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Quality Improvement Performance

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The Quality Improvement Program (QI Program) and the Quality Improvement Workplan (QI Workplan) are developed annually.

The QI Program describes the steps the health plan takes to manage member care. This includes:
  • How the plan provides services that the member may need to stay healthy
  • Key activities put in place by the health plan to continuously improve service and the member’s overall health results
QI Program Goals and Purpose The most important goal is to improve members’ health. The program sets goals that includes different activities in the health plan’s service area. The 2021 goals include the following areas:
  1. Member experience
  2. Access to affordable health care
  3. Quality of care and service for members
  4. Centers for Medicare and Medicaid Services (CMS) requirements
The QI Workplan: Annually, leaders within the health plan collaborate to develop the QI Workplan. The QI Workplan identifies activities related to the goals of the QI Program. These activities relate to quality member care and services.  Each activity has a goal date for completion and who within the health plan is accountable for that area. There is also a review of activities, which includes tracking any issues and deciding how to solve them quickly and effectively.

Model of Care:
The Model of Care goals are focused on 4 key areas:
  1. Helping care coordination and quality of service
  2. Assisting members who experience a change in care
  3. Ensuring members have access and accessibility to health care
  4. Giving members the appropriate resources to prevent health issues and treat chronic health care problems
2020 Quality Program Evaluation Summary results:
  1. Quality Program Goals that were met in 2020:
    • The plan does not qualify due to its size for a Part C Overall 2021 Star Rating. The plan did receive a Part D Summary Rating of 4 Stars out of five (5) Stars for 2021 Star Ratings. Please visit https://www.medicare.gov for more information on Star Ratings.
    • The plan received 5 out of five (5) Stars on the following 2021 Star Rating measures:
      • Special Needs Plan (SNP Care Management) – 5 Stars out of five (5) Stars
      • Care for Older Adults – Medication Review- 5 Stars out of five (5) Stars
      • Care for Older Adults – Functional Status Assessment-5 Stars out of five (5) Stars
      • Care for Older Adults – Pain Assessment- 5 Stars out of five (5) Stars
      • Statin Use in Persons with Diabetes (SUPD)- 5 Stars out of five (5) Stars
    • Reporting member’s Health Assessment completion to CMS
    • Electronic Medical Record improvement to meet quality goals
    • Completed required CMS activities
    • Model of Care training was given to health plan staff
    • Model of Care training made available to providers on the health plan website
    • Model of Care goals measured and reviewed by health plan leaders
  2. Challenges:
    • COVID-19
    • Challenges with reports
  3. Opportunities:
    • Continuing education to staff about the clinical model and care coordination
    • Providing education to skilled nursing facilities where members live