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3. QI Program Objectives Goals

The QI Program is designed to produce prospective, concurrent, and retrospective analyses of the Plan's activities in order to improve the quality of care and service members receive. The specific goals of the Program are to ensure that Horizon:

  • Provides coverage for health care that is reasonable and necessary with an emphasis on the promotion of health in a safe, effective and efficient manner
  • Assesses the appropriateness and timeliness of the care and services being provided
  • Promotes members' ability to maintain themselves in the least restrictive setting of their choice, as allowed by their health status, physical capabilities and behavioral health conditions.
  • Optimizes care delivery for members with special and/or complex care needs
  • Identifies members' needs and coordinates care to address the needs of the member
  • Focuses on the quality of medical and behavioral health care and services provided to all members
  • Works to identify and reduce health care disparities within its membership
  • Strives to improve member and provider satisfaction
  • Maintains oversight of delegated entities
  • Maintains oversight of the credentialing and re-credentialing of providers
  • Meets current National Committee for Quality Assurance (NCQA) Health Plan Accreditation requirements
  • Works to improve plan performance on HEDIS, Stars, CAHPS, HOS and Performance Improvement Projects (PIPs)
  • Works to ensure compliance with state and federal law and all applicable contract requirements

3.1 Program Evaluation

The QI Program is evaluated annually by the Quality Management Department with input from all business areas represented on the Quality Improvement Committee (QIC). The format of the QI Program Evaluation parallels the QI Program's Work Plan and includes:

  • A description of completed and ongoing QI activities that address quality of clinical care and quality of service
  • Evaluation and assessment of member safety activities
  • Tracking and trending of data to assess program performance in measures of quality of care and quality of service
  • An analysis of improvements in quality of care and service to members
  • A critical assessment of barriers to achieving goals and root cause analysis
  • An evaluation of the overall effectiveness of the QI Program

The QI Program Evaluation is presented annually to the QIC for review, comments, and approval. The Vice President and Chief Medical Officer (VP/CMO), or a designee, annually presents the QI Program Evaluation to the Horizon Healthcare of New Jersey Board of Directors.