2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Quality Improvement Programaccess to care. Complaints, grievances, andappeals are tracked in aggregate to identify trendsand opportunities for improvement. The aggregatereport is reviewed quarterly by the CareCoordination Management Team. Trends aretracked and addressed. Where indicated, actionplans are developed to address opportunities forboth procedural and individual case activities. Theuse of guidelines is measured annually usingHEDIS ® , the PPA, or an internally developedmethodology.15. Early and Periodic Screening, Diagnosis, andTreatmentThe Early and Periodic Screening, Diagnostic andTreatment (EPSDT) Program for Tot-to-Teen healthchecks (also called Well-Child checkups) is in placefor Presbyterian Centennial Care members asrequired by the New Mexico Human ServicesDepartment (HSD). EPSDT services are measuredannually using HEDIS ® and the PPA.16. Health Risk Assessment and Personal HealthAssessmentsFor Centennial Care: All members who are new toPresbyterian Centennial Care complete an initialHealth Risk Assessment of their physical andbehavioral health needs. Results of theseassessments enable Presbyterian to determine ifnew members would benefit from carecoordination, case management, or diseasemanagement program services.For Medicare: All the Medicare members who arenew to Presbyterian Medicare Advantage productsare encouraged to complete an initial PersonalHealth Assessment (PHA) of their physical andbehavioral health needs. Results of theseassessments enable Presbyterian to determine ifnew members would benefit from carecoordination, case management, or diseasemanagement program services.The employer groups that participate in the HealthyAdvantage Wellness Program have access toWebMD ® for the PHA. The assessment covers awide range of common illnesses and risk factors.Members can use their PHA score to determinewhich tools would be of help to them, includingweb-based interactive consumer health tools,printed educational materials, and public or privateresources related to their specific health needs.They can also receive advice about improvingbehaviors that impact their health. Referrals to carecoordination, case management, and diseasemanagement programs are available for memberswith chronic illnesses and members who need helpobtaining care.17. Culturally Appropriate ServicesPresbyterian supports culturally competent andsensitive services. These services begin with anunderstanding and respect for language, ethnicity,race, age, and gender-based differences. It isessential that these differences are recognized andshared with our staff when interacting withmembers verbally, non-verbally, and in writing.Without effective interactions, members may notunderstand their health care benefits or be able toparticipate fully in the recommended course ofprevention and treatment.At all levels of operations, Presbyterianacknowledges and promotes the importance of and12-72014 Practitioner and Provider Manual - Ver. 3