Federal Employee Health Benefits

Keystone Health Plan Patient Safety Initiatives

Background

Keystone Health Plan Central (KHP Central) is committed to safe and effective care for our members. Our Quality Improvement Department oversees the principal aspects of the patient safety initiatives. Following is detail on KHP Central's patient safety efforts.

Credentialing/Recredentialing of Providers

KHP Central's credentialing/recredentialing process provides a mechanism to ensure that providers are properly credentialed and appropriate for KHP Central's network. Primary care physicians and specialists are initially credentialed for admission into KHP Central's network and are recredentialed every three years thereafter consistent with National Committee on Quality Assurance (NCQA) standards. Facility providers are also initially credentialed and then recredentialed on a three-year basis.

KHP Central reviews medical records and conducts office site visits for primary care physicians and specialists as part of the credentialing/recredentialing process. The purpose of these assessments is to ensure that the prospective practice measures up to KHP Central standards for safe and effective care.

KHP Central uses specific requirements in our credentialing/recredentialing decisions. We apply corrective action plans when providers fall short of quality standards. By conducting a thorough credentialing/recredentialing process, KHP Central is promoting the provision of quality care in a safe environment for our members.

Quality of Care Reviews

KHP Central uses the quality of care complaint process to monitor the quality of care provided to members and to identify any trends that would suggest that the standard of care is being compromised. This process ensures appropriate follow-up on complaints concerning the quality of the member's care. These complaints may be received from members, KHP Central utilization management and quality improvement clinical staff, medical directors, or provider relations representatives. The Quality Improvement Department is responsible for investigating all quality of care complaints and for providing the results of these investigations to KHP Central's medical directors who determine if a quality of care issue exists. All quality of care complaints are tracked for the providers involved to identify providers who will receive appropriate corrective actions or termination from the network.

Pharmacy Benefits

• Express Scripts, Inc. (ESI) is KHP Central's Pharmacy Benefits Manager. ESI's system maintains patient drug history to detect potentially harmful duplicate therapies, drug-drug interactions and drug-age interactions for the purpose of informing the pharmacist of these precautions.
• Medication information sheets, which describe the medication, its possible side effects and cautions, are provided with each new prescription.
• Drug consultations with the pharmacists are offered to all KHP Central members with the prescription drug benefit.
• Prior authorizations are required for certain high-risk drugs identified for their potential for abuse.
• ESI and KHP Central have a program that expands the number of precautionary alerts and prevents the pharmacist from filling a prescription that carries a severe caution before careful evaluation. The pharmacist may exercise an override using his/her professional judgment or after obtaining additional information from the prescribing physician or member.
• Therapy limitations have been instituted for specific medications to promote adherence to the appropriate course of therapy, prevent misuse or abuse and medication stockpiling.
• The Retrospective Drug Utilization Review Program provides feedback to physicians on drug-drug/drug-disease interactions, over/under utilization and drug-age/drug pregnancy alerts

Disease Management Programs

KHP Central offers the following Disease Management programs: Asthma, Depression, Diabetes, Chronic Obstructive Pulmonary Disease, Heart Failure, Low Back Pain, Cholesterol Management, Nicotine Cessation and Maternity. These programs include information to educate the member about his/her disease in order to maintain the quality of life. In addition, KHP Central offers Intense Care Management for members with particularly complicated medical conditions. In those situations, KHP Central care managers work with the member to design a personalized program with the member's special needs in mind. Those Intense Care Management programs currently include Asthma, Diabetes, Chronic Obstructive Pulmonary Disease, Heart Failure, Low Back Pain, Fractured Hip and High Risk Maternity.

Provider Education

KHP Central uses periodic provider newsletters, monthly updates to the Provider Administrative Manual, specific provider mailings and routine site visits to communicate patient safety-related information with physicians.

We issue evidence-based treatment guidelines to promote appropriate care consistent with the guidelines issued by recognized authorities, e.g., the American Diabetes Association. KHP Central also shares disease-specific profiles with the members' physicians.

Questions about KHP Central's patient safety efforts may be addressed by contacting KHP Central Customer Service Department by phone at 1-800-622-2843 (TDD: 1-800-669-7075) or via email at CustomerService@khpc.com.