Provider Manual
Section 5: Case
Management / Reporting Responsibilities
Table of Contents
5.1 Case Management Definition, Objectives, Responsibilities
(Including Health Assessment and Screening)
5.2 Plan Utilization Management Program
5.3 Quality Management Plan / Quality Assurance and Improvement
5.4 Coordination of Care Policies
5.5 Long Term Care, Discharge Planning
5.6 Emergency Services Notification
5.7 Records and Reporting Responsibilities
5.8 Member Delete Procedure
5.9 Appointment No-Show Follow-Up Procedures
5.10 Administrative Member Request
Attachment A - Adult Preventive Care and Childhood
Preventive Care
Attachment B - Quality Management Plan / Quality
Assurance and Improvement
5.1 Case
Management Definition, Objectives, Responsibilities
(Including Health Assessment and Screening)
top
5.1.a Definition of Case Management
The California Department of Health Care Services defines
case management as “Guiding the course of resolution of a personal medical
problem (including the ‘problem’ of the need for health education, screening or
preventive services) so that the recipient is brought together with the most
appropriate provider at the most appropriate times, in the most appropriate
setting.”
Five requirements are necessary for the case management
system to function. These are as
follows:
Ř
Case Managed Members are required to select a
Primary Care Physician (PCP), or to be assigned to a Primary Care Physician.
Ř
Primary Care and Referral Physicians are
required to contract with the Alliance for
provision of services at rates established by the Alliance and by the Department of Health
Services Medi-Cal fee-for-service program.
Ř
Through prior authorization, Primary Care
Physicians will direct Member referral to all services except Emergency,
Limited Allied Services (Medi-Cal line of business only), OB-GYN, and certain
family planning services as defined in the Agreement.
Ř
To facilitate accessibility of care to Members
of the Alliance, individual and group practice
Primary Care Physicians, in private and public settings, will be geographically
located throughout Santa Cruz and Monterey Counties.
Ř
Providers serving Alliance Medi-Cal members must
have a current Medi-Cal provider number.
5.1.b Objectives
The objectives of physician case
management of Member medical care are as follows:
Ř
To foster continuity of care and longitudinal
Provider/Member relationships for Members in Santa Cruz
and Monterey Counties.
Ř
To coordinate the care of members in order to
achieve satisfactory care results.
Ř
To contribute to the reduction of the use of
hospital emergency rooms as a source of non-emergency, first-contact and urgent
medicine by Members.
Ř
To reduce unnecessary self-referral to specialty
providers by Members.
Ř
To discourage medically inappropriate use of
pharmacy and drug benefits by Members.
Ř
To facilitate Member understanding and use of
disease prevention practices and early diagnostic services.
Ř
To provide a structure for Physicians to manage
services to Members by means of the following:
1. Selection
of Referral Physicians for quality of care, and adherence to the case
management system and to cost effective delivery of services.
2. Measurement
of individual and group Primary Care Physician performance on the basis of
quality of care data.
Ř
To allow the movement of Members from one
Primary Care Physician to another as necessary and as set forth in Section 3 of
the Agreement “Physician/Member Relationship.”
5.1.c Primary
Care Physician Responsibilities
The responsibilities of Primary Care Physicians are as
follows:
A.
As specified in the Agreement, to provide the specified
scope of Primary Care Physician Services to Linked Members who have the physician
as their Primary Care Physician.
B.
To authorize all Medically Necessary non-emergency
Hospital and Referral Physician Services for each Case Managed Member, and to
arrange for those services to be delivered by Hospitals and Providers who
contract with the Alliance.
C.
To coordinate and direct appropriate care for Members
by means of initial diagnosis and treatment, obtaining second opinions as
necessary, consultation with Referral Physicians and follow-up of care to
assess the results of the primary care, medication regimen and special
treatment within the framework of integrated, continuous care.
D.
To record legibly and fully Member visits, efforts to
contact members, treatment, and consultation reports in the medical record.
E.
To facilitate and ensure member quality of care by
establishing procedures to contact Members when they miss appointments,
requiring rescheduling for additional visits, or confirming referrals to a
Referral Physician for care.
F.
To maintain Member medical records for Members
consistent with standard medical practice and to make Member medical records
available upon request for audit/review by the staff of the Alliance, the
California Department of Health Care Services, the Department of Managed Health
Care and the U.S. Department of Health and Human Services. A request of a member’s medical record from a
provider by the Alliance
staff, does not require a separate “release of medical record” signed
permit. The record is to be submitted
without a fee.
G.
To participate in and accept the Alliance’s continuing peer review of case
managed and referred medical services.
H.
To use as appropriate the appeal procedures for
Providers as established by the Alliance.
I.
To preserve the dignity of the Member.
J.
To coordinate Member discharge planning and referral to
long term care with Alliance
staff.
K.
To provide Primary Care Physician Services, which
include, but are not limited to the following health assessment and health
screening services.
1. An
initial health assessment for all of the PCP’s Linked Members scheduled
within one hundred and twenty (120) days following enrollment, unless PCP
determined that a Linked Member’s medical record is sufficiently current to
allow for an assessment of such Member’s health status. At a minimum, an initial health assessment
shall include a medical history, weight and height data, blood pressure,
preventive health screening set forth below, discussion of appropriate
preventive measures, and arranging for future follow-up appointments as
indicated. Screening using the Staying
Healthy Assessment Tool is included in the 120 day health assessment.
2. Preventive
health care using nationally recognized criteria. Please refer to adult and pediatric standards
of care in Attachment A following this section.
3. PCP shall ensure that each of PCP’s pregnant
Linked members is assessed to determine the medical need for
Comprehensive Perinatal Services Program (CPSP) services and shall provide or
arrange for the provision of such needed services.
By providing or
arranging for such services, PCP shall ensure the following:
a. That
a comprehensive initial risk assessment and obstetrical record shall be
completed on all of PCP’s pregnant Linked members at the initiation of
pregnancy related services.
b. Evaluation
of such Member’s risk status shall be performed and recorded at each trimester
and at the postpartum visit. All
identified risk conditions shall be followed up by interventions designed to
ameliorate or remedy the condition or problem.
c. When
medically appropriate and as specified in Alliance
policies, PCP shall refer their high-risk PCP’s Linked Members to specialists,
refer Members for genetic screening, and refer Members for admission to
appropriate Hospitals for delivery.
L. To provide Primary Care Physician
Services which include, but are not limited to diagnosis and treatment of PCP’s
Linked Members’ medical conditions which are Covered Services and which are
identified through CHDP assessments.
Such diagnosis and treatment shall be initiated within sixty (60) days
of the CHDP assessment.
M. Contractor may at any time seek
consultation with Plan’s Medical Director on any matter concerning the
treatment of a Member.
5.2 Plan Utilization
Management Program top
Policy Objective:
Provide an overview of the
Central Coast Alliance for Health Utilization Management Program. All Alliance
utilization management policies are included in this manual on compact disc,
located in the binder pocket of this manual.
5.2.1 Purpose
Central
Coast Alliance for Health’s Utilization Management
(UM) Program oversees the delivery of health care services rendered to its
member population. The program is
designed to ensure that utilization issues are identified, documented, and reviewed
and that appropriate improvement plans are initiated to address utilization
problems in a consistent and timely manner.
The Program implements measures to monitor the health care services
delivered to members, identify issues which impact service and quality, improve
health care outcomes, and resolve problems and recommend action plans. The UM Program will:
A. Ensure
that medical and surgical services provided to Alliance members are medically necessary.
B. Provide
a mechanism to address access and timeliness of care.
C. Initiate
documentation to support investigation of potential quality of care issues.
D. Identify
and resolve problems which result in excessive utilization of resources and
inefficient delivery of health care services.
E. Assess
the effects of cost containment activities on the quality of care delivered.
5.2.2 Goals and Objectives
A. Facilitate
appropriate allocation of resources through systematic monitoring and
evaluation of the appropriateness, quality and cost effectiveness of medical,
surgical and mental health care services.
B. Improve
the quality of patient care through identification and communication of
potential quality issues to the Quality Management Committee for action and
resolution.
C. Identify
and take appropriate action where over-utilization and under-utilization are
identified through prospective, concurrent and retrospective review, profiling
of services and the medical review of claims.
5.2.3 Scope
The Utilization
Management Program is comprehensive, systematic and ongoing. It includes all aspects of health care,
encompassing all services and practitioners who have direct impact on patient
care. It includes reviews of health care
services in the inpatient, outpatient, skilled nursing, and pharmacy settings.
5.2.4 Functions
A. Review
of patient care including prospective, concurrent and retrospective medical
record review.
B. Provide
objective assessment of health care providers, identifying potential problems
relating to the quality of care, safety and resource utilization.
C. Profile
services to determine standard norms and identify aberrant deviation from the
standard.
D. Monitor
and investigate potential under- and over-utilization.
E. Investigate
timeliness of service, lack of access and duplication of services.
F. Review
providers through a peer review mechanism.
5.2.5 Authority and Responsibility
Central Coast Alliance for
Health’s Medical Director and Associate Medical Director have the authority and
responsibility to ensure that an effective UM Program is established, supported
and maintained. The Medical Director or
Associate Medical Director are the only individuals who
may deny service authorization requests.
Authorization decisions are based upon nationally recognized standards
including:
·
Milliman Care Guidelines
·
United
States Preventive Services Task Force (USPSTF)
·
State of
California Department of Health Services (DHS) and
·
Nationally
recognized standards of practice from organizations such as:
Ř
American
Academy of Family Physicians (AAFP)
Ř
American
College of Obstetricians and Gynecologist (ACOG)
Ř
American
College of Physicians (ACP)
Ř
American College of Radiology (ACR)
Ř
American
College of Surgeons (ACS)
Ř
American
Diabetes Association (ADA)
Ř
American
Gastrointestinal Association (AGA)
Ř
American
Medical Association (AMA)
Ř
American
Urological Association (AUA)
Ř
Centers
for Disease Control (CDC)
Ř
National
Cancer Institute (NCI)
5.2.6 Utilization Management Process
A. Identification of Utilization Issues
will be accomplished through various sources including, but not limited to:
1. Pre-authorization. Some non-emergency hospital admissions
require pre-admission certification.
Admission certification may be obtained within 180 days prior to
admission or on the next working day for medical/surgical inpatient emergency
admissions. Authorization must be
obtained for some outpatient surgery select outpatient diagnostic/therapeutic
services. Please refer to the Provider
Section of the Alliance
website to determine if a procedure requires authorization (www.ccah-alliance.org). You will also find a complete listing of
authorization and coordination of care policies on the website.
2. Admission, concurrent and retroactive reviews
3. Case management activities and discharge
planning
4. Individual case review, in which individual
cases are assessed for medical necessity, level of care, appropriateness of
site and duration, benefit determination and delays in the provision of health
care services. Individual review will be
performed prospectively, concurrently and
retrospectively.
B. Action Plan
Any quality issue
identified as requiring correction shall require an action plan. An action plan may include, but is not
limited to: Provider education, member
education, staff development, administrative changes, provider contract
changes, and alteration of provider privileges.
The Peer Review and Credentialing Committee shall review issues to
determine if standards of care are being met.
Improvement plans will be developed and disseminated from these review
determinations and re-evaluations conducted to measure change.
5.2.7 Review Activities
A. Prospective Review
Prospective
review allows appropriate benefit determination, the evaluation of proposed
treatment, determination of medical necessity and level of care
assessment. Requests for services will
be made by mail or fax to the Alliance Health Services Department for prior
authorization approval. Authorization
for elective services will be accepted up to 6 months prior to the service
date, depending upon the type of service.
B. Concurrent Review
Concurrent review is the process of reviewing health
care services at the time they are being rendered to ensure the medical
necessity, appropriate level and appropriate duration of care, and to evaluate
the efficiency of treatment/services rendered.
C. Discharge Planning
Discharge planning is initiated to facilitate the
transition of beneficiaries to the next phase of care through coordination with
a multi-disciplinary team. The functions
of discharge planning are to identify discharge planning needs early in the hospital
stay, coordinate discharge plans with a multi-disciplinary team, and assist in
obtaining the necessary authorization for the post discharge services
needed. The Alliance staff will work with the hospital’s
discharge planning staff, as needed, in member discharge planning.
D. Primary Care
Provider Case Management
The Primary Care Provider shall
initiate Case Management to ensure appropriate utilization and timely delivery
of quality health care for the member while monitoring services to control
cost. The Alliance Health Services staff
is available to assist Primary Care Providers in locating resources and
assisting with challenging situations.
1. Functions: The functions of Case Management are to
identify appropriate candidates based on catastrophic diagnosis, high cost,
etc., develop and implement cost-effective care plans for those members
identified to be appropriate candidates, serve as an advocate to coordinate and
optimally utilize health care and community related services for the member,
inform health care professionals, members and their families of available
community resources, assist in the coordination of care with health care
disciplines, facilitate the timely delivery of health care services in the most
cost-effective settings, and identify potential quality of care issues as well
as potential fraudulent or abusive practices.
2. Administrative members are those members
whose eligibility status, either permanent or temporary, is not appropriate for
inclusion in the Alliance
capitated case management system. In
some of these cases, the Medical Director will designate an attending physician
(non-capitated case manager) to provide services/care for administrative
members.
3. Administrative members do not require PCP
authorization to access specialty care.
E. Retrospective Review
Retrospective review is the review of medical
necessity, appropriateness and quality of care after the care has been rendered
and after the patient has been discharged from the health care setting.
5.3 Quality Management Plan
/ Quality Assurance and Improvement top
The Central Coast Alliance for Health (the Alliance) is a public agency established to
enter into contracts with:
4 The Department of Health Services (DHS)
to serve the Medi-Cal enrollees in Santa Cruz
and Monterey Counties, and
4 The California Managed Risk Medical
Insurance Board (MRMIB) to serve enrollees in the Healthy Families Program.
4 The
Department of Managed Health Care for oversight of all other licensed lines of
business.
The Alliance is dedicated to improving the health
and well being of the residents of our region. Our mission is to:
4 Ensure appropriate access to health care
services for local members enrolled in the Medi-Cal, Healthy Families, Healthy
Kids and Alliance Care IHSS programs.
4 Improve medical outcomes, minimize
unnecessary suffering and cost, and improve and promote self-care and wellness.
4 Increase provider satisfaction and
participation in serving members needs.
The Alliance
has established a comprehensive Quality Management Program (QMP) for all of its
quality assurance and quality improvement activities. The Health Services Policy Quality
Management Program (QMP) provides a more detailed description of the QMP,
including:
4 Program Oversight and Implementation
4 Reviews and Approvals
4 QMP Goals and Objectives
4 Scope of Care
4 Systematic Processes
4 Quality Improvement (QI) Staff Role
Definitions
The Quality Improvement Plan outlines activities for the year
and provides a key element in implementing our overall Quality Management Plan
to both assure and improve quality.
Please see Attachment B of this section for an 2007 Quality
Improvement Plan.
5.4 Coordination of Care
Policies top
5.4.1 Mental Health and California Children’s
Services
A Memorandum of
Understanding (MOU) is an agreement between the Alliance and a division of the
County Health Services Agency that delineates how the two entities will
coordinate provision of covered services (for both Medi-Cal and Healthy
Families recipients) and/or public health services, as appropriate, and which
delineates the roles and responsibilities of each agency related to specific
public health services.
Public Health Services with MOUs
The Alliance maintains MOUs with the following
divisions of the Santa Cruz County Health Services Agency and Monterey County
Health Services Department.
A. County Mental Health
B. Women, Infants and Children (WIC) Program
C. Maternal, Child and Adolescent Health
Division, Comprehensive Perinatal Services Program (CPSP)
D. California Children’s Services (CCS)
E. Family Planning Division
F. Immunization (IZ) Services Division
G. Public Health Tuberculosis (TB) Division
H. Sexually Transmitted Disease (STD) Services
Division
I. HIV Testing Program
J. Child Health and Disability Prevention
Program
5.4.2
Members with Developmental Disabilities
In accordance with MMCD Letter 97-03, the health plan
provides medically appropriate services to members who have or are suspected of
having a developmental disability and members who are at high risk of parenting
a child with a developmental disability.
The plan also collaborates with the San Andreas Regional Center and
Local Education Agencies for delivery of services to members with developmental
disabilities.
The Alliance
provides members identified or suspected of having developmental disabilities
with all medically necessary and appropriate developmental screenings, primary
preventive care, diagnostic and treatment.
The plan has the authority to determine medical necessity for covered
services. Members requiring medically
necessary but “carved out” services are referred to the appropriately funded
agency, such as the Local Education Agencies (LEA) and the San Andreas Regional
Center (SARC).
Members with
developmental disabilities are linked to Primary Care Providers (PCP). PCPs provide members with all appropriate
preventive services and care including necessary EPSDT services. Preventive care is provided per the current
guidelines of American
Academy of Pediatrics and
the United States Preventive Services Task Force for Adults.
·
The PCP provides or arranges for medically
necessary care to correct or ameliorate developmental disabilities.
·
The PCP provides for all medically necessary
therapies and items of durable medical equipment within the scope of practice;
for those necessary services beyond the scope of practice, referrals are made
and coordinated with the appropriately funding agency.
·
The PCP or health plan refers members to SARC
who are in need of non-medical, home and community based services such as:
o
training in skills for daily living
o
acquisition of skills and behavior
o
family support
o
day habilitation
o
respite care
o
residential care or assisted living arrangements
·
Children over the age of 36 months and adults
with or suspected of having developmental disabilities are referred to SARC
when desired by the member or his/her guardian if the member is a minor.
·
Referrals include:
o reason
for referral
o complete
medical history including developmental screens
o results
of developmental assessments and other diagnostic tests
·
PCPs refer members for medically necessary
services to specialists for complex medical problems beyond the scope of
practice of the PCP. Such referrals
include:
o
mental health providers
o
state approved prenatal diagnostic services
Case Management
·
Alliance
case management support staff coordinate care with the PCP via:
o
consultation when developing the member’s SARC
service plan
o
provision of medical documentation and reports
as requested by the SARC case manager
o
follow-up of care between PCP, specialists and
SARC
o
The Alliance
Childrens Case Manager and Medical Social Worker are the designated liaisons
with the Regional
Center.
Dispute
Resolution
·
If there is disagreement as to which agency is
responsible for provision of services, and the Liaisons are unable to resolve
the dispute, the matter is elevated to the Alliance Medical Director for review
and discussion with the Regional
Center leadership.
5.5 Long Term Care,
Discharge Planning top
When a provider is discharging a member to a Long Term Care
(LTC) facility the Discharge Planner should:
Verify member’s Alliance
eligibility.
Discharge member who is a Medi-Cal recipient to a facility
that has a Medi-Cal provider number and has a State Skilled Nursing Facility
license. For other lines of business,
providers should check the Member Handbook/Evidence of Coverage for benefit
scope and limitations. The Member
Handbook/Evidence of Coverage may be found on our website at www.ccah-alliance.org on the “Members
Home Page” under the specific line of business.
The admitting LTC needs to notify the Alliance by submitting the MC 171 (LTC
Admission and Discharge Notification Form).
Depending on the date of notification, one of the following will occur:
1.
If the Alliance
receives notification in the first 10 days of the month, the change to
administrative member status will be made effective for that same month
retroactive to the first of the month.
2.
If the Alliance
receives notification after the 10th, the change will be effective
the 1st of the following month.
(This is because the allocation of capitation payments to the PCPs
occurs in the beginning of the month.)
When a member is admitted and discharged from long term
care, the facility will send the Alliance
the MC 171 form. Member Services
Department Staff will re-link the member to a Primary Care Provider, who will
assist the member in selecting or continuing care with a PCP.
LTC facilities are state mandated to inform the Alliance of admissions to
a nursing facility on an MC-171 form and through a LTC Treatment Authorization
Request (TAR).
Discharges from Mental Health Units to State licensed
Skilled Nursing Facilities require prior authorization. Discharges to IMDs or locked facilities will
need authorization from the member’s county Mental Health Agency if the member
is a Medi-Cal recipient. For all other
lines of business, the Member Handbook/Evidence of Coverage should be checked
for scope of benefit and Mental Health Provider. The Member Handbook/Evidence of Coverage may
be found on our website at www.ccah-alliance.org
on the “Members Home Page” under the specific line of business.
5.6 Emergency Service
Notification top
A.
Emergency Services are defined in the Agreement as those
health care services required for the alleviation of severe pain or those
services required to diagnose or treat unforeseen medical conditions which if
not immediately diagnosed and treated could lead to disability or death.
B.
Emergency services rendered by Providers do not require
prior authorization.
C.
Hospital emergency admissions and emergency room
outpatient services require that:
1. When a Member presents an
emergency condition to an emergency room for outpatient services, the Attending
Physician/Hospital should:
a. Verify Member eligibility and Primary Care
Physician or Administrative Member status by telephoning Alliance Eligibility
Verification System or Eligibility Clerk.
b. Notify the Primary Care Physician within
twenty-for (24) hours of service.
c. Forward a copy of the emergency room report
or face sheet to the Primary Care Physician within twenty-four (24) hours of
rendering services.
d. Forward a copy of the emergency room report
or face sheet documenting Primary Care Physician authorization and emergency
nature of the services, to the Alliance
along with the standard hospital outpatient claim form.
2. When a Member presents an emergency
condition at a Hospital or other Provider facility and is admitted for
inpatient services, the Attending Physician/Hospital shall notify the Primary
Care Physician as soon as possible.
5.7 Reports and Reporting Responsibilities top
Maintenance of Records
The Alliance requires that
you maintain records regarding services that you provide to Alliance members. Records should be maintained in accordance
with applicable state and federal privacy laws.
The Alliance
has the right to review your records for claims authorization, service
authorization and when we are performing medical audits.
Records should be maintained in a manner consistent with
professional practices and prevailing community standards.
You are to maintain
records for the shorter of seven (7) years after termination of your agreement
with the Alliance
and, the period of time required by state and federal law and Membership
Contracts, including the period required by the Knox Keene Act and Regulations,
and by the Medicare and Medi-Cal programs.
Access To and Copies of Records
Health Services staff from Central Coast Alliance for Health
may request records from your office for one of our covered members for a
number of reasons:
·
Quality improvement studies mandated by the
State of California
(such as HEDIS)
·
Authorization requests
·
Claims payments issues
·
Assistance with case coordination
·
Determine “Administrative Membership” requests
·
Possible CCS referrals
·
Follow-up to a member complaint
For the above purposes, the Alliance may obtain medical records for our
covered members without a signed release of information pursuant to the
following legal authority: Title 22,
Section 51009, adopted from the Welfare and Institutions Code Section 14100.2.
Your contract indicates that the Alliance, government officials and
accrediting organization shall have access to your records. The first copy of records provided to the Alliance is to be provided
at no cost. Each copy provided
thereafter will be reimbursed at five cents (.05) per page.
In addition, you are contractually required to provide
access to and copies of records to various government officials as stated in
your agreement. Such information shall
be available for inspection, examination and copying at all reasonable times at
your office or at some other mutually agreeable location in California.
Copies of such information shall be provided to Government Officials
promptly upon request. The disclosure
requirement includes, but is not limited to, the provision of information up
request by DHS relating to any pending litigation.
Copies of Clinical Information
When you see a member who is not linked to your practice you
are required to forward a copy of the initial consultation report and summary
of patient care to the Member’s Primary Care Physician, at no cost. You may do this by mail or by fax.
Reporting Encounter Data
Encounter
Data are detailed data about individual services
provided by a capitated managed care entity.
The level of detail about each service reported is similar to that of a standard
claim form. Encounter data are also sometimes referred to as "shadow
claims".
ü
Capitated Providers
Capitated providers are required by the Alliance to submit claims for all of their
services, even though they are “pre-paid” by capitation. Claims that have been pre-paid via capitation
are considered “encounter data”, in that the claim describes the details of
patient encounters with the PCP.
The Alliance
requires encounter data submission at least once a month. This data is critical for disease management
programs and HEDIS studies. Most
importantly, this data is used by the State to set future plan revenue, which
has a direct impact on our payments to providers.
PCPs may transmit encounter data via paper or electronically using the
HIPAA compliant, Ansi 837 format. If you
would like to send this information electronically, please contact our EDI
Support Unit at 831-430-5650.
The 837 HIPAA compliant implementation guides are available at the
following website:
http://www.wpc-edi.com/hipaa/HIPAA_40.asp
Confidentiality of Information
The names of Members receiving public social services are
confidential and are to be protected from unauthorized disclosure. This includes all information, records and
data collected and maintained for the operation of the Agreement.
Alliance
contracted providers are not to use any such information for any purpose other
than carrying out the terms of their agreement.
In compliance with the HIPAA regulations, Members are entitled to an
accounting of any disclosure of information.
5.8 Member Delete Procedure top
Please review the following Alliance guidelines prior to submitting your Request
For Deletion of Patient From Case Management List form:
5.8.1 Make Sure You Have An Appropriate Reason To Request A Deletion
Appropriate reasons to delete a patient:
The most common
problems that lead a physician to need to delete a patient from Case Management
are listed below:
a.) Failure to keep scheduled
appointments. Requires:
1. Three
failures in a twelve month period, specify dates.
2. Good
faith efforts by office to contact and remind the patient of appointment(s).
3. Documentation
of such efforts, either in patient chart or written office procedures.
4. Narrative
description of other factors, if appropriate.
b.) Repeated emergency room use contrary to
PCP’s instruction.
c.) Patient circumventing case management.
d.) Unreasonable demands for referrals (not
including second opinion)
e.) Excessive requests for non-medically
necessary medications/narcotics
f.) Abusive or disruptive behavior
g.) Unable to establish a satisfactory
doctor/patient relationship
Inappropriate Reason to Delete a Patient
Physicians cannot
delete patients simply because they are very sick and have a diagnosed
condition which would be difficult to manage or would adversely affect the PCP
risk pools. To allow such shifting of
patients is neither good medicine nor in the interests of any participating
physician. It also defeats the goal of
the Alliance Plan to spread actuarial risk across all PCPs and provide
continuity of care to Alliance
members.
5.8.2 Filling out the Delete Request Form
A Deletion Request Form must be completed for each member you are deleting
(deleting one person from a family does not automatically delete the entire
family). The Deletion Request Form is
designed to allow a narrative description of the events leading to your request. Be sure to give the specific information (e.g., dates of missed appointments or an
explanation of a patient’s abusive behavior) as well as your efforts to correct
the problem with the patient. Your
request may be delayed or denied without specific information and/or
documentation about the circumstances which led to the request.
In Section 7 - Forms, of this manual, you will find a copy
of the Deletion Request Procedure and forms to be used when requesting the
deletion of an Alliance Member from your Case Management List.
5.8.3 Where to Send the Delete Request Form
Facilitation of the
Delete Request Form is the responsibility of the Provider Services Department
at the Alliance. Please send your Delete Requests to:
For Santa Cruz County
Provider Services Department
Central
Coast Alliance for Health
1600 Green Hills Road, Suite 101
Scotts Valley, CA 95066
or FAX to Provider Services at (831)
430-5857
For Monterey County
Provider Services Department
Central
Coast Alliance for Health
1000 S. Main St., Suite 313
Salinas, CA 93901
or FAX to Provider Services at (831)
755-8226
5.8.4 Effective Date of Deletion
If your request is approved, typically the effective date of the member deletion is
the first day of the month following the date your request is approved and
processed by the Alliance. However, the Alliance may determine a later effective date
to allow adequate time for internal processing and for contacting the member so
that he/she may select another Primary Care Provider:
5.8.5 Processing of your Request
Processing of your
Delete Request involves the following basic steps at the Alliance:
a. Review of Request Form for completeness,
accuracy, and appropriate details.
b. Contact the member to obtain their version
of the events.
c. Associate Medical Director review and
decision to approve, defer or deny the Request.
d. Associate Medical Director generates
written notification to the PCP.
e. Member Services Representative notifies
the member of the deletion (if approved).
5.8.6 What To Do While You’re Waiting For The
Deletion To Become Effective
The member will remain
linked to your practice until the effective date indicated in the letter you
receive from Provider Services. Until
that date, you are required to ensure access to care either by providing it
yourself or referring the member out to another provider via the Referral
Authorization Form (RAF). In addition,
you are responsible for authorizing any specialty care services that the member
may require until the effective date of the delete.
Important Note: The Alliance
is accountable to State and Federal regulatory agencies to ensure that
physicians do not terminate care to patients inappropriately. Alliance
members have the right to file a formal complaint or grievance if they perceive
they were treated unfairly.
5.9 Appointment No-Show Follow-Up Procedures top
The purpose of the
form, found in Section 7 of this Provider Manual, is to provide a mechanism for
physicians to notify the Alliance
of missed appointments in an effort to preserve the physician/patient
relationship; assist physicians with patient compliance and empower members to
be responsible and to participate in their own health care.
When an Alliance member
misses an appointment with your office, without calling to cancel or
reschedule, complete the form and forward it to the Alliance by fax or mail to:
For Santa Cruz County
Provider Services Department
Central
Coast Alliance for Health
1600 Green Hills Road, Suite 101
Scotts Valley, CA 95066
or FAX to Provider Services at (831)
430-5857
For Monterey County
Provider Services Department
Central
Coast Alliance for Health
1000 S. Main St., Suite 313
Salinas, CA 93901
or FAX to Provider Services at (831)
755-8226
The Alliance Member Services staff will attempt to contact
the patient and educate them about the importance of keeping their scheduled
physician appointments.
The Alliance
will document their efforts on the form and return it to your office to file in
the patient’s chart.
Important Note: This procedure is intended to be used in
conjunction with, not in place of, your current office policy for missed
appointments. The Alliance contract requires that the Primary
Care Physician establish procedures to contact members when they miss
appointments which require rescheduling.
In Section 7 -
Forms, of this manual, you will find a copy of the form to be used when
reporting that an Alliance Member from your Case Management List has missed an
appointment.
5.10 Administrative Member Request top
The Alliance assigns
Administrative Member status to Medi-Cal members whose service needs are
such that inclusion in the Alliance
capitated case management system would be inappropriate. Assignments to administrative member status
may be based on either the members’ medical condition or administrative
eligibility status. To maximize the
patient-provider relationship and to coordinate care, administrative members
are encouraged to select and identify a Primary Care Provider (PCP). Services for administrative members will be
paid on a fee-for-service basis based upon prevailing Medi-Cal rates.
I. Administrative Members by
Specified Administrative Service Category
A. New members. Upon Alliance
eligibility, members will have up to thirty (30) days to select a PCP. During that interim period, the member will
not be assigned to any PCP.
B. Monterey and
Santa Cruz County foster children residing out of
county.
C. Share of cost members, for services
received after the member has met their share of cost for the month.
D. Members who receive retroactive Medi-Cal
benefits as assigned by the State.
E. Long term care facility
residents when length of stay is expected to exceed thirty (30) consecutive
days.
F. Members that have
permanently moved of county and still have Santa Cruz
or Monterey County benefits.
G. Newborns, (until the
newborn is assigned to a PCP) - usually 30 – 60 days - as
newly eligible.
II. Administrative
Members by Specified Clinical Condition
Those members whose clinical condition as listed below and
meets the specific criteria. These
members are assigned administrative member status by the Alliance’s Medical Director.
A. HIV/AIDS (Human Immunodeficiency
Virus/Acquired Immune Deficiency Syndrome): When a member has a positive HIV serological
test and if either the member or his or her physician request administrative
member status. Administrative member
status will be granted. An AIDS
qualifying diagnosis is no longer required as a criteria effective July 1,
1997.
B. ESRD (End Stage Renal Disease): A patient who meets the Medicare definition
for ESRD may be considered for administrative member status. To be eligible for consideration for this
category, members must need either hemodialysis or peritoneal dialysis to
maintain life.
C. Major Organ Transplants: Patients who have received a major organ
transplant within the past year or who have been evaluated by an appropriate
specialist physician, and a transplant is recommended or approved, can be
considered for administrative member status.
The transplant provider must submit a letter verifying that the member
is eligible for a transplant including a statement of medical necessity. The member will remain in this category for
one year after the transplant, after which time ongoing assignment to
administrative case managed status will be considered as a continuity of care
issue.
D. Hospice: A patient who elects to participate in a
hospice program can be considered for administrative member status. The member will need to have signed the
hospice election form and will continue in this category as long as their care
is provided by a hospice program.
III. Other
Administrative Member Categories
A. CCS (California
Children Services): Members
approved for CCS benefits by the Santa Cruz or Monterey County CCS
office will be classified as administrative members. This category may be time limited and is
reviewed periodically.
B. Continuity of Care: Members with complex medical conditions who
require out-of-plan services to maintain continuity of care.
1. When a provider or a member requests
conversion to administrative member status to maintain continuity of care, the
decision of the Medical Director will be based upon the following factors:
a. Whether
in-plan PCPs are capable and willing to provide primary care services to the
member.
b. Whether
comprehensive clinical care (primary and specialty care) could be managed by a
single out-of-plan physician or group.
c. Whether
the patient has medical care-in-progress that if disrupted, would be
detrimental to the health of the patient.
d. The
presence of extenuating circumstances which makes care by an out-of-plan
provider more appropriate to maintaining the health of the patient.
2. Administrative members may be re-linked to a
Primary Care Provider if the circumstances warranting the administrative member
status no longer exist.
3. Members or their physicians may request
consideration for administrative member status for continuity of care. Member request will be processed through
Member Services Department Staff, and reviewed by the Health Services
Department Staff. The Health Service
Department Staff will contact the providers as necessary to obtain medical
documentation. Each case will be
reviewed by the Medical Director or Associate Medical Director.
4. The Health Services Staff will notify the
provider and the member of the decision of approval or denial to administrative
member status.
IV. Plan
Responsibility
A. The Health Services Department will
encourage the member with administrative member status to access care within
the Alliance
network.
B. The member will receive a letter with their
new ID card from the Member Services Department. The Member ID Card will reflect the Alliance as PCP.
C. Cases are
reviewed to determine the need for continued administrative member status as
follows:
1. California Children’s Services (CCS) when
case is closed by CCS.
2. LTC when the Alliance receives notification of discharge
from LTC facility.
3. Transplants on an annual basis.
In Section 7 - Forms, of this manual, you will find a copy
of the form to be used when requesting the Administrative classification of an
Alliance Member from your Case Management List.
I. 2007 Adult Preventive Care Guidelines
The Central Coast Alliance for Health (Alliance) is pleased to provide the 2007 Adult Preventive Care Guidelines to assist you in caring for
your patients. These guidelines are
based on recommendations of the United
States Preventive Services Task Force (USPSTF). Also included for your reference is the
Centers for Disease Control and Prevention (CDC) 2007 Recommended
Adult Immunization Schedule.
Additional Preventive Care Support Available from the Alliance
Outreach: If you have made at least two documented
attempts to bring in a member for care and you would like help with further
follow-up, please fax the following to Alliance
Member Services at (831) 430-5856:
Member’s Name
Either Member’s Alliance ID
# or Social Security #
Member’s Phone Number (if
available)
Alliance Member Service staff will attempt to contact
the member and provide education about the importance of making and keeping
well visit appointments.
Educational
Materials:
a.
Our Health Education web site provides a variety of
information at
b.
http://www.ccah-alliance.org/healthed.htm
c.
Low-literacy patient education materials on many topics
are available at http://www.ccah-alliance.org/healthtips.htm
Preventive Care
References and Resources
If you would like more information regarding Preventive
Care, we recommend the following resources and web sites:
·
USPSTF Recommendations for Preventive Care:
http://www.ahrq.gov/clinic/uspstfix.htmf
·
The Centers for Disease Control and Prevention
(CDC) 2007 Recommended Adult
Immunization Schedule:
http://www.cdc.gov/vaccines/recs/schedules/default.htm#adult
Central Coast Alliance
for Health -- Health Services Policy #2.62:
Adult Preventive Care
2007 CDC Recommended Adult Immunization Schedule
CENTRAL
COAST ALLIANCE
FOR HEALTH
Health Services Policy
|
|
POLICY #:
HS-2.62
|
SUBJECT: Adult
Preventive Care
|
|
Effective Date:
February 1996
|
Approved By: Barbara Flynn, RN
|
|
Review Date: October 2003
|
Reviewed By: Barbara Flynn, RN/ B. Palla M.D.
|
|
Review Date: February 2006
|
Reviewed By: Barbara Flynn, RN/ B. Palla M.D.
|
|
Review Date: February 2007
|
Reviewed By: Julio Porro, MD/ B. Palla M.D.
|
|
Review Date: April 18, 2007
|
Reviewed By: Quality Management Committee
|
I. Policy
Objective:
To establish guidelines for Adult Preventive Care Screening.
To specify and define the Alliance
guidelines for adult health screening and preventive services provided by
primary care physicians, as recommended by:
·
United States Preventive Services Task Force (USPSTF)
·
State of
California Department of Health Services (DHS) and
·
Nationally
recognized standards of practice from organizations such as:
Ř
American
Academy of Family Physicians (AAFP)
Ř
American
College of Obstetricians and Gynecologist (ACOG)
Ř
American
College of Physicians (ACP)
Ř
American College of Radiology (ACR)
Ř
American
College of Surgeons (ACS)
Ř
American
Diabetes Association (ADA)
Ř
American
Gastrointestinal Association (AGA)
Ř
American
Medical Association (AMA)
Ř
American
Urological Association (AUA)
Ř
Centers
for Disease Control (CDC)
Ř
National
Cancer Institute (NCI)
II. Definitions:
1.
These
guidelines address periodic health and behavioral risk screening and preventive
services for asymptomatic adults.
2. Individuals identified as being at high risk for a given condition
may require screening at intervals that are more frequent or performing
additional screening tests specific to the condition. High-risk individuals are
defined as those individuals whose risk behaviors: family history,
socioeconomic status, ethnic background, or lifestyle are associated with a
higher tendency towards a specific disease.
3.
Any
required interventions are considered to be an integral component of primary
care, and consequently, the compliance of each PCP in performing these may be
audited by the Alliance
annually. These required interventions are in bold (see below). All
other interventions are considered recommended and constitute good clinical
care, but not required by the Alliance
and are not considered an audit criteria.
III. Content of Screening Visits:
A.
PCPs
must complete a comprehensive health assessment including a health history,
health behavior risk assessment, and physical examination for each new member
linked to their practice within 120 days of enrollment.
1.
The
member’s health history must include information concerning: current and past
medical conditions and medications; allergies; tobacco, alcohol, and street
drug use; adult immunizations; past hospitalizations and family health history.
2.
The
health behavior risk assessment must include at least those items contained
within the age-specific recommendations of the USPSTF.
3.
The
physical examination should be comprehensive and include determination of
height, weight, blood pressure, dental screening, and other age and
risk-specific interventions.
4.
The
comprehensive health assessment should include documentation of WIC referral
for all WIC eligible members (pregnant, breastfeeding, or postpartum women).
B.
If a
member has not been seen for an initial health assessment visit or for periodic
health screening visits, the PCP should either perform the indicated screening,
behavioral risk assessment, and preventive interventions during episodic
visits, or recommend that the member schedule a visit for the purpose of health
screening.
C.
If a new
member to a PCP’s practice has received health-screening services from another
provider within the past 3 years, medical records should be requested and
transferred to the new PCP.
D.
If the
member is an already established patient of a PCP before becoming a member AND
has had a screening examination within the past 12 months, no initial health
assessment is required.
IV. Documentation:
A. Preventive
services offered and/or performed as well as health education provided either
verbally or in writing must be documented in the member’s medical record. Optimally, this information should be entered
on an age-specific summary sheet, so that completed and still needed services
can be monitored efficiently.
V. Monitoring and Quality Improvement:
A. As part of the ongoing audit of medical
records and state and federally required quality improvement initiatives,
documentation of adult preventive health services is periodically reviewed.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Blood Pressure
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
No studies have
evaluated the optimal intervals for repeated screening. Because of
limitations in the precision of testing, a minimum of 2 years may be needed
to reliably measure a change in bone mineral density; however, longer
intervals may be adequate for repeated screening to identify new cases of
osteoporosis. Yield of repeated screening will be higher in older women,
those with lower BMD at baseline, and those with other risk factors for
fracture.
There
are no data to determine the appropriate age to stop screening and few data
on osteoporosis treatment in women older than 85. Patients who receive a
diagnosis of osteoporosis fall outside the context of screening but may require
additional testing for diagnostic purposes or to monitor response to
treatment.
|
|
II. 2007 Childhood Preventive Care Guidelines
1.
Policy
Objective:
To establish guidelines for Childhood Preventive Care
Screening.
To specify and define the Alliance guidelines for periodic
health screening and preventive health services for members up to 21 years old
provided by primary care providers. The Alliance uses the current American Academy
of Pediatrics (AAP) Recommendations for
Preventive Pediatric Health Care, as well as the current ACIP/AAP
immunization schedule, in formulating plan specific standards and
guidelines. Since all Alliance primary care providers who care for
Medi-Cal children are expected to be enrolled as CHDP providers, all other CHDP
policies related to the provision of pediatric preventive services are
applicable as well.
A.
The following standards and guidelines address periodic
health screening and preventive services for low risk, asymptomatic children
and adolescents. Individuals identified
as being at high risk for a given condition may require screening at intervals
that are more frequent or the performance of additional screening tests
specific to the condition. High-risk
individuals are defined as those individuals whose risk behaviors, family
history, socioeconomic status, ethnic background, or life style is associated
with a higher tendency towards a specific disease.
B.
PCPs who provide periodic health screening to members
under the age of 21 years old must adhere to the periodicity and content of the
current AAP “Periodicity Schedule for Health Assessment Requirements by Age
Groups”, as included in attachment 1.
C.
In addition to the content of the AAP guidelines,
certain CHDP required interventions must be provided as well. At each periodic health-screening visit,
these include:
a. Comprehensive
health and developmental history, including assessment of both physical and
mental health development.
b. Assessment
of nutritional status and screening for obesity.
c. Dental
screening, including inspection of the mouth, teeth, and gums. PCPs must refer
children to a dentist annually, starting at age three.
d. Tobacco
smoking history or exposure:
1. Exposure
to passive (second-hand) smoke.
2. Tobacco
used by patient.
3. Counseled
regarding, or referred, for tobacco use prevention or cessation.
D.
PCPs must endeavor to complete an initial health
assessment within 90 days of assignment to the practice (and within 120 days of
enrollment as an Alliance
member) unless it has been determined by the PCP practice that the member’s
medical records contain complete and current information consistent with the
health assessment criteria stated above.
E.
Immunizations must be provided according to the current
schedule of the Advisory Committee on Immunization Practices (ACIP), AAP, and
the American Academy of Family Physicians (AAFP), as
provided in “Recommended Childhood Immunization Schedule,” attachment 2.
a. When
immunizations are provided at sites other than the PCP’s office, the provider
should notify the PCP’s office of the immunization given and the date.
b. If
this is not possible, the member or parent/guardian of the member must be
advised to provide this information to the PCP at the next visit.
c. PCP
office should be requesting previous medical record(s) to show a complete
history.
F.
Unless the member has received a periodic health
screening (well visit) within the periodicity schedule, in attachment 1, the
member, or the member’s parent/guardian, must be informed at the time of each non-emergency primary care
visit of the availability of well visits
available through the PCP’s practice, or at another site offering well visits .
a. Should
the member not receive periodic health screening services according to the
attached schedule, either:
1. The
voluntary refusal of the member (or the parent/guardian) regarding the use
of well visits should be documented in
the member’s medical record, or:
2. There
should be documentation of an outbound phone call or written communication from
the provider to the member advising of the need to schedule a periodic health
screening appointment.
b. In
the case where a child scheduled for a periodic health screening visit is not
seen as scheduled, the PCP’s staff should contact the member (or
parent/guardian) to reschedule the visit, and document same in the medical
record.
G.
Appointments for preventive services (well visits)
should be scheduled within 6 weeks from the time of the request.
H.
Diagnosis and treatment of any medical conditions
identified through the periodic health screening process, either by the PCP or
through referral to a specialist, must be initiated within 60 days of
identification. Justification for delays
beyond 60 days are to be entered into the member’s medical record.
For Medi-Cal members, a CHDP PM160
form must be completed at each well visit in addition to documentation of the
visit findings in the medical record.
a. For
CHDP clients, a copy of the PM 160 form is to be given to the member or
parent/guardian after completion of the visit. Upon request by the member, or
the parent/guardian of the member, the PCP must provide additional discussion
or consultation regarding the results of the health assessment.
b. Completed
PM-160 forms are to be submitted to the Alliance
within 60 calendar days of the member’s visit.
I.
Parents of children found to have conditions which
could constitute eligibility for the California Children’s Services (CCS)
Program should be so informed. The PCP’s staff should initiate a referral to
the county CCS office, regarding the finding of a
potentially eligible child.
K. Documentation
of Women, Infant and Children Program (WIC) referral or participation must be
made for all eligible children (i.e. children under the age of five years) at
the initial IHA and at subsequent well visits.
L.
Monitoring and Quality Management
a. Reports
of encounter data will be reviewed periodically by the Alliance Quality
Management staff for appropriateness and timeliness of child and adolescent
preventive care services.
b. As
a component of the ongoing audit of medical records in each PCP’s practice,
documentation of children’s preventive services will be reviewed periodically.
2007 Quality
Improvement Plan
1.
Introduction
The Central Coast Alliance for Health (the Alliance)
is the local managed care health plan serving Medi-Cal and Healthy Families
members in Santa Cruz and Monterey
Counties, Healthy Kids in Santa Cruz County,
and In-Home Support Services in Monterey
County.
The Alliance
is dedicated to improving the health and well being of the residents of our
region. Our mission is to:
Ensure
appropriate access to health care services for local members enrolled in the
Medi-Cal, Healthy Families, and Healthy Kids programs
Improve
medical outcomes, minimize unnecessary suffering and cost, and improve and
promote self-care and wellness
Increase
provider satisfaction and participation in serving members needs
The Alliance
has established a comprehensive Quality Management Program (QMP) for all of its
quality assurance and quality improvement activities. The Health Services Policy Quality
Management Program (QMP) provides a more detailed description of the QMP,
including:
Program
Oversight and Implementation
Reviews
and Approvals
QMP
Goals and Objectives
Scope
of Care
Systematic
Processes
Quality
Improvement (QI) Staff Role Definitions
The Quality Improvement Plan (QIP) outlines activities for
the year and provides a key element in implementing our overall QMP to both
assure and improve quality.
1.1
2007 QIP Purpose
The 2007 Quality Improvement Plan (QIP) outlines the
activities intended to assure and improve the quality of care for all Alliance members within the limits of the resources
available to the Alliance
and its participating providers. Additionally, we intend the QIP to meet the
requirements of state and federal agencies and standards, such as the National
Committee for Quality Assurance (NCQA) Health Plan Employer Data and
Information Set (HEDIS®), and Quality Improvement System for
Managed Care (QISMC).
1.2
QIP Scope
We have designed the QIP to provide a structured and
organized activity schedule that outlines the aspects of care we intend to
review throughout the year. Systematic,
comprehensive, and ongoing, the QIP includes a review of important aspects of
the delivery of health care services. It
encompasses all services, physicians, and vendors who have direct or indirect
impact on the medical care of Alliance
members in inpatient, outpatient, skilled nursing, ancillary, care management,
and pharmacy settings. It also includes
development of clinical protocols and standards.
We have set up our data systems to identify and track
different lines of business, namely Healthy Families and Medi-Cal for each
county, Healthy Kids for Santa Cruz County only, and In-Home Support Services for Monterey County only. Although these programs are monitored
separately, we hold them to the same quality standards.
1.3
QIP Goals and Objectives
The QIP objectives parallel the Quality Management Program
(QMP) objectives:
Monitor
and evaluate patient care through prospective, concurrent, and retrospective
reviews of services
Establish
performance standards:
·
Ensure appropriate care is not withheld or
delayed
·
Monitor and evaluate possible over- and
under-utilization of services
·
Establish, maintain, and enforce Confidentiality
and Conflict of Interest policies
Monitor
and assure regulatory compliance with state, federal, and other regulatory
agencies
Evaluate
and improve patient care outcomes
·
Provide member suggestion mechanisms
·
Identify Potential Quality of care Issues (PQIs)
·
Review and investigate PQIs and take corrective
action regarding Verified Quality Issues (VQIs) where appropriate
·
Monitor and evaluate corrective actions
Educate
Evaluate the Quality Management Program
2. Planned Activities for 2007
Continual
Quality Assurance Activities, assuring on-going quality of care
Regulatory
Compliance Activities, measuring the effectiveness of quality of care
Quality
Improvement Projects (QIPs), measuring and improving quality of care
2.1
Continual Quality Assurance Activities
The following activities form much of the regular day-to-day
work within the Health Services Department that assures the on-going quality of
care delivered to Alliance
members.
2.1.1
Physician/Vendor Credentialing/Recredentialing
The Alliance Credentialing/Recredentialing
process meets NCQA standards, including the credentialing of mid-level
practitioners. Recredentialing occurs
every 3 years and includes a site review by a plan Utilization/Onsite Review
Nurse.
Information Management
(Medical Records): Each newly
credentialed and recredentialed Alliance primary
care provider has ten of his/her Alliance
medical records reviewed as part of the facility review and credentialing
process. Depending on the scope of the
physician’s practice, records are reviewed for five adults and five children,
or all ten are adults or children as appropriate. Medical records are reviewed for
documentation, organization and completeness of the medical record in relation
to medical history, current treatment, and preventive measures. Confidentiality of medical records is always
a prime consideration. All medical
records reviewed at the Alliance
or at a provider facility are maintained according to regulations to maintain
strict confidentiality.
The Physician Peer Review/Credentialing
Committee (PRC) presents regular confidential reports (usually quarterly) to
the Board regarding credentialed and recredentialed providers.
2.1.2
120-Day Initial Health Assessments
The Alliance continues to identify new members on
provider eligibility lists and to identify members who need to be scheduled for
a 120-Day Initial Health Assessment. We
have implemented the Individual Behavior Risk Assessment requirement as part of
the initial health assessment and ongoing preventive health visits. Compliance with the 120-Day Initial Health
Assessment requirement is tracked on an annual basis.
2.1.3
Case Management
The Alliance currently uses five different kinds
of case managers:
·
Medical Social Worker
·
Long Term Care Case Manager
·
Children’s Case Manager
·
CCS Liaison
·
Chronic Disease Case Manager
The Alliance tracks and analyzes the volume and
outcomes of case management activities.
The specific indicators to be monitored in 2007 include the following:
·
Volume and types of case management referrals
·
Sources of case management referrals
·
Categorization of referral outcomes
·
Trending of referral status
The Health Services Director and
the Health Programs Manager report these results periodically to the Board.
2.1.4
Health and Disease Management
During 2007, the Alliance Health
Services department will continue to implement components of important health
and disease management programs for members with diabetes and asthma. These
programs will affect all areas of the Alliance
service region, and will be reviewed for access, quality, and outcomes.
Reporting on these activities
occurs as part of the Quality Improvement Project responsibilities.
2.1.5
Risk Management
Wheelchair Timeliness Report: The Alliance Utilization Review Team tracks
the timeliness of all wheelchair purchases and repairs and reports this to the
Board each calendar quarter. The
specific indicators monitored include the following:
2.1.6
Potential Quality Issues and Verified Quality Issues
Potential Quality Issues (PQIs)
are documented on a standardized form.
The Medical Director then reviews the PQI and the accompanying
information to make a determination whether a Verified Quality Issue (VQI) does
in fact exist.
If the PQI is not a quality
issue, it will be logged, closed, and filed.
Closed PQI logs will be monitored annually for trends.
Cases determined to be VQIs by
the Medical Director may be presented to the Physician Peer
Review/Credentialing Committee (PRC) for review. The PRCC will make recommendations for
corrective actions as appropriate. Each
VQI will be assigned a Quality of Care Classification and an Adverse Effect
Rating by the Medical Director to give an indication of the impact of the
problem upon the patient.
Where appropriate, the Medical
Director or PRCC will develop a Corrective Action Plan (CAP) that includes
recommendations, planned follow-up, the time frame for completing the action,
and the person(s) responsible for implementing the plan.
For more information on PQIs,
VQIs, and CAPs, please consult the Health Services Policies and Procedures
Manual sections regarding these areas.
The Medical Director or Quality
Improvement Manager reports status and trends of PQIs/VQIs as a standing agenda
item at QMC meetings.
2.1.7
Education
Clinical Practice Guidelines: The following care guidelines are regularly
reviewed, approved, and distributed to providers:
·
Child Preventive Health
·
Adult Preventive Health
·
Asthma
·
Diabetes
·
Chlamydia
Perinatal Outreach: To promote early prenatal care, the Alliance
sends a letter about health education services to all new female members of
childbearing years, and all members who fill a prenatal vitamin
prescription. The letter urges early
entry into prenatal care for pregnant members and offers information and
support on having a healthy pregnancy, on request. Providers also refer members to other support
services. A Health Programs Coordinator
calls the member, helps with access to appointments and services, and sends
low-literacy health education materials.
Health Programs staff also provide phone follow-up with new mothers to
encourage compliance with the recommended postpartum visit, breastfeeding,
immunization of the newborn, and enrollment of the newborn. The Alliance
offers an incentive gift for mothers who have their postpartum check-up within
21 to 56 days after delivery. The
effectiveness of these activities is measured both through HEDIS®
perinatal measures and regular reports by the Health Programs Manager.
Immunization: In addition to the postpartum phone reminder,
the Alliance
mails immunization reminders to families when infants are 3 and 9 months of
age. Using claims data, the Alliance sends monthly
notices to providers of their members who are overdue at 9 or 18 months of
age. With the help of grant funding for Santa Cruz County members, a Health Programs
Coordinator calls the families whose children are overdue. The effectiveness of these activities is
measured through HEDIS® immunization measures and quarterly reporting.
Adolescent Well-Care: The Alliance
“Teen Tune-Up!” program sends members age 12 to 18 a birthday well-care
reminder and incentive offer. Teens that complete the exam receive two movie
passes as an incentive, and are eligible for a bi-monthly raffle for a mountain
bike. The Alliance also sends providers a monthly list
of teen members who have not had a well-care exam in the last 12 months. In addition to the above activities, a Health
Programs Coordinator provides education and training to the office staff. The
effectiveness of these activities is measured through the HEDIS®
adolescent well-care measure.
Breast and Cervical Cancer
Screening: Twice a year, the Alliance sends a reminder
notice to members who are overdue for mammography or pap smears. Providers also receive a list of their
overdue members. The effectiveness of
these activities is measured through HEDIS® breast and cervical
cancer screening measures.
Chlamydia Action lists: Twice a year, the Alliance sends providers action lists of
their members who may need chlamydia screening.
The effectiveness of these activities is measured through HEDIS®
chlamydia screening measure.
Diabetes and Asthma
Education: The Alliance covers comprehensive self-management
education for diabetes and asthma. The Alliance sends
educational materials to members with diabetes and asthma, encouraging them to
get appropriate medical care, practice
self-care, and attend self-management education. Alliance Health Programs is currently in
discussion with a vendor to find a suitable home diabetes education
program. The Alliance also distributes semi-annual Action
Lists to providers regarding their members with asthma or diabetes, and various
reminders directly to affected members.
The Alliance
began investigating various options to move toward electronic clinical data
sharing with providers for diabetes and chronic illness in 2004-05, and has
implemented semi-annual provider mailings outlining relevant utilization of
members with Asthma and Diabetes. In
2007, an online reporting tool will be rolled out to participating
providers. This online tool will allow
providers to see their practice patterns on demand. The effectiveness of all these activities is
measured through HEDIS® diabetes and asthma measures, and in
tracking and trending the utilization patterns of patients with these
diagnoses.
Other Health Education
Efforts: The Alliance sends an annual flu shot reminder to
high risk members, refers members to smoking cessation services, offers general
health education through the member newsletter and other print materials, and
conducts health outreach through a local farmers’ market and Spanish language
radio. As part of Alliance obesity efforts, up to 50 members at
any given time are sponsored to attend Weight Watchers® weight loss
program. The Alliance collaborates with community partners
on primary prevention activities for diabetes, asthma, obesity, and other
chronic diseases.
Medical Director Meetings: The Alliance Medical Director continues to
attend the statewide meetings to discuss quality improvement initiatives and
activities.
Memoranda of Understanding
(MOUs): The Alliance continues to
work with health departments and local agencies and coalitions on the delivery and
coordination of quality health care to Alliance
members, and ongoing review and education of network providers.
Cultural and Linguistic and
Health Education Group Needs Assessment:
During CY 2001, the Alliance
completed an initial Group Needs Assessment (GNA) report for DHS and
MRMIB. The report included findings and
recommendations for improvement of services in these areas. Another GNA for MediCal was completed in June
of 2006. The next Healthy Families GNA is scheduled to be completed during the
June 2007.
