Quality Improvement

Quality Improvement

We shall implement and maintain an ongoing, comprehensive quality assessment and performance improvement program. The Centers for Medicare and Medicaid Services (CMS) defines quality as the degree to which the contractor increases the likelihood of desired outcomes of its members through its structural and operational characteristics, the provision of services that are consistent with current professional, evidence-based knowledge and interventions for performance improvement.

Quality Improvement

Quality improvement program activities shall, at a minimum, consist of the following:• Performance improvement projects• Collection and submission of performance measurement

data, including member experience of care• Mechanisms to detect both underutilization and

overutilization of services• Mechanisms to assess the quality and appropriateness of

care furnished to members with special health care needs • Quality of care concerns• External quality review• Advisory committees and learning collaboratives

Performance Improvement Projects

• We shall conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care and non-clinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction.

• We shall complete performance improvement projects annually to facilitate the integration of project findings and information into the overall quality assessment and improvement program.

Performance Measurement

• We shall participate in the measurement and reporting of performance measures required by the Department of Health Care Policy and Financing (HCPF), with the expectation that this information will be placed in the public domain.

• We shall consult with HCPF to develop measurement criteria, reporting frequency and other performance measurement components.

• We shall provide data, as requested, to enable HCPF or its designee to calculate the performance measures, unless the data is already in HCPF’s possession.

• We shall support network providers to collect and report information required to calculate the performance measures.

Member Experience of Care

• We shall monitor member perceptions of well-being and functional status, as well as accessibility and adequacy of services.

• We shall use tools to measure member perception and those tools shall include, at a minimum, the use of member surveys, anecdotal information, call center data, and grievance and appeals data.

Member Experience of Care

• We shall assist HCPF or it’s designated vendor with the annual administration of the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS) for both adults and children to measure member satisfaction with network providers.

• We shall support HCPF in administering the Experience of Care and Health Outcomes (ECHO) survey for behavioral health developed by the Office of Behavioral Health among members accessing behavioral health services at community mental health centers (CMHC) and other contracted behavioral health providers.

Quality Improvement

Mechanisms to Detect Overutilization and Underutilization of Services• We shall implement and maintain mechanisms to

detect overutilization and underutilization of services, and to assess the quality and appropriateness of care furnished to members, including members with special health care needs.

• We shall monitor members’ utilization of services and pharmaceuticals, and coordinate ongoing care.

Quality of Care Concerns

• We shall investigate any alleged quality of care (QOC) concerns, which are defined as concerns raised by HCPF or providers, or concerns discovered by the Contractor. The Contractor shall not consider member complaints about care to be QOC concerns and should process these complaints as grievances

• For QOC concerns involving network providers, the regional organization may use the process of its professional review committee, as set forth in sections 12-36.5-104 and 12-36.5-104.4, C.R.S.

External Quality Review

• Annually, we shall participate in an external independent site review and performance measure validation. External quality review activities shall be conducted in accordance with federal regulations 42 C.F.R. § 438 and the CMS mandatory activity protocols.

External Quality Review

This annual external review may include, but is not limited to, the following:• Medical record review- for external review activities involving medical

record abstraction, we shall obtain copies of the medical records from the sites in which the services reflected in the encounter occurred at no cost to HCPF or its vendors

• Performance improvement projects and studies

• Surveys

• Network adequacy during the preceding 12 months

External Quality Review

This annual external review may include, but is not limited to, the following:• Calculation and audit of quality and utilization indicators

• Administrative data analyses

• Review of individual cases

• Care coordination record review

• Provider site visits

• Encounter data validation

Quality Improvement

Advisory Committees and Learning Collaboratives• Program Improvement Advisory Committees (PIAC) –

We shall participate in both a statewide and regional PIAC to engage stakeholders and provide guidance on how to improve health, access, cost, and satisfaction of members and providers in the program.

• Operational Learning Collaborative – We shall participate in a monthly department operational learning collaborative to monitor and report on ourselves and the Accountable Care Collaborative.