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Legal & Mandates

Quality Improvement Program

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Our 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
Program Objectives

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.

Program Evaluation

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.

2014 QI Program Goals
Evaluation
Support and promote all aspects of PCMH and TCCI Programs as a means to improve quality of care, safety, access, efficiency, coordination and service.
  • Over 85% of CareFirst Primary Care Practitioners (including Nurse Practitioners) participate in the PCMH program.
  • Over 1 million CareFirst Members are cared for by PCMH practitioner panels.
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.
  • Collaboration with Healthways, Inc. was expanded to include care coordination for commercial and Medicare PCMH and Complex Case Management (CCM), disease management, wellness, and lifestyle management.
  • CareFirst worked with Magellan Behavioral Healthcare aligns behavioral health and substance abuse care to support and enhance PCMH.
  • On January 1, 2014 CVS became the Pharmacy Benefits Manager for CareFirst and throughout 2014, CareFirst collaborated with CVS/Caremark to establish care coordination programs (comprehensive medication review and specialty programs) and convenience care access.
  • Partnerships were developed to support and enhance TCCI care coordination programs, which include:
  • Hospice and Skilled Nursing Facility (SNF) Partners: Genesis, HCR ManorCare, FutureCare and Lorien. In total, there are 63 SNFs associated with these organizations.
  • Best Doctors provides “interconsultation” to provide an expert review of complex cases.
  • CardioCom is a wholly owned subsidiary of the Medtronic Corporation specializing in remote monitoring services which will be the vehicle for the Enhanced Monitoring Services Program.
  • Preferred partners to provide home based services.
Provide data to clinicians to promote evidence- based clinical practice and informed referral choices.
  • Through iCentric, Providers have 24/7 access to population and Member specific claims based and care coordination data.
  • SearchLight reports are available at Practitioner, practice and panel levels allowing panels to evaluate aggregate performance and utilize data to identify those attributed Members needing support.
  • Program Consultants are provided to PCMH panels; to analyze data and highlight potential opportunities for increased cost savings and improved quality. Additionally, they reinforce the availability and functionality of portal tools that are available to PCPs to assist them with population management.
  • CareFirst specific experience was used to identify quality and cost information to help Primary Care Physicians (PCP) make informed 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.
  • HEDIS® and CAHPS® measurements were used to compare plan performance to national standards and benchmarks.
  • Ongoing monitoring of PCMH outcomes in both clinical care, efficiency and service – practitioners annually provided with a PCMH report card, which stores and tracks all quality measures that play a key role in the panel’s Outcome Incentive Award.
  • Assess and measure quality, safety and efficiency of clinical care and quality of service through the annual Quality Improvement Program and monitoring of delegate performance.
  • Incorporates input from providers, practitioners, Members and partners to improve quality and access to care.
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.
  • CareFirst offers multiple avenues to reach our diverse Membership.
  • The Language Line provides interpreters, at no cost to Members and providers.
  • CareFirst’s Disease Management and Wellness programs offer printed educational materials in English and Spanish. In addition, multi-lingual nurses are employed in our call centers. Our Health Risk Assessment is available in Spanish for online and printed formats.
  • Within care plans, Members are queried as to cultural and ethnic preferences.
  • Through CareFirst Commitment, funds are provided to community organizations to reduce or eliminate racial disparities and to improve the quality and safety of care in the regions we serve.
  • Priorities for strategic giving for 2014 were concentrated in the following five areas: 1) Maternal Health, BMore for Healthy Babies 2) Nursing Shortage, Project RN 3) Telemedicine in Behavioral Health 4) Safety Net programs 5) Community Foundations.
  • Local Care Coordinators (LCCs), assigned to PCMH practices, live in their specific region and are familiar with the health care systems in that area, enabling them to tailor care to the population they serve.
Monitor and oversee the performance of delegated functions.
  • CareFirst oversees delegates’ performance and assures compliance with accreditation, regulatory and CareFirst standards. The following functions are delegated: quality improvement, utilization management, case management, pharmaceutical safety, disease management, credentialing, wellness and Member connections.
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.
  • Through its two provider networks, CareFirst has a network of highly qualified providers and practitioners to meet the needs of Members that it serves. In its credentialing process:
    • 3,173 new practitioners credentialed in 2014
    • 2,973 practitioners re-credentialed in 2014
    • CareFirst monitors and oversees credentialing for our delegated provider groups.
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.
  • Awarded NCQA Health Plan accreditation for both HMO/POS (BlueChoice) at the Accredited level and PPO (BluePreferred) at the Commendable level.
  • Full regulatory compliance in Maryland for BlueChoice and in Virginia for BlueChoice and BluePreferred.
  • Awarded Managed Care Health Insurance Plan (MCHIP) Certification of Quality Assurance for Virginia products.
  • Integrated Marketplace QI Strategies to maintain compliance with CMS regulations for Exchange product offerings.
Address health needs of the communities we serve.
  • Expanded the TCCI Program. TCCI incorporates a number of key components designed to engage individuals and improve and manage health including:
    • Health Promotion, Wellness and Disease Management Services Program – Consists of lifestyle and Disease Management coaching by licensed professional coaches who are expert in motivating people toward healthier lifestyles and reducing risk if they are headed towards or already have certain common chronic diseases.
    • Pharmacy Coordination Program – Available for patients with certain diseases that require high cost biologic or other pharmaceuticals that must be administered according to rigorous treatment plans.
    • Expert Consult Program – offers an outside expert opinion from leading physicians in the field(s) needed by the patient with a highly complex diagnosis, condition, or disease.
    • Urgent Care & Convenience Access Program – Offers, where available, organized backup to PCMH panels as after-hours support for patients with urgent care needs.
    • Centers of Distinction Program – To include highly specialized, high cost categories of care that are accessed by targeted referrals to centers throughout the country that have been prescreened and certified by BCBSA.
    • Behavioral Health and Substance Abuse Program – To include a range of services that target the mental health issues of a Member that often accompany physical illnesses or that may stand alone.
    • Preauthorization Program – A review of certain proposed services to Members that are usually infrequent but that are high cost and where evidence of medical need must be established before approval for payment is given.
    • Telemedicine Program – Offers the integration of voice, data, and image to create a virtual visit to a provider for a Member.
  • Provide wellness programs to keep Members healthy, which include a health risk assessment, health advisor, telephonic and online coaching, onsite screenings and wellness seminars.
Support QI principles throughout the organization, acting as a resource in process improvement.
  • Through QI committee framework, Process Improvement Specialists work within intra and interdivisional areas with collaborative work teams to promote quality improvement.

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