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- Quality Improvement Program Description
- Utilization Management Summary
- Appropriate Use and Coverage of Prescription Medications
Quality Improvement Program Description
To request a printed version of our Quality Improvement Program Description, please contact us at quality@healthpartners.com or contact Member Services.
The mission of HealthPartners is to improve the health of our members, our patients and the community. The philosophy of HealthPartners is manifested by its commitment to provide integrated, cost efficient healthcare to serve the diverse needs of its members and of its healthcare purchasers. This commitment is attained through the creation of partnerships among members, providers, purchasers, and the community. To this end, HealthPartners is guided by the following philosophy:
1. Deliver the highest-quality healthcare by improving the health status of the population we serve and improving care outcomes and patient safety in close partnership with care providers.
2. Set the standard for service excellence in the industry by being patient focused and member centered.
3. Continuously improve the value and cost effectiveness of our care-delivery, financing, and administrative systems.
4. Set an example by improving the quality, cost, and accessibility of care for all citizens and set an example that becomes the standard for quality, efficiency, and health improvements.
Purpose
The purpose of the Quality Improvement Program is to fulfill the HealthPartners mission by improving the health and functioning of our members by advancing safe, effective, patient-centered, timely, efficient, and equitable care.
Scope
HealthPartners' Quality and Utilization Program activities and initiatives encompass medical, behavioral health, dental, and select administrative services across preventive, acute, and chronic episodes of care. The scope of the Quality Improvement Program includes:
- the full spectrum of clinical services offered
- all locations of care delivery
- all providers of care
- all members and recipients of care
- the administrative services and processes of the plan
The following aspects of care and service delivery are included in the Quality Improvement program.
1. Clinical Quality Improvement
Clinical topics relevant to HealthPartners' membership are evaluated on an annual basis. Priority is given to topics that, because of their prevalence or severity, have the potential for significant impact on our population and are amenable to improvement through focused action.
2. Patient Safety
Ensuring protective and safe patient care is one of the most important measurable outcomes of HealthPartners' systematic approach to improving patient care. HealthPartners has embraced the pursuit of perfection in healthcare. We recognize that errors occur during the care of patients, and that these errors are a source of significant suffering, illness, cost and death. We are committed to reducing these errors for our members and patients wherever they receive care.
3. Behavioral Health
HealthPartners' behavioral health management programs include quality initiatives, monitoring, and evaluation. Quality initiatives include Partners for Better Health goals, performance measurement and analysis, and clinical-practice guidelines. Monitoring and evaluation includes quality of care (case reviews), outcomes of care, process of care, access to behavioral health, member satisfaction, and provider satisfaction.
4. Service Improvement
Service improvement initiatives are pursued as appropriate based on the results of satisfaction surveys, complaint analysis, and monitoring of Member Services activities.
5. Access and Availability of Services
Monitoring is conducted to ensure members can adequately access health plan services and receive timely healthcare services from primary care, behavioral health, and specialty providers.
6. Member Experience
Customer satisfaction is assessed using a variety of methodologies including surveys, complaint analysis, focus groups, etc.
7. Provider Satisfaction
Provider satisfaction with the health plan is assessed through satisfaction surveys and feedback from health plan providers.
Goals and Objectives
HealthPartners' Quality Improvement program has established the following goals and objectives to support its mission and philosophy:
- To identify opportunities for improvement in the delivery of healthcare services
- To design, implement, and evaluate procedures and programs to improve care
- To ensure timely access to appropriate services
- To provide access to highly qualified healthcare providers
- To assess enrollee satisfaction regarding the quality of healthcare services
- To ensure a comprehensive provider network
- To educate providers and members and facilitate the delivery of preventive healthcare services
- To collaborate with providers to ensure safe, efficient, and effective delivery of care
- To ensure compliance with all relevant laws, rules, and regulations promulgated by state and federal agencies
Process
A variety of mechanisms are used to identify topics for quality monitoring and/or improvement. Priority is given to topics that, because of their prevalence or severity, have the potential for significant impact on our population and are amenable to significant improvement through focused action. The following activities support implementation of the Quality Improvement Program:
Program Evaluation
On an annual basis, HealthPartners' quality and utilization management activities are evaluated and approved by the Quality Committee of the Board and the Board of Directors. Modifications to the Quality Improvement Program description are made annually, based on the results of the annual review process, as well as observations, trends, and patterns identified in response to current and new state and federal regulatory mandates. Quality and patient experience results are published annually and made available at www.healthpartners.com.
Confidentiality
The confidentiality of all data and information obtained, developed, or reviewed in association with the quality improvement program and/or peer review is maintained. The requirement to protect confidentiality applies to all health plan personnel, committee members, and others having access to such information.
Utilization Management Summary
Part of helping our members stay healthy is making sure they get the care they need when they need it. To help coordinate effective, accessible and high-quality healthcare, HealthPartners uses utilization management programs. These programs are based on the study of patient populations to evaluate appropriate levels of care. They use guidelines for the best medical practices based on the most up-to-date medical evidence.
Our utilization management programs include activities to reduce the underuse, overuse and misuse of health services. These programs include:
- inpatient concurrent review and care coordination to ensure a safe and timely transition from the hospital
- "best practice" for selected kinds of care
- outpatient case management to provide care coordination
- the CareCheck program to coordinate out-of-network hospitalizations
Prior approval is required for a small number of services and procedures. These are listed on the HealthPartners website and are also available by calling Member Services. Typically, your doctor will request this approval on your behalf. Decisions about coverage are based on coverage criteria, which are also posted on the Web site and available from Member Services.
HealthPartners does not employ incentives that encourage barriers to care and service. Our Outcomes Recognition Program rewards doctors who achieve the highest levels of quality and service to patients.
Confidentiality
The confidentiality of all individually identifiable data and information obtained, developed or reviewed in association with the quality improvement program is strictly protected.
Appropriate Use and Coverage of Prescription Medications
We strive to provide our members with coverage of medications that are high quality, safe and cost effective. We do this in several ways, including use of:
- a prescription drug formulary of medications that have been reviewed and approved for coverage based on quality, safety, effectiveness and value
- a program to assist members who require many different medications to avoid unintended drug interactions
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