The Role of Timely Insights in Enhancing Quality of Care and Boosting Star Ratings Performance in 2024

In 2023, CMS revealed Medicare Advantage plan average Star Ratings fell compared to last year, with only 31 plans achieving five stars, compared with 57 the year prior. For many health plans and payers, unnecessary readmissions, poor visibility into quality measures and coding gaps, and limited care coordination all stand in the way of progress.

With the right quality management solution, however, health plans can overcome these challenges and strengthen their provider network’s ability to close gaps in care that contribute to suboptimal Healthcare Effectiveness Data and Information Set (HEDIS) measure performance and Star Ratings.

Time is of the Essence: Moving on From Manual Workflows

Manual workflows used to identify and manage discharged patients are time consuming, making it impossible to get actionable data. By the time information reaches the care teams, it is now old news and no longer relevant to the patient’s current condition and may exceed the time allowed to meet the requirements.

Manual workflows and other ineffective documentation approaches can create additional problems, such as missing documentation in the medical record, a National Committee for Quality Assurance (NCQA) HEDIS audit requirement. Without streamlined reporting for all stakeholders involved across the continuum of care, patients experience a gap in follow-up care required after a patient is discharged from the hospital.

Closing potential gaps in care requires proactive and swift response time to activate internal quality management and network provider teams, which is only available to health plans that have real-time access to data and insights. 

By leveraging PointClickCare’s Quality and Coding Management solution, health plans can gain the upper hand in optimizing quality and performance metrics. With real-time identification of members who have time-sensitive follow-up needs (e.g., follow-up or transitions of care measures), health plans can leverage our vast care collaboration network to detect, identify, and surface when members meet the requirements for a HEDIS measure. They can then act quickly to trigger workflows with care management teams and providers to support rapid care coordination and intervention, regardless of the EHR or IT system they are using. 

Scaling to Meet Health Plans’ 2024 Quality Improvement Goals

PointClickCare helps health plans scale to drive quality improvement across networks, enable real-time collaboration to reduce care and coding gaps, and improve Medicare Advantage plan quality and financial performance. We can help your team:

• Identify members requiring follow-up or transition of care support based on HEDIS requirements
• Deliver real-time notifications to enable care managers and/or downstream network providers to support proactive interventions to close time-sensitive care gaps 
• Send discharge summaries to network providers for identified follow-up care and medication reconciliation 
• Leverage HEDIS specifications to streamline provider performance monitoring and comprehensive reporting

Positive Outcomes as a Result of Quality and Coding Management

Quality Coding and Management helps risk bearing entities reduce costs, influence quality of care, and ultimately improve Medicare Advantage plan performance. The efficacy of PointClickCare tracking and care gap alerts was recently evaluated through close collaboration with a national health plan partner to validate standard criteria against the health plan partner’s claims and authorization data.

Using admission-discharge-transfer (ADT) encounter notifications, PointClickCare accurately identified >70% of time-sensitive HEDIS care gaps in real-time, allowing the health plan to activate their native workflow and network to close the care gap in the required timeframe. With this support, payers can improve their management of quality programs, enhance access to care for beneficiaries, and ensure the program’s sustainability while providing quality healthcare services.

If you’re ready to take on these challenges with the help of PointClickCare and solutions like Quality and Coding Management, watch our recent webinar, The Next Level in Quality: Closing Time-Sensitive Care Gaps, and learn how we can help health plans boost performance in 2024.