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. To do this, we rely on our Quality Management (QM) program to monitor 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 HEDIS® MY 2022 results show that Optimum HealthCarecare improved its performance and met quality goals in many HEDIS® measures. These areas include:

  • Breast Cancer Screening
  • Controlling High Blood Pressure
  • Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  • Hemoglobin A1c Control for Patients with Diabetes
  • Kidney Health Evaluation for Patients with Diabetes
  • Osteoporosis Management in Women Who Had a Fracture
  • Statin Therapy for Patients with Cardiovascular Disease
  • Transitions of Care: Patient Engagement
  • Transition of Care: Medication Reconciliation Post- Discharge

Areas where we would like to improve our performance include:

  • Colorectal Cancer Screening
  • Eye Exam in Patients with Diabetes
  • Transitions of Care: Notification of Inpatient Admission
  • Transitions of Care: Receipt of Discharge Information

View our full quality Health Plan Report Card.

Additional information HEDIS® and Performance Measurement.

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

Last updated 10/01/2023