NY Manual
SHP Manual

New York Provider Manual
14.3 Clinical Practice Guidelines | 14.5 Quality Improvement – Medicare

14.4 Studies, Surveys, and Investigations

Studies - Medicaid and Managed Long Term Care (MLTC)

Every two years, the Managed Care Organizations (MCOs) participating with Medicaid and Managed Long Term Care (MLTC) programs are required by the NYSDOH to conduct a Performance Improvement Project (PIP) in a priority topic area or a topic relevant to the MCO’s population demographics. A PIP, as defined by the NYSDOH, is a methodology for facilitating MCO and provider-based improvements in quality of care. PIPs place emphasis on evaluating the success of interventions to improve quality of care.  Through the PIPs MCOs and providers determine what processes need to be improved and how they should be improved. Providers are strongly encouraged to participate in the conduct of these studies, as well as in the implementation of action plans to improve performance. Participation can be accomplished by becoming a member of Healthfirst’s quality improvement committees. 

We are also mandated to participate in the NYSDOH's focused clinical studies on an annual basis.  The NYSDOH determines the topic of focus.  Participating providers are expected to cooperate with medical record reviews necessary to conduct these studies, comply with medical records standards, and meet required performance thresholds established for the project. The projects, their results, and updates are published in The Source, our provider newsletter, and/or on the Healthfirst website, at www.healthfirst.org as well as reported quarterly at the Quality Improvement Committee and the Board Meetings. For information on how to become a member of Healthfirst’s Quality Committee, or to obtain copies of the projects, please contact the Clinical Performance Management department.

Contract Period
Study Topic
 
2015
 
 
2015
 
 
2015
 
Improving the Identification of Smokers in the Adult 18-64 y.o. Medicaid Population and Increasing the Utilization of Smoking Cessation Benefits (PIP)
 
NY Depression Screening Validation Study (Focused Clinical Study)
 
Reduce the number of falls requiring medical intervention (MLTC
PIP)

Studies – Medicare, Special Needs Plans (SNP), and Fully Integrated Duals Advantage (FIDA)

Each year, Managed Care Organizations (MCOs) participating with Medicare, Special Needs Plans (SNPs), and Fully Integrated Duals Advantage (FIDA) programs are required by CMS to conduct a Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) for a topic that is relevant to these member populations. The CCIP is a five year study and the QIP is a three year study.
 
Contract Period
Study Topic
 
2012
 
 
2013
 
 
2013
 
 
2016
  
  
2016
 
 2016 
 
IImprove Medication Adherence for Medicare Members with Cardiovascular Disease on Statins and/or ACEI/ARB (CCIP)
 
Improving Cardiovascular Disease Outcomes through Medication Management (iSNP CCIP)
 
Reduction of All Cause Hospital Readmission for Healthfirst iSNP Members through Use of Continuity of Care Medication Reconciliation Tools (iSNP QIP)
 
Improving the health outcomes of our members with COPD through increased pharmacotherapy compliance after an acute exacerbation and Spirometry testing to monitor the efficacy of treatment and disease severity (QIP)
 
Reduce the number of falls requiring medical intervention (FIDA QIP)
 
Improving the rates of dilated retinal exams among our members with diabetes (FIDA CCIP)

 

The topic of cardiovascular disease was selected by CMS for the 2012 CCIP and 2013 iSNP CCIP.  CMS selected this health issue to support the Million Hearts Initiative. Additional information on this campaign can be found at the following website: http://millionhearts.hhs.gov/about_mh.html. The 2013 QIP focuses on the reduction of 30-day, all-cause hospital readmissions.  The 2016 QIP will strive to improve the health outcomes of Medicare members with COPD while the 2016 FIDA QIP addresses fall prevention and the FIDA CCIP aims to incease dilated retinal exam screenings among our diabetic FIDA population.

 

Member Satisfaction Surveys

The NYSDOH and CMS conduct annual member satisfaction surveys which are administered by third party survey vendors and provide the plans with their individual results. The NYSDOH and CMS use the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys as well as the Qualified Health Plan Enrollee Experience Survey (QHPEES) as its survey tools. The CAHPS surveys & QHPEES are a set of standardized questions that assess member satisfaction with the experience of care. The surveys are based on randomly selected samples of members from the MCO and summarize satisfaction with the experience of care through ratings and composites. The members’ perception and experience with their providers impact a major portion of these ratings and composites. It is important that providers participating with Healthfirst conduct the delivery of services in their offices and facilities at the highest quality level, ensuring that the needs of their patients (our members) are met to their satisfaction. Results of these surveys are communicated to providers through newsletters, our website, and/or special mailings. If you need more information about the CAHPS surveys, please visit the NCQA website, www.ncqa.org. If you need more information about the QHPEES, please visit www.CMS.gov.

 

Quality-of-Care Investigations

To ensure the quality and safety of the services provided to its members, as well as to improve member satisfaction, Healthfirst responds to any identified concerns or issues regarding provider performance through a quality review process. Review of quality-of-care referrals can include, but is not limited to, medical record review, provider contact, member contact, referral for peer review, interdepartmental review, review by the Medical Director, and review by the clinical members of the Healthfirst Quality Committee. All clinical quality-of-care referrals are trended and tracked to identify patterns. When the inquiry/review has been completed and a final disposition is assigned to the referral, the outcome/recommendation is communicated to the referring and concerned parties, as appropriate. Information about the inquiry and review is forwarded to the Credentialing department for inclusion in the provider’s files.