U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Univera Healthcare's Patient Safety Officer:

• Jay I. Pomerantz M.D., Regional Vice President & Chief Medical Officer

I. Internal Corporate Initiatives

A. Univera Case Management

In Case Management, the medical, behavioral health and professional staff handling the member's personal health care information are sensitive to safety and well being as it relates to social, economic, demographic and psycho-social surroundings. In-house and On-site processes are in place to ensure those safety issues of members and case managers are addressed. The processes are designed to decrease risk and increased safety when conducting case management activities telephonically or in the field.

Case Management plans for the management of incidents that may impact or compromise the safety and well being of a member and/or case manager. The guidelines assist with identification of and intervention for situations of apparent or immediate jeopardy to the health or welfare of a member. Situations covered in these guidelines include:

• child and elder abuse
• domestic violence
• suicide
• disease and infection prevention and control

The Plan offers crisis intervention training and seminars annually. Case Management staff who communicate with members on a regular basis are encouraged to attend a session annually. This process was established to ensure compliance with CM-URAC 2.0 Standards.

B. Leapfrog and hospital initiatives

Focus has been on the “Leaps” of Computer Physician Order Entry (CPOE) to reduce medication errors, evidence-based referrals for surgeries, and Intensivists for ICU staffing. In WNY a hospital system has begun to consolidate services around the highest volume providers in their system. We also have been identifying “best practice” in patient safety in contracted facilities and when possible, sharing this with our other contracted facilities.

C. FLRx Patient Safety Initiatives

Patient safety when utilizing pharmaceuticals is important to the Health Plan.

POINT OF SERVICE SAFETY CHECKS

Edits: Effective in October 2000, FLRx implemented drug utilization review (DUR) messaging to pharmacists alerting them to drug-drug interactions. The nationally based program administered by First Database is utilized. Messages are displayed to pharmacists as prescriptions are being processed on line. Over 99% of all claims are processed on-line and subject to drug utilization review edits. On-line claims processing provides a series of standard safety and accuracy checks including:

• Drug/drug Interaction - Alerts pharmacist when a member has a potential drug/drug interaction with a new prescription. This alert reduces the chance of drug interactions when members use multiple pharmacies.
• Duplicate Therapy - Notifies the pharmacist when a member is being prescribed a duplicate therapy to an existing prescription.
• Too early refill - Prevents a member from refilling a drug prior to 75% of the current supply being exhausted. This edit helps to reduce stockpiling and waste and may be overridden for exceptions such as vacations. This edit can also alert the pharmacist that the member may be taking medications incorrectly and thus, needing a refill too soon. The edit promotes education and counseling.
• FDA guideline - Dosage checks - Specific drugs are checked for high dose/low dose, age appropriate dose. This alert provides a safety check for members.
• FDA guideline - Quantity checks - Limits quantities on specific drugs to either FDA recommended guidelines for maximum dosage or standards of clinical practice. This alert provides safety check for members and reduces drug stockpiling. This edit may be overridden in cases of medical necessity.
• Dose efficiency edits - Limits quantities for selected drugs to prevent a member from taking 2 lower strength pills when there is a single, higher strength pill available. This edit may be overridden for medical necessity.

UTILIZATION SAFETY

Prior Authorization: In order to assure members access to safe, effective drug therapy and to protect against waste and inappropriate use, FLRx has implemented prior authorization on selected prescription medications.

Prior authorization medications have:

• Clinical value for a narrowly defined population as defined by FDA guidelines and literature based evidence for use.
• Potentially serious side effects if used inappropriately.
• High potential for misuse or abuse due to direct to consumer advertising or a general lack of understanding on how to use the drug most safely and effectively.
• Cosmetic uses.

Prior-authorization helps assure that the clinical situation of the patient, including the underlying condition, choice of the drug, dose and frequency, is appropriate for the use of that particular drug. The process involves a review by our pharmacy management clinical team. Our team uses criteria approved by community physicians and pharmacists and provides guidance to both the physician and the member. Additionally, prior authorization provides an important safety check in the system that the drug is not being submitted in error by the pharmacy. This is of particular concern where the drug has a serious side effect profile.

PROVIDER AND MEMBER EDUCATION INITIATIVES

FDA Alerts: FDA alerts emerge very frequently making it practically impossible to notify everyone, all the time. Major FDA alerts, as well as new drug interactions, are addressed in the “Rx Facts - Clinical Updates.” This publication is sent to pharmacies and practitioners who sign up to receive it.

Product Recalls: Practitioners and members are notified of product recalls if the medication has been prescribed/filled for the member in the preceding four (4) months.

Rx Facts: Monthly newsletter with the latest pharmaceutical information for providers.

D. Other outpatient initiatives

Physician Office Site Visits

Offices of physicians applying to participate with the Health Plan receive a site visit to ensure compliance with physical and environmental safety requirements. Practitioners who are not in 100% compliance with the requirements are required to submit plans of correction, which must be received and approved prior to presentation to the Credentials Committee for appointment approval.

Ongoing Monitoring of Physician Office Sites

Member complaints regarding physician office sites are monitored in an ongoing manner to ensure that potential safety issues are identified in a timely manner. Those complaints identifying potential physical safety concerns are investigated through the quality review process.

Patient Specific Automated Office Reminders

Many clinical offices, in the WNY region currently, receive patient specific time of service reminders outlining preventative health screenings that have not been performed as well as listings of medications recently refilled to compare with those prescribed for frequency and compliance. This information ensures that the PCP is aware of all medications the patient is on that may have been prescribed by other practitioners in efforts to reduce the risk of a medication being prescribed that would interact harmfully with another medication the member is currently on. Also, individual patient prescription drug profiles and/or patient disease profiles are shared with he patient's doctors via quarterly reports.

Rate Based Indicator Reports

Clinical indicators and sentinel events for outpatient and inpatient care are tracked and trended on a quarterly basis against thresholds to monitor for patterns of care provided. Data points falling outside of thresholds are drilled into for further analysis to determine potential care patterns that may cause undue risk to members with regards to care complications, misdiagnosis, etc.

Clinical Quality Concerns

Individual quality of care concerns regarding practitioners that are forwarded to Quality Management are investigated and reviewed against established acceptable standards and patterns of care through the established peer review process. Concerns are provided a severity level based on review outcome to identify the level, if any, that the care provided did not follow the acceptable standards. In addition, practitioner trends or significant digression from acceptable clinical and safe practices are further reviewed for presentation to the Credentials Committee as necessary.

Disease Management Programs

Population based disease management programs provide targeted reminders and educational programs to identified members and their treating practitioner. These reminders and educational programs notify the member and practitioner of screenings/tests/or medication refills which are due according to the evidenced-based clinical guidelines which support the chronic illness program. These screenings/tests/medications have been proven to reduce and/or prevent harmful complications to members with chronic illness. By raising awareness and encouraging use of these needed services and medications, the Plan addresses the safety of these individuals through avoidance of detrimental complications. The disease management program using the evidence-based guidelines designs interventions shown in the literature to offer the maximal opportunity for the member to receive the appropriate care intervention. Current Disease Management Programs include: Hypertension, Coronary Artery Disease, Diabetes, and Asthma.

Quality Based Incentive Programs

There are several initiatives aimed at providing incentives to providers for the delivery of quality care. In Western NY there are several separate initiatives that focus on proper prescribing practices, a pilot to provide financial incentives for meeting predefined quality goals, as well as provision of efficient care. There are ongoing discussions to expand the pilot program for quality based measures into the general provider population.

Continuity and Coordination of Care

The Plan monitors for exchange of information between PCPs and specialists and also between institutional providers and PCPs to ensure that the PCP maintains awareness of all care and treatment, including all medications, provided to his/her patient across the continuum.

II. External Associations and partnerships

• JCAHO

Health Plan hospital contracts require maintenance of certification, if certified and if not a review process to assure compliance with similar guidelines.

• On January 1, 2003, compliance with JCAHO's six National Patient Safety Goals became mandatory. Aggregate data on organization compliance with the requirements will be published at the end of 2003. Individual organization performance data will become available approximately one year later.
• JCAHO has announced a new accreditation process beginning January 2004, which will assume continuous accreditation readiness. The new accreditation process, referred to as Shared Visions - New Pathways focuses on quality and safety of care and strives to provide strong incentives for organizations to provide safe, high-quality care at all times. The expectation is that accredited organizations will be in “compliance with 100 percent of the Joint Commission's standards 100 percent of the time.”

As an outgrowth to the new accreditation process, beginning in 2006, all regular accreditation surveys by JCAHO will be unannounced. Currently the regular accreditation surveys are scheduled in advance. Unannounced surveys will be pilot-tested in volunteer organizations during 2004 and 2005.

B. URAC

URAC has taken an active approach to promote patient safety standards through its accreditation standards. In addition, URAC is involved in qualitative research to identify effective patient safety practices in medical management programs as noted below.

Patient Safety in Utilization Management (UM) Systems: URAC has initiated a research project, funded by the Robert Wood Johnson Foundation, that examines how UM programs identify and address possible patient safety issues. URAC is analyzing how UM information technology (IT) systems are programmed to flag patient safety problems and how program staff respond to flags through investigation or intervention. URAC's study will establish baseline information on UM IT practices relating to patient safety, and identify preliminary “best practices” in UM information management and follow up strategies

Patient Safety in Disease Management Programs: URAC recently announced a second project to showcase Disease Management Practices for Employers and Health Plans funded by a grant from AdvancePCS. URAC is seeking information on approaches to improve patient safety through disease management (DM) programs. In February 2003, URAC issued a “call for innovative practices,” and organizations are invited to submit information on how their DM programs contribute to improved patient safety. Selected programs will be published on URAC's Web site as brief case studies and distributed to employers, purchasers, health plans, and other organizations as a tool to educate on effective DM practices.

Innovative DM practices will be categorized into the five areas of patient safety practices outlined by the National Quality Forum (NQF) (also noted on page10 of this report):

• Improving Patient Safety by Creating a Culture of Safety
• Matching Healthcare Needs with Service Delivery Capability
• Facilitating Information Transfer and Clear Communication
• Adopting Safe Practices in Specific Clinical Settings or Specific Processes of Care Increasing Safe Medication Use

C. AMA

The AMA convenes the Physician Consortium for Performance Improvement (The Consortium). Its' mission is to improve patient health and safety by:

• Identifying and developing evidence-based clinical performance measures that enhance quality of patient care and that foster accountability;
• Promoting the implementation of effective and relevant clinical performance improvement activities; and
• Advancing the science of clinical performance measurement and improvement.

The Consortium includes methodological experts, clinical experts representing more than 50 national medical specialty societies, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS). The Consortium is partnering with physicians, insurers, and payers from both the private and public sectors to improve the quality of chronic care.

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