Medicaid - QM Department

Quality At Freedom 1st Specialty Medicaid

We are committed to promoting healthy lifestyles and improving the health status of enrollees. As such, Freedom Health’s Board of Directors directed the company to establish a Quality Management Program designed to promote quality care and service excellence. We are committed to improving the health of members, and promoting healthy lifestyles. Through our Quality Management (QM) Program, we establish goals and structure to support this commitment. We monitor and evaluate the quality and appropriateness of care provided to our members. The overall goal of this program is to achieve quality care and services for our members. We achieve this goal through the design, implementation and improvement of organizational systems. You can call Member Services 1-877-655-2424 to request a paper copy of our QM Program. Providers can contact their Provider Relations Representative for an electronic or paper copy of the program.

Program Overview

The Quality Management (QM) Program is based on the quality principle that improvement results from ongoing and systematic measurement, intervention, and follow-up of key aspects of care. Primary responsibility for administration of the QM Program is vested in the Medical Director, but all employees share in the responsibility to define and implement improvements that enhance clinical efficiency, provide effective utilization and focus on improved outcome management. A major focus of the Quality Management Program is the establishment of clinical initiatives involving quality improvement projects, focus studies, and interventions designed to improve performance measures. The QM Program utilizes performance measurement data, national benchmarks and root-cause analyses to identify opportunities for improvement. These opportunities for improvement are identified on an ongoing basis. Practitioner involvement, as well as the staff and analytical resources devoted to quality improvement activities, are important aspects of our QM Program, and contribute to ongoing improvements.

Monitoring Quality

Each year, we evaluate the Quality Management program, and progress toward meeting our goals. One of the tools we use to evaluate the QM program is HEDIS® (Healthcare Effectiveness Data and Information Set). HEDIS® is developed by the National Committee for Quality Assurance (NCQA) and is the most widely used rating system in health care. Most health plans, including Freedom Health, use HEDIS® to measure the quality of services we provide to our members. Using HEDIS®, we establish performance goals, develop and implement improvement plans each year. Information relevant to our HEDIS® results will be published through our newsletters and website.

For more information on Agency defined HEDIS® and Quality Measures, go to: http://ahca.myflorida.com/Medicaid/quality_mc/submission.shtml

You can also find Health Plan information published annually on the Agency for Healthcare Administration (AHCA) website: www.floridahealthfinder.gov/HealthPlans/Default.aspx

National Committee for Quality Assurance’s (NCQA) Health Plan Report Card site: reportcard.ncqa.org/plan/external/plansearch.aspx

 

Patient Safety

We promote health and safety of our members. Our Patient Safety Program promotes member safety in all care settings. Safety improvement initiatives are incorporated into plan activities, and evaluated for effectiveness. The goals of our Patient Safety program include:

  • Providing effective and safe health care.
  • Improving medication safety.
  • Monitoring medication reconciliation.
  • Implementing improvement initiatives that allow us to monitor the safety of care provided

The Patient Safety Plan monitors and analyzes the following patient safety performance indicators, including:

  • Pharmacy data and summary reports
  • Patient Safety reports;
  • Complaints, grievance issues and summary reports
  • HEDIS® results and outcomes
  • Medication Reconciliation Post-Discharge
  • Use of High-Risk Medications In the Elderly
  • Potentially Harmful Drug-Disease Interactions In the Elderly
  • Annual Monitoring for Patients on Persistent Medications

Measuring effectiveness

The process to measure quality program effectiveness includes an annual evaluation, quality studies and improvement initiatives. The quality study design incorporates the establishment of baseline data, data analysis, development and implementation of interventions, and re-measurement to evaluate the effectiveness of interventions and overall improvement. Quality management outcomes are reported regularly to the Quality Management Steering Committee.

Quality Management Program Guidelines & Standards

Medical care management activities are an important component of the Quality Management Program. Key elements include preventive health and clinical practice guidelines and standards, over and under-utilization monitoring, use of review criteria, and clinical peer review of medical appropriateness. The Plan has ongoing disease management and case management programs. You can call Member Services 1-877-655-2424 to request additional information on our clinical or preventive health guidelines. Providers can contact their Provider Relations Representative on how to obtain an electronic or paper copy of medical or other guidelines, or refer to the Provider Manual.

Member Rights and Responsibilities

You have rights as a member of your health plan. You also have responsibilities that will help your doctor take care of you. Click on this link to find out more about your Rights and Responsibilities.

Advance Directives

Advance Directives help you make choices about your health care in case you become sick. Click on this link to find out more about Advance Directives.

To learn more about Advance Directives or to access Advance Directive forms, visit the following resources: http//:www.floridahealthfinder.gov/reports-guides/advance-directives.aspx

Preventive Health Care

Preventive care is important. Here are some examples of preventive health care services you may need:

  • Wellness Visit
  • Blood pressure screening
  • Lipid screening
  • Obesity screening and counseling
  • Colorectal cancer screening (ages 50-75)
  • Diabetes screening
  • Flu and pneumonia shots

In addition, women may need other tests such as cervical and breast cancer screenings.

If you have a health problem, it is best to know about it early. Finding health problems early will reduce your risk of complications. Please talk to your doctor about preventive health care exams.

To learn more about the preventive health guidelines that the Plan has approved, visit the following website: www.USPreventiveServicesTaskForce.org

Cultural Competency

Freedom 1st Specialty Medicaid wants to help you with your health care needs. We have a program to provide services that meet our members’ special cultural needs. We can help if you don’t speak English. We want to make sure we understand any special needs you have.

Call Member Services for more information about our programs: 1-877-655-2424 or TDD/TTY at 1-800-955-8771

Last Updated: 10/01/2017