Quality Improvement

Windsor Health Plan, Inc. (WHP), is dedicated to administering benefits to our members that are member centered, safe, timely, equitable, effective and efficient. WHP is committed to providing our members access to high-quality, comprehensive and cost- effective medical and pharmacy benefits. WHP also believes health care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status. To support our role in overseeing the quality of care provided to our members, WHP has developed a Quality Improvement Program (QIP).

WHP’s Quality Improvement Program utilizes an integrated, continuous quality improvement approach whereby clinical, operational and financial data are collected, analyzed and trended to measure current operations and identify opportunities for improvement. Identified issues are reviewed and prioritized, and improvement interventions are undertaken with a goal of improving company results and meeting the clinical and service needs of our members and providers.

The QIP applies to internal and external functions, including health plan services and internal performance, as well as clinical processes and outcomes of care provided to members by health care providers. The scope of the QIP is comprehensive, spanning the full range of clinical and health administrative services provided to all members.

In addition, the QIP supports its practitioners and providers in this mission through various processes, programs and monitoring activities, including oversight of services provided by its delegates. These may include, but are not limited to:

Member Complaint Process - Complaints are tracked and trended by category and reported on quarterly. Complaints related to quality of care are assessed, investigated and analyzed to identify care system delivery improvements.

Credentialing/Recredentialing Process - Ensures members are provided with a choice of qualified, competent practitioners and providers. Criteria for credentialing and recredentialing include practice site assessment data, medical record audit data, utilization indicators and practitioner/provider-specific complaint data.

Clinical Practice Guideline Process - Supports the establishment of best-practice criteria based on national practice guidelines to reduce variation in the care delivered to WHP members.

Under/Over Utilization Monitoring - Utilization data is monitored to identify and address under/over utilization. Information is used to provide feedback and develop education for practitioners, providers and members, including support for appropriate use of resources.

Continuity and Coordination of Care Monitoring - Key indicators identifying potential problems with the continuity and coordination of care are assessed at least quarterly and trended over time to ensure the quality of care provided to our members. Other related policies include provisions for processes to ensure care is continued if a practitioner leaves the provider network.

Medical Technology Assessment - Allows for review of the efficacy of the technology based on national research data and local medical practice.

Confidentiality/HIPAA – All employees or participating practitioners engaging in Quality Improvement activities must uphold the established principles of patient and practitioner confidentiality and individual privacy as defined in WHP’s Compliance Plan and Standards of Conduct Program and according to HIPAA/HITECH regulations.

Practitioner and Provider Participation – Practitioner and provider participation is essential to the success of the Quality Improvement Program. Their participation may include, but is not limited to, committee participation, assistance and review of criteria or guidelines and other peer review activities, response to surveys or interviews.

Availability and Accessibility – WHP has established standards for availability and accessibility (e.g., to routine, urgent and emergency care, telephone appointments, etc.); standards for facilities in which patients receive ambulatory care; and medical record standards related to accessibility, availability and medical record keeping. Performance on these dimensions of care is measured against standards that are described in the provider manual, policies and quality monitors.

Pharmacy Services – WHP’s Pharmacy Department coordinates and manages the Medicare Part D Program for WHP’s Medicare Part D beneficiaries by providing appropriate and cost-effective drug therapy. The department supports contracted providers in order to continually improve the quality and cost effectiveness of pharmacy services and to support effective and efficient administration of covered pharmacy benefits. The department additionally manages the transition and formulary selection process through the oversight and direction of the WHP Pharmacy and Therapeutics (P&T) Committee. The WHP Pharmacy Department provides oversight of the WHP Pharmacy Benefit Manager (PBM) who provides pharmacy benefit management services to WHP.

Utilization Management – Utilization Management includes Utilization Review, Pre–services Organization Determinations, Concurrent Review and Care Management. WHP provides Utilization Management to ensure that the care/services/equipment being provided are appropriate, a covered benefit, medically necessary, and/or meet established clinical criteria, as well as providing evaluation, monitoring and coordination of care for members through the Care Management process. Clinical criteria that govern these program components include at least the following:

Chronic Care Improvement Programs (CCIPs) – Chronic Care Improvement Programs are used to coordinate health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Care Management efforts are included in the overall management of the disease process. WHP follows the nationally recognized standards and definition set by the Disease Management Association of America. The purpose of the program(s) is to cost effectively utilize, coordinate, evaluate, monitor, track and trend services and outcomes of specific diseases. Data from the monitoring activities provide a source for identifying any potential areas for improvement. The “Chronic Care Improvement Program” document is a detailed description formatted in the CMS-proposed reporting template.

Special Needs Plans Model of Care – WHP’s Special Needs Plans (SNPs) provide and help coordinate health care services that are pertinent and medically necessary to our members who have dual eligibility (Medicaid/Medicare), diabetes and persistent mental health conditions. The focus of each plan is on providing an evidence-based model of care to its membership that includes vulnerable individuals, the frail/disabled, those having multiple chronic conditions, and those near the end of life. The model of care for each SNP defines and supports opportunities to improve care for SNP members, primarily through improved coordination and continuity of care, as well as improved self-management skills and adherence to the treatment plan by the member.

WHP’s SNPs focus on monitoring health status, managing chronic diseases, avoiding inappropriate hospitalizations, and helping beneficiaries move from high risk to lower risk on the care continuum. The goal is to ensure, through early and appropriate clinical interventions, that SNP members in all settings receive quality care which is timely, effective, efficient, equitable, safe, and patient centered.

CMS-Required Reporting

WHP collects, analyzes, and reports data from CMS-required reporting on quality and outcome measures. Collection and analysis of the data permit WHP to measure health outcomes and other indices of quality and to utilize the data to identify opportunities for improvement. These data sources include:

Healthcare Effectiveness Data and Information Set (HEDIS®) – This is a set of standardized performance measures designed to ensure that consumers have the information they need for reliable comparison of organization performance. Specific areas of concentration include: effectiveness of care, access/availability of care, and improving our members’ ability to make informed health care choices.

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surveys – A comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers, such as the communication skills of providers and the accessibility of services.

Medicare Health Outcomes Survey (HOS®) - The goal of the Medicare HOS program is to gather valid and reliable health status data in Medicare managed care for use in quality improvement activities, plan accountability, public reporting, and improving health. All managed care plans with Medicare Advantage (MA) contracts must participate.