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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 Health, Behavioral Health, and Substance Use

Type of Care Timeliness Standard
Urgent Within 24 hours of initial identification of need

Urgent is defined as the existence of conditions that are not life-threatening but require expeditious treatment because of the prospect of the condition worsening without clinical intervention.

Outpatient follow-up after hospitalization or residential treatment Within seven days after discharge
Non-urgent, symptomatic*

*For behavioral health/substance use disorder (SUD), cannot consider administrative or group intake processes as a treatment appointment for non-urgent, symptomatic care or place members on waiting lists for initial requests

Within seven days after request

Behavioral health/SUD ongoing outpatient visits: Frequency varies as the member progresses and the type of visit (e.g., therapy session versus medication visit) changes. This should be based on member’s acuity and medical necessity.

Physical Health Only

Type of Care Timeliness Standard
Emergency 24 hours a day availability of information, referral, and treatment of emergency medical conditions
Routine (non-symptomatic well-care physical examinations, preventive care) Within one month after request*

*Unless required sooner by AAP Bright Futures schedule

Behavioral Health and Substance Use only

Type of Care Timeliness Standard
Emergency (by phone) Within 15 minutes after initial contact, including TTY accessibility
Emergency (in-person) Urban/suburban areas: within one hour of contact

Rural/frontier areas: within two hours of contact

Psychiatry/psychiatric medication management- urgent Within seven days after request
Psychiatry/psychiatric medication management- ongoing Within 30 days after request
SUD Residential for Priority populations as identified by Office of Behavioral Health in order:

  • Women who are pregnant and using drugs by injection;
  • Women who are pregnant;
  • Persons who use drugs by injection;
  • Women with dependent children;

Persons who are involuntarily committed to treatment

Screen a member for level of care needs within two days of request.

If admission to the needed residential level of care is not available, refer the individual to interim services, which can include outpatient counseling and psychoeducation, as well as early intervention clinical services (through referral or internal services) no later than two days after making the request for admission. These interim outpatient services are intended to provide additional support while waiting for a residential admission.

SUD Residential Screen a member for level of care needs within seven days of request.

If admission to the needed residential level of care is not available, refer the individual to interim services, which can include outpatient counseling and psychoeducation, as well as early intervention clinical services (through referral or internal services) no later than seven days after making the request for admission. These interim outpatient services are intended to provide additional support while waiting for a residential admission.

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

Read SUD quality measures guidance for providers here

Clinical Practice Guidelines

Clinical Practice Guidelines are reviewed every two years, or sooner as appropriate. If you would like to provide feedback or have any questions regarding the Clinical Practice Guidelines, please email QualityManagement@coaccess.com.

Preventive Care

Pediatric Health Maintenance (American Academy of Pediatrics)
Pediatric Immunizations (Centers for Disease Control and Prevention)
Perinatal and Prenatal Care for Women and Infants (Epocrates)
Postpartum Care for Women (ACOG)

Physical Health
Down Syndrome (American Academy of Pediatrics)
Pediatric Obesity (National Institutes of Health)

Behavioral Health and Substance Use
Attention Deficit Hyperactivity Disorder (American Academy of Child and Adolescent Psychiatry)
Bipolar Disorder – Child (American Academy of Child and Adolescent Psychiatry)
Generalized Anxiety Disorder – Child (American Academy of Child and Adolescent Psychiatry)

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 Organization)

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 (The American Journal of Gastroenterology)
Obesity – Adult (Obesity Society, American Heart Association, American College of Cardiology)
Sexual Behaviors in <25 Years Olds (American Family Physician)
Smoking Cessation (US Preventative Services Task Force)

Behavioral Health and Substance Use
Alcohol and Substance Use Screening, Brief Intervention, and Referral to Treatment, SBIRT (Centers for Medicare and Medicaid)
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)