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Monitoring Quality Management

QM Program

Our goal at Optimum Healthcare is to help our members improve their health by providing the best care and service options. In order to do this, we rely on our Quality Management (QM) program. The QM program monitors the quality of care given by Plan providers. The QM Program also looks for areas of service that need to be improved.

Measuring Success

Every year, we measure to see the progress we have made toward meeting our goals for healthy members. One of the tools we use to do this is called HEDIS®, which stands for Healthcare Effectiveness Data and Information Set. HEDIS® is a very common tool used by health care plans to see how well they are serving their members. We use these HEDIS® results to see where we need to focus our improvement efforts.

HEDIS® Results

Our 2020 HEDIS® MY 2020 results show that Optimum Healthcare improved its performance and met quality goals in many HEDIS®measures. These areas include:

  • Antidepressant Medication Management: Acute Phase Rx
  • Antidepressant Medication Management: Continuation Phase Rx
  • Controlling High Blood Pressure
  • Comprehensive Diabetes Care: Blood Pressure Controlled <140/90 mm Hg
  • Comprehensive Diabetes Care: Nephropathy
  • Transition of Care: Medication Reconciliation Post- Discharge
  • Pharmacotherapy Management of COPD: Bronchodilator

Areas where we would like to improve our performance include:

  • Colorectal Cancer Screening
  • Follow-Up Hospital Mental Illness
  • Osteoporosis Management in Women
  • Persistent of Beta-Blocker Treatment After a Heart Attack

You can view our full quality Health Plan Report Card at:

For more information on HEDIS® and Quality Measurement, go to:

You can also call Member Services at 1-866-245-5360.

Last updated 10/01/2021