Annual Quality Improvement Program Summary

For Our Members

Our mission is to improve the health and well-being of our members and the communities in which they live. We align our efforts around the Institute for Healthcare Improvement’s Triple Aim framework of improving overall population health, improving the patient experience of care, and reducing overall healthcare costs. Improving health and healthcare is a continuous process, and is a goal shared among all involved in the healthcare industry. The fundamentals of our quality improvement program include coordinated efforts, regular measurement of processes and outcomes, specific performance targets, feedback, sharing of best practices, and continued evolution.

Overall, 2018 was a successful year. Significant cross-departmental collaboration and our continued focus on the Capital BlueCross mission and corporate strategy and goals along with IHI’s Triple Aim enabled our success.

Program Goals

  • Improve the health and experience of care while providing the best value for our members
  • Measure, monitor, and improve programs to ensure the safety of our members
  • Improve the member experience
  • Reduce unnecessary readmissions through improving continuity and coordination and transition of care and addressing members’ complex health needs
  • Ensure compliance with all federal and state regulations, as well as accrediting

Program Scope

  • Focus on population health management that addresses member’s health services needs across various levels of care
  • Develop policies and procedures to facilitate appropriate utilization of healthcare services
  • Facilitate a safe and effective network of providers while ensuring accessibility and availability of care and services
  • Assess member and provider satisfaction with experience and implement effective interventions
  • Provide special considerations for cultural competency needs related to language, ethnicity, gender, age, complexity of health needs, and economic status to assist members in effectively accessing and using covered benefits

Monitoring of Goals and Achievements in 2018

  • Expansion of our partnerships
    • Negotiated long-term contracts with several major health system partners
    • Added new facility contracts
  • Implementation of our five-day hospital readmission payment policy
    • Improved coordinated care transitions
    • Reduced readmissions
  • Focused on ensuring safe care for our members
    • A comprehensive review and update to our quality of care and service review processes
    • Enhanced measurement and tracking of provider-specific quality issues and more direct communication and interventions with providers exceeding thresholds
  • Launched an opioid strategy team
    • Led efforts to impact the opioid crisis
    • Implemented quantity limits on opioid prescriptions
    • Researched and helped our members manage pain
  • Evolution of the population health management program
    • Provided tools and interventions to improve the health of all our members
    • Established a focused workgroup to address the rising prevalence and costs of our diabetic and prediabetic members
    • Rebranded and expanded our telemedicine services to include Virtual Care for low severity conditions
  • Started a musculoskeletal program
    • Promoting patient safety for members undergoing certain musculoskeletal procedures
  • Evolved our behavioral health strategy
    • Identified key interventions to improve access to quality behavioral health services
    • Integrated medical and behavioral healthcare
  • Member and provider experience
    • Surveys were administered with a member-focused team reviewing and analyzing the results
    • Regular tracking and analysis of member complaints allowed for timely and appropriate interventions
  • Submitted our National Committee for Quality Assurance (NCQA) health plan accreditation renewal survey