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

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.

QI Program

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.
  • Over 85 percent of CareFirst Primary Care Practitioners (PCPs), including Nurse Practitioners, participate in the PCMH program. An additional 328 PCPs were added to the program, including all practices previously in the state of Maryland’s PCMH pilot.
  • 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.
  • Developed committees to assure oversight for our key partners. Worked collaboratively with Healthways, Magellan, Medtronic and CVS Caremark to align their programs with our PCMH program.
  • Enhanced iCentric to support bi-directional data exchange.
  • Engaged community providers, hospitals, specialists in the development of enhancements.
  • Partnered with national specialty organizations in the development of TCCI programs, and evaluation of the program.
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 of specialists to help PCPs 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® CAHPS® and QRS 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 QI 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.
  • Local Care Coordinators, 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, networks, 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:
    • 2,684 new practitioners credentialed in 2015
    • 3,249 practitioners re-credentialed in 2015
    • CareFirst monitors and oversees credentialing/recredentialing 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) and PPO (BluePreferred) at the accredited 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.
  • In 2015, the following programs were launched to address the continuum of care:
    • Wellness and Disease Management
    • Behavioral Health and Substance Abuse
    • Comprehensive Medication Review
    • Specialty Pharmacy Programs
    • Community Based Programs—Chronic Kidney Disease, Sleep Management Program
    • Telehealth
    • Expert Consult for pain in hip, knees, neck
    • Transitioned to new formulary
    • Continuation of CMMI Medicare Grant for common model
Support QI principles throughout the organization, acting as a resource in process improvement.
  • Through QI committee framework, Process Improvement Specialists work within intradivisional and interdivisional areas with collaborative work teams to promote quality improvement.

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