Molina Healthcare of Ohio, Inc. established a Quality Improvement Program (QIP) to provide the structure and key processes to enable the plan to carry out its commitment to ongoing improvement of care, service and the health of its membership. The QIP is an evolving program that is responsive to the changing needs of the health plan membership and the standards established by the medical community, regulators and accrediting bodies.
To meet the objectives of the QIP, activities are focused in the following areas:
Improvement of the health status of health plan membership
- Preventive health programs, including:
Rewards for Healthy Choices member incentive program for seeking preventive health services
Postcard reminders regarding recommended preventive health services
Reminder calls to members regarding recommended preventive health services
Missed service alert system which reminds members of missed preventive services at contact points with members
Preventive health guidelines available to members and providers
Educational articles on preventive services in member and provider communications
Participation in state-mandated Performance Improvement Projects (PIPs) related to:
- Promoting annual dental visits for children
- Promoting EPSDT services for children and adolescents
- Disease Management Programs for members with chronic conditions, including:
Asthma & COPD
Hypertension, Coronary Artery Disease and Congestive Heart Failure
Diabetes
- Medical Case Management for members with special and/or complex medical needs
- Clinical Practice Guidelines available to members and providers
- Internal comprehensive management of behavioral health care services
Evaluation of utilization of health care services
- Continuous monitoring of aggregate utilization statistics to identify potential issues in rates of utilization services
- Monitoring of denial and appeal rates from the prior authorization process
- Quality of care issue review and resolution specific to inappropriate utilization of services
- Evaluation of HEDIS® rates for preventive health services among Molina members; provider-specific rates are available
- Communication of significant HEDIS® measures to providers
- Missed preventive service reports by provider available
Ensuring the quality of care and service provided to members
- Review and resolution of potential quality of care issues in cooperation with involved providers
- Review and resolution of potential quality of service issues in cooperation with involved providers
Identification and implementation of appropriate safety and error avoidance initiatives in collaboration with network providers
- Member and provider safety initiatives including:
Publication of safety-related articles in member and provider communications
Distribution of safe office practice standards to providers
- Clinical office site assessments
Improving the coordination and continuity of member health care
- Quality of care issue review and resolution specific to coordination of care
- Medical record audit for evidence of coordination of care
- Provider Satisfaction Survey including assessment of providers’ satisfaction with coordination of care between settings
Evaluation of access and availability of care and service
- Comprehensive quarterly network analyses for access to primary, specialty and ancillary care
- Monthly review of member access grievances
- Annual provider appointment and after hours availability surveys
- Continuous monitoring of Member Services call statistics to ensure results are within standards
Ensuring that medical records comply with standards of structural integrity and contain evidence of appropriate medical practices for quality care
- Random audits of medical records are performed to ensure compliance with standards.
Oversight of member and provider satisfaction measurement and improvement activities
- Annual CAHPS member satisfaction survey results evaluated
- Annual Provider Satisfaction Survey conducted and results evaluated
Development and distribution of preventive health and clinical practice guidelines relevant to the membership to support delivery of appropriate health care
Management of Molina’s interface with practitioners, providers and members
Management of health care provider and practitioner credentialing and recredentialing
Evaluation of the effectiveness of QI activities in producing measurable improvement in the care and service provided to our members
- Interdisciplinary teams analyze all service and process improvement opportunities and programs and determine actions for improvement evaluating results.