QUALITY IMPROVEMENT PROGRAM
|
|
- Myles Francis
- 5 years ago
- Views:
Transcription
1 QUALITY IMPROVEMENT PROGRAM EmblemHealth s mission is to create healthier futures for our customers and communities. We will do this by providing members with a broad range of benefits and conscientious service; striving to enhance the experience for health care professionals; offering high value to those who purchase our health plans; working with government agencies to increase access to coverage; and partnering with the communities in which we live and work to improve their overall health. EmblemHealth continues to have a comprehensive quality improvement program that encompasses all operational areas and establishes a framework and processes that continuously work to improve the health care and services our members receive. We routinely monitor and review the following areas to ensure that our members have access to the highest quality medical and behavioral care and services: Quality of care Quality of service Patient safety Care management Member and physician satisfaction Accessibility Availability Delegation Member complaints and appeals Health management tools Cultural diversity We use various data sources and software to measure quality improvement processes and outcomes, and determine barriers to improvement, including but not limited to Healthcare Effectiveness Data and Information Set (HEDIS ) and Consumer Assessment of Healthcare Providers and Systems (CAHPS ) data. The data helps determine appropriate ways to improve quality and overcome barriers. Highlights of the Quality Improvement Program include, but are not limited to the following: QUALITY OF CARE Clinical and health promotion activities are systematically selected and prioritized. Interventions are based upon recognized evidence-based clinical guidelines and member-specific needs. Activities focused on optimizing the health and well-being of EmblemHealth s members include but are not limited to: Members personalized health communications. These are designed to make members aware of any gaps in preventive or chronic maintenance care and empower them to make educated choices that affect their health and well-being. Targeted incentive mailing to Medicaid members who are missing certain tests, well-visits, or dental visits. Mailing of preventive health guidelines, member newsletters, and health and wellness information in an effort to help members maintain their health. Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_OTH-WEB_40617_2017QualityImprovementProg 12/17
2 Calls to members to confirm certain diagnoses, such as rheumatoid arthritis or osteoporosis, and encourage them to use appropriate medications and go for appropriate tests. Medication adherence activities, including contacting those providers with members who did not refill needed medications. A new Provider Incentive Award Program for high volume health care professional groups was launched in Collaborative relationships with the groups quality teams and leadership were built as a result of the program. Monthly gaps in care reports, report cards, and Healthcare Effectiveness Data and Information Set (HEDIS ) measure dashboards were distributed to groups highlighting performance and opportunities for improvement. Calls to members recently discharged from the hospital to ensure the member gets appropriate follow-up care with a health professional. A gap in care program with several health homes. Training materials, outcome reports, and monthly gaps in care reports are shared with the health homes. Continued collaboration with Disease Management, Case Management, and Pharmacy departments to promote HEDIS, New York State Quality Assurance Reporting Requirements (QARR ) and Centers for Medicare and Medicaid Services (CMS) Medicare Star Ratings Program measures. Partnerships with vendors who conduct in-home tests, such as bone mineral density and diabetic testing. EmblemHealth offers members with certain health conditions access to education and support through its Care Management PATH (Positive Actions Toward Health) programs. These programs complement the care members receive from their doctors and assist the member by helping them better understand and manage their condition. Eligible members are offered Care Management PATH programs for the following conditions: Asthma Chronic Obstructive Pulmonary Disease (COPD) Diabetes Coronary Artery Disease (CAD) Heart Failure Chronic Kidney Disease and End-Stage Renal Disease Healthy Beginnings PATH Pregnancy Management Program Tobacco-Free PATH Smoking Cessation Program Serious and Persistent Mental Illness Disease Management Services These programs provide interventions based on members assessments. Services include but are not limited to: One-on-one telephonic health coaching and monitoring based on care plans created by a registered nurse and/or other health care staff. The plan addresses each member s physical, behavioral, and emotional health and accounts for the members lifestyle and cultural needs. Educational materials about symptom management, health and safety risks, treatments, diet, and nutrition. Periodic evaluations of members health. Health care professionals receive updates on their patients health status. Quarterly newsletters for health care professionals highlighting the latest information on chronic illnesses. Coordination of care between members and their medical professionals, as well as support-services for caregivers. Community-based support services, including culturally and language-appropriate community-based services. Members satisfaction with the Care Management PATH program is measured annually and improvement activities are implemented when required. EmblemHealth also provides unique and specialized health outreach programs such as EmblemHealth Neighborhood Care, Care for the Family Caregiver, and the National Diabetes Prevention Program. 2
3 EmblemHealth collects and analyzes data in an effort to continually monitor its performance and identify areas for improvement. EmblemHealth uses Healthcare Effectiveness Data and Information Set (HEDIS ) scores to determine if members are getting needed preventive screenings and treatments. Continual monitoring of HEDIS scores allows EmblemHealth to identify areas of improvement in member s care and service. Improved scores year over year indicate that EmblemHealth is continuing to reduce gaps in the health care its members receive. EmblemHealth compares the Plan s HEDIS scores to relevant industry benchmarks, such as National Committee for Quality Assurance (NCQA) Quality Compass, CMS Medicare Star Ratings Program, and New York State averages to measure its performance compared to other health plans. HIP MEDICARE HMO Adult Access to Preventive/Ambulatory Care 95.55% 95.62% 95.74%** Annual Monitoring for Patients on Persistent Medications: Total 93.60% 94.03% 86.94%** Breast Cancer Screening 78.11% 79.22% 78.00% Colorectal Cancer Screening 74.19% 78.50% 72.00% Comprehensive Diabetes Care: HbA1c Test 94.44% 95.95% 93.81%** Comprehensive Diabetes Care: Eye Exam 76.09% 82.28% 72.00% Comprehensive Diabetes Care: Monitor Nephropathy 96.62% 97.22% 96.00% Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 76.66% 78.97% 78.00% Osteoporosis Management in Women Who Had a Fracture 55.09% 57.02% 52.00% *Benchmark: Medicare 2018 Part C & D Star Rating Technical Notes 4-Star Benchmark. ** These are not CMS Medicare Star Ratings program measures; 2017 Quality Compass National HMO Average 75th percentile is used for Benchmark. HIP MEDICAID Breast Cancer Screening 67.51% 70.21% 71.46% Cervical Cancer Screening 70.19% 77.87% 73.49% Colorectal Cancer Screening 49.42% 55.61% 60.65% Comprehensive Diabetes Care: Eye Exam 63.68% 65.94% 62.83% Controlling High Blood Pressure 53.11% 62.20% 64.32% Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 79.90% 83.01% 80.92% Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase (30 Days) Follow-Up Care for Children Prescribed ADHD Medication: Continuation Phase (270 Days) 39.97% 60.89% 58.00% 46.67% 70.40% 67.38% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 41.32% 50.80% 65.45% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 58.04% 67.87% 79.24% Timeliness of Prenatal Care: Initial Visit 76.98% 87.80% 87.66% *Benchmark: QARR Statewide Average for measurement year HIP EXCHANGE HMO (QUALIFIED HEALTH PLAN (QHP))* MEASURE HEDIS 2016 HEDIS 2017 Annual Monitoring for Patients on Persistent Medications: Total 85.82% 87.68% Appropriate Testing for Children with Pharyngitis 90.00% 93.75% Breast Cancer Screening 72.63% 69.54% Cervical Cancer Screening 73.11% 60.98% Colorectal Cancer Screening 52.55% 50.73% Controlling High Blood Pressure 46.68% 47.20% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 42.86% 61.54% Timeliness of Prenatal Care: Initial Visit 76.92% 88.10% *Benchmark is unavailable for Qualified Health Plan (QHP) 3
4 HIP COMMERCIAL HMO Adult Access to Preventive/Ambulatory Care 93.20% 93.29% 94.59% Adolescent Well Care Visits 58.69% 61.71% 42.72% Annual Monitoring for Patients on Persistent Medications: Total 85.89% 87.89% 83.65% Breast Cancer Screening 74.13% 74.84% 74.72% Cervical Cancer Screening 79.23% 84.23% 73.76% Colorectal Cancer Screening 65.38% 68.35% 65.80% Comprehensive Diabetes Care: HbA1c Test 89.85% 91.40% 91.64% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 45.80% 53.33% 58.43% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 62.25% 68.94% 75.98% Timeliness of Prenatal Care: Initial Visit 80.05% 90.26% 87.98% *Benchmark: 2017 Quality Compass National HMO Average 50 th percentile GHI COMMERCIAL PPO Antidepressant Medication Management: Acute Treatment (84 days) 61.54% 68.42% 68.06% Antidepressant Medication Management: Continuation Phase (180 days) 48.49% 56.62% 52.20% Chlamydia Screening in Women: Total (16 24 years) 64.47% 65.68% 43.14% Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase (30 Days) 37.33% 55.70% 38.59% Follow-Up Care for Children Prescribed ADHD Medication: Continuation Phase (270 Days) 36.36% 75.00% 44.44% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 43.71% 51.68% 50.64% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 61.08% 67.11% 71.08% *Benchmark: 2017 Quality Compass National PPO and EPO Average 50 th percentile EmblemHealth also uses Consumer Assessment of Healthcare Providers and Systems (CAHPS ) to survey its members about the interpersonal aspects of their health care as well as the members relationship with their doctor and experiences with their health plan. CAHPS results are publically reported on various forums and used by consumers to guide their selection of health plans. CAHPS are required by CMS for Medicare and the Qualified Health Plan Enrollee Experience Survey for the Qualified Health Plans. They are also required by the New York State Department of Health, Federal Employee Health Benefits (FEHB), the National Committee for Quality Assurance (NCQA), and URAC. Additionally, CAHPS results impact the Medicare Stars Quality Bonus Program and the New York State Department of Health Medicaid Quality Incentive Program and the potential revenue associated with both programs. Accreditation EmblemHealth submitted its renewal for the National Committee for Quality Assurance (NCQA) Health Plan accreditation for HIP Commercial HMO/POS, HIP Medicare HMO and HIP Exchange HMO in The Plan also submitted for first-time accreditation for GHI Commercial PPO. Desktop submission included submission of policies, procedures, materials, reports (including studies and analysis followed by an on-site audit which included review of grievance and appeals files, credentialing/ re-credentialing files, case management files, and utilization management files). EmblemHealth was awarded a Commendable accreditation status for HIP Medicare HMO and received an Accredited status for HIP Commercial HMO/POS, GHI Commercial PPO, and HIP Exchange HMO. The NCQA accreditation statuses remain in effect through September 12, EmblemHealth continues to hold full accreditation from URAC for Health Utilization Management and CORE standards for HIP Commercial EPO/PPO and GHI Commercial EPO/PPO. These accreditations remain in effect through July 1, Additional highlights of EmblemHealth s combined HEDIS, CAHPS, and NCQA Accreditation standards scores can be viewed at NCQA Health Insurance Plan Ratings ( ). 4
5 QUALITY OF SERVICE EmblemHealth continually monitors experiences with the health plan to identify ways to improve the services it provides to its members and health care professionals. Customer Service EmblemHealth monitors member and health care professional (provider) telephone service standards that include specific service levels. The results are tracked and trended. The table below details the Customer Service Call Center metrics for 2016 compared to prior years: CALL CENTER METRICS METRIC GOAL PPO HMO Total # of Calls Received n/a 2,138,526 2,274,727 2,384,286 2,229,824 Total # of Calls Answered n/a 2,091,095 1,998,489 2,325,506 2,081,047 Average Speed of Answer (ASA) 20 Seconds % of Member Calls Answered in 45 seconds (30 seconds in 2014 and 2015) 80% of Calls 66.84% 65.11% 75.82% 83.37% % of Health Care Professional (Provider) Calls Answered in 60 Seconds 80% of Calls n/a 39.28% n/a 54.78% Abandonment Rate 2% or less 2.22% 12.00% 2.38% 6.3% First Call Resolution 85% 86.43% 87.20% 81.99% 82.81% Call center teams focused on developing plans to improve quality within the call centers during As part of this effort, we implemented a Customer Connection Quality Program to all EmblemHealth Call Centers. The program s purpose is to provide a foundation for evaluating Customer Service Advocates while empowering them to personalize each customer experience. Coaching, reminders on key components, customer feedback via an after-call survey, and quality audits are all incorporated into the program. Program enhancements began in 2016 and continued into Claims Operations EmblemHealth monitors its claims processing standards, which includes specific target service levels. We monitor and measure the following to gauge progress in meetings goals: Mean Processing Time All Claims (Days). Percentage Paid in 30 Days. The results are continually tracked and trended and process improvements are implemented as identified. The table below contains details of the Claims Processing metrics for 2016: CLAIMS OPERATIONS SUMMARY FOR 2016 HMO METRIC MEDICAL HOSPITAL Total Claims Processed 8,307,781 7,723,136 1,377,855 1,126,680 Mean Processing Time All Claims (Days) % Paid in 30 Days (Goal: 99%) 99.84% 98.76% 98.72% 94.38% CLAIMS OPERATIONS SUMMARY FOR 2016 PPO METRIC MEDICAL HOSPITAL DENTAL Total Claims Processed 17,926,155 18,295, , , ,851 1,004,222 Mean Processing Time All Claims (Days) % Paid in 30 Days (Goal: 99%) 99.57% 94.75% 99.63% 98.57% 98.79% 96.77% 5
QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:
QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More informationGateway to Practitioner Excellence GPE 2017 Medicaid & Medicare
Gateway to Practitioner Excellence GPE 2017 Medicaid & Medicare Recognizing and Rewarding Excellent Practices Improving the Health of Gateway Members PRACTICE ELIGIBILITY (see PCMH slide #27 for separate
More informationColorado Choice Health Plans
Quality Overview Health Plans Accreditation Exchange Product Accrediting Organization: Accreditation Status: URAC Health Plan Accreditation (Marketplace ) Full Full: Organization demonstrates full compliance
More informationMedical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management
G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14
More informationNote: Accredited is the highest rating an exchange product can have for 2015.
Quality Overview Accreditation Exchange Product Accrediting Organization: NCQA HMO (Exchange) Accreditation Status: Accredited Note: Accredited is the highest rating an exchange product can have for 215.
More informationPassport Advantage Provider Manual Section 8.0 Quality Improvement
Passport Advantage Provider Manual Section 8.0 Quality Improvement Table of Contents 8.1 Quality Improvement Program 8.2 Clinical Practice Guidelines 8.3 Star s 8.4 Quality of Care Concerns 8.3 Practitioner
More informationFriday Health Plans of Colorado
QUALITY OVERVIEW Health Plans of Colorado (formerly Colorado Choice Health Plans) Serving Colorado for over 4 years, Health Plans utilizes a community-focused model. We work hand in hand with local providers
More informationEmblemHealth Advocate for Quality
EmblemHealth Advocate for Quality 2013 Average Health Care Spending per Capita, 1980 2009 Adjusted for differences in cost of living 1 Dollars Source: OECD Health Data 2011 (June 2011). THE COMMONWEALTH
More informationAnthem BlueCross and BlueShield
Quality Overview BlueCross and BlueShield Accreditation Exchange Product Accrediting Organization: Accreditation Status: NCQA Health Plan Accreditation (Commercial HMO) Accredited Accreditation Commercial
More informationQuality: Finish Strong in Get Ready for October 28, 2016
Quality: Finish Strong in 2016. Get Ready for 2017 October 28, 2016 Agenda Stars: Medicare Advantage Quality Changes for 2017 Pay for Quality and PCMH Programs Important Announcements! 7 Stars: Medicare
More informationMcLaren Health Plan Quality Improvement Update 2014
McLaren Health Plan Quality Improvement Update 2014 Since the incorporation of McLaren Health Plan (MHP) in November 1997, the staff has continued to utilize their extensive clinical and administrative
More informationtotal health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees
total health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees total health and wellness Whether you want to ease stress, lose weight, or
More informationAt EmblemHealth, we believe in helping people stay healthy, get well and live better.
At EmblemHealth, we believe in helping people stay healthy, get well and live better. Welcome to the 2017 course on Special Needs Plan Model of Care. This year s course is focused on how we can successfully
More informationFlorida Medicaid: Performance Measures (HEDIS)
Florida Medicaid: Performance Measures (HEDIS) Justin M. Senior Florida Medicaid Director Agency for Health Care Administration Senate Health Policy October 20, 2015 Statewide Medicaid Managed Care (SMMC)
More informationIMPROVING THE QUALITY OF CARE IN SOUTH CAROLINA S MEDICAID PROGRAM
IMPROVING THE QUALITY OF CARE IN SOUTH CAROLINA S MEDICAID PROGRAM VICE PRESIDENT, PUBLIC POLICY & EXTERNAL RELATIONS October 16, 2008 Who is NCQA? TODAY Why measure quality? What is the state of health
More informationTO BE RESCINDED Patient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM TO BE RESCINDED 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model
More informationMedicare Advantage Star Ratings
Medicare Advantage Star Ratings December 2017 The Star Rating System measures how well Medicare Advantage (MA) and its prescription drug plans perform for consumers. As an integrated health system, Presbyterian
More informationKaiser Permanente QUALITY OVERVIEW OVERALL RATING : 3.4 COMPANY AT A GLANCE. Company Statistics. Accreditation Exchange Product
QUALITY OVERVIEW Permanente As the state s largest nonprofit health plan, Permanente is committed to improving the health of our members and our state as a whole. Permanente is made up of: Foundation Hospitals
More informationQuality Management Report 2018 Q1
Quality Management Report 2018 Q1 Care Wisconsin Participates in Many Quality Initiatives Across the State and Federal Levels These activities include: Centers for Medicare & Medicaid Services (CMS) Department
More informationProviderReport. Managing complex care. Supporting member health.
ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be
More informationBlue Advantage (PPO) SM 2018 Quality+Partnerships
Blue Advantage (PPO) SM 2018 Quality+Partnerships Your Partner in Quality Care BlueCross BlueShield of Tennessee is committed to ensuring our members have access to a network of high quality providers.
More informationYour health comes first
Your health comes first Here are the many ways we re working to ensure the quality of your care At Amerigroup, our focus is on you. We want to help you get and stay healthy. That s why we have many programs
More information2016 Quality Management Annual Evaluation Executive Summary
2016 Quality Management Annual Evaluation Executive Summary July 2017 Mission and Vision The purpose of the 2016 Annual Evaluation is to assess IEHP s Quality Program. This assessment reviews the quality
More information2019 Quality Improvement Program Description Overview
2019 Quality Improvement Program Description Overview Introduction Eon/Clear Spring s Quality Improvement (QI) program guides the company s activities to improve care and treatment for the member s we
More information2012 QUALITY ASSURANCE ANNUAL REPORT Executive Summary
2012 QUALITY ASSURANCE ANNUAL REPORT Executive Summary Jai Medical Systems Managed Care Organization, Inc. (JMS) and its providers have closed out their fifteenth full year in the Maryland Medicaid HealthChoice
More informationQuality Measurement Approaches of State Medicaid Accountable Care Organization Programs
TECHNICAL ASSISTANCE TOOL September 2014 Quality Measurement Approaches of State Medicaid Accountable Care Organization Programs S tates interested in using an accountable care organization (ACO) model
More informationQuality Management Report 2017 Q4
Quality Management Report 2017 Q4 Care Wisconsin Participates in Many Quality Initiatives Across the State and Federal Levels. These activities include: CMS DHS DHS & CMS HEDIS Member Satisfaction (CAHPS
More informationtotal health and wellness
total health and wellness Programs exclusively for our Blue Shield members total health and wellness Whether you want to ease stress, lose weight, or quit smoking we ll help you reach your goals. Our health
More informationNEW Provider Orientation
NEW Provider Orientation About Golden Shore Medical Group Overview Golden Shore Medical Group (formerly Molina Medical Group) is owned and operated by J. Mario Molina, M.D. Dr. Molina continues his father
More informationPatient-centered medical homes (PCMH): Eligible providers.
ACTION: Final DATE: 09/20/2016 8:11 AM 5160-1-71 Patient-centered medical homes (PCMH): Eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationarizona health net a better decision sm Putting you at the center of everything we do.
arizona health net a better decision sm Putting you at the center of everything we do. Nothing s more important than your health. When you re healthy, you want to stay healthy. When you re sick or have
More information2018 PROVIDER TOOLKIT
1100 Circle 75 Parkway Suite 1100 Atlanta, GA 30339 2018 PROVIDER TOOLKIT Understanding the Centers for Medicare and Medicaid (CMS) Stars Rating System What is CMS Quality Star Ratings program? CMS evaluates
More informationAnthem BlueCross and BlueShield HMO
Quality Overview BlueCross and BlueShield Accreditation Exchange Product Accrediting Organization: NCQA (Exchange) Accreditation Status: Accredited Note: Accredited is the highest rating an exchange product
More informationQuality Management (QM) Program AmeriHealth Pennsylvania
Quality Management (QM) Program AmeriHealth Pennsylvania Goals and Objectives The goals and objectives of the Quality Management (QM) Program are to promote the quality and safety of medical and behavioral
More informationMedicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP)
Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Drug and Health Plan Contract Administration Group Donna Williamson & Brandy Alston December 6, 2016
More informationPROVIDER. Newsletter BETTER QUALITY IS OUR GOAL IN THIS ISSUE MEDICARE 2015 ISSUE II
MEDICARE 2015 ISSUE II PROVIDER Newsletter BETTER QUALITY IS OUR GOAL Our Quality Improvement (QI) program is dedicated to finding ways to help deliver better care and service to our members, in collaboration
More information2012 HEDIS/CAHPS Effectiveness of Care Report for 2011 Measures Oregon Commercial Business
2012 HEDIS/CAHPS Effectiveness of Care Report for 2011 Measures Oregon Commercial Business About HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS 1 ) is a widely used set of performance
More informationHouseCalls Objectives
Overview Agenda Overview Objectives Background Case studies Member Experience Primary Care Provider Experience Referrals and Follow-up Influence on Centers for Medicare & Medicaid Services (CMS) Star Ratings
More information2016 Member Incentive. Program Descriptions. Our mission is to improve the health and quality of life of our members
2016 Member Incentive Program Descriptions Our mission is to improve the health and quality of life of our members Member Incentive Program Descriptions I. Purpose Passport Health Plan (Passport) has developed
More informationOxford Condition Management Programs:
Oxford Condition Management Programs: Helping your employees learn, be encouraged and get support. Committed to helping improve the health and well-being of those we serve and improve the health care
More informationTable of Contents. ii 2016 New Jersey HMO & PPO Performance Report
Table of Contents Commissioner s Letter... 1 Introduction... 2 Quality Matters... 3 Staying Healthy... 4 Breast Cancer Screening... 5 Cervical Cancer Screening... 6 Colorectal Cancer Screening... 7 Childhood
More informationProvider Services and Network Management Newsletter
A healthier you. A healthier community. In this Issue: Provider Services and Network Management Newsletter Fall 2017, Volume2 : Issue2 We won the RFP... Pg. 1 Care Management... Pg. 2 CAHPS... Pg. 3 Incentives...
More informationALL NEW ALOHACARE WEBSITE
NEWS FOR PHYSICIANS AND PROVIDERS QUARTER 4 2017 NEW STREAMLINED PRIOR AUTHORIZATION PROCESS AlohaCare will implement a simplified and reduced list of services requiring Prior Authorization effective January
More informationCommunicator. the JUST A THOUGHT. Ensuring HEDIS-Compliant Preventive Health Services. Provider Portal Features. Peer-to-Peer Review BY DR.
WINTER 2016 MHS NEWSLETTER FOR PHYSICIANS Ensuring HEDIS-Compliant Preventive Health Services Here are a few best practice strategies for raising HEDIS and EPSDT onsite review scores, as demonstrated by
More informationThe Heart and Vascular Disease Management Program
Element A: Program Content The Heart and Vascular Disease Management Program GHC-SCW is committed to helping members, and their practitioners, manage chronic illness by providing tools and resources to
More information2017 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members
2017 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2017 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart
More informationMedi-Cal Performance Measurement: Making the Leap to Value-Based Incentives. Dolores Yanagihara IHA Stakeholders Meeting October 3, 2018
Medi-Cal Performance Measurement: Making the Leap to Value-Based Incentives Dolores Yanagihara IHA Stakeholders Meeting October 3, 2018 Why Standardization? MEDI-CAL CROSS PRODUCT San Francisco Health
More information=======================================================================
======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Secretary
More informationPATH Program. Getting Started Guide
PATH Program Getting Started Guide We have a BIG opportunity. Together, we can empower and encourage people to take an active role in their health. Preventive health care services help people find and
More informationPrograms and Procedures for Chronic and High Cost Conditions Related to the Early Retiree Reinsurance Program
s and Procedures for Chronic and High Cost Conditions Related to the Early Retiree Reinsurance HealthPartners Disease and Case Management programs are targeted to those who have been identified with a
More informationand HEDIS Measures
1 SC Medicaid Managed Care Initiative and HEDIS Measures - 2009 Ana Lòpez De Fede, PhD Institute for Families in Society University of South Carolina Regina Young, RNC SC Department of Health and Human
More informationPROVIDER NEWSLETTER. Illinois 2016 Issue II DISEASE MANAGEMENT IMPROVING MEMBERS HEALTH IN THIS ISSUE
Illinois 2016 Issue II PROVIDER NEWSLETTER DISEASE MANAGEMENT IMPROVING MEMBERS HEALTH Disease Management is a no-cost, voluntary program to assist members with specific chronic conditions. A member is
More informationHHW-HIPP0314 (9/13) MDwise Annual IHCP Seminar. Exclusively serving Indiana families since 1994.
HHW-HIPP0314 (9/13) MDwise 101 2013 Annual IHCP Seminar Exclusively serving Indiana families since 1994. Agenda Indiana Health Coverage Overview MDwise Overview MDwise Hoosier Healthwise MDwise Healthy
More informationFor more information on any of the topics covered, please visit our provider self-service website at
Quality improvement summary The results are in We d like to share with you our annual quality improvement summary of clinical performance and service satisfaction. Throughout the year, we evaluate data
More informationOregon's Health System Transformation
Oregon's Health System Transformation MEASUREMENT PERIOD Baseline Year 2011 and Calendar Year 2013 JUNE 24, 2014 TABLE OF CONTENTS Executive Summary...iii 2013 CCO Performance and Quality Pool Distribution...1
More informationCalifornia Pay for Performance: A Case Study with First Year Results. Tom Williams Integrated Healthcare Association (IHA) March 17, 2005
California Pay for Performance: A Case Study with First Year Results Tom Williams Integrated Healthcare Association (IHA) March 17, 2005 Agenda National Perspective California Program Overview Data Collection
More information2015 Quality Improvement Work Plan Summary
2015 Quality Improvement Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how
More informationBlue Cross and Blue Shield of Illinois Provider Manual. Quality Improvement
Blue Cross and Blue Shield of Illinois Provider Manual Quality Improvement 2017 Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an
More informationEnhancing Outcomes with Quality Improvement (QI) October 29, 2015
Enhancing Outcomes with Quality Improvement (QI) October 29, 2015 Learning Objectives! Introduce Quality Improvement (QI)! Explain Clinical Performance Person-Centered Medical Home (PCMH) Measures! Implement
More information2017 QUALITY PLAN WORK PLAN. Kaiser Permanente of Washington 2017 Quality Work Plan
Kaiser Permanente of Washington 2017 Quality Work Plan 1 Achieve 2017 Quality Goals: Improve population health, the quality, safety and satisfaction of the customer experience while improving affordability
More informationKeenan Pharmacy Care Management (KPCM)
Keenan Pharmacy Care Management (KPCM) This program is an exclusive to KPS clients as an additional layer of pharmacy benefit management by engaging physicians and members directly to ensure that the best
More informationMove the Needle on Difficult Quality Measures: How Health Plans Can Control High Blood Pressure
Move the Needle on Difficult Quality Measures: How Health Plans Can Control High Blood Pressure A Centauri Health Solutions Sm White Paper By melanie Richey 2016 by Centauri Health Solutions, Inc. All
More informationChapter 2 Provider Responsibilities Unit 5: Specialist Basics
Chapter 2 Provider Responsibilities Unit 5: Specialist Basics In This Unit Topic See Page Unit 5: Specialist Basics Participation in the Highmark s Networks as a Specialist 2 Specialist and Personal Physician
More informationTufts Health Public Plans. Provider Manual
2017 Tufts Health Public Plans Provider Manual Can t find information you need in this manual? Be sure you ve selected the correct provider manual, or follow one of the links below: Commercial Provider
More informationPatient-centered medical homes (PCMH): eligible providers.
ACTION: Final DATE: 09/21/2018 3:40 PM 5160-1-71 Patient-centered medical homes (PCMH): eligible providers. (A) A Patient-centered medical home (PCMH) is a team-based care delivery model led by primary
More informationUPMC Health Plan. Value Based Insurance Design (VBID) Spark Your Health
UPMC Health Plan Value Based Insurance Design (VBID) Spark Your Health Value Based Insurance Design (VBID) Spark Your Health Medicare Advantage Summit April 6, 2017 Helene Weinraub 1 The statements contained
More informationPROVIDER NEWSLETTER. MISSOURI 2017 Issue I ANNUAL PROVIDER SATISFACTION SURVEY IN THIS ISSUE JOIN THE CONVERSATION ON SOCIAL MEDIA
MISSOURI 2017 Issue I PROVIDER NEWSLETTER ANNUAL PROVIDER SATISFACTION SURVEY Thank you all who participated in the annual survey process in 2016. Missouri Care continues to focus efforts on the experiences
More informationHEALTH MATTERS. Avoid the Flu: Get Vaccinated FALL Know the Signs of Baby Blues. Time for a Checkup. Leaving the Hospital? Questions?
Time for a Checkup Know the Signs of Baby Blues pg 2 pg 5 pg 6 Leaving the Hospital? HEALTH MATTERS FALL 2016 Avoid the Flu: Get Vaccinated Having a flu vaccine is the best way to prevent the flu. It s
More informationMEDICARE PART D STAR RATINGS & PHARMACY PERFORMANCE
MEDICARE PART D STAR RATINGS & PHARMACY PERFORMANCE LISA R. ERWIN, R.PH., CGP SENIOR CONSULTANT AUGUST 21, 2015 WHO IS GORMAN HEALTH GROUP? Gorman Health Group is the leading solutions and consulting firm
More informationMeasuring Value and Outcomes for Continuous Quality Improvement. Noelle Flaherty MS, MBA, RN, CCM, CPHQ 1. Jodi Cichetti, MS, RN, BS, CCM, CPHQ
Noelle Flaherty MS, MBA, RN, CCM, CPHQ 1 Jodi Cichetti, MS, RN, BS, CCM, CPHQ Leslie Beck, MS 1 Amanda Abraham MS 1 Maria Uriyo, PhD, MHSA, PMP 1 1. Johns Hopkins Healthcare LLC, Baltimore Maryland Corresponding
More informationQuality Measures for HMO s: Understanding HEDIS
Quality Measures for HMO s: Understanding HEDIS DANE COUNTY IMMUNIZATION COALITION MEMBERSHIP MEETING November 29, 2011 Elaine Rosenblatt MSN, FNP-BC Director, Quality and Care Management UW Medical Foundation/
More informationFor fully insured groups of 100 or more eligible employees. HealthyOutcomes. A fully-integrated health management solution that works for you
For fully insured groups of 100 or more eligible employees HealthyOutcomes wellness case management condition care maternity A fully-integrated health management solution that works for you HealthyOutcomes
More informationMCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities
2018 MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities Quality Department CAN_2790318S CMS Requirements The Centers of Medicare & Medicaid Services (CMS)
More information2015 Congestive Heart Failure. Program Evaluation. Our mission is to improve the health and quality of life of our members
2015 Congestive Heart Failure Program Evaluation Our mission is to improve the health and quality of life of our members 2015 Congestive Heart Failure Program Evaluation Program Title: Congestive Heart
More informationQUALITY IMPROVEMENT. Articles of Importance to Read: Quality Improvement Program. Winter Pages 1, 2, 3, 4 and 5 Quality Improvement
Important information for physicians and other health care professionals and facilities serving UnitedHealthcare Medicaid members Winter 2009 QUALITY IMPROVEMENT Quality Improvement Program The Quality
More informationSpecial Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training
Special Needs Plans (SNP) Model of Care (MOC) Initial and Annual Training 2018 Learning Objectives Program participants will be able to: List the three overall goals of the SNP Model of Care Describe the
More informationTime to Check Your Progress!
Depression Treatments Making Strides Get Smart About Antibiotics pg 2 pg 4 pg 6 Health Matters FALL 2015 Time to Check Your Progress! It is important to stay healthy, not just for your own well-being,
More informationPopulation Health: Physician Perspective. Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH DSRIP September 24, 2015
Population Health: Physician Perspective Kallanna Manjunath MD, FAAP, CPE Medical Director AMCH DSRIP September 24, 2015 Population Health: Physician Perspective Presentation objectives: Brief Bio Population
More informationManaging Risk Through Population Health Initiatives
Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty
More informationCMHC Healthcare Homes. The Natural Next Step
CMHC Healthcare Homes The Natural Next Step Partners in Planning A collaborative effort involving Dept. of Social Services (Mo HealthNet) Dept. of Mental Health Primary Care Association (FQHCs) Coalition
More informationAssessing the Quality of California Dual Eligible Demonstration Health Plans
M A Y 2 0 1 2 Assessing the Quality of California Dual Eligible Demonstration Health Plans T A B L E O F C O N T E N T S Overview... 1 Introduction... 2 Table 1: Plan Rating Overview... Summary of Quality
More informationSpecial Needs Plan Provider Education
Special Needs Plan Provider Education Learning Goals What is a Special Needs Plan (SNPs) What differentiates a SNP from other MA plans What SNPs are offered by Freedom Health and Optimum Healthcare 2 Care
More informationMaternity Management. The best part? These are available to you at no additional cost. Intro
Telligen provides the following services for Connecticut Carpenters members to help you better manage your health and enjoy a good quality of life. The programs include both Maternity Management and Condition
More informationDisclosures. Platforms for Performance: Clinical Dashboards to Improve Quality and Safety. Learning Objectives
Platforms for Performance: Clinical Dashboards to Improve Quality and Safety Disclosures The program chair and presenters for this continuing pharmacy education activity report no relevant financial relationships.
More informationQuality Improvement Program Evaluation
Denver Health Medical Plan, Inc. Quality Improvement Program Evaluation 2013 Commercial and Exchange Products 1 Page Table of Contents I. Executive Summary...3 II. Quality Improvement Program Evaluation
More informationDISEASE MANAGEMENT PROGRAMS. Procedural Manual. CMPCN Policy #5710
DISEASE MANAGEMENT PROGRAMS Procedural Manual CMPCN Policy #5710 Effective Date: 01/01/2012 Revision Date(s) 11/18/2012; 10/01/13 ; 01/07/14 Approval Date(s) 12/18/2012 ; 10/23/13, 05/27,14 Annotated to
More informationCore Metrics for Better Care, Lower Costs, and Better Health
Core Metrics for Better Care, Lower Costs, and Better Health IOM Roundtable on Value & Science-Driven Health Care September 27, 2012 Washington, D.C. Sam Nussbaum, M.D. Executive Vice President, Clinical
More informationForeign Service Benefit Plan
Simple Steps to Living Well Together Foreign Service Benefit Plan 2018 Wellness Benefits and Incentive Rewards Health Plan Accredited by The FOREIGN SERVICE BENEFIT PLAN has Health Plan Accreditation from
More informationDual-eligible SNPs should complete and submit Attachment A and, if serving beneficiaries with end-stage renal disease (ESRD), Attachment D.
Attachment A: Model of Care for Dual-eligible SNPs MA Contract Name: Geisinger Health Plan MA Contract Number: H3954-097 Type of Dual-eligible SNP: Full The model of care describes the MAO's approach to
More information2015 Member Incentive. Program Evaluation. Our mission is to improve the health and quality of life of our members
25 Member Incentive Program Evaluation Our mission is to improve the health and quality of life of our members 25 Member Incentive Program Evaluation Annual Participation Rate Program Title: Member Incentive
More informationPharmacy Quality Measures. Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2013
Pharmacy Quality Measures Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2013 Objectives Explain the purpose of quality measures and how they are developed Identify quality
More informationProvider Information Guide Complex Care and Condition Care Overview
Complex and Overview Introduction Complex and are essential components of Passport Health Plan s (Passport) Coordination services, which are used to support the practitioner-patient relationship and plan
More informationHow to Improve HEDIS Reporting Among Providers and Improve Your Health Plan Rankings
How to Improve HEDIS Reporting Among Providers and Improve Your Health Plan Rankings Introduction In today s value-focused market, health plan rankings, such as those calculated by the National Committee
More informationProvider Training Quality Enhancement 2016
Provider Training Quality Enhancement 2016 1 What s Ahead? Why Are We Here? 3 NCQA Accreditation & HEDIS 4-6 Medicare Start Rating & HEDIS 7 Provider s Role and Expectation 8-11 Staying Healthy During
More informationBenchmark Data Sources
Medicare Shared Savings Program Quality Measure Benchmarks for the 2016 and 2017 Reporting Years Introduction This document describes methods for calculating the quality performance benchmarks for Accountable
More informationAnthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect. Quality improvement strategies
Serving Hoosier Healthwise, Healthy Indiana Plan Quality improvement strategies Learning objectives At the conclusion of this session, participants will be able to describe: Managed care products and eligible
More informationQuality Management Utilization Management
Aetna Better Health Aetna Better Health Kids Quality Management Utilization Management 2015 Program Evaluation EXECUTIVE SUMMARY Aetna Better Health, a Medicaid Physical Health-Managed Care Organization
More informationFlorida Medicaid. Managed Care Quality Assessment and Improvement Strategies. 2011/2012 Update
Florida Medicaid Managed Care Quality Assessment and Improvement Strategies 2011/2012 Update Agency for Health Care Administration Florida Medicaid s quality assessment and improvement strategies reflect
More informationAssistance. Improving. Consumer Health. Strategies for
Assistance Strategies for Improving Consumer Health A resource to help educate consumers about available preventive health incentives and eliminating barriers to receiving care www.bhpi.org www.healthsharesolutions.org
More information