Health Plan of San Joaquin 2020/2021 Quality Management Program Evaluation
Health Plan of San Joaquin’s (HPSJ) mission is to “provide healthcare value and advance wellness through community partnerships.” In tandem, the vision is to “Continuously improve the health of our community.” In line with this mission and vision, HPSJ’s Quality Management (QM) Program 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, including physical or developmental disabilities, multiple chronic conditions and severe mental 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 QM Program
The scope of the QM Program 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 HPSJ. Behavioral health services for members with severe functional impairment are “carved out” of the contract by the state to the County Behavioral Health System. Coordination of medical and behavioral health care is an integral part of HPSJ’s Care Management Program.
Continuous quality management and improvement is accomplished through QI teams who conduct:
- Systematic data collection
- Qualitative and quantitative analysis
- Identification of improvement opportunities
- Activity planning and implementation
- Ongoing monitoring and evaluation
The Quality Management and Improvement program includes an array of indicators to measure critical clinical processes and outcomes. The QMUM Work Plan delineates the critical performance measures that define the scope and range of the Quality Management and Improvement Program. Components addressed includes:
- 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 QM Program 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
Progress towards QI Goals 2020/2021
HPSJ implemented many initiatives during that have impacted rates significantly in a positive way. Unfortunately, due to the impact of COVID-19 on our community providers, the positive impact is not fully realized. HPSJ directs interventions in three focus areas: provider, member, and data. Provider initiatives take the form of incentives, alerts, newsletters, and the Provider Partnership Program. Member interventions take the form of education, outreach, and incentives. Data improvements include expanding and maintaining supplemental data sets, data analysis and pursuing additional supplemental data sources. Health Plan of San Joaquin has grouped measures under domains to focus and align its improvement efforts. The four domains include Women’s Health, Children’s Health, Acute and Chronic Disease Management.
Planned Opportunities for Improvement
HPSJ has identified measures that have the biggest impact to our community and will focus HEDIS 2021 initiatives on those areas. Based on guidance received from the Department of Healthcare Services the plan’s focus with be the newly developed MCAS or the Managed Care Accountability Set. To develop an effective strategy, the plan has assigned each high priority measure into 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
- Wellness visits
- Well Child visits
- Behavioral Healthcare Measures
- Follow up ADHD medication initiation phase, and the acute phase
- Antidepressant Medication Management acute, and continuation phase
HPSJ annually evaluates member experience through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and grievance reporting. The CAHPS survey was sent to adult as well as caregivers for child members. All results from the survey are reflective of 2020 but are fielded and reported in 2021. Both adult and child surveys noted declines in both response rate and many composite ratings. Overall grievances were increased in both counties from fiscal year 2020 to 2021. Key trends in grievances are access to care and quality of care. In 2020, the focus on supporting the provider network through the COVID-19 pandemic and provider education for access to care were implemented. These initiatives proved ineffective in improving member satisfaction, however, they may have been integral to preventing further deterioration during the public health emergency. In 2020, key drivers of declining rates were access to specialty care, customer service, and coordination of care. Priorities focusing on these opportunities are outlined in the 2020-2021 work plan.
In conclusion, HPSJ’s 2020/2021 QI Annual Evaluation and Effectiveness findings inform the 2020/2021 QI 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 of San Joaquin’s Quality Management Program is to develop methods to continually improve the quality of medical care, and service provided to its membership. Towards this goal the Quality Improvement 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 Management Evaluation or call 209.942.6300 to request a paper copy.