Optima Health, through its commitment to excellence, has developed a comprehensive program directed toward improving the quality of care, safety, and appropriate utilization of services for our members. The Quality Improvement program is designed to implement, monitor, evaluate, and improve processes within the scope of our health plan on a continual basis in order to improve the health of our members every day.
Quality Improvement Highlights
QI Program and HEDIS® Progress Report
Optima Health offers a comprehensive quality improvement program that focuses on objectively and systematically improving the quality of medical and behavioral health care and services for our enrolled members. In 2011, our improvement efforts were acknowledged by National Committee for Quality Assurance (NCQA) as we were awarded an Excellent accreditation status for Commercial HMO/POS, Commercial PPO and our Medicaid Plan. NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, managed behavioral healthcare organizations, physician organizations and credentials verification organizations. Annually, a review of the health plan epidemiology and demographics and analysis of the previous year quality improvement monitoring rates is completed and an updated program is develop to monitor services that are high volume, high cost, high risk and / or problem prone. Although significant progress has been made, this is an evolving process with many remaining opportunities to improve the care and service of our members.
Quality Improvement Program for 2011 includes:
- Specific interventions for prevention include reminder cards and /or calls to members and follow up communication with the physicians.
- Health risk assessment and welcome calling programs to identify specific chronic diseases are encouraged for our membership, with appropriate follow up activities.
- Specific Disease Management programs are available and encouraged for those members with diabetes and asthma.
- Programs promoting healthy pregnancy continue to be a priority.
- Service activities to improve access to health care and satisfaction with the health plan and with the care received from our practitioners and providers.
- Complaints and occurrence monitoring to ensure that our members needs are met by the highest level of care and service.
- Investigating new procedures and treatment through comprehensive technology assessment review.
- Credentialing and recredentialing activities along with medical record review and education
For more information about Quality Improvement at Optima Health please contact the Quality Improvement Department at 552-7350. For more information regarding NCQA visit the web site at www.ncqa.org.
HEIDIS® results: Download 2011 HEDIS® Results
Initiatives to improve quality of care:
Member Satisfaction
Annual satisfaction surveys are conducted to measure the satisfaction of our members with the various aspects of the health plan, the care they receive, and their access to physicians.
View the Member Satisfaction Survey results
Complaints and Concerns
The quality improvement program thanks our members for notifying us of any complaint or concern. We view these as an opportunity to improve the services we provide by tracking and analyzing the information received.
Quality Improvement Work Plan and Annual Summary
The Quality Improvement work plan is an annual written document developed that includes the structure, activities, accountability, and goals of the Quality Improvement Program. The Quality Improvement Program effectiveness is measured by comparing the performance measure outcomes from year to year. The performance measures are based on nationally recognized goals and/or internal goals based on the plan population. These measures are evaluated annually and measured against national averages.
Hard copies of these items are available upon your request by contacting the Quality Improvement Department at (757) 552-7350 or toll free (866) 425-5257.