................... 11 VI. Care Monitoring and Case Management System ............................................... 13 VII. Staffing, Training and Verification ...................................................................... 14 VIII. Patient Rights and Responsibilities .................................................................... 18 IX. Privacy, Security and Confidentiality .................................................................. 18 X. Accountability and Structure ............................................................................... 18

Appendices ........................................................................................................................ 19 Appendix A: Pregnancy Care Program Clinical References ...................................................... 19

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I. Introduction The comprehensive Evolent Health Pregnancy Care Program, known as “Mommy Steps” at Passport Health Plan, description outlines the components of the integrated Pregnancy Care Program (referred to in the rest of the document as Program), explains how Evolent identifies patients and assesses their individual needs, provides evidence on which the Program is based, presents the criteria for identifying eligible patients, details the services and support offered and conveys the Program goals. The Program is designed to optimize patients’ prenatal, postpartum and interpregnancy health status, improve pregnancy outcomes and empower patients to be active participants in their well-being.

The Program focuses on three distinct patient populations:

• Patients at low risk for complications of pregnancy and adverse birth outcomes • Patients at moderate risk for complications of pregnancy and adverse birth outcomes • Patients at high risk for complications of pregnancy and adverse birth outcomes

II. Program Philosophy The prenatal and postpartum period is a time of increased and unique vulnerability in a woman’s life, but also represents an ideal time during which consistent contact with the healthcare delivery system, enhanced maternal investment in adopting healthy behaviors, and increased attentiveness to personal health will allow at-risk individuals to be identified and supported. The Program employs a patient-centered approach to care that includes evidence-based care interventions to optimize patients’ prenatal, postpartum and interpregnancy health status. Comprehensive care collaboration and continuous risk assessment throughout the pregnancy and postpartum period ensures that every patient is receiving the appropriate level of motivational and emotional support that aligns with her readiness for behavior change to address physical and behavioral health needs, lifestyle risks, personal preferences and goals, and psychosocial, cultural and educational needs.

The Program promotes healthy pregnancy and birth outcomes by empowering patients to be active participants in their well-being and ensuring they have the support and resources needed to manage their pregnancy. The Program aims to address the individual’s needs with interventions that are targeted to specific risk levels and tailored to each stage of pregnancy, including education on benefits and risks associated with behaviors that may affect pregnancy outcomes, identifying and coordinating care for women who are at high risk for complications of pregnancy and poor birth outcomes, and removing barriers which may impede access to prenatal and postpartum care. The Program implements strategies to support and enhance the patient-provider relationship to improve the quality and coordination of care delivered to pregnant and postpartum patients. The Program uses a provider-driven and patient-centric multidisciplinary care team to successfully implement evidence-based interventions to address the patient’s individual health needs, gaps in care and barriers identified through comprehensive screening and assessment. The team-based model focuses on optimizing the prenatal and postpartum health of the patient by utilizing the specific skill sets of the OB Provider, Registered Nurse Care Advisor (RN CA), Health Educator (HE), Community Health Worker (CHW), Licensed Social Worker (LSW) and Pharmacist as appropriate to meet the patient’s individual needs. The patient’s primary care

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advisor is an RN CA, or an HE. The role overseeing the patient’s care needs will be determined by the patient’s risk level and the complexity of identified needs. The RN CA performs a comprehensive assessment and develops a care plan. The HE performs a comprehensive screening and develops and action plan. When developing care plans or action plans, the care team focuses on the holistic needs of the patient that have been identified through screening and assessment, including the patient’s physical and behavioral health status, lifestyle risks, psychosocial, cultural and educational needs, personal preferences and goals, barriers and readiness for behavior change. The care team also considers the patient’s health plan benefits and local community and government agency resources that may provide services and support outside of the patient’s covered benefits to improve the health and well-being of the patient.

The Program emphasizes early identification of patients that are at risk for adverse pregnancy outcomes, increased utilization, and higher cost. Patients are identified through multiple ways, including provider notification of pregnancy, ADT feeds, real time utilization management authorizations, patient self-referral and Evolent Health’s predictive modeling algorithms, based on independent medical, pharmaceutical, laboratory and behavioral health claims, as well as eligibility and demographic variables.

Operational Model and Pregnancy Care Program Focus

The Program operates at the local and national level. This structure enhances efficient resource utilization and is designed to maximize administrative efficiency. Since each client has unique needs based on the maturity of its markets and the demographics of its patients, the Program can be tailored to fit those needs while focusing on maintaining fidelity to evidenced-based program interventions and maintaining consistency in approaches.

The focus of the Program is to provide patients with access to quality prenatal and postpartum care and services while coordinating benefits based on holistic needs. The Program defines quality care as treatment that:

• Supports the implementation of the provider’s plan of care • Encourages early and regular prenatal care and is accessible to patients in a timely

fashion • Provides service and support from a care management team that is sensitive to a

patient’s increased and unique vulnerability during pregnancy • Provides service and support from a care management team that is sensitive to racial,

ethnic and cultural considerations • Improves the patient's physical and emotional status • Promotes health and healthy lifestyle beliefs and behaviors • Is based on accepted medical principles and follows evidence-based practices • Identifies patients’ pregnancy care preferences • Uses technology and other resources effectively • Is sufficiently documented

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Pregnancy Care Program Goals and Objectives The primary goal of the Program is to promote healthy pregnancies and reduce pregnancy-related complications and poor birth outcomes including preterm delivery (less than 37 weeks gestation), low birth weight (less than 2500 grams), primary cesarean delivery, NICU admissions and maternal postpartum readmissions.

The objectives of the Program are to: • Improve care coordination for patients in collaboration with their provider(s) • Support the provider plan of care • Increase compliance with antepartum and postpartum care guidelines and a schedule of

appropriate prenatal care visits based on gestational age and pregnancy risk factors • Partner with the patient and the provider(s) to develop a personalized care plan or action

plan that addresses all aspects of the patient’s health, including physical, emotional and environmental aspects

• Address patient needs regarding adequate support and resources at home • Increase the number of patients engaged with a CA • Identify pregnant patients through the provider notification of pregnancy process,

utilization management process, patient self-referral, provider referral and the Evolent predictive model

• Continuously monitor patients’ pregnancy risk and adjust intensity of services based on level of risk identified

• Facilitate safe antepartum and postpartum care transitions and improve adherence to the hospital discharge care plan

• Honor the patient’s preferences for care • Review medications to prevent adverse effects or interactions and promote medication

adherence by identifying and addressing barriers • Coordinate a comprehensive community-based network of services and support • Identify and negotiate contracts with those services outside of the existing network • Facilitate comprehensive collaboration across the entire care team • Optimize pregnancy care management and close relevant gaps in evidence-based care • Educate patients about pregnancy and other conditions, health behaviors and risks that

impact pregnancy outcomes • Encourage self-management support by assisting and educating the patient on

navigating the health care system • Lower total medical expense by reducing avoidable ER visits, antepartum inpatient

admissions, NICU stays, postpartum readmissions and duplicative or unwarranted services by educating the patient and proactively coordinating access to care in the appropriate setting at the appropriate time

Metrics and Target of the Program

The following metrics are used to measure the overall effectiveness of the Pregnancy Care – High Risk Program. These measures are used annually for trending, analysis and identifying opportunities for improvement.

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Measuring Effectiveness Metrics

Performance Metric Numerator Denominator Data

Source Program Level

Target Process/Outcome Performance Metrics

Care Plan Timeliness

Patients with a completed care plan within 14 calendar days (10 business days) of a completed assessment

Pregnancy Care programs with a non-administrative assessment submitted

Identifi

80%

Contact Frequency* High Risk Cases meeting the denominator criteria for which average contacts per month is at least 2 (calculated as total count of attempted patient contacts that took place after the assessment submission date divided by the program duration in months) Moderate Risk Cases meeting the denominator criteria for which average contacts per month is at least 1 (calculated as total count of attempted patient contacts that took place after the assessment submission date divided by the program duration in months) Low Risk Cases meeting the denominator criteria for which average contacts per month is at least 0.3 (calculated as total count of attempted patient contacts that took place after the assessment submission date divided by the program duration in months)

Pregnancy Care programs with a non-administrative assessment submitted

Identifi 80%

Graduation Programs meeting the denominator criteria whose closure status is "Closed-Problem Resolved/Goals Met,” who are engaged for the minimum duration required, and who met the critical graduation goals

Pregnancy Care programs with a non-administrative assessment submitted

Identifi 75%

Percentage of patients identified in the 1st trimester or within 42 days of plan enrollment if the patient became a Passport member after she became pregnant

Patients identified for Pregnancy Care within the 1st trimester or within 42 days of plan enrollment if the patient became a Passport member after she became pregnant

Patients identified for Pregnancy Care

Identifi 25%

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*At this time, Passport Health Plan targets high risk members for the Pregnancy Care program and does not engage Moderate and Low risk members in this way. Passport has the ability to expand to Moderate and Low risk as Care Advisor caseloads allow.

III. Clinical Evidence and Guidelines Used to Develop the Program

Evolent references evidence-based, medical society and national industry standards in development, ongoing maintenance, and updates of the Program. The evidence is reviewed by at least two clinical staff with appropriate knowledge of clinical guidelines and peer reviewed, evidence-based studies. A multidisciplinary team from clinical leadership and other subject matter experts, such as research and evaluation analysts, then review the evidenced based sourcing to assure alignment with program content and processes.

The evidenced-based guidelines for the Program are reviewed on an annual basis, or more frequently as needed. At the time of review, clinical staff, including Medical Directors, suggest revisions to Program content based on clinical evidence and areas where operational improvements are needed to improve program performance. Evolent’s Clinical Quality Committee (CQC) is ultimately responsible for approval of the underlying evidence-based guidelines adopted. Training materials are updated and presented to staff when changes are approved and incorporated into program design. Patient program materials are updated based upon current evidence, cultural and linguistic appropriateness, and are distributed as indicated.

To ensure measures used for reporting are consistent with any recommended changes in clinical practices, updates that may impact measures are shared with Evolent’s Analytics team.

Pregnancy Care Program Clinical Evidence-Based Guidelines and References The clinical evidence-based guidelines (EBGs) and references used to inform program design and performance metric reporting for the Program are cited in Appendix A. IV. Identifying Patients for Pregnancy Care Pregnancy Care Program Identification Criteria

A standardized screening is completed to identify risk factors associated with adverse pregnancy outcomes and includes assessing psychosocial risk factors with validated tools, a woman’s attitude toward her pregnancy, and support systems available. Individuals will stratify into one of three levels of Pregnancy Care based on risks identified from the screening or a predictive risk score. Care is coordinated across each integrated program level including Low Risk, Moderate Risk, and High Risk. Note: Passport Health Plan targets high risk members for engagement in Pregnancy Care Management. Interventions (such as educational mailings) are provided across all risk levels. Multiple data sources, identified below, are utilized to identify patients appropriate for the Pregnancy Care Program. The profile of the patients identified for the Program are as follows:

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Pregnant patients are stratified into Pregnancy Care – High Risk based on having one or more of the following conditions or problems:

Pregnancy Care – High Risk

Young Maternal Age: equal to or less than 18 years of age

Underweight – BMI less than 18.5

Tobacco/Electronic Nicotine Delivery System Use, Alcohol Use or Substance Use*

*Currently in a Substance Use Treatment Program, including Opioid Agonist Therapy (e.g., methadone, buprenorphine)

Prescription Opioid Use

Homelessness or Unstable Housing

Domestic Violence/Intimate Partner Violence

Unwanted Pregnancy

Serious Mental Illness/Serious Emotional Disturbance: Severe Depressive Disorders, Severe Anxiety Disorders, Bipolar Disorders, Schizophrenia, PTSD or other Trauma Disorders, Eating Disorders, Other

Behavioral Health Screenings: PHQ-9 score > 15, GAD-7 score > 15, CAGE AID score > 2

Chronic Medical Conditions: Diabetes, Hypertension, Asthma, Systemic Lupus Erythematosus, Chronic Renal Disease, Cardiac Disease, Thyroid Disease, Seizure Disorders, Sickle Cell Disease, HIV

Current Pregnancy: Gestational Diabetes

Current Pregnancy: Hypertensive Disorders of Pregnancy: Preeclampsia – Eclampsia, Gestational Hypertension, Chronic Hypertension w/Superimposed Preeclampsia

Current Pregnancy: Multiple Gestation (Twins, Triplets, Higher-Order Pregnancy)

Current Pregnancy: Placental Abnormalities (e.g., Placenta Previa, Placenta Accreta, Placenta Percreta, Vasa Previa)

Current Pregnancy: Fetal Complications including Major Fetal Anomaly (diagnosed/confirmed by amniocentesis, CVS, ultrasound/fetal MRI), Fetal Growth Restriction (IUGR), Polyhydramnios, Oligohydramnios

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Current Pregnancy: Preterm Labor (defined as the presence of uterine contractions of sufficient frequency and intensity to effect progressive effacement and dilation of the cervix prior to term gestation) or PPROM (Preterm Premature Rupture of Membranes)

Short Interpregnancy Interval: less than 6 Months

History of Preterm Spontaneous Delivery less than 37 Weeks Gestation

PPROM (Preterm Premature Rupture of Membranes)

History of Cervical Insufficiency/Incompetent Cervix in Previous Pregnancy

Utilization: Antepartum Inpatient Admission in Current Pregnancy

Utilization: 2 or more Inpatient Admissions in Previous 6 Months

Utilization: Missed 2 or more Prenatal Care Visits, Not Rescheduled

Postpartum: Maternal Postpartum Inpatient Readmission

Postpartum: Postpartum Enrollment in the Pregnancy Care Program

Postpartum: Edinburgh Postnatal Depression Scale score > 10 and/or Patient Reports Thoughts of Self-Harm

Postpartum: Preeclampsia-Eclampsia, Gestational Hypertension, Chronic Hypertension w/Superimposed Preeclampsia

Postpartum: Newborn Status: Fetal Death (stillbirth) > 20 weeks Gestation or Neonatal Death

Postpartum: Newborn Status: Discharged - Not in Mother’s Custody

Postpartum: Newborn Status: Admitted to NICU and Remains in NICU

Pregnant patients are stratified into Pregnancy Care – Moderate Risk based on having one or more of the following conditions or problems:

Pregnancy Care – Moderate Risk

Advanced Maternal Age: equal to or greater than 40 years of age

Obesity Class III – BMI equal to or greater than 40

Substance Use less than 3 Months Prior to Current Pregnancy (Exclude Tobacco/Alcohol)

SDoH: Food Insecurity, Financial Insecurity (Mortgage/Rent, Utilities, Food, Clothing Child Care), Lack of Transportation, English Not Primary Language Requiring Interpreter Services

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Mild/Moderate Depressive or Anxiety Disorders

History of Postpartum Depression in Previous Pregnancy

Behavioral Health Screenings: PHQ-9 score > 5 up to 14, GAD-7 score > 5 up to 14

Short Interpregnancy Interval: equal to 6 Months up to 12 Months

History of Gestational Diabetes in Previous Pregnancy

History of Hypertensive Disorders of Pregnancy in Previous Pregnancy: Preeclampsia – Eclampsia, Gestational Hypertension, Chronic Hypertension w/Superimposed Preeclampsia

Utilization: Late Entry into Prenatal Care: greater than or equal to 14 Weeks

Pregnant patients are stratified into Pregnancy Care – Low Risk based on the following criteria:

Pregnancy Care – Low Risk

Absence of Moderate or High-Risk Indicators

Any patient meeting the eligibility criteria for the Program with a complicating behavioral health (BH) condition can be referred to the BH Care Advisor on the care team. Because BH is integrated into Pregnancy Care, patients will have both physical and behavioral health needs addressed within the Program. Evolent leverages both automated (rules-based) and manual (query and clinical referral-based) processes to identify patients for the Program. The data sources below are used in a proprietary predictive model that analyzes the severity of diagnoses across three dimensions: 1) diagnosis progression, 2) management interventions, and 3) addressing complications to target clinically those patients in which an impact is possible. The following data sources are used within the predictive model and run monthly. Other data

sources, indicated below, are factored into the model based on availability:

Data Source Typical Update

Frequency 1. Medical Claims Monthly 2. Pharmacy Claims Monthly 3. Health Risk Appraisal/Patient Questionnaire Annually 4. Electronic Medical Record data (when available) Weekly 5. Data collected in Identifi from Condition Care or Practitioners As available 6. Hospital Admission, Discharge & Transfer feeds As available 7. Laboratory Values, as available As available

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In addition to the above data sources, patients can be referred to the Program through: • The Utilization Management team • The Care team staff managing the patient in another Evolent Health Population

Management Program, such as Complex and Condition Care, Transition Care or Behavioral Health Care

• A discharge planner • Internal departments, such as Pharmacy • The 24-hour nurse advice line (health information line), as applicable • Patient, family or caregiver(s), self-referral • Practitioners, including behavioral health providers • Ancillary providers, behavioral health managed care organizations, pharmacists,

disability management programs, employer groups, or staff from community agencies

Initial Assessment Processes Patients eligible and identified for the Program are initially outreached and engaged through telephone or face to face contact. The patient’s name, address, and/or date of birth are utilized to verify, identify and protect the patient’s privacy. Upon enrollment in the Program, a member of the care management team will complete a screening and/or assessment to confirm or identify risk level, if unknown. Additional needs will be assessed including Social Determinants of Health (SDoH), barriers that may prevent the patient from adhering to the pregnancy plan of care, the patient’s attitude toward her pregnancy and support systems available. A review of the medications the patient is currently taking is completed to ensure that the patient does not suffer adverse effects or interactions from medications contraindicated in pregnancy. Upon completion of the screening and/or assessment and identification of any problems that the patient is experiencing, a care plan or action plan will be developed in collaboration with the patient, focusing on the patient’s personal goals, wishes and preferences. The patient may choose to opt out of the program at any time.

Times Frames to Conduct Outreaches and Assessments

Patients are initially outreached as follows:

• Within 5 business days of receiving the case via an Action Item in Identifi or within 1 business day of notification of discharge*, a Care Advisor will begin outreaching to the patient and/or caregiver.

• Initial assessments are completed within 14 business days of initial outreach. The goal is to complete the initial assessment during the enrollment and initial screening interactions.

*At Passport Health Plan, Care Advisors will begin outreaching within 2-4 business days of notification of discharge.

Assessments The Program has its own distinct screenings and assessments based on its focus. The patient’s risk level and reason for enrollment in the program will determine the appropriate screening and/or assessments to be completed. The Program’s antepartum and postpartum assessments are intended to provide the Pregnancy Care team with a comprehensive evaluation of the

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patient’s needs, barriers, and preferences to inform the development of a personalized care plan/action plan aimed at helping the patient adhere to her provider’s plan of care and ensure that the appropriate resources and support are coordinated in collaboration with the patient and the patient’s providers.

The initial screening and assessment include, but are not limited to, the following:

• Clinical history, including medications • Health status, including medical and behavioral health condition-specific issues • Mental and socioeconomic health status needs, preferences and barriers • Life-planning activities such as living will, advance directives, and power of attorney • Cultural and linguistic needs, preferences, or limitations • Social determinants of health • Visual and hearing needs, preferences or limitations • Health beliefs and behaviors including smoking, diet and exercise • Patient’s available benefits and community resources • Patient’s available support systems

Interventions by Stratified Risk Level* Interventions Low Risk Moderate Risk High Risk Outreach to the patient to enroll in the Program Welcome Packet with care management overview letter, educational booklet and support resources

Completion of a screening or assessment by a non-licensed/licensed member of the care team, which includes coaching/education/self-management support during the interaction

Self-management support Prenatal outreach occurs at least once per trimester Prenatal outreach occurs at least every 20 business days

Prenatal outreach occurs at least every 10 business days

Postpartum outreach occurs at least every 20 business days

Postpartum outreach occurs at least every 10 business days

Postpartum Packet with letter, educational materials and support resources

*At Passport Health Plan, High Risk members are targeted for engagement in Pregnancy Care Management. All identified pregnant members receive a welcome packet with educational material. If Care Advisor caseloads allow for expansion to target Moderate or Low Risk members, the above interventions for Low Risk and Moderate Risk will be applied as applicable.

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V. Care Planning Processes For patients at high risk, the RN CA, in coordination with the OB provider/Specialist(s) and patient, will develop an individualized care plan. The care plan includes patient-specific preferences, barriers, prioritized goals, self-management activities, referrals, a schedule of follow-up interactions and a process to assess progress. At Passport Health Plan, High Risk patients are currently targeted for engagement in Pregnancy Care Management. If Care Advisor caseloads allow for expansion to moderate or low risk patients, then a care team member, in coordination with the OB provider/Specialist(s), will work collaboratively with the patient to develop an action plan which focuses on the patient’s goals, preferences and care coordination needs. The care management team’s activities are targeted to facilitate the achievement of addressing the patient’s holistic needs and goals, resolving barriers and reducing risks. Personalized care plans/action plans take into consideration the following:

• Patient preferences to prioritize goals • Reevaluation of progress, including problem solving and resetting of goals when

progress is not being made • Assigning key responsibilities for specific goals to the appropriate extended care team

member • Involving caregiver(s) when the patient provides consent • Understanding the patient’s plan benefits, network, and community-based services • Care transitions and the need to reassess and modify to ensure appropriateness based

on the patient’s current level of care and needs.

Prioritized Goals

• Identifying barriers to meeting goals and complying with the care plan/action plan • Developing follow-up coaching/care coordination encounter schedule with patient • Developing and communicating patient self-management plans • Assessing progress against care plans/action, and modifying as needed

Referrals and Barriers to Care As part of the assessment and care planning process, patients may be referred to network, community, or governmental support agencies to address individual needs. The primary staff is responsible for ensuring that patients are referred to appropriate member of the extended care team. Members of the extended care include, but are not limited to, the following: RN CA, BH CA, HE, CHW, LCSW, Dietician and Pharmacist. It is the responsibility of the primary staff member to follow-up on internal and external referrals to verify that the referral was completed and evaluate the outcome.

In addition, the care management team is responsible for identifying all relevant barriers preventing a patient from adhering to her provider’s treatment plan and schedule of prenatal and postpartum care visits. There are multiple forms of barriers, including physical or mental disabilities, financial, transportation, language, hearing, motivation, culture and confidence barriers, as well as social determinants of health. It is a core responsibility of the primary staff to identify options and solutions to mitigate and address barriers.

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Assessing Progress For each active patient, progress in meeting the care plan/action goals and objectives is reviewed, monitored, and reassessed based on agreed upon priorities from patient and care management team. Development and communication of the patient’s self-management plan is an essential component of all care plans. Identification of barriers that may prevent a patient from achieving her goals and accomplish the objectives outlines in the care management plan is critical and the care management team will work with the patient and provider to address barriers as needed.

The schedule for follow-up communication with patients is notated in the clinical documentation system.

Case Closure Once a patient has delivered and is 8 weeks postpartum, she is evaluated for appropriateness of discharge from the Program. Patients at high risk are evaluated at 10 weeks postpartum. The Program may be closed for the following reasons:

• Condition has stabilized • Needs have been met • Goals have been met • Patient declines continued participation • Patient does not respond to outreach attempts after three attempts and an “unable to

reach” letter • Maximum benefit is obtained from the program • Patient has expired • Patient is no longer enrolled in a client-sponsored health plan product

VI. Care Monitoring and Case Management System

Evolent Health utilizes a clinical documentation system, Identifi, which automates the evidence-based clinical guidelines and algorithms used to perform the Pregnancy Care assessment and ongoing management of the patient. Identifi leverages perinatal care guidelines and evidence-based screening tools, such as the PHQ9, to ensure the patient treatment plan and adherence to evidence-based standards of practice are assessed. See Appendix A for the guidelines being used to inform assessment questions, responses and actions.

In addition, the assessment leverages branching logic to allow follow-up questions to be skipped depending upon the response to the initial question. In addition, logic is applied for the automated creation of patient goals and problems aimed at ensuring consistent delivery of the program.

From an ongoing management perspective, the Identifi platform has a standard care plan template that includes a library of problems, goals and interventions (PGIs) that have been informed by the guidelines.

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The system automatically documents the staff member’s name, date and time of action on the case or when an interaction with the patient has occurred. The care management team member assigns the next follow-up within the system, based on the patient’s needs and request. All successful interactions and unsuccessful attempts with the patient and/or provider are documented in the patient’s record in Identifi Care.

Staff are trained to schedule the next interaction with the patient at the end of each call and to create an action item to prompt their next interaction with the patient.

Identifi is at the heart of Evolent Health’s case management solution with a growing set of automated features to provide accurate documentation of the actions/interactions with the patient, the providers and the care team.

VII. Staffing, Training and Verification Evolent Health’s Care Management Team is composed of the following staff categories: role type, licensure requirements, and primary responsibilities.

Staff Role Role

Type Licensure Required Primary Responsibilities

Manager, Care Management

Clinical License required in each state where their team is managing patients

• Manages/supervises the day to day activities of the CM team

• Facilitates case review conferences • Provides performance coaching and feedback to

team members • Evaluates reports and performance on a regular

basis with the team

Registered Nurse Care Advisor/Manager

Clinical License required in each state where CA is serving patients (may be through Compact arrangements)

• Owns primary relationship with the patient and her PCP if assigned as the primary staff

• Conducts assessments for catastrophic and transition care patients

• Provides self-management coaching, care coordination services and refers patients to other care team members as appropriate

• Responsible for development and implementation of the care plan

Registered Dietitian

Clinical License required in each state where RD is serving patients

• Supports RN CA and works with patients to implement their nutritional/dietary plan

• Identifies barriers and problems - solves with patients to maintain their behaviors to adhere to the plan

• Adds supporting documentation to the existing care plan

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Staff Role Role Type

Licensure Required

Primary Responsibilities

Licensed Social Worker or Behavioral Health Care Advisor/Manager

Clinical License required in each state where the LSW is serving patients. In some markets, there may also be a BH CA (same licensure requirements apply).

• Supports RN CA to identify and remove behavioral, social, economic and safety related barriers to care and care plan adherence including referrals to psychiatrists and network social workers

• Adds supporting documentation to the existing care plan

• Facilitates the identification and access to network, community and governmental support services to meet key needs of the patient

• Accesses database of local resources for patients and their caregivers to connect patients to needed services

Licensed Pharmacist

Clinical License required in each state where pharmacist is serving patients

• Supports RN CA to identify and coach patients needing support with medication adherence strategies and behaviors

• Reviews medication reconciliations for patients during care transitions, and assists CA with completion of medication reconciliation as needed

• Works with providers to modify medication regimens, when appropriate, to better meet the needs of the patient

Health Educator/Coach*

Non-Clinical N/A • Owns primary relationship with the enrollee and her PCP if assigned as the primary staff

• Conducts screenings for Pregnancy Care

• Provides self-management coaching, care coordination services and refers patients to other care team members as appropriate

• Responsible for development and implementation of the Action Plan

Community Health Worker/Care Coordinators*

Non-Clinical No licensure requirements

• Conducts interviews with patients to determine health literacy and need for interpreter services

• Conducts outreach calls to encourage patients/caregivers to participate in care management programs

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Staff Role Role Type

Licensure Required

Primary Responsibilities

• Assist in providing information/referrals to governmental and community agencies

• Scheduling provider visits on behalf of patient

• Maintain library on current available community resources

Program Coordinator

Non-Clinical No licensure requirements

• Works under the direction of the CM team by running reports, assigning cases to teamwork list/action item list

• Sends out letters and helps the team manage to service level and timeliness metrics

Care Connector**

Non-Clinical No license requirements

• Takes inbound calls from enrollees and connects them to the Care Management team

*These care team members are not currently deployed with the Pregnancy Care program at Passport at this time.

**This is a Passport-specific role.

Staffing needs are based upon specifically designed staffing models which support the needs of the programs and the population being served. The staffing models are provided to clients as appropriate.

The Care Management team, including market Medical Directors and Senior Directors of Market and Central Clinical Operations have a minimum of three to five years of clinical experience. All staff are properly trained and supervised. Evolent Health’s Vice President of Clinical Programs and Performance and Vice President of Clinical Operations have ultimate responsibility for oversight and implementation of the Pregnancy Care Program. Regional or Market Medical Directors, and Senior Directors of Market and Central Clinical Operations, are responsible for the daily departmental operational activities for each client and for the national remote staff that support multiple clients.

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The following grid reflects the essential processes for how CM team members interact with patients, practitioners and other clinical staff:

Patient and Practitioner Interactions with the

Clinical Team

Patient and Practitioner Interactions with the Non-Clinical Team

Providing Access to Clinical Staff for

Practitioner Requests

Approval of Processes

RN CA owns the following: • Primary relationship with the

patient and PCP • Conducts initial assessments

for Pregnancy Care – High Risk

• Outreach to PCPs and specialists to inform on care plan and notify of changes in health status

• Responsible for the care plan development and patient progress on the plan

• Self-management coaching • Referrals and follow-up to

network and community resources

• Case conference presentations

RD owns the following: • Dietary and nutritional

counseling • Referrals to local RD resources • Helps patient adhere to plan by

identifying and removing barriers and reinforcing plan

• Responsible for communicating and updating care plan related to nutrition, diet and exercise

LSW owns the following: • Identification and problem

solving to remove/mitigate barriers related to social determinants of health, economic or patient disabilities

• Identification of local network resources to provide community-based support

• Responsible for communicating and updating care plan related to psychosocial issues and related barriers

PharmD owns the following: • Reviews medication

reconciliations for patients during care transitions, and assists CA with completion of med rec as needed

• Counsels patients on medication adherence methods

• Works with physicians on changing medication regimens when appropriate

Non-clinical staff interact with patients in the following ways: • Primary relationship with

patient and PCP when assigned as primary staff

• Conducts initial screening on all pregnant patients if risk is unknown or for Pregnancy Care – Moderate Risk/Low Risk

• Outreach to patients to encourage program participation and schedule visits with the patient’s providers

• Help patients find a PCP, close care gaps and educate patients on alternatives for accessing non-emergent care

• Health Coaches and Community Health Workers assist patients with providing information on community and governmental based service agencies

Situations when Non-clinical staff refer patients or practitioners to the clinical team: • Patient or practitioner asks

to speak to a clinician or has a specific clinical question

• The nonclinical staff does not know how to respond to a patient or practitioner

• The patient is expressing that they are experiencing significant signs and symptoms of their condition

• An emergent situation where patient or physician need immediate help

• Screening reveals high risk indicators

Practitioners in the network are informed on how to access the Pregnancy Care Program through the following means: • Client clinical leadership

meetings • Provider website provides an

overview of the program, referral forms and phone numbers for contacting CM team patients

• Care Plans/Action Plans provided to practitioners include the RN CA name and phone number

• Health Coaches outreach to practitioners to inform them of patients enrolling and dis enrolling from the program as well as notification of transitions

• Yearly e-News notifications Onsite visits done by Provider Network Management Team and Population Health Managers

The physicians on the CQC are responsible for: • Approving communication

processes. • Approving clinical guidelines • Approving changes to

program clinical content and design

• -Approving KPI and target changes

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Initial Training, Monitoring and Ongoing Training for Staff All care management staff receive a consistent and comprehensive role-dependent new hire orientation. Formal training is delivered via a blended methodology including side-by-side training sessions, virtual interactive sessions, and self-paced/e-learning modules. Both the design/development staff and the delivery staff have the responsibility of measuring the effectiveness of the curriculum. The initial training provided to the staff includes:

• Confidentiality/Handling of Protected Health Information • How to handle emergency situations • Evidence used to develop the programs • Behavioral change models • Goal setting • Referral process • Cultural competence • Health Literacy • Motivational Interviewing and Engagement techniques • Identifi system training

Staff are required to maintain competency by participating in internal and external educational programs, conferences and, as applicable, continuing clinical education programs on an annual basis. To maintain consistent delivery, the staff are evaluated through an internal quality review process monthly, which includes a focused performance coaching program of random sample file reviews and Identifi reports. Staff are given feedback on their performance following these evaluations and through a standard, formal, bi-annual performance evaluation process.

When opportunities for improvement are identified through the internal performance/quality review process, action plans are developed to meet defined goals. Training is provided to the clinical team or individual based on 1) coaching program findings, 2) changes to program design, 3) changes in populations being managed, 4) changes in guidelines and peer reviewed evidence, and 5) changes to Identifi workflow. Verification of Licensure All clinical staff are required to have an active, unrestricted license. A license is required in each state where patients are served and must be obtained within 90 days of staff starting at Evolent or within 90 days of notification of client membership in a new state. No staff member will engage patients in a state where the staff does not have a current, active, unrestricted license. The Human Resources (HR) department is responsible for conducting primary source verification for current, active licenses of the clinical staff prior to onboarding. Monitoring of Staff Licensure Verification, Sanctions and Complaints The HR team is responsible for reminding individuals and their manager 90 days in advance of the license renewal date. If an individual staff member fails to renew or obtain his/her additional license(s) within a 90-day period, he/she will not be allowed to engage patients in that state until an active license is obtained. Failure to procure a license within an appropriate timeframe may be grounds for termination. The HR team is responsible for conducting an annual sanction process for Medicare, Medicaid and licensure related sanctions. Staff may also report sanctions against themselves directly to HR and/or their manager. HR immediately validates any self-reported sanctions and implements appropriate action, if necessary.

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VIII. Patient Rights and Responsibilities Handling and Resolving Patient Complaints Evolent Health has a policy and procedure for registering and responding to patient complaints about the Program and/or the care management staff, including:

• Documenting the details and context of the complaint and actions taken • Investigating the complaint, including any aspect of the clinical care involved • Forwarding complaints not related to CM to the appropriate area or client • Notifying and updating patients on the progress of the investigation and the final

disposition of the complaint • Turnaround times for resolving routine and urgent complaints. Please refer to policy

CM.DM.022 Patient and Provider Complaints for timeframes.

IX. Privacy, Security and Confidentiality The details of patient rights to privacy, security and confidentiality are described in two policies and procedures: 1) CORP028 Records Retention and 2) CM.DM.025 Care Management Compliance with HIPAA Privacy Regulations.

X. Accountability and Structure Accountability for the management of the quality of clinical care and service provided to patients resides with the CQC. The VP of Clinical Operations, VP of Clinical Programs and Performance and Regional Medical Directors are responsible for oversight of the Program’s development and implementation. These responsibilities, in addition to monitoring the effectiveness and improvement of the care management and population health programs, are supported by the CQC. Committee membership includes Vice Presidents from Clinical Operations and Clinical Programs and Performance, Directors from Quality, Pharmacy, Analytics and Care Management, as well as, Regional Chief Medical Officers and Medical Directors. The CQC meets quarterly.

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APPENDICES Appendix A: Pregnancy Care Program Clinical References

Core Program Clinical Guidelines Source: American Academy of Pediatrics, American College of Obstetricians and

Gynecologists Article Title: Guidelines for Perinatal Care 8th Edition

Author(s): American Academy of Pediatrics, American College of Obstetricians and Gynecologists

Publication Date: 2017 Link:

ACOG-Guidelines for PerinatalCare-8th

Source: American Diabetes Association

Article Title: Standards of Medical Care in Diabetes

Author(s): American Diabetes Association Publication Date: 2018 Link: https://professional.diabetes.org/content-page/standards-medical-care-diabetes/

Source: American College of Obstetricians and Gynecologists Article Title: Optimizing Postpartum Care: ACOG Committee Opinion No. 746:

Author(s): American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice in collaboration with task force members Alison Stuebe, MD, MSc; Tamika Auguste, MD; and Martha Gulati, MD, MS

Publication Date: 2018 Link: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-

Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care