Practice guidelines

• Evaluate and improve quality care and provide an educational reference for physicians.

Clinical guidelines are reviewed annually to ensure that the guideline is current and reflects evidence based medicine.

Hayes Guidelines for experimental and investigational treatments

• Care provided to members is state of the art and is based on nationally recommended evidence based guidelines

Hayes Guidelines are updated biannually to ensure that the guidelines provide the most up to date evidence based information.

Physician prescription utilization profiling for pharmaceutical management. Reviews physician formulary adherence and average cost of prescription drugs.

• Promote better formulary adherence. Promotion of medication regimes that are consistent with best practices.

Pharmaceutical reports on physician prescription utilization patterns are tracked and evaluated with recommendations for improvement over time.

Diabetes program assists members and their physicians to manage diabetes

• More members with diabetes receive appropriate tests and diabetic care for early detection of complications.
• Decrease in rates for complications such as lower extremity amputation, ESRD, blindness ad hospitalization.

HEDIS measures will be evaluated to look at health outcomes related to Diabetes and address opportunities for improvement

Breast cancer Initiative Program assists members with breast cancer detection

• Members will receive appropriate detection tests to detect breast cancer and will be educated on breast self-exam.

HEDIS measures will be evaluated to look at health outcomes related to breast cancer and address opportunities for improvement.

Inpatient quality of care indicators - readmission rate

• Review and identify quality of care issues and /or service issues, identify the involved entity and request a corrective action plan.

Readmission rates will be evaluated and opportunities to reduce readmission rates will be tracked and implemented.

Credentialing and Recredentialing of providers

• Prevent adverse outcomes by utilizing credentialed providers

These findings are presented to the Quality Improvement Committee. Tracking and trending and opportunities for improvement will be addressed.