Quality Management

Quality Management (QM) Program

We want to improve the medical care and services our enrollees receive. That is the goal of our Quality Management program. We want to make sure you receive quality care that it is safe and convenient. We want to make the way we do things better, so that you and your providers stay happy.

The providers that take care of you are checked by our staff.  Some of the ways we do this are:

  • We mail reminders for:

- Well visits and dental visits
- Women’s health screenings, like mammograms and Pap smears
- Pregnancy care

  • Quality improvement program to reduce premature births
  • Quality improvement program to in increase proper Attention Deficit and Hyperactivity Disorder (ADHD) diagnosis, treatment and drug use
  • Quality improvement programs in taking care of chronic conditions like diabetes, high blood pressure, coronary artery disease, heart failure, asthma, chronic obstructive lung disease, depression, HIV, and Hepatitis C
  • Quality programs that check on how doctors take care of their patients
  • Evaluation of how well doctors are providing care and service. We use a tool called HEDIS®. HEDIS stand for Healthcare Effectiveness Data and Information Set. Over 90 percent of all health plans use HEDIS to measure care provided. Some things HEDIS looks at:

- Well-child and adolescent checkups are completed
- Shots are given on time
- Pregnancy visits are completed
- Eye and foot exams, blood work, urine test and check-ups are given to enrollees with diabetes
- Treatment of asthma occurs
- Treatment of high blood pressure happens
- Adult access to wellness care takes place

We try to keep quality in all we do. Each year, we take a look at what we do. This is called the “QM Program Evaluation”. It lets us know if something is working well for our enrollees and providers. It also lets us know what we need to change. Some things it includes are:

  • The program structure
  • Committee involvement
  • Achievements and accomplishments
  • The goals we achieved
  • Results from provider and member satisfaction survey
  • Enrollee education
  • Prevention and wellness activities
  • A summary of overall findings

In 2018, we were successful in these areas:

  • Earning a NCQA Health Plan Award
  • Sending text message reminders to make sure you get the services you need
  • Making sure you get phone calls and letters of important services and tests you need
  • Having home health see pregnant women in their homes

We always look for ways to get better. For 2019, we will:

  • Have a person come to your home to do lab or other tests.  They will talk with you about your health and help you schedule a visit with your doctor
  • Have health fairs in your community, and special events at local schools and churches
  • We care about you and want to make sure you are happy with the services we provide.   We are training our staff to make sure they listen and hear your concerns. 
  • We value what you think.  We have a committee that you can join so your voice can be heard.
  • We want you to be able to see a doctor when you need to so we are getting more doctors to join our plan 

You will also receive an enrollee satisfaction survey. We want to know about your experience with:

  • Your doctor
  • The care you received from your doctor
  • How well your doctor listen to you
  • How much time your doctor spends with you
  • Getting the care you need and how quickly
  • How often your primary care provider (PCP) knows about the care you get from other doctors
  • The service you receive from our employees
  • Information we give you on preventive care

Aetna Better Health Quality Improvement (QI) program

Keeping you healthy is important to us. We want you to be happy. Some things we did well in 2017 include:

  • Help you get to doctor visits with better transportation services
  • Lower Emergency Room visits by managing care better
  • Added more doctors to serve you. Our main goal is to make sure you have:

We want to satisfy you.  

Our main goal is to make sure you have:

  • The right kind of care, at the right time, by the right person
  • Easy access to good health care
  • Support you when you need it
  • Happiness with the services you get

This is just some of the things we want to do for you. You can call Enrollee Services 24 hours a day/7 days a week toll free for more information. Call us at 1-855-242-0802 to find out more about our QI programs. You can also ask for a written copy of our QI Program. We will send it to you after you ask for it.