Common use of Quality Management and Improvement Program Clause in Contracts

Quality Management and Improvement Program. ‌ The Contractor’s Medical Director shall be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall have objectives that are measurable, realistic and supported by consensus among the Contractor’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall have ongoing comprehensive quality assessment and performance improvement activities aimed at improving the delivery of health care services to members. As a key component of its Quality Management and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving health outcomes of Hoosier Healthwise members. The Contractor shall establish different provider and member incentives for its Hoosier Healthwise population. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall meet the requirements of 42 CFR 438 subpart E on Quality Assessment and Performance Improvement and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Plan. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members with special needs, (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects to be incorporated into subsequent quality improvement projects; and (iii) produce quality of care reports at least annually. The Contractor’s Quality Management and Improvement Program shall: ▪ Include developing and maintaining an annual Quality Management and Improvement Program Work Plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪ Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪ Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each task.

Quality Management and Improvement Program. ‌ The Contractor’s Medical Director shall be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall have objectives that are measurable, realistic and supported by consensus among the Contractor’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall have ongoing comprehensive quality assessment and performance improvement activities aimed at improving the delivery of health care services to members. As a key component of its Quality Management and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving health outcomes of Hoosier Healthwise members. The Contractor shall establish different provider and member incentives for its Hoosier Healthwise population. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall meet the requirements of 42 CFR 438 subpart E on Quality Assessment and Performance Improvement and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Plan. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members with special needs, (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects to be incorporated into subsequent quality improvement projects; and (iii) produce quality of care reports at least annually. The Contractor’s Quality Management and Improvement Program shall: ▪  Include developing and maintaining an annual Quality Management and Improvement Program Work Plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪  Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪  Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each task.

Quality Management and Improvement Program. ‌ The Contractor’s Medical Director shall be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall have objectives that are measurable, realistic and supported by consensus among the Contractor’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall have ongoing comprehensive quality assessment and performance improvement activities aimed at improving the delivery of health care services to members. As a key component of its Quality Management and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving health outcomes of Hoosier Healthwise members. The Contractor shall establish different provider and member incentives for its Hoosier Healthwise population. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall meet the requirements of 42 CFR 438 subpart E D on Quality Assessment and Performance Improvement and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Plan. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members with special needs, (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects to be incorporated into subsequent quality improvement projects; and (iii) produce quality of care reports at least annually. The Contractor’s Quality Management and Improvement Program shall: ▪  Include developing and maintaining an annual Quality Management and Improvement Program Work Plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪  Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪  Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each task.  Incorporate an internal system for monitoring services, including data collection and management for clinical studies, internal quality improvement activities, assessment of special needs populations and other quality improvement activities requested by OMPP.  Participate appropriately in clinical studies, and use Healthcare Effectiveness Data and Information Set ® (HEDIS®) rate data and data from other similar sources to periodically and regularly assess the quality and appropriateness of care provided to members. In assessing the quality and appropriateness of care provided to members under 21 years of age, the Contractor must act in accordance with EPSDT/Health Watch requirements.  Collect measurement indicator data related to areas of clinical priority and quality of care. OMPP will establish areas of clinical priority and indicators of care. OMPP reserves the right to identify additional conditions at any time, as the areas reflect the needs of the Indiana Medicaid populations. These areas may vary from one year to the next and from program to program. Examples of areas of clinical priority include:  HIV and Hepatitis C care  Behavioral health and physical health care coordination;  Immunization rates;  Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services;  Prenatal care;  Postpartum care;  Blood lead testing ;  Emergency room utilization;  Access to care;  Special needs care coordination and utilization;  Asthma;  Obesity, especially childhood obesity;  Tobacco dependence treatment, especially for pregnant women;  Inpatient and emergency department follow-up;  Timely follow-up and notification of results from preventive care; and  Integrated medical and behavioral health utilization.  Report any national performance measures developed by CMS in the future. The Contractor must develop an approach for meeting the desired performance levels established by CMS upon release of the national performance measures, in accordance with 42 CFR 438.240(a)(2), which allows CMS to specify measures and topics for performance improvement projects.  Have procedures for collecting and assuring accuracy, validity and reliability of performance outcome rates that are consistent with protocols developed in the public or private sector. The CMS website contains an example of available protocols.

Quality Management and Improvement Program. ‌ The Contractor’s Medical Director shall be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall have objectives that are measurable, realistic and supported by consensus among the Contractor’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall have ongoing comprehensive quality assessment and performance improvement activities aimed at improving the delivery of health care services to members. As a key component of its Quality Management and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving health outcomes of Hoosier Healthwise members. The Contractor shall establish different provider and member incentives for its Hoosier Healthwise population. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall meet the requirements of 42 CFR 438 subpart E on Quality Assessment and Performance Improvement and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Plan. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members with special needs, (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects to be incorporated into subsequent quality improvement projects; and (iii) produce quality of care reports at least annually. The Contractor’s Quality Management and Improvement Program shall: ▪ Include developing and maintaining an annual Quality Management and Improvement Program Work Plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪ Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪ Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each task.

Quality Management and Improvement Program. ‌ The ContractorMCO’s Medical Director shall must be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall must have objectives that are measurable, realistic and supported by consensus among the ContractorMCO’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall MCO must have ongoing comprehensive quality assessment and performance improvement activities aimed at improving its internal functioning, improve the delivery of health care services to members. As a key component of its Quality Management members and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving improve health outcomes of Hoosier Healthwise its members. The Contractor shall establish different provider and member incentives for its Hoosier Healthwise population. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall MCO must meet the requirements of 42 CFR 438 subpart E on Quality Assessment and Performance Improvement D and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Planquality management program. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members member with special needs, (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects and to be incorporated into subsequent quality improvement projects; and (iii) produce new information on quality of care reports at least annuallyevery year. The ContractorMCO’s Quality Management and Improvement Program shallmust: ▪ • Include developing and maintaining an annual Quality Management and Improvement Program Work Plan quality improvement plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪ Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪ • Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each tasktask • Incorporate an internal system for monitoring services, including clinically appropriate data collection and management for clinical studies, internal quality improvement activities, assessment of special needs population and other quality improvement activities requested by OMPP • Participate appropriately in clinical studies, such as the Health Plan Employer Data and Information Set® (HEDIS®) measures and in other studies requested by OMPP, such as assessment of the quality and appropriateness of care provided to members, in accordance with EPSDT/Health Watch requirements HOOSIER HEALTHWISE STATE/MCO CONTRACT CONTRACT ATTACHMENT 1: MCO SCOPE OF WORK • Collect measurement indicator data related to areas of clinical priority and quality of care. The Hoosier Healthwise Clinical Studies and the Quality Improvement Committees will establish areas of clinical priority and indicators of care. These areas may vary from one year to the next, and they will reflect the needs of the Hoosier Healthwise population. Examples of areas of clinical priority and measurement studies include: • Immunization rates • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service utilization • Prenatal care • Blood lead testing • Emergency room utilization • Access to care • Special needs care coordination and utilization • Report any national performance measures developed by CMS. The MCO must develop an approach for meeting the desired performance levels established by CMS upon release of the national performance measures, in accordance with 42 CFR 438.240(a)(2). • Have procedures for collecting and assuring accuracy, validity and reliability of performance measures that are consistent with protocols developed in the public or private sector. The CMS website contains an example of available protocols. The MCO must conduct an audited HEDIS Survey and Consumer Assessment of Health Plans Survey (CAHPS) annually in its quality management and improvement activities per OMPP guidelines. The MCO is encouraged to participate in the Best Clinical and Administrative Practices (BCAP) Quality Framework initiative. BCAP is a proven method to improve quality within Medicaid managed care that the Center for Healthcare Strategies has developed. Information regarding BCAP is available in Attachment K of this RFP. OMPP reserves the right to require the MCO to participate in BCAP after the first contract year.

Quality Management and Improvement Program. ‌ The Contractor’s Medical Director shall be responsible for the coordination and implementation of the Quality Management and Improvement Program. The program shall have objectives that are measurable, realistic and supported by consensus among the Contractor’s medical and quality improvement staff. Through the Quality Management and Improvement Program, the Contractor shall have ongoing comprehensive quality assessment and performance improvement activities aimed at improving the delivery of health care services to members. As a key component of its Quality Management and Improvement Program, the Contractor shall develop incentive programs for both providers and members, with the ultimate goal of encouraging appropriate utilization of health care resources and improving health outcomes of Hoosier Healthwise HIP members. The Contractor shall may establish different provider and member incentives for its Hoosier Healthwise populationHIP populations. As a part of the Contractor’s Quality Management and Improvement Program, the Contractor shall participate in OMPP’s annual performance improvement program. The Contractor shall meet the requirements of 42 CFR 438 subpart E D on Quality Assessment and Performance Improvement and the National Committee for Quality Assurance (NCQA), including but not limited to the requirements listed below, in developing its Quality Management and Improvement Program and the Quality Management and Improvement Program Work Plan. In doing so, it shall include (i) an assessment of quality and appropriateness of care provided to members with special needs, including all medically frail HIP members; (ii) complete performance improvement projects in a reasonable time so as to allow information about the success of performance improvement projects to be incorporated into subsequent quality improvement projects; and (iii) produce quality of care reports at least annually. The Contractor’s Quality Management and Improvement Program shall: ▪  Include developing and maintaining an annual Quality Management and Improvement Program Work Plan which sets goals, establishes specific objectives, identifies the strategies and activities to undertake, monitors results and assesses progress toward the goals. ▪  Have in effect mechanisms to detect both underutilization and overutilization of services. The activities the Contractor takes to address underutilization and overutilization must be documented. ▪  Have written policies and procedures for quality improvement. Policies and procedures must include methods, timelines and individuals responsible for completing each task.  Incorporate an internal system for monitoring services, including data collection and management for clinical studies, internal quality improvement activities, assessment of special needs populations and other quality improvement activities requested by OMPP.  Participate appropriately in clinical studies, and use Healthcare Effectiveness Data and Information Set ® (HEDIS®) rate data and data from other similar sources to periodically and regularly assess the quality and appropriateness of care provided to members. In assessing the quality and appropriateness of care provided to members under 21 years of age, the Contractor must act in accordance with EPSDT/Health Watch requirements.  Collect measurement indicator data related to areas of clinical priority and quality of care. OMPP will establish areas of clinical priority and indicators of care. OMPP reserves the right to identify additional conditions at any time, as the areas reflect the needs of the Indiana Medicaid populations. These areas may vary from one year to the next and from program to program. Examples of areas of clinical priority include:  HIV and Hepatitis C care  Behavioral health and physical health care coordination;  Immunization rates;  Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services;  Prenatal care;  Postpartum care;  Emergency room utilization;  Access to care;  Special needs care coordination and utilization;  Asthma;  Obesity,  Tobacco dependence treatment, especially for pregnant women;  Inpatient and emergency department follow-up;  Timely follow-up and notification of results from preventive care; and  Integrated medical and behavioral health utilization.  Report any national performance measures developed by CMS in the future. The Contractor must develop an approach for meeting the desired performance levels established by CMS upon release of the national performance measures, in accordance with 42 CFR 438.240(a)(2), which allows CMS to specify measures and topics for performance improvement projects.  Have procedures for collecting and assuring accuracy, validity and reliability of performance outcome rates that are consistent with protocols developed in the public or private sector. The CMS website contains an example of available protocols.