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.