Dr. Magras joined CHNCT on July 18th and brings with him an extensive amount of clinical and physician executive experience from a variety of settings including the nation’s largest for-profit healthcare system, academic medical centers, a managed care plan, and a hospitalist practice. His experience has included utilization review, case and disease management, care management redesign, quality, practice redesign, risk, global cost management, and emerging payment models.

With 27 years of experience as an internist/hospitalist, Dr. Magras spent the last 16 years as a physician executive and has served as a senior-level executive of a complex multi-hospital and multi-service nonprofit health system in an integrative role. Prior to joining CHNCT, Dr. Magras served as a senior director physician consultant at Huron Healthcare, where he worked with provider systems and payers nationally for clinical transformation and clinical integration projects.

Dr. Magras is a thought leader in care management redesign and physician performance management. In addition to his clinical and management experience, he also specializes in quality improvement, quality management, and risk management. He is a Six Sigma Green Belt, with training in crew resource management and high reliability. Dr. Magras is board certified by the American Board of Internal Medicine and the American Board of Quality Assurance and Utilization Review Physicians, and is a certified healthcare quality manager (CHQM). He is a resident of Orange, Connecticut, and has lived in the state since 2010.

Dr. Magras may be reached by phone at 203.949.4127 or by email at lmagras@chnct.org

This message applies only to eligible providers that would like to attest to the Medicaid EHR Incentive Program for the first time.

If you have not attested to the Medicaid EHR Incentive Program during any previous years and would like to participate, 2016 is the last year in which providers can attest to the program for the first time.

The Medicaid EHR Incentive Program is entirely voluntary. You may qualify for the incentive if at least 30% of your patients use Medicaid insurance.

More information about this program can be found on the CMS website, and for more specific information about Connecticut, at the UConn CHATTER Website.

There will also be several virtual information sessions in November 2016. More information about these will be coming soon.

To participate in this program, you will need to get an electronic health records system, register with CMS, and then complete an attestation in the MAPIR system.

Your first incentive payment will be $21,250 and for each subsequent year you attest you can receive $8,500 until 2021.

For more information, contact:

Phone: 1.844.607.7455

Email: CTMedicaidEHR@uconn.edu

Web: http://chatter.uconn.edu/ehr-incentive-program

This is the first in a series of articles which focuses on a specific report available to all PCPs with a login to HUSKY Health’s secure provider portal and access to the portal reports. Once a HUSKY Health provider account is created and access to reports is obtained, PCP practices will receive an email notification whenever new reports are posted to their accounts. Portal reports are a great resource for tracking when HUSKY Health patients are due for certain visits or screenings and will also help you manage members who have more immediate needs due to a hospital visit or management of a condition.

The Daily Admission and Discharge Report

The Daily Admission and Discharge Report is generated on a daily basis. The timely follow up with your HUSKY Health patients who have been discharged from the hospital is important to continued care in the post-acute setting and preventing readmissions. This report details your attributed members who have been admitted to and discharged from an inpatient setting.

The following data is provided for patients included in this report:

• Date of admission
• Date of discharge
• Primary diagnosis code for the admission
• Indication if a member was readmitted within 30 days

All HUSKY Health portal reports include an ICM indicator which details whether a member is or has been enrolled within the CHNCT Intensive Care Management program, or has a case which is pending. This will help providers know whether care coordination services are or have already been provided to a member such that they may decide whether the member should be referred to ICM at that time.

Once you obtain access to your provider portal reports, you will receive notification each time new reports are available to you. This notification indicates that you have a member discharged from an acute care hospital who should be contacted immediately to ensure a follow-up visit within seven days of discharge. A follow-up visit within seven days of discharge has been shown to be the most effective intervention to ensure that your HUSKY Health patients understand their plan of care, have received any necessary medications or medical equipment, and have care coordinated with any specialists they may need to see.

This post-discharge appointment is an opportunity to:

• Follow-up on any results from diagnostic tests pending at the time of discharge; such results may not have been available to the hospital attending physician
• Perform medication reconciliation including the review of any new medications that may have been started, medications that may have been discontinued, and any potential medication interactions
• Educate patients on each medication, the reason for taking each, how to manage the timing of medications, and any dietary restrictions

These activities all help to mitigate the risk of the patient being readmitted.

To access your Daily Admission and Discharge Report and other reports, access your account by going to portal.ct.gov/husky. Click “For Providers,” then “Provider Login” to sign into your account; if you are a new user, create a user name and password. Once you login to your account, you’ll be able to access your reports by clicking “Reports/Data”; if you have not yet requested report access, you’ll be prompted to complete the Request for Report Access form. New requests for report access take a few days to process. When a practice has report access, it will receive notification emails each time new reports are added to its account.

For more detailed instructions on creating your HUSKY Health account and obtaining access to the Provider Portal Reports, please click here or click on “Download the User Registration and Form Completion How To Guide” under “For Technical Support” on the login page.

The majority of data required for HEDIS^® measures is obtained via claims; however, there are some measures that require data collected by medical record review conducted by CHNCT staff.

A compliance audit of results at a plan level is conducted by an NCQA certified HEDIS^® auditor. HEDIS^® data affords a unique opportunity to assess the care provided to the entire Connecticut Medicaid membership as a whole. Details on four of the HEDIS® measures that require medical record review are given below to help providers prepare for 2017 HEDIS^® record collection. For questions about any of the measures presented below, the documentation required, or any other questions you may have about HEDIS^® and record collection, please email quality@chnct.org or call 1.866.317.3301.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CDC measures the percentage of members 18–75 years of age with diabetes (type 1 or type 2) who had each of the following during the measurement year:

In order to meet the requirements of this measure, the medical record must include the following:


1. The most recent HbA1c test during the measurement year including the date the test was performed and the HbA1c lab result
2. Screening or monitoring for diabetic retinopathy demonstrated through one of the following in the medical record:

• A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year
• A chart or photograph of retinal abnormalities taken in the measurement year with a review by an eye care professional (optometrist or ophthalmologist)
• A negative retinal or dilated exam (negative for retinopathy) by an eye care professional (optometrist or ophthalmologist) in the year prior to the measurement year
3. Nephropathy screening or monitoring test or evidence of nephropathy demonstrated through one of the following in the medical record:
• A urine test for albumin or protein with the date the test was performed and the result or finding, spot urine (e.g., urine dipstick or test strip) for albumin or protein
• Documentation of a visit to a nephrologist
• Documentation of a renal transplant
• Documentation of medical attention for any of the following (no restriction on provider type):
• Diabetic nephropathy
• End Stage Renal Disease (ESRD)
• Chronic Renal Failure (CRF)
• Chronic Kidney Disease (CKD)
• Renal insufficiency
• Proteinuria
• Albuminuria
• Renal dysfunction
• Acute Renal Failure (ARF)
• Dialysis, hemodialysis or peritoneal dialysis
• Evidence of ACE inhibitor/ARB therapy
4. Blood pressure control gathered from the most recent BP level (taken during the measurement year) is <140/90 mm Hg, with no restriction on provider type

It’s important for members with diabetes to be educated about staying up-to-date on their annual screenings. This ensure that members are getting appropriate care and will also provide them with the opportunity to work with their healthcare team to improve their quality of life. There is still time to schedule and complete annual screenings for your patients who are still due for 2016!

HEDIS^® includes a measure called Adult BMI Assessment (ABA). ABA measures the percentage of members 18–74 years of age who had an outpatient visit and whose body mass index was documented during the measurement year or the year prior to it.

In order to meet the requirements of this measure, the medical record must include the following:

• For members ages 20 years or older on the date of service for a visit occurring during the measurement year or the year prior to the measurement year, documentation of the member’s weight and BMI value
• For members younger than 20 years on the date of service for a visit occurring during the measurement year or the year prior to the measurement year; documentation of the member’s height, weight, and BMI percentile. The BMI percentile may be documented as a value (e.g., 80th percentile) or plotted on an age-growth chart. Documentation of ranges and thresholds will not meet the requirements for this measure.

Your practice may not require a chart review if an appropriate ICD-10 code is documented on a claim indicating that a BMI assessment was completed with the specified value or percentile.

If you have members scheduled for an outpatient visit who have not had a BMI assessment within the last two years, this assessment should be performed and coded properly. Proper coding using the correct ICD-10 codes for BMI will reduce the amount of chart reviews that are necessary. All assessments completed by December 31, 2016 will be used for this measure.

¹ Catenacci, V., Hill, J., Mitchell, N., Wyatt, H. (2011) Obesity: Overview of an Epidemic. NIH Public Access Author Manuscript. Sourced from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228640/pdf/nihms334812.pdf.

Frequency of Ongoing Prenatal Care Measure

The FPC measures the number of prenatal visits an individual who delivered a live birth had with an OB/GYN, FP, CNM, or a PA/NP working in an obstetric office based on gestational age and the month of the member’s enrollment in the HUSKY Health program. The data is used to calculate percentages of visits completed vs. visits expected. The goal is for members to have completed greater than or equal to 81% of their expected prenatal visits.²

In order to meet the requirements of this measure, the medical record must include the following:

1. The date each prenatal care visit occurred
2. Evidence of one of the following for each visit:
• Physical obstetrical exam that includes one of the following
• Auscultation for fetal heart tone
• Pelvic exam with obstetric observations
• Measurement of fundus height

Note: A standardized prenatal flow sheet may be used for documentation of any of the above

• Evidence that a prenatal care procedure was performed, such as:
• Screening test in the form of an obstetric panel
• TORCH antibody panel
• Rubella antibody/titer with Rh incompatibility blood typing
• Ultrasound (echography) of pregnant uterus
• Documentation of Last Menstrual Period (LMP) or final Estimated Date of Delivery (EDD) in conjunction with one of the following:
• Prenatal risk assessment and counseling/education
• Complete obstetrical history

Note: Final EDD is especially important to accurately calculate gestational age and the number of expected prenatal visits.

All documentation should also include the initials of the MD or CNM/NP who performed the visit. Visits conducted by an RN are not counted as a prenatal visit for meeting HEDIS measure requirements.

Prenatal and Postpartum Care Measure

The PPC measures the timeliness of prenatal care and postpartum care.

The measure, which has two components, focuses on whether individuals who delivered a live birth met the following two criteria when performed by an MD, CNM, or PA/NP who works in an obstetric office:

• Received a prenatal care visit within the first trimester or within 42 days of enrolling in the HUSKY Health program
• Received a postpartum visit within 21 to 56 days after delivery

In order to meet the prenatal portion* of this measure, the medical record must include the following:

1. The date the first prenatal care visit occurred
2. Evidence of one of the following for first visit:
• Physical obstetrical exam including one of the following
• Auscultation for fetal heart tone
• Pelvic exam with obstetric observations
• Measurement of fundus height

Note: A standardized prenatal flow sheet may be used for documentation of any of the above

• Evidence that a prenatal care procedure was performed, such as:
• Screening test in the form of an obstetric panel
• TORCH antibody panel
• Rubella antibody/titer with Rh incompatibility blood typing
• Ultrasound (echography) of pregnant uterus
• Documentation of Last Menstrual Period (LMP) or final Estimated Date of Delivery (EDD) in conjunction with one of the following:
• Prenatal risk assessment and counseling/education
• Complete obstetrical history

Note: Final EDD is especially important to accurately calculate gestational age and the number of expected prenatal visits.

*The documentation requirements for the prenatal portion of the PPC measure match the documentation requirements for the FPC measure.

In order to meet the postpartum portion of this measure, the medical record must include the following:

1. The date the postpartum visit occurred
2. Evidence of one of the following:
• Pelvic exam
• Evaluation of weight and BP with an assessment of breasts and abdomen; a notation of “breastfeeding” is acceptable for an assessment of breasts
• Notation of postpartum care of “PP care,” “PP check,” “6-week check,” or completion of a preprinted postpartum care form

Note: Incision checks done prior to day 21 after delivery do not count as a postpartum visit towards HEDIS^® measure requirements. Delivery date and live birth notation should also be included in the documentation.

The ICM Healthy Beginnings program provides education and support to pregnant individuals through outreach and coaching. A significant goal for Healthy Beginnings is to help make sure members receive their recommended prenatal and postpartum care. To refer members to ICM, please call 1.800.440.5071, extension 2025, or fax a completed ICM Referral Form to 1.866.361.7242. The ICM Referral Form may be downloaded by clicking here or visiting portal.ct.gov/husky. Select “For Providers,” “Provider Bulletins & Forms” then “ICM Referral Form” on the right-hand side of the page

²Technical Specifications for Health Plans, HEDIS 2017 Volume 2 (2016), National Committee for Quality Assurance.

At any time, your practice may request a session with any one of CHNCT’s functional areas:

• Provider Engagement Services – the first line of support for providers who have questions about managing the administrative requirements of HUSKY Health
• Member Engagement Services – CHNCT’s representatives are ready and able to help members and providers access benefits and navigate services
• Intensive Care Management – comprehensive care coordination services provided by CHNCT nurse Care Managers to support members with complex and chronic conditions
• Community Support Services – CHNCT offers Community Health Workers to assess member socioeconomic needs and provide education and coaching to access community resources and care coordination services
• Transitional Care – CHNCT’s Transitional Care nurses provide support to members during and after a hospital admission and following an Emergency Department visit
• Prior Authorization – CHNCT is dedicated to providing timely review of medically necessary services requiring prior authorization; our clinical reviewers and non-clinical staff utilize a person-centered approach to the review process
• Community Practice Transformation – The State of Connecticut offers a unique Person-Centered Medical Home program which both incentivizes primary care practices for their participation and provides consultative know-how from well-versed medical home experts at no cost to the practice, while also improving quality of care
• Medical Economics & Quality Management – CHNCT maintains the highest standard of measurable quality metrics and this department is responsible for data reporting, analysis, and clinical evaluation of health outcomes by implementing provider interventions focused on improving the health of the members that we serve

You’ll be receiving an email with more information about the CHNCT Provider Collaborative. For more information click here or go to portal.ct.gov/husky, click “For Providers” then “Provider News, Trainings & Events,” then “Provider Collaborative.” To leverage the Collaborative for your practice, please call 1.800.440.5071 or email us at provider@chnct.org.

Families in your practice with HUSKY Health benefits may be eligible for Supplemental Nutrition Assistance Program (SNAP) assistance through food stamps, free or reduced-price school meals, summer meals, or the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Unfortunately, these families may not know what programs are available to them or how to access them.

CHNCT recently began an outreach program to families who may be eligible for WIC. Our goal is to help educate members about valuable services, such as nutritional education, breastfeeding support, and supplemental foods that WIC offers. Families can contact 211 or go to http://www.ct.gov/dph/lib/dph/wic_2015/local_agency_list_10_14.pdf to find the WIC office closest to them.

Use the guide below to refer families you serve to needed resources. If your HUSKY Health patients need help accessing services, please call us at 1.800.440.5071 Monday – Friday, 8 a.m – 6 p.m to refer them for assistance. HUSKY Health is here to help members be as healthy as they can be; ensuring that immediate and basic needs are met is a critical component to member health and well-being.

² Released by the Connecticut Food Bank and Feeding America http://map.feedingamerica.org/county/2014/child/connecticut

Food Resources

Program	How Does This Help	How To Access
SNAP (food stamps)	Helps income eligible families with the cost of food in grocery stores and farmers’ markets	Local DSS Regional Office or https://www.connect.ct.gov/access/jsp/access/Home.jsp, or call End Hunger CT!’s SNAP Call Center for prescreening and SNAP application assistance at 1.866.974.SNAP (7627) or go online at http://www.endhungerct.org/snap/
Free or Reduced School Meals	Provides breakfast, lunch, and/or after-school snacks to children of income eligible families with children in schools and residential childcare institutions	Children whose families are receiving SNAP are automatically eligible for free school meals and are directly certified upon acceptance of their applications at DSS. Benefits are accessed through individual schools. Application forms are sent home at the beginning of each school year. Forms may be requested from the school at any time throughout the school year. Caregivers should contact their child’s school directly.
Summer Meals for Children	Provides meals to children 18 and under when school is out at approved Summer Food Service Program Sites	Find a participating site by location at http://www.endhungerct.org/summer-meals/
WIC	Provides supplemental food and services to pregnant individuals and their children to age 5 (the date of the youngest child’s 5th birthday)	Call 211 or apply at a local WIC agency. For a list of WIC agencies, go to http://www.ct.gov/dph/lib/dph/wic_2015/local_agency_list_10_14.pdf
Food Pantry	Provides supplemental food onsite	For a list of food pantry locations in Connecticut, go to http://www.ctfoodbank.org/get-help/pantry-locator/
Mobile Pantry	Trucks distribute supplemental food to families in need in areas without ready access to static food pantry locations. Mobile Pantry trucks serve all counties within Connecticut.	For a list of current locations with distribution dates and times, go to http://www.ctfoodbank.org/get-help/programs/connecticut-food-banks-mobile-pantry-schedule/
Mobile Food Share	Trucks distribute perishable foods to people in need. Mobile Food Share trucks serves locations throughout Hartford and Tolland Counties.	For a list of locations, go to http://site.foodshare.org/site/PageServer?pagename=help_mobile

Providers may refer members to ICM for this Hepatitis C outreach program upon prescribing the anti-viral medication to help speed member access to these care coordination services; please call 1.800.440.5071, extension 2025, or fax a completed ICM Referral Form to 1.866.361.7242. The ICM Referral Form may be downloaded by clicking here or visiting portal.ct.gov/husky. Select “For Providers,” “Provider Bulletins & Forms” then “ICM Referral Form” on the right-hand side of the page.

Upon identification of members with Hepatitis C through provider referral or claims data, ICM nurses will contact members to complete an assessment. For this program, the ICM assessment will focus on supporting members with following their medication instructions, completing the recommended lab work and following up with their PCPs. During the initial call with a member, an ICM nurse will explain the program and ask if the member wants to participate. Upon member acceptance of participation in the ICM Hepatitis program, the ICM nurse will call the member every two weeks to assess his or her participation with taking the anti-viral medication as prescribed and will help ensure appropriate follow-up care. Our ICM nurses are dedicated to managing any barriers to care members may face while undergoing treatment for Hepatitis C. Education with regard to both medications and reinfection along with help to make medical appointments, fill prescriptions and get to and from appointments will all be addressed by ICM nurses through dedicated coaching and follow-up.

Because practices can help bring ICM services to members with Hepatitis C through referral upon the start of medication therapy, ICM will also be contacting many provider practices directly to provide education and materials in support of this initiative. The ICM team will be partnering with as many practices as they can to promote this initiative to ensure that members with Hepatitis C are offered care coordination services as early in their treatment as possible. Provider brochures and member handouts will be distributed to help remind you of available services and to encourage member acceptance of ICM care coordination to assist members with their completion of their medication therapy.

By partnering together to help our members with Hepatitis C, we can achieve better outcomes.