The 2016 Health Care Improvement (HCI) quality program initiatives encompass both internal and external collaborative efforts, such as partnerships with community practitioners, provider’s agencies with the goal of providing quality and comprehensive healthcare to members in an integrated manner.
The purpose of the Quality Program is to support the mission of the Health Plan to improve the health of its member’s and the community it serves. Every effort is made to empower members and employers to become active participants in their personal health status through educated, informed decision making. Collaboration with practitioners and providers ensure the rendering of safe, high quality care with the appropriate utilization of applicable services. The core goal of the program is to improve the health of our membership through initiatives focusing on chronic disease, patient safety, continuity of care and service quality. The Program maintains a supportive framework focused on the fundamental of providing comprehensive, effective healthcare services across the entire care continuum.
The core efforts of the work plan are plan wide and revolve around the improvement of targeted measures associated with cardiovascular and diabetic chronic disease states, improving transition from one setting to another to ensure strong continuity of care, empowering members with chronic disease to become active partners in improving their own health status, maximizing patient safety, increasing overall member experience, and meeting external regulatory and accreditation demands. Overall improved health of membership and increased service quality is the desired outcome.
The 2016 Quality Program Goals are:
Improve member and community health by improving performance for preventive health, behavioral health, chronic and acute care services through implementation of activities with a multi-year focus.
Focus on Cardiovascular (CAD/CHF) Disease and Diabetes
Improve Member Health Outcomes through Gap Closure and Medication Adherence
Improve Transitions in Care for High Risk Members with Chronic Conditions
Improve Member Sense of Self-Empowerment in Chronic Conditions
Increase Patient Safety
Be a 5-STAR rated Medicare Advantage Plan
Meet or Exceed External Regulatory and Accreditation Demands
Attain a high level of member and provider satisfaction with the Health Plan
Promote evidence based medicine while exceeding industry quality measure benchmarks including; HEDIS / CAHPS / QARR, NCQA, CMS and NYSDOH indicators.
In accordance with the Health Plan's Quality Improvement Program, staff oversees the quality improvement initiatives and quality management accreditation and compliance requirements related to Behavioral Health (BH). This program is committed to facilitating timely continuity and coordination of care for all members seeking medically necessary behavioral health services. These services are offered to our entire managed care population, including commercial, Medicare and Medicaid Members.
Medical Record Review Standards
The Health Plan requires that information in medical records be maintained in a manner that is confidential, current, comprehensive and organized (for easy retrieval by the treating practitioner and the Health Plan). The standards pertain to assessment, treatment, health promotion, patient safety, and confidential coordination and continuity of care.
Our Quality Management Committee establishes performance goals. Random samples of Primary Care Physician charts are reviewed each year. A Quality Management representative will work with you or your office staff to arrange review of medical records selected for review. See the complete Standards for Medical Record Review (PDF).
Facility/Office Site Standards
The Health Plan may perform office site visits for any practitioners at the time of initial credentialing, or re-credentialing. In addition, the Health Plan will also respond to and investigate complaints from any source regarding deficiencies in the physical site of the practice. Continued contracting may depend on a satisfactory site review. See the Credentialing Site Visit Checklist (PDF). The Health Plan may perform a site visit on a facility that does not meet certain established credentialing criteria as outlined in the:Credentialing/Recredentialing of Health Delivery Organizations (PDF).
Appointment Availability Standards
We're committed to ensuring that our provider network is sufficient for members to receive care in a timely manner. Our Quality Management staff monitor access and availability through phone and on-site surveys. The New York State Department of Health also periodically conducts "secret shopper" surveys.
Serious Adverse Events/Other Provider-Preventable Conditions
As outlined in the quality policy, the coverage and reimbursement criteria applicable to Serious Adverse Events/Other Provider-Preventable Conditions and Hospital Acquired Conditions/Health Care-Acquired Conditions that occur in a hospital setting is addressed. As part of Health Plan's Quality Improvement Program, this quality policy is consistent with the development of other programs designed to assure quality of care.