2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Quality Improvement Program6. Continuity and Care CoordinationContinuity and care coordination that membersreceive is monitored to improve communicationacross the Presbyterian’s health care network andbetween medical and behavioral health carepractitioners. Information exchange betweenmedical and behavioral providers must be memberapprovedand be conducted in an effective, timely,and confidential manner. PCPs are encouraged tomake timely referral for treatment of behavioralhealth disorders commonly seen in their practices.Drug use evaluations of psychopharmacologicalmedications are conducted to increase appropriateuse or decrease inappropriate use, and to reducethe incidence of adverse drug reactions. Data iscollected and analyzed to identify opportunities forimprovement. Collaborative interventions areimplemented when opportunities for improvementare identified.7. Standards of CarePresbyterian has processes in place to assure thathealth care services provided to members arerendered under reasonable standards of quality ofcare consistent with prevailing professionallyrecognized standards of medical practice. This ismonitored through the credentialing,recredentialing, and quality of clinical careprocesses.8. Service Quality ConcernsService quality concerns from members,practitioners, and providers are tracked bothindividually and in aggregate to identify potentialproblems with quality of services. Provider networkmanagement investigates service-relatedcomplaints that involve providers. Interventions areidentified, developed, and implemented, asappropriate.9. Clinical Practice GuidelinesClinical practice guidelines for acute and chronicmedical conditions and behavioral health disordershave been adopted using current and evidencebasednationally recognized sources. The clinicalpractice guidelines are reviewed at least every twoyears and are appropriately updated anddisseminated. Practitioners are involved in thereview and approval of all guidelines. The use ofguidelines is measured annually using NCQAHealthcare Effectiveness Data and Information Set(HEDIS ® ), the Physician Performance Assessment(PPA), or by an internally developed methodology.10. Preventive Health Care GuidelinesPresbyterian adopts preventive health careguidelines from nationally recognized, evidencebasedguidelines for all age groups. The use ofguidelines is measured annually using HEDIS ® , thePPA, or an internally developed methodology. (Seethe QI Program: HEDIS ® Medical Record DataAbstraction section at the end of this chapter for athorough discussion of HEDIS ® .)11. Member Medical RecordsTo ensure that the Presbyterian provider networkmeets a minimal set of standards for medicalrecord documentation, individual practitioneradherence to standards is monitored and comparedto performance goals. Presbyterian regularlyassesses compliance with these standards and awritten report is mailed to the practice outlining the12-52014 Practitioner and Provider Manual - Ver. 3