Quality Improvement Program
Carolina Care Plan's mission is to serve as a partner to our clients, providing innovative, long-term healthcare solutions through our products and services.
To support this mission, Carolina Care Plan’s Care Management department
has implemented a comprehensive Quality Improvement (QI) Program and continually
redesigns this program to:
Carolina Care Plan's mission is to provide cost-effective access to quality healthcare for our members by delivering leading-edge health insurance products and related services, that maintain a strong financial foundation, control of our destiny and remain a strong employer. To support this mission, Carolina Care Plan’s Care Management department
has implemented a comprehensive Quality Improvement (QI) Program and continually
redesigns this program to:
- Improve the quality of healthcare services for members and their
access to those services
- Communicate clinical information to members and providers
- Monitor and evaluate the quality and safety of healthcare provided
to members
- Achieve and maintain formal accreditation
Quality Improvement Program Publications
Quality Improvement Program Activities
To learn more about specific QI Program Activities developed by
Carolina Care Plan,
please select a topic from the list below.
Member and Provider
Member
Provider
Member and Provider
Accessibility Standards
Carolina Care Plan’s goal is to ensure that each member has timely access to provider treatment.
Standards have been established for network primary care physicians (PCPs) and specialists.
These
standards
are published annually in provider and member
newsletters, provider directories, and posted on this Web site. Compliance with
accessibility standards is monitored via audits and HEDIS member satisfaction
surveys. In addition, QI Analysts review member complaints regarding access
and implement provider corrective action plans (CAPs) as indicated.
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Care Management Department
Utilization management (UM), case management and health
management activities comprise a comprehensive care management program, and are
integrated with clinical quality improvement activities. All Care Management
and quality improvement activities report through the same committee structure,
and all staff ultimately report to the Chief Medical Officer for clinical
issues and the Vice President of Care Management for all administrative issues.
UM activities within care management include prior approval, concurrent review, retrospective review,
discharge planning, chart audit and medical claims review for medical/surgical services.
Case management is a multidisciplinary process and involves the
coordination of complex care needs while facilitating flexible, individualized
plans of care and utilizing community resources. This process is a
collaborative effort between the member, family, physician and other members of
the healthcare delivery team. The case management process provides cost-effective options for selected members with complex medical and social needs.
Health management activities include identification of eligible
members, completion of needs assessments, determination of the appropriateness
of services, formulation of an individualized plan of care, implementation of
services, measurement and evaluation of the plan of care, and a program
evaluation.
Carolina Care Plan
offers several
health management programs
to assist members with a chronic disease or pregnancy.
Reports focused on care management activities are generated on a
routine basis and are utilized to assess the effectiveness, appropriateness,
and efficiency of the care management program.
Contact the Care Management Department.
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Clinical Care and Service Studies
Each year
Carolina Care Plan
identifies clinical and service concerns/topics for focused studies and/or
interventions. Selection of topics is made with substantial input from the
Clinical Quality Improvement (CQI) and the Service Quality Improvement
committees. A variety of sources are utilized to identify topics, including
Healthy People 2010, Healthy Children 2010, Healthcare Effectiveness Data and
Information Set (HEDIS), care cost analysis, member demographics analysis,
claims data analysis, medical record reviews, provider and member surveys, and
referrals of potential quality issues from
Carolina Care Plan
staff and committees. The objective in identifying topics is to ensure they
represent and address the needs of the member population. Topics may address
the total population or specific segments of members (i.e., women of
childbearing years, asthmatic members, etc.).
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Educational Communications
Carolina Care Plan
continues to channel its efforts towards the educational component of quality
improvement. Providers receive information via the
Professional Provider Manual and newsletters. Members receive
newsletters, direct mailings, and their certificate of coverage.
The physician newsletter,
Eye on Quality,
and the member newsletter,
Health News,
contain articles highlighting critical care and health information, in
addition to articles that focus on member safety in various settings.
Health News
articles encourage members to take an active role in helping to prevent
injuries and errors that might affect their safety.
Carolina Care Plan
also publishes
Quality Connections,
a newsletter designed specifically for our hospital
providers.
Educational information is also available through
WebMD on the
Carolina Care Plan
site.
Carolina Care Plan's
Clinical Quality Improvement Department may be contacted at 800/586-4523.
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Preventive Care Service
Clinical preventive care service is an essential aspect of
medical practice today. To promote the delivery of regular preventive care
services by physicians and utilization of such services by members,
Carolina Care Plan
annually reviews
preventive care guidelines.
The guidelines are developed and
updated by the Clinical Quality Improvement Department and participating
network physicians biennially, or when appropriate. Currently, prenatal,
pediatric and adult guidelines exist. The guidelines are considered minimum
standards which all Primary Care Physicians (PCPs) are expected to meet when
providing routine medical care to members.
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Members
Appropriate Care
To ensure all members receive the most appropriate medical care
available,
Carolina Care Plan
has a team of people who review certain treatments, tests or hospital stays in
a process called “utilization management”.
Carolina Care Plan
requires all employees, contracted physicians and management staff who deal
with utilization management activities to sign a statement acknowledging the
following:
-
Utilization management decisions are based only on the appropriate use of care
and services for the member.
-
Carolina Care Plan
does not directly or indirectly reward or incent providers or any other
individuals participating in utilization management decisions for denying or
limiting coverage or service.
-
Carolina Care Plan
does not provide financial incentives for utilization management decisions that
result in the underutilization of care or service.
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Company-wide Member Appeals Monitoring
Carolina Care Plan
has a formal process for members which
advises them of their right to file an appeal and provides timeframes for
appeal resolution. Members are informed of their rights through their
certificate of coverage, medical determination letters, EOB (Explanation of
Benefits), and member newsletters. Members are also notified of their rights
when they contact the Customer Service department with a grievance about a
denied claim or service. Grievances are tracked for timeliness and trended to
identify potential issues for quality improvement intervention.
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Safety Monitoring and Activities
The Carolina Care Plan Quality Improvement Program Description
provides a detailed description of each
of the safety topics listed below:
-
Inpatient Mortality Reports
-
Hospital Incurred Injuries/Adverse Occurrence Tracking
-
Prescription Medication Monitoring
-
Ongoing Review of Potential Quality of Care Issues
-
Office Safety Review
-
Communication with Providers and Members
-
Focused Studies on Member Safety
Following the release of the 1999 Institute of Medicine (IOM)
report, To Err is Human: Building a Safer Health System, a coalition of
employers formed The Leapfrog Group. Leapfrog's goal is to improve the safety
of hospitalized patients through the implementation of three initiatives:
computerized physician order entry (CPOE), evidence-based hospital referral,
and Intensive Care Unit (ICU) physician staffing. Details of the Leapfrog
initiatives are available on their web site at
www.leapfroggroup.org.
The web site also offers a survey that hospitals may complete to
report their progress toward meeting the Leapfrog safety standards.
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Satisfaction Measurement and Improvement
Maintaining high levels of member satisfaction is a primary goal
of the Quality Improvement Program. Objectives of member satisfaction
activities are to:
-
Provide members with opportunities to express their opinions about
Carolina Care Plan
products and service
-
Share member perceptions with providers to encourage performance improvements
-
Utilize member input to identify potential areas for quality improvement action
Vehicles utilized to achieve the above objectives include:
-
Member satisfaction surveys, including general surveys and surveys focused on
specific products, populations, or concerns
-
Analysis of member complaints and appeals
-
Analysis of members' requests to change providers
-
Monitoring telephone service and implementing corrective action plans to
achieve optimum results regarding the following service parameters:
-
Incoming calls per day
-
Wait time to reach a service representative
-
Calls connected (caller remains on the line)
-
Time required to access customer's claims history
-
Number of inquiries resolved on initial contact
-
Turnaround time for inquiries unresolved on initial contact
Carolina Care Plan
tracks member complaints for timeliness and trends the complaints to identify
potential issues for quality improvement intervention.
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Provider
Affirmative Statement
Carolina Care Plan
is committed to ensuring the appropriate utilization of care and service
provided to all members. To ensure this commitment,
Carolina Care Plan
has asked all employees, consultants, and management staff involved in
utilization management decisions to sign a statement that affirms their
understanding of the following:
-
Utilization management decisions are based only on the appropriate use of care
and services for the member.
-
Carolina Care Plan
does not directly or indirectly reward or incent providers or any other
individuals participating in utilization management decisions for denying or
limiting coverage or service.
-
Carolina Care Plan
does not provide financial incentives for utilization management decisions that
result in the underutilization of care or service.
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Credentialing
To support Carolina Care Plan’s mission, the Administrative Credentialing Department:
-
Collects network providers' credentialing documents as part of the
credentialing and recredentialing process
-
Ensures data input quality and submits providers to the Credentialing Committee
-
Promotes compliance with national quality and regulatory standards by following
set policy and procedures
-
Ensures timely recredentialing
To support Carolina Care Plan’s mission, the Clinical Credentialing Department:
- Promotes compliance with national quality and regulatory standards by making credentialing requirements easily accessible
- Educates the provider community to the nationally recognized standards of documentation, confidentiality, medical records organization and accessibility, and patient appointment accessibility
- Oversees delegated entities to ensure compliance with Carolina Care Plan standards
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Practice Guidelines
To promote the provision of quality healthcare services and the
management of selected conditions and chronic diseases,
Carolina Care Plan
develops and disseminates practice
guidelines
to providers for input and adoption. Such guidelines are based upon,
but not limited to, guidelines from the American Medical Association (AMA), the
American Psychiatric Association (APA), the American College of Obstetrics and
Gynecology (ACOG) and other specialty physician boards and colleges. Practice
guidelines are reviewed at least every two years and updated as necessary to
reflect changes in medical practice.
Carolina Care Plan
monitors physician compliance with published guidelines via periodic medical
record review and claims data analysis. Results of monitoring activity are
analyzed and used to develop and implement interventions for the education
of providers regarding Carolina Care Plan
guidelines.
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Network Availability Measurement and Improvement
To ensure that network providers and hospitals are available to
members, Carolina Care Plan has established standards for the following:
-
Appropriate ratios of PCPs and specialists to members
-
Geographic location and travel time to providers/hospitals
Carolina Care Plan
seeks to maintain a comprehensive practitioner network available for its
members.
Carolina Care Plan
defines specific goals in comparison to the total available practitioner
population and geographic availability across practitioner specialties. In
addition,
Carolina Care Plan
monitors member complaints and member satisfaction regarding provider network
availability across practitioner specialties as well as cultural and/or
linguistic needs. With these goals, members will have sufficient
practitioner alternatives available to meet their medical needs. Once goals are
attained in a region, recruiting efforts are terminated and resources are
focused on improving practitioner availability in deficient areas.
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Network Clinical and Service Issues
The QI Program is responsible for identifying potential clinical
and service issues, investigating potential causes and solutions, taking action
to improve performance, and evaluating the effectiveness of these actions.
Personnel from the following operational areas are primary
sources for identifying possible concerns regarding quality of care and
service:
-
Benefit Administration
-
Care Management
-
Claims/Member Services
-
Clinical Credentialing
-
Clinical Quality Improvement
-
Marketing
-
Network Management
-
Professional Contracting
Cases with potential clinical or service issues are logged into
either the Contact Online Reporting System (CORS) or the PReview Managed Care
System and investigated. Clinical issues are referred to the CQI Department for
review and may result in review by the Chief Medical Officer and/or the CQI
Committee.
In cases where provider performance issues are noted and
improvements are not achieved within reasonable time frames,
Carolina Care Plan
has instituted a provider termination process. The policies and procedures on
termination include a formal provider appeal process where appropriate.
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Satisfaction Measurement and Improvement
Maintaining high levels of provider satisfaction is another goal
of the QI Program. Objectives of provider satisfaction activities are to:
-
Afford providers the opportunity to express their opinions about
Carolina Care Plan
policies and procedures regarding claims payment, the Care Management process,
and various administrative components of the managed care products
-
Share provider perceptions with internal
Carolina Care Plan
departments to encourage performance improvements
-
Utilize provider input to identify potential areas for quality improvement
action
Vehicles utilized to achieve the above objectives include:
-
Provider satisfaction surveys
-
Analysis of provider comments in response to the distribution of guidelines,
newsletters, and other communications
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