Providing Quality Care (2024)

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to report their satisfaction with their healthcare, including their experience with their providers and health plan. The CAHPS survey scores are made available to the public and can determine whether patients and members stay with their provider or health plan or look elsewhere for their care. Surveys are sent to our members from February through June.

You are essential to providing the highest-quality healthcare possible for our members, and your satisfaction is important to us, too. We assess your experience with the health plan through an annual Provider Satisfaction Survey. These survey results will be reviewed by Ambetter from Louisiana Healthcare Connections and will be key to helping us improve the provider experience, so please be sure to complete the survey if you receive one. Your feedback informs improvement opportunities and quality initiatives.

During the credentialing process, Ambetter from Louisiana Healthcare Connections obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or re-credentialing application at any time by calling your health plan Provider Engagement Representative.

If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify Ambetter from Louisiana Healthcare Connections as soon as possible so we can update our Provider Directory. Having access to accurate provider information is vitally important to our members, and we want to work together to ensure continuity of care can be maintained for Ambetter from Louisiana Healthcare Connections members.

Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage

Ambetter from Louisiana Healthcare Connections does not reward providers, practitioners, or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. Nationally recognized criteria (such as InterQual or MCG) are used if available for the specific service request, without additional criteria (e.g., clinical/medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.

Submitting complete clinical information with the initial request for a service or treatment will help us make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting the UM department at the health plan.

Providing quality care to our members includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult primary care provider or specialist, contact Ambetter from Louisiana Healthcare Connections or reference the information in the Provider Manual. We can assist in locating an in-network adult care provider or arranging care if needed.

The health plan formulary/Preferred Drug List (PDL) is based on the plan benefits and is updated on a regular basis. If you believe a medication merits an addition to the PDL, a request may be submitted using the Formulary Change Request form. The current PDL, which includes information regarding covered drugs, restrictions, prior authorization requirements, limitations, etc., is located on the health plan website.

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:

  • Address historical and contemporary injustices;
  • Overcome economic, social, and other obstacles tohealth and healthcare; and
  • Eliminate preventable health disparities

To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. For more information about Culturally and Linguistically Appropriate Services (CLAS) Standards, see https://thinkculturalhealth.hhs.gov/clas.

Together, we must make language assistance services available to people with Limited English Proficiency (LEP) at all points of contact during all hours of operation and at no cost to our members. We are here to help get language assistance to Ambetter from Louisiana Healthcare Connections members and providers without unreasonable delay at all vital points of contact. You can schedule language services, including telephone and face-to-face interpretation for non-English languages and American Sign Language, by calling our Provider Customer Contact Center or by calling the toll-free number on the back of our member’s ID card. Additional resources are found on the website.

The health plan encourages our providers to engage in Cultural Humility trainings and education to promote positive interaction with diverse cultures.

For more information about the Cultural and Linguistic Competency e-Learning Program from the Office of Minority Health (OMH), see https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6. This program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS as a way to improve quality of care.

Our Care Management team is available for members who may benefit from increased coordination of services. The team is available to assist and support providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.

The care management team helps members:

  • Achieve optimum health, functional capability, and quality of life through improved management of their disease or condition.
  • Determine and access available benefits and resources.
  • Develop goals and coordinate with family, providers, and community organizations to achieve these goals.
  • Facilitate timely receipt of appropriate services in the right setting.

Early intervention is essential to maximizing treatment options and minimizing potential complications associated with illnesses, injury, or chronic conditions. Members can receive services through face-to-face visits, over the phone, or in a provider's office. You can directly refer members to the Care Management program at any time by calling the health plan or initiating a referral on the Provider Portal.

Every year Ambetter from Louisiana Healthcare Connections assesses appointment availability for PCPs, specialists, and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent/sick visits, etc.) and type of practitioner. Please review the Provider Manual for the expectations of how quickly our members should be able to get an appointment.

Providers are expected to follow member rights. Members are informed of their rights and responsibilities in their member handbook.

Member rights include, but are not limited to:

  • Receiving all services the health plan provides.
  • Being treated with dignity and respect.
  • Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies.
  • Being able to see their medical records.
  • Being able to receive information in a different format in compliance with the Americans with Disabilities Act.
  • Access to language services at all points of contact during all hours of operation and at no cost to the member.

Member responsibilities include:

  • Understanding their health problems and telling their healthcare providers if they do not understand their treatment plan or what is expected of them.
  • Keeping scheduled appointments and calling the physician's office whenever possible if there is a delay or cancellation.
  • Showing their member ID card at appointments.
  • Following the treatment plans and instructions for care that they have agreed on with their healthcare practitioner.

We encourage you to reference the Provider Manual to review the full list of rights and responsibilities.

The American Board of Internal Medicine (ABIM) Foundation encourages practitioners and patients to "Choose Wisely." This initiative seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures.

Please visit choosingwisely.org to download informational resources for your patients and clinicians to promote shared decision-making.

Providing Quality Care (2024)

FAQs

How would you ensure the quality of care you provide? ›

How to Improve Quality of Care in Healthcare
  1. Prioritize Training and Education. The nursing staff at your facility or residence is key to improving quality. ...
  2. Increase Access to Care. ...
  3. Engage Patients and Families. ...
  4. Improve Communication. ...
  5. Measure and Monitor Quality. ...
  6. Set Tangible Goals. ...
  7. Relay Progress Back to Staff.

What is providing quality care? ›

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. It is based on evidence-based professional knowledge and is critical for achieving universal health coverage.

How do you demonstrate quality of care? ›

Best practices for delivering quality patient care
  1. Show respect. ...
  2. Express gratitude. ...
  3. Enable access to care. ...
  4. Involve patients' family members and friends. ...
  5. Coordinate patient care with other providers. ...
  6. Provide emotional support. ...
  7. Engage patients in their care plan. ...
  8. Address your patients' physical needs.
Mar 6, 2020

How do you provide quality in healthcare? ›

Build effective communication and collaboration among medical staff. Create health prevention and promotion initiatives. Motivate change that drives improvement in healthcare. Use data to assess risk and identify areas for change.

How do you provide quality? ›

How do you ensure quality in business operations?
  1. Define quality standards and metrics.
  2. Implement quality control and assurance processes.
  3. Train and empower your staff.
  4. Engage and delight your customers.
  5. Review and improve your quality continuously. Be the first to add your personal experience.
  6. Here's what else to consider.
Aug 17, 2023

What is an example of quality patient care? ›

Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values, ensuring that patients' values guide all clinical decisions. Timely: Reducing waits and sometimes harmful delays for both those who receive and provide care.

What does it mean to provide quality? ›

Quality is fulfilling the customers' purpose in a way that matters to them. Quality simply means delivering to the customer what they expected. Quality means doing it right when no-one is looking.

What is quality and effective care? ›

According to the National Academy of Medicine, quality health care is care that is safe, effective, patient-centered, timely, efficient, and equitable.

How do you measure quality in care? ›

The Key lines of enquiry (KLOES) are used to inspect whether regulated health and social care services are safe, effective, caring, responsive and well-led, and provide a baseline for good and outstanding care.

What are the basics of quality care? ›

Quality of care is the measure of how well healthcare services are providing desired outcomes. The pillars that quality of care is based upon include being effective, safe, and people-centered. People-centered quality of care focuses on the needs of a patient and respecting their culture and who they are.

How do you use quality of care in a sentence? ›

He is instrumental to the quality of care and hence the quality of life for the patient. A decrease in administrative costs might result, for example, if an organization improves its quality of care and thus reduces its premiums for malpractice insurance.

How important is quality of care? ›

Quality in healthcare is of utmost importance as it directly impacts the well-being and outcomes of patients. Ensuring high-quality care involves various aspects, including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

How do nurses provide quality care? ›

To provide quality care to patients, nurses must offer emotional support and empathy. They also need to be resourceful, innovative, and collaborative with other members of the health care team.

What are examples of quality measures in healthcare? ›

Types of Health Care Quality Measures
  • Whether the health care organization uses electronic medical records or medication order entry systems.
  • The number or proportion of board-certified physicians.
  • The ratio of providers to patients.

How do you ensure good quality? ›

How do you ensure your products or services are top quality?
  1. Define quality standards. Be the first to add your personal experience.
  2. Implement quality control. Be the first to add your personal experience.
  3. Establish quality assurance. ...
  4. Monitor quality performance. ...
  5. Improve quality continuously. ...
  6. Here's what else to consider.
Aug 23, 2023

How do you ensure the patient is satisfied with the care you have provided? ›

Show courtesy: Kind gestures and polite words make a patient very comfortable. Listen and understand: encourage patients to tell their problem. Invite and answer their questions. Inform and explain: it promotes compliance.

How do you ensure quality in the workplace? ›

You can improve the quality of your work with the following steps:
  1. Define what quality work is with each project. ...
  2. Plan each individual task. ...
  3. Assign goals or deliverables. ...
  4. Delegate tasks. ...
  5. Create a quality work environment. ...
  6. Create a list of resources. ...
  7. Make editing a part of the timeline. ...
  8. Measure the quality of the work.
Jun 24, 2022

How will you ensure support for the caregiver? ›

If you notice the caregiver is struggling or if their loved one's needs are not being adequately addressed, be their voice. Help them access the appropriate resources, services, or medical attention. This advocacy ensures that the caregiver and their care recipient receive the care and support they genuinely require.

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