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

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®)

Key Metrics Summary

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


Improvement noted in the following measures:

  • Adults’ Access to Preventive/Ambulatory Health Services
  • Breast Cancer Screening
  • Colon Cancer Screening
  • Care of Older Adults
  • Diabetes: Attention for Nephropathy
  • Follow up After Hospitalization for Mental Illness
  • Pharmacotherapy Management of COPD Exacerbation
  • Statin Therapy for Patients with Cardiovascular Disease
  • Patient Engagement after Discharge

Integrated QI Activities

Coordinated improvement interventions across a variety of departments including but not limited to Medical Management, Pharmacy, Credentialing, Member Services, Compliance, Operations, and Provider Network.

Quality Improvement Project (QIP)

Successfully implemented the new QIP required specific to the HEDIS measure Follow Up (30

day) after Hospitalization for Mental Illness with improvement noted.

Chronic Care Improvement Program (CCIP)

Successfully implemented new CCIP “Reducing the Severity of Diabetes” by improving adherence to diabetes medication.

CAHPS Survey Results

Improvement noted in the following measures:

  • Annual Flu Vaccine
  • Getting Appointment and Care Quickly
  • Getting Needed Prescription Drugs
  • Health Plan Customer Service
  • Rating of Drug Plan
  • Rating of Health Plan

Quality of Care (QOC) Reviews

We investigated, trended, and took action as necessary on all potential quality of care issues within established time frames.

Provider (PCP) Reports: Monthly profile reports are available on the provider portal to provide information on performance of measures for preventive care and chronic conditions. The measures selected provide valuable information to help improve the delivery of healthcare.

Reducing Health Care Disparities

We continue to collect and report member race, ethnicity, and language data needed to address and decrease disparities in health care. We also ensure all member mailings include appropriate translation instructions and monitor member utilization of the language line.

QI Program Priorities for 2022

In 2022, we will remain committed to a seamless enrollee experience with adequate access to high quality, coordinated care and services with the goal to decrease the burden of disease and improve health outcomes. We will prioritize improving the health of our members and reducing health care disparities with our continuing efforts to:

  • Continue focus on improvement of all performance measures, including:
    • Improve access to care and services.
    • Improve compliance with prescribed health screenings.
    • Enhance chronic disease management.
    • Continue member and provider outreach initiatives to improve utilization of services
  • Strengthen our processes to address care gaps, including:
    • Maintaining effective care management and Long Term Services and Supports programs.
    • Improving communication among the Plan and medical and behavioral health providers to ensure effective coordination of care.
    • Using information collected from all member assessments to create an effective care plan for every member.
    • Focusing on preventive care, including immunizations and dental care.
    • Ensuring effective medication adherence and transitions of care programs.
    • Reviewing and updating evidence-based clinical practice guidelines to promote implementation of comprehensive medical and health care practices, including preventive, diagnostic and treatment services.
  • Expand efforts to assist and empower members to manage and improve their health in collaboration with their health care providers.
  • Improve member safety through ongoing monitoring and investigation of potential quality of care issues.

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 learn more.