QI Program Goals and Objectives

Objectives:

• Evaluate and maintain a high quality provider network through a formalized credentialing and recredentialing process.
• Maintain a structured, ongoing oversight process for quality improvement functions performed by practitioners, providers, and independently contracted delegates.
• Implement activities to monitor and address continuity and coordination of care between physical and behavioral health specialties and within the medical care system.
• Establish long-term collaborative relationships with the physician and provider network to consistently improve the quality and cost effectiveness of care and services delivered to our members.
• Specify standards of care, criteria and procedures as well as assess compliance with such standards and adequacy and appropriateness of health care resources utilized.
• Monitor member satisfaction with quality of care and services received from network physicians, providers, practitioners and delegates.

Objectives:

• Assure that adequate resources are available to provide appropriate, accessible and timely health care services to all members according to evidence based rules.
• Evaluate new medical technology, new application of existing technologies and determine their coverage status in the context of Horizon’s benefit packages.
• Continually monitor, evaluate, and improve Horizon's performance using benchmarks and goals based on national data.
• Ensure appropriate coordination of care between clinical settings.

Objectives:

• Continually identify and outreach to members at risk and/or with gaps in care.
• Identify healthcare disparities in order to develop appropriate intervention tools including staff cultural competency education.
• Establish programs focused on the chronic conditions of our members in order to empower members to actively participate in and take responsibility for their own health through the provision of education, counseling, and access to quality health care providers and tools.
• Expand planned interventions in existing health management programs and strengthen coordination between clinical and behavioral health management activities, and appropriate discharge planning.
• Select, distribute and maintain preventive health guidelines that are: age, gender, culture, and risk status appropriate; describe the prevention or early detection interventions along with the recommended frequency and conditions under which the interventions are required; document the source upon which it is based, review and update bi-annually or as needed.
• Develop population based programs that address our members' needs in the areas of wellness, members with emerging risk, multiple chronic conditions and patient safety and outcomes across medical settings. Promote member engagement/participation in these programs.

Objectives:

• Provide members with semiannual publications and access to a website that contains information to improve their knowledge about clinical safety issues.
• Collaborate with physicians, providers and practitioners to establish a means of promoting and maintaining safe clinical practices.
• Address patient safety through continuous review of quality of care issues and require corrective action from providers involved.
• Evaluate provider (physicians and hospitals) performance with respect to the quality of care delivered to members.
• Utilize evidence based practice guidelines, monitor and assess the extent to which members receive care consistent with the guidelines.
• Provide members with 24/7 access to clinical staff for informational questions and education about assessing their basic health care needs.
• Evaluate patient safety through continuous monitoring of polypharmacy utilization.
• Assess the over and under-utilization of services as needed.

Objectives:

• Ensure easy and timely access to accurate information through Horizon customer service units and/or the Horizon website.
• Resolve inquiries, complaints and appeals in a timely manner.
• Measure member and provider satisfaction through analysis of complaints and survey data to identify areas for improvement and develop improvement action plans.

Objectives:

• Monitor and update workflows and processes to continuously meet regulatory requirements for quality improvement and compliance as needed.
• Initiate and monitor quality improvement activities, which meet or exceed accreditation standards.
• Fulfill the quality related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by independent external review and accreditation bodies.