Quality Improvement Interview: Fallon Community Health Plan

Fallon Community Health Plan has established itself at the top of the charts for the past three years on the Centers for Medicare and Medicaid Services’ Medicare Advantage Star Ratings.  This year, the plan once again received 4.5 stars, an indicator of its commitment to – and success at – providing high quality health care to its members.

We spoke with Beth Foley, senior director of Quality Services at Fallon, about the health plan’s performance, including its strengths, areas of improvement and measures on which it is focusing.

Because of the plan’s history as an integrated staff model, in which preventive medicine is integral to patient care, Fallon has traditionally done very well on preventive and screening measures. A substantial portion of the health plan’s Medicare membership is seen by a provider network with which Fallon has a close working relationship.

It is due in part to this connection, along with a robust electronic medical record, that screening and preventive measures have remained a particular strength of Fallon’s. As Foley says, it is second nature to make sure members are getting their screenings. “That’s what we’re all about.”

Fallon also performed highly on the Care for Older Adults measure of the Star Ratings, pertaining to Medicare Advantage Special Needs Plan (SNP) enrollees (vulnerable populations who include dual-eligibles and those with chronic conditions). Foley attributes the plan’s significant improvement to supplemental data sources, more vigorous outreach to physicians and better documentation of medications and functional status assessments.

Fallon’s quality in this area is particularly significant to their members, as most of its members are in their 80s and 90s.

One of the most valuable aspects to the Star Ratings is the ability to benchmark data and set goals for improvement. There are always areas in which plans can improve, and the quality data facilitates these efforts. Currently, Fallon is focusing on the readmissions measure, which needs to be at 5 percent to receive top marks.

The plan is looking to bring the “navigator model,” used for its SNP NaviCare, into their general Medicare Advantage plan.

NaviCare, as Foley explains, is a highly successful care model that employs a comprehensive care team to look after patients. She expects that this will help to coordinate care, resulting in better medication adherence, better health outcomes and fewer readmissions.

Because of the ability to see how current performance stacks up against prior performance – as well as the ratings of other organizations – Fallon is able to set informed, attainable goals and focus on achieving them.