Fidelis SecureCare of North Carolina Provider Manual

Quality Program
Purpose
The purpose of the Quality Improvement (QI) Program is to promote and continuously
improve the quality of clinical care (medical and behavioral health) and service that is
provided by facilities, physicians, and other providers to our members. Integral to the QI
program is a commitment to provide appropriate care and resources to our members in
the most appropriate setting with minimal disruption to their routines and that of their
families and other caregivers.
Goals
1. Evaluates the effectiveness of the model of care.
2. Promotes consistent member care delivery.
3. Enables early detection and resolution of issues that affect FSC members, their
families, practitioners and providers.
4. Collects, analyzes and reports beneficiary complaints and grievances.
5. Conducts performance assessments and medical record reviews, which enable
the corporate QM Director to identify and implement performance management
programs.
6. Produces outcome reports that demonstrate the value of complex medical
management and care coordination of frail elderly.
7. Collects, analyzes and reports data to comply with CMS-required quality and
outcome measures that enable members to compare health coverage options,
i.e., Consumer Assessment of Healthcare Providers and Systems (CAHPS)
survey, Health Outcomes Survey (HOS) questionnaire, HEDIS measures, and
Structure and Process standards.
8. Surveys beneficiaries, plan personnel, caregivers, and network providers.
9. Assists practitioners and providers in improving the safety of their practices.
Targeted Quality Programs
Fidelis is committed to ensuring the highest level of clinical care for our members. We
understand that, because frail, vulnerable residents often have a higher number of comorbidities
than any other group, our approach to their care must address all of the
disease states and conditions present in each individual.
To meet the challenge, our comprehensive medical panel of family practice, geriatric
and internal medicine physicians; pharmacists; nurses; psychologists; psychiatrists and
social workers has developed clinical programs that incorporate the latest research data
and best medical practices.
A description of Fidelis’ targeted quality programs follows:
• Medication Therapy Management
• Provider and/or Member Appeals
Quality Program