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Quality Improvement
QI Program Design
CareFirst implements an annual QI work plan that outlines specific clinical and service-related improvement activities using HEDIS as a framework.
The QI program provides the framework for the Plan to continuously improve the quality and safety of clinical care and services provided to Plan members.
HEDIS, developed by the National Committee for Quality Assurance (NCQA), is a set of standard measures used to evaluate health plans on their effectiveness, access and cost of care as well as their use of services and member satisfaction. HEDIS helps consumers and employer groups compare managed health care plans.
QI Goals and Activities
Ongoing clinical activities include monitoring and evaluation of the following:
- Physician performance against established clinical guidelines
- Effectiveness of care (preventive care and treatment)
- Effectiveness of disease management programs
- Physician performance against medical record documentation standards
- Under and over-utilization
- Continuity and coordination of care
Ongoing service activities include monitoring and evaluation of the following:
- Physician performance against standards for availability and accessibility
- Staff performance against Plan service standards
- Complaints and appeals resolution
- Member and provider satisfaction
- Oversight of delegated functions
CareFirst and CareFirst BlueChoice communicate regularly with providers and practitioners regarding their QI activities through a variety of methods such as newsletters, Internet and special mailings. You may also call the Quality Improvement Department or log on to www.carefirst.com and to find the latest information about the following QI activities:
CareFirst and CareFirst BlueChoice offer Disease Management programs designed to reinforce and support the physician's plan of care. The programs identify members with chronic conditions, who are eligible for disease management. The programs help educate members about their diseases and how to manage them, which will improve medical outcomes and quality of life. Services range from quarterly educational mailings to case management, and access to a support nurse by phone 24-hours a day, seven days a week.
To obtain more information about, or to enroll patients into the diabetes, coronary artery disease or congestive heart failure programs administered by Healthways, Inc. call 800-783-4582.
Great Beginnings
The Great Beginnings program is designed to support the prenatal care and education expectant mothers receive from their physicians.
When a member enrolls in Great Beginnings, a case manager contacts the expectant member to review her medical history and to identify any other conditions that may affect her pregnancy. The case manager continues to contact the member during each trimester of her pregnancy to see how she is feeling and to answer any questions. If the expectant mother has not chosen a pediatrician, the case manager may assist the member in finding a pediatrician close to her home.
If there are any complications during pregnancy, the case manager works closely with the physician to coordinate necessary services and provide additional support and information to the member.
Case managers are available to answer questions Monday - Friday, 8:30 a.m. - 4:30 p.m. For more information about the program, call 888-264-8648.
QI Committees
CareFirst's multi-disciplinary committees and teams work closely with community physicians to develop and implement the QI Program.
Clinical practitioners, including designated behavioral health care practitioner(s), provide input and feedback on quality improvement program activities through participation on the following committees:
- Quality Improvement Advisory Committee (QIAC) The QIAC is a multi-specialty committee of practitioners that advises the Plan about standards of medical and behavioral health care.
- Quality Improvement Committee (QIC) The QIC evaluates the quality and safety of clinical and behavioral health care and the quality of services provided to members
- Credentialing Advisory Committee (CAC) The CAC reviews the credentials of practitioners and other providers applying for initial or continued participation in the Plan.
- Care Management Committee (CMC) The CMC monitors and analyzes the care management program and promotes efficient use of health care resources by members and practitioners
- Pharmacy and Therapeutics (P&T) Committee The P&T committee advises the Plan on the development of the pharmacy services program and the CareFirst formulary.
- Ad hoc committees or work groups
NCQA
In January 2002, CareFirst BlueChoice, CareFirst's HMO, and BluePreferred, a CareFirst PPO, received the National Committee for Quality Assurance's (NCQA's) highest accreditations. BlueChoice earned Excellent, the highest level of HMO accreditation. BluePreferred was granted Full accreditation, the highest level for PPOs.
These accreditation levels are awarded to plans that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement.
NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. NCQA's Accreditation standards are publicly reported in five categories:
- Access and Service: Do health plan members have access to the care and service they need?
- Qualified Providers: Does the health plan assess each doctor's qualifications and what health plan members say about its providers?
- Staying Healthy: Does the health plan help members maintain good health and detect illness early?
- Getting Better: How well does the health plan care for members when they become sick?
- Living with Illness: How well does the health plan care for members when they have chronic conditions?
Medical Record Documentation Standards
Practitioner Office Standards
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