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Quality Improvement

AmeriHealth Caritas VIP Care Plus has a Quality Improvement (QI) program to make sure health care and services our members receive are:

  • High quality.
  • Safe.
  • Right for the members' needs.
  • Efficient.
  • Effective.

We help our members avoid preventable disease, manage chronic illnesses and disabilities, and maintain or improve health and quality of life.

We review our QI program each year to see how we are doing. This review includes suggestions for improvement and setting goals for the next year.

Our mission is to help people get care, stay well, and build healthy communities. The Quality team supports this mission by checking on the health care and services members receive. We help with:

  • Health and disease management programs for members in a manner that meets the cultural and language needs of our members
  • Outreach to members to help them get the care and health education they need
  • Programs to serve our members who have special health care needs
  • Continuity and coordination of care
  • Member and provider surveys and using the responses to improve our services
  • Reviewing the quality of care and services given by AmeriHealth Caritas VIP Care Plus medical, dental, vision, and pharmacy providers
  • Access to and availability of care and services

QI Program Strengths and Accomplishments in 2018

Chronic Care Improvement Program

Completed final review for the Centers for Medicare and Medicaid Services (CMS) Chronic Care Improvement Program (CCIP) that focused on: Reducing the Incidence and Severity of Cardiovascular Disease. Improvement noted in rate of adherence for cholesterol (statin) medications.

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey

Improvement noted in the following measures:

  • Health Plan Customer Service
  • Getting Needed Prescription Drugs
  • Care Coordination

Healthcare Effectiveness Data and Information Set (HEDIS®)

Improvement noted in the following measures:

  • Colon Cancer Screening
  • Care of Older Adults
  • Diabetic Eye Exam
  • Patient Engagement after Discharge
  • Follow-Up after ED Visit for People with Multiple High-Risk Chronic Conditions
  • Non-Recommended PSA-Based Screening in Older Men
  • Potentially Harmful Drug-Disease Interactions in the Elderly
  • Adults' Access to Preventive/Ambulatory Health Services
  • Plan All-Cause Readmissions

Key Metrics Summary

  • Improve Access to Essential Services – Goals partially met with noted improvement
  • Network adequacy meets CMS standards.
  • Improve Coordination of Care – Goals not met; action plans implemented
  • Improve Seamless Transitions of Care – Goals partially met with noted improvement
  • Improve Access to Preventive Health Services – Goals partially met with noted improvement
  • Improve Health Outcomes – Goals not met; action plans implemented.
  • Improve Appropriate Utilization of Services – Goals partially met with noted improvement

Quality Improvement Project

Completed final review for the Michigan Department of Health and Human Services (MDHHS) Quality Improvement Project (QIP) that focused on: Reducing Avoidable Hospitalizations. Improvement noted in readmission rate, transition of care program intervention rate, and rate of PCP follow up.

Quality of Care (QOC) Grievances and Concerns

All 2018 QOC grievances and concerns were processed within the required timeframes. All outcomes were forwarded to the Credentialing Committee for review.

QI Program Priorities for 2019

In 2019, we will remain committed to a seamless enrollee experience with adequate access to high quality, coordinated and culturally competent clinical care and services across the care continuum, including transitions of care, with the goal to decrease the burden of disease and improve health outcomes.

  • We will continue to strengthen our care gap processes to monitor, analyze, and evaluate the delivery, quality, and appropriateness of healthcare provided to enrollees specific to management of chronic disease and preventive healthcare and services. This will include:
    • Maintaining an effective care management and Long Term Services and Supports (LTSS) programs.
    • Improving communication among the Plan and medical and behavioral health providers to ensure effective collaboration.
    • Completing all enrollee assessments to gather as much information as possible to use to create an effective care plan for every enrollee.
    • Continuing to focus on preventive health screenings and medication adherence.
    • Reviewing, updating, and monitoring use of evidence-based clinical practice guidelines.
  • Continue processes that ensure every enrollee has an established relationship with a Primary Care Provider.
  • Improve collaboration between enrollees and their providers to improve health outcomes.
  • Improve our ability to collect meaningful information regarding social determinants of health and lessen their negative impact.

Call Member Services at 1-888-667-0318 (TTY/TDD 711), seven days a week, 8 a.m. – 8 p.m., if you would like to lear