Federal Employee Health Benefits

Community Health Plan Patient Safety Initiatives

Community Health Plan is committed to conducting activities to improve patient safety and reduce risk for members. The Plan will work in collaboration with network providers to provide a "climate" for safety. These activities include, but may not be limited to:

Quality of Care

Individual Case Review
The Provider Relations/Quality Review Committee reviews individual cases in which the standard of care received by a member is in question. The review includes an examination of medical records and information received from the involved providers.

Sentinel Events Review
Quality indicators are used to identify events/occurrences that require investigation to determine if there are quality concerns. Quality indicators may include adverse outcomes that may be closely associated with a poor process of care. The quality indicators for Community Health Plan include:

1. Unplanned readmission to a hospital within 30 days of discharge
2. Unexpected death:
3. Suicide attempt while hospitalized
4. Medication errors with unfavorable outcome
5. Blood transfusion error
6. Complications to care
7. Wrong patient/wrong site (surgery/radiology).

Utilization Analysis
Analysis of frequently used procedures, inpatient utilization, ambulatory care utilization, mental health utilization, and pharmacy utilization is conducted through Quality Improvement. Utilization that falls into either the 10^th or 90^th percentile undergoes focus review. In the past such review has resulted in addition of tonsillectomies and adenoidectomies being added to the prior authorization list, focused review of cardiac catheterization against ACC guidelines to insure appropriateness of use, and implementation of step therapy protocols for COX II inhibitors and Montelukast (Singulair®) for Seasonal Allergic Rhinitis.

Pharmacy Programs
Community Health Plan's pharmacy benefits manager, PharmaCare, processes pharmacy claims at the point of sale. Prescriptions are verified through a drug utilization review process that identifies potential interactions with other medications, duplicate pharmaceuticals within the same drug class, and age and weight dosage problems. Step therapy protocols for COX II inhibitors and Montelukast (Singulair®) for Seasonal Allergic Rhinitis were put in place in 2003. In 2004, a program that can apply quantity limits to narcotic and analgesic combination products was implemented.

Credentialing
Community health Plan has established credentialing policies that require us to select and recredential physicians every 3 years. Our credentialing process follows recognized accrediting standards and includes such requirements as medical school degree and state licensure, board certification, valid state and federal narcotics licenses and history of legal claims.

To participate in our network, hospitals and other health care facilities must be accredited by the Joint Commission on Health Care Organization or their site reviews by the Centers for Medicare and Medicaid Services must show that the facilities meet our quality and certification standards. In addition, facilities must show proof of state licensure, Medicare certification and minimum malpractice coverage.

Physician Compliance with Practice Guidelines
Compliance with practice guidelines that are associated with the Plan's disease management programs (diabetes, CHD, asthma, COPD) is measured annually. Results of the studies are communicated through focused interventions by our provider services manager for the DM programs, through the Provider Advisory Committee for the DM programs, and in the Provider Newsletter. Such communication has resulted in increased compliance with guidelines as shown in the progression of improvement over the years that the DM programs have been in place.

Community Health Line
Community Health Line is our health resource line that is available 24-hours-a-day, 7 days a week. Community Health Line is staffed by nurses dedicated to answering health questions and insuring that patients are directed to the most appropriate avenue of care. The service is completely free-of-charge.

Disease Management
Community Health Plan's Community Connections Disease Management Programs are designed to help members manage chronic conditions in coordination with their physicians. Disease management programs focus on member education and self-management strategies, with a goal of improving overall health and promoting the best possible quality of life. We currently offer programs on diabetes, coronary heart disease/congestive heart failure, asthma, chronic lung disease (COPD), low back pain and depression.

These programs are provided at no additional cost to Community Health Plan members who are diagnosed with any of these conditions. Call the Community Health Plan customer service number on the back of your Community Health Plan card to see if you are eligible for the programs or for more information about the programs.

Diabetes Connections is available to eligible members with type 1 or type 2 diabetes. This program includes educational phone calls, mailings and diabetes management guidelines that can help members stay in control of the disease so they can live a healthy and productive life. A system of interventions improves members' health and prevents, delays or reduces the severity of long-term complications.

Cardiac Connections coordinates and integrates all of the healthcare needs of members diagnosed with heart disease and congestive heart failure. This program reflects current, evidence-based guidelines for care and best practices and uses a system of telephone calls, mailings and cardiac management guidelines that help members stay in control of the disease and live a healthy and productive life.

Asthma Connections provides asthma-specific interventions and includes a focus on the pediatric population. Interventions are provided by clinical staff and include phone calls to members and their physicians, asthma-specific care management, and member and provider education.

COPD Connections is a comprehensive, population-based program for members with airflow obstruction due to chronic bronchitis, emphysema or asthma. Using a combination of area clinicians and home pulmonary rehabilitation services, the COPD program delivers interventions, including phone calls to members and providers, care management, and member and provider education.

Low Back Pain Connections provides low back pain interventions by the clinical staff through phone calls to members, back care material mailings, and member and provider education. This program helps members quickly regain their usual activity level, return to work earlier and prevent reoccurrence of low back pain.

CARE Connections is designed for members who have been diagnosed with depression, who have been hospitalized for depression or are at high risk of being hospitalized, or who are in need of significant assistance in accessing Behavioral Health care. Behavioral Health nurses provide telephonic support, educational mailings, and coordination of care between the health plan, the member, and the member's providers with respect to depression management.