Quality Improvement Program
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
QI Program Goals and Objectives
- 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 extension for Medicare members.
- Maintain overall medical trend at or below 4.5 percent.
- Implement methods, tracking, monitoring, and oversight processes for all TCCI Programs to measure their value and impact for appropriate patients with complex health care needs.
- All elements of the CareFirst TCCI program will be operating at targeted levels in 2016 (cumulative/active at year end):
- Percent Admissions Triaged by HTC = 99 percent
- Complex Case Management Care Plans = 40,000
- Behavioral Health and Substance Abuse Care Plans = 10,000
- Comprehensive Medication Review Cases = 7,500
- Chronic Care Coordination Active Care Plans = 16,000/10,000
- Specialty Pharmacy Coordination Cases = 11,000
- Behavioral Health Pharmacy Consultation = 300
- Medication Therapy Management = 500,000
- Home Based Services Cases = 10,000
- Community Based Program Cases = 5,000
- Enhanced Monitoring Program Cases = 5,000
- Expert Consult Cases Tier 1 = 750
- Expert Consult Cases Tier 2 = 250
- 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 and members to use their benefits to their fullest.
- 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, improve network adequacy and improve cultural competency in materials and communications.
- Monitor and oversee the performance of delegated functions especially for high priority partners (CVS Caremark, Magellan, Healthways and Medtronic).
- 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.
- 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.
- Provide insight based on SearchLight data to increase the knowledge base of the medical panels in the evaluation of their outcome measures.
- 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).
- Support quality improvement principles throughout the organization; acting as a resource in process improvement activities.
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.
|2015 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.||
|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.||