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Quality Improvement Program

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Our 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
Program Objectives

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.
  • 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 we use 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.

Goals
Evaluation
1. Support and promote all aspects of CareFirst’s PCMH Program.
  • Program launched January 2011.
  • 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.

 

2. Form partnerships with clinicians and organizations to identify our members’ health and service needs and work on programs to make improvements in these areas.
  • Partnership with Healthways, Inc. to provide Local Care Coordinators to CareFirst’s PCMH practices.
  • Working with Holy Cross Hospital to provide Community Based services for members with congestive heart failure.
  • Behavioral health visits to CareFirst PCPs are now part of PCMH and focus on educating PCP practices about the role of Magellan in the PCMH program and making them aware of the services offered to members. Magellan staff has also educated physician groups on behavioral health issues, provided simple screening tools to assess potential behavioral health issues and outlined referral processes to access services.
3. Provide data that encourages clinicians to practice evidencebased medicine and make informed choices when making referrals.
  • Continuing to use the MedVantage HealthSmart application, used to build a library of evidencebased clinical quality measures and care alerts. CareFirst monitors and reports compliance with guidelines by using claims data and verification from practitioners. Physicians can monitor their patients’ compliance and any gaps in care.
  • Providing SearchLight reports to PCMH panels, allowing PCMH practices access to secured, webbased data and reporting.
4. Maintain a systematic process to continuously identify, measure, assess, monitor and improve the quality, safety and efficiency of clinical care and quality of service.
  • Conducted HEDIS® and CAHPS® surveys, showing use of services and satisfaction.
  • Ongoing monitoring of PCMH outcomes in both clinical care and service  –  practitioners provided with a yearly 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 Evaluation.
5. 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.
  • PCMH practitioners and coordinators are offered a “Communicating with Patients” training module. Using this module, practitioners and their staff can learn to overcome cultural differences, language barriers and low health literacy to effectively assist their patients.
  • To meet the language needs of members, CareFirst offers the AT&T Language Line at no cost to members and providers. CareFirst also provides an online site in Spanish, and produces educational materials, brochures and mailings in Spanish.
  • 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.
  • CareFirst donated funds to reduce or eliminate racial disparities and to improve the quality and safety of care in the communities we serve. Through CareFirst Commitment, CareFirst has formed partnerships with community groups to address infant mortality in the District of Columbia, Maryland and Northern Virginia. CareFirst also provides care coordination and PCMH services to safety net clinics in those areas.
6. Monitor and oversee the performance of delegated functions of certain vendors and large provider groups.
  • CareFirst oversees delegates’ performance against standards for quality improvement, utilization management, case management, disease management, credentialing, and member connections. We create and monitor corrective action plans as needed.
7. Develop and maintain a high quality network of health care providers.
  • 3,119 new practitioners credentialed in 2012.
  • 3,128 practitioners re‐credentialed in 2012.
  • CareFirst monitors and oversees credentialing for our delegated provider groups.
8. Operate a QI Program that meets federal, state, and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies.
  • Maintained NCQA Commendable accreditation for both HMO/POS (BlueChoice) and PPO(BluePreferred).
  • Demonstrated full regulatory compliance in Maryland for BlueChoice and in Virginia for BlueChoice and BluePreferred.
9. Address health needs of the communities we serve.
  • Expanded the Total Care and Cost Improvement (TCCI) Program, the centerpiece of which is our PCMH Program. TCCI includes a number of key factors designed to involve individuals and improve and manage health, including:
    • Hospital Transition of Care Program – ensures coordination and continuity of health care as patients transfer between different locations following a hospital admission.
    • Complex Case Management (CCM) – available for patients with advanced or critical illnesses – case managers provide care coordination services together with all specialists involved in the patient’s care.
    • Chronic Care Coordination Program (CCC) – Local Care Coordinators are assigned to each PCMH practice and carry out Care Plans developed under the direction of the PCP to provide coordination of care for patients with multiple chronic illnesses.
    • Home Based Services Program – available to patients in CCM or CCC who need support at home, sometimes for a long period of time.
    • Enhanced Monitoring Program – focuses on patients at high risk for breakdown leading to a hospital admission or emergency room visit due to ongoing, usually chronic conditions and illnesses.
    • Pharmacy Personal Advisor Program – assess and review pharmacy claims to identify high possibility of drug interaction, overdosing, side effects, etc. – local pharmacists provide patient‐specific counseling and education.
    • Specialty Pharmacy Coordination Program – available for patients with certain diseases that require high‐cost biologic or other pharmaceuticals that must be given according to precise 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.
    • Community Based Program – a group of local programs, such as diabetes education/management, cardiac rehab and palliative care.
    • Urgent Care Backup Program – offers, where available, organized backup to PCMH panels as after‐hours support for patients with urgent care needs.

  • Provide Wellness programs to keep members healthy – health risk assessment, health advisor, telephonic and online coaching, onsite screenings and wellness seminars.
10. Support quality improvement principles throughout the organization, acting as a resource in process improvement.
  • Continuing to work with other CareFirst departments on an ongoing basis.

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