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Quality

We are committed to understanding and improving quality health care programs for our members. Find out what we expect from our contracted providers.

Quality Management

We want to be as transparent as possible about the expectations we have of our providers. Our Quality Assessment and Performance Improvement (QAPI) Program exists to ensure that members receive access to high-quality care and services in an appropriate, comprehensive, and coordinated manner that meets or exceeds community standards.
The scope of our QAPI program includes, but is not limited to, the following elements of care and service:

  • Accessibility and availability of services
  • Member satisfaction
  • Quality, safety and appropriateness of clinical care
  • Clinical outcomes
  • Performance improvement projects
  • Service monitoring
  • Clinical practice guidelines and evidence-based practices

We partner with the Colorado Department of Health Care Policy and Financing and the Health Services Advisory Group to administer three satisfaction surveys throughout the year.

We evaluate the impact and effectiveness of the QAPI program on an annual basis and use this information to improve operational systems and clinical services. Information about the program and summaries of results are available to providers and members upon request and is also published in provider and member newsletters.

Accessibility and Availability of Services

Excessive wait times leave members dissatisfied with both their health care provider and health plan. We request that our network providers adhere to state and federal standards for appointment availability for members. If you are unable to provide an appointment within the required timeframes, listed below, please refer the member to us so we can help them find the care they need in a timely manner.

We monitor your compliance with appointment standards in the following ways:

  • Surveys
  • Member grievance monitoring
  • Secret shopper evaluation of appointment availability

Access to Care Standards

Physical Heath Appointment Standards

Type of Care Standard
Routine care (non-symptomatic, well care physical exam, preventive care) Scheduled within 30 calendar days of request**

*For CHP+, does not apply to appointments for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty (30) calendar days

**Unless required sooner for recommended Bright Futures screenings

Non-urgent care (symptomatic) Scheduled within 7 calendar days of request
Urgent care Scheduled within 24 hours of request

Behavioral Health Appointment Standards

Type of Care Standard
Routine care (non-urgent, symptomatic behavioral health services) Within 7 days of member’s request
Urgent care Within 24 hours of initial contact by member
Emergency services (face-to-face) Urban/suburban: within 1 hour of contact Rural/frontier: within 2 hours of contact
Emergency services (phone) Within 15 minutes of initial contact
Outpatient follow-up appointments after hospital (behavioral health & physical health) Within 7 days after discharge from a hospitalization

Quality of Care Concerns and Critical Incidents

A quality of care concern is a complaint made regarding a provider’s competence or care that could adversely affect the health or welfare of a member. Examples include prescribing a member the wrong medication or discharging them prematurely.

A critical incident is defined as a patient safety event not primarily related to the natural course of the patient’s illness or condition that reaches a patient, and results in death, permanent harm, or severe temporary harm. Examples include a suicide attempt requiring prolonged and exceptional medical intervention, and being operated on the wrong side or the wrong site.

You must report any potential quality of care concerns and critical incidents that you identify during a course of treatment of a member. The identity of any provider reporting a potential concern or incident is confidential.

A Colorado Access medical director will review each concern/incident and score them based on the level of risk/harm to the patient. A facility might receive a call or letter about the incident that includes education about best practices; a formal corrective action plan; or could be terminated from our network. To report a quality of care concern or critical incident, fill out the form located online at coaccess.com/providers/forms and email it to qoc@coaccess.com.

Please note that reporting any potential quality of care concerns or critical incidents is in addition to any mandatory reporting of critical incidents or child abuse reporting as required by law or applicable rules and regulations. Please refer to your provider agreement for details. If you have any questions, please email qoc@coaccess.com.

Comprehensive Records

Providers are responsible for maintaining confidential medical records that are current, detailed and organized. Comprehensive records help facilitate communication, coordination and continuity of care, as well as effective treatment. We may perform patient record audit/chart reviews to assure compliance with our standards. For the specific requirements, see Section 3 of the Provider Manual here.

We create annual quality reports for each of our RAE regions and our CHP+ HMO program that detail the progress and effectiveness of each component of our Quality Improvement Program. These reports include a description of the techniques used to improve performance, a description of the qualitative and quantitative impact the techniques had on quality, the status and results of each performance improvement project conducted during the year and opportunities for improvement.

Read the annual quality report for Region 3 here

Read the annual quality report for Region 5 here

Read the annual quality report for our CHP+ HMO program here

Clinical Practice Guidelines

Preventive Care

Pediatric Health Maintenance (American Academy of Pediatrics)
Pediatric Immunizations (Centers for Disease Control and Prevention)
Prenatal Care (Epocrates)

Physical Health
Down Syndrome (American Academy of Pediatrics)
Obesity – Child (Smoking Cessation (US Department of Health and Human Services)

Behavioral Health
Alcohol and Substance Use Screening, Brief Intervention, and Referral to Treatment, SBIRT (Centers for Medicare and Medicaid)
Attention Deficit Hyperactivity Disorder (American Academy of Child and Adolescent Psychiatry)
Bipolar Disorder – Adult (American Psychiatric Association)
Bipolar Disorder – Child (American Academy of Child and Adolescent Psychiatry)
Major Depressive Disorder (Agency for Healthcare Research and Quality)
Substance Use Disorders (American Psychiatric Association)

Resources

Preventive Care
Adult Health Maintenance (Massachusetts Health Quality Partners)
Adult Immunizations (Centers for Disease Control and Prevention)
Influenza Vaccination (Centers for Disease Control and Prevention)
Postnatal Care to Reduce Infant Mortality (World Health Organzation)

Physical Health
Appropriate Antibiotic Use (Centers for Disease Control and Prevention)
Asthma (National Institutes of Health)
COPD (Global Initiative for Chronic Obstructive Lung Disease)
Diabetes Care (American Diabetes Association)
Gastroesophageal Reflux Disease (Agency for Healthcare Research and Quality)
Obesity – Adult (Obesity Society, American Heart Association, American College of Cardiology)
Sexual Behaviors < 25 Years Old (American Family Physician)

Behavioral Health
Alcohol and Substance Use Screening, Brief Intervention, and Referral to Treatment, SBIRT (Centers for Medicare and Medicaid)
Attention Deficit Hyperactivity Disorder (American Academy of Child and Adolescent Psychiatry)
Bipolar Disorder – Adult (American Psychiatric Association)
Intensive Outpatient Services (US Department of Health and Human Services)
General Anxiety Disorder (American Family Physician)
Major Depressive Disorder (Agency for Healthcare Research and Quality)
Substance Use Disorders (American Psychiatric Association)

Health Spotlight
COVID-19 (CDC)
COVID-19 (CDPHE)
Health Disparities (Article)