Quality management and improvement efforts

Quality improvement strategy

We’re working hard to improve the service, quality and safety of health care. One way we do this is by measuring how well we and others are doing.

We work with groups of doctors and other health professionals to make health care better.

Our clinical activities and programs are based on proven guidelines.

We give you and your doctors information and tools that may help you make decisions.

Program goals

We aim to:

• Meet our members’ health care needs
• Measure, monitor and improve clinical care and quality of service
• Institute company-wide initiatives to improve the safety of our members and communities
• Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups

Program scope

We work to make your health care better by:

• Developing policies and procedures that reflect current standards of clinical practice
• Reviewing preventive and behavioral health services, and how care is coordinated
• Addressing racial and ethnic disparities in health care that could negatively impact quality health care
• Monitoring the effectiveness of our programs
• Studying the accessibility and availability of our network providers
• Monitoring the overuse and underuse of services for our Medicare members
• Performing credentialing and recredentialing activities
• Assessing member and provider satisfaction

Program outcomes

Each year we check to see how close we are to meeting our goals. Here's what we did in the past year:

• We internally collected data on a set of clinical measures. Each year, we use the results to set new goals and improve selected measures. We also use them to provide ongoing quality improvement activities such as cancer screenings, member outreach, and member wellness reminders.
• We continued to measure member satisfaction and deliver member initiatives. These included redesigning our member website to enhance the user experience and allow our members to locate in-network providers through the online provider directory.
• Through our Local Care Management Program, we continued to deliver local, cohesive care to our members. We did this through increased member and provider engagement, early identification of high-risk members, and leveraging community resources to identify comprehensive solutions for member conditions that go beyond clinical care.
• We collaborated with medical and behavioral health to monitor and improve continuity and coordination of care.
• We developed a Population Health Management clinical model that provides structure and resources to support our members’ needs.
• We improved our patient safety program to help our members make informed health choices.
• We continued to help our members with their mental health needs.