Legal & Mandates
- 2015 ACA Rate Increase Justification
- Patient Rights & Responsibilities
- Health Care Fraud Prevention
- Quality Improvement
- Mental Health Parity
- MD Proposed Rate Increase Law
- Virginia Claims or Coverage Denials
Quality Improvement Program
The goal of CareFirst’s Quality Improvement (QI) Program is to constantly improve the quality and safety of clinical care, including behavioral health care, and the quality of services provided to our members. CareFirst works to provide access to health care that meets The Institute of Medicine’s aims of being “safe, timely, effective, efficient, equitable and patient‐centered.”
The quality process supports ongoing efforts to improve clinical care and services through activities such as:
- assessment and improvement of clinical care
- safe clinical practices
- measuring quality of services and satisfaction
- efficient use of resources
- interventions to provide accessible, efficient, quality health care for every member
The QI Program’s objectives are to:
- Support and promote all aspects of the CareFirst Patient‐Centered Medical Home (PCMH) and Total Care and Cost Improvement (TCCI) programs in order to improve quality of care, safety, access, efficiency, coordination and service.
- Meet targeted TCCI goals, in order to achieve a measurable reduction in the need for hospital inpatient and outpatient services.
- Meet PCMH "Measures That Matter" goals related to the number of emergency room visits, hospital admissions and hospital readmissions.
- Establish partnerships with clinicians and organizations to put into action interventions that address the identified health and service needs of our membership and that are likely to improve desired health outcomes.
- Provide data that encourages clinicians to practice evidence‐based medicine and make informed choices when making referrals.
- Maintain a systematic process to continuously identify, measure, assess, monitor and improve the quality, safety and efficiency of clinical care and quality of service.
- Assess the cultural, ethnic and language needs of our members and consider such diversity when analyzing data and implementing interventions to reduce health care disparities.
- Monitor and oversee the performance of delegated functions of certain vendors and large provider groups.
- Develop and maintain a high quality network of health care providers.
- Operate a QI Program that meets federal, state and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies.
- Address health needs of the communities we serve.
- Support quality improvement principles throughout CareFirst, acting as a resource in process improvement.
CareFirst recognizes that large racial and ethnic health disparities exist and that communities are becoming more diverse. Racial, ethnic and cultural background influence a member’s view of health care and its results. CareFirst uses member race, ethnic and language data to find where disparities exist, and uses the information in quality improvement efforts.
The QI team, with input from appropriate CareFirst staff, writes a detailed description of all the completed and ongoing QI activities on the QI Work Plan for the year. The Quality Improvement Council and the Service & Quality Oversight Committee review the QI Program Evaluation at least once a year.
2013 QI Program Goals
|Support and promote all aspects of the CareFirst Patient-Centered Medical Home (PCMH) Program.||
|Form partnerships with clinicians and organizations to identify our members’ health and service needs and work on programs to make improvements in these areas.||
|Provide data that encourages clinicians to practice evidence-based medicine and make informed choices when making referrals.||
|Maintain a systematic process to continuously identify, measure, assess, monitor and improve the quality, safety and efficiency of clinical care (physical and behavioral health), and quality of service.||
|Assess the cultural, ethnic and language needs of our members and consider such diversity when analyzing data and implementing interventions to reduce health care disparities.||
|Monitor and oversee the performance of delegated functions of certain vendors and large provider groups.||
|Develop and maintain a high quality network of health care practitioners and providers.||
|Operate a QI Program that meets federal, state, and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies.||
|Address health needs of the communities we serve.||
|Support Quality Improvement principles throughout the organization, acting as a resource in process improvement.||