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Quality At America's 1st Choice

We are committed to promoting healthy lifestyles and improving the health status of enrollees.  As such, America’s 1st Choice’s Board of Directors directed the company to establish a Quality Management Program designed to promote quality care and service excellence.  We are committed to improving the health of members, and promoting healthy lifestyles.  Through our Quality Management (QM) Program, we establish goals and structure to support this commitment.  We monitor and evaluate the quality and appropriateness of care provided to our members.  The overall goal of this program is to achieve quality care and services for our members.  We achieve this goal through the design, implementation and improvement of organizational systems.  You can call Member Services 1-888-796-0946 to request a paper copy of our QM Program.  Providers can contact their Provider Relations Representative for an electronic or paper copy of the program.

 

Program Overview

The Quality Management (QM) Program is based on the quality principle that improvement results from ongoing and systematic measurement, intervention, and follow-up of key aspects of care.  Primary responsibility for administration of the QM Program is vested in the Medical Director, but all employees share in the responsibility to define and implement improvements that enhance clinical efficiency, provide effective utilization and focus on improved outcome management.   A major focus of the Quality Management Program is the establishment of clinical initiatives involving quality improvement projects, focus studies, and interventions designed to improve performance measures.  The QM Program utilizes performance measurement data, national benchmarks and root-cause analyses to identify opportunities for improvement. These opportunities for improvement are identified on an ongoing basis.  Practitioner involvement, as well as the staff and analytical resources devoted to quality improvement activities are important aspects of our QM Program, and contribute to ongoing improvements.

 

Use of Performance Indicators

Each year, we evaluate the Quality Management program, and progress toward meeting our goals.  One of the tools we use to evaluate the QM program is HEDIS (Healthcare Effectiveness Data and Information Set).  HEDIS is developed by the National Committee For Quality Assurance (NCQA) and is the most widely used rating system in health care.  Most health plans, including America’s 1st  Choice use HEDIS to measure the quality of services we provide to our members.  Using HEDIS, we establish performance goals, develop and implement improvement plans each year.  Information relevant to our HEDIS results will be published through our newsletters and website.  You can also find HEDIS information published annually on the Centers for Medicare and Medicaid Services (CMS) at www.medicare.gov. (by clicking on the link you will be leaving the America's 1st Choice website.)

HEDIS® 2011 Results

 

Patient Safety

We promote health and safety of our members. Our Patient Safety Program promotes member safety in all care settings.  Safety improvement initiatives are incorporated into plan activities, and evaluated for effectiveness.  The goals of our Patient Safety program include:

  • Providing effective and safe health care.
  • Improving medication safety.
  • Monitoring medication reconciliation.
  • Implementing improvement initiatives that allow us to monitor the safety of care provided

 

Measuring effectiveness

The process to measure Patient Safety program effectiveness includes an annual evaluation, quality studies and improvement initiatives.   The quality study design incorporates the establishment of baseline data, data analysis, development and implementation of interventions, and re-measurement to evaluate the effectiveness of interventions and overall improvement.  Patient Safety outcomes are reported annually to the Quality Management Steering Committee.   The Patient Safety Plan monitors and analyzes the following patient safety performance indicators, including:

  • Pharmacy data and summary reports
  • Patient Safety reports;
  • Complaints, grievance issues and summary reports
  • HEDIS results and outcomes
  • Medication Reconciliation Post-Discharge
  • Use of High-Risk Medications In the Elderly
  • Potentially Harmful Drug-Disease Interactions In the Elderly
  • Annual Monitoring for Patients on Persistent Medications

 

Quality Management Program Guidelines & Standards

Medical care management activities are an important component of the Quality Management Program, and key elements include practice guidelines and standards, over and under utilization monitoring, use of review criteria, and clinical peer review of medical appropriateness. You can call Member Services 1-888-796-0946 to request additional information on our clinical or preventive health guidelines.  Providers can contact their Provider Relations Representative on how to obtain an electronic or paper copy of the guidelines.

 

Other Resources

If you’re looking for other helpful resources, we suggest the following:

• Clinical Preventive Services for Normal-Health Adults:  Recommendations of the US Preventive Services Task Force, Department of Health and Human Services

• The Guide to Clinical Preventive Services 2010-2011: Recommendations of the US Preventive Services Task Force, Department of Health and Human Services