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 the QI program is to continuously improve the quality and safety of clinical care, including behavioral health care, and the quality of services provided to Plan members/enrollees within and across healthcare organizations, settings and levels of care. CareFirst strives to provide access to healthcare that meets The Institute of Medicine’s (IOM) 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 service and satisfaction
- Efficient use of resources
Specific QI Program goals and objectives are:
- Support and promote all aspects of the CareFirst Patient Centered Medical Home (PCMH) program and the Total Care and Cost Improvement (TCCI) programs as a means to improve quality of care, safety, access, efficiency, coordination and service.
- Expand the “Common Model” for Medicare fee-for-service beneficiaries beyond the CMMI Innovation Grant to support financial extension or expansion for Medicare Members.
- Maintain overall Medical Trend at or below 3.5 percent for the third consecutive year.
- Identify criteria for each TCCI program to ensure appropriate Members are engaged.
- Implement methods, tracking, monitoring, and oversight processes for all TCCI Programs to measure their value and impact.
- Meet targeted TCCI goals, in order to achieve a measurable reduction in the need for hospital and outpatient services.
- Establish collaborative partnerships to proactively engage clinicians, providers, and community hospitals and organizations to implement interventions that address the identified (medical and behavioral) health and service needs of our membership throughout the entire continuum of care and those that are likely to improve desired health outcomes;
- Promote the provision of data and support to clinicians to promote evidence-based clinical practice and informed referral choices;
- Maintain a systematic process to continuously identify, measure, assess, monitor and improve the quality, safety and efficiency of clinical care (medical and behavioral health), and quality of service;
- Assess the race, ethnicity, language, interpreters, cultural competency, gender identity, and sexual orientation needs of our diverse populations while considering such diversity in the analysis of data and implementation of interventions to reduce health care disparities;
- Monitor and oversee the performance of delegated functions especially for high priority partners (CVS, Magellan, Healthways and Medtronic);
- Develop and maintain a high quality network of health care practitioners and providers;
- Operate a QI Program that is compliant with and responsive to federal, state, and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies;
- Utilize iCentric, the core operating system used by TCCI participants, to seamlessly connect members to their programs.
- Provide insight based on Searchlight data to increase the knowledge base of the Medical Panels outcome measures;
- Efficiently serve more than 100,000 members in The PCMH/TCCI platform in 2015.
- Address health needs of all patients along the health care continuum, including those with complex health needs; and
- Support quality improvement principles throughout the organization; acting as a resource in process improvement activities.
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.
|Support and promote all aspects of PCMH and TCCI Programs as a means to improve quality of care, safety, access, efficiency, coordination and service.||
|Establish collaborative partnerships with clinicians, hospitals and organizations to implement interventions that address the identified (physical and behavioral) health and service needs of our Membership throughout the entire continuum of care in order to improve desired health outcomes.||
|Provide data to clinicians to promote evidence- based clinical practice and informed referral choices.||
|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 linguistic needs of our diverse populations and consider such diversity in the analysis of data and implementation of interventions to reduce health care disparities.||
|Monitor and oversee the performance of delegated functions.||
|Develop and maintain a high quality network of health care practitioners and providers by enhancing credentialing requirements and contributing to a systematic monitoring and evaluation process.||
|Operate a QI Program that is compliant with and responsive to 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 QI principles throughout the organization, acting as a resource in process improvement.||