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Quality Improvement

Molina Healthcare of Texas 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.

Scope of Program Activities:

The Molina Healthcare QI Program encompasses the quality of acute, chronic and preventive health care and services provided in both the inpatient and outpatient setting to Molina Healthcare’s population as determined by age, disease categories, risk status and products. The scope of service includes, but is not limited to those provided in institutional settings, ambulatory care, home care and behavioral health. Contracted provider groups, primary care and specialty practitioners and ancillary providers may render these services.

Molina Healthcare’s Behavioral Health (BH) is committed to comprehensive behavioral healthcare management in partnership with the member and the practitioner. The BH Program coordinates and monitors the delivery of BH services to all members as designated in their assigned benefits. Full consideration of general medical issues in the management of BH care delivery is provided to enhance the quality of care through improved treatment delivery and outcomes as well as strengthen member and provider satisfaction.

Important Aspects of Care and Service

To provide for overall quality functioning as a managed care plan, Molina Healthcare continuously monitors important aspects of care and service. These aspects or activities include, but are not limited to:

  • Access/Availability, to include health risk assessments, appointment scheduling, network composition and geographical analysis
  • Continuity/Coordination of Care
  • Case and Disease Management Programs as measured by the use of and compliance with evidence-based guidelines and processes for structured assessment and follow-up
  • Appropriateness of Care as measured by:
    • Comparison of performance parameters against established benchmarks
    • Under/Over Utilization
    • Use of and compliance with clinical practice guidelines
    • Grievance and Case Review processes
    • Monitoring and Distribution of Enrollee Rights and Responsibilities
  • Behavioral Health and Chemical Dependency Care and Services as measured by the use of and compliance with clinical practice guidelines
  • Long Term Care
  • Chronic/Acute Care
  • Member Safety/Error Avoidance
  • High-Risk/High-Volume/Problem-Prone Care
  • Preventive Care and Services as measured by the use of and compliance with clinical practice guidelines
  • Members with special health care needs
  • Members with complex health needs who may need case management and/or care coordination
  • Member outreach to ensure effective coordination of services (i.e., clinical, transportation, support to access care, etc.)
  • HEDIS® Measurement/Reporting and activities to address performance gaps
  • Member and Practitioner Satisfaction with medical and behavioral health services, including CAHPS®
  • Medical Coverage Guidance Documents
  • Health Plan Service Standards and Operational Performance Thresholds
  • Quality of Care/Critical Incident Clinical Case Review and Serious Reportable Adverse Events and Hospital Acquired Conditions
  • Pharmacy Services and Medication Management
  • Cultural, Ethnic, Racial and Linguistic Needs and Services for Molina Healthcare's members including a focus on cultural and linguistic competency and enrollees within diverse communities
  • Demographic, health status, and utilization patterns of enrolled populations
  • Health Management Information Systems performance and data capture
  • Plan determined quality improvement projects, internal and collaborative (QIP/PIP)
  • Applicable and appropriate measures of health outcomes and indices of quality for the target populations and sub-populations
  • Co-morbid conditions and complexities associated with concurrent/on-going or unresolved medical and behavioral health issues

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