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 QI 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 2020 – 2021

  • CMS Five-Star Rating System preference: AmeriHealth Caritas VIP Care improved from four stars to four and a half stars in contract year 2020 (CMS Five-Star Rating System year 2020).
  • Chronic Condition Improvement Program: Improved diabetic adherence to diabetic clinical guidelines: Improvement is noted in 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).
  • Customer service: The plan achieved a Five-Star CMS Rating in members reporting that customer service gave them needed information and treated them with respect and courtesy.
  • 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 and microalbumin testing.
  • 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 Stars Rating in Calendar Year (CY) 2020
  • Measures that achieved a CMS Five-Star rating, or 100% of Goal:
    • Care for Older Adults – Medication Review.
    • Medication Reconciliation Post-Discharge.
    • Statin Use in Persons with Diabetes.
    • Statin Therapy for Patients with Cardiovascular Disease.
    Measures that achieved a CMS Four-Star rating or "Met Goal"
    • Breast Cancer Screening.
    • Colorectal Cancer Screening.
    • Annual Flu Vaccine.
    • Care for Older Adults — Pain Assessment.
    • Diabetes Care — Eye Exams.
    • Diabetes Care — Kidney Disease Monitoring.
    • Diabetes Care — Blood Sugar Controlled.
  • Integrated care management (ICM) program: Our plan implemented a Transition of Care team to help assist members with obtaining the care and services they need post-hospitalization.
  • 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.
  • Key indicators: We monitored key indicators for inpatient/outpatient utilization trends including admissions, average length of stay, and outpatient services and events.
  • Model of Care:
    • The revised Model of Care submitted in 2021 received a three-year approval with a final score of 100%
    • AmeriHealth Caritas VIP Care has been approved by National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2024, based on a review of AmeriHealth Caritas VIP Care Model of Care.
    • The 2020 Annual Model of Care Program Evaluation showed continued improvement in several areas:
      • Improving Access to Essential Services — 75% of Goals Met.
      • Improving Access to Affordable Care — 66% of Goals Met.
      • Improving Seamless Transitions of Care — 100% of Goals Met.
      • Improving Access to Preventive Health Services — 100% of Goals Met.
      • Improving Beneficiary Health Outcomes — 87.5% of Goals Met.
      • Improving Appropriate Utilization of Services — 100% of Goals Met.
  • 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 continued to provide a monthly Quality Improvement Provider Score Card to our Primary Care Providers.
  • Quality of care (QOC) reviews: We investigated, trended, and took action as necessary on potential quality of care concerns within established time frames 100% 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 and monitor member utilization of the language line.
  • Social Determinants of Health (SDOH): We implemented a new member survey to collect SDOH data to help identify members' needs and decrease health care disparities.

Our goals for 2022

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 addressing issues identified through 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 1-866-533-5490 (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.