Issue link: https://www.e-digitaleditions.com/i/66539
(continued from last page) knee, and he is scheduled for yet another knee surgery soon. Not only does Sam suffer from pain and mobility issues on a daily basis, he also has depression and anxiety which are often present in patients with chronic pain, and this com- pounds his daily struggles. This member was identified for the Right Choices Program by his health plan due to the use of mul- tiple providers, multiple pharma- cies and over use of the Emergency Room. Jacob worked with Sam to educate him about using only the approved providers on the RCP list, and he was able to change Sam's sole pharmacy provider to one that was closer to his house. Jacob also worked with the primary care pro- vider's office to add specialists to the list of approved providers so that Sam could get the needed care for his knee pain and depression. During the past few months, Ja- cob has developed a good relation- ship with Sam, which Sam seems to like a lot. Jacob calls to check in with him, and continues to be sure that Sam's medical needs are met. Sam has been following his plan of care and has stayed in network for the past three months, and that is a huge change in his behavior. Sam told Ja- cob that he really feels like someone is looking out for him, because Ja- cob isn't just calling him to work on a problem. He just seems to care what happens to him. While providing care management services for RCP members at times is very consuming and challeng- ing, Jacob will tell you that working with members like Sam, gives him a sense of professional fulfillment. It reminds him of why he became a nurse in the first place: for the joy of building a helpful and healing rela- tionship that allows another person be lifted up to better care for him- self. And that's what Jacob's daily mission is all about. A care manager is available for each health plan we work with at CMCS. Preparing for Health Care Reform Like many health care organizations, CMCS is actively preparing for changes expected from Health Care Reform. CMCS assesses readiness in three principal areas: Regulatory Readiness, System Analytics, and System Performance and Ef- ficiency. The following diagram illustrates CMCS approach to "Readiness for Health Care Reform." Regulatory Compliance CMCS's applications are ICD-10 and 5010 compliant. Work groups are re- viewing medical policy, benefit configuration and operational work flows that are impacted by these new requirements. System Analytics CMCS has expanded its scope of services to address population health man- agement. New applications with enhanced analytics licensed from MEDai and our proprietary care management application provides the platform for risk stratification, monitoring utilization and measuring clinical and financial outcomes. These applications support collection of quality data that can be provided to our networks, network providers, and health plans to identify im- provement opportunities that address NCQA quality goals. System Performance and Efficiency Investments have been made in system applications that will support new ini- tiatives in Health Care Reform. Examples of new system functionality include: bundled payment methodologies, enhanced editing, support of value-based benefit designs and development of more efficient ways to disseminate data and health information to plans, providers and members. In addition to systems preparedness, CMCS has created a data analytic team to support reporting needs of our customers. CMCS's systems infrastructure combined with its operational experience in commercial and government- sponsored programs, provides a solid foundation to meet the upcoming challenges in the health care industry. ADA Standards of Care for Members with Diabetes N A quick reference guide (see next page) for providers by Linda Grosser, RN, CNP CQA, the National Committee for Quality Assurance, is the accrediting organization for Managed Care En- tities. The Healthcare Effectiveness and Data Information Set known as HEDIS® is the name of the qual- ity measures established by NCQA. Consumers and employers can use HEDIS® data to help select the best health plan. Many health plans focus on LDL-C scores, to indicate whether or not members with diabetes are receiving the care they need. The NCQA 90th% tile for this quality measure is 85.2%. The HEDIS® Comprehensive Diabetes Care (CDC) quality measure applies to members who are 18-75 years old. Standards of care for diabetes are published by the American Diabetes Associa- tion (ADA) and are summarized in the table on the next page as a quick reference guide for provid- ers. The complete ADA standards of care can be found at: http://care.diabetesjournals.org/ content/35/Supplement_1/S11.full CMCS connections 3 2nd qu arter 2012