Quality Improvement

AmeriHealth Caritas VIP Care has a Quality Improvement (QI) program to monitor the quality of services our members receive. Our goal is to make sure health care and services our members receive are:

  • High quality.
  • Safe.
  • Appropriate.
  • Efficient.
  • Effective.

We review our Quality Improvement program each year to see how we are doing. This review includes suggestions for improvement, as well as goals for the next year.

Our mission is to help people get care, stay well, and build healthy communities by creating programs to serve our members who have special health care needs.

Accomplishments in 2018 – 2019

  • CMS Five-Star Quality Rating System performance: AmeriHealth Caritas VIP Care improved from 3.5 Stars to 4 Stars in Contract Year 2018 (Stars 2020).
  • Chronic Condition Improvement Program: Improving Diabetic Adherence to Diabetic Clinical Guidelines Improvement is noted in 2018 members having a controlled HbA1c, diabetic retinal eye screenings and blood pressure control.
  • Credentialing: The Credentialing department adhered to all regulatory and accrediting standards for credentialing. The Credentialing department continues to maintain a National Committee for Quality Assurance (NCQA) certification as a Credentials Verification Organization (CVO).
  • Community outreach events: Seventeen community outreach events were held in 2018, with the majority being arranged for AmeriHealth Caritas VIP Care members helping to close Healthcare Effectiveness Data and Information Set (HEDIS®) care gaps for diabetic screenings.
  • Customer service: The plan's Member Services representatives met service-level performance goals for call abandonment rates below 5 percent and average speed of answer in 30 seconds or less throughout the year.
  • Delegation monitoring: The plan improved delegation oversight and reporting by utilizing the Corporate Delegation Oversight department and coordinating with the Medicare Compliance team.
  • Disease management programs: We coordinated a home visit outreach program with a provider group to improve compliance with HbA1C testing, microalbumin testing, and diabetic retinal eye exams.
  • Health Risk Assessment (HRA) tracking: We implemented departmental quarterly reporting to monitor Medical Management performance against CMS standards for HRA timeliness at both initial and annual assessments, helping to improve completion timeliness.
  • HEDIS improvement in calendar year (CY) 2018:
    • Care for Older Adults Medication Reviews improved 5%
    • Care for Older Adults Functional status assessments improved 4%
    • Care for Older Adults Pain Assessment improved 2%
    • Diabetic HbA1c control improved 7%
    • Diabetic eye exams improved 13%
    • Medication Reconciliation Post Discharge improved 12%
    • Readmission Rate per decreased to 9%
    • Statin Therapy for patients with cardiovascular disease improved 11%
  • Intensive care management (ICM) program: The plan established a Community Health Navigator team to conduct member visits in facilities and homes to assist in finding hard-to-reach-members.
  • Integrated QI activities: We coordinated improvement interventions across a variety of departments including but not limited to Medical Management, Pharmacy, Credentialing, Member Services, Compliance, Operations, and Provider Network.
  • Model of Care:
    • The revised Model of Care submitted for review in 2018 received a three-year approval with a final score of 98.33 percent.
    • AmeriHealth Caritas VIP Care has been approved by NCQA to operate as a Special Needs Plan (SNP) until December 31, 2021, based on a review of the AmeriHealth Caritas VIP Care Model of Care.
    • The 2018 Annual Model of Care Program Evaluation showed continued improvement in several areas:
  • Network adequacy meets or exceeded provider availability goals per CMS standards.
  • Patient safety: We monitored patient safety through review of potential adverse events and quality of care/quality of service member reporting.
  • Preventive screening programs: The plan implemented a colorectal cancer screening program to include in-home testing for our special needs population.
  • Provider collaboration improvement: We implemented a monthly Quality Improvement Provider Score Card in 2018.
  • Provider satisfaction: Overall provider satisfaction rates increased by 5 percent for AmeriHealth Caritas VIP Care providers.
  • Quality Improvement Project (QIP): We implemented a new program to improve adherence to clinical guidelines for diabetic members (2017 baseline year).
  • Quality of care (QOC) reviews: We investigated, trended, and took action as necessary on potential quality of care concerns within established time frames 100 percent of the time.
  • Reducing health care disparities: We continue to collect and report member race, ethnicity, and language data needed to address and decrease disparities in health care. We also require all member mailings include appropriate translation instructions and monitor member utilization of the language line.

Our goals for 2021

The plan will continue to focus on reducing cardiovascular disease and diabetes, increasing preventive screenings and medication adherence, and improving health outcomes.

We will also prioritize improving the health of our members and reducing health care disparities with our continuing efforts to:

  • Improve access to care and services through assessing the availability and accessibility of providers.
  • Improve compliance with prescribed health screenings.
  • Continue member and provider outreach initiatives to improve utilization of services.
  • Enhance chronic disease management through:
    • Maintaining effective care management programs.
    • Effectively using the HRA and robust care planning.
    • Designing effective medication adherence programs.
    • Reviewing and updating evidence-based clinical practice guidelines to promote implementation of comprehensive medical and health care practices, including preventive, diagnostic and treatment services.
  • Improve coordination of care between medical and behavioral health providers, home health care agencies, and long-term care service providers by systematically improving care management communication with these providers
  • Improve member safety through ongoing monitoring and investigation of root cause analyses and trends for potential quality of care and credentialing/recredentialing issues, as well as issues with complaints and appeals.
  • Empower members to work more collaboratively with their health care providers in implementing their care plans to maintain and/or improve their health.
  • Implement other QI initiatives to address ongoing support of process improvement, and the adoption of best practices within the managed care industry.

Call Member Services at 1-800-450-1166 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31, if you:

  • Would like to learn more about our QI program and its goals, activities, and outcomes.
  • Feel that you did not get quality care. Our QI team will look into the issue.
  • Are going home from the hospital and don't have the support you need. Our Care Connectors can help.