Christine G' Leyden, RN, MSN

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Christine G. Leyden, RN, MSN
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Overview

• URAC and the Importance of Accreditation to
  Quality Management across the Continuum of Care
• Medical Management and the Patient Safety Role
• Future directions

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About URAC

• Nonprofit, independent organization founded in
  1990 originally chartered to accredit utilization
  review services now offers 16 distinct
  accreditation programs across the continuum of
  care
• Twenty-two of the top 25 US health plans hold
  URAC accreditation
• URAC accredits more of the top 25 PPOs than any
  other accreditation organization
• URAC Health Web Site program launched in 2001
  Accredits 36 sites/over 250 portals including
  WebMD, Healthwise, KidsHealth, May Clinic and
  Consumer Health Interactive
• URAC currently accredits over 400 organizations
  operating in all 50 states
• URAC is now recognized in 38 states, District of
  Columbia, and four federal agencies (OPM,
  Department of Defense, VA,CMS)
• AIS Directory of Health Plans, 2005

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Regardless of Plan Design URAC Standards Promote
Quality Care and Accountability Across Continuum
Health CareContinuum
Acute Illness/ Discretionary Care
At Risk
Chronic Illness
Well
Catastrophic
Consumer Health Care Needs
Pharmacy Benefit Management Link
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What URAC Accreditation Tells You About Quality
Across the Continuum of Care
URAC Accreditation assures the consumer
purchaser that the following has been reviewed
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Enhanced Patient Safety, Quality Improvement
Central to URAC StandardsHow URAC
Accreditation Promotes the Institute of Medicine
(IOM) Six Aims of Quality Health
Care Crossing the Quality Chasm, National
Academy of Sciences, 2003.
January 1, 2006 URAC formally adopted IOMs
definition of patient safety. Now requiring
organizations seeking accreditation to include a
specific patient safety/consumer quality
improvement program.
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Movement to a Consumer-focused EnvironmentCurrent
Trends

• While price-haggling over healthcare cost remains
  constant, seven in 10 consumers who have talked
  to a hospital are successful at negotiating a
  lower price (Harris, 12/05)
• Those in consumer-driven plans were more than 50
  more likely to ask about medical costs
  (McKinseyCo, 6/05)
• 30 of consumers say that they would turn away
  from information on a health website if it lacked
  endorsement from a trusted independent
  organization (URAC/Harris Interactive Consumer
  Poll)

Source for photo and facts Consumer-Directed
Health Plan Report- Early Evidence is Promising
McKinsey Company, June 2005
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Employers are challenging their vendors to
demonstrate Consumer Focus for Coordinated Care

• Care Management Vendors
• Shared decision-making and consumer education
• Health Plans
• Access to information on health care cost and
  quality
• Outreach/education
• Understanding of financial
• responsibility
• Consumer websites
• Credible sourced content
• Site effectiveness

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Value-based Purchasing is Evolving as Purchasers
DemandGreater Accountability for Consumer Focus
CURRENT
FUTURE
Transparency is one element of Consumer Focus
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Key Questions for Care Management Vendors

• For example, does the Case Management firm
  address
• Education of consumers on their rights and the
  process used to inform them of service choices?
• Provide consumers with a copy of the treatment
  plan, follow-up appointments, and who to contact
  for assistance?
• Identification of cost-effective alternatives,
  and monitoring of timely services by providers?
• Informed consent, advance medical directives?
• Consumer right to notice and a rationale when
  case management services are changed?
• Ethics training re advocacy for consumer needs,
  non-discrimination, and conflicts-of-interest?

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Key Questions for Health Plans

• Is provider cost and quality information
  available to consumers?
• Before enrollment, does the plan provide
  consumers with benefit/coverage guidelines,
  satisfaction ratings, provider directories, and
  tools to self-manage care?
• Does the plan provide consumers a Health Risk
  Assessment?

• Is consumer information presented in a format and
  appropriate language? Is health literacy
  considered?
• Does the plan proactively provide consumers
  access to prevention and wellness information?
• Do consumers receive instructions on how to get
  assistance via e-mail, telephone, or in person?

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Key Questions for Health Websites

• Does the site
• Safeguard consumer privacy?
• Disclose ownership and financial sponsorship?
• Clearly identify advertising and medical content
  sponsored by third parties?
• Disclose the source (authorship) and timeliness
  of medical content and its editorial policy?
• Have mechanisms for consumer feedback?
• Keep its links up-to-date and relevant?

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Medical Management Services for Coordinated Care

• Medical management practices include
• Utilization Management (UM),
• Case Management (CM),
• Disease Management (DM),
• Pharmacy Benefit Management Services
• Drug Treatment Management Services
• Demand Management through health call centers
  (HCC) and
• external review (independent review
  organizations (IRO).
• Medical management services may be offered as
  distinct functions, or may be integrated with
  other medical management and network offerings.

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Barriers to Coordinated Care

• Lack of on-site patient interface
• Impact is on subset of population
• Lack of integration with other system elements
  and
• Lack of standardization assessment, data entry,
  codes and nomenclature, performance benchmarks
• Quality improvement feedback mechanisms not
  established
• Lack of stakeholder awareness of MM role
• Patient safety indicators not defined
• Limited leverage with providers and facilities

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Patient safety is a coordinated care strategy

• Patient safety freedom from accidental
  injury ensuring patient safety involves the
  establishment of operational systems and
  processes that minimize the likelihood of errors
  and maximizes the likelihood of intercepting them
  when they occur.
• To Err is Human. Institute of Medicine, 1999

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URAC Standards that Promote Patient Safety
Continuity of Care
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Health Plan Participating Providers Credentials
Monitoring
MANDATORY
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DISEASE MANAGEMENT STANDARD DM 2
Evidence-Based Practice
Mandatory

• Disease management practices for each clinical
  condition are based on scientific evidence and
  includes input from clinical content expert(s)
  one of which must include a provider in the
  specialty area, that
• a) Is reviewed annually and updated as needed
• b) Review applicability of clinical practice
  guidelines to the specific program design

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DISEASE MANAGEMENT STANDARDDM 9 Requirements
for Measuring Program Performance by Clinical
condition
Mandatory

• The disease management program measures program
  performance and effectiveness for each clinical
  condition in a manner that reflects
  evidence-based standards of care by
• Establishing clinical process(es) and outcome(s)
  objectives for each condition
• Measuring at least two outcomes, one of which is
  clinical, for each condition targeted based on
  objectives established for that condition and
• Comparing performance data to program outcome
  goals.

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DRUG THERAPY MANAGEMENT DTM 5 Coordination of
Care

• The organization is able to coordinate care for
  targeted individuals with care management plans.
  Coordination may include one or more of the
  following (n/a)
• (a) Establishing processes that allow appropriate
  sharing and communication of consumer information
  among health care providers who have a need to
  know (such processes should be able to identify
  those practitioners who need to have access to
  this information) or (4)
• (b) Maximizing the productivity of drug therapy
  management providers through appropriate use of
  information technology and other communication
  tools or (3)
• (c) Providing a capability that allows one
  provider to refer consumers to another. (4)

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CM 19 CASE MANAGEMENT PLAN OF CARE

• The organization establishes and implements a
  policy to document for every consumer a case
  management plan specific to the individual
  consumer that
• Is developed by a case manager in collaboration
  with the consumer and members of the health care
  team and
• Identifies
• Short term goals
• Long term goals
• Time frames for re-evaluation (follow-up) and
  response to services
• Resources to be utilized and
• Collaborative approaches to be used (including
  family and physician participation).

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DM and DTM Activities that Could Promote Safety

• Examples of Potential QIPS
• Identify patient safety and health promotion
  opportunities through existing data analysis.
• Incorporate patient safety issues into guidelines
• Define patient safety triggers to enable early
  identification of issues.
• Include patient safety issues as part of routine
  DM screening and assessment.
• Design a reporting cascade for sentinel events.
• Engage the DM industry leadership for ideas in
  how to design and implement integrated patient
  safety programs.

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Consumer Safety Mechanism
The organization has a mechanism to respond on an
urgent basis to situations that pose an
immediate threat to the health and safety of
consumers
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Consumer Safety QIP Requirements
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Collaborative Patient Safety Roles for Medical
Management
Prevention
Reporting
Tracking
COORDINATED
Intervention
Education
Authorizing
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ACTIVITES TO PROMOTE CONSUMER SAFETY
COORDINATED CARE

• Integration of Provider Quality Data with the
  re-credentialing process
• PBM, CM, DM and DTM activities proactively shared
  with providers and consumers
• Multiple points of entry for disease management
  referrals
• ER Case Management referrals
• Activities to enhance follow-up appointment
  compliance

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Barriers of Medical Management in the Patient
Safety Role

• Lack of on-site patient interface
• Lack of integration with other system elements
• Quality improvement feedback mechanism not
  established
• Limited leverage

• Patient safety indicators not defined
• Lack of stakeholder awareness of the medical
  management role
• Lack of standardization assessment, data entry,
  codes, performance benchmarks

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Strengths of Medical Management in the Patient
Safety Role

• Evidence based guidelines
• Decision support tools
• Clinical professionals
• Direct patient and/or provider interaction (for
  some)
• Real time data access and link to claims data

• Routine use of CPT and ICD9 codes to classify
  activities
• Routine use of patient assessment
• Routine use of patient education

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UM Activities that Could Promote Safety

• Examples of Potential QIPS
• Sentinel events tracking
• Medication assessments
• Comparison of treatment to guidelines
• Discharge planning
• Report to facilities or customers
• Channeling or referral
• Counseling providers

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CM Triggers and Flags CM Activities that Could
Promote Safety

• Typical Triggers for Case Review
• Examples of Potential Quality Improvement
  Projects
• Unexpected mortality
• Unusual LOS
• Unexpected transfer to higher intensity of care
• Unexpected readmission
• Unexpected return to OR
• Hospital acquired infection
• Failure/delay in diagnostic testing
• Failure/delay in transfer to appropriate setting

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Moving Forward

• Integration of DTM, PBM, HUM, DM, and CM services
  
• Consumer Value Based Health Purchasing Measures
  Project (CVBHPM)
• Major Standards Revision to address continuity of
  care services

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Further Questions

• Christine Leyden, Director of Accreditation
• 1220 L Street, NW
• Suite 400
• Washington, DC 20005
• www.urac.org
• 202-216-9010