Quality assessment improvements template



MO HEALTHNET MANAGED CARE ANNUAL EVALUATION REPORT TEMPLATETABLE OF CONTENTSEXECUTIVE SUMMARYOverview of the Quality Improvement ProgramOverview of the Effectiveness of the Quality Improvement ProgramDEVELOPMENT, APPROVAL AND MONITORING OF THE QI PROGRAMQuality and Compliance CommitteeAnalysis of Quality Improvement ProcessOverall Effectiveness of the Quality Improvement ProgramStrengths and AccomplishmentsOpportunities for ImprovementPOPULATION CHARACTERISTICSRace/EthnicitySpecial NeedsLanguages IdentifiedOpt OutsQUALITY INDICATORSHEDIS MeasuresTrends in Missouri Medicaid Quality Indicators HEDIS Indicators by MO HealthNet Managed Care Health Plans Within Regions, Live BirthsACCESSIBILITY OF SERVICESAverage Speed of AnswerCall Abandonment RateNon-Routine Needs AppointmentsRoutine Needs AppointmentsAccess to Emergent and Urgent CareNetwork Adequacy -- Provider/Enrollee Ratios24 Hour Access/After Hours AvailabilityOpen/Closed PanelsCultural CompetencyMultilingual ServicesRequests to Change PractitionersFRAUD AND ABUSEPrevention, Detection, InvestigationTraining and EducationINFORMATION MANAGEMENTClaims Processing – Timeliness of Claims PaymentMembershipProvidersQUALITY MANAGEMENTProvider SatisfactionMember Care Management Services for both Physical and Behavioral HealthDisease Management ProgramClinical Practice GuidelinesCredentialing and Re-CredentialingMedical Record ReviewRIGHTS AND RESPONSIBILITIESProvider Complaint, Grievance and Appeal ManagementMember Grievance and Appeal ManagementConfidentialityUTILIZATION MANAGEMENTUtilization Improvement Program ScopeDischarges Per Year*Inpatient Visits*Average Length of StayRe-Admissions*Emergency Department Utilization*Outpatient Visits*Over/Under UtilizationInter-Rater ReliabilityTimeliness of Care DeliveryTimeliness of Prior Authorization/Certification Decision Making*Per 1000 membersPERFORMANCE IMPROVEMENT PROJECTS (PIP)ClinicalNon-ClinicalOn-going Interventions and ImprovementsEffect on Health Outcomes and Member SatisfactionWORKPLAN FOR NEXT YEARAPPENDICESSUBCONTRACTOR OVERSIGHT EVALUATIONThe Subcontractor Oversight Evaluation Report shall contain information concerning the effectiveness and impact of the health plan’s quality assessment and improvement strategy as it relates to subcontractors. The report must provide information that indicates that data is collected, analyzed, and reported and health plan operations are in compliance with State, Federal, and MO HealthNet Managed Care contractual requirements. The report must incorporate multiple year outcomes and trends. The report must show that the health plan’s QA&I Program is ongoing, continuous, and based upon evaluation of past outcomes. At a minimum, the Subcontractor Oversight Evaluation shall include the following: OVERVIEW OF SUBCONTRACTOR INCLUDING CONTRACT EFFECTIVE DATESDESCRIPTION OF DELEGATED SERVICES/PRODUCTS/ACTIVITIESDESCRIPTION OF MO HEALTHNET MANAGED CARE HEALTH PLAN’S OVERSIGHT PROCESS FOR ALL SUBCONTRACTORS (must include, but shall not be limited to, the following:)Review of subcontractor contract compliance with requirements included in the MO HealthNet Managed Care contract with state Subcontractor policies and procedures comply with subcontractor/ MO HealthNet Managed Care health plan’s/state contract requirementsImplementation of policies/procedures/contract requirementsOVERSIGHT OUTCOMES/FINDINGS (must include, but shall not be limited to, the following:)Access/availabilityFraud and abuseGrievances and appealsPerformance projects and HEDIS measuresEncounter dataPrior authorization denialsTimely payment WORK PLAN FOR NEXT YEARRevised January 2016 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download