NEVADACARE PATIENT SAFETY INITIATIVES

Patient Safety Initiatives

NevadaCare, Inc. has a very strong commitment to quality and patient safety. You can't have one without the other. Our commitment to achieving the highest level of satisfaction from its members and providers is demonstrated by achieving JCAHO accreditation and using NCQA HEDIS measures to improve our quality programs, patient safety and satisfaction levels. We strive to ensure that our managed care plan delivers the right procedure, in the right setting, at the right time. Our performance and quality have been evaluated by the most respected independent organizations.

JCAHO Accreditation
If members receive their healthcare from JCAHO accredited healthcare environments, shouldn't their health plan be JCAHO accredited as well? The Joint Commission on Accreditation of Health Care Organizations (JCAHO) is an independent, non-profit organization dedicated to improving the quality of healthcare. It reviews and accredits hospitals and managed care companies based on a thorough review of key quality and performance measures. By reviewing and maintaining JCAHO accreditation NevadaCare strives to:

• Improve Care to the individuals served, by raising the safety and quality of care to the highest possible level through the use of performance improvement concepts that continuously improve the standards for quality of care, treatment and services.
• Strengthen Community Confidence by ensuring the consistent effective and efficient delivery of safe and appropriate care through partnering with providers and members by removing barriers to care.
• Support Network Providers through education and on-site review for managed care requirements including State and Federal requirements.
• Ensure Uniformity of Process by choosing the most stringent compliance requirements across all populations, government and commercial alike.
• Build Compliance into processes and truly operationalize quality so the focus remains on supporting the provider/patient relationships on an on-going basis to ensure resources are expended for operational activities rather than "preparing" for a review, be it a survey or audit.

Our Patient Safety Initiatives
Here are examples of ways that NevadaCare is working to help improve patient safety.

• Patient Care Coordinator: When a patient is discharged from the hospital, they are contacted to ensure follow-up appointments are kept, prescriptions are filled and DME equipment is delivered.
• OB High Risk Program: We work with providers to identify and follow high risk pregnancies to ensure a healthy infant outcome.
• Well Woman Reminder Cards: On the member's birthday a reminder card is sent regarding preventative well women care.
• Home Safety Checks: Prior to all hip and knee replacement surgeries, home health services does a home safety check to ensure a safe post-op environment and prepare for post-op physical therapy.
• Member Newsletters: Members receive written educational information through member newsletters. Also available is one on one telephonic contact, to inform members of available options. There is also on-line access to a web site for review of topics.
• Referral to Centers of Excellence: NevadaCare refers patients for a number of specialized procedures to hospitals that do high volumes of those procedures.
• Philosophy of Approach: NevadaCare's approach is that most errors can be avoided by improving systems and safeguards, rather than by punishing individuals. "When requirements are not met quality approach does not look for a person to blame, rather it looks to the process and considers the problem an opportunity for improvement."
• Compliance: Bi-annually NevadaCare notifies providers of those members who have been identified as non-compliant with physician treatment plans.
• New and Emerging Medical Treatment: When a provider or member requests coverage for a new treatment, drug or device, we review each request individually. Our review process is thorough, thoughtful and led by the Medical Directors of NevadaCare. They are well supported by expert perspectives, including a variety of internal and external resources.

NevadaCare is active in supporting the consumer/provider relationship in the provision of safe and appropriate care through the following activities:

• Intensive credentialing process to ensure that only those providers who meet Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards are part of the NevadaCare, Inc. Network.
• Review of the environment where all care will be delivered whether it is in, for example, the provider office, hospital or outpatient surgery center. This review includes, at a minimum, evaluation of infection control; fire safety; staff competency; appropriate staffing levels; equipment maintenance; security; and, (bio) hazardous materials.
• Provider Advisory Committee review and recommendation of clinical practice guidelines that are based on the most current medical criteria and standards of care.
• Ongoing review of medical records to ensure that current standards of care are being met.
• Corrective action to providers not meeting standards.
• Routine assessment of claim submissions and associated codes that may indicate a quality of care concern.
• Thorough research into all quality of care complaints made by consumers.
• Adoption of the JCAHO Patient Safety Goals which include provider and consumer education via newsletters.

CARE MANAGEMENT

Through Care Management NevadaCare enhances patient safety by focusing on outcomes for overall wellness in many programs including disease management, prescription drug care and managed behavioral health. These programs serve to educate our members about patient safety and bring an increased level of awareness when members participate in the quality of care that improves their quality of life. Each program is proactive, patient focused and outcome oriented with safety as its primary goal.

Disease Management
Managing a disease requires coordination between physician, pharmacist and patient. NevadaCare programs are designed to educate participants on topics related to their specific condition, compliance with their physician's treatment plan and assisting the patient in making lifestyle changes that will help them better manage their chronic condition.

Managed Behavioral Health
NevadaCare's behavioral health provider identifies and provides Care Management Programs for members at high risk for hospitalizations or high utilizers of behavioral health services. Care Management Programs such as substance abuse, history of suicide attempts or violence, help to maintain members in the treatment setting that is least disruptive to their daily lives and reduces unnecessary hospitalizations.

Transplant Coordinator
For the complexity of organ donation and transplants, NevadaCare has a specific Transplant Coordinator Case Manager for clinical management and organization. Meeting the sensitive needs of these patients and working with providers of care collectively, ensures comprehensive care.

Asthma Program
This program was developed to identify, diagnose and manage those members with asthma. The program is also designed to improve medication compliance and provider follow-up.

Synagis Protection Program
This program was developed for members receiving Synagis injections. Members are provided care by Pediatric Pulmonary Specialists, as opposed to this medication being given by home health providers.

Hospitalist Program
The Hospitalist Program is the exclusive inpatient primary medical care provider for plan members ages 18 years and older requiring non-obstetric admissions. This Hospitalist Program performs as the PCP for inpatients. The hospitalist doctors are available 24 hours a day, referring patients to specialists as needed and monitoring the use of specialty services. Patients always have access to their inpatient physician, who then updates their PCP upon discharge.

PHARMACY QUALITY CARE PROGRAM

R/X^x Pharmacy Solutions, Inc is the pharmacy benefit management company for NevadaCare and is also a sister affiliate company to NevadaCare, Inc. Therefore, R/X^x is inherently involved with all pharmacy benefit oversight for NevadaCare, working directly with the NevadaCare Health Services and Quality Oversight departments. This process provides an enhancement to patient safety and improvement in health outcomes by monitoring the ways in which drugs are prescribed and used.

The Pharmacy Quality Care Program grew out of a positive working relationship. The patient benefits because of the cooperative relationship between NevadaCare and R/X^x. The pharmacy staffs from both organizations provide direction and administration of important safety programs listed below:

Quality Assurance Programs
This process provides an enhancement to patient safety and improvement in health outcomes by monitoring the ways in which drugs are prescribed and used.

Therapeutic Guidelines
These guidelines provide an opportunity to educate physicians on the standards of drug therapy that prove the most effective in treating specific diseases. This educational process helps ensure appropriate drug usage.

Prior Authorization Programs
This approval process encourages the most appropriate and cost effective use of medication through use of step protocols and clinical reviews thereby discouraging inappropriate prescribing of complex drugs. The review also allows us to identify candidates for case management.

Drug Utilization Review
The goal of this program is to identify potential prescription-related problems such as drug-drug interactions, drug-allergy interactions, drug-disease interactions, drug-pregnancy interactions, duplication in therapy, refill-to-soon, drug-age, under or overdosing or inappropriate therapy.

• Drug-Drug Interaction Screening: The goal is to identify potential drug-drug interactions at the time the prescription is filled. When the pharmacist enters the prescription information into the pharmacy database, the system compares it with all other prescriptions that the member is receiving and if there is a potential for life-threatening complications or permanent damage that may be caused by this combination of drugs. The pharmacist will receive a message identifying the potential problem. The pharmacist can then confirm with the physician to proceed.
• Prospective Drug Review: This occurs prior to a patient receiving a particular prescription. This review provides an opportunity for R/X^x to send a message to the pharmacist at the point of dispensing.
• Retrospective Drug Review: As part of the Pharmacy Quality Care Program, the clinical pharmacists at NevadaCare and R/X^x work cooperatively to accomplish the goals of the review. The review includes:
  • Clinical pharmacist review of identified patient profiles.
  • Discussion of identified issues with the prescribing physician to include: therapeutic appropriateness, therapeutic interchange, quality of care, potential drug interactions, over/under utilization, and proper use of first-line therapy.
  • Physician analysis and profile reporting, including physician consultation, formulary compliance, generic utilization, outcomes management and identification of potential fraud and abuse.