Quality Improvement Program

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The goal of the Quality Improvement (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 within and across health care organizations, settings and levels of care. CareFirst strives to provide access to health care that meets the Institute of Medicine’s aim of being safe, timely, effective, efficient, equitable and patient-centered.

The QI 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:

  1. Address needs of all patients along the entire health care continuum, including those with complex health needs (advanced developmental, chronic physical and/or behavioral illness, or complicated clinical situations);
  2. Support and promote population health initiatives through all aspects of the CareFirst Patient Centered Medical Home (PCMH) and the Clinical Programs to improve quality of care, safety, access, efficiency, coordination, and service;
  3. Maintain overall Medical Trend, including pharmacy, at or below 5.0 percent;
  4. Implement methods, tracking, monitoring, and oversight processes for all Clinical Programs to measure their value and impact for appropriate patients with complex healthcare needs;
  5. Establish collaborative partnerships to proactively engage clinicians, providers, hospitals and other community organizations to address the identified (medical and behavioral) health and service needs of our membership throughout the entire continuum of care which are likely to result in improved health outcomes;
  6. Promote the provision of quality and cost data and support to clinicians to promote evidence-based clinical practices and informed referral choices; and members’ full utilization of their benefits;
  7. 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 services;
  8. 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, improve network adequacy and improve cultural competency in materials and communications;
  9. Monitor and oversee the performance of delegated functions especially for high priority partners (CVS, Sharecare and AIM);
  10. Develop and maintain a high-quality network of health care practitioners and providers meeting the needs and preferences of its membership by maintaining a systematic monitoring and evaluation process;
  11. 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;
  12. Provide insight based on Searchlight data, a data repository in iCentric where data is categorized by Panel, PCP, and/or Practice, to increase the knowledge base of the Medical Panels in the evaluation of their outcome measures;
  13. Support quality improvement principles throughout the organization; acting as a resource in process improvement activities;
  14. Heighten enterprise-wide awareness and understanding of quality through an ongoing communication strategy directed toward all levels of the organization;
  15. Develop and maintain the highest quality of health care; ensure positive health outcomes for our specific populations; keep cost at a minimum, and enable member access to the full spectrum of needed healthcare services; and
  16. Create an awareness for social determinants of health; including, what they are and how they affect our members’ ability to fulfill their health goals.

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.

QI Program

2018 QI Program GoalsEvaluation
Support and promote all aspects of the CareFirst Patient Centered Medical Home (PCMH) program and the Total Care and Cost Improvement (TCCI) programs to improve quality of care, safety, access, efficiency, coordination, and service. High adoption of the Core Target by providers. Each month 99% of the 40,000 high risk Core Target Members were successfully assessed and connected to supporting services as clinically appropriate. Improvement in PCMH panel engagement and cost savings continued, with 72% of panels earning outcome incentive awards in 2018. In 2017, CareFirst helped save 223 million dollars against the expected cost of care.
Maintain a high-quality network of providers and practitioners to meet the needs of the population we serve. CareFirst intentionally increased the behavioral health network by 2,000 providers in the PPO and over 3,000 providers in the HMO. In 2018, 97.4% of claims by volume were paid to the 51,307 providers in the CareFirst network.
Maintain overall Medical Trend at or below 5.0 percent. In-area medical trend (adjusted for rebates, excluding Affordable Care Act) was 5.47% for 2018 – slightly above the target goal of 5%. The admission rate held steady in 2018, however, the readmission rate decreased by 4.3%.
Implement methods, tracking, monitoring, and oversight processes for all TCCI Programs to measure their value and impact for appropriate patients with complex healthcare needs. A program management and accountability structure was in place for each TCCI program. An in-depth program evaluation was completed in the fall and determined positive results (clinical or financial) for programs.

Ensure all elements of the CareFirst TCCI Program will be operating at targeted levels in 2018 (maintaining at least 4 out of 5 quality score) by actively managing core target list identifying members with complex health needs:

  • Percent Admissions Triaged by Hospital Transition of Care (HTC) = 99%
  • Comprehensive Medication Review (CMR):
  • CMR Tier 1 Service Requests: 4,000
  • CMR Tier 2 Interventions with Recommendations: 720,000
  • CMR Tier 2 Percent of Drug Savings Review Recommendations Implemented: 60%
  • Medical and Behavioral Health Care Coordination Care Plans = 37,500
  • Specialty Pharmacy Coordination Cases = 12,000
  • Home Based Services Cases = 10,000
  • Community Based Program Cases = 5,000
  • Enhanced Monitoring Program Cases = 4,000
  • Expert Consult Cases Tier 1 = 1,500
  • Expert Consult Cases Tier 2 = 400
  • Telemedicine encounters = 4,000 video visits
  • Percent Admissions Triaged by HTC = 99%;
  • Comprehensive Medication Review (CMR):
i. CMR Tier 1 Service Requests: 2,370
ii. CMR Tier 2 Interventions with Recommendations: 747,637
iii. CMR Tier 2 Percent of Drug Savings Review

Recommendations Implemented: 60%;

  • Medical and Behavioral Health Care Coordination Care Plans = 36,125 Quality score for adult was 72.7 and for pediatrics it was 72.0.
  • Specialty Pharmacy Coordination Cases = 11,033
  • Home Based Services Cases = 3,602;
  • Community Based Program Cases = 3,280;
  • Enhanced Monitoring Program Cases = 3,568;
  • Expert Consult Cases Tier 1 & Tier 2 = 826
  • Telemedicine encounters = 15,982 video visits

In some but not all cases, target goals were met. For those not meeting target goals, we continue to monitor performance to ensure goals are met in the upcoming year. Specific programs have implemented changes to help reach goals and serve our members to our best ability.

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. Clinical compacts were established between primary care and specialty providers.
  • Utilized committees to assure oversight for our key partners.
  • We worked collaboratively with Sharecare, Medtronic, and CVS to align their programs with our clinical programs.
  • iCentric was enhanced to support bi-directional data exchange.
  • Community providers, hospitals, and specialists were engaged in the development of these enhancements.
  • CareFirst partnered with national specialty organizations in the development of clinical programs.
Promote the provision of quality and cost data and support to clinicians to promote evidence-based clinical practice and informed referral choices and members to use their benefits to their fullest. iCentric, our online health record system, offers 24/7 access to population and member specific claims and care coordination data for members engaged in a care plan. This system is used to document the members’ history, current health status, and progress toward meeting goals. SearchLight reports are available to practitioners, practices, and at the panel levels so they may evaluate aggregate performance and utilize data to identify those attributed members needing support. Practice Consultants assist PCMH panels in data analysis and identify potential opportunities for increased cost savings and improved quality. Additionally, Local Care Coordinators (LCCs) reinforced the availability and functionality of portal tools for PCPs to assist with population management. CareFirst offered Primary Care Physicians (PCP) specific experience to help them identify cost data for specialists and make informed referrals.
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. CareFirst utilized industry standard reporting measures such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Clinical Quality, Customer Service, and Resource Use Measures (QCR), and Quality Rating System (QRS) to compare plan performance to national standards and benchmarks for 13 reporting populations. Clinical Quality Scorecards were used for ongoing monitoring of PCMH outcomes by tracking and assessing clinical care, efficiency, and service. Beginning in 2013, Engagement Score rates across all panels have continued to improve by 19.3% annually. CareFirst assessed and measured quality, safety, and efficiency of clinical care and quality of service through the annual Quality Improvement Program and by monitoring delegate performance; and incorporated input from providers, practitioners, members, and partners in assessing quality and access to care.
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, improve network adequacy and improve cultural competency in materials and communications. Spanish was the predominant non-English language within our region. CareFirst offered multiple avenues to reach our diverse membership. The Language Line provided interpreters, at no cost to members and providers. CareFirst’s Disease Management and Wellness programs offered printed educational materials in English and Spanish. Multi-lingual nurses were employed in our call centers. Our Health Risk Assessment was available in Spanish online and in printed format. Within care plans, members were queried as to cultural and ethnic preferences. Through CareFirst Commitment, funds were provided to community organizations to reduce or eliminate racial disparities and improve the quality and safety of care in the regions we serve. Local Care Coordinators (LCCs), assigned to PCMH practices, lived and worked in their specific regions. These individuals are familiar with the local health care systems and support and tailor care plans to the populations they serve. CareFirst directly collected Cultural, Ethnic, Racial, and Linguistic (CERL) information from members and indirectly inferred race/ethnicity from analysis of zip code.
Monitor and oversee the performance of delegated functions especially for high priority partners (CVS, Sharecare, and Medtronic). CareFirst oversaw delegates’ performance and assured compliance with accreditation, regulatory, and CareFirst standards. The following functions were delegated: quality improvement, utilization management, case management, pharmaceutical safety, disease management, credentialing, networks, wellness, and member connections. Magellan delegation was revoked for Credentialing and Networks effective January 1, 2018 and for Case Management, Quality Improvement, and Utilization Management effective April 1, 2018. Extensive discussion took place between CareFirst and Sharecare to delegate Wellness and Disease Management prior to agreement on January 1, 2018. Delegation discussions began with new delegation entities, including AIM for Utilization Management; Triage Logic, and ProtoCall for the Behavioral Health Triage Line. With expanding delegation activities, a Delegation Oversight Committee was formed in 2018 to assure complete monitoring of all delegates based on delegation agreements and compliance requirements.
Develop and maintain a high-quality network of health care practitioners and providers meeting the needs and preferences of its membership by maintaining a systematic monitoring and evaluation process. 4,195 practitioners were added to the CareFirst network. Overall provider data accuracy improved through greater automation with Council for Affordable Quality Healthcare (CAQH), increasing accuracy from 54% to 60% on a practitioner basis and 73% to 80% on an individual data element basis. The Networks Management team successfully transitioned the Behavioral Health network from Magellan to CareFirst in 2018, with 96% of providers re-contracted and 92% of institutional contracts completed. Behavioral Health network-in-network providers performed well with 100% of appointments scheduled within the standard timeframes, and 50 additional providers added. In 2018, 97.4% of claims were paid to in-network providers. For the 6th year in a row, CareFirst continued to rank #1 for HMO professional discounts, based on the latest result from Hewitt benchmarking reports. Networks completed the quarterly termination process for providers with zero-dollar payments in the prior six months.
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. This past summer NCQA conducted a discretionary survey for our Behavioral Health program, since we brought it on last April. This survey confirmed CareFirst was in compliance with Behavioral Health Standards.
Provide insight based on Searchlight data to increase the knowledge base of the Medical Panels in the evaluation of their outcome measures. We successfully launched customizable reporting functionality in 2018 in order to supply providers with more tailored information to drive practice transformation. Business plans for all Tier 1 and 2 Panels (and some Tier 3 Panels in multi-Panel enterprises) drove conversations with providers and practice administrators about their initial record of performance in 2018 vs. their desired end state for the year. These insights promoted improved referral patterns through the provision of specialist data available within SearchLight.
Address health needs of all patients along the health care continuum, including those with complex health needs (advanced developmental, chronic physical and/or behavioral illness, or complicated clinical situation). Patient Activation Measure (PAM) correlates with future ER visits, hospital admissions and readmissions, medication adherence and more. Patient activation is regularly assessed among members receiving care coordination. In 2018, the PAM score for members in a care plan increased by 8.41 points, correlating to a 17% decrease in hospitalizations and an 17% increase in medication adherence. The PCMH team assessed an average of 99% of Core Target 1 and Core Target 3 identified members during 2018. Assessment included a discussion between the LCC and the PCP.
Support the migration of behavioral health program from delegation to internal functions. In February, Behavioral Health Care Coordination (BHCCs) transitioned to CareFirst and all operations were fully in house on April 1, 2018. There was no disruption in ongoing care plans as a result of the transition. By year-end, over 3,100 Behavioral Health and Substance Use cases were touched by hospital coordinators and nearly 10,000 care plans were managed by behavioral health care coordinators. Behavioral health support was also added to our Hospital Transition of Care team, with on-site nurses at the largest behavioral health facilities and telephonic support at all other facilities. Behavioral health support was also added to our national case management team supporting members all over the United States. All programmatic decisions and processes have been designed to comply with mental health parity and a formal internal evaluation is in progress to ensure all components follow and maintain parity.
Support quality improvement principles throughout the organization; acting as a resource in process improvement activities. The QI team continues to focus on quality improvement initiatives throughout the organization, using our Quality Improvement Committee (QIC) as the platform to present and discuss quality improvement projects and concerns. These improvements are documented through our committees’ minutes to show how we are acting on the specific area’s quality concerns. Quality Improvement Specialists worked within intra-divisional and interdivisional work teams to promote quality improvement throughout the organization.

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