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Model of Care: Evaluate Your Plan’s Evaluation Process!

Updated: Apr 3

Co-Authored by Anita McCreavy

It is that time of year when plans evaluate their Quality Improvement Program and Model of Care successes or failures. What many plans don’t review however, is the actual process or methodology that is used to evaluate these very important programs. Developing a Quality Performance Evaluation or assessing the performance of the Model of Care requires health plans to make important strategic and tactical decisions about the way in which their team, in conjunction with their provider network, will work together to coordinate care for their members. The associated Quality Performance work plans are then updated or adjusted and serves as the strategic plan for your care management, member services, provider relations, risk adjustment, quality performance, Stars/quality, and marketing teams. Often plans do not include the departments or strategies that have extreme interdependent importance.

The Quality Performance Improvement Plans represent the framework of a health plan’s operational infrastructure and offers powerful potential through which to drive sound operations, care coordination, provider engagement, quality improvement, service excellence and improved health outcomes.

For organizations operating a Medicare Advantage Prescription Drug (MAPD) Plan or a Special Needs Plan (SNP), the annual evaluation is not just a legal or regulatory requirement. Quality Performance Improvement Plans capture and document strategic vision by which to provide services to members, to collaborate with providers, to manage and coordinate care, and to conduct operations. It also includes a thorough analysis of a plan’s structure, staffing model, organizational training, technology, and reporting to ensure performance is on track for your applicable MAPD or SNP.

Perhaps because Quality Performance addresses the entire spectrum of a health plan’s clinical and operational processes and systems, annual performance evaluations are often developed and updated by a small team of experienced subject matter experts within a health plan versus inclusion of the multiple affected departmental leaders.

Rebellis Group’s team has the experience to work with the organizations team to ensure the annual Quality Performance evaluation meets standards but also is written with audit lenses and best practices for execution. This process deserves due diligence and should begin within the first quarter of each year and may take a month to complete. Rebellis considers this length of time allowing for applicable depth of evaluation, and leadership or committee review and approval.

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