Our Dedication to Quality Improvement

As a member, your health is our first priority. That's why we have a Quality Assessment Performance Improvement (QAPI) program. The QAPI program looks for ways to make our services better. That can make it easier for you to stay healthy.

QAPI program features

The QAPI program works to improve the quality of your health care. It gives us a structure and guidelines for medical clinical care, behavioral clinical care, and other member services.

The program also helps our members improve their health and wellness by:

• Developing programs for members with special needs.
• Offering programs that help members manage their health.
• Arranging home visits and wellness events.
• Making health education available to members.
• Planning events to help you get care, find resources and learn better ways to take care of you.

Our goal is to make sure health care and services our members receive are:

• High quality
• Safe
• Appropriate
• Efficient
• Effective

We review our QAPI program each year to see how we are doing. This review includes suggestions for improvement, as well as goals for the next year.

Our mission is to help people get care, stay well, and build healthy communities by creating programs to serve our members who have special health care needs.

Recent accomplishments

• Chronic condition improvement program: Improved diabetic adherence to diabetic clinical guidelines.
• Credentialing: The Credentialing department adhered to all regulatory and accrediting standards for credentialing. The Credentialing department continues to maintain a National Committee for Quality Assurance (NCQA) certification as a Credentials Verification Organization (CVO).
• Delegation monitoring: The plan improved delegation oversight and reporting by utilizing the Corporate Delegation Oversight department and coordinating with the Medicare Compliance team.
• Health risk assessment (HRA) tracking: Improved departmental quarterly reporting to monitor Medical Management performance against CMS standards for HRA timeliness at both initial and annual assessments, helping to improve completion timeliness resulting in a 2% improvement.
• Integrated care management (ICM) program: Our plan implemented a Transition of Care team to help assist members with obtaining the care and services they need post-hospitalization.
• Integrated QI activities: We coordinated improvement interventions across a variety of departments, including, but not limited to, Medical Management, Pharmacy, Credentialing, Member Services, Compliance, Operations, and Provider Network.
• Key indicators: We monitored key indicators for inpatient/outpatient utilization trends including admissions, average length of stay, and outpatient services and events.
• Model of Care: Monitored performance of Model of Care metrics.
• Patient safety: We monitored patient safety through review of potential adverse events and quality of care/quality of service member reporting.
• Preventive screening programs: The plan implemented a colorectal cancer screening program to include in-home testing for our special needs population.
• Provider collaboration improvement: We continued to provide a monthly Quality Improvement Provider Score Card to our Primary Care Providers.
• Quality of care (QOC) reviews: We investigated, trended, and took action as necessary on potential quality of care concerns within established time frames 100% of the time.
• Reducing health care disparities: We continue to collect and report member race, ethnicity, and language data needed to address and decrease disparities in health care and monitor member utilization of the language line.
• Social determinants of health (SDOH): We implemented a new member survey to collect SDOH data to help identify members' needs and decrease health care disparities.

Future goals

The plan will continue to focus on reducing cardiovascular disease and diabetes, increasing preventive screenings and medication adherence, and improving health outcomes.

We will also prioritize improving the health of our members and reducing health care disparities with our continuing efforts to:

• Improve access to care and services through assessing the availability and accessibility of providers.
• Improve compliance with prescribed health screenings.
• Continue member and provider outreach initiatives to improve utilization of services.
• Enhance chronic disease management through:
  • Maintaining effective care management programs.
  • Effectively using the HRA and robust care planning.
  • Designing effective medication adherence programs.
  • Reviewing and updating evidence-based clinical practice guidelines to promote implementation of comprehensive medical and health care practices, including preventive, diagnostic and treatment services.
• Improve coordination of care between medical and behavioral health providers, home health care agencies, and long-term care service providers by systematically improving care management communication with these providers.
• Improve member safety through ongoing monitoring and investigation of root cause analyses and trends for potential quality of care and credentialing/recredentialing issues, as well as addressing issues identified through complaints and appeals.
• Empower members to work more collaboratively with their health care providers in implementing their care plans to maintain and/or improve their health.
• Implement other initiatives to address ongoing support of process improvement, and the adoption of best practices within the managed care industry.

Call Member Services at 1-866-533-5490 (TTY 711), Monday through Friday, 8 a.m. to 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. to 8 p.m., from October 1 to March 31.