The Molina Healthcare of New Mexico, Inc. (Molina Healthcare) Quality Improvement (QI) Program is a comprehensive framework for continuous assessment and focused improvement of all aspects of health care delivery and service. We annually assess the effectiveness of the QI Program so as to provide the structure and key processes that enable us to plan and implement our care and service goals on an ongoing basis. The QI Program is an evolving program that is responsive to the changing needs of our members and the advances and changes in clinical practice. The current QI Program activities focus on critical areas for improving the service to and health status of our membership based on ongoing measurement and analysis of our programs.
The QI Program operates by:
- Continuously monitoring performance according to, or in comparison with objective, measurable performance standards - National, Regional or at the Local/Plan level;
- Analyzing information and data to identify trends;
- Prioritizing opportunities for improvement;
- Designing interventions for improvement;
- Implementing those interventions;
- Re-measuring the processes;and
- Evaluating the effectiveness of the interventions and identifying additional opportunities for improvement.
The purpose of the QI Program is to provide a formal process to monitor and evaluate the quality, utilization, appropriateness, safety, efficiency and effectiveness of care and service delivered to Members using a multi-dimensional approach. This approach enables the organization to focus on opportunities for improving operational processes as well as health outcomes and Member, practitioner and provider satisfaction. The QI Program promotes and fosters accountability of employees, network and affiliated health personnel for the quality and safety of care and services provided to Molina Healthcare Members.
The major areas of emphasis of the Quality Improvement Program are, in no specific order:
- Health Promotion and Education;
- Patient Safety;
- Collaborative Activities;
- Privacy and Confidentiality;
- Regulatory Compliance;
- Credentialing and Recredentialing;
- Risk Management;
- Disease Management;
- Pharmaceutical Management; and
Our quality improvement strategies focus on strengthening our ability to meet the agenda of quality measurement and improvement. One way we assess our quality of care is with the NCQA (National Committee Quality Assurance) HEDIS® (Healthcare Effectiveness Data and Information Set) measurement tool.
This measurement tool provides accurate and comparable assessment of our quality of care. The HEDIS® rates for our Medicaid product line are based on the clinical care received during the previous year.
Our HEDIS® scores continue to improve and we are encouraged by the rate increases for appropriate medication for asthma, Well-Child Care and Adolescent Well-Care Visits, timeliness of prenatal care and diabetic retinal eye exams. Our HEDIS® scores continue to improve and we are encouraged by the rate increases for appropriate medication for asthma, Well-Child Care and Adolescent Well-Care Visits, timeliness of prenatal care and diabetic retinal eye exams. Our HEDIS® scores continue to improve and we are encouraged by the rate increases for appropriate medication for asthma, Well-Child Care and Adolescent Well-Care Visits, timeliness of prenatal care and diabetic retinal eye exams.
Data and expert opinion sources help guide the direction of the QI program and include:
- Data generated from our claims and encounters to analyze inpatient/outpatient diagnoses, HEDIS® data, ethnicity prevalence, and other indicators.
- Clinical Practice Guidelines (CPG's) based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. The recommendations do not favor any particular treatment based solely on cost considerations.
- Preventive Care Guidelines (PHG's) targeted to all age groups and disseminated by national and specialty organizations. They focus on improving members' access to preventive health services and encourage practitioners to promote routine screenings. We monitor the preventive health delivery through annual HEDIS® rates and quarterly missed services reports.
Our Clinical Quality Improvement Committee (QIC), whose members are contracted network practitioners and Molina medical directors, annually reviews and adopts the CPG's and PHG's. The Clinical Practice Guidelines are available on the Molina Healthcare Provider Website as are the Preventive Health Guidelines.
Printed copies of the CPG's and PHG's are available upon request. To obtain a paper copy of our CPG's or our PHG's call Molina Healthcare's Health Improvement Hotline at 1-800-377-9594, extension 182618 or 1-505-342-4660, extension 182618.
We have on-going programs associated with major, high-risk, acute and chronic illnesses that address member needs, health deficits and health care disparities including:
- Asthma and diabetes education
- We worked on helping Members with asthma improve the quality of their lives by teaching them how to control their asthma and help them stay out of a hospital. We did a study that showed that many Members in Southeast New Mexico were only using rescue inhalers. We wrote a letter to all PCP's in the state asking them to look at the medications Members are actually using for their asthma. We asked PCP's to stock asthma supplies in their offices so Members who were having an asthma attack could get care at the office and not have to go to the Emergency Room.
- We worked on helping Members with diabetes improve the quality of their lives by teaching them how to control their diabetes and help them stay out of a hospital or get complications from diabetes. We see that that many Members with Diabetes don't get the tests and care they need. We plan on trying to improve diabetes care by educating Members and practitioners about the care Members should get even more than we do now.
- Information and programs on how to be healthy when you are having a baby
- Our motherhood matters program reached out to a large number of Members who were pregnant and helped them have a good experience with having a baby as well as getting the best possible care while they were pregnant. We noticed a lot of new Moms did not have a follow up after the baby was born. We plan on trying to further encourage new Moms to keep this important appointment after the baby is born.
- Information if you want to lose weight or quit smoking
- We offer weight management programs for our Members to assist them with weight loss goals. Centennial Care Members may qualify for the Weight Watchers Program® if they meet BMI criteria. Members may also sign up for a free online resource at www.SparkPeople.com.
- We encourage our Members who smoke to try and quit. We can help by paying for medication if your practitioner says you need it. Members will need to register for the Quit For Life tobacco cessation program in order for these medications to be approved. The medication must be covered on the Molina Healthcare pharmacy formulary list.
Other studies and programs include decreasing unnecessary ED visits and antibiotic use with upper respiratory infections. A major initiative is the design and implementation of a complex case management program to manage and improve the health of members with special needs and the Medicare members.
The Patient Safety Program identifies appropriate safety projects and error avoidance for Molina Healthcare members in collaboration with their primary care providers. Molina continues to support safe personal health practices for our members through our infant car seat safety program, pharmaceutical management and disease management programs and education delivered through member newsletter articles. We also monitor the provider network for Medical Record Documentation Standards as poor documentation can lead to increased errors, duplicative work, and fragmentation of care across the spectrum of healthcare delivered. We monitor for quality of care issues and track or trend adverse events. We perform studies to asses that Coordination of care is occurring with the Members PCP.
To learn more about our Quality Improvement Plan, or to receive a copy of our Quality Improvement Plan call Molina's Health Improvement Hotline at 1-800-377-9594, extension 182618 or 1-505-342-4660, extension 182618.
Paper copies of information posted on our website are available upon request.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Such services are funded in part under contract with the State of New Mexico.