Our mission is to maximize the quality of life, health, security and independence for our members who have Senior Care Options (SCO), Medicare Advantage Special Needs (SNP) and our Nursing Home Certifiable (HMO SNP) plans. It is critical that we provide members with top quality care and service. We have established a Quality Improvement Team, structure and contributing resources to deliver on this goal. The Quality Improvement Team monitors nationally established indicators of business performance and compares them to benchmarks to identify opportunities for improvement.
By using this approach, Senior Whole Health of Massachusetts is continuously working to improve the care and services it provides for members.
- Quality Improvement Program
The Senior Whole Health Quality Improvement (QI) Program provides the structure and key processes that enable the health plan to carry out its commitment to ongoing improvement of care and service, and improvement of members' health. The QI Program assists the organization to achieve these goals. It is an evolving program that is responsive to the changing needs of the health plan's customers and the standards established by the medical community, regulatory and accrediting bodies.
The key quality processes include but are not limited to:
- Implementation of programs and processes to improve members' outcomes and health status.
- Collaboration with our contracted provider network to identify relevant care processes, develop tools and design meaningful measurement methodologies for the provided care and service.
- Evaluation of the effectiveness of programs, interventions and process improvements and determine further actions.
- Designing effective and value-added interventions.
- Continuously monitoring performance parameters and comparing to Senior Whole Health standards, national and regional benchmarks, as well as regulatory requirements.
- Analysis of information and data to identify trends and opportunities, and the appropriateness of care and services.
- Oversight and improvement of delegated functions; Claims, UM and Credentialing.
- Ensuring a quality and adequate provider and Health Delivery Organization network through appropriate contracting, studies and Credentialing processes.
- Evaluating member satisfaction with their experience of care through the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey.
- Conducting provider satisfaction surveys with specific questions about the UM process, such as determining the level of satisfaction with getting a service approved, obtaining a referral and case management.
The QI Program promotes and fosters accountability of employees and network and affiliated health personnel for the quality and safety of care and services provided to Senior Whole Health members.
- Standards for Medical Record Documentation
Providing quality care to our members is important, therefore, Senior Whole Health has established standards for medical record documentation to help ensure the highest quality of care. Medical record standards enable, promote quality care through communication, coordination and continuity of care, and efficient and effective treatment.
Senior Whole Health's medical record documentation standards include:
- Medical record content
- Medical record organization
- Ease of retrieving medical records
- Confidential patient information
- Standards and performance goals for participation providers
For a detailed description of the standards and performance goals, refer to the Provider Manual.
- Access and Availability
Access to Care
SWH of MA maintains access to care standards and processes for ongoing monitoring of access to health care (including behavioral health care) provided by contracted primary PCPs (adult and pediatric) and participating specialist (to include OBGYN, Behavioral Health Providers, and high volume, high impact specialists). Providers are required to conform to the Access to Care appointment standards listed below to ensure that health care services are provided in a timely manner. The standards are based on 90% or greater availability for Emergency Services and 90% or greater for all other services. The PCP or his/her designee must be available 24 hours a day, 7 days a week to members.
All Providers who oversee the member’s health care are responsible for providing the following appointments to SWH of MA members in the timeframes noted:
Medical Appointment Types
Within 30 calendar days
Within 7 calendar days
Within 24 hours
After Hours Care
24 hours/day; 7 day/week availability
Specialty Care (High Volume)
Within 45 calendar days
Specialty Care (High Impact)
Within 45 calendar days
Urgent Specialty Care
Within 24 hours
Within 21 calendar days in the first trimester, within 14 calendar days in the second trimester and within 7 days thereafter
Dental Providers (Routine)
Within 45 calendar days
Dental Providers (Urgent Care)
Within 48 hours
Behavioral Health Appointment Types
Within 24 hours
Within 14 calendar days
Follow-up Routine Care
Within 7 calendar days
Additional information on appointment access standards is available by contacting the Provider Service Center at (855) 838-7999
Office Wait Time
For scheduled appointments, the wait time in offices should not exceed thirty (30) minutes. All PCPs are required to monitor waiting times and adhere to this standard.
All Providers must have back-up (on call) coverage after hours or during the Provider’s absence or unavailability. SWH of MA requires Providers to maintain a twenty-four (24) hour phone service, seven (7) days a week. This access may be through an answering service or a recorded message after office hours. For PCPs and OB/GYNs, if a recorded message is used, it must provide an option to direct the Member to a live person. The service or recorded message should instruct Members with an Emergency to hang-up and call 911 or go immediately to the nearest emergency room.
Please visit the Provider Manual for additional information on access and availability.
- HEDIS® Measures of Focus
Our goal at Senior Whole Health (SWH) is to work with our providers to ensure that every member receives the very best care. In addition, state and federal governments are demanding a healthcare industry that is driven by quality.
SWH of MA monitors the following measures:
- Diabetes monitoring for members with diabetes
- Behavioral Health & Medical readmission rates
- Adolescent Well-Care Visits
- Adult access to preventive/ambulatory health services
- Prenatal and Postpartum Care
- Childhood Immunization Status
- COPD or Asthma Admission Rate
- Heart Failure Admission Rate
SWH of MA supports and promotes the use of evidence-based performance measures that help drive the adoption of recommended care and improvements in population health. The Healthcare Effectiveness Data and Information Set (HEDIS®), is owned by the National Committee for Quality Assurance (NCQA) and is the most widely used measure set for driving quality rating systems, as well as for its individual measures which are increasingly used by employers, health plans, and government agencies to drive pay-for-performance quality programs.
HEDIS measures cover a wide span of indicators related to the management of physical and behavioral health. Final performance is calculated over the first six months of every calendar year for the prior calendar year. Some measures allow medical record data, and some reviews occur across a multi-year period.
In areas of most concern to your patients, HEDIS helps compare how managed care plans perform. Senior Whole Health closely monitors the HEDIS rates to help us identify opportunities for us to improve the health of our members. Our goal is to be better than 75% of other Medicaid health plans in the nation.
Visit the NCQA website to learn more about HEDIS.
We depend on our providers to:
- Submit accurate and complete claims and encounter data within a timely manner of the rendered service
- Ensure that you and your office staff comply with our requests for medical records in the timeframes requested
- Notify our staff or delegated vendor immediately if the patient listed on a request for medical records is not seen by your practice
- Provide medical records for a member who was seen by a provider who has retired, died or moved, as data collection can go back as far as 10 years
- Assist us with quality improvement activities that improve the health and wellness of our population
SWH’s responsibility is to:
- Provide education and information as needed regarding HEDIS® and other performance measures for which we request your cooperation and assistance
- Communicate with you by phone, fax, in writing, or through secure electronic communications to request medical record documentation to verify service delivery
If you have any questions, would like additional information about HEDIS®, or have suggestions for our Quality Improvement Program, please contact Provider Services.
HEDIS® Tip Sheets
Each year Senior Whole Health sets goals to improve our services to members. Annually we measure member satisfaction using the Consumer Assessment of Healthcare Providers and Systems survey (CAHPS®). The survey looks at key satisfaction drivers through the continuum of care, including health plan performance and the member's experiences in the physician office. Survey instruments are sent to adult members and parents of child members. Results are collected and analyzed to track member satisfaction with health plan performance and to identify opportunities for improvement. Senior Whole Health 's goal is to be better than 75 percent of other Medicaid health plans in the nation who report their results to the National Committee for Quality Assurance (NCQA).
CAHPS® Tip Sheets
Detailed results can be found by clicking below:
If you have any questions, would like additional information about CAHPS®, or have suggestions for our Quality Improvement Program, please contact Provider Services.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).