QI Program
We are committed to the provision of a well-designed and well-implemented Quality Improvement (QI) program. Our culture, systems and processes are structured around this mission to improve the health of all enrolled members.
Scope
The scope of the QI Program is comprehensive and addresses both the quality and safety of clinical care and quality of services provided to Buckeye Health Plan's members including medical, behavioral health, dental and vision care as included in the health plan’s benefits. Buckeye Health Plan incorporates all demographic groups, lines of business, benefit packages, care settings, and services in QI activities, including preventive care, emergency care, primary care, specialty care, acute care, short-term care, long-term care (as applicable per Buckeye Health Plan's products), and ancillary services. Buckeye Health Plan’s QI Program monitors the following:
- Acute, complex, and chronic care management
- Behavioral health care
- Compliance with member confidentiality laws and regulation
- Compliance with preventive health and clinical practice guidelines
- Continuity and coordination of care
- Delegated entity oversight
- Department performance and service
- Employee and provider cultural competency
- Marketing practices
- Member enrollment and disenrollment
- Member grievance and appeals system
- Member experience
- Member safety
- Primary care provider changes
- Pharmacy
- Primary care provider after-hours telephone accessibility
- Provider appointment availability
- Provider complaints
- Provider network adequacy and capacity
- Provider experience
- Selection and retention of providers (credentialing and recredentialing)
- Medical management
- Population health management
- Utilization management, including over- and under-utilization
Goals & Objectives
Our primary QI Program goal is to improve members’ health status through a variety of meaningful quality improvement activities implemented across all care settings and aimed at improving quality of care and services delivered.
Additionally, Buckeye Health Plan’s QI Program goals include but are not limited to the following:
- Ensuring health plan members receive accessible, appropriate, cost-effective, and high quality health and behavioral care and services throughout the care continuum;
- Emphasizing the delivery of personalized care, allowing the provider to maintain their key role of managing the needs of BHP members;
- Employ a population health management approach emphasizing health promotion and disease prevention, collaboration with community-based agencies and addressing social determinants that may contribute to inequities in health care.
- Creating and implementing processes and programs that respond to and address the culturally and linguistically diverse needs of BHP’s members;
- Helping individuals navigate the health care system by reducing barriers and supporting them to reach their optimal health;
- Network quality of care and service will meet industry-accepted standards of performance;
- Meeting industry-accepted standards of performance for health plan services;
- Minimizing fragmentation and/or duplication of services through integration of quality improvement activities across functional areas;
- Meeting BHP’s established performance targets for member and provider satisfaction;
- Maintaining compliance with preventive health and clinical practice guideline performance targets. This includes, but is not limited to, compliance with guidelines for immunizations, prenatal care, diabetes, asthma, etc.;
- Maintaining compliance with all applicable regulatory requirements and accreditation standards.
Credentialing Standards
For consideration to participate in the Buckeye Health Plan network, all licensed physicians and other licensed healthcare professionals who have an independent relationship with Buckeye Health Plan must complete an application for participation and submit copies of applicable supporting documentation.
Cultural Competency Plan
Buckeye Health Plan is committed to establishing multicultural principles and practices throughout its organizational systems of services and programs. That mission is supported by facilitating the process by which Buckeye Health Plan can respond to the health care needs of all individuals, regardless of their ethnic, cultural, religious beliefs or language. Our Cultural Competency plan is reviewed and updated annually.
Participation in QI
Buckeye Health Plan requires providers and practitioners to cooperate with all Quality Improvement activities, as well as allow the use of provider and/or practitioner performance data, to ensure the success of the QI Program. The Buckeye Health Plan QI Program is outlined on the Buckeye Health Plan website www.buckeyehealthplan.com and is available upon request. If you are interested in learning more about Buckeye Health Plan's QI Program, please contact Buckeye Health Plan at 1-866-246-4358 and ask to speak with the Quality Improvement Department.