Table of Contents

Best Practice: Peninsula Regional Medical Center's PEARLS Program
2002 Immunization Recommendations
NCQA Validates CareFirst's Commitment to Quality
Recent Literature on Cardiovascular Disease, Cancer, Diabetes, Asthma and Over-the-Counter Remedies
Behavioral Health: Challenges of Diagnosing Children and Adolescents with ADHD
Recognizing ADHD Symptoms: Snap-IV Rating Scale (Adapted)
Care Management Meets Individual Health Care Needs
Care Team Disease Management Programs
Philosophy of Care

Peninsula Regional Medical Center’s PEARLS Program

The following is presented in an effort to highlight hospital “best practice” around the region. CareFirst BlueCross BlueShield (CareFirst) wants to share with you the innovative ways in which Maryland, Virginia and Washington, D.C., hospitals are improving quality of care while controlling the rising cost of health care. Look for additional “best practice” features in future issues of HealthInk.

Named for “pearls of wisdom,” PEARLS is Peninsula Regional Medical Center’s (PRMC’s) monthly newsletter aimed at identifying opportunities for care efficiencies among DRGs with especially high denial rates. Created by a subcommittee of the hospital’s Resource Management Improvement Team, each one-page issue tackles a top denial-generating DRG by presenting clinical guidelines, including admission criteria, outpatient care alternatives, length of stay recommendations and documentation requirements. Now in its fourth year, PEARLS has gained national recognition for the Salisbury, Md., hospital.

PRMC’s Resource Management Improvement Team was designed as a much-needed forum for a dialogue between areas like UR and Patient Care Management looking to reconcile quality of care with denials. To determine the most effective way to present their ideas to the hospital’s physicians, the team surveyed doctors from all departments and was asked for a monthly, one-page newsletter. The PEARLS committee was thereby formed and consists of Clinical Quality Improvement Support Director Donna Thompson, R.N., B.S.N.; Patient Information Director Gwyn Kravec; Patient Care Management Director Sharon Robbins; Utilization Review specialist for denials and appeals Marygrace Ellis; PRMC hospitalist Rob Coker, D.O.; Finance representatives as needed; and physician advisor to Patient Care Management Chris Snyder, D.O., whose tireless championing of PEARLS to his colleagues throughout the hospital is reportedly responsible for the program’s launch.

In its first months, the team set out to identify the hospital’s top 15 denied DRGs. Many denials were coming from strokes, so the team pulled 10 random charts to derive denial clues.

“We found that some patients were being admitted without meeting established criteria,” says Ms. Thompson. “In other cases, medically appropriate services were not being documented to our payors’ satisfaction.” These findings led the PEARLS team toward compiling what they call “Points to Remember:” brief clinical recommendations and documentation reminders for a particular DRG focused on utilizing the most appropriate care for each patient. “Points to Remember” are aimed at helping the hospital stay within goal length of stay guidelines,” says Ms. Thompson. For example, PEARLS’ “Points to Remember” on pneumonia reminds physicians that according to the American Thoracic Society Guidelines, “… the decision to hospitalize is not necessarily a commitment to long-term patient care. Rather, it is a decision that certain patients should be observed closely until it is clear that their infection is responding to therapy” and should be moved to a lower level of care at that time.

“Points to Remember” also are aimed at encouraging accurate and complete charting of a patient’s condition, including comorbidities, which helps the hospital and payors alike. Documentation that adequately captures a patient’s severity and disease complexities can better help an insurer like CareFirst identify intervention opportunities.

Each PEARLS newsletter is a one-page overview of PRMC’s current denial rates and length of stay compared to the state average; length of stay and documentation guidelines from InterQual (now PEARLS’ primary review criteria), Milliman and Robertson’s (M&R) or another widely accepted guideline for that DRG; and “Points to Remember” compiled by the PEARLS team.

The PEARLS team developed a newsletter for each of the 15 top-denied DRGs in its first year-and-a-half covering DRGs like pneumonia, chest pain and unstable angina. At the request of its doctors, PEARLS also has addressed non-DRG topics, including compliance, blood loss anemia and breast cancer screening and diagnosis. The PEARLS team looks for ways to measure efficiencies in these and similar categories for which there are no denied days. For example, MRI numbers were used in a PEARLS issue on low back pain to help target the hospital’s high utilization of these tests.

The team also produces PEARLS “remeasures”— a yearly progress report on a previously covered DRG. These remeasures graph denied days improvement data along with a “Points to Remember” refresher and any new guidelines. The PEARLS remeasure for pneumonia, for example, illustrated PRMC’s drop from the previous year’s 89 denied days to just 29. “Our doctors love to see the improvements,” says Ms. Thompson.

PEARLS helped PRMC’s Patient Care Management department realize a 34 percent decrease in denial dollars over two years and has been recognized by the Advisory Board Company of Washington, D.C., as a Top 20 innovative idea in denials management. PRMC has sold PEARLS on CD-ROM to almost a dozen hospitals around the country, including Johns Hopkins Bayview Medical Center in Baltimore and St. Vincent’s Hospital in New York City (known most recently for treating scores of victims of the Sept. 11 tragedy). St. Vincent’s director of Case Management, Toni Cesta, Ph.D., recently requested PRMC’s permission to reproduce a PEARLS tool in the upcoming second edition of her book The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice.

For more information or to purchase the PEARLS program, call Donna Thompson at 410-543-7740.

2002 Immunization Recommendations

The American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and the American Academy of Family Physicians (AAFP) issued their annual “Recommended Childhood Immunization Schedule for 2002” earlier this year. The 2002 schedule charts the recommended time frames for routine administration of currently licensed* vaccines for children through age 18.

*as of Dec. 1, 2001

Key Changes

No major changes have been made regarding specific vaccines since the publication of the 2001 schedule. However, the 2002 schedule has been redesigned to depict the use of catch-up routines for children and adolescents who fall behind or start their immunizations late (see yellow shaded areas). The schedule also graphically emphasizes the immunization needs of the preadolescent patient (see purple shaded areas).

In the early 1990s, programs established to promote hepatitis B immunization for infants and young children eventually resulted in significantly improved immunization rates for these groups. As a result, the 2002 schedule encourages the routine use of hepatitis B vaccine for all infants before hospital discharge to:

• Safeguard against maternal hepatitis B testing errors and testing reporting failures.
• Protect neonates discharged to households in which hepatitis B-chronic carriers other than the mother may reside.
• Enhance the completion of the childhood immunizations series.

Clinical Management

A May 2001 national survey indicated that only 21 percent of the responding physicians used immunization tracking and immunization recall systems. To help practitioners and their staff assess needed vaccinations at each office visit (and thereby reduce missed opportunities), the 2002 schedule places children and preadolescents into identifiable categories for quick reference.

It is important to keep in mind that during 2002, new vaccine recommendations may be made, changes in vaccine availability may occur and other vaccine products may be approved by the Food and Drug Administration (FDA). This year’s recommendations also are accompanied by caveats concerning certain vaccines in light of current national shortages. A thorough overview of the 2002 schedule is available in the CDC’s Morbidity and Mortality Weekly Report.

CareFirst BlueCross BlueShield (CareFirst) updates its own “Recommended Childhood Immunization Schedule” annually to reflect any changes made to the AAP, ACIP, CDC and AAFP schedule.

*These vaccines are recommended for selected populations only.

Adapted from "Recommended Childhood Immunization Schedule — United States, 2002"

NCQA Validates CareFirst’s Commitment to Quality

In January, CareFirst BlueChoice, CareFirst’s new subsidiary HMO, and BluePreferred, a CareFirst PPO plan, received the National Committee for Quality Assurance’s (NCQA’s) highest accreditations following a rigorous and voluntary review process conducted in December 2001.

BlueChoice earned “Excellent” accreditation, NCQA’s highest level of HMO accreditation. BluePreferred was granted "Full" accreditation, the highest level for PPOs. Significant achievements for both plans, these accreditation levels are only awarded to plans that meet or exceed NCQA’s exacting standards and have excellent programs for continuous quality improvement.

NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. The various standards and performance measures that make up NCQA’s accreditation program fall into the following six categories:

• Quality Improvement
• Utilization Management
• Physician Credentialing
• Members’ Rights and Responsibilities
• Preventive Health Services
• Medical Records

NCQA President Margaret E. O’Kane says “earning ‘Excellent’ accreditation reflects a health plan’s ability to work with its members and physicians to improve the quality of clinical care. It shows that they are building the kinds of partnerships that are critical to delivering great care and great service.” CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. extend their appreciation to all network physicians for their outstanding quality of care and their continuing commitment to the CareFirst Quality Improvement programs.

Recent Literature on Cardiovascular Disease, Cancer, Diabetes, Asthma and Over-the-Counter Remedies

By T.A. Dadisman, M.D., medical director, Preventive Medicine

This article is intended to call your attention to recent information you may have missed on management of cardiovascular disease, cancer, diabetes and asthma, along with some recent literature on issues concerning over-the-counter remedies.

Challenges of Diagnosing Children and Adolescents With ADHD

The Three Faces of ADHD

Attention-deficit hyperactivity disorder (ADHD) is one of the most common behavioral health diagnoses of children and yet one of the most complex. Affecting as many as one in every 20 school-age children, this long-lasting disorder occurs three times as often in boys as in girls until late adolescence when the male to female ratio becomes equal.

ADHD can masquerade in three different forms. One can be viewed as the quiet version (inattentive); another, the noisy version (hyperactive); and the third, a mixture of symptoms. All three versions have significant long-term consequences if not identified and treated at an early age. Symptoms often are demonstrated by the age of 7. Girls with ADHD, as well as both girls and boys with predominantly inattentive-only symptoms, are prone to late or even missed diagnosis.

By recognizing the implications of the hyperactive, inattentive and combined sets of symptoms, clinicians can play an early and critical role in helping affected children and their families.

For some children, ADHD manifests itself as loud and disruptive outbursts, hyperactivity with restlessness and impulsive behavior. For others, their symptoms are much quieter: inattentiveness to detail, difficulty organizing tasks and an inability to follow instructions. Many factors must be considered by clinicians to make a firm diagnosis of ADHD and to recommend the best treatment regimen for each child.

The stress ADHD can bring to families is significant and often contributes to other difficulties within the home. Individualized treatment and teamwork among health providers, parents and teachers can help children with ADHD to learn, thrive and ultimately become successfully functioning adults.

Etiology

ADHD crosses all races and socioeconomic classes. Its etiology is multifactorial. Genetics play a role, as siblings of children with ADHD are five times more likely to develop ADHD than siblings of children in families without ADHD. Metabolic dysfunction of the noradrenergic and dopaminergic systems is involved. Toxic substance exposures, such as fetal exposure to tobacco smoke during pregnancy, as well as prenatal and perinatal events, also may play a role.

Recognizing ADHD Symptoms

Complicating the diagnostic process is the fact that up to 50 percent of children with ADHD also have other complex disorders. These often include oppositional defiant disorders, anxiety disorders, major depression and learning disorders. As they grow older, a subset of children with ADHD also is more prone to developing substance use problems. Diagnosis also is difficult because children with ADHD may have normal or above average intelligence, which causes them to overcompensate for their disorder. This intelligence also can increase their frustration in coping with their disorder. Early diagnosis of children with ADHD, however difficult, is critical. Recognizing the inattentive and the hyperactive/impulsivity criteria sets of the disorder will assist you in that effort.

Symptoms of ADHD With Inattention Dominant

To make a diagnosis of inattentive ADHD, six or more of the following symptoms need to have persisted for at least six months to a degree that is problematic and inconsistent with a child’s developmental level.

• A lack of attention to detail, demonstrated in careless mistakes in schoolwork or other activities
• Difficulty sustaining attention in tasks or play activities
• Poor listening skills
• Difficulty in following instructions and failure to finish schoolwork
• Difficulty organizing tasks
• Forgetfulness in daily activities
• A tendency to lose things necessary for tasks
• Avoidance of tasks requiring sustained mental effort
• A tendency to be easily distracted by extraneous stimuli

Symptoms of ADHD With Hyperactivity/Impulsivity Dominant

To make a diagnosis of hyperactive ADHD, six or more of these symptoms need to have persisted for at least six months to a degree that is problematic and inconsistent with a child’s developmental level.

• Frequent fidgeting or squirming while seated
• Jumping from seat when remaining seated is expected
• Running about or climbing in inappropriate places
• An inability to play quietly, alone or with others
• Excessive talking
• Impulsivity
• Blurting out answers before questions are completed
• Difficulty awaiting turn
• A tendency to interrupt or intrude on others

A rating scale based on the above criteria sets has been adapted from the SNAP-IV (Swanson, Nolan and Pelham) Questionnaire. This 18-item tool uses DSM-IV criteria and has demonstrated validity in differentiating children who have ADHD from children without this disorder. This questionnaire is to be completed by the child’s parent. The first nine items form a subscale of inattention and the second nine form a subscale of hyperactivity/impulsivity. A positive screen is indicated when three or more items in either subscale are scored at two or higher and/or when either subscale's average item score is greater than one.

Components of a Thorough Diagnosis

Because ADHD is a complex disorder, diagnosis is ideally a team process involving the child’s school and family and often more than the child’s primary care provider.

There are several key components to making an accurate diagnosis of ADHD:
• Thorough physical exam, including hearing and vision testing, to note any physical illnesses or conditions that might contribute to the child’s problems
• Careful evaluation of memory, motor, listening and speaking abilities
• Consultation with teachers regarding academic difficulties, classroom behavior and interpersonal behavior with peers using rating scales as one tool to standardize feedback
• Consideration of the family’s structure, physical history and any special problems that could explain the child’s behavioral difficulties

Treatment: Diverse and Complex

Both medical and behavioral health interventions contribute to the successful long-term treatment of ADHD. Behavioral and family therapy, with the addition of educational aids and psychological support, can assist the ADHD child in becoming a successfully functioning adult. These interventions also help prevent the serious long-term problems that can develop and persist into adulthood, including depression, substance use, employment difficulties and relationship problems.

Medication Interventions

Stimulants are the most commonly used medications for ADHD treatment and target the ability to focus and reduce hyperactive and/or aggressive behavior. The ultimate goal of medication titration is finding the right individualized dosage of medication that “normalizes” the child’s behavior. Other agents include tricyclic antidepressants and buproprion.

Behavioral Interventions

Behavioral interventions reward “good” behavior and track this behavior through daily cross reporting of teachers and parents on the child’s school and home activities. Special classrooms designed to reduce extraneous stimuli can help the child, as can special programs provided outside normal school hours. Making sure that teachers and aides are trained in the challenges of ADHD also will benefit the child’s performance.

Research is continuing on ADHD treatment options and the short-term vs. long-term effectiveness of various approaches. The family, school and health care provider team all play critical roles in a child’s successful and continually evolving plan of care.

For More Information on ADHD

Multiple practice guidelines for the evaluation and treatment of ADHD are available, including:

American Academy of Child & Adolescent Psychiatry Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults With Attention-Deficit Hyperactivity Disorder (1997)

National Institute of Mental Health Consensus Statement on Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder (1998)

Prevalence and Assessment of Attention-Deficit Hyperactivity Disorder in Primary Care Settings. American Academy of Pediatrics, Pediatrics, Vol. 107, No. 3, March 2001, pp. 1-11

Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit Hyperactivity Disorder. Pediatrics, Vol. 105, No. 5, May 2000, pp. 1158-1170

Clinical Practice Guideline: Treatment of the School-Age Child With Attention-Deficit Hyperactivity Disorder. Pediatrics, Vol. 108, No. 4, October 2001, pp. 1033-1044

Multimodal Treatment Study of Children With ADHD. Archives of General Psychiatry 1999; 56 (12): 1073-1086

If you are currently treating any children or adolescents for ADHD, you also may want to make parents aware of Web resources like www.chadd.org and www.add.org.

SNAP-IV RATING SCALE (ADAPTED)

Child's name ________________________________ Child's age____________________

Adapted from the SNAP-IV Teacher and Parent Rating Scale
James M. Swanson, Ph.D., University of California, Irvine, CA 92715

Care Management Meets Individual Health Care Needs

CareFirst’s Care Management program is designed to meet the individual health care needs of patients with complex conditions using available plan benefits. The program includes case management, which is a collaborative process involving the patient’s physician and an assigned CareFirst case manager (a registered nurse) who can help assess, plan, implement, coordinate, monitor and evaluate options and services for members with complex health care needs.

Complex cases are those that require coordination of multidisciplinary services, monitoring and assessment. Examples include high-risk obstetrics, neuromuscular disease, CVA, COPD, CHF, asthma, rehabilitation, wound care, oncology and diabetes. The Care Management case manager will collaborate with you and the rest of the patient’s health care team to ensure that your plan of care is implemented and make certain that the member’s complex needs are met with the necessary care. The same case manager is the lead coordinator of special care needs and follows your patient throughout the continuum of care, including inpatient, alternative inpatient, outpatient and home health care settings. The case manager will contact and update you on a regular basis. To augment the telephonic case management process, the case manager also may visit the patient in acute or alternative settings, at home or in your office and may attend health care team meetings as needed. Our case managers also can assist members in finding available community resources.

To refer a patient to Case Management, call one of the following numbers:

CareFirst BlueChoice HMO and CareFirst BlueCross BlueShield Indemnity members:
410-605-2623 or 888-264-8648

FreeState Health Plan members: 410-605-2413 or 888-264-8648.

Care Team Disease Management Programs

Our Care Team disease management programs are designed to provide eligible members who have asthma, diabetes, heart disease or cancer with access to an experienced registered nurse who can help coordinate and reinforce their plan of care, answer their questions and monitor their progress. Participation is voluntary and confidential and is offered at no additional cost.

Patients enrolled in our asthma, diabetes and heart disease programs receive a packet of educational materials and regular disease-specific newsletters aimed at helping them better understand and manage their condition.

To enroll patients who have diabetes, coronary artery disease or congestive heart failure, call Health Management Corporation at 800-783-4582.

To enroll patients over 18 years of age who are undergoing active treatment for cancer, call Quality Oncology at 888-245-5407.

To enroll patients who have asthma, call our Quality Improvement Department at 800-323-4472.

Philosophy of Care

We represent a philosophy of health care that emphasizes active partnerships between patients and their physicians. We believe that comprehensive health care is best provided by networks of health care professionals who are willing to be held accountable for the satisfaction of their patients and the quality of their services. We are committed to high standards of quality and professional ethics and to the principle that patients come first.

We believe that patients should have the right care, at the right time and in the right setting. This includes preventive care, as well as comprehensive care for acute and chronic illness — at home, at the doctor’s office and in the hospital.

We believe that all health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.

We believe that patients should have a choice within their health plans of physicians who meet high standards of professional training and experience, and that informed choice and the freedom to change physicians are essential to building active partnerships between patients and doctors.

We believe that health care decisions should be the shared responsibility of patients, their families and health care professionals, and we encourage physicians to share information with patients on their treatment options, medical conditions and health status.

We believe that consumers have a right to information about health plans and how they work. We believe that working with people to keep them healthy is as important as making them well.

We value prevention as a key component of comprehensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.

We believe that access to comprehensive, affordable care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.

Adapted from the American Association of Health Plans

CareFirst’s Mission

CareFirst shall be the leading regional health care company recognized for a comprehensive portfolio of high-quality, innovative products and administrative services. Our purpose is to provide the best value to our customers in partnership with the health care community and in an environment that promotes respect, fairness and opportunity for our associates.

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