Quality Management

Introduction to Health Plan

The Health Plan of San Joaquin (HPSJ) is contracted as a two-county health plan serving San Joaquin and Stanislaus Counties.  It is publicly sponsored, not-for-profit Health Maintenance Organization (HMO) contracted with the California Department of Health Care Services (DHCS) for Medi-Cal members.  

HPSJ is an established plan with just over 20 years of service to the community.  The National Committee for Quality Assurance (NCQA) awarded HPSJ accreditation in 2015.  The Quality Management (QM) plan is designed to meet the requirements of the State of California as well as NCQA.

Goals
The QM goals are to promote improvement every year for clinical and service outcomes of the plan.  These goals are achieved through partnering with our community providers by review of priorities for our members for promoting health and prevention.  HPSJ has an organization wide commitment to the quality of care, service and safety.

Quality metrics are shared with HPSJ providers in order to track member gaps in care and needs.  HPSJ continually updates and improves the provider access for the web communications of programs and outcomes.

Behavioral Health
HPSJ has contracted with Beacon Health Services and College Health IPA to provide screening, care coordination and management of members with mild to moderate mental health outpatient behavioral health needs.  The services for members with severe impairment are carved out to the county behavioral health services agencies for San Joaquin and Stanislaus.

Leadership
The San Joaquin County Health Commission (CHC) has the ultimate authority and responsibility for the management of quality program for HPSJ.  This governing body oversees, approves, promotes, recommends changes and supports the strategic plan, goals and objectives of the QM program.  The CHC does the following:

  • Reviews and approves the annual QM program description
  • Reviews and approves the annual QM work plan
  • Reviews and approves the annual QM evaluation
  • Reviews an approves other QM reports from the Quality Management Utilization Management (QMUM) Committee
  • Ensures appropriate resources to implement the QM program.

Key QM Leaders:

Chief Medical Officer (CMO)
The CMO has an unrestricted license in California as a physician.  The CMO reports to the Chief Executive Officer and communicates the QM reports to the CHC.  The CMO has ultimate oversight for the QM program and activities.

Behavioral Health Provider
A psychiatrist with an unrestricted license in California serves as an active participant on the QMUM committee.  The psychiatrist is involved in advice for the behavioral health aspects of the QM program and behavioral health related issues and policies and procedures.  This psychiatrist also participates in the development or revision of clinical practice guidelines, new technology assessment and behavioral health outcomes.

Medical Directors (MD)
HPSJ has two full time Medical Directors with valid, unrestricted California licenses.  The MDs report to the CMO and are responsible for managing the medical decisions and communications for the Medical Management Department.

Director of QM
The QM director is a Registered Nurse, responsible for the direct oversight, supervision, and management of the QM Program activities.  The Director reports to the CMO.

Director of Utilization/Disease Management (UM/DM)
The Director of UM/DM is a Registered Nurse, responsible for the direct oversight, supervision and management of the Case Management, Utilization Management and Disease Management Program.

Director of Pharmacy and Clinical Programs
This position reports to the CMO and is a pharmacist with an unrestricted California license.  This position is responsible for the integrity of the data collection, reporting and analysis, as well as the management of the pharmacy personnel and the Pharmacy Benefit management.

 Compliance Officer
The Compliance Officer reports to the CEO and is responsible for oversight and management of all compliance related issues within the organization.

All of the positions noted above coordinate efforts to promote and maintain optimal quality management for the HPSJ members.

Additional areas that support the QM Program

  • Executive Team
  • Member Services
  • Provider Services and Contracting
  • Claims
  • Finance
  • Information Technology
  • Marketing

Patient Safety
HPSJ is committed to patient safety.  The QM program documents target areas for safety annually; Facility Site Reviews, Medication Safety Programs, and programs for Continuity and Coordination of Care.

Annual QM Evaluation and Work Plan
HPSJ completes both of these documents on an annual basis.  The evaluation helps the plan focus on priority processes and outcomes.  The work plan sets how HPSJ will make positive changes.  Measures of success are changed on an ongoing basis to enable the plan to make the right priorities.

All three are a combined effort of the HPSJ to continue quality improvement and make progress with the management of quality.  The member and provider are the primary targets for achieving the improvements.


Posted on January 8th, 2018 and last modified on January 8th, 2018.