Quality Management

*CY24 cut points to be released in October 2025.

§ New measure, cut points to be released October 2025.

Program Goals

The Trinity Health Plan of Michigan QM program is a comprehensive program designed to comply with regulatory requirements to monitor the quality of care and services provided by the Trinity Health Plan of Michigan delivery system. This includes administrative activities of the Plan and its contracted providers.

The program’s purpose is to pursue opportunities for improving medical care, service and the well-being of our members. The focus is on continuous quality improvement with a constant eye on how care and services can be provided at a higher level of quality. Dedicated Trinity Health Plan of Michigan resources are allocated to conduct ongoing quality assessment of performance toward goals with problem resolution, as necessary.

The QM program focuses on three dimensions of health care delivery:

1. Delivery system structure itself
2. Processes involved in delivering health care
3. Results of care delivery

By continuously monitoring and evaluating these three dimensions of health care delivery, Trinity Health Plan of Michigan constantly strives to provide the highest quality care in the most appropriate setting in the most efficient manner to attain the utmost satisfaction of Trinity Health Plan of Michigan members.

Program Activities

A variety of activities are involved in implementing the Trinity Health Plan of Michigan QM program including, but not limited to, the following:

• Risk management/quality concern reporting.
• Monitoring of member service activities, including complaints, appeals and grievances.
• HEDIS data collection/monitoring.
• Member satisfaction surveys.
• Member-based performance improvement projects/studies.
• Provider-based performance improvement.
• Physician access and availability surveys.
• Review of quality concerns for each physician at the time of recredentialing.
• Required data reporting to CMS, such as hospital acquired conditions and serious reportable adverse events.

Risk Management/Quality Concern Reporting

The goal of Risk Management, a component of the QM program, is to control and minimize possible risks arising in the direct provision of care, as well as risks associated with administration of the Plan. The Risk Management/Quality Concern Reporting Form provides a reporting mechanism for contracted providers to report risk management cases or quality concerns. This reporting mechanism is used to identify cases/incidents with potentially serious, undesirable and/or unexpected occurrences that may include loss of life, limb or function or has the potential to adversely affect Trinity Health Plan of Michigan’s reputation. If there is a risk management or quality concern issue in your office regarding a member, please contact Trinity Health Plan of Michigan’s QM Department at the email listed in the Contact Us section of this manual.

Outcomes, Evaluations and Member-Based Studies

The outcomes of clinical care are measured in the following terms: improved health, illness and death reduction, whether the treatment or therapy improved outcome as planned, whether the medical action positively altered the course of the disease’s natural history and whether clinical actions taken provided positive outcomes. Outcomes evaluation identifies potentially adverse events resulting from quality issues. Adverse outcomes identified in significant number or scope are investigated and member-based studies are conducted to improve measurable outcomes.

Access and Availability

An additional measure of quality is the access to care and availability for our members. Access means that medically necessary care is available in a timely manner and that members are able to schedule appointments and obtain any required referrals, as indicated, based on clinical needs. Availability means that Trinity Health Plan of Michigan has made arrangements for the provision of all covered services to members by the proper types, mix and number of network providers. The standards for measuring the adequacy of access and availability are stipulated in the Trinity Health Plan of Michigan Provider agreement and Trinity Health Plan of Michigan’s Network Practitioner’s Access and Availability Standards.

The access and availability requirements which have been approved by Trinity Health Plan of Michigan’s Quality Management Committee are as follows:

• Telephone coverage service 24 hours a day, seven (7) days a week.
• Member calls returned within 24 hours. This includes attempts made to members by leaving voice mail messages, leaving verbal messages with other relatives, etc.
• Urgent appointments scheduled with the PCP or a network PCP acting on your behalf within three days of the request. Urgent appointments are identified as any convolution of persistent symptoms which are perceived urgent by a prudent layperson or that may endanger members not seen within 48 hours.
• Routine appointments are scheduled by the PCP or a network PCP acting on your behalf within ninety (90) days of request.
• Members with a concern they view as needing medical attention prior to routine appointments, under the assistance of health plan case management, may be requested for access within the 90-day timeframe.
• Covered services are provided in a culturally competent manner to all members including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities.
• Members have timely access to copies of pertinent information from their medical records.
• Compliance with standards is evaluated by reviewing medical records, claims and encounter history, scheduling systems and records, complaints and grievances, and member satisfaction and disenrollment surveys.

Member and Provider Satisfaction

Trinity Health Plan of Michigan monitors members’ perceptions of the quality of care and services received. Member satisfaction is considered an indicator of the success of an organization in providing quality care.

Trinity Health Plan of Michigan assesses member satisfaction using the following sources of information: member complaints and grievances, PCP change requests, and random sampling by CMS through use of standardized disenrollment surveys and member satisfaction surveys. Trinity Health Plan of Michigan may also periodically conduct independent provider and member satisfaction surveys to assess provider access and availability, members’ perception of access to care and services, wait times, referrals, explanations of care, members’ education and members’ participation in the decision-making process to meet their health care goals.

Trinity Health Plan of Michigan also monitors providers’ perceptions of the quality of administrative services provided by Trinity Health Plan of Michigan. Network provider surveys are periodically conducted to evaluate provider satisfaction and identify areas for improvement.