Quality Assessment and Performance Improvement (QAPI) Program
AmeriHealth Caritas Louisiana’s mission is to help people get care, stay well, and build healthy communities. We have a special concern for those who are poor. We provide a vigorous infrastructure for the continuous monitoring, evaluation, and improvement of care and service.
QAPI program features
The QAPI program uses a formal process to systemically monitor and objectively evaluate the quality, appropriateness, efficiency, effectiveness, and safety of the care and service provided to our members. The process involves representation from each of the respective committees that encompasses every department throughout our organization: Quality Assurance Performance Improvement Committee (QAPIC), Quality of Clinical Care Committee (QCCC), Quality of Service Committee (QSC), Regional Member Advisory Committee (MAC), Credentialing Committee, Compliance Committee, Culturally and Linguistically Appropriate Services Committee (CLAS), Pharmacy and Therapeutics Committee (PT), and the Provider Advisory Committee (PAC). The QAPI Program provides oversight and guidance for the following:
- Determining practice guidelines and standards on which the program’s success will be measured.
- Complying with applicable laws and regulatory requirements, including but not limited to, Louisiana Department of Health (LDH), other applicable state and federal regulations, and National Committee for Quality Assurance (NCQA) accreditation standards.
- Providing oversight of all delegated services.
- Ensuring that a qualified network of providers and practitioners is available to provide care and service to members through the credentialing/recredentialing process.
- Conducting member and practitioner satisfaction surveys to identify opportunities for improvement.
- Reducing health care disparities by measuring, analyzing, and redesigning services and programs to meet the health care needs of our diverse membership.
- Evaluating and mitigating member safety issues through the credentialing process, quality of care investigation, risk management program, pharmaceutical management program, and monitoring of member complaints and grievances.
- Accessing the quality and appropriateness of care furnished to enrollees with special health care needs.
- Achieved a status of “Accredited” on April 21, 2021, from NCQA, demonstrating the plan’s programs for service and clinical quality are well established and meet rigorous requirements for consumer protection and quality improvement. A final score of 141 points out of the total 141 possible points (100%) was achieved, with no opportunities for improvement identified. The accreditation is effective until April 24, 2024.
- Achieved a score of 100% from NCQA in the Multicultural Health Care (MHC) survey on distinction on May 5, 2021, demonstrating the effectiveness of AmeriHealth Caritas Louisiana in providing culturally and linguistically sensitive services and working to reduce health care disparities. This distinction is effective until May 5, 2023.
- Demonstrated growth as well as variation among the alternative payment model contracts established.
- Successfully conducted several Community Outreach Programs such as Baby Showers, Wellness Days, Caritas on the Move, and Whole Health Action Management.
- Met all goals for Primary Care Practitioners, High Volume and Impact Specialist, Psychiatrist, and Behavioral Health Specialist in 2019 with no gaps identified for provider to member ratio or for geographic access for the providers.
- Maintained over a 95% compliance rate for our Provider Medical Record Review process defined by the Louisiana Department of Health.
- Facilitated hands-on provider trainings by educating providers on information and resources that can be obtained through the provider portal, NaviNet.
- In collaboration with the Medical Directors and provider network staff, executed targeted Quality provider trainings for physical health and behavioral health practitioners to educate on services and tools offered to members and providers to increase overall performance on HEDIS rates and performance improvement projects.
- Maintain NCQA accreditation status with improvement in Health Plan Rating — our renewal survey is in early 2024.
- Increase provider compliance rate to meet or exceed standards for after-hours accessibility.
- Strengthen outreach initiatives and initiate new opportunities for identified incentive-based HEDIS measures and measures that scored below the Quality Compass 25th percentile.
- Continue ongoing development of initiatives that promote provider use of NaviNet for identification of clinical care gaps.
- Recruit additional provider specialists in all geographic areas who have not historically participated in the Louisiana Medicaid program.
- Expand network of providers, through telemedicine, for physical and behavioral health services. Expand telehealth access in emergency rooms where certain provider types are not readily available.
- Partner with additional providers for AmeriHealth Caritas Louisiana sponsored Wellness Days to address care gaps.
- Continue to strategize and implement processes to improve HEDIS scores and CAHPS® survey results, with emphasis on areas that need improvement.
- Continue the quarterly CAHPS workgroup with biannual all-associate CAHPS training to improve member experience.
- Ongoing continuous education to providers and staff to improve understanding of Performance Improvement Projects and HEDIS measures, emphasizing the importance of improving member and provider compliance with clinical care guidelines through provider and staff education materials and presentations.
- Increase community involvement and engagement to identify opportunities to reduce health care disparities (race, ethnicity, and language).
- Continue to reduce health care barriers and increase health outcomes by identifying unmet needs through social determinants of health (SDOH) survey analysis.
For additional information or questions, please contact a Provider Services representative at 1-888-922-0007.