Certain aspects of clinical care and service data may identify opportunities to maximize the use of quality improvement resources. Priority will be given the following:
The annual analysis of member demographic and epidemiological data
Those aspects of care which occur most frequently or affect large numbers of members
Those diagnoses in which members are at risk for serious consequences or deprivation of substantial benefit if care does not meet community standards or is not medically indicated
Those processes involved in the delivery of care or service that, through process improvement interventions, could achieve a higher level of performance
Use of Committee Findings
To the degree possible, quality improvement systems are structured to recognize care for favorable outcomes as well as correcting instances of deficient practice. The vast majority of practicing physicians provides care resulting in favorable outcomes. Quality improvement systems explore methods to identify and recognize those treatment methodologies or protocols that consistently contribute to improved health outcomes. Information of such results is communicated to the Board of Directors and providers on a regular basis. Written communication to primary practitioners is the responsibility of the Committee chairperson. Submission of written corrective action plans, as necessary, is required for the Committee's approval. Significant findings of quality improvement activities are incorporated into practitioner educational programs, the re-credentialing process, and the re-contracting process and personnel annual performance evaluations. All quality improvement activities are documented and the result of actions taken recorded to demonstrate the program's overall impact on improving health care and the delivery system.
Clinical Practice Guidelines
Community Health Group utilizes evidence-based practice guidelines to establish requirements and measure performance on a minimum of three practice guidelines (acute, chronic and behavioral health) annually to strive to reduce variability in clinical processes. Practice guidelines are developed with representation from the network practitioners. The guidelines are implemented after input from participating practitioners of the Clinical Quality Improvement, Utilization Management and Pharmacy and Therapeutics Committees. Guidelines will be reviewed and revised, as applicable, at least every two years.
Preventive Health/HEDIS® Measures
The Clinical Quality Improvement Committee will determine aspects of care to be evaluated based on member population and regulatory requirements. At a minimum, HEDIS performance indicators will be monitored annually based on product type, i.e. Medi-Cal or Medicare. These include:
Adult Body Mass Index (BMI) Assessment1,2
Annual Monitoring for Patients on Persistent Medications1
Antidepressant Medication Management
Appropriate Testing for Children with Pharyngitis1
Appropriate Treatment for Children with Upper Respiratory Infection1
Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis1
Breast Cancer Screening1
Care for Older Adults1
Cervical Cancer Screening1
Childhood Immunizations Status1
Quality Improvement Program Description
Children and Adolescent’s Access to Primary Care Providers1
Chlamydia Screening in Women1
Cholesterol Management After Cardiovascular Events (Screening rate only)1,2
Colorectal Cancer Screening2
Comprehensive Diabetes Care1,2
Controlling High Blood Pressure1,2
Follow-Up After Hospitalization for Mental Illness2
Flu Shots for Older Adults2
Glaucoma Screening in Older Adults2
Identification of Alcohol and Other Drug Services2
Medication Reconciliation Post-Discharge2
Medical Assistance with Smoking Cessation (Advising Smokers to Quit)
Osteoporosis Management in Women Who Had a Fracture2
Pharmacotherapy Management of COPD Exacerbation 1, 2
Persistence of Beta Blocker Treatment After a Heart Attack1,2
Pneumonia Vaccination Status for Older Adults2
Potentially Harmful Drug-Disease Interactions in the Elderly2
Prenatal and Postpartum Care: Timeliness of Prenatal Care1
Prenatal and Postpartum Care: Postpartum Care1
Use of Appropriate Mediations for People with Asthma1
Use of Imaging Studies for Low Back Pain1
Use of Services – Ambulatory Care
Use of Services – Inpatient Utilization
Use of Services – Outpatient Drug Utilization2
Use of Spirometry Testing in the Assessment and Diagnosis of COPD1
Weight Assessment/Counseling for Nutrition & Physical Activity for Children/Adolescents1
Well Child Visit in the Third, Fourth, Fifth, and Sixth Years of Life1
1Medi-Cal Members Only
2Medicare Members Only
Disease Management Programs
The health care services staff, Clinical Quality Improvement Committee and network practitioners identify members with, or at risk for, chronic medical conditions. The Clinical Quality Improvement Committee is responsible for the development and implementation of disease management programs for identified conditions. Disease management programs are designed to support the practitioner-patient relationship and plan of care. The programs will emphasize the prevention of exacerbation and complications using evidence-based practice guidelines. The active disease management programs and their components will be identified in the annual QI work plan.
Complex case management and chronic care improvement are major components of the disease management program. Specific criteria are used to identify members appropriate for each component.
Member self-referral and practitioner referral will be considered for entry into these programs.
Following confidentiality standards, eligible members are notified that they are enrolled in these programs, how they qualified, and how to opt-out if they desire. Case managers and care coordinators are assigned to specific members or groups of members and defined by stratification of the complexity of their condition and care required. The case managers/care coordinators help members navigate the care system and obtain necessary services in the most optimal setting.
Quality Improvement Program Description
Components of complex case management and chronic care improvement programs shall include:
Members' right to decline participation or disenroll from case management programs and services
Initial assessment of members' health status, including condition-specific issues
Documentation of clinical history, including medications
Initial assessment of activities of daily living
Initial assessment of mental health status, including cognitive functioning
Initial assessment of life planning activities
Evaluation of cultural and linguistic needs, preferences or limitations
Evaluation of caregiver resources
Evaluation of available benefits
Development of a case management plan, including long- and short-term goals
Identification of barriers to meeting goals or complying with the plan
Development of a schedule for follow-up and communication with the member
Development and communication of self management plans for members
Process to assess progress against the case management plans for members
Continuity and Coordination of Care
The continuity and coordination of care that members receive is monitored across all practice and provider sites. As meaningful clinical issues relevant to the membership are identified, they will be addressed in the quality improvement work plan. The following areas are reviewed for potential clinical continuity and coordination of care concerns.
Primary care services
OB/GYN services
Behavioral health care services
Inpatient hospitalization services
Home health services
Skilled nursing facility services
The continuity and coordination of care received by members includes medical care in combination with behavioral health care. Community Health Group collaborates with behavioral health practitioners to ensure the following activities are accomplished:
Information Exchange – Information exchange between medical practitioners and behavioral health practitioners must be member-approved and be conducted in an effective, timely, and confidential manner.
Referral of Behavioral Health Disorders – Primary care practitioners are encouraged to make timely referral for treatment of behavioral health disorders commonly seen in their practices, i.e., depression.
Evaluation of Psychopharmacological Medication – Drug use evaluations are conducted to increase appropriate use, or decrease inappropriate use, and to reduce the incidence of adverse drug reactions.
Data Collection – Data is collected and analyzed to identify opportunities for improvement and collaborate with behavioral health practitioners for possible improvement actions.
Implementations of Corrective Action – Collaborative interventions are implemented when opportunities for improvement are identified.