Clinical Strategy & Implementation
What is Clinical Strategy?
Series of activities to improve our members health.
What is SDOH?
Social determinants of health
What is HEDIS?
Healthcare Effectiveness Data and Information Set.
What is the goal of the Clinical Strategy Department?
Develop clinical programs with positive outcomes for our members, providers, and the community.
What are the three focus areas of Health Equity?
Maternal Health, Obesity, BH (Opioids)
How is HEDIS data collected?
Administrative (Claims, lab, RICAIR) Medical Record Review
What is is the first step in building a clinical program?
Identify the Need
What are the top three languages spoken by our members across all three products? (As of 2022)
English, Spanish, and Portuguese
What are the three components of the NCQA Health Plan Rating?
prevention and equity - experience - treatment
What are the levers we have to influence Health outcomes
CM, UM, Providers, Benifits, CBO
What are the top three cities that our members live in (as of 2022)?
Providence 30% Pawtucket 11% Woonsocket 7%
What is the continuous quality improvement methodology we use?
Plan Do Study Act
What are the four program evaluation measures?
Cost Quality Experience Equity
What are the top three chronic conditons identified for our members?
Hypertension depression obesity
What is member/provider disatisfaction with Neighborhood, its benefits or processes or its provider network?
Complaints/Grievances