Setting priorities are critical to creating integrated risk and quality programs


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Embarking on the quest to improve your risk and quality integration may seem daunting, with so many moving parts to consider. The challenge is to know where you’re going and how to get started.

The journey to an effective risk-plus-quality strategy is easier to navigate when you employ best practices to increase provider engagement, create efficient member touch points, and appropriately align funding to improve program efficiency.

Start off by assessing your organizational structure and your strategy. Next, think of the teams within your organization as fellow travelers on this integration journey. If they are typically siloed within the organization, bring them together to discuss their programs that touch members and providers, and how those can be better aligned. Identify opportunities, prioritize areas of focus, and set targeted return on investment. Engage providers and members. Plan to use data, analytics and reporting to inform and sustain performance.

Your path to integrated risk adjustment and quality programs should include five critical checkpoints:

  • Analytics — Collect data to build member and provider profiles and identify opportunities.
  • Targeting — Determine which programs are the best fit for the needs of your specific members and providers.
  • Intervention — Deploy activities that close clinical and coding gaps to improve risk adjustment and quality.
  • Submission — Collect, report and submit data to the Centers for Medicare & Medicaid Services (CMS), and the Department of Health and Human Services.
  • Compliance — Integrate active compliance surveillance and monitoring throughout the entire program.

You may have to consider outside factors in your strategy planning as well, such as ICD-10 implementation. How will it influence your programs? How will required ICD-10 training for providers affect your risk adjustment education and in-office assessment programs?

At the intersection of risk and quality, you’ll find that you’ll need to use all the tools in your toolbox to successfully design an integrated program. Those tools include:

  • Established relationships with members and providers
  • Capability to offer providers useful data the point of care
  • Building and continually resetting strategies and goals
  • Integrated reporting