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    Healthcare Plan Information

    Optima Health Plan Patient Safety Initiatives

    Improving the Quality of Healthcare by Reducing Medical Errors and Increasing Patient Safety

    Responsibility for patient safety efforts is located in Optima's Quality Improvement Department.

    Optima Health Plan has developed materials on how to prevent medical errors which it has shared with it's providers and encouraged it's providers to review with their patients. Optima Health Plan has worked with providers through the "Resistance Kills" campaign to reduce the over-prescribing of antibiotics. Optima also provides Primary Care Physicians with lists of the pharmaceuticals dispensed to members assigned to them so that the PCPs may check for possible drug interactions and overdoses. Educational sessions are conducted with providers to discuss treatment methodologies and ways to improve patient compliance with prescribed courses of treatment. In addition, Optima continues to address patient safety through the methods below.

    Pharmacy

    Argus Health Systems, Inc. processes pharmacy claims for the plan. Concurrent drug utilization review edits available through Argus and performed at the retail and mail order level are: Drug/drug duplication; Therapeutic duplication; Early refill; Drug Interactions including drug/drug, drug/allergy, drug/age, drug/gender, drug/disease; Substance abuse; Over-utilization; Dosage consolidation; and Fraud. Pharmacists receive the appropriate alert when processing a prescription claim. The Argus system searches all claims processed for a member, not simply those processed at a particular pharmacy.

    The Pharmacy and Therapeutics Committee, a committee of network physicians and pharmacists make decisions about the use of drugs within the plan. The Committee looks at peer-reviewed medical literature and obtains input from appropriate medical specialty groups. The Committee decides to require pre-authorization for some drugs due to safety concerns. When reviewing drugs for addition to the preferred/standard drug list, safety is one of the primary areas of evaluation. When deemed useful for specific patients groups, the Committee may develop usage criteria and require pre-authorization for use of a drug. This ensures the most appropriate members receive the drug. For example, based on the FDA recommendations, the Committee instituted a pre-authorization for Oxycontin use limiting the medication to cancer sufferers and chronic pain relief only. Also in the interest of the population, the Committee decided to place all ACE Inhibitor medications and their diuretic combination products on the preferred/standard list. This was done in response to the overwhelming amount of data supporting the reduction of morbidity and mortality as a result of taking these medications to treat many disease states that are prevalent in the community. In the past, the Committee has left drugs off the preferred/standard list due to safety concerns. Examples of these drugs include Baycol, Duract, Posicor, and Trovan. All of these drugs were subsequently removed from the market.

    Medical

    Optima Health Plan has extensive Case Management and Disease Management programs in place. Members in active treatment for a condition are assigned case managers who monitor the quality and appropriateness of care received. Optima provides education and follow-up for members with chronic conditions, such as diabetes. In addition, all network hospitals are Joint Commissioned Certified. This includes monitoring the following patient safety areas: Medication errors and corrective actions for these areas; Patient falls; Patient restraints.

    Medical Care Management Case Managers conduct daily concurrent evaluations of care being provided in the hospital and also monitor and develop actions regarding occurrences. Some of these monitors are: Deaths; Delays in diagnostic testing; Delays in getting consultant referrals; In hospital injuries; Unplanned re-admissions to the hospital; Unplanned transfers; Return to ICU/CCU; Return to OR. Based on trend analysis of reporting, hospitals are notified of results requiring action to correct. To date there were no continuing action plans at any network hospital.

    Optima also reviews all complaints and grievances regarding services provided to the members. These complaints are trended and all complaints are reviewed and actions provided within the NCQA standards for follow-up.

    Optima Medical Care Management continues to utilize the pre-certification process in order to obtain all necessary information to assure safe services are being preformed by credentialed providers. All new technology requested services go through a 4-part screen to assure that the request and approval would be in conjunction with standard medical practice and would benefit the member long-term.

    Medical Care Management reviews all requests for transplantation services and utilizes Center of Excellence as determined by United Resource Network. These centers are reviewed the their results at 1 year, 5 year and 10 year survivor rates, number of cases and complication rates.

    All Optima contracted physicians are reviewed by a physician credentialing body. The contents of the review are within NCQA standards. Physicians not meeting quality standards are not permitted in the network and do provide services to members.

    Sentara Healthcare, parent corporation of Optima Health Plan, participates with the ICU/USA project improving care provided to patients in the ICU. Physicians and hospitals are continuously monitored for a number of areas to assure the ICU environment it safe and performing quality services. Currently this project is being done at Sentara Norfolk General.

    Any of the above activities are reviewed at the Quality Management Meetings and at the Utilization Management (Medical Care Management Meetings). Any trends are noted and actions are developed to ensure compliance with Quality Management Program and NCQA.

    Consumer and Patient Information

    "Tips to Help Prevent Medical Errors" is one publication which Optima Health Plan has used during the year to encourage members to become more involved in their medical care. Optima Health Plan continues to present a community awareness program that focuses on appropriate use of antibiotics. Postcards, newspapers, TV, and radio sequences are used to promote the idea that viral infections do not respond to antibiotics and the overuse of antibiotics leads to increased levels of bacterial resistance. The projects is known as the "Resistance Kills" program and is projected to decrease the resistance of Strep pneumo (a common bacteria) over a three year time period. The community, physicians, and media all are significantly involved. Optima also continues to conduct classes on disease management, specifically for those members with diabetes.

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