Module 6: Using Form CMS-416 Dental Data

Module 6: Using Form CMS-416 Dental Data


Welcome to Module 6, a review of using Form CMS-416 Dental Data. This module is part of the CMS web-based training for Form CMS-416 Dental Data Reporting. Please visit the CMS Web-Based Training homepage at Medicaid.gov to find links to modules covering additional topics. There, you will also find a document that contains links to all the resources mentioned in this module. For questions about the Form CMS-416 or the Oral Health Initiative, you can access the complete Form CMS-416 reporting instructions on the Early and Periodic Screening, Diagnostic, and Treatment page at Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected] This module will cover several learning objectives and additional content related to Form CMS-416 Dental Data. After completing this module: You will understand how Form CMS-416 dental and oral health data are used to track progress on the CMS Oral Health Initiative. You will know the basic steps of a quality improvement (or QI) project and how to access additional resources to support improvement in delivering quality dental and oral health services. And you will also understand how states have used Form CMS-416 data in oral health QI projects. The content covered in this module includes: The Oral Health Initiative and its relationship to Form CMS-416 data. The Principles and methods of QI. And examples of state initiatives to improve oral health quality and access. What is the CMS Oral Health Initiative and why is it important? Here’s some context: In 2010, CMS launched the Oral Health Initiative (or OHI) to address a critical gap in children’s health: Tooth decay remains one of the most common chronic childhood diseases, causing pain, loss of school days, infections, and even death. But despite recent improvements, fewer than half of children enrolled in Medicaid are receiving at least one preventive dental service in a year, and there remains a wide variation across states. The focus of the CMS Oral Health Initiative is to increase access to dental and oral health services for children enrolled in Medicaid and CHIP, with a specific focus on prevention. Our goal is to increase by ten percentage points the proportion of enrolled children, between the ages of 1 and 20, who receive a preventive dental service in a year. This is our national goal. To achieve this goal, we need to see progress in every state. So every state also has a goal of increasing the delivery of preventive dental services by ten percentage points. CMS is committed to increasing access to dental services for children enrolled in Medicaid and CHIP. For more information on the Oral Health Initiative, please visit the Dental Care page at Medicaid.gov. Additional information on childhood tooth decay, and policy approaches to combatting it, is available from the Children’s Dental Health Project at cdhp.org. The data from Form CMS-416 is at the core of the Oral Health Initiative. CMS uses data reported on the Form CMS-416 to track improvement on the Oral Health Initiative goal. Specifically, we use the data reported on Line 12b, preventive dental services. Let’s look at the chart on the right to better understand the goal, and how we use Form CMS-416 data to track progress. CMS set the baselines for the Oral Health Initiative using federal fiscal year (or FFY) 2011 data. In FFY 2011, on a national level, 42 percent of children between the ages of 1 and 20 received at least one preventive dental service. Since our goal is to improve that by ten percentage points, the goal is to reach 52 percent of children. Our initial target date was FFY 2015, but since we didn’t quite reach the goal by that date the effort is continuing. You may be wondering what we consider to be a “preventive dental service.” Preventive services include cleanings, sealants and fluoride treatments. They do not include exams or x-rays, which are considered to be diagnostic services. So the Oral Health Initiative is one way we use the data on the Form CMS-416 to track progress and improve performance. But the data on all of the dental lines, specifically Lines 12a through 12g, can be used by states and CMS to track progress related to children’s oral health. Now let’s take a look at exactly how the data on Form CMS-416 is used to compute progress on the Oral Health Initiative preventive dental services goal. As I mentioned, the goal is to increase by ten percentage points the percentage of children ages 1 to 20 enrolled in Medicaid that received a preventive dental service. As we’ve learned in previous modules, only children who have been enrolled for at least 90 continuous days are included in the reporting on the dental lines of the Form CMS-416. Thus, our metric is limited to those children. Because CMS believes that this metric is an important indicator of the strength of a state Medicaid program, it has been included in the Child Core Set of quality measures. In that measure set, it has been given the label PDENT, to stand for “preventive dental services.” Now let’s review the formula for calculating PDENT using the Form CMS-416 data. To calculate PDENT, we use data from two lines on the form: Line 1b – the number of children enrolled for at least 90 continuous days; and Line 12b – the number of children enrolled for at least 90 continuous days who received a preventive dental service. Since PDENT considers only children ages 1 to 20, we first need to subtract out the children in the “under 1” age bracket from the total. We have to do this both for line 1b and line 12b. Next we do the division. PDENT is calculated by taking the total number of children ages one to twenty in Line 12b and dividing that by the total number of children ages one to twenty in Line 1b. The result is the proportion of all children ages 1 to 20 enrolled for at least 90 continuous days who received a preventive dental service. Find more information in the Dental Services Excerpt from the 2014 Secretary’s Annual Report on the Quality of Care for Children in Medicaid and CHIP, available in the Use of Dental Services in Medicaid and CHIP report at Medicaid.gov. Additional information on the Child Core Set is also available on the CHIPRA Initial Core Set of Children’s Health Care Quality Measures page at Medicaid.gov. CMS uses additional metrics to understand how states are performing on children’s oral health. For example, we look at the rate at which sealants are placed on children’s permanent molars. Sealants are one of the most effective preventive measures for children’s oral health. Dental Sealants for 6 to 9 Year Old Children at Elevated Caries Risk was added to the Child Core Set in 2015. This measure reflects the percentage of enrolled children in the age category of 6 to 9 years who are at “elevated” risk for developing tooth decay, or caries, and who received a sealant on a permanent first molar tooth within the reporting year. To learn how this measure differentiates children at elevated risk for developing caries, you can consult the measure specification available on the child core set page on Medicaid.gov. Since this sealant measure is relatively new in the Child Core Set, there were no baselines or results to display at the time this video was made. However, we did want to share with you some data on the placement of sealants in children. The chart on the right, entitled Healthy People 2020 Baseline and Target, depicts the percentage of all children in the United States, regardless of type of dental coverage, ages 6 to 9, receiving a dental sealant on a permanent first molar. Data used to make this chart is from the National Health and Nutrition Examination Survey and is available from the Centers for Disease Control and Prevention- National Center for Health Statistics. As you can see, during the baseline period of 1999 to 2004, 25.5 percent of children aged 6 to 9 received dental sealants on a permanent first molar. The Healthy People 2020 target is to increase this to 28.1 percent. Additional information on the Child Core Set is available on the CHIPRA Initial Core Set of Children’s Health Care Quality Measures page at Medicaid.gov. Shifting from how CMS and states can use the Form CMS-416 data to measure progress and drive improvement, now, let’s talk about what quality improvement is and how to achieve it. We begin by presenting a particular framework for quality improvement called The Model for Improvement. This Model was developed by the Institute for Healthcare Improvement. The Model for Improvement provides a structure for designing and implementing quality improvement (or QI) projects. On the left side of the slide, you will see a graphic showing the components of The Model for Improvement. There are three questions and the Plan-Do-Study-Act (or PDSA) cycle. Together, these are the building blocks of a strong QI project. Now let’s walk through each of the three questions and the PDSA cycle. The first of the three questions is What are we trying to accomplish? Answering this question will help your team articulate where you want to be. The second question is How will we know that a change is an improvement? Answering this question will help you measure your progress toward where you want to be. And finally the third question is What change can we make that will result in improvement? Answering this question will help your team identify and support the policies or practices that will drive improvement. Now, let’s go over the 4 steps of the PDSA cycle. First, we start with Plan. This involves selecting and planning for a small test of change. In the next step, Do, you carry out a test of the change. In the third step, Study, you Study data before and after the test of the change and reflect on what was learned. And in the last step of the cycle, Act, you plan the next change cycle or scale up the current change into implementation. Once all four steps have been completed, the cycle begins again. This graphic representation of The Model for Improvement and PDSA cycle was developed by Associates in Process Improvement. Let’s dive deeper into the PDSA Cycle and walk through an example. Just to review: the PDSA Cycle is a core QI process that consists of four steps: PLAN the change to be tested. DO a test of the change. STUDY data before and after the test of the change and reflect on what was learned. And finally ACT to plan the next change cycle or scale up the current change to implementation. Once all four steps have been completed, the cycle begins again. Now, let’s look at each step and how a state Medicaid agency might use them for a Quality Improvement project to increase the utilization of dental services. In the Plan step, an agency decides to encourage improvement in the proportion of children who receive a preventive dental service. The agency collaborates with stakeholders to develop a small test of change. Let’s say it is to test a new payment model that provides incentives to participating dental providers in a high-need part of the state. In the second step, Do, the agency takes all the necessary steps to implement the small test of change they have planned with stakeholders. In the third step, Study, the agency examines its claims data to see whether dental utilization has improved, and partners with community groups to survey enrollees about whether they have experienced an improvement in accessibility to dental services. And in the last step in the cycle, Act, the agency revises the payment model based on the results of the Study step, develops corresponding educational materials, and expands the intervention to a broader network of providers for another round of testing. Data play a central role in any Quality Improvement project. Let’s look at the Model for Improvement and how data can be used with each of the three questions and in each step of the PDSA cycle. In the Model for Improvement, the first question we want to ask is What are we trying to accomplish? Data can point to gaps in quality to help you target an area for improvement. Also, you will want to choose an objective, or goal, for your Quality Improvement project that you can measure and track with data you have or can acquire. The next question is how will we know that a change is an improvement? You can use multiple forms of data to capture information about performance on your QI objective before and after you implement an intervention to learn about its impact. And finally, what change can we make that will result in improvement? Data can help you spot drivers of quality that you can leverage when selecting a change that will improve performance in your targeted area. Now, let’s review how you can use data within the PDSA cycle. Under the first step, Plan, you can use data to plan a test of change, including a target population, an intervention, and a measurement strategy. You also set your baselines and your improvement goals. Next, in the Do step, you start to implement your test. As you implement your test of change, you can collect qualitative and quantitative data to help you evaluate the implementation of your intervention. The third step is to Study. In this step, you will study the data before the test of change and evaluate the data collected during the test to see whether the change is having the desired effect, as well as whether there are any unintended consequences of the change. And the last step in the cycle is to Act. In this step, you will share what you learned with key stakeholders to gain insight into how to adapt your QI strategy for subsequent tests of change. And remember, once all four steps have been completed the cycle begins again. Now let’s consider how the data from the Form CMS-416 can be used for quality improvement. The dental data on the Form CMS-416 is aggregated annually and at the state level. Such aggregated data can be especially helpful when your team is examining the big picture, but it can be challenging to use to demonstrate change in small tests because of the length of time between collections. Project teams may find it useful to identify additional data sources, such as monthly reports from claims systems, that can be used for the rapid-cycle evaluation required in a PDSA process. Here are some helpful tips to keep in mind. In QI, simple and useful measures are more important than perfect measures. Focus on selecting measures that will help you learn. Qualitative data can be used as a leading indicator; it is available before quantitative data and can serve as an early herald, telling you what patients, providers, staff, and other stakeholders are saying about the test of change that is underway. And finally, consider how you’ll track whether change is happening evenly, or if some populations are being left out. Stratification strategies may help. Now we will look at how a couple of states have used these Quality Improvement strategies. Form CMS-416 is one source of data that can be helpful in developing and implementing a quality improvement project. The two states we’ll examine through case studies are: Connecticut And Iowa First, let’s look at how Connecticut has used the Model for Improvement. We start here by talking about the first step in the cycle, Plan. In 2005, a research and advocacy organization analyzed eligibility and encounter data for dental services from Connecticut’s Medicaid managed care organizations. Their report found that over half the children in the state had not received any dental care in the past year. This low utilization rate had been fairly stable for several years. The report also found that several socio-demographic factors were correlated with the likelihood of a child receiving dental care. These included Age Race or ethnicity Geographic region Primary language And enrollment in a specific managed care plan. The 2005 report from Connecticut Voices for Children is available at ctvoices.org. Let’s move on to the second step in the cycle, the Do step. Connecticut officials engaged stakeholders statewide to identify drivers of change and potential barriers related to children’s utilization of dental services. Drivers of change are the factors that influence your quality target. You can identify these drivers by investigating the underlying cause of the problem you are trying to solve, or deciding which factors might control the outcome you are interested in. These processes will help you develop your theory of change that will result in improvement. In 2008, the state decided to implement a series of strategies to improve children’s access to, and utilization of, dental services. The table in the bottom half of this slide outlines several strategies and implementation efforts Connecticut employed. Let’s review each of these. The first strategy was to restructure oral health benefits by creating a carve-out for dental services. A carve out is an arrangement in which some benefits (such as dental services) are excluded from the set of services provided by a contracted medical managed care organization, and instead are provided through a contract with a separate managed care organization or benefits manager. To address this first strategy, the state established a dental Administrative Services Only (or ASO) contract with a single vendor. The state’s second strategy was to recruit more dental providers to join their network of Medicaid dentists. To do this, Connecticut increased reimbursement rates for oral health services, and expanded the scope of practice for dental hygienists. The third strategy was to conduct outreach to expand awareness in key communities of the dental benefit and how to access services. In Connecticut, key communities included pregnant women and Medicaid members identified as non-utilizers of dental services. To address this third strategy, an outreach partnership disseminated educational materials to community agencies, faith communities, primary care providers, and hospital emergency departments. The third step in the PDSA cycle is to Study. Connecticut officials continued to monitor dental utilization data following implementation of the Quality Improvement strategies, and found that the percentage of Medicaid-enrolled children receiving preventive dental services increased by nearly 30 percentage points. The chart on this page shows utilization of Preventative Dental Services for children ages zero to twenty in Connecticut for federal fiscal years 2006 through 2013. You can see that we are using the data from the Form CMS-416. The top green line, representing the total number of children reported on line 1b, shows an increase from 281,910 in federal fiscal year 2006 to 328,795 in federal fiscal year 2013. The bottom red line, representing the total number of children reported on line 12b, also shows an increase — from 77,818 in federal fiscal year 2006 to 188,004 in federal fiscal year 2013. The PDENT calculation is also listed in this table. Connecticut’s PDENT performance was 27.6 percent in federal fiscal year 2006 and increased to 57.2 percent in federal fiscal year 2013. For purposes of understanding this chart it is important to note that for federal fiscal years 2006 through 2009, CMS did not distinguish between eligibles, or children, with any period of enrollment from eligibles, or children, with 90 days of continuous enrollment. Therefore, denominator data for those years is taken from Line 1 of the Form CMS-416. Starting in federal fiscal year 2010, only eligibles, or children, enrolled for at least 90 continuous days were reported on the dental lines. And such children were separately reported on Line 1b.Thus, the results shown here for 2010 and forward represent children enrolled for at least 90 continuous days. As a reminder, PDENT is calculated by dividing Line 12b by Line 1b. The 2005 report containing utilization data was produced by Connecticut Voices for Children and is available at ctvoices.org. The final step in the PDSA cycle is to Act. Since they had gotten such good results, Connecticut decided to maintain the Quality Improvement strategies put in place to ensure continued access to dental services for children in Medicaid and CHIP. In addition, stakeholders identified additional recommendations for future initiatives to improve oral health care quality in the state. These included: Maintain the Medicaid dental reimbursement rates for children’s dental services. Continue to monitor racial and ethnic differences in access to care and utilization and to investigate ways to reduce disparities. Evaluate the impact of expanding pediatric primary care to include oral health assessment and prophylaxis for very young children. And investigate trends in adult dental care utilization, including care for pregnant women before and after the special outreach initiative. The 2005 report containing additional recommendations was produced by Connecticut Voices for Children and is available at ctvoices.org. Now that we’ve examined Connecticut’s Quality Improvement work through the lens of the PDSA Cycle, let’s take a step back and look at how their work fit in to the 3 questions in the Model for Improvement. First, they asked themselves what are we trying to accomplish? Connecticut wanted to Increase access to and utilization of oral health care services by children enrolled in Medicaid and CHIP. Then, they asked how will we know that a change is an improvement? They did this by monitoring enrollment and claims data from children enrolled in Medicaid and CHIP. Finally, they asked what change can we make that will result in improvement? The changes they decided upon were restructuring the way oral health benefits were administered in Medicaid and CHIP, increasing reimbursement to attract more providers, and conducting outreach in key communities to spread awareness of the importance of dental care for children and how to find a participating dentist. Connecticut’s QI strategy achieved meaningful improvement for children’s oral health care. Let’s now look at a Quality Improvement effort in Iowa using the Model for Improvement framework. First, the PDSA Cycle: As part of the first step, Plan, Iowa Medicaid officials tracked data submitted on the Form CMS-416 and noted persistent unmet need for oral health services among enrolled children, with fewer than 40 percent of enrolled children receiving a preventive service in federal fiscal year 2005. They also noted that utilization of oral health services was particularly poor among very young children. State legislators responded by passing a law that required the Medicaid agency to develop a dental home program to ensure access to dental care for enrolled children younger than 12. By establishing I-Smile, a system of care coordination for oral health care, Iowa officials hoped to increase the number of children using services. For more information on child enrollment in oral health services in Iowa, please visit the Iowa Department of Public Health website at idph.iowa.gov. Additional information on Iowa’s state legislature and lawmaking is available from the Iowa Legislature website at legis.iowa.gov. More information on I-Smile is available at ismiledentalhome.iowa.gov. Now, let’s see what Iowa did next under the Do step of the PDSA cycle. In particular, Iowa relied on dental hygienists hired as I-Smile coordinators in each county health department. These coordinators helped to support local implementation of oral health access expansion strategies that addressed the specific needs of each county’s target population. These oral health access expansion strategies included: Providing oral health education for a variety of audiences and settings, including: Area early childhood programs and parents Faith-based organizations that serve minority families Staff from nursing training programs And back-to-school registrations and kindergarten round-ups. In addition, these strategies involved working with city officials to improve fluoride levels within public water supplies; Training health and medical staff in local offices on oral screening, fluoride varnish application, and referral for dental care; Providing lunch-and-learn trainings for dental office staff with a focus on seeing children younger than 3; And finally working with dental advisory groups on community health needs assessment and oral health program planning. For more information on oral health access expansion strategies, please visit the Iowa Department of Public Health website at idph.iowa.gov. Next, Iowa moved into the third step, Study. A recent report, the 2014 I-Smile Annual Report on Children’s Oral Health in Iowa, shows that there has been significant improvement in the utilization of oral health services since the I-Smile initiative was launched: For Medicaid-enrolled children age 0 to 12, there was a 59 percent increase in the number of children who saw a dentist in 2014 as compared to 2005. For very young children (ages 0 to 5), nearly four times as many children received a preventive dental service in 2014 as compared to 2005. To view the 2014 I-Smile Annual Report on Children’s Oral Health in Iowa online, please visit the Iowa Department of Public Health website at idph.iowa.gov. Through the last step of the cycle, Act, Iowa has identified additional areas for continued improvement, as well as how to incorporate I-Smile activities into the changing landscape of payment reform. For example, I-Smile coordinators continue to promote dental care utilization for very young children (under age 1), and offer training to medical and dental office staff. Also, as Accountable Care Organizations (or ACOs) emerge, Iowa will consider how to link the I-Smile model and its strategies within ACO planning and implementation. ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily with the goal of giving coordinated high quality care to their patients, often through collaboration with a payer or insurer. To learn more about additional areas for continued improvement, please visit the Iowa Department of Public Health website at idph.iowa.gov. Now that we’ve examined Iowa’s Quality Improvement work through the lens of the PDSA Cycle, let’s take a step back and look at how their work fit in to the 3 questions in the Model for Improvement. First, they asked themselves what are we trying to accomplish? As with Connecticut, Iowa sought to increase access to and utilization of oral health care services for children enrolled in Medicaid and CHIP. Then, they asked how will we know that a change is an improvement? They did this by monitoring enrollment and encounter data for children enrolled in Medicaid and CHIP, as well as by tracking progress achieved through implementation of strategies tailored to the needs of different state regions. And finally, they wanted to know what change can we make that will result in improvement? The changes that Iowa chose to implement included leveraging partnerships with other agencies and entities (such as public health departments and nutrition programs), training providers in delivering services to key populations, and establishing partnerships with community stakeholders to identify additional needs and spread improvements. Iowa implemented a Quality Improvement strategy that restructured the way oral health services were delivered in the state and as result achieved significant gains in children’s use of dental services. In thinking about our two state examples, let’s review some lessons learned. By analyzing claims and encounter data, including data used for reporting the Form CMS-416, Iowa and Connecticut identified gaps in oral health utilization among Medicaid-enrolled children. In partnership with stakeholders, state officials used these data to: Identify drivers of change Develop and implement Quality Improvement strategies And monitor progress toward goals Connecticut and Iowa aren’t the only states who have worked to improve delivery of dental and oral health services to children. Several states have undertaken Quality Improvement projects targeting oral health for children enrolled in Medicaid and CHIP. The resources listed here provide more information about Quality Improvement principles, methods, and tools that can be used by state Medicaid and CHIP agencies. These QI resources include: The Quality Improvement Workshop Series The QI 101 – Learning series including Getting Started, Developing Aims and Selecting Change Strategies, and Measuring and Monitoring Improvements. The QI 201 Learning Series The Toolkit for Improving Oral Health Care in Medicaid and CHIP And the Form CMS-416 Web-Based Training Homepage To view these and other resources, please visit the CHIPRA Initial Core Set of Children’s Health Care Quality Measures and the Learn How to Report the CMS 416 Dental Data pages at Medicaid.gov. Let’s review the Module 6 summary. In this module: You learned how to calculate state performance on preventive dental services, the metric used for the Oral Health Initiative goal. You also learned the steps involved in an oral health quality improvement project. And finally, you learned how two states, Connecticut and Iowa, used data to identify gaps in oral health utilization, drive improvement efforts, and monitor progress. Congratulations! You have completed Module 6: Using Form CMS-416 Dental Data. This is the last module in the Form CMS-416 Dental Data Reporting Web-Based Training series. To access other training modules, and relevant Form CMS-416 resources, please visit the CMS Web-Based Training homepage at Medicaid.gov. For questions about the Form CMS-416 or the Oral Health Initiative, access the complete Form CMS-416 reporting instructions on the Early and Periodic Screening, Diagnostic, and Treatment page at Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected]

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