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Program Scope

The scope of the QI Program encompasses the clinical and service aspects of the care its members receive. The QI Program implements Braven Health’s efforts to monitor and improve preventive, acute, chronic, behavioral and rehabilitative aspects of care. The QI Program also reviews the Plan’s initiatives and outcomes related to member and provider satisfaction, member and provider education, access and availability of care, disparities in health care, continuity and coordination of care, member appeals/grievances, quality-of-care concerns, clinical and service quality metrics and the credentialing of providers. The QI Program is also charged with making changes to improve Braven Health’s performance on Healthcare Effectiveness Data and Information Set (HEDIS), Stars, Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS). Future accreditation efforts and audits completed by the Quality Management Department and other Horizon departments are also reviewed as part of the QI Program. The following quality assurance activities are also developed and monitored on an ongoing basis:

  • Adoption of clinical guidelines for the management of selected common conditions and basic health maintenance, and distribution of all standards, protocols, and guidelines to all providers and upon request to enrollees and potential enrollees.

  • Review of medical policies addressing the diagnosis, treatment and management of clinical conditions, which allow for the application of clinical judgment and professional discretion based on the unique circumstances of an enrollee’s medical condition, level of functioning, and contributing family and social factors.

  • Monitoring the quality and adequacy of medical and behavioral health care including: 1) evaluating the consistency with which clinicians apply criteria in decision making and 2) assessing possible over-treatment/over-utilization of services and 3) assessing possible under-treatment/under-utilization of services.

  • Evaluation of procedures for focused medical care evaluations to be employed when indicators suggest that quality may need to be studied, including procedures for conducting problem-oriented clinical assessment of care rendered to individual enrollees.

  • Review of procedures for prompt follow-up of reported problems and grievances involving quality of care issues. Timeframes for prompt follow-up and resolution, which follow the standard, described in the Centers for Medicare & Medicaid Services (CMS) Guidelines.

  • Monitoring of Hospital Acquired Conditions and Provider–Preventable Conditions including the implementation of a no payment policy and a quality monitoring program consistent with CMS.

  • Data Collection Procedures for gathering and trending data including outcome data.

  • Review of inpatient hospital mortality rates for trending and analysis.

  • Ensuring corrective action procedures are in place for informing subcontractors and providers of identified deficiencies or areas of improvement, conducting ongoing monitoring of corrective actions, and taking appropriate follow-up actions, such as instituting progressive sanctions and due process for appeals.

  • Review of discharge planning procedures to ensure adequate and appropriate discharge planning, including coordination of services for enrollees with special needs.

  • Monitoring of providers for compliance with state and federal laws and regulations including but not limited to, advance directives; family planning services for minors; and other issues as identified.

  • Tracking of emergency care utilization and follow-up actions, including individual counseling, to promote appropriate use of urgent and emergency care settings.

  • Establishment of medical policies addressing new technology and new uses for existing technologies including medical procedures, behavioral health, drugs, devices, assistive devices, and durable medical equipment which are based on scientific evidence.

  • Collecting data and acting on opportunities to improve continuity of care for all members including collaborative care between behavioral health and medical health care providers.