POLICY: Category: Care Management Policies Care Management 2.1 Patient Tracking and Registry Functions Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure management and monitoring of patient information and use of information to support patient care POLICY Patient Tracking and Registry Functions It is the policy of ProHealth Physicians that: 1. Clinicians and staff will collect required clinical and non-clinical data in either the Practice Management System (PMS) or EHR. a. Consistent use of required clinical and non-clinical data will be monitored quarterly. b. Data will be organized and saved in a searchable format. 2. On an annual basis, the Clinical Performance Committee or other clinical leadership body and PC Board will review existing clinical measures and as appropriate identify new quality indicators based on national clinical measures (including conditions and targets). Provider performance will be monitored at least quarterly and will be reported to each practice and individual provider as well as to applicable health plans and other external entities as appropriate. PROCEDURES Patient Tracking and Registry Operations 1. Patient Data a. Administrative/Billing Data i. The following data elements will be requested from all patients and captured in either the PMS or EHR: name, date of birth, gender, marital status, address, primary/contact telephone number, email address, language preference, race/ethnicity (not required, only recorded when voluntarily self-identified), emergency contact information, legal guardian, health insurance coverage and preferred method of communication. The PMS and EHR automatically assign an account number/medical Record Number (MRN) to each patient. ii. Patients will be asked to review and update their registration information at least annually or at the next visit (more frequently as needed) either in advance of their appointment or at check in. Updates/corrections will be made accordingly. iii. Additional information that will be maintained in searchable format in either the PMS or EHR include current and past diagnoses, dates of previous visits and billing codes for services. iv. When available, external ID numbers (i.e., health plan ID number) will be recorded. b. Clinical Data 1
i. The following clinical data elements will be requested from or captured for all patients and stored in the EHR: status of age-appropriate preventive services (immunizations, screenings and counseling), allergies and adverse reactions, blood pressure, height, weight, calculated body mass index, lab results, presence of imaging results, presence of pathology reports, and presence of advance directives for adult patients. ii. For children under age 18 calculated BMI is a percentile. BMI will be plotted on the CDC BMI-for-age growth charts in the EHR to obtain a percentile ranking. c. Monitoring Quarterly reports will be provided to each practice and Practice Management showing the percent of patients seen in the last three months for whom the practice has entered the elements found in sections 1.a.i., 1.b.i. and 1.b.ii. of this policy. Practices that are not capturing the specified administrative/billing and clinical data for at least 75% of patients will be notified and asked to initiate process improvements in order to meet the goal. d. Organizing Clinical Data The following clinical information will be documented and organized in the EHR: i. Problem lists ii. Medication lists including over-the-counter medications, supplements, alternative therapies and prescription medications iii. Age-appropriate risk factors, e.g., smoking iv. Narrative progress notes v. Age-appropriate standardized screening tools for developmental testing vi. Growth charts plotting height, weight, head circumference (2 years and younger) and BMI for patients younger than 18 years. 2. Clinical Performance a. At least annually, the Clinical Performance Committee will review established measures and as appropriate identify new measures and the PC Board will adopt clinical processes and outcomes to be measured and will set performance standards to be applied to all ProHealth patients. The processes and outcomes identified will be consistent with national quality measures. b. Providers will receive patient-specific data on a regular basis through reports and the EHR to assist with identification and follow-up of patients to whom the clinical measures apply. c. Provider performance will be monitored and periodically reported to each provider. d. The Clinical Performance Committee will develop and implement performance improvement plans and adjust as needed to address providers whose performance does not meet adopted targets. e. At least annually, performance of providers and ProHealth will be reported to health plans and other external entities. Reporting will be consistent with national measures and will include diagnosis and procedure codes, prescribed medications, lab tests and results, 2
radiology orders and results, blood pressure values and applicable data from hospital admissions as available. 3
Category: Care Management Policies 2.2 Population Management Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure management of care for individual patients according to their conditions and needs POLICY Population Management It is the policy of ProHealth Physicians that: 1. Consistent with criteria approved by the PC Board, information about patients requiring predetermined care and age-appropriate screenings or counseling will be made available to practices and individual providers. 2. Outreach to schedule patients requiring predetermined care and age-appropriate screenings or counseling will be done by telephone, mail or other electronic communication. 3. Practice and provider performance will be monitored and made available to each practice and provider at least quarterly. PROCEDURES Population Management 1. Identification of Patients Requiring Care, Screenings or Counseling a. Patients in need of specific care, screenings and/or counseling consistent with criteria approved by the PC Board will be identified and information made available to practices either through reporting or the EHR. Information provided will include details necessary to manage the identified patients, such as demographic information, diagnosis codes, risk factors, etc. b. Identified patients will be those who require: i. Age-appropriate screening tests, immunizations and/or risk assessments ii. Counseling (i.e., smoking cessation) iii. Pre-visit planning iv. Clinical review or action v. Follow-up based on prescription of specific medications vi. Reminders for preventive care, specific tests and/or follow-up visits vii. Care management support 2. Patient Outreach a. Patients age 3 and older who are coming due or are overdue for preventive care will receive reminders through ProHealth s Wellness Outreach process. Patients younger than age 3 will be tracked for age-appropriate preventive care at each practice site. Guidelines for preventive care intervals are approved as part of the clinical performance process. 4
b. Patients identified as needing follow-up for other specified reasons will receive telephonic outreach from staff at the practice site or central office (i.e., care management staff), automated telephone reminders, mail or other electronic communication (i.e., email, patient portal, etc.). c. Provider performance will be monitored and reported to each provider at least quarterly. 5
Category: Care Management Policies 2.3 Orders and Results Tracking Effective Date: Est. 12/1/2010 Revised Date: Purpose: To improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results POLICY Orders and Results Tracking It is the policy of ProHealth Physicians that: 1. Practice staff will order and track all medications and imaging, lab and other diagnostic tests through the EHR and will respond to all duplicate test order alerts. a. Lab and imaging results from tests performed by ProHealth will be interfaced directly from the lab results system and/or PACS into the EHR. Results of other imaging, lab and other diagnostic tests performed by non-prohealth providers will be received directly from the provider by fax or mail and scanned and/or entered into the EHR, or through other electronic means. b. Results from non-prohealth providers that are received by fax or mail will be scanned and/or entered into the EHR within the specified time frame (as outlined below in sections 1.e and 1.f). c. Providers will review and evaluate results within the specified time frame (as outlined below in sections 1.e. and 1.f.). Current and historical lab results will be reviewed within the EHR. 2. Practice staff will communicate normal and abnormal test results to patients/families within the specified time frame (as outlined below in section 2.). 3. Patients will be provided appropriate information about their prescribed medication(s) as needed or upon request. 4. At practices that care for newborns, practice staff will obtain the results of screening and metabolic tests performed in the hospital, when available, within the specified time frame (as outlined below in section 4). 5. Certain tasks and/or standing orders may be delegated to non-provider staff consistent with protocols approved by the Clinical Council and/or PC Board. Examples of tasks and standing orders that may be delegated include prescription refills, anticoagulation management, communication of diagnostic results to patients, triage, patient education and disease management. PROCEDURES Orders and Results Tracking 1. Tracking, Follow-Up and Managing Orders and Results a. Practice staff will order all diagnostic tests and consultations in the EHR and will verify duplicate checking alerts for all duplicate test orders. b. Practice staff will routinely track all diagnostic tests and consultations ordered in the EHR until results are available for the provider s review. 6
c. Practice staff will retrieve results for tests and consultations performed by ProHealth providers through the EHR. Results for tests and consultations performed by non- ProHealth providers will be received by fax, mail or other electronic means. d. Results of critical tests and consultations as determined by the provider will be routed for review (either on paper or as a task if the results are in the EHR) to the ordering provider for review within 4 hours of receipt. Following provider review of paper results, results will be scanned into the EHR within 3 business days. e. Results of non-critical tests and consultations will be routed to the ordering provider for review (either on paper or as a task if the results are in the EHR) within 1 business day of receipt. Following provider review of paper results, results will be scanned and filed into the EHR within 3 business days. f. Providers will routinely review all lab results for patients for triage as well as comparison. g. As additional EHR functionality is available, the use of alerts for appropriateness of tests ordered will be enabled. 2. Communication of Results to Patients/Families a. Clinically significant abnormal test results, as determined by the provider, will be communicated to patients/families within one business day or at the time of the patient s next visit as deemed appropriate by the provider upon their review. b. Normal test results will be communicated to patients/families within 3 business days or at the next visit, whichever occurs first. 3. Information about Prescribed Medications a. Upon the patient s request, or as determined by the provider, the patient will be given written information from the EHR regarding their prescribed medication(s) at the visit, or upon follow-up. b. The provider or practice staff will address any patient questions about their prescribed medication(s) at the visit, upon follow-up or at the patient s request. 4. Newborn Screening and Metabolic Tests a. At practices that care for newborns, practice staff will confirm receipt of hospital newborn screening and metabolic tests, when available, prior to the newborn s first office visit or within 4 weeks of the newborn s date of birth. b. If results, when available, are not received within the indicated time frame, as determined by the provider, practice staff will contact the hospital to obtain the needed results. As determined by the provider, if results cannot be obtained the necessary tests will be repeated. 5. Delegation of Tasks 7
a. Ordering of medications and certain other tasks and standing orders may be delegated to non-provider staff consistent with protocols approved by the Clinical Council and/or the PC Board and within Connecticut State Law. b. Tasks and standing orders that may be delegated include prescription refills (i.e., for specified chronic conditions), ordering of lab tests (i.e., standing orders for physical exams), management of patients on anticoagulation medications, communication of diagnostic results to patients, triage, patient education and disease management. c. Delegated tasks and standing orders will periodically be reviewed and revised by the Clinical Council with final approval by the PC Board. 8
Category: Care Management Policies 2.4 Referral Tracking Effective Date: Est. 12/1/2010 Revised Date: Purpose: To improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners. POLICY Referral Tracking It is the policy of ProHealth Physicians, that: 1. Providers will order all referrals through the EHR, including all required documentation. 2. Providers will define critical referrals based on their clinical judgment. Critical referrals will be tracked until consultant reports or diagnostic test results are returned to the provider for review. 3. Practice staff will verify whether referrals require health plan approval. PROCEDURES Referral Tracking 1. All referrals will be ordered through the EHR and will include the following: a. Referring provider b. Reason for referral and other relevant clinical information (i.e., reason for consultation, pertinent clinical findings, family or social history, plan of care, etc.) c. Administrative details including insurance information and pre-authorization, if required. 2. If the referral is critical, it will be noted as asap (two days) or urgent (same day) in the EHR. 3. Practice staff will track all critical referrals until diagnostic test results or consultant reports are received and reviewed by the ordering provider. Reports/results may be received by mail, phone, fax or other electronic means. 4. As part of critical referral tracking and to ensure appropriate care is received, practice staff will follow up with patients and/or consultants when consultation results are not received. 9
Category: Care Management Policies 2.5 Identifying and Managing Clinically Important Conditions Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure that patient care is coordinated and managed according to individual conditions and needs. POLICY Identifying and Managing Clinically Important Conditions It is the policy of ProHealth Physicians that: 1. The clinical performance process will include reporting of data to identify the most frequently seen diagnoses and the most important risk factors in ProHealth s patient population. 2. Evidence-based diagnosis and treatment guidelines will be developed, implemented and monitored for at least three clinically important conditions for each practice site. 3. The implementation of evidence-based guidelines for the identified clinically important conditions will be supported by practice staff and/or central resources through actions such as pre-visit planning and development of individualized care plans with treatment goals. Patients will be provided with tools to encourage compliance with evidence-based guidelines. 4. Patients diagnosed with one or more of the identified clinically important conditions will be assessed for willingness to practice self-management and readiness to change. Patients who are identified as suitable for self-management support will receive educational resources, selfmonitoring tools and lists of community programs to encourage and ensure self-management of their condition(s). PROCEDURES Identifying and Managing Clinically Important Conditions 1. Frequently Seen Diagnoses and Important Risk Factors a. Using data from the PMS and/or EHR, the most frequently seen conditions and important risk factors will be reported at least annually. b. One or more of the following criteria will be used to identify the most frequently seen conditions and important risk factors: number of patients with the condition or risk factor, number of visits for the condition or risk factor and/or total charges associated with the condition or risk factor. In addition, important risk factors may also be identified based on community-based demographic characteristics and their presence or absence in ProHealth s patients. c. This data will be presented to the Clinical Performance Committee for analysis and further action, as appropriate. 2. Identifying Clinically Important Conditions a. Clinically important conditions will be chosen by the Clinical Council and approved by the PC Board using some or all of the following criteria: 10
i. Most frequently seen conditions ii. Ability to treat or change the condition (i.e., through care management or by following clinical guidelines) iii. Conditions already identified for performance measurement or that have been targeted for performance improvement. b. The Clinical Performance Committee will review data to identify the clinically important conditions at least annually, to be followed by approval of the selected conditions by the Clinical Council and/or the PC Board. Considerations used to determine the clinically important conditions may include: i. Prevalence of certain conditions in ProHealth s patient population ii. Review of public health data to identify clinically important conditions in the area s population iii. Consultation with clinical leadership to obtain clinician input 3. Managing Clinically Important Conditions a. For patients with any of the identified clinically important conditions pre-visit planning will be conducted, including: i. Review of required tests ii. Current medications iii. Upcoming appointments iv. Other clinical reminders b. Care management activities during the visit will include: i. Review of medication list, including assessing barriers when patient has not filled, refilled or taken prescribed medications. ii. Development/review of individualized care plans and treatment goals, including assessing barriers when patients have not met treatment goals. iii. Review of self-monitoring results (i.e., blood pressure and glucose diaries, weight charts, food records, etc.) and incorporation into the medical record. iv. Assessment of progress toward goals through longitudinal representation of patient s historical or targeted clinical measurements. v. Review of EHR care guide(s), new referrals or medications (including possible side effects, compliance and barriers to purchasing), orders for tests and required follow-up. vi. Review of barriers to meeting treatment goals (i.e., transportation, financial or insurance issues, lack of understanding or motivation, scheduling, etc.) and appropriate goal setting to help patient overcome barriers. vii. Provision of health diaries, resources guides and tracking tools to encourage compliance with care plan. c. Care management activities following the visit will include follow-up with the patient by telephone after the visit to assess progress toward goals, assess compliance, clarify treatment plan and answer patient questions. 11
4. Patient Self-Management Support a. Each provider will identify those patients diagnosed with one or more of the identified clinically important conditions who could benefit from self-management support. b. The medical record of any patient whom the provider determines does not require selfmanagement support (i.e., patients already achieving good outcomes) should contain a note indicating that the patient does not require self-management support. c. Practice staff may meet with patients/families and use questionnaires and selfassessment forms to determine each patient s readiness and ability to manage his/her condition(s). d. Patients who are suitable candidates for self-management will be provided with: i. Educational materials in the patient s/family s language of choice and at an appropriate literacy level. These may include resource sheets, brochures, videos and fact sheets. ii. Self-monitoring tools such as personal health records and diaries to use to record results at home. iii. Lists of support programs at area hospitals, senior centers and community-based organizations. Examples of topics for these programs may include smoking cessation, asthma or diabetes education, weight loss or exercise. Centralized care management staff will confirm that these programs are taught by qualified instructors. iv. Written care plans including instructions on managing their condition(s) and other resources available such as counseling and support groups. 12
Category: 2.6 Continuity of Care Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure patients receive proper services when care is being transitioned. POLICY Continuity of Care It is the policy of ProHealth Physicians that patients who have received care in facilities (including emergency rooms, hospitals, surgical centers and skilled nursing facilities) and those with clinically important conditions will receive assistance in maintaining continuity of care. For patients indentified as having received care in facilities, staff may communicate with the facility and follow-up with the patient, to provide or coordinate necessary follow-up care and activities. PROCEDURES Continuity of Care 1. Reports will be received from health plans, hospitals, skilled nursing facilities and surgical centers identifying patients who have received care in their facilities. Clinical information will be sent to the appropriate facility upon notification or request. 2. Patients when identified will be called within 1 business day of discharge to schedule followup appointments. Discharge information will be reviewed to identify patients at risk for adverse outcomes. In addition, staff will assist patients with other follow-up care, as necessary. This may include counseling, referrals to community resources, self-management support programs or disease management programs. 3. Staff will regularly communicate with patients/families regarding continuity of care issues. Communication will be via telephone or e-mail, according to patient/family preference. 4. Eligible patients will be encouraged to participate in external disease management programs. ProHealth s care managers will communicate regularly via phone or e-mail with the patient and external case manager to assure follow-up care and to provide information about available educational resources. 5. The practice will review when available the written care transition plan for the patient and/or family that includes: a. Medication self-management directions b. Information about their health condition and the symptoms that may signal a worsening of their condition c. Goals to improve their health condition 6. As needed, patients will be provided with names of specialists or other providers and/or staff will call to schedule appointments for the patient. 13