Health Plan’s mission is to “provide healthcare value and advance wellness through community partnerships.” In tandem, the vision is “Healthy Communities with Equitable Access to Quality Care” In line with this mission and vision, Health Plan’s Quality Improvement and Health Equity Transformation Program (QIHETP) goals are to:
- Improve the quality and efficiency of health care provided to our patients.
- Improve members’ experience with services and care received.
- Improve patients’ health outcomes.
- Provide culturally sensitive and linguistically appropriate services.
- Promote the safety of all members in all treatment settings.
- Ensures timely access and availability of services for all members, including those with complex or special needs, physical or developmental disabilities, multiple chronic conditions and behavioral health illnesses.
- Promote processes to ensure the availability of “safe, timely, effective, efficient, equitable, patient centered care and collaborate with the network providers and the community.
Scope of the QIHETP
The scope of the QIHETP is comprehensive and addresses both the quality and safety of medical and behavioral health care provided to our members and participants for all lines of businesses. Behavioral Health care is a benefit for the Medi-Cal members and is administered by Health Plan. Direct care for behavioral health services that treat members with severe functional impairment are “carved out” of the agreement by the state. Therefore, the County Behavioral Health System manages treatment and services. Coordination of medical and behavioral health care is an integral part of Health Plan’s Care Management Program.
Continuous quality management and improvement is accomplished through Quality Improvement (QI) teams who conduct:
- Systematic data collection
- Qualitative and quantitative analysis
- Identification of improvement opportunities
- Activity planning and implementation
- Ongoing monitoring and evaluation
The QIHETP includes an array of indicators to measure critical clinical processes and outcomes. The Quality Improvement and Health Equity (QIHE) Work Plan delineates the critical performance measures that define the scope and range of the QIHETP. Components addressed include but are not limited to:
- Accessibility of Services
- Availability of Services
- Grievances and Appeals
- Clinical Quality Improvement
- Service Quality Improvement
- Adverse Outcomes/Sentinel Events
- Member Satisfaction/Experience (CAHPS)
- Practitioner Satisfaction/Experience
- Clinical Practice Guidelines
- Continuity and Coordination of Care
- Effectiveness of The Quality Improvement Program
- Patient Safety
- Delegation Oversight
Other areas that have an impact on the QIHETP include:
- Practitioner/Provider Credentialing and Re-Credentialing
- Utilization Management Processes and Outcomes
- Inter-Rater Reliability Testing
- Practitioner Performance
- Pharmacy Management
- Facility Site Reviews
- Data Governance
Managed Care Accountability Set (MCAS) Results for Measurement Years 2021 – 2023
The MCAS measures are a selection of measures procured by the California Department of Health Care Services that represent important process and outcome measures relevant to the members served
| Managed Care Accountability Set | MY2021 | MY2022 | MY2023 |
| Controlling High Blood Pressure | 57.18% | 59.37% | 68.61% |
| Glycemic Status Assessment for Patients with Diabetes (>9%) | 38.44% | 35.52% | 35.52% |
| Childhood Immunization Status: Combination 10 | 36.98% | 36.50% | 27.98% |
| Immunizations for Adolescents: Combination 2 | 39.17% | 37.55% | 40.88% |
| Lead Screening in Children | NR | 46.11% | 46.47% |
| Cervical Cancer Screening | 56.26% | 56.93% | 63.99% |
| Prenatal Care | 88.08% | 87.59% | 85.40% |
| Postpartum Care | 78.83% | 79.08% | 84.43% |
| Breast Cancer Screening | 47.29% | 50.44% | 50.54% |
| Follow-Up After ED Visit for Substance Abuse – 30 days | 7.17% | 17.08% | 17.49% |
| Follow-Up After ED Visit for Mental Illness – 30 days | 59.69% | 52.39% | 23.71% |
| Asthma Medication Ratio | 48.07% | 58.86% | 66.45% |
| Developmental Screening in the First Three Years of Life | NR | 27.34% | 25.05% |
| Topical Fluoride for Children | NR | 2.15% | 19.05% |
| Well-Child Visits in the First 30 Months of Life – 0 to 15 Months – Six or More Well-Child Visits | 44.63% | 50.36% | 51.67% |
| Well-Child Visits in the First 30 Months of Life – 15 to 30 Months – Two or More Well-Child Visits | 58.30% | 60.67% | 62.46% |
| Child and Adolescent Well-Care Visits | 46.23% | 47.26% | 49.44% |
| Chlamydia Screening in Women | 58.54% | 58.78% | 59.77% |
Planned Opportunities for Improvement
Health Plan has identified measures that have the biggest impact on our community and will focus measurement year 2025 initiatives on those areas. Based on guidance received from the Department of Health Care Services the focus will be on a combination of the State’s Bold Goals, Managed Care Accountability Set (MCAS) rates, and reducing health disparities. To develop an effective strategy, Health Plan has assigned each high priority measure into health care domains outlined below.
- Women’s Healthcare
- Breast Cancer Screening
- Cervical Cancer Screening
- Chlamydia Screening
- Prenatal and Postpartum care
- Acute and Chronic Disease Management
- HbA1c testing
- Controlling Diabetes
- Diabetic Prevention
- Adult BMI
- Controlling Hypertension
- Asthma Medication Ratio
- Plan All Cause Readmission
- Children’s Healthcare
- Immunizations
- Wellness visits
- Well Child visits
- Behavioral Healthcare Measures
- Follow up after ED visits for both mental health visits and substance use visits
- Antidepressant Medication Management
Health Equity
Health Plan is committed to promoting health equity as a core component within the quality strategy. Health Plan recognizes that health disparities are often rooted in social, economic, demographic, and geographic factors, so striving to eliminate these inequities in healthcare delivery is a top priority. Health Plan’s aim is to ensure that all members, regardless of their background or circumstances, have access to resources and care they need to achieve optimal health outcomes. While the overarching goal is to improve the health of the entire Health Plan population, this can only be achieved through recognition of the unique needs of different communities. As part of our commitment to health equity, Health Plan will undertake efforts to take concrete actions toward health equity. For CY2025, these actions include:
- Seek National Committee for Quality Assurance (NCQA) Health Equity Accreditation
- Stratify medical, behavioral, and member experience quality metrics to identify disparities
- Stratify utilization and member and staff experience with Culturally and Linguistically Appropriate Services (CLAS), to identify disparities
- Develop targeted action plans for at least one identified disparity in member access or health outcome.
For Calendar Year 2025, specific interventions related to health equity have been developed.
Reducing Perinatal Disparities for Black Members
Health Plan aims to reduce the health disparity for timely post-partum care for African American women by 5% by 12/31/2025.Programs aimed at addressing the needs of African American women have been developed. Health Plan outreaches to members and facilitates an introduction to Black Infant Health (BIH) for enrollment in their wrap around, culturally tailored and inclusive community services to receive education and support throughout their pregnancy and postpartum periods. Pregnant members who are identified by the plan are given contact information for the organization or are connected telephonically to representatives in real time if interested. Members can opt-in to the BIH program and curriculum. They receive personal care products and incentives for attending classes and are allowed to participate in graduation ceremonies after 9 classes are complete. BIH participants are also eligible for plan-based incentives for completing prenatal and postpartum care.
Equity Practice Transformation (EPT) Payments Program
In collaboration with The Department of Health Care Services, Health Plan is implementing primary care provider practice transformation programs to advance health equity and reduce COVID-19-driven care disparities by investing in up-stream care models and partnerships to address health and wellness by funding practice transformation. These efforts aligned with value-based payment models will allow Medi-Cal providers to better serve the state’s diverse Medi-Cal enrollee population. To align with the goals of the DHCS Comprehensive Quality Strategy and Equity Roadmap, these funds will pay for delivery system transformation for primary care practices (pediatrics, family practice, adult medicine primary care, primary care OB/GYN, and/or behavioral health providers in primary care settings) focused on advancing DHCS’ equity goals in the “50 by 2025: Bold Goals” Initiative and to prepare them to participate in alternative payment models.
The EPT program will fund transformation activities that will help practices improve quality, close gaps in care, and prepare for value-based care. Per DHCS application guidelines, there are required and optional activities that applying practices will need to consider. Required activities that practices will need to complete or attest out of are a.) Empanelment and Access, b.) Technology and Data, c.) Patient-Centered, and Population-Based Care. In addition, practices may commit to optional activities, such as:
- Evidence-Based Models of Care
- Leadership & Culture
- Behavioral Health
- Social Health, and Value-Based Care and Alternative Payment Models
Child Health Equity Sprint Collaborative
The Institute for Healthcare Improvement (IHI) is partnering with DHCS to continue the work already started by California Advancing and Innovating Medi-Cal (CalAIM). Together, IHI and DHCS have designed a 12-month Child Health Sprint Collaborative that focuses on supporting Managed Care Plans (including Health Plan) to implement best practices in children’s preventive services with their network providers and plan-based teams to provide effective, equitable whole-person pediatric care. Specifically, the focus of the Child Health Equity Collaborative is to improve the completion of well-child visits (WCVs) for infants (0-30 months) and adolescents (15-18 years old). All California Managed Care Plans are required to participate.
Working with DHCS and Managed Care Plans, the IHI is using a comprehensive strategy to reduce equity gaps, improve access, and build capacity across Medi-Cal. Critical elements of the strategy include effective team-based care, automation and effective use of technology, including Electronic Health Records, population health management, and addressing social drivers of health. The Collaborative coordinates regular meetings and training sessions with Managed Care Plans. Health Plan is partnering with Golden Valley Health Center on this important initiative. Health Plan staff participating in the Sprint include Manager, HEDIS and Quality Reporting; Coordinators for HEDIS and Quality Reporting; Manager, Accreditation, HEDIS, and NCQA, Quality Director, Manager, Cultural and Linguistic, and Manager, Health Education.
The final phase of this work will provide results and analysis of the work completed in the 12-month collaborative. The results will then be used to provide valuable insight and guidance to IHI and DHCS on how to best scale up and disseminate the key learnings, change ideas, and results in a sustainable and impactful manner.
Diversity, Equity, and Inclusions (DEI) Training
Health Plan will provide Diversity, Equity, and Inclusion (DEI) training specific to the regions served, and will address demographics, health related social needs, disparity impacts, including seniors and persons with disabilities, those with chronic conditions, and those with specialty mental health service and/or substance use needs, those with intellectual and developmental disabilities, and children with special healthcare needs. DEI training will incorporate the following:
- Explicit consideration of structural and institutional racism and its impact on members, staff, network providers, subcontractors, and downstream subcontractors
- Information about relevant health inequities and identified cultural groups in the service area(s) including:
- Beliefs about illness and health
- Member experience and perceived discrimination and the impact of implicit bias
- Lesbiany, gay, bisexual, transgender, queer, or questioning, intersex, asexual and more (LQTBQIA+) concerns and the need for gender affirming care
- Methods for interacting with the healthcare system
- Traditional and home remedies which may impact how the provider should treat the member and
- Language and literacy needs
- Leveraging the strong collaboration between Provider Services, Population Health, and the Health Education team brings regulatory requirements, health disparities, cultural awareness and SDOH-related information to provider teams and to the communities Health Plan serves. The Health Equity – focused provider education will incorporate information required by DHCS APL 23-025, which states that member specific characteristics related to religion, ancestry, national origin, creed, mental disability, physical disability, medical condition, genetic information, health status, and marital status will be considered when creating educational materials for the provider network. Furthermore, health equity-focused education will also leverage stratified data provided by the C&L Team which identifies gaps in interpreter and translation services. The ultimate goal is to improve the quality of care delivered by providing culturally specific, linguistically congruent communication with the populations Health Plan serves. Last, but not least, education provided to both providers and members will incorporate the feedback obtained from members of the CAC by recommending opportunities to eliminate barriers in care.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Health Plan annually evaluates member experience through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey reporting. The CAHPS survey was sent to adult as well as caregivers for child members. All results from the survey are reflective of 2023 but are fielded and reported in 2024. Both adult and child surveys noted declines in both response rate and many composite ratings. Priorities focusing on these opportunities are outlined in the 2024-2025 work plan.
Conclusion
In conclusion, Health Plan’s 2023/2024 QIHE Annual Evaluation findings inform the 2024/2025 QIHE Work Plan. Key issues and improvement opportunities are monitored routinely to ensure that adequate input is received and implemented on a regular basis. The goal of Health Plan’s QIHETP is to develop methods to continually improve the quality of medical care and service provided to its membership. Towards this goal the Quality Improvement and Health Equity Department will continue to work within its continuous quality improvement model focused on member-focused quality initiatives that can be most impactful. The plan will continue to analyze quality indications to ensure goals/benchmarks are being met.
Please visit www.hpsj.com/quality to download and read the entire Quality Improvement and Health Equity Evaluation or if you have a question or would like a paper copy, call Customer Service toll-free 1-888-936-7526 (PLAN) TTY 711, Mondy-Friday, 8:00 a.m. to 5:00 p.m.