Quality Assessment and Performance Improvement (QAPI) Program

Program Scope

The QAPI program includes a wide range of activities for:

• Complaints, grievances and appeals
• Access to and availability of network providers, including behavioral health
• Continuity, coordination and transition of care
• Credentialing and re-credentialing
• Delegation oversight (oversight of entities contracted by CountyCare)
• Health and wellness
• Record reviews and site surveys
• Member rights and responsibilities
• Member satisfaction
• Patient safety
• Utilization (inpatient and outpatient medical services)

Member-Driven Quality Strategy

CountyCare wants to provide quality health care coverage for members. CountyCare members want care and service to be the best they can be. Members also want easily available appointments and a broad selection of providers, resulting in efficient, effective care.  Health care providers desire a good relationship with CountyCare so that they can best support members. CountyCare’s QAPI program is designed to address all these needs.

Understanding members’ perceptions and expectations is central to high quality. CountyCare learns about members and other important stakeholders through:

• Member and provider satisfaction surveys (every year)
• Member Advisory Committee feedback (every three months)
• Health outcome reports (every month)
• Utilization management data (daily and reports every month)
• Complaint and appeal data (daily and reports every three months)
• Progress reports on Quality Improvement Work Plan goals (every three months)

Identifying Opportunities for Improvement

CountyCare evaluates the full spectrum of clinical care including inpatient, outpatient, ancillary, pharmacy, emergency services, home health, and skilled nursing care. To identify improvement opportunities, CountyCare has to focus on priorities which include:

• High and moderate risk members
• High-volume services
• Problem-prone areas that may expose members to risk

CountyCare analyzes information from numerous sources including claims and utilization data for medical, behavioral and pharmacy services, to member complaints and appeals, to member and practitioner satisfaction surveys.  Key measures includes HEDIS (Health Plan Effectiveness Data and Information Set) rates, Consumer Assessment of Health Plan Satisfaction (CAHPS) survey results and reports from the State such as the Illinois Medicaid Plan Report Card.  Health risk assessments and clinical performance improvement studies also provide valuable data, as well as internal performance measures and audit results.

When a potential improvement opportunity emerges, CountyCare considers these factors:

• How is the improvement relevant to our member population?
• What is our ability to make an impact?
• What is the potential for integration with other programs?
• What are the applicable laws and regulations?
• What are the potential program costs and resource needs?
• Are regional or national benchmarks available for goal-setting?

Once an opportunity is selected, CountyCare sets measurable goals against current baseline measures, and re-measures periodically to assess the improvement’s effectiveness.

Quality Improvement (QI) Method

CountyCare uses the Plan-Do-Study-Act (PDSA) model to identify and implement QI strategies and activities:

• Plan: Evaluate data, identify improvement opportunities, and determine appropriate intervention strategies based on best practices and known barriers.
• Do: Implement program(s) to address identified needs and barriers.
• Study: Measure the effects of the improvement and assess its effectiveness.
• Act: Continue intervention if effective. Adjust as necessary to achieve goal targets. Repeat cycle if intervention does not achieve desired result.

The PDSA process continues until we meet our goals, or until results show we need to focus resources in another way.

Annual Work Plan

CountyCare prepares an annual Quality Improvement Work Plan that outlines key quality improvement activities for the year. The activities support our clinical and service priorities and align with the organization’s strategic initiatives.

Work plan activities throughout CountyCare are planned to improve clinical and service quality for members, practitioners, and other stakeholders, both external and internal. For example, the previous work plans have included activities designed to:

• Improve behavioral health services for alcohol and substance abuse disorders
• Improve follow-up care after hospitalization.
• Expand real-time alerts of emergency room visits and hospitalizations
• Evaluate long-term care
• Improve wellness through prevention and disease management programs and initiatives
• Increase health risk assessments and care plans
• Improve member satisfaction and the member experience

Activity “owners” measure and report on their progress at least quarterly. Activities or goals may change during the year based on these assessments.

Example of QI activities are:

• Evaluates the network providers to ensure members have access to a qualified health care team
• Promote safety in health care through communication to members and providers
• Publishes health guidelines to help members know what care they need and when
• Provide prompt information to health care providers so they know what they need to improve
• Develop rewards for members or providers who participate in high quality care
• Change a part of the system, such as the CountyCare phone tree, to give better service

Program Evaluation

CountyCare evaluates the QI program annually. We review the year’s clinical and service quality activities and measure our progress toward work plan goals. We also look at our Quality Improvement Committee structure, program resources, and the key challenges and barriers encountered during the year. The program evaluation report includes:

• Descriptions of the year’s QI activities
• Measurements and trending to assess performance
• Analysis of CountyCare’s success in demonstrating improvements
• Evaluation of the overall effectiveness of the QI program
• Recommendations for changes in areas that did not meet annual goals

Each year’s program evaluation forms the basis of the next year’s work plan.

HealthChoice Illinois Medicaid Health Plan Report Card