Quality At Optimum Health Care

We are committed to promoting healthy lifestyles and improving the health status of enrollees. As such, Optimum HealthCare’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 1-866-245-5360 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 Optimum HealthCare, 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.

You can also find HEDIS® information published annually on the Agency for Healthcare Administration (AHCA) website: www.floridahealthfinder.gov/HealthPlans/Default.aspx (by clicking on the link you will be leaving the Optimum HealthCare website) and the National Committee for Quality Assurance’s (NCQA) Health Plan Report Card site: reportcards.ncqa.org/#/health-plans/list

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 1-866-245-5360 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.

Preventive Health Information:

The plan has approved preventive health guidelines. We recommend that our doctors and members follow these guidelines.

  • The Guide to Clinical Preventive Services: Recommendations of the US Preventive Services Task Force, Department of Health and Human Services
  • The clinical summaries in the Guide are abridged versions of recommendations from the U.S. Preventive Services Task Force (USPSTF). To view the full recommendation statements, supporting evidence, or recommendations published after March 2014, go to www.USPreventiveServicesTaskForce.org

If you’re looking for other helpful resources, we suggest the following:

You will find additional information about preventive health services covered by your health plan in your plan’s Summary of Benefits.

Cultural Competency

Optimum 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: 1-866-245-5360 or TDD/TTY at 1-800-955-877

Last Updated: 08/01/2017