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    How one health plan aims to improve quality


    Providers work with multiple payment models and plan types in providing care to a wide demographic of patients. What’s the best strategy for working with providers and outlining your strategy for quality improvement as a health plan?

    This was the focus of a presentation at Qualipalooza, the second annual RISE quality leadership summit in San Antonio, Texas, June 29 to 30. The session was led by Frances Johnson, BSN, MBA/HCM, director of quality management at BlueCross/BlueShield of North Carolina and Lauren Hampshire, director of corporate clinical quality at CareSource and titled, “Enhancing Cooperation With Your Provider Network To Streamline Quality Improvement.” The talk focused on how areas for improvement could be identified and what plans can do to motivate change.

    Hampshire participated in a Q&A with Managed Healthcare Executive (MHE) in the days before the conference.

    MHE: What is the strategy at CareSource for promoting quality improvement?

    Hampshire: I’m going to be speaking on CareSource’s quality improvement plan and providing insight and how it aligns with organizational mission. Our mission is to make a lasting difference in our members' lives by improving their health and wellbeing. So our quality strategy really aligns back to that mission and to the Triple Aim.

    We approach this from three perspectives—an overall strategy, an organizational commitment to that strategy, and partnering with healthcare providers.

    MHE: How does a central vision and organizational support promote quality?

    Hampshire: Our quality governance structure is committed to ensuring our organization is delivering that quality of care to our members and we are aligning to that strategy. That strategy lines back up to our business plan, but also to our mission. Senior leadership supports this by creating a sense of urgency for improvement. They act as good role models, remove obstacles for the front line services, and articulate a shared vision.

    MHE: What kinds of tools can plans offer providers to improve quality on the front line?

    Hampshire: Partnering with providers is one of the key pillars of the quality strategy. We look for opportunities to share the development of goals with our healthcare providers. In some cases, we have value-based reimbursement programs, and I think one of the key things with that is really collaboration.

    The goal is to achieve a platform for shared quality and population health management goals, as well as to look for shared initiatives. It all does back to that central focus of the mission and working with providers to take care of patients.

    MHE: What do you hope plans will take away from your session and implement at their own organizations?

    Hampshire: Keep focused on quality strategies, organizational commitment, and how to reinforce trusted relationships with primary care. Find out how the plan can help the primary care provider and understand what care opportunities members have.

    It’s about setting up success for the member, the provider and the plan. Keep focused on what we are trying to do as healthcare providers. How do we help members coordinate care, improve health outcomes, and improve the experience of care. Ultimately, we’re all really driving to those three key things that the Triple Aim speaks to.


    Rachael Zimlich, RN
    Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare ...


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