Health Care Institutions

Size: px
Start display at page:

Download "Health Care Institutions"

Transcription

1 Chapter 10 Health Care Institutions Slide Show developed by: Richard C. Krejci, Ph.D. Professor of Public Health Columbia College

2 Key Questions What institutions make up the Healthcare System? Observation vs. inpatient What types of inpatient facilities exist in the United States? What types of outpatient facilities exist in the United States?

3 Questions What do we mean by quality of healthcare services? How can health care be coordinated among the multiple institutions that provide health services? What types of healthcare delivery systems are being developed and how can they ensure the efficient coordination of health care services?

4 More Questions How can electronic medial records facilitate coordination of care and improve overall quality? How is technology being used to improve the quality of care? What mechanisms are being used to monitor and ensure the quality of health care? Can disclosure of medical errors contribute to the overall quality of health care?

5 Health Care Institutions - Nursing Home Care Fred ended his walk one day in the emergency room. He seemed confused about how to get home. "It looks like we are dealing with Alzheimer s, Fred s doctor told Fred s wife Sonya at their next appointment. Taking care of Fred at home was not easy. Home health aides and occasional weekend relief called "respite care" eased the burdens for a while. The new assisted living facilities looked attractive, but Fred s family just could not afford it. When Fred fell and broke his hip he required hospitalization for surgery. The hospital discharge planner arranged for a skilled nursing home for rehabilitation services. After a few weeks of rehabilitation the only alternative was long term or custodial care in a nursing home. The care at the nursing home was not what the family had expected. The staff did clean him up before the announced family visits but when the family arrived for an unannounced visit they were shocked to see Fred lying half naked in the wheelchair. The end came almost two years from the day they moved him permanently to the nursing home. Looking back the family asked, how can we do better to address the needs of Alzheimer s patients?

6 Inpatient The Two Major Types of Facilities Hospitals (General & Specialty) Skilled nursing and rehabilitation facilities Nursing homes Institutional hospices Outpatient Medical clinics Diagnostic testing clinics Treatment clinics

7 Hospitals Categorized by Funding Source and Financial Arrangement (~5000) Private non-profit For-profit (investor owned) 90% in the U.S. are non-profit Government Select groups (VA Hospitals) Institutional Some are affiliated with Medical Schools

8 Skilled Nursing and Rehabilitative SNRS Short term Services (SNRS) Specific goal of rehabilitation/recovery Nursing Homes (est.16,000 facilities with 1.5 million residents) Long term services Regulated by the State Provide dressing, feeding, & bathing services 85% are private non-profit

9 Respite Respite Care and Hospice Temporary care from primary care givers Hospice Life expectancy <6 months Provide comfort, emotional support, and palliation Institution or place of residence

10 Community Health Centers The Health Centers Consolidation Act of 1996 can be found under Section 330 of the Public Health Service Act Federal 330 grants are available For medically underserved areas (MUA) or medically underserved populations (MUP) Requirements all grantees must have: non-profit, public, or tax exempt status provisions for comprehensive primary health care services, referrals, and methods for access to follow-up care a governing board consisting of patients a plan in place to make financial adjustments to meet the needs of the population

11 What is Meant by Quality of Health Care Services? In what areas are assessments conducted? Structure Physical and organizational infrastructure Process Procedures and formal processes Outcomes Cure rates to complications

12 Characteristics of Healthcare Quality: National Committee for Quality Assurance Characteristic Meaning Examples How measured? Access and Service Access to needed care and good customer service Enough primary care physicians and specialists Satisfaction of patients in terms of problems obtaining care Patient satisfaction surveys. Patient grievances and follow-up, interviews with staff

13 Characteristics of Healthcare Quality: National Committee for Quality Assurance Characteristic Meaning Examples How measured? Qualified providers Personnel licensed and trained and patients satisfied with services System for checking credentials, sanctions Patient satisfaction with availability of providers for specialized care Presence of system for checking credentials Patient satisfaction surveys

14 Characteristics of Healthcare Quality: National Committee for Quality Assurance Characteristic Meaning Examples How measured? Staying healthy Quality of services that help people maintain good health and avoid illness Presence of guidelines for appropriate clinical services Evidence that patients are receiving appropriate screening tests Review of independently-verified clinical records Review of responses from patients

15 Characteristics of Healthcare Quality: National Committee for Quality Assurance Characteristic Meaning Examples How measured? Getting better Quality of services that help people recover from illness Presence of method for evaluating new procedures, drugs, and devices to ensure that patients have assess to the most up-todate care Providing specific services, such as smoking cessation Review of independentlyverified clinical records Interviews with staff

16 Characteristics of Healthcare Quality: National Committee for Quality Assurance Characteristic Meaning Examples How measured? Living with illness Quality of services that help people manage chronic illness Programs to assist patients to manage chronic conditions like asthma Review of independentlyverified clinical records Provision of specific services, such as eye examinations for diabetics Interviews with staff

17 How Can Health Care Be Coordinated Among the Multiple Institutions that Provide Healthcare Services? Goals of the Healthcare delivery system 1. Connect impatient and outpatient services 2. Provide short-term and long-term clinical services 3. Provide a coordinated system of care through the integration of the many different providers

18 What Types of Coordination of Care Are Needed & What Purposes Do They Serve? Coordination is sought between institutions and settings where care is delivered; it formally links institutions, services, and information There are four types of coordination: 1. Clinician patient relationship 2. Institutional coordination 3. Financial coordination 4. Coordination between health care and public health

19 Type of Coordination of Care, Intended Functions and Challenges with Implementation Type of Coordination Clinician-patient relationship Intended function Continuity as a mechanism for ensuring coordination Development of individual relationships built on knowledge and trust over extended periods of time Challenges with implementation Multiple clinicians involved in care Team rather than individual concept of primary care Frequent changes in insurance coverage require change in health professionals

20 Type of Coordination of Care, Intended Functions and Challenges with Implementation Type of Coordination Institutional Coordination Intended function Coordination of individual s information between institutions needed to inform individual clinical and administrative decision making Challenges with implementation Different structures and governance often lead to lack of coordination between inpatient facilities and between inpatient and outpatient facilities

21 Type of Coordination of Care, Intended Functions and Challenges with Implementation Type of Coordination Financial Coordination Intended function Implies that a patient has comprehensive coverage for services provided by the full range of Institutions Maximize the efficiency of the care received and to minimize the administrative effort required to manage the payment system Challenges with implementation Lack of comprehensive insurance coverage often means that essential services cannot be delivered or cannot be delivered at the most efficient or effective institutional site

22 Type of Coordination of Care, Intended Functions and Challenges with Implementation Type of Coordination Coordination between Health care and Public health Intended function Coordination of services between clinical care and public heath requires communication to ensure follow-up and to protect the health of others Challenges with implementation Lack of coordination of services between public health services and clinical care is often based on lack of Communication (technologies are needed)

23 What Types of Healthcare Delivery Systems Are Being Developed, and How Can They Help Ensure Coordination of Health Care? Kaiser Permanente Veterans Administration The Affordable Care Act has a large number of provisions that encourage demonstration projects for Medicare patients

24 What are the Potential Roles for a Connected (Interlinked) Electronic Health Information System? 1. Health information and data 2. Order entry/management 3. Decision support management 4. Electronic communication and connectivity 5. Patient support 6. Results management 7. Administrative processes 8. Reporting and population health

25 Technology in Medicine Traditionally dependent on the financial market Has not brought down the overall costs of health care. Treatment and prevention Advances in research Tracking the human genome has led to new diagnostic and therapeutic approaches Integrative medicine and health coaching (via telecommunication and internet) How do we pay for this? (next week- chapter 11)

26 What Mechanisms Are Being Used to Monitor and Ensure the Quality of Health Care in the U.S.? Accreditation of academic institutions Individual credentialing of health professionals Increasing requirements for continuing education, recertification, and maintenance of licensure Integrating financial compensation with quality of care through the use of pay-for-performance approaches

27 Mechanisms That Insure Quality of Health Care Hospital privileges and approval to perform specific procedures Accreditations of additional health care organizations including clinical practices Malpractice liability for doctors, nurses, and technicians (next slide) Disclosure of medical errors (~ 40K deaths/year)

28 Establishing Medical Malpractice Legal Concepts Under Negligence Law 1. Duty was owed 2. Duty was breached 3. The breach caused an injury 4. Damages occurred

29 Addressing a Medical Error Facts about the event Presence of error or systems failure Expression of regret Formal apology Recommendations from the Joint Commission on Health and Human Services 2001.

30 Can Disclosing Medical Errors Contribute to Quality of Care and Serve as an Alternative to Malpractice? Institutions are now integrating the disclosure process with other aspects of patient safety and risk management activities Provide support for the disclosure process, including educating clinicians Growing acceptance of disclosure as a way of addressing medical errors

31 Summary 1. The major health care institutions include both inpatient and outpatient facilities. 2. The health care delivery system includes hospitals; skilled nursing and rehabilitation services; nursing homes; respite care; hospice care; and community health centers. 3. The quality of health care services can be determined through structure, process, and outcome measures. 4. Advances in technology and communication have enhanced the overall quality of health care in America. 5. Taking a proactive and preventative approach is one of the key ways to minimize the risk of medical errors.

32 The End Slide show was developed by: Richard C. Krejci, Ph.D. Professor of Public Health Columbia College of SC All Rights Reserved

MEMBER HANDBOOK. Health Net HMO for Raytheon members

MEMBER HANDBOOK. Health Net HMO for Raytheon members MEMBER HANDBOOK Health Net HMO for Raytheon members A practical guide to your plan This member handbook contains the key benefit information for Raytheon employees. Refer to your Evidence of Coverage booklet

More information

Provider Manual Provider Rights and Responsibilities

Provider Manual Provider Rights and Responsibilities Provider Manual Provider Rights and Welcome To Kaiser Permanente This section of the Manual was created to help guide you and your staff in understanding your rights and responsibilities as our contracting

More information

Provider Manual. Utilization Management Care Management

Provider Manual. Utilization Management Care Management Provider Manual Utilization Management Care Management Utilization Management This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente s Resource Stewardship

More information

arizona health net a better decision sm Putting you at the center of everything we do.

arizona health net a better decision sm Putting you at the center of everything we do. arizona health net a better decision sm Putting you at the center of everything we do. Nothing s more important than your health. When you re healthy, you want to stay healthy. When you re sick or have

More information

total health and wellness

total health and wellness total health and wellness Programs exclusively for our Blue Shield members total health and wellness Whether you want to ease stress, lose weight, or quit smoking we ll help you reach your goals. Our health

More information

total health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees

total health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees total health and wellness Programs exclusively for our Blue Shield members For small businesses with 2 to 50 eligible employees total health and wellness Whether you want to ease stress, lose weight, or

More information

Conflict of Interest Disclosure. Telemedicine: Credentialing And Best Practices. Learning Objectives. Learning Objectives. Telehealth.

Conflict of Interest Disclosure. Telemedicine: Credentialing And Best Practices. Learning Objectives. Learning Objectives. Telehealth. Conflict of Interest Disclosure Telemedicine: Credentialing And s Catherine M. Ballard Partner Bricker & Eckler LLP 614-227-8806/cballard@bricker.com Use the following statement or disclose any relationships

More information

Delegation Oversight 2016 Audit Tool Credentialing and Recredentialing

Delegation Oversight 2016 Audit Tool Credentialing and Recredentialing Att CRE - 216 Delegation Oversight 216 Audit Tool Review Date: A B C D E F 1 2 C3 R3 4 5 N/A N/A 6 7 8 9 N/A N/A AUDIT RESULTS CREDENTIALING ASSESSMENT ELEMENT COMPLIANCE SCORE CARD Medi-Cal Elements Medi-Cal

More information

Your Plan Explained. MetLife. UnitedHealthcare Group Medicare Advantage (PPO) Group Number: 12359

Your Plan Explained. MetLife. UnitedHealthcare Group Medicare Advantage (PPO) Group Number: 12359 2016 Your Plan Explained MetLife UnitedHealthcare Group Medicare Advantage (PPO) Effective: January 1, 2016 through December 31, 2016 Group Number: 12359 Benefit highlights MetLife 12359 Effective January

More information

Health Advocate Core Advocacy. Features

Health Advocate Core Advocacy. Features Health Advocate Core Advocacy Features Meeting Every Need Efficient and Dependable The Personal Health Advocate (PHA) is a trained professional, typically a registered nurse, supported by medical directors

More information

MEDICARE By Peter G. Pan

MEDICARE By Peter G. Pan Wendell K. Kimura Acting Director Research (808) 587-0666 Revisor (808) 587-0670 Fax (808) 587-0681 LEGISLATIVE REFERENCE BUREAU State of Hawaii State Capitol Honolulu, Hawaii 96813 No. 02-13 October 7,

More information

Clinical Nurse Specialist (CNS)

Clinical Nurse Specialist (CNS) Clinical Nurse Specialist (CNS) Paula Halcomb, MSN, DNP, APRN, ACNS-BC paula.halcomb@uky.edu Jill Dobias, MSN, APRN, ACCNS-AG, OCN, AOCNS jill.dobias@uky.edu Dee Sawyer, MS, APRN, MLDE, AGCNS-BC, BC-ADM,

More information

Provider Manual. Section 8: Quality Assurance and Improvement

Provider Manual. Section 8: Quality Assurance and Improvement Provider Manual Table of Contents SECTION 8: QUALITY ASSURANCE AND IMPROVEMENT (QI)... 3 KAISER PERMANENTE QUALITY MISSION STATEMENT... 3 8.1 ORGANIZATIONAL STRUCTURE AND ACCOUNTABILITIES... 3 8.1.1 Kaiser

More information

National Survey on Consumers Experiences With Patient Safety and Quality Information

National Survey on Consumers Experiences With Patient Safety and Quality Information Summary and Chartpack The Kaiser Family Foundation/Agency for Healthcare Research and Quality/Harvard School of Public Health National Survey on Consumers Experiences With Patient Safety and Quality Information

More information

PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011

PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011 PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011 PRESENTED BY ALVA S. BAKER, MD, CMD Maine Medical Directors Association Faculty Disclosures: Dr. Baker has disclosed that he has no relevant

More information

Provider Characteristics Codes

Provider Characteristics Codes NUCC Provider Characteristics Codes JULY 2018 VERSION 3 NUCC PROVIDER CHARACTERISTIC CODES 1 Designed and generated by Washington Publishing Company, www.wpc-edi.com. Copyright 2018 American Medical Association

More information

Colorado Choice Health Plans

Colorado Choice Health Plans Quality Overview Health Plans Accreditation Exchange Product Accrediting Organization: Accreditation Status: URAC Health Plan Accreditation (Marketplace ) Full Full: Organization demonstrates full compliance

More information

CHAPTER 6: CREDENTIALING PROCEDURES

CHAPTER 6: CREDENTIALING PROCEDURES We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider

More information

Section 4 - Referrals and Authorizations: UM Department

Section 4 - Referrals and Authorizations: UM Department Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation

More information

Certification of Health Care Provider (Family and Medical Leave Act of 1993)

Certification of Health Care Provider (Family and Medical Leave Act of 1993) Certification of Health Care Provider (Family and Medical Leave Act of 1993) U.S. Department of Labor Employment Standards Administration Wage and Hour Division (When completed, this form goes to the employee,

More information

Notice of Privacy Practices

Notice of Privacy Practices River Valley Chiropractic LLC Notice of Privacy Practices Effective 9/2014; Revised 9/2014 If you have any questions about this notice, please contact the River Valley Chiropractic Privacy Officer at 308-534-5840.

More information

Understanding Your Options for Care. in a Nursing Home or Assisted Living Facility

Understanding Your Options for Care. in a Nursing Home or Assisted Living Facility Understanding Your Options for Care in a Nursing Home or Assisted Living Facility 2017 Please keep in mind that the following information does not substitute for the advice of an attorney. To discuss your

More information

I. Disclosure Requirements for Financial Relationships Between Hospitals and Physicians

I. Disclosure Requirements for Financial Relationships Between Hospitals and Physicians 2400:1018 BNA s HEALTH LAW & BUSINESS SERIES provided certain additional elements (based largely on the physician recruitment exception) are satisfied. 133 10. Professional courtesy, 42 C.F.R. 411.357(s)

More information

Community Health Workers: ACA and Redesign Funding Opportunities

Community Health Workers: ACA and Redesign Funding Opportunities Community Health Workers: ACA and Redesign Funding Opportunities What are the Goals of the Affordable Care Act and Redesign? Increased Coverage Better Population Health Higher Quality, More-Patient Centered

More information

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services

More information

WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service

WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service WakeMed Rehab Hospital provides an integrated, comprehensive delivery of rehabilitation services utilizing evidenced-based practice directed

More information

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.2 Procedures Requiring Prior Authorization. G.3 How to Contact or Notify Medical Management G.2 At a Glance G.2 Procedures Requiring Prior Authorization G.3 How to Contact or Notify G.4 When to Notify G.7 Case Management Services G.10 Special Needs Services G.12 Health Management Programs G.14

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 07 Medical Day Care Services Authority: Health-General Article, 2-104(b), 15-103, 15-105, and 15-111, Annotated

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care

More information

2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.

2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. 2018 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc. Welcome from Kaiser Permanente It is our pleasure to welcome you as a contracted provider (Provider) participating under

More information

Fidelis Care New York Provider Manual 22C-1

Fidelis Care New York Provider Manual 22C-1 Fidelis (MAP) is for individuals who have Medicare and Medicaid coverage and who have a chronic illness or disability. Member Eligibility Fidelis provides managed long-term care services to members who:

More information

Provider Rights. As a network provider, you have the right to:

Provider Rights. As a network provider, you have the right to: NETWORK CREDENTIALING AND SANCTIONS ValueOptions program for credentialing and recredentialing providers is designed to comply with national accrediting organization standards as well as local, state and

More information

Tele-Behavioral Health at Kaiser Permanente. Andrew Bertagnolli, PhD April 28, 2014

Tele-Behavioral Health at Kaiser Permanente. Andrew Bertagnolli, PhD April 28, 2014 Tele-Behavioral Health at Kaiser Permanente Andrew Bertagnolli, PhD April 28, 2014 Key Legal & Compliance Issues Professional licensure Clinician must be licensed to practice in the state the patient

More information

RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services

RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services (Last Updated: July 15, 2013) Ryan White HIV/AIDS Program funds are intended to support only the HIV-related needs of clients. All

More information

AgeWell New York Provider Relations 1991 Marcus Avenue Suite M201 Lake Success, NY 11042

AgeWell New York Provider Relations 1991 Marcus Avenue Suite M201 Lake Success, NY 11042 Dear Provider/Facility: Thank you for your interest in becoming a network provider/facility for AgeWell New York, LLC. In accordance with our commitment to the quality of health care services delivered

More information

IU Health Goshen CHNA Action Plan:

IU Health Goshen CHNA Action Plan: IU Health Goshen CHNA Action Plan: 2016-2018 The mission of IU Health Goshen is to improve the health of our communities, by providing innovative, outstanding care and services through exceptional people

More information

Academic Year Is from 12:00am on August 16 th to 11:59pm on August 15 th. This is the coverage period for CampusCare.

Academic Year Is from 12:00am on August 16 th to 11:59pm on August 15 th. This is the coverage period for CampusCare. CampusCare A self-funded student health benefit plan for the students at the University of Illinois at Chicago including the Rockford and Peoria campuses. *Please note: The Urbana-Champaign and Springfield

More information

Friday Health Plans of Colorado

Friday Health Plans of Colorado QUALITY OVERVIEW Health Plans of Colorado (formerly Colorado Choice Health Plans) Serving Colorado for over 4 years, Health Plans utilizes a community-focused model. We work hand in hand with local providers

More information

I. LIVE INTERACTIVE TELEDERMATOLOGY

I. LIVE INTERACTIVE TELEDERMATOLOGY Position Statement on Teledermatology (Approved by the Board of Directors: February 22, 2002; Amended by the Board of Directors: May 22, 2004; November 9, 2013; August 9, 2014; May 16, 2015; March 7, 2016)

More information

DEMONSTRATED NEED FOR SKILLED CARE FOR MEDICARE PATIENTS: SKILLED NURSING SERVICES

DEMONSTRATED NEED FOR SKILLED CARE FOR MEDICARE PATIENTS: SKILLED NURSING SERVICES DEMONSTRATED NEED FOR SKILLED CARE FOR MEDICARE PATIENTS: SCOPE: All Ascension At Home, LLC colleagues. For purposes of this policy, all references to colleague or colleagues include temporary, part-time

More information

Hospital Transitions: A Guide for Professionals.

Hospital Transitions: A Guide for Professionals. Hospital Transitions: A Guide for Professionals 2017 www.medicarerights.org Medicare Rights Center The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure

More information

Benefits Why AmeriHealth Caritas VIP Care Plus Was Created

Benefits Why AmeriHealth Caritas VIP Care Plus Was Created Benefits Benefits Why AmeriHealth Caritas VIP Care Plus Was Created The Medicare Medicaid Plan, AmeriHealth Caritas VIP Care Plus, was created to coordinate Medicare and Medicaid services, simplify the

More information

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800) Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience

More information

Chapter 4 Health Care Management Unit 5: Quality Management

Chapter 4 Health Care Management Unit 5: Quality Management Chapter 4 Health Care Management Unit 5: Quality Management In This Unit Topic See Page Unit 5: Quality Management Quality Management Program 2 Prevention and Wellness 4 Clinical Quality 5 Network Quality

More information

GEISINGER HEALTH PLAN GEISINGER INDEMNITY INSURANCE COMPANY GEISINGER QUALITY OPTIONS, INC. PRACTITIONER CREDENTIALING CRITERIA

GEISINGER HEALTH PLAN GEISINGER INDEMNITY INSURANCE COMPANY GEISINGER QUALITY OPTIONS, INC. PRACTITIONER CREDENTIALING CRITERIA GEISINGER HEALTH PLAN GEISINGER INDEMNITY INSURANCE COMPANY GEISINGER QUALITY OPTIONS, INC. PRACTITIONER CREDENTIALING CRITERIA Each health care practitioner must, at the time of application for initial

More information

CHI Mercy Health. Definitions

CHI Mercy Health. Definitions CHI Mercy Health Definitions If you have any questions about this notice, please contact the CHI Mercy Health s Privacy Office at (701) 845-6540 or 570 Chautauqua Blvd, Valley City ND 58072. Notice of

More information

Provider Selection Criteria for PreferredOne Participating Practitioners

Provider Selection Criteria for PreferredOne Participating Practitioners Provider Selection Criteria for PreferredOne Participating Practitioners General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product for which

More information

Section V: To be completed by the PIHP contract manager as applicable. Section VI: To be completed by the PIHP Credentialing Committee as applicable.

Section V: To be completed by the PIHP contract manager as applicable. Section VI: To be completed by the PIHP Credentialing Committee as applicable. Sections I-IV: To be completed by the organizational provider at the time of initial network application for enrollment and credentialing; or at the time of the biennial re-credentialing. Section I. Agency

More information

Professional Drivers Health Network. What?

Professional Drivers Health Network. What? Professional Drivers Health Network What? An Integrated Occupational Health Program The definition - the ability of a worker to function at an optimum level of well-being at a worksite as reflected in

More information

Avmed medicare. Keeping You Informed

Avmed medicare. Keeping You Informed Avmed medicare Keeping You Informed Summer/July 2016 inside Your Primary Care Physician... 2 Preventive Healthcare... 2 Transferring Your Medical Records... 3 Mental Health Benefits... 3 Medical Technology...

More information

Kaiser Permanente QUALITY OVERVIEW OVERALL RATING : 3.4 COMPANY AT A GLANCE. Company Statistics. Accreditation Exchange Product

Kaiser Permanente QUALITY OVERVIEW OVERALL RATING : 3.4 COMPANY AT A GLANCE. Company Statistics. Accreditation Exchange Product QUALITY OVERVIEW Permanente As the state s largest nonprofit health plan, Permanente is committed to improving the health of our members and our state as a whole. Permanente is made up of: Foundation Hospitals

More information

POLICY SUBJECT: POLICY:

POLICY SUBJECT: POLICY: POLICY SUBJECT: Healthcare Provider Documentation and Compliance Standards Business: Madonna Rehabilitation Hospital - Omaha Date of Origin: 7/1/2016 System: Quality & Risk Management Review Date: 07/25/2016

More information

MEMPHIS LUNG PHYSICIANS FOUNDATION AN OFFICE OF BAPTIST MEDICAL GROUP NOTICE OF PRIVACY PRACTICES

MEMPHIS LUNG PHYSICIANS FOUNDATION AN OFFICE OF BAPTIST MEDICAL GROUP NOTICE OF PRIVACY PRACTICES MEMPHIS LUNG PHYSICIANS FOUNDATION AN OFFICE OF BAPTIST MEDICAL GROUP NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

More information

Basic Covered Benefits and Services

Basic Covered Benefits and Services Basic Covered Benefits and A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Bed Liners Coverage Covered for members age 4 and up; Prior

More information

2016 Summary of Benefits

2016 Summary of Benefits 2016 Summary of Benefits Health Net Jade (HMO SNP) Kern, Los Angeles and Orange counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0175 CMS Accepted 09082015

More information

NOTICE OF PRIVACY PRACTICES MOUNT CARMEL HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES MOUNT CARMEL HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES MOUNT CARMEL HEALTH SYSTEM Effective Date: 9/23/ 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

Care & Support Through the Stages of Serious Illness. n Palliative Care. n Hospice Care. n Grief Support. n Opportunities to Learn

Care & Support Through the Stages of Serious Illness. n Palliative Care. n Hospice Care. n Grief Support. n Opportunities to Learn Care & Support Through the Stages of Serious Illness n Palliative Care n Hospice Care n Grief Support n Opportunities to Learn n Ways to Support Our Mission More comfort, less stress. It s possible for

More information

The Medicare Hospice Benefit. What Does It Mean to You and Your Patients?

The Medicare Hospice Benefit. What Does It Mean to You and Your Patients? The Medicare Hospice Benefit What Does It Mean to You and Your Patients? The Medicare Hospice Benefit By the time Congress established the Medicare Hospice Benefit in 1982, hundreds of organizations in

More information

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program: QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care

More information

The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories.

The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories. Medical Staff Bylaws New Category Proposal ARTICLE 4. CATEGORIES OF THE MEDICAL STAFF 4.1 CATEGORIES The Staff shall be divided into Active, Ambulatory Proceduralists, Affiliate and Honorary Categories.

More information

Understand healthcare facilities and organizational structure with focus on LTC.

Understand healthcare facilities and organizational structure with focus on LTC. Unit A Nurse Aide Workplace Fundamentals Essential Standard 1.00 Understand the range of function, legal and ethical responsibilities of the nurse aide within the healthcare system. Indicator 1.01 Understand

More information

Kaiser Permanente Washington - Pre-Authorization requirements:

Kaiser Permanente Washington - Pre-Authorization requirements: Kaiser Permanente Washington - Pre-Authorization requirements: Kaiser Permanente Washington requires pre-authorization for most services to be covered. The information below outlines pre-authorization

More information

Complete Senior Care Enrollment Agreement

Complete Senior Care Enrollment Agreement Complete Senior Care Enrollment Agreement I have received the Enrollment Handbook and a copy of the Provider Network and have had the opportunity to ask questions. Name: Address: (First) (Middle) (Last)

More information

providing quality, whole-person health care to all, especially the poor

providing quality, whole-person health care to all, especially the poor A Federally Qualified Health Center providing quality, whole-person health care to all, especially the poor Three locations: East Liberty Lincoln-Lemington Hosanna House (dental care only) 6023 Harvard

More information

ANCILLARY/FACILITY APPLICATION CREDENTIALING / RE-CREDENTIALING

ANCILLARY/FACILITY APPLICATION CREDENTIALING / RE-CREDENTIALING ANCILLARY/FACILITY APPLICATION CREDENTIALING / RE-CREDENTIALING Please attach copies of all applicable documents to the application: Copy of all Federal, State and/or local licenses required to operate

More information

Commercial. Health Net. Group Retiree Plans. HMO Medicare Coordination of Benefits (COB) Pam White, We help members make informed decisions.

Commercial. Health Net. Group Retiree Plans. HMO Medicare Coordination of Benefits (COB) Pam White, We help members make informed decisions. Commercial Health Net Group Retiree Plans HMO Medicare Coordination of Benefits (COB) Pam White, Health Net We help members make informed decisions. Health Net HMO Medicare Coordination of Benefits At

More information

T M A V e r s i o n TABLE OF CONTENTS PART DEFINITIONS

T M A V e r s i o n TABLE OF CONTENTS PART DEFINITIONS (a) General. 1 (b) Specific definitions. 1 Abortion. 1 Absent treatment. 1 Abuse. 1 Abused dependent. 1 Accidental injury. 2 Active duty. 2 Active duty member. 2 Activities of daily living. 2 Acupuncture.

More information

PURPOSE: POLICY: not

PURPOSE: POLICY: not PAGE: 1 EFFECTIVE: 3/2007 7/2013 / 04/10/2015 PURPOSE: The purpose of this policy is to provide an atmosphere of respect and caring and to ensure that each patient's ability and right to participate in

More information

Alphabet Soup of Provider Credentialing. Anne Hanzel Alta Partners, LLC

Alphabet Soup of Provider Credentialing. Anne Hanzel Alta Partners, LLC Alphabet Soup of Provider Credentialing Anne Hanzel Alta Partners, LLC Why is Credentialing Important? Patient Safety Build practice base Allow for discounted amounts Direct link to managed care systems

More information

PRIVACY AND ANTI-SPAM CODE FOR OUR ORGANIZATION

PRIVACY AND ANTI-SPAM CODE FOR OUR ORGANIZATION PRIVACY AND ANTI-SPAM CODE FOR OUR ORGANIZATION Please refer to Appendix A for a glossary of defined terms. INTRODUCTION The Personal Health Information Protection Act, 2004 (PHIPA) came into effect on

More information

Utilizing a Pharmacist and Outpatient Pharmacy in Transitions of Care to Reduce Readmission Rates. Disclosures. Learning Objectives

Utilizing a Pharmacist and Outpatient Pharmacy in Transitions of Care to Reduce Readmission Rates. Disclosures. Learning Objectives Utilizing a Pharmacist and Outpatient Pharmacy in Transitions of Care to Reduce Readmission Rates. Disclosures Rupal Mansukhani declares grant support from the Foundation for. Rupal Mansukhani, Pharm.D.

More information

5/1/2017 THE BEST DEFENSE IS A GOOD OFFENSE OBJECTIVES. Preparing for a Home Health Medicare Recertification Survey

5/1/2017 THE BEST DEFENSE IS A GOOD OFFENSE OBJECTIVES. Preparing for a Home Health Medicare Recertification Survey THE BEST DEFENSE IS A GOOD OFFENSE Preparing for a Home Health Medicare Recertification Survey OBJECTIVES To gain an understanding how the Medicare Conditions of Participation (CoPs), the individual G-tags,

More information

INFORMATION ABOUT YOUR OXFORD COVERAGE REIMBURSEMENT PART I OXFORD HEALTH PLANS OXFORD HEALTH PLANS (NJ), INC.

INFORMATION ABOUT YOUR OXFORD COVERAGE REIMBURSEMENT PART I OXFORD HEALTH PLANS OXFORD HEALTH PLANS (NJ), INC. OXFORD HEALTH PLANS (NJ), INC. INFORMATION ABOUT YOUR OXFORD COVERAGE PART I REIMBURSEMENT Overview of Provider Reimbursement Methodologies Generally, Oxford pays Network Providers on a fee-for-service

More information

Blue Cross and Blue Shield of Illinois Provider Manual. Extended Care Facility Section

Blue Cross and Blue Shield of Illinois Provider Manual. Extended Care Facility Section Blue Cross and Blue Shield of Illinois Provider Manual Extended Care Facility Section 2017 Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve

More information

Your Guide to Hospital Discharge

Your Guide to Hospital Discharge Your Guide to Hospital Discharge Table of Contents Introduction...2 Planning for Discharge...3 What is Discharge Planning?...3 The Discharge Planning Team...8 Who Are the Key Players?...8 Recovery Facilities

More information

MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities

MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities 2018 MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities Quality Department CAN_2790318S CMS Requirements The Centers of Medicare & Medicaid Services (CMS)

More information

CareMore Special Needs Plans Model of Care. Annual Evaluation 2015 Performance

CareMore Special Needs Plans Model of Care. Annual Evaluation 2015 Performance CareMore Special Needs Plans Model of Care Annual Evaluation 2015 Performance The Special Needs Plans (SNPs) Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit

More information

SAMPLE Medical Staff Self-Assessment Questionnaire

SAMPLE Medical Staff Self-Assessment Questionnaire Hospital Name: Person Completing the Assessment: Date: I. Executive Leadership Yes No 1. Is there a medical staff member or members on the governing board? 2. Does medical staff leadership meet routinely

More information

Presenter Disclosure Information

Presenter Disclosure Information The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/2013 2010, American Heart Association 1 1 2

More information

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION

VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION GENERAL INFORMATION Primary Practice Facility Location The type of application being submitted: Please choose facility type (check all that apply):

More information

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised February 17, 2010 Revised September 23, 2013 Revised July 1, 2016 This Notice of Privacy Practices applies to the

More information

Course Module Objectives

Course Module Objectives Course Module Objectives CM100-18: Scope of Services, Practice, and Education CM200-18: The Professional Case Manager Case Management History, Regulations and Practice Settings Case Management Scope of

More information

LOUISIANA MEDICAID PROGRAM ISSUED: 04/15/12 REPLACED: CHAPTER 24: HOSPICE SECTION 24.3: COVERED SERVICES PAGE(S) 5 COVERED SERVICES

LOUISIANA MEDICAID PROGRAM ISSUED: 04/15/12 REPLACED: CHAPTER 24: HOSPICE SECTION 24.3: COVERED SERVICES PAGE(S) 5 COVERED SERVICES COVERED SERVICES Hospice care includes services necessary to meet the needs of the recipient as related to the terminal illness and related conditions. Core Services (Core services) must routinely be provided

More information

The Basics: Getting Started on Disease- Specific Care Certification

The Basics: Getting Started on Disease- Specific Care Certification The Basics: Getting Started on Disease- Specific Care Certification May 4, 2017 David Eickemeyer, MBA Associate Director, Certification Today s Objectives Define the main components of Disease- Specific

More information

Organizational Provider Credentialing Application

Organizational Provider Credentialing Application Prior to completing this credentialing application, please read and observe the following: INSTRUCTIONS This form should be typed (using a different font than the form) or legibly printed in black or blue

More information

healing. caring. living. community

healing. caring. living. community healing. caring. living. community Welcome to Springbrook Nursing and Rehabilitation Center is located in Silver Spring, Maryland and provides comprehensive nursing and rehabilitation services. A Nursing

More information

UCMC Physical Therapy Critical Care Fellowship Overview

UCMC Physical Therapy Critical Care Fellowship Overview UCMC Physical Therapy Critical Care Fellowship Overview Mission of Physical Therapy Fellowship Program: In conjunction with the University of Chicago Medicine s mission to provide superior healthcare,

More information

Quality Measurement at the Interface of Health Care and Population Health

Quality Measurement at the Interface of Health Care and Population Health 1 Institute of Medicine Committee on Quality Measures Healthy People Leading Health Indicators December 10, 2012 Quality Measurement at the Interface of Health Care and Population Health Shari M. Ling,

More information

General Information. 12 General Information

General Information. 12 General Information General Information 12 General Information Duke University In 1839, a group of citizens from Randolph and adjacent counties in North Carolina assembled in a log schoolhouse to organize support for a local

More information

Optum/OptumHealth Behavioral Solutions of California Facility Network Request Form / Credentialing Application

Optum/OptumHealth Behavioral Solutions of California Facility Network Request Form / Credentialing Application Optum/OptumHealth Behavioral Solutions of California Is the facility currently in the Optum network? Yes No Acceptance into the Optum/OptumHealth Behavioral Solutions of California (Optum) provider network

More information

Self-Insured Schools of California: Schools Helping Schools

Self-Insured Schools of California: Schools Helping Schools Self-Insured Schools of California: Schools Helping Schools Blue Shield of California Access+ HMO Plan 2016/2017 Enrollment Guide Blue Shield of California offers health benefits to school districts that

More information

DOCTORS HOSPITAL, INC. Medical Staff Bylaws

DOCTORS HOSPITAL, INC. Medical Staff Bylaws 3.1.11 FINAL VERSION; AS AMENDED 7.22.13; 10.20.16; 12.15.16 DOCTORS HOSPITAL, INC. Medical Staff Bylaws DMLEGALP-#47924-v4 Table of Contents Article I. MEDICAL STAFF MEMBERSHIP... 4 Section 1. Purpose...

More information

An Initiative to Improve Patient Discharge Satisfaction

An Initiative to Improve Patient Discharge Satisfaction An Initiative to Improve Patient Discharge Satisfaction Speaker Disclosure Statement Sally Strong, RN, APN-CNS, CNRN, CRRN Clinical Nurse Specialist Marianjoy Rehabilitation Hospital Adjunct Faculty Elmhurst

More information

Summary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA

Summary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).

More information

Privacy Practices Home Visit Doctor, LLC July 2017

Privacy Practices Home Visit Doctor, LLC July 2017 Privacy Practices Home Visit Doctor, LLC July 2017 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Organizational Provider Credentialing Application

Organizational Provider Credentialing Application Organizational Provider Credentialing Application New Mexico Organizational provider identification Legal business name (as reported to the IRS): Medicaid number: Doing Business As (DBA) name (if applicable):

More information

In Solidarity, Paul Pecorale Second Vice President

In Solidarity, Paul Pecorale Second Vice President Caregiving Guide Dear NYSUT Member: On behalf of the NYSUT officers and Board of Directors, we are proud to provide you with this publication, Caregiving Guide. In addition to providing information, referral

More information

At EmblemHealth, we believe in helping people stay healthy, get well and live better.

At EmblemHealth, we believe in helping people stay healthy, get well and live better. At EmblemHealth, we believe in helping people stay healthy, get well and live better. Welcome to the 2017 course on Special Needs Plan Model of Care. This year s course is focused on how we can successfully

More information

I. OPERATIONAL CHARACTERISTIC: PATIENT-CENTEREDNESS

I. OPERATIONAL CHARACTERISTIC: PATIENT-CENTEREDNESS I. OPERATIONAL CHARACTERISTIC: PATIENT-CENTEREDNESS A. FOCUS AREA: INFORMATION TO PATIENTS ABOUT PCMH 1. The organization provides information to the patient about: (indicate Yes or No to each item) Yes

More information