The goal of the NMHC Quality Improvement Program (QIP) is to develop, implement, and maintain a quality program that meets the unique and diverse needs of our membership, New Mexico communities, and of the health care delivery system. The program’s intent is to deliver care that exceeds expectations, promotes innovation in reimbursement strategies and opportunities to change health behaviors, and incorporates highly integrated clinical care approaches to improve health outcomes.
Implementation of NMHC’s quality plan supports service delivery, quality health care, and patient safety for our members. The promotion of quality, enabled and sustained through the creation of appropriate infrastructure, requires the following:
- Ensuring Qualified Health Plan (QHP) and National Committee for Quality Assurance (NCQA) Accreditation status.
- Ensuring compliance with ACA and state regulations, rules, and legislation.
- Developing an integrated set of core services, programs, and interventions to improve health outcomes of members while actively engaging providers.
- Developing effective monitoring and evaluation programs of health care services to meet or exceed current standards while identifying opportunities for continuous improvement and subsequent implementation of solutions.
- Developing effective processes and educational opportunities to reduce medical errors and improve patient safety.
- Identifying and responding to health care disparity issues to improve quality of care.
- Developing and implementing programs in alignment with ACA.
- Implementing and evaluating the quality improvement program and activities to be aligned with the National Strategy for Quality Improvement in Health Care.
The NMHC QIP activities are integrated within all health plan operations and provide mechanisms for the coordination of quality improvement, medical and behavioral health management, member services, and all essential plan functions that contribute to the quality of member care, services, and experience. The QIP is reflective of the local health care delivery system and provides for a systematic approach to continuous improvement, encompassing the quality of evaluation and improvement activities across the continuum of health care services that impact members and providers.
The following program components are essential in the promotion of quality health care delivery and plan services and are covered as part of the QI Program:
- Complaints and Appeals Processes
- Member Satisfaction (CAHPS®, Qualifying Health Plan [QHP] Enrollee Experience Survey, and Other)
- Customer (member, producer, practitioner/provider, employer) Communications
- Member Services
Integrated Clinical Management
- Disease Management/Chronic Condition Management/Complex Case Management
- Community Health Worker Program
- Utilization Management
- Clinical Practice Guidelines
- Pharmacy and Therapeutics
- New Technology Evaluation
- CMS Quality Rating System
- Continuity and Coordination of Care (Medical and Behavioral)
- Culturally and Linguistically Appropriate Services
- Wellness and Health Promotion
- Patient Safety
- Network Management and Credentialing/Re-credentialing
- Provider/Practitioner Satisfaction
- Contracting: Provider/Practitioner
- Accessibility and Availability
- NCQA Accreditation
- QHP and Exchange Requirements