HomeMy WebLinkAboutMINUTES - 12201994 - 1.88 FI
Ta BOARD OF SUPERVISORS
FROM: Mark Finucane, Contra
Health Services Director Cor„}„
DATE: December 2, 1994 �*
SUBJECT: Approval of Contra Costa Health Plan's Quality Management �•
Plan
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION
APPROVE the 'Contra Costa Health Plan Quality Management Plan
which has received approval from State Department of Health
Services and Contra Costa Health Plan Advisory Board.
AUTHORIZE that Contra Costa Health Plan's Quality Management
Plan is to cover health care provided to Contra Costa Health
Plan members, including all Health Services Department services
and all authorized out-of-plan care.
ESTABLISH the Contra Costa Health Plan Integrated Quality
Assessment Committee and DELEGATE the Board of Supervisors'
quality management functions to that body. The Integrated
Quality Assessment Committee will consist of at least eight
members:
Contra Costa Health Plan Executive Director
Contra Costa Health Plan Medical Director
Merrithew Memorial Hospital & Clinics Medical Staff President
Merrithew Memorial Hospital & Clinics Executive Director
Member of the Board of Supervisors
Community Provider
Public Health Division Representative
Mental Health Division Representative
APPOINT the Contra Costa Health Plan Medical Director as the
individual responsible and accountable for the operation of
Contra Costa Health Plan's Quality Management Plan. The Medical
Director of Contra Costa Health Plan will review and approve all
quality management documents before they are forwarded by the
Integrated Quality Assessment Committee to the Board of
Supervisors for their review and approval.
CONTINUED ON ATTACHMENT: X YES SIGNATURE:
t
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ON aa ,,M-661!k aoJIT) APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
I HEREBY CERTIFY THAT THIS IS A TRUE
UNANIMOUS (ABSENT AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
cc,. ATTESTED
Milt S. Camhi, Executive Director PHIL BATCHELOR, CLERK OF THE BOARD OF
Health Services Administration SUPERVISORS AND COUNTY ADMINISTRATOR
M382/7-83 BY 0 A ,DEPUTY
Page 2
II. FINANCIAL IMPACT
Expenses of the Contra Costa Health Plan Quality Management Plan
will be paid by member premiums.
III. REASONS FOR RECOMMENDATION/BACKGROUND
Both the State Department of Health Services and the State
Department of Corporations require that Contra Costa Health Plan
establish an internal Quality Management Plan for its members.
The State Department of Health Services requires that all Medi-
Cal Prepaid Health Plan (PHP) contractors have an approved
Quality Assessment and Improvement Plan (QAIP) . This plan must
include all services for Contra Costa Health Plan members
including those provided by all divisions of the Health Services
Department and all authorized out-of-plan care. The Department
of Corporations also requires that to move forward with Medi-Cal
managed care, including establishing the Local Initiative, that
Contra Costa Health Plan must have a Quality Management Plan.
The establishment of the Contra Costa Health Plan Integrated
Quality Assessment Committee and the appointment of the Contra
Costa Health Plan Medical Director as the individual responsible
and accountable for Contra Costa Health Plan Quality Management
will provide the mechanisms the State requires for an approvable
Quality Assessment and Improvement Plan.
The Department of Health Services approved the Quality
Management Plan on November 10, 1994 and the Contra Costa Health
Plan Advisory Board endorsed the plan at its November 30, 1994
Executive Committee meeting.
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TABLE OF CONTENTS
PAGE
SECTION I: WRITTEN QUALITY MANAGEMENT PLAN DESCRIPTION
A. GOALS AND OBJECTIVES 1-2
B. ORGANIZATIONAL STRUCTURE 2-5
1. INTEGRATED QUALITY ASSURANCE 3
COMMITTEE
2. CCHP ADVISORY BOARD 4
3. CCHP QUALITY COUNCIL 4-8
C. SCOPE OF CARE/SERVICES 8-9
D. SPECIFIC ACTIVITIES 9-15
1. ADVERSE EVENT REVIEW 9
2. SENTINEL DIAGNOSIS REVIEW 9-10
3. AMBULATORY MEDICAL RECORD REVIEW 10-11
4. PREVENTIVE CARE GUIDELINES REVIEW 11
5. QUALITY MEASUREMENT STUDIES 11-12
6. COMPLAINTS AND GRIEVANCE REVIEW 12
7. CREDENTIALING/RECREDENTIALING 12-13
8. RISK MANAGEMENT 13-14
9. PATIENT SATISFACTION SURVEYS 14
10. MEMBER SATISFACTION SURVEYS 14
11. PROVIDER SATISFACTION SURVEYS 15
12. OTHER QUALITY ASSESSMENT ACTIVITIES 15
E. INDIVIDUALS RESPONSIBLE FOR THE QUALITY 15-18
REVIEWS AND QA ACTIVITIES
1. MEDICAL DIRECTOR 15-16
2. QUALITY MANAGEMENT/UM COORDINATOR 16-17
F. CONTINUOUS ACTIVITY 18
G. PROVIDER REVIEW 19
H. FOCUS ON HEALTH OUTCOMES 19
I. CCHP WORKPLAN 1994-95 19
PAGE
SECTION II: QUALITY KANAGEMENT PROCESS 20
ft
A. SPECIFICATIONS OF CLINICAL OR HEALTH 20
SERVICES DELIVERY AREAS OF CONCERN
B. USE OF QUALITY INDICATORS 20-21
C. USE OF CLINICAL CARE STANDARDS/PRACTICE 21-22
GUIDELINES
D. ANALYSIS OF CLINICAL CARE AND RELATED 22
SERVICES
E. IMPLEMENTATION OF REMEDIAL/CORRECTIVE 22
ACTIONS
F. ASSESSMENT OF EFFECTIVENESS OF CORRECTIVE 22-23
ACTIONS
G. EVALUATION OF CONTINUITY AND EFFECTIVENESS 23
OF THE QMP
SECTION III: ACCOUNTABILITY TO THE GOVERNING BODY 24
SECTION IV: ENROLLEE RIGHTS AND RESPONSIBILITIES 25
A. WRITTEN POLICY ON ENROLLEE RIGHTS 25
B. WRITTEN POLICY ON ENROLLEE RESPONSIBILITIES 25
C. COMMUNICATION OF POLICIES TO PROVIDERS 25
D. COMMUNICATION OF POLICIES TO 26
ENROLLEES/MEMBERS
E. ENROLLEE/MEMBER GRIEVANCE PROCEDURES 26-27
F. ENROLLEE/MEMBER SUGGESTIONS 27
G. STEPS TO ASSURE ACCESSIBILITY OF SERVICES 27
H. WRITTEN INFORMATION FOR MEMBERS 27
I. CONFIDENTIALITY OF PATIENT INFORMATION 27-28
J. TREATMENT OF MINORS 28
K. ASSESSMENT OF MEMBER SATISFACTION 28-29
PAGE
SECTION V: STANDARDS FOR AVAILABILITY AND ACCESSIBILITY 30
A. ADVICE NURSE PROGRAM 30
SECTION VI: MEDICAL RECORDS STANDARDS 31
A. ACCESSIBILITY AND AVAILABILITY OF MEDICAL 31
RECORDS
B. RECORD KEEPING 31-32
C. RECORD REVIEW PROCESS 32
SECTION VII: UTIL12ATION REVIEW 33
A. PLAN DESCRIPTION 33
1. PURPOSE 33
2. GOALS 33
3. OBJECTIVES 33
B. ORGANIZATION STRUCTURE 33-34
C. PLAN ACTIVITIES 34
D. CONCURRENT REVIEW 34-35
E. RETROSPECTIVE REVIEW 35
SECTION VIZI: CONTINUITY OF CARE SYSTEM 36
SECTION IB: QMP DOCUMENTATION 37
A. SCOPE 37
B. MAINTENANCE AND AVAILABILITY 37
OF DOCUMENTATION
SECTION %: COORDINATION OF QA ACTIVITIES WITH OTHER 38
MANAGEMENT ACTIVITY
$URRS:TABLCONT.QA
Contra Costa Health Plan
Quality Assurance Improvement Plan
ATTACHMENTS
A. ORGANIZATIONAL STRUCTURE OF CCHP QUALILTY MANAGMU NT PLAN
B. CCHP ADVISORY BOARD BY-LAWS AND COMMISSION ORDERS AND ROSTER
C. AMBULATORY MEDICAL RECORD REVIEW FORMS AND GUIDELINES
D. CCHP DESCRIPTION OF MIS AND OTHER FUNCTIONS
E. CREDENTIALING/RECREDENTIALING GUIDELINES
F. MEMORANDUM OF UNDERSTANDING BETWEEN CCHP AND MMH&C REGARDING
DELEGATION
G. QA COORDINATOR JOB DESCRIPTION
H. MMH&C QUALITY ASSURANCE PLAN
I. CCHP SERVICE PROTOCOLS
J. WORKPLAN FOR CCHP QMP, 1994-95
K. CCHP BABY TRACKING PROGRAM
L. CCHP QMP PROCESS DIAGRAM
M. EVIDENCE OF COVERAGE DOCUMENT
N. MEMBER HANDBOOK
O. CONFIDENTIALITY POLICY
P. PATIENTS RIGHTS REGARDING MEDICAL TREATMENT
Q. ACCESS STANDARDS
R. ADVICE NURSE QA/UM PLAN AND SURVEY REPORT CARD
S. PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
T. PATIENT ACCESS TO MEDICAL RECORDS
U. CCHP MEMBER SATISFACTION SURVEY
V. CCHP QUALITY MANAGEMENT "TOOLS"
W. BOARD OF SUPERVISORS ORDER DELEGATING QA
X. ORGANIZATIONAL STRUCTURE OF OFFICE OF MEDICAL DIRECTOR
SUM ATTACIO
SECTION I: WRITTEN QUALITY MANAGEMENT PLAN DESCRIPTION (QNP)
The purpose of the Contra Costa Health Plan (hereafter called CCHP)
Quality Management Plan is to objectively evaluate, systematically
monitor, and continually improve the quality of care and services
provided to the enrollees. In collaboration with providers, CCHP will
establish clinical and service standards which will serve as benchmarks
for measurement and improvement. Quality management will encompass all
functional disciplines of the Health Plan.
A. GOALS AND OBJECTIVES
1. To facilitate a partnership with CCHP and its providers,
members and Health Plan managers for the continuous
improvement of quality health care delivery.
a. Promote and build quality into the Health Plan's
organizational structure and processes.
b. CCHP will conduct ongoing communication and training
of its staff in areas related to quality improvement
activities.
2. CCHP will provide ongoing monitoring and evaluation of
patient care and services to ensure that care provided the
Plan members meets the requirements of good medical
practice and is positively perceived by Health Plan
members and associated providers.
a. Develop, implement, and evaluate guidelines of
medical practice.
b. Develop medical care administrative guidelines
related to quality management activities (i.e. ,
access/availability, credentialing/recredentialing,
peer review, etc. )
C. CCHP will survey both Health Plan members as well as
providers regarding satisfaction with the quality of
services provided.
3. CCHP will ensure prompt identification and analysis of
opportunities for improvement and implement a remedial
plan of action and follow up.
a. Identify and assess relevant aspects, problems and
concerns of health care services available to the
Health Plan members.
b. Continually review and improve the CCHP Quality
Assurance and Improvement Plan.
C. Give periodic feedback to the Health Plan
2
customers/members and providers regarding
measurement and' outcome of quality assurance and
improvement activities.
4. By enhancing the scope of the Contra Costa County Health
Services Risk Management program, CCHP will incorporate
all service areas in the community as the result of
expansion and will:
a. Define risk program parameters by
incident/occurrence type.
b. Trend incidents/occurrences for evaluation by the
Quality Council/Medical Director/Executive Director.
C. Work jointly with the existing Risk Management
Committee at Merrithew Memorial Hospital and Clinics
(hereafter called MMH&C) to develop Risk Management
educational/prevention activities.
5. CCHP will maintain compliance with local, state, and
national regulatory requirements. CCHP will apply for
relevant accreditation.
a. Monitor regulatory requirements for Quality
Assurance/Risk Management and respond accordingly.
b. Ensure that the reporting system provides adequate
information for meeting regulatory external review
requirements.
6. The Quality Management Plan will create and issue reports
of its activities to the Integrated Quality Assessment
Committee and the Board of Supervisors.
B. ORGANIZATIONAL STRUCTURE
The organization of CCHP's QMP reflects the uniqueness found
within the Contra Costa County Health Services Department. The
county owns and operates MMH&C and has established a Federally
qualified, Knox-Keene licensed HMO within its health services
department. The Contra Costa County Board of Supervisors
serves as the governing body for the hospital and clinics, all
Public Health operations, and the HMO.
The physician and non-physician providers are employees of
Contra Costa County and work directly for MMH&C, which provides
approximately 85% of the care provided to CCHP members. The
remainder of care is provided by out-of-plan hospitals and
providers. All physicians must be members of the Medical
Staff, which is governed by a specific set of bylaws. They
ultimately report to the Board of Supervisors. In the past,
3
the Board of Supervisors has delegated Quality Management
activities to the Medical Staff.
Until the recent past, CCHP has relied on the existing, and
continually improvinc
9
Quality Assurance Plan of MMH&C and the
Medical Staff Due to recent audit
findings, CCHP s Se ng" heYcl..... ir'ectly responsible for the
quality of care and service received by their members and must
have its own internal Quality Management Plan.
This has necessitated organizational changes to accommodate the
required authority that CCHP needs from the Board of
Supervisors to accomplish its Quality Management Plan. The
organizational structure found indtc + '` has management
approval in principle, but is pending i'okkdl`b.oard approval.
The key components of the QMP are:
1. A new INTEGRATED QUALITY ASSURANCE COMMITTEE (IQAC) will
be formed to which the County Board of Supervisors will
delegate the responsibility for the quality of medical
care and services received by Health Plan members anywhere
in the county-wide delivery system, or with any contracted
community hospital, medical group, IPA, or individual
provider.
This committee will have broad multi-disciplinary
representation and will include governing board members,
community provider, CCHP Executive Director and Medical
Director (or designee) , and a representative from the
MMH&C Medical Staff and Hospital Administration.
Committee Responsibilities:
a. Approve the CCHP QMP and periodic updates
b. Receive quarterly reports from the CCHP Quality
Council, review progress on the QMP workplan, and
resolve issues brought to the committee, or make
recommendations to the Board of Supervisors as
required.
C. Approve recommendations from the Credentialing
Committee, or to serve as an appeal board for
contested denials of credentialing by any provider.
d. To review an annual QMP report and submit it to the
Board of Supervisors for approval.
e. To provide support to the Quality Council regarding
issues requiring the cooperation of various
divisions and clinical operations and has the
4
authority to ensure that the mission of CCHP's QMP
is accomplished.
2. CONTRA COSTA HEALTH PLAN ADVISORY BOARD
The CCHP Advisory Board was created by an order of the
Contra Costa Board of Supervisors on January 16, 1979 "S+e
..:....
' tChY& lE #3 >' t'a ;'#Z`...? ...� ,5 'Y .�sL?:
............Ai�v sory""'Board`' hasbroadoversigtit'' 'functions`''"'and
advises the Health Plan on policy decisions, provides
input from the community and enrollees, reviews the
financial plan, rate setting, marketing, provider
relations surveys, etc. It will review and approve the
CCHP Quality Assurance and Improvement Plan, and the
annual work plan, and monitor the progress through regular
reports from the Quality Council.
The CCHP Advisory Board has a membership position for a
Medi-Cal Health Plan member. This representative, along
with other community representatives, will ensure that the
special needs of the Medi-Cal membership are addressed by
the Health Plan.
The CCHP Advisory Board will forward the approved reports
from the Quality Council to the Integrated Quality
Assessment Committee. The Advisory Board reports directly
to the Board of Supervisors, but for the purposes of
Quality Assurance it will pass the reports and information
to the IQAC.
The current membership of the CCHP Advisory Board is found
in Attachment B.
3. THE CCHP QUALITY COUNCIL
The CCHP Quality Council is the primary working committee
of the QMP. This group will meet at least bi-monthly to
receive and evaluate information from the CCHP Quality
Management Plan Coordinator for all delegated Quality
Management activities and perform non-delegated• Quality
Management functions for the contracted providers, e.g. ,
community clinics, Planned Parenthood facilities, and
individually contracted primary care and specialty
physicians and ancillary services which do not have an
internal Quality Management Plan.
This group will receive and evaluate reports from the CCHP
Credentialing Committee, Utilization Committee, Member
Relations, and Provider Relations.
5
MEMBERSHIP:
CCHP Medical Director (Chair)
Member Relations
Provider Relations
Advice Nurse Manager
Pharmacy Representative
Two Primary Care Physicians (one from the community)
Two Specialty Physicians (Obstetrics and Pediatrics)
CCHP Assistant Medical Director
CCHP Quality Management Plan Coordinator
The committee membership appointments, where possible,
will be for two years, staggered in the case of medical
providers, to ensure appropriate continuity within the
committee.
The group will be staffed by the CCHP Quality
Management/Utilization Coordinator.
A. COUNCIL RESPONSIBILITIES:
1. Develop and submit to the IQAC a workplan for the
coming year.
2. Receive and evaluate QM reports on a quarterly basis
from all delegated QM committees and ensure that the
delegated QM activities comply with all regulatory
standards required for delegated activities.
Feedback will be given to delegated QM committees
regarding identified problems, and follow up with
the Quality Council will ensure resolution of any
quality problems.
3. Give assistance and direction through the Quality
Management Plan Coordinator to all Quality
Management committees regarding the development of
quality indicators. Because of the potential of
multiple practice locations and types, the use of
identical clinical indicators will add consistency
across the delivery system and allow the development
of a larger data base.
4. Integrate information received from Member
Relations, Provider Relations, and Utilization
Management into the QM workplan. Opportunities can
be identified to improve the quality of medical care
and service, address access issues for all regions
of the plan, improve continuity of care and
appropriateness of care.
5. Assist the Medical. Director in developing strategies
to address identified problems with the various
6
provider groups. In the case of issues with MMH&C
providers, the Medical Director will take those
issues directly to the Medical Staff Executive
Committee for resolution. The Quality Council will
follow each issue to ensure resolution satisfactory
to the Council.
6. The Quality Council will collate information from
all delegated QM activities and its own activities
into a quarterly report for the IQAC committee. At
the end of each year, the Quality Council will
submit an annual report to IQAC for review,
approval, and submission to the Board of
Supervisors.
7. Since the majority of QM activity with providers
will be delegated to the MMH&C QM Committee, the
CCHP Quality Council, through the assistance of the
CCHP QM/UM Coordinator, will work closely with their
staff to coordinate special projects, develop
meaningful quality indicators across the delivery
system, and incorporate CCHP member and provider
survey information. These efforts will be
accomplished in the format of continuous quality
improvement.
8. Utilization information collected by CCHP will be
collated with the MIS of MMH&C to examine quality
through utilization management perspectives.
Special analysis attention will be paid to identify
over, as well as under- utilization of resources.
Outcome measures will be reported using HEDIS
standards.
9. Standards/practice guidelines used in the CCHP QMP
will be updated upon the availability of new
information or regulatory standards.
10. The Quality Council is responsible for taking
appropriate remedial action whenever, as determined
under the CCHP QMP, inappropriate or substandard
services are furnished, or services that should have
been furnished were not.
Examples are:
a. Documented evidence of inappropriate provider
or staff behavior.
b. Delay in diagnosis.
C. Peer reviewed evidence of poor quality care.
d. Evidence of withholding of a valid member
benefit.
7
e. Inadequate access to emergent or urgent care.
f. System failure resulting in poor quality of
care or service.
g. Utilization information showing over or under-
utilization of medical services, especially
specialty referrals.
h. Inappropriate use of hospital resources and
other hospital oriented issues discovered
through use of quality indicators.
11. The Quality Council is responsible for the logistics
of corrective action. These include:
a. Specification of person(s) or body responsible
for making the final determination regarding
quality problems.
b. Specific actions to be taken.
C. Provision of feedback to appropriate health
professionals, providers, and staff.
d. Determine the schedule and accountability for
implementing corrective actions.
e. Should corrective action not be successful in
the allotted time, modifications of the
corrective action take place as appropriate.
f. Total inability to achieve corrective action
will result in the recommendation to the
Medical Director and the CCHP Advisory Board
that the specific affiliation identified be
terminated for cause per specification of the
provider contract.
12. The Quality Council is responsible for all delegated
QM activities:
a. Delegated activities such as credentialing and
other QM functions are governed by contract
agreements. The authority and responsibility
of the delegated functions remains with the
CCHP.
b. The entities to whom activities have been
delegated will provide the Quality Council with
periodic reports of those activities, and all
files and records of those activities must be
available for CCHP review upon their request.
C. The QM/UM Coordinator is responsible for
obtaining reports, at least semi-annually, from
the delegated entities, and submitting these
reports to the Quality Council for comparison
with CCHP QMP standards and to ascertain the
quality of care or activity being provided:
8
d. The Quality Council will evaluate and approve
quality improvement plans so delegated and will
review these plans at least annually.
13. The Quality Council will review the quarterly QM
report from the Advice Nurse Program and provide
direction in setting quality indicators for this
program or specific quality studies.
C. SCOPE OF CARE/SERVICES
In order to fulfill the goals and objectives of this plan and
to efficiently utilize resources, the CCHP Quality Management
Plan functions as an integrated activity within the Health
Plan. This includes interactions with "the Clinical Health
Services, Provider Relations, Claims Department, and Member
Services Departments. Direct attention will be given to high
volume, high risk areas of patient care and service. CCHP has
developed SERVICE PROTOCOLS in each of these areas. These
protocols include: 1) Service Strategy, 2) Service Standard,
and 3) Service Audit "4t4ttat2rit < j.
.:; :., ....,,,..,.......................�,..w:.�;:,w..;..
Review activities will encompass the following:
1. Quality and utilization of clinical care and services,
including inpatient and outpatient, provided by hospitals,
staff and contracted primary care and specialty physicians
and ancillary providers, such as home health, dental,
hospice care, and the like. Special attention will be
given to the needs of minority groups with special
cultural and language needs.
2. Continuity and coordination of care will be evaluated,
with attention to under or over utilization.
3. Review of the Health Plan administrative services. This
will include credentialing, utilization management,
quality management, and risk management.
4. Evaluation and monitoring of member and provider
satisfaction information. The review will include
member/provider perceptions and outcomes of care to
members.
5. Access to routine, urgent, and emergency care will be
evaluated against Health Plan and regulatory standards.
6. Environmental Safety and Infection Control will be
monitored in two ways: Delegated - Merrithew Memorial
Hospital and Clinics is accredited by JCHO for all in and
out patient facilities and must be in compliance with
Federal, State and local regulations.
9
This delegated activity is monitored through the QMP
Coordinator by the CCHP Quality Council.
The second way applies to all new sites developed by CCHP.
These sites must undergo initial evaluation for
Environmental Safety and Infection Control using the most
current available DHS "tool", checklists, and records.
This will be done by the office of the Medical Director,
_ supervised by the QMP Coordinator. Ongoing evaluation must
also be done according to current DHS regulations, using
the appropriate tools, and this activity will be
supervised by and reported to the CCHP Quality Council.
D. SPECIFIC ACTIVITIES
The CCHP Quality Management Plan activities utilize a variety
of mechanisms to measure and evaluate the total scope of
services provided to CCHP members. The following activities
are used to conduct reviews that reflect important aspects of
care:
1. ADVERSE EVENT REVIEW
The objectives of the Adverse Event R@view are: 1) to
identify patterns of adverse events that suggest
opportunities for process improvement, and 2) to ensure
that the individual cases identified as risk management
issues are reviewed by the Health Plan Medical Director.
Partial List of Adverse Events:
.Unanticipated death
.Unplanned readmission to the hospital within 30 days
.Unplanned return to the operating room
.Unplanned transfer to a higher level of care
.Admission following ambulatory surgery
.Neurological deficits not present on admission
.Neonatal Intensive Care Unit admissions
2. SENTINEL DIAGNOSIS REVIEW
The objectives of the Sentinel Diagnosis Review are: 1)
to identify patterns of adverse events that suggest
opportunities for process improvement, and 2) to insure
that individual cases identified as risk management issues
are reviewed by the Health Plan Medical Director.
A Sentinel Diagnosis is a marker condition where timely
and appropriate medical management, patient education, and
other outpatient therapies should result in patients being
managed successfully in the ambulatory setting with little
10
need for hospitalization. The inpatient record is the
source of data for the review.
Partial List of Sentinel Diagnoses:
Diabetic Ketoacidosis
Perforated/Abscessed Appendix
Stroke or TIA
Drug Toxicity Allergy
Hypokalemia
Asthma
Prematurity
3. AMBULATORY MEDICAL RECORD REVIEW
The objectives of the Ambulatory Medical Record Review
(AMRR) are: 1) to evaluate the structural integrity of the
medical record, and 2) to evaluate ambulatory medical
record documentation for the presence of information that
conforms to good medical practice and is necessary to
provide quality care.
The concepts of structural integrity and information
necessary to conform to good medical practice are
operationalized through the use of indicators identified
in the AMRR assessment instrument ►C } .
For capitated network providers, twenty (or statistically
valid sampling) of randomly selected ambulatory medical
records of Primary Care Physicians with panels of 100
members or more are reviewed annually. For PCPs with
panels of less than 100 members, a random sampling method
is used. Data is collected by clinical reviewers trained
in the use of the AMRR instrument. Overall study results
and opportunities for improvement are reported to the
Health Plan's Quality Council. Feedback of AMRR results
and areas for improvement are disseminated to the Primary
Care Physicians. Follow up reviews are conducted as
required. For MMH&C, twenty randomly selected ambulatory
records will be audited.
INDICATORS:
Conformance With
Structural Integrity Good Medical Practice
Sex Problem list
Date of birth Current medication
. Home address Allergies and adverse rx
Home or work phone Past medical history
Employment Dated entries
Occupation (adult only) Provider name
Marital status Provider profession
Patient identification Legibility
Individual medical records Chief complaint
Organization Immunizations (adult & ped)
4. PREVENTIVE CARE GUIDELINES REVIEW
The objective of the preventive care guidelines review is
to monitor the use of scientifically-based preventive care
guidelines for improving the quality of care provided by
primary and specialty care physicians.
The Quality Council reviews and endorses the adult
preventive care guidelines which are primarily developed
by the U.S. Preventive Services Task Force. They are
intended to serve as a baseline for providing appropriate
preventive services.
Pediatric preventive care guidelines, taken from the
American Academy of Pediatrics, are also reviewed and
approved by the Quality Council. In addition, for those
pediatric members eligible for CHDP services, the CHDP
guidelines will be endorsed and followed.
The CCHP uses these preventive guidelines as standards of
preventive care against which the providers are measured.
CCHP will ensure that the provider offices have access to
all appropriate written standards for preventive care.
5. QUALITY MEASUREMENT STUDIES
Quality measurement studies are designed to objectively
and systematically monitor and evaluate the quality and
appropriateness of care and service provided to members.
The link between the complaint/grievance system lies in
one of two processes: First the complaint is reviewed by
the Office of the Medical Director and hopefully resolved.
The Quality Management Plan Coordinator will monitor these
minor complaints for resolution and recurrence and make
this part of the routine reporting to the Quality Council.
The head of member relations sits on the Quality Council
and can provide direct input to the council on any
identified QA issues brought by the Quality Management
Plan Coordinator.
There are 33 clinical areas of concern listed in Chapter
3 of the Health Care Quality Improvement System for
Medicaid Managed Care Guide for States.
The Quality Council will select Childhood Immunizations
and Pregnancy as proposed by the above mentioned guide for
states, and additionally select topics for focused studies
12
that are suggested by review of member and provider
surveys, utilization data which might reveal over or
under-utilization, or member complaints about the quality
of care. Most of these issues would fall out from the
list of 33 clinical concerns mentioned above.
6. COMPLAINTS AND GRIEVANCE REVIEW
The objectives of the review of complaints and grievances
are to monitor, evaluate, and timely and effectively
resolve member concerns, and identify opportunities for
improvement in the quality of care and services rendered.
to CCHP members.
contains a description of the Complaint and
grievance process and data collection methodology for
CCHP. it3t8# s describes the .complaint resolution
procesi"""t r the member. The complaints received by the
Member or Provider Relations section are forwarded to the
Plan Medical Director for review.
7. CREDENTIALING/RECREDENTIALING
The selection and credentialing of network physicians and
staff physicians of MMH&C is the foundation on which
CCHP's Quality Management Plan is built.
All physicians participating with CCHP undergo a careful
review of their qualifications, including education and
training, licensure status, board certification, hospital
privileges, malpractice history, DEA number, history of
license restriction or revocation, change in hospital
privileges, in accordance with CCHP credentialing policy
ee Attar »t G tprehe a...v .... r ri ia2 .sae
es ? : nar$ }: ' All physicians undergoing credentialing
and recredentialing are reviewed by the CCHP credentialing
committee and referred to the Quality Council, the CCHP
Advisory Board, the IQAC, and finally to the Board of
Supervisors for final approval.
RECREDENTIALING is performed on a biennial basis. In
addition to the information obtained during initial
credentialing, the recredentialing process also includes
review of data from: 1) member complaints, 2) results of
quality reviews, 3) utilization management, 4) member
satisfaction surveys, 5) reverification of hospital
privileges and current licensure, and 6) completion of
Sections XV through IXX of the CCHP Credentialing
Questionnaire.
DELEGATION of the credentialing and recredentialing
responsibilities is covered in the Memorandum of
13
Understanding Between CCHP and MMH&C and the Medical Staff
# n »3?'..
::::::.....:.. .:. .v h,v:....:
m++tcwtvwri2i2ri•:;::iP%x4if.i+�4..4k i:ACiv+
If credentialing and recredentialing is delegated to an
IPA or medical group, CCHP will require: 1) access to all
credential files of all providers who see CCHP members, 2)
compliance with established CCHP credentialing policy or
guidelines, 3) periodic updates to the Quality Council
regarding all credentialing activities with contracted
providers, 4) immediate notification of CCHP of any change
in privileges or sanctions of a provider who sees CCHP
members, 5) agreement to the above will be specified in
all provider contracts to whom credentialing has been
delegated, and 6) subject to process review and
acceptance by the Quality Council.
REPORTING of serious quality deficiencies resulting in the
suspension or termination of a practitioner will be the
responsibility of the CCHP Quality Council.
APPEALS by a provider who has had a reduction, suspension,
or termination of privileges with CCHP are handled in the
following manner:
a. Provider is advised in writing of the action and the
reason, with instructions for an appeal if desired.
b. Provider meets with the Credentialing Committee to
review the action and provide any extenuating
information.
C. Credentialing Committee decides on overturning the
decision or letting it stand and notifies the
provider of its decision. The matter is then
referred to the Integrated Quality Assurance
Committee for final determination.
d. The IQAC, after legal council, issues a final
decision and notifies the provider.
S. RISK MANAGEMENT
The objectives of risk management are two-fold: 1) to
reduce the incidence and expense of medical malpractice
claims and tort litigation, and 2) to address and prevent
conditions that could result in adverse publicity or a
legal claim against the CCHP.
CCHP works closely with MMH&C Risk Management Committee.
Complaints from members suggesting a poor outcome or
injury are forwarded to the Plan Medical Director for
review. If after there is a determination of even
14
possible liability, the file is forwarded to the Risk
Management Committee for investigation. Legal council for
Contra Costa County is represented on the committee, as
well as members from the Quality Assurance Committee. Any
areas requiring a change in practice or in the care of a
specific provider are referred to the Medical Quality
Assurance Committee for disposition.
CCHP tracks cases referred to the Risk Management
Committee and will obtain information from the Medical
Quality Assurance Committee regarding corrective actions
taken in their quarterly report to the Quality Council.
In the extreme case of withholding a staff physician's
privileges, the CCHP Medical Director is to be informed
per agreement 1.See 'i€ ' >.
9. PATIENT SATISFACTION SURVEYS
The administrators of CCHP and MMH&C recognize the
importance of satisfied patients and the critical role
that its primary care providers have in meeting this
objective. The purpose is to measure the performance of
PCPs relative to level of patient satisfaction of care and
reinforce and strengthen performance by providing
meaningful feedback to physicians on how patients perceive
their care.
A variety of survey instruments will be used. Random
sampling will be done of patients who just received care
from a CCHP provider. The survey seeks the member's
impression regarding the courtesy, communication skills
and perceived knowledge base of the physician. The survey
results and opportunities for improvement are reported to
the Quality Management Committee. Action plans to address
areas of improvement are developed as necessary. Feedback
of the survey results and areas for improvement are
communicated to the PCPs on a periodic basis.
10. MEMBER SATISFACTION SURVEYS
Member satisfaction surveys are designed to: 1) assess
what services are important to consumers, 2) assess member
satisfaction with the service received from their Health
Plan, 3) assess member re-enrollment, 4) assess service
performance in comparison with competitors, and 5) assess
differences between dissatisfied and satisfied members
with the managed care system.
Survey results are reviewed by the Quality Council to
identify opportunities for improvement. Action plans to
address areas of improvement are developed as necessary.
15
11. PROVIDER SATISFACTION SURVEYS
Provider satisfaction surveys are designed to: 1 (assess
what services are important to CCHP providers, and 2)
assess provider satisfaction with CCHP.
The survey results are conducted annually for both PCP and
specialty providers. These results are reviewed by the
Quality Council to identify areas of improvement.
12. Monitoring and evaluation activities are done by the QMP
Coordinator. Performance standards will be developed using
available national, state, local, or professional
guidelines as they become available. The primary care and
specialty physicians may "benchmark" certain performance
parameters and prospectively monitor performance of those
parameters as specific quality indicators. These results
should be reported over time by the QMP Coordinator as
data is collected. Modification of parameters will occur
after review by the Quality Council.
13. OTHER QUALITY ASSESSMENT ACTIVITIES
The Quality Council and other sources may identify issues
that require a focused review. For example:
a. Drug usage review to assess the utilization of
appropriateness of therapeutic agents.
b. Under and over-utilization review to monitor the
utilization of health care services, including
specialty referrals, or evidence of poor quality
care associated with over-utilization or under-
utilization.
C. Quality of service issues to assess the need for
improving systems related to meeting the service and
educational needs of Health Plan members.
E. INDIVIDUALS RESPONSIBLE FOR THE QUALITY REVIEWS AND QUALITY
MANAGEMENT ACTIVITIES:
1. MEDICAL DIRECTOR
The QMP identifies the plan Medical Director as the
responsible medical leader for the quality of medical care
and services for all CCHP members. While the Medical
Director will be a working Quality Council member, all
quarterly and annual reports to the IQAC will be reviewed
and approved by the Medical Director. The Medical
Director will supervise the Quality Management/UM
Coordinator.
Peer Review Process - The Medical Director will be
actively informed of the results of the Merrithew Memorial
16
Hospital and Clinics peer review process conducted by the
Medical Quality Assessment Committee. the authority for
sharing this information with the CCHP Medical Director is
found in the Memorandum of Understanding between CCHP and
Merrithew Memorial Hospital and Clinics and Medical Staff
(see Attachment F) .
Since CCHP has no providers, all peer review is delegated
and the requirements of delegation in the areas of Quality
Assessment and UR is dictated by the regulations on
delegation required of CCHP. The CCHP Quality Council will
review and act on any peer review concerns.
The Medical Director will have access to reports from
MMH&C QM activities and may meet with the Medical Staff
President, the Medical Executive Committee, the Medical
Quality Assessment Committee, the Quality Council, or the
Professional Affairs Committee to explain special needs of
the Health Plan, or to work towards resolution of
identified health care delivery problems.
2. QUALITY MANAGEMENT/UM COORDINATOR
The QM/UA Coordinator is responsible for a wide variety of
activities within the plan and acts as a liaison with
MMH&C and all other Network providers. A partial list of
duties include:
a. Ongoing monitoring and evaluation of data from all
sources.
b. Introducing new standards
C. Identify need for focused QM studies
d. Identify Medi-Cal social or cultural issues that
should concern the QMP.
e. Receive and analyze, with the Medical Director,
utilization management data. Outcomes analysis
according to set standards will be monitored; trends
identified, and data reported to the Quality
Council.
f. Monitor Environmental and Safety standards and
Infection Control.
g. Inspect new provider sites and perform an audit of
the office according to the standards referenced in
the DHS MMCD Letter No. 94-3 prior to implementing a
contract.
17
h. Monitor quality of service issues, working with the
Provider Relations, Member Satisfaction, and other
sources; assist in resolution, or bring the issues
to the Quality Council.
i. Receive reports and monitor the compliance of all
delegated activities.
J . As a member of the Quality Council, report all
activities on a regular basis to the Quality
Council, prepare quarterly and annual reports for
the IQAC and Board of Supervisors after review by
the Quality Council and the Medical Director.
k. Develop clinical indicators, and the collection and
monitoring of necessary data, - and report to the
Quality Council.
1. Schedule and arrange for minutes of all committees
and Council. Maintain records of all meetings.
M. Develop the annual QMP workplan with assistance of
the Quality Council and monitor the progress at
regular intervals, reporting to the Quality Council.
n. Monitor the progress of all internal committees and
organize reports of their activities to the Quality
Council. At the outset, assist in the formation of
committees, writing protocols, identifying committee
functions and membership with the assistance of the
Medical Director.
o. Supervises Mental Health Utilization Review Program.
p. Report any changes in the CCHP QMP to State
Department of Health Services.
q. Other duties as identified.
Proposed job descriptions are included in let
Other tasks will be assigned additionally as
P.
appropriate.
The Credentialing Committee is staffed by the Provider
Relations secretary, who will organize meetings, manage
the credentialing process, maintain confidential files,
keep minutes of the meetings, and obtain credentialing
reports from other provider organizations to whom CCHP has
delegated credentialing.
Other support staff, such as clerical help and clinical
auditors, will be added. to the programs as required.
18
3. The organizational chart of the Office of the Medical
Directorshows the areas of responsibility
for the leical "Director and the delegated role of the
Assistant Medical Director. The Assistant Medical Director
continues to spend two days per week working as a Family
Physician.
Another important change is the development of the
CCHP/Merrithew Memorial Hospital and Clinics Liaison
Committee. This committee consists of the president of the
medical staff, the chair of the division of ambulatory
care committee, a primary care physician from the delivery
system largest ambulatory facility, and the Medical
Director of CCHP.
This committee serves a critical role in the
implementation of the CCHP. It has the endorsement of the
Merrithew Memorial Hospital and Clinics Administrator.
Through the process of ongoing monitoring of CCHP's
members care, or as the result of external audit findings,
the CCHP Medical Director has direct access and support of
the medical staff and Merrithew Memorial Hospital and
Clinics administration to address issues of quality of
care and service.
CCHP will monitor corrective action plans to ensure that
the issues are resolved as quickly as possible. This
committee may refer issues directly to the medical staff
quality assurance committee if they feel that is
appropriate. The CCHP Quality Management Coordinator will
apply the CCHP Quality Management "tools" (found in
Attachment V) to identify problems, monitor progress, and
work cooperatively with Merrithew Memorial Hospital and
Clinics Quality Management Department.
F. CONTINUOUS ACTIVITY
Assessment of quality must take place over time. It is
important to have adequate data in terms of numbers of members
involved in focused reviews, an adequate incidence of the issue
being studied, and enough time lapsed to be able to identify
trends.
Current approaches to quality assessment have moved away from
the "bad apple" approach to one which focuses on outcomes
management. This approach demands attention to the full span
of care, including prevention, early detection of disease, and
cost-effective quality care to provide an optimum outcome. The
Quality Management Plan for CCHP will embrace this approach,and
continue to learn how to provide the best possible care in an
environment that often has social, cultural, and economic
barriers.
19
G. PROVIDER REVIEW
The CCHP QMP provides for review by physicians and other health
professionals at a variety of levels. The Medical Staff is
actively involved and manages the MMH&C QM plan and has an
active peer review process. The Medical Director and Assistant
Medical Director of CCHP have practice experience and
experience in managed care quality assurance activities. Rey
committees have representatives from the Medical Staff,
community physicians, both PCPs and specialists.
Every effort will be made to give appropriate and timely
feedback to all CCHP providers of the QM activities and
results. Direct communication with providers, newsletters and
other publications will be used.
H. FOCUS ON HEALTH OUTCOMES
The Health Plan will design activities in quality management
with the goal of improving health outcomes. The collection of
HEDIS data, sharing of information with other health plans, 'and
participating where possible in national studies will help keep
CCHP abreast of current trends and new information.
I. CCHP 1994-95 WORK PLANA ``'` `
The workplan provides a blueprint for the QMP activities for
the calendar year. It identifies the action, lead person(s) ,
target date, date completed, and the expected outcomes. The
workplan is approved by the CCHP Advisory Board and may be
modified from time to time during the year as required.
20
SECTION II: QUALITY MANAGEIKENT PROCESS pffil .
The process begins with the identification of problems from a variety of
sources shown in the diagram. The issues or problems are processed by
the Quality Management Coordinator. Minor problems are handled by the
QMC with assistance by the Medical Director if necessary, and if
resolved, followed for compliance. If problem is not easily resolved, it
is processed with the Quality Management Tools. This process is shown in
Lbiae " .
If the data collection and analysis still reveals a significant problem,
it is referred to the Quality Council for evaluation. Other activity is
reported on a regular basis to the Council. The problem is then either
resolved, or not, or new issues may be introduced from the Quality
Council. Resolution leads to follow up and monitoring, with feedback to
appropriate sources and the Council. Failure at resolution results in a
referral of the problem to the Integrated Quality Assessment Council,
where resources from this diverse committee may contribute to problem
resolution.
Should the IQAC fail to find resolution, the problem is referred to the
Board of Supervisors. Final resolution leads back to the follow up loop.
Reporting activities are shown in the diagram from the Quality Management
Coordinator through committees and ultimately to the Board of
Supervisors.
A. SPECIFICATION OF CLINICAL OR HEALTH SERVICES DELIVERY AREAS TO
BE MONITORED:
In Parts C and D of Section I, the scope of care/services and
specific activities are detailed. Special emphasis will be
placed on the needs of the Medi-Cal population, and
additionally, the recommended HCFA clinical areas of concern
will be addressed.
In the development of annual work plans, the Quality Council
will address other important aspects of care and service and
respond to specific recommendations from regulatory agencies.
The MMH&C Quality Management Plan will be closely monitored by
CCHP l -Ohk
eri ;. The CCHP QM/UM Coordinator will work
close y"-with 'the MMH&C QM staff to ensure that there is a
coordinated effort between their system and the developing out-
of-plan network QM activities.
B. USE OF QUALITY INDICATORS:
1. CCHP Quality Council will identify and use quality
indicators that are objective, measurable, and based on
current knowledge and clinical experience.
21
2. CCHP will address over time the HCFA Medicaid Bureau's
list of priority clinical and health services delivery
areas of concern. CCHP will monitor and evaluate quality
of care through studies which include, but are not limited
to, the quality indicators also specified by the HCFA's
Medicaid Bureau.
C. USE OF CLINICAL CARE STANDARDS/PRACTICE GUIDELINES:
1. The QMP studies selected by the CCHP Quality Council to
monitor quality of care will use delivery standards or
practice guidelines specified for each area identified in
"A" above.
2. The standards/guidelines will be based on reasonable
scientific evidence. When required by regulatory agencies
who provide specific standards of care, CCHP will comply.
Other standards of care or practice guidelines will be
reviewed by plan providers. Again, coordination with the
QMP of MMH&C will ensure that standards used and approved
by them are consistent with those used for the CCHP
Network as it is developed.
3. The standards/guidelines used by CCHP will focus on the
process and outcomes of health care delivery, as well as
access to care.
4. The Quality Council will ensure that the
standards/guidelines of care are continuously monitored
and updated.
5. Practice standards/guidelines will be disseminated to all
providers as they are adopted or modified. This may occur
through additions to the provider manual, or by specific
written communication.
6. The standards/guidelines will address preventive health
care services. CCHP will use the U.S. Preventive
Services Task Force Recommendations and the American
Academies of Pediatrics and Obstetrics, unless, for
example, there is a disagreement with a specific standard,
such as the recommendations for mammography. For
pediatric prevention standards, the Academy of Pediatric
recommendations, or the DHS or.,,..-CHDP. standards, if
different, will
.......supercedeCIuN ? < C CCHP
y�rac.�cg �zogza�a.�� � ..... ..........:
7. The standards/guidelines will be developed, which address
the full spectrum of population enrolled in the Plan.
This will include commercial members, Medi-Cal members,
Basic Adult Care, Medicare, and AFDC. Each of these
populations may have specific requirements in the practice
22
standards/guidelines.
8. CCHP will use approved practice standards/guidelines
across the spectrum of providers involved with the Plan:
a. MMH&C Medical Staff and contracted specialists
b. Contracted Network Providers
c. Mental Health
d. Public Health Clinics
D. ANALYSIS OF CLINICAL CARE AND RELATED SERVICES:
1. The MMH&C QMP has specific physician review of cases which
have been brought to the attention of the Medical Quality
Assurance Committee through a variety of sources:
a. Member complaints or grievances
b. QMP Special Studies
C. Input from the CCHP Medical Director or CCHP Quality
Council
d. Risk Management Committee
e. UM committee
The analysis will include the identified quality
indicators and clinical standards or practice guidelines.
2. Multi-disciplinary teams, such as the MMH&C Systems
Integration Committee, will be used, where indicated, to
analyze and address systems issues.
E. IMPLEMENTATION OF REMEDIAL/CORRECTIVE ACTIONS:
The implementation of remedial/corrective actions are the
responsibility of the Quality Council and the Medical Director
and is fully described in Section I-A and E (inclusive) and
graphically shown inCusY .
F. ASSESSMENT OF EFFECTIVENESS OF CORRECTIVE ACTIONS:
As actions are taken to improve care, follow up monitoring will
occur as part of the action plan on a scheduled basis and
periodically thereafter.
The organization as a whole shall be assured that corrective
actions and follow up monitoring are accomplished through the
23
review and evaluation of periodic and annual Quality Assurance
reports to the Integrated Quality Assurance Committee and to
the Board of Supervisors.
Q. WALUATION OF CONTINUITY AND EFFECTIVBNEBB OF THS QMP:
1. CCHP will conduct regular and periodic examination of the
scope and content of the QMP to ensure that it covers all
types of services in all settings, as specified in Section
I-C (1-5) .
2. A QMP Annual Report will be written at the end of each
year which addresses: QM studies and other activities
completed; trending of clinical and service indicators and
other performance data; demonstrated improvements in
quality; areas of deficiency and recommendations for
corrective action; and an evaluation of the overall
effectiveness of the QMP.
3. There should be evidence that QM activities have
contributed to significant improvement in the care
delivered to members.
24
SECTION III: ACCOUNTABILITY TO THE GOVERNING BODY
A. OVERSIGHT OF THE CCHP QXP:
A Board of Supervisors order is pending :.:`lf ' , which
describes the Board's requirement to ap ove of iel""overall
QMP, an annual QM plan, assigns responsibility for all QM
activities, and provides the necessary resources for the
organization to carry out its QMP.
B. ANNUAL QMP REVIEW:
The Board of Supervisors will formally review each annual QMP
report and will take action where appropriate. The Board must
be assured that: studies undertaken, results, subsequent
actions, and aggregated data on utilization and quality of
services rendered to assess the QMP's continuity,
effectiveness, and current acceptability are included.
C. PLAN MODIFICATION:
The Board of Supervisors, upon receipt of regular reports from
the IQAC delineating actions taken and improvements made, shall
take action when appropriate and direct that the operational
QMP be modified on an ongoing basis to accommodate review
findings and issues of concern within the managed care
organization. This activity is documented in the minutes of
the Board of Supervisors in sufficient detail to demonstrate
that it has directed and followed up on necessary actions
pertaining to Quality Assurance.
25
SECTION IV: ENROLLEE RIGHTS AND RESPONSIBILITIES
CCHP is dedicated to its members to provide the best possible health care
at an affordable price. The rights of its members are outlined in
various materials provided to the.,member: 1) Member Handbook
me.
2) Evidence of Coverage, c °: t' 3) County of Con.Nra'�`�as
::> r
ealth Services Policy on the RfifidifiV341ity of Patient Information,
' a° ta"?� <`* , 4) Patient Bill of Rights and Responsibilities,
and 5 Patient Access To Medical Records,
The above listed Attachments include the following requirements:
A. WRITTEN POLICY ON ENROLLEE RIGHTS:
1. To be treated with respect and recognition of their
dignity and need for privacy.
2. To be provided with information about the organization,
its services, the practitioners providing care, and
members rights and responsibilities.
3. To be able to choose primary care practitioners, within
the limits of the plan network, including the right to
refuse care from specific practitioners.
4. To participate in decision-making regarding their health
care.
5. To voice grievances about the organization or care
provided.
6. To formulate advance directives.
7. To have access to his/her medical records in accordance
with applicable Federal and State laws.
B. WRITTEN POLICY ON ENROLLEE RESPONSIBILITIES:
1. Providing, to the extent possible, information needed by
professional staff in caring for the member; and'
2. Following instructions and guidelines given by those
providing health care services.
C. COMMIINICATION OF POLICIES TO PROVIDERS:
CCHP will provide a copy of the organization's policies on
members' rights and responsibilities to all participating
providers.
26
D. COMMUNICATION OF POLICIES TO ENROLLEES/MEMBERS:
CCHP provides information to its members on the following
topics
: .
w:«•:aa::r:..;�,:z:;a::::.::.::.:::w:w:aw:o�a�;z,Mw�aazaa;:oa,:t�•a�:...�:v:.44
1. Rights and responsibilities of members;
2. Benefits and services and how to obtain them;
3. Provision of after-hours care and emergency coverage;
4. Organization's policy on referrals to specialty care;
5. Charges to members, including:
a. policy on payment of charges; and
b. copayment and fees for which the member is
responsible;
6. Procedures for notifying those members affected by the
termination or change in any benefits, services, or
service delivery office/site;
7. Procedures for appealing decisions adversely affecting the
member's coverage, benefits, or relationship to the
organization;
8. Procedures for changing practitioners;
9. Procedures for disenrollment; and
10. Procedures for voicing complaints and/or grievances and
for recommending changes in policies or services.
E. ENROLLEE/MEMBER GRIEVANCE PROCEDURES:
CCHP has systems, linked to the QMP, for resolving members'
complaints and formal grievances. This system includes:
1. Procedures for registering and responding to colnplaints
and grievances in a timely fashion. The organization will
establish and monitor standards for timeliness;
2. Documentation of the substance of complaints or
grievances, and actions taken;
3. Procedures to ensure a resolution of the complaint or
grievance;
4. Aggregation and analysis of complaint and grievance data
and use of the data for quality improvement; and
27
5. An appeal process for grievances.
F. ENROLLEE/MEMBER SUGGESTIONS
CCHP offers the members opportunities to offer suggestions for
change of policies and procedures through its Member Relations
Department.
G. STEPS TO ASSURE ACCESSIBILITY OF SERVICES
CCHP takes steps to promote accessibility of services offered
to its members. These steps include:
1. Identifying points of access to the primary care clinics,
specialty care, and hospital services for its members;
2. At a minimum, members are given information about:
a. how to obtain emergency services during regular
hours of operation (access through the 24-hour
Advice Nurse Program) ;
b. how to obtain emergency and after-hours care; and
C. how to obtain the names, qualifications, and titles
of the professionals providing and/or responsible
for their care.
8. WRITTEN INFORMATION FOR MEMBERS
1. Member handbook, HealthSense, and other publications.
2. Many health information booklets are available in Spanish,
which represents the largest minority language.
I. CONFIDENTIALITY OF PATIENT INFORMATION
_, h `' - CCHP ensures that:
1. The organization has established in writing, and enforced,
policies and procedures on confidentiality, especially
medical records. MMH&C has guidelines for all of its
staff and employees.
2. Office sites and clinics have mechanisms that guard
against unauthorized or inadvertent disclosure of
confidential information to persons outside of the medical
care organization.
3. The organization shall hold confidential all information
obtained by its personnel about enrollees related to their
examination, care and treatment and shall not divulge it
28
without the enrollee's authorization, unless:
a. it is required by law;
b. it is necessary to coordinate the patient's care
with physicians, hospitals, or other health care
entities, or to coordinate insurance or other
matters pertaining to payment, or
C. it is necessary in compelling circumstances to
protect the health or safety of an individual.
4. Any release of information in response to a court order is
reported to the patient in a timely manner.
5. Enrollees records may be disclosed, whether or not
authorized by the enrollee, to qualified personnel for the
purpose of conducting scientific research, but these
individuals may not identify, directly or indirectly, any
individual enrollee in any report of the research or
otherwise disclose participant identity in any manner.
J. TREATMENT OF MINORS
CCHP has a written policy given to the enrollee on the
treatment of minors.
E. ASSESSMENT OF MEMBER SATISFACTION
CCHP conducts regular member satisfaction surveys
11' o >
2. The surveys include content on perceived problems in
quality, availability, and accessibility of care.
2. The surveys assess at least a sample of:
a. all Medi-Cal members
b. Medi-Cal member requests to change practitioners
and/or facilities; and
C. disenrollment by Medi-Cal members.
3. As a result of the surveys, CCHP:
a. identifies and investigates sources of
dissatisfaction;
b. outlines action steps to follow up on the findings,
and
29
C. informs practitioners and providers of assessment
results.
4. CCHP reevaluates the effects of the above activities at
its staff meetings and the results of surveys will be
presented to the Quality Council for their consideration.
30
SECTION V: STANDARDS FOR AVAILABILITY AND ACCESSIBILITY
CCHP has standards for availability and accessibility which are found in
t: aitltt; Waitingtime for appointments and the len of time
waiting"'to"see a provider after checking in is monitored on a periodic
basis, with feedback to the providers. Because waiting time is one of
the most frequent member complaints CCHP receives, every effort is being
made to negotiate expansion of clinic hours. Particular attention is
paid to geographic needs of the Medi-Cal members for access.
ADVICE NURSE PROGRAM
The Advice Nurse Program is a critical program to ensure that both
populations of CCHP and non-members receive appropriate and timely care
at MMH&C. The major task for the Advice Nurse is to make an immediate
assessment and evaluation of the acuity of the call. The Advice Nurse
then implements appropriate level of triage and disposition of the
client/member. The categories of triage are subdivided into: 1) Emergent,
2) Urgent, and 3) Non-Urgent. Delayed criteria for emergent calls which
are potentially life threatening require immediate intervention. After
the Advice Nurse establishes the call as an emergency, either 911 system
is engaged, and/or when appropriate, immediate transfer is made to the
Emergency Department.
After emergencies have been triaged, the Advice Nurse then assesses calls
that meet the criteria for second level of urgent, non-life threatening
problems of patients with major illnesses/injuries, and ensures treatment
within 20-120 minutes. Third level patients with non-urgent, chronic,
minor problems are given advice according to the Advice Nurse Medical
Guidelines. These guidelines/protocols are smart algorithms which assist
the Advice Nurse to arrive at standardized care for the caller/client
when disposition of client is determined and follow up care decisions are
made.
Furthermore, with non-urgent patients, the Advice Nurse has access to the
Appointment Scheduling computer and will find either appropriate urgent
care appointment, preferably with client's primary care physician and/or
a routine appointment. The Advice Nurse computer program has, in
addition, a comprehensive health information library which can be
accessed by both the Advice Nurse and members independently (this
component is targeted for three months after start up) . Follow up calls
to ensure continuity of care are also made by the Advice Nurse
facilitated by computer generated list of patients requiring follow up.
The.Advice Nurse Quality Assessment and Utilization Tracking is described
in trit' t.
.............................................
31
SECTION VIs MEDICAL RECORD STANDARDS
A. ACCESSIBILITY AND AVAILABILITY OF KEDICAL RECORDS:
1. CCHP will require in all out-of-plan provider contracts
that the medical records of CCHP members are available for
quality reviews conducted by the Secretary, State Medicaid
agencies, or agents thereof.
2. Medical records are available to the providers at each of
the MMH&C sites, the Emergency Room or Urgent Care, and
the in-house specialty clinics. If the record is not
available for any reason, an attempt is made for the
originating clinic to FAX current information, or
specifically information requested by a provider.
3. Medical records will be released according to guidelines
for the purpose of changing providers or moving out of the
area, etc.
B. RECORD KEEPING:
CCHP will promote maintenance of the medical records in a
legible, current, detailed, organized and comprehensive manner
that permits effective patient care and quality review. MMH&C
has a Medical Records Committee that conducts regular reviews
of their hospital and ambulatory medical records. This
function is delegated to MMH&C through the delegation agreement
found in a The CCHP Quality Council will review QM
reportsfor'medaal*""record standards requirement.
1. Medical Records Standards:
These standards are outlined in detail in SECTION I, D-3.
The standards are audited as described using the
Ambulatory. Medical Record Review form found in
3 ;< The attachment includes:
a. Definition of Indicators for Adult and Pediatric
Patients
b. Risk Group Categories
C. Preventive Health Guidelines
d. Recommended Schedule for Evaluation and Immunization
of Infants and Children
e. AMRR Review Forms, Adult and Pediatric
32
2. Patient Visit Data:
The AMMR review form has questions regarding patient
visit data. These are:
a. History and physical examination
b. Treatment plan
C. Diagnostic test ordered
d. Therapies and other prescribed regimens
e. Follow up: Encounter notes have a notation, when
indicated, concerning follow up care, call, or
visit. Specific times to return should be specified
in weeks, months, or PRN. Unresolved problems from
previous visits are addressed in subsequent visits.
f. Referrals and results
g. All other aspects of patient care, including
ancillary services
C. RECORD REVIEW PROCESS:
The record review guidelines are spelled out in SECTION I,
D-3. The Ambulatory Medical Record Review form will be used to
evaluate the medical records of providers. By standardizing
the audit form, comparison data can be collected.
Another important aspect of the AMRR process is to give
feedback to the providers audited. Re-audits should be planned
for any review that was totally unsatisfactory and periodic
reviews on those which had only minor deficiencies.
33
SECTION VII: UTILIZATION REVIEW
A. PLAN DESCRIPTION:
1. PURPOSE
The Utilization Management Plan at CCHP is charged to
objectively monitor, evaluate and positively influence the
delivery of high quality and cost effective medical care
and services .
2. GOALS
The goal of CCHP is to efficiently utilize health
resources available, to ensure and improve the medical
appropriateness and to monitor the quality of medical
services provided to its members.
3. OBJECTIVES
a. To provide and/or improve access to the health care
services in the most appropriate and cost efficient
setting.
b. To provide and/or improve access to appropriate and
cost efficient health care services.
C. To facilitate the partnership of the providers,
members, employers, and health plan toward
appropriate utilization of health care services.
d. To evaluate and monitor the provision of health care
services rendered to members of CCHP in order to
support providers to enhance care and/or access of
services when appropriate/indicated.
e. To identify members considered Nat high risk" for
incurring extensive health care expenses, or
requiring extensive and ongoing medical care for
chronic or catastrophic illness to ' ensure
appropriate care is rendered through the most
efficient use of benefit resources available.
f. To reduce overall health care expenditures by
developing and implementing programs which encourage
preventive health care behaviors.
B. ORGANIZATIONAL STRUCTURE
CCHP has the authority/accountability for the Utilization
Management Program which is under the direction of the Medical
Director. The Quality Management/UM Coordinator assists in the
34
process, working closely with other administrative departments.
C. PLAN ACTIVITIES
PROSPECTIVE REVIEW
Prospective Review consists of preauthorization of health care
services including hospitalizations, elective surgical
procedures, emergency services, and selected medical
treatments. Prospective Review also includes review and
authorization of out-of-plan referrals.
An integral part of this process involves communicating the
decision status of the services being requested. The physician
and member receive notification of the referral status. The
physician and/or member are entitled to appeal any services
which were denied.
A detailed description of policies and procedures utilized in
prospective review are provided in plan office.
1. Methodology
CCHP uses nationally recognized and locally developed
guidelines and criteria to conduct Prospective Review.
These guidelines are reviewed, approved, and updated
periodically by the Quality Council consisting of
participating physicians.
A copy of the guidelines, criteria, and policy/procedures
regarding the use and revision of criteria is available
in the plan office.
D. CONCURRENT REVIEW
Concurrent Review consists of the ongoing review of the
patients hospitalized via physician communication, chart
review and communication with other health care
professionals involved in the patients' care. Concurrent
Review also includes coordinating discharge plans to
ensure services are in compliance with the members
available health care benefits. Case management and focus
review strategies are implemented to identify and
efficiently manage those patients with chronic or
catastrophic disease conditions. Other services which
would be categorized under Concurrent Review would be
outpatient ancillary services, physician practices,
procedures and selected claims.
A detailed description.of policies and procedures utilized
in Concurrent Review is provided in the plan office.
35
1. Methodology
CCHP utilizes nationally recognized and locally
developed guidelines and criteria to conduct
Concurrent Review. These guidelines are reviewed,
approved, and updated periodically by the Quality
Council consisting of participating physicians.
A copy of the guidelines, criteria, and
policy/guidelines regarding the use and revision of
criteria is available in the plan office.
E. RETROSPECTIVE REVIEW
Retrospective Review is a multi-dimensional process which
may consist of reviewing records for those health care
services rendered to a patient which had not been
previously authorized to make a coverage determination.
In addition, the Retrospective Review process involves
gathering of financial information and clinical data to
track utilization for reporting and trending purposes.
The analysis of the data, which may be sorted in a variety
of ways, is used in recredentialing, to educate providers,
and for utilization management program revisions to
improve the appropriate utilization of health care
services.
A description of policies and procedures utilized in
Retrospective Review are provided in the plan office.
1. Methodology
CCHP utilizes nationally recognized and locally
developed guidelines and criteria to conduct
Retrospective Review. These guidelines are
reviewed, approved, and updated periodically by the
Quality Council consisting of participating
physicians.
A copy of the guidelines, criteria, and
policy/procedures regarding the use and revision of
criteria are available in the plan office.
36
SECTION VIII: CONTINUITY OF CARE SYSTEM
CCHP has primary care as its major focus. Since CCHP does not employ its
own physicians, it must work closely with MMH&C Medical Staff and
Hospital Administration. The Memorandum of Understanding between CCHP
and MMH&C and Medical staff Ah3 ` ', defines the delegation of
Quality Assurance and retains" over the process affecting its
members.
Continuity of care issues are addressed directly with the President of
the Medical Staff or brought to the attention of the Medical Executive
Committee. The clinic system is designed to support primary care, and
the majority of the providers are Family Practice physicians. Efforts
are made to assign patients to a primary care physician. This is often
difficult due to the nature of the population served, which includes
Basic Adult Care, the homeless, and FFS Medi-Cal members. These members
may go where they choose for care, and maintaining continuity is
difficult. Resolution of this problem will be assisted by the current
health care reforms to bring FFS Medi-Cal into managed care.
CCHP has a case management program run by the Advice Nurse Program.
Experienced PHNs are used for case management. This has resulted in a
decrease in ER utilization, a decrease in specialty referrals, and
happier members. Providers from anywhere in the system may access the
CCHP Case Managers.
37
SECTION IZ: QXP DOCIIMENTATION
A. SCOPE:
CCHP will document that it is monitoring the quality of care
across all service and treatment modalities according to its
written QMP. This will be carried out over multiple review
periods and not on a concurrent basis.
H. MAINTENANCE AND AVAILABILITY OF DOCMUWTATION:
CCHP will maintain and make available to the State, and upon
the request of other regulatory agencies, studies, reports,
protocols, standards, worksheets, minutes, or such other
documentation as may be appropriate, concerning its QM
activities and corrective actions.
38
SECTION Z: COORDINATION OF QM ACTIVITIES WITH OTHER MANAGEMENT ACTIVITY
The QMP activities of CCHP are under the direction of the CCHP Medical
Director. The Medical Director is a member of the CCHP Senior Staff and
reports to the Executive Director. Important information resulting from
the QMP process is presented to the Senior Staff for input and comments.
Confidentiality will always be maintained in these discussions, and only
general trends, issues, and opportunities for improvement will be
presented. QM information is useful to the CCHP executive staff in the
following ways:
A. QM INFORMATION WILL BE USED IN RECREDENTIALING, RECONTRACTING,
AND/OR ANNUAL PERFORMANCE EVALUATIONS;
B. QM ACTIVITIES WILL BE COORDINATED WITH OTHER PERFORMANCE
MONITORING ACTIVITIES, INCLUDING UTILIZATION MANAGEMENT, RISK
MANAGEMENT, AND RESOLUTION AND MONITORING OF MEMBERS COMPLAINTS
AND GRIEVANCES;
C. CCHP QM PLAN WILL LINK WITH OTHER MANAGEMENT FUNCTIONS OF THE
HEALTH PLAN SUCH AS:
1. network changes and development
2. benefits redesign
3. practice feedback to physicians
4. medical management systems (e.g. pre-certification)
5. patient education
6. member services
LC:QAIPC'CHP.94
Contra Costa Health Plan
Quality Assurance Improvement Plan
ATTACHMENTS
A. ORGANIZATIONAL STRUCTURE OF CCHP QUALILTY MANAGEMENT PLAN
B. CCHP ADVISORY BOARD BY-LAWS AND COMMISSION ORDERS AND ROSTER
C. AMBULATORY MEDICAL RECORD REVIEW FORMS AND GUIDELINES
D. CCHP DESCRIPTION OF MIS AND OTHER FUNCTIONS
E. CREDENTIALING/RECREDENTIALING GUIDELINES
F. MEMORANDUM OF UNDERSTANDING BETWEEN CCHP AND MMH&C REGARDING
DELEGATION
G. QA COORDINATOR JOB DESCRIPTION
H. MMH&C QUALITY ASSURANCE PLAN
I. CCHP SERVICE PROTOCOLS
J. WORKPLAN FOR CCHP QMP, 1994-95
K. CCHP BABY TRACKING PROGRAM
L. CCHP QMP PROCESS DIAGRAM
M. EVIDENCE OF COVERAGE DOCUMENT
N. MEMBER HANDBOOK
0. CONFIDENTIALITY POLICY
P. PATIENTS RIGHTS REGARDING MEDICAL TREATMENT
Q. ACCESS STANDARDS
R. ADVICE NURSE QA/UM PLAN AND SURVEY REPORT CARD
S. PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
T. PATIENT ACCESS TO MEDICAL RECORDS
U. CCHP MEMBER SATISFACTION SURVEY
V. CCHP QUALITY MANAGEMENT "TOOLS"
W. BOARD OF SUPERVISORS ORDER DELEGATING QA
X. ORGANIZATIONAL STRUCTURE OF OFFICE OF MEDICAL DIRECTOR
BURW ATTACHMP
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ATTACHMENT B
CONTRA COSTA COUNTY
CONTRA COSTA HEALTH PLAN ADVISORY BOARD
BY-LAWS
GOALS
The goals of the Contra Costa Health Plan (CCHP)*, a health maintenance organization, are to
be responsive to the health needs of the people of Contra Costa County; to ensure that the CCHP
is being fully utilized to meet those needs; and to encourage the promotion and awareness of
CCHP to the general public, and in particular to the medically needy.
ARTICLE I: NAME
The organization to be known as Contra Costa Health Plan Advisory Board.
ARTICLE II: FUNCTIONS
A. To review, evaluate and advise the County Board of Supervisors of the needs and special
problems of the Contra Costa Health Plan.
B. To review and evaluate the CCHP budget and any amendments thereto, and to
recommend program priorities to the Staff and Board of Supervisors.
C. To report or submit recommendations to the County Board of Supervisors regarding
plans, development, goals, and policies of the CCHP Program when appropriate.
D. To advise the Executive Director on policies, goals, operations, and related matters of
the CCHP.
E. To encourage public understanding of CCHP and to provide support throughout the
County for its development.
ARTICLE III: MEMBERSHIP
A. Twelve members, residing in Contra Costa County, appointed by the Board of
Supervisors, to serve three year terms, but not more than three consecutive terms.
* Also called "The Plan"
B. At least one member to have expertise in health maintenance organizations and one
member with financial expertise to be included in the membership.
C. One-third of the membership to be Contra Costa Health Plan consumers (one position is
reserved for a Medi-Cal member).
D. The Director of Health Services to serve as a non-voting member.
E. A third consecutive absence or five (5) absences in a rolling twelve (12) months from a
regular Advisory Board meeting will be considered a resignation from the Advisory
Board, and a replacement will be recommended to the Board of Supervisors. Exception
to this policy requires approval by the Advisory Board.
F. A person appointed to fill a vacancy is to serve for the unexpired term of the member
replaced.
G. Resignations, in writing, are to be sent to the Board of Supervisors. The Advisory Board
will initiate action to obtain a replacement.
H. The Advisory Board may appoint individuals as consultants to assist in the operations of
the Advisory Board as deemed necessary.
ARTICLE IV: OFFICERS
A. Officers elected to be Chairperson and Vice-Chairperson.
B. Officers to be elected by the Advisory Board members at the regular February meeting,
or at the earliest possible meeting thereafter.
C. Upon the vacancy of the Advisory Board Chairperson, the Advisory Board will elect a
new Chairperson at the following meeting.
D. Officers to serve in one office for no more than two successive one year terms.
ARTICLE V: VOTING
A. Each member to have the authority to speak and cast one vote on all matters presented
before or pertaining to the activities of the Advisory Board.
B. Quorum: 50% plus one.
C. A majority vote necessary to pass motions.
ARTICLE VI: DUTIES AND RESPONSIBILITIES OF OFFICERS
A. The Chairperson presides at all CCBP Advisory Board meetings.
B. The Chairperson establishes an agenda for each meeting and directs staff in the
preparation of the minutes of the previous meeting, and any other relevant material to
the meeting.
C. The Chairperson submits an annual report outlining the Advisory Board's actions to the
County Board of Supervisors at the end of each calendar year; a proposed program of
Board activity for the forthcoming year to be included in the annual report.
D. The Chairperson and Vice-Chairperson shall represent the Board at all times when the
Board's representation is deemed necessary.
E. The Vice-Chairperson shall assist the Chairperson as directed by the latter, and shall
assume all obligations and authority of the Chairperson in his/her absence.
F. The Chairperson serves as ex-officio member of all Committees except the Nominating
Committee.
ARTICLE VII: MEETINGS
A. At least nine meetings a year at a time and place agreed upon.
B. Notice of all regular meetings, the Minutes of past meetings and Committee reports, to
be mailed to each member seven (7) days prior to the day named for such meeting. The
mailing to include the agenda for the upcoming meeting. All meetings to be governed
by Roberts Rules of Order.
C. Special meetings to be called at the Chairperson's discretion, or upon the written request
of Advisory Board members. Notice of special meetings to be mailed to all Board
members seven days in advance.
D. All CCHP Advisory Board meetings to be open to the public.
ARTICLE VIII: COMMITTEES
A. Committees to be appointed by the Chairperson as necessary to carry out the business
of the Advisory Board.
B. Standing Committees will be:
1. Finance and Management
2. By-laws
3. Health Delivery Services
4. Marketing
5, Executive - membership will include the Chairperson, Vice-Chairperson,
immediate past Chairperson and one member elected by the Advisory Board.
C. All amendments passed by a majority of Advisory Board members to be a part of these
By-laws.
ARTICLE IX: FISCAL CONSIDERATIONS
Members will be reimbursed for actual and necessary expenses incurred in connection with
Advisory Board duties.
Adopted: 1/84
Amended: 3/85
Amended: 3/87
G.C:BY.LAW
IN T1ic WARD Or SJPER:iSGa5
OF
CONTRA COSTA COUNTY, STATE OF CALIFORNIA
In the ?natter of: )
)) January 16, 1979
Creation of an HiiD
Advisory Board.
The Board, on November 14, 1978, having referred to the Finance .
Committee a proposal from the Human Resources Director and County Administrator
for the creation of a Health Maintenance Organization Advisory Board and the.
Finance Committee having reported to the Board recon-mending the creation of
such an Advisory Board; and
The Board members having discussed the Finance Coranittee report
and having decided that the numbers of the WO Advisory Board nominated by
the individual Board members should also serve fixed terms of office, (rather
than at the pleasure of the nominating mer•.ber of the Board as mentioned in
paragraph 3 of said report);
IT IS BY THE BOARD:ORDERED THAT:
1. An HMO Advisory Board is created effective February 1, 1979;
2. The HMO Advisory Board shall be composed of nine (9) members;
3. Each member of the Board of Supervisors shall nominate one
member for the HMO Advisory Board;
4. Three (3) members of the HMO Advisory Board shall be members
of the County's Ht10 and at least two (2) of the W40 members
shall represent medically underserved populations served by
the W40. All applications shall be forwarded to the Internal
Operations Committee (Supervisor Nancy Fanden and Supervisor
Tom Powers) for review and recommendation to the Board.
5. One member of the W10 Advisory Board shall be the Director of
Health Services or the Director's designee;
6. The members of the MO Advisory Board appointed to the seats
mentioned in'paragraphs.3 and 4 above shall serve three-year
terms;
7. For the initial seating of the members of the HMO Advisory Board
appointed under paragraphs 3 and 4 above, the members shall draw
lots for terms of one, two, or three years such that there will
be two members with terms expiring January 31, 1980; three members
with terms expiring January 31, 1981, and three members with terms
expiring January 31, 1982;
B. The MO Advisory Board shall be responsible for reviewing the
operation of the County's W40 and providing advice to the Board
of Supervisors on matters relating to the H.tO as well as other
duties which may be assigned to them fram tine to time by the
Board of Supervisors;
9. The nem5ers of the H':0 Advisory Board shell be entitled'to
reir5urserert for actual enj necebser • expen=:s related to their
membership on the H':^ Advisa•v Board in W."p nee :,i.il the
COU-1t, 's volunt__- ^:,l:c!
10. The Board of Supervisors authorizes the Acting I'.edical
Director to cowwnicate to appropriate Federal agencies
the Board's action in creating the W40 Advisory Board and
the Board's request that active review of their PI40
Qualification Application be undertaken at the earliest
possible time;
11. The IMO Advisory Board report directly to the•Board of
Supervisors;
12. The H"O Advisory Board coordinate their efforts with the-
Human Services Advisory Commission and other appropriate
Advisory Boards and Commissions whenever the subject matter
under discussion affects other programs or services which
are the concern of other Advisory Boards and Coar:�issions;
13. The Director of Health Services provide any necessary
staff services to the 1140 Advisory Board from present
staff.
PASSED BY THE BOARD ON JNIUARY 16, 1979.
3 hereby certify that the foregoing is a true and correct copy of
an order entered on the minutes of said Board of.Supervisors on the date
aforesaid.
Witness my hand and the Seal of the Board
of Supervisors
affixed this 16th day of January, 1979
J. R. OLSSON, CLERK
Deputy Clerk
t
Orig: Human Resources Agency
Acting Medical Director
PHP Administrator
Chair, MS.AC
Courty Administrator
County Counsel
1979 Finance Cn=- ittve
r d./sup...
P. Dint-,_r, PID .
In the Board of Supervisors
of -
Contra Costa County, State of California
March 13 09 80
M the Matter of
Proposed Expansion of Health
Maintenance Organization
Advisory Board.
The Board on February 26, 1980 having referred to the
Internal Operations Committee (Supervisors R. I. Schroder and
E. H. Hasseltine) and to the Health Maintenance Organization
Advisory Board the request of the Executive Director of the
Contra Costa Health Plan that the MIO Advisory Board be expanded
from vire to twelve members (as suggested by the U.S. Department
of Health, Educa�tion—and Welfare Site Visit Team) to provice addi-
tional representatic . from the areas of manavprert e7pprtise,
financial expertise, and commercial health plan enrollees; and
Supervisor Schroder having reported that the FAMO Advisory
Board concurred in the expansion of members from nine to eleven
but did not believe that anyone with HMO management expertise is
required since the rirector of Health Services is already a member
of the Advisory Board; and
Supervisor Schroder having stated that the Committee
believes that the request of the Federal Government should be met
and notes that the membership of the Director of Health Services
does not necessarily guarantee that an individual experienced in
1010 management will be on the Advisory Board; and
The Committee having recommended that the HMO Advisory
Board be expanded from nine to twelve seats to include individuals
meeting the following criteria: E-10 management expertise, financial
expertise, and Health Plan enrollee--commercial status; that the
Board of Supervisors declare said seats vacant; and that established
Board policy be followed in posting the vacancies; and
Supervisor S. W. McPeak having recommended that the three
additional positions not be filled by employees of the County Health
Services Department or Contra Costa Health Plan unless prior approval
is obtained from HEW;
IT IS BY THE BOARD ORDERED that the aforesaid recommendations
are AiFROVAZD.
PASSED by the Board on lurch 18, 1980.
1 hereby certify that the foregoing is o true and correct copy of an order entered on the
minutes of said Board of Supervisors on the date aforesaid.
Witness my hand and the Seal of the Board of
CC: Health-Services Director Supervisors
Public Information affixed this 18th day of 2iarch 1980
Officer
F-10 Advisory Board '�
County Ad4ministrator J. R. OLSSON, Clerk
Hunan Services By ?24r— `J -E-.sem_ , Deputy Clark
Vera Nelson
MACHMEN'T B
.
4NTtA �OSTAHEALTH 'I.A1�1 ADX!LSORY SOAttD HERS
SEPTEII+IBER 1994
PAUL KATZ, Chair Labor Representative and Contra Costa Health Plan Member
2104 Holbrook Drive
Concord, CA 94519
Work: 228-1600 Home: 687-3706
HENRY F.TYSON, Vice Chair Chief, Medicare Program Review Section, Health Care Financing Administration
756 Hazlewood Drive
Walnut Creek, CA 94596
Work: (415)7443434 til October 10
Work: (415)744-3651 Home: 938-2176
FAX. (415)744-3761
BOBBI BONNET, RN, MPA County Employee and Contra Costa Health Plan Member
250 Gilger Ave., Martinez, CA 94553
Work: 646-4690 Home: 372-8506
MICHAEL GARCIA Executive Director-Process Reengineering,'Pacific Bell
2409 Saddleback Drive (Certified Employee Benefits Specialist)
Danville, CA 94506
Work: 823-8484 Home: 838-7355
FAX: (510)275-0899
FRANCIS GREENE Director of Pittsburg Pre-school Coordinating Council
Home: 56 Barrie Drive
Pittsburg, CA 94565
Work: 1760 Chester Dr., Pittsburg
Home: 432-4566 Work: 439-2061
JEFFREY B. KALIN Cardiology Lab. Manager at Stanford Medical Center. Fifteen years experience
1014 Camino Verde Circle in hospital and community-based healthcare services
Walnut Creek, CA 94596
Work: (415) 725-3894 Home: 932-3918
FAX: (415) 725-1138
JACK MCGERVEY HMO Experience -Former Kaiser Employee
23 Marlee, Pleasant Hill 94523
Work&Home: 932-1378
HOWARD W. MITCHELL, MD, MPH Retired Physician/Administrator with special interest in public health, medical
185 Shoreline Court administration and international health.
Richmond, CA 94804
Home: 232-1605
LISA VEGVARY Contra Costa Health Plan Member
3330 Wren Ave.
Concord, CA 94519
Work&Home: (510) 825-0175
ADVISORY BOARD COM]WTITEES
VMCUTNE MARKS ING HEALTH C FINANCE SCREENING
Paul Katz (C) Jack McGervey(C) Howard W.Mitchell MD(C) Henry Tyson(C) Howard Mitchell
Jack McGervey Jeffrey Kalin Francis Greece Michael Garcia Paul Katz
Henry Tyson Bobbi Bonnet Jack McGervey
(alternate)
Distribution: County Administrator's Office
Health Services Director's Office
Merrithew Memorial Hospital and Clinic's Executive Director
Linda Brun&Senior CCHP Staff
Advisory Board Packet
JI:ABM-September 26, 1994
ATTACHMTT C
AMBULATORY MEDICAL RECORD REVIEW
DEFINITIONS OF INDICATORS
Note: It is recommended that patients be enrolled In the health plan for a minimum of
6 months and have sufficient visits (at least two visits) for the chart to be eligible for
review. Only documentation for the current membership period Is to be reviewed,
(exception question 14).
The numbered definitions of indicators correspond with numbered Indicators on the
Adult/Pediatric Ambulatory Medical Record Review Tool. Exceptions for Pediatric reviews are
noted. The corresponding Pediatric question numbers have been placed in (); e.g., (8 Peds).
Where indicators contain the word and, all components of the definition must be present to
answer the question in the affirmative.
Timeframe: Review all entries for the two years preceding the last visit.
INDICATORS:
1. (1 Peds) Sex.
The sex of the patient is identified by male or female, boy or girl, man or
woman, or by the appropriate symbols. The sex of the patient must be
documented in the provider's or provider's designee's history and physical
assessment, progress notes or in the face sheet which is completed by the
member or provider's office staff.
2. (2 Peds) Date of birth.
The actual month, day and year the patient was born. Date of birth does not
equal the patient's age. The date of birth must be documented in the
provider's or the provider's designee's history and physical assessment,
progress notes or in the face sheet which is completed by the member or
provider's office staff.
3. (3 Peds) Home address.
The address of the patient's primary residence, e.g., street and town.
• 4. (4 Peds) Home or work telephone numbers of patient and/or patient's spouse.
Definition: If no phone, no phone should be documented. For PEDIATRIC
cases, the home phone number or work number of at least one parent is
required. if no phone, no phone should be documented.
5. Occupation.
Definition: A description of what the patient does for a job. Examples are
pilot, waitress, lawyer, student, retiree, housewife, or unemployed.
• 6. (S Peds) Employer.
Definition: A description of the patient's employer. Acceptable documentation
Is "business or corporation", "self-employed", "student% "attends university,
college or school", "retired", and "homemaker". If patient does not work,
unemployed is documented. For PEDIATRIC cases, the employer of at least
one parent is included. If neither parent works, unemployed is documented.
• 7. Marital status.
Definition: Acceptable documentation Is"single", "married", 'divorced",
"separated", "husband% "wife", "Mrs. "Mr.", "Miss". Not included for
PEDIATRIC reviews.
•
S. (6 Peds) All pages with entries In the record contain patient identification.
Definition: Name, social security number or other unique patient identifier is
on all pages with entries.
9. (7 Peds) There is an individual medical record for each individual receiving
care. OR, if information on family members is kept in the same record, there
is an individual sheet for each family member.
10. (8 Peds) The medical record is organized.
Definition: Chart is in chronological (or reverse chronological) order and
content is in a consistent format. Consistent format means reports are in
respective sections of the ambulatory medical record, e.g., laboratory
information is in the lab section of the ambulatory medical record or
laboratory information is in a consistent location in the progress notes.
• 11. (9 Peds) The record contains an updated, completed problem list or summary
of health maintenance exams.
Definition: An updated completed problem list summarizes significant
illnesses, medical conditions, past surgical procedures, or chronic health
problems which is updated as new problems are encountered, as evidenced in
the progress notes. The problem list can be in a separate section or can be
listed as a problem In the progress notes. If no past or current illnesses,
conditions, or past surgical procedures, there is a statement that no current or
past problems are noted. In this case, there is a summary of health
maintenance exams such as well woman exam, well child exam, routine check
up or complete physical exam.
12. (10 Peds) List of current prescription medications.
Definition: Current prescription medications are documented on a separate
medication sheet or are listed in a consistent location in a progress note. This
would include medications prescribed during the visit or being renewed over
the phone. OR, if no current medications, there is indication in the progress
notes that medications have not been prescribed.
• 13. (11 Peds) Allergies and adverse reactions to medications are prominently
displayed.
Definition: The patient's medication allergies and adverse reactions to
medications must be consplcuously listed in the ambulatory medical record or
on the front or inside cover of the medical record folder. OR, if allergies and
adverse reactions to medications are absent, "No known allergies" (NKA), or
"NA", or"none" is conspicuously documented in the ambulatory medical record
or on the front or inside cover of the medical record folder. Conspicuously,
means in an obvious location, e.g., upper corner or left or right side of
progress note. You should not have to search for this Information.
Example: Allergy- Penicillin
Adverse Reaction - Rash, Hives
• 14. (12 Peds) There is a past medical history in the record.
Definition: For patients seen 3 or more times a past history should be easily
identified and should include history of immediate Family members, or a note
indicating there are no family history of problems, serious accidents,
operations and illnesses. Easily identified means it should be in one central
area, not scattered throughout the chart. An inpatient history and physical
taken by the provider, is acceptable. For children, past medical history will
relate to prenatal care and birth. For patients seen less than 3 times, there is
a past history noted for the current condition, such as when there is a visit for
hypertension there is a family history for hypertension, a patient history and
progress note for hypertension. (For females more than 18 years of age, there
must be an obstetrics and gynecological history.) If there has been no break in
the patient/physician relationship and there is a past history in the chart that
was completed while the patient had another form of insurance, the criteria is
met.
* 15. (13 Peds) Each entry is dated.
Definition: This includes progress notes, problem list, medical list, assessment
form, etc.
' 76. (14 Peds) Each entry in the record contains the provider's name or initials.
Definition: Applies to all office staff, RNs, LPNs, Medical Assistants, and
physicians. Each entry has the provider's name or initials. These may be hand
written, typed, or a signature stamp used. Where the name or initials are
typed or a signature stamp is used, a counter signature os counter initials
must appear. Where the record is from a solo practitioner, each entry is to be
signed or initialed. Entries include medication renewals and telephone orders.
17. (15 Peds) Each entry in the record contains the provider's profession.
Definition: Applies to all RNs, LPNs, Medical Assistants, and physicians. Each
entry has the provider's profession. This may be hand-written, typed, or be
Identified once within the medical record on a signature log. This definition
also applies to solo practices. Entries include medication renewals and
telephone orders.
• 18. (16 Peds) Each entry is legible to the reviewer.
Definition: All Indicators must be legible to the reviewer. If an indicator
cannot be noted because It is not legible or the entire entry is not legible, then
Indicator 18 (16 Peds) Is w.
19. (17 Peds) For each visit, the reason for the visit or chief complaint is noted.
The review of systems exam coincides with the reason for the visit or the chief
complaint.
(18 Peds) Immunizations are documented in the record. (PEDIATRIC reviews
only).
Definition: Immunizations have been documented in a designated section, in
the progress notes or there is a statement that the immunizations are up-to-
date. This applies to children ages 2 months to 6 years old.
RISK GROUP CATEGORIES - IMLtt1tT0 NYM�LItS IM 1AltLM7lt�lf ON cwurn
(1) ORAL CAVITY- Exposure to tobacco.excessive ETON. or reports of suspicious symptoms or
lesions detected on self-cxam.
(2) THYROID PALPATION - lix of upper-body irradiation.
(3) BREAST EXAM - Females with family history of premenopausal breast cancer in Cult degree
relative.
f 4 TESTICLE EXAM - Hx of cryptorchidism, orchiopexy or testic-A- -.trophy.
(5) SKIN EXAM - Personal or family history of skin cancer. history of increased exposure to
sunlight,or clinical evidence of precursor lesions (e.g., dysplastic nevi, certain congenital nevi).
(6) CAROTID AUSCULTATION - Risk factors for cerebrovascular or cardiovascular disease, or
history of neurologic symptoms (TIA's) or cerebrovascular disease.
(7) fn- Markedly obese patients, family history of diabetes, or history of gestational diabetes.
(8) RUBELLA- Females without evidence of Immunity.
(9) VDRL- Prostitutes,sex with multiple partners in areas in which syphilis is prevalent,or
contacts of persons with active syphilis.
(10) WA FOR BACTE - Diabetics.
(11) CHLAMYDIA- Pts. attending STD clinics or other high-risk healthcare facilities, (adolescent and
family planning clinics), or with other risk factors (multiple partners, partner with multiple
sexual contact,age < than 20).
(12) GC CULTURE- Prostitutes, sex with multiple partners or a partner with multiple contacts,
sexual contact of persons with cultured-proven gonorrhea, or persons with history of repeated
episodes of gonorrhea.
(13) BW- Pts. seeking treatment for STD's; homosexual and bisexual men; past or present use of IV
drugs; history of prostitution or multiple sex partners; females whose past or present partners
were HIV-infected, bisexual, or IV drug users; persons residing or born in area with high
prevalence of HIV; or transfusions 1978-1985.
(14) RFARING - Regular exposure to excessive noise.
(15) =- Household members of persons with TB, others at risk for close contact with the disease
(staff of TB clinics, homeless shelters, nursing homes, substance abuse treatment facilities,
dialysis units,correctional facilities); recent immigrants or refugees from countries in which TB
is common; migrant workers; residents of nursing homes, correctional institutions, or homeless
shelters; or persons with certain underlying illness (e.g., HIV infection).
(16) EKG - Males who would endanger public safety should they experience a sudden cardiac event
(e.g., commercial pilots).
(17) MAMMOGRAM - Females 35 and older with family history with premenopausal breast cancer in
first degree relative.
(18) COLONOSCOPY- Family history of familial polyposis coli or cancer family syndrome.
(19) FORT/SIGMOIDOSCOPY- Persons 50 and older with first degree relative with colorectal
cancer, personal history of endometrial, ovarian, or breast cancer; or previous diagnosis
inflammatory bowel disease, adenomatous polypys, or colorectal cancer.
(20) PAP SMEAR- No previous documented screening in which smears have been consistently
negative.
(21) FOBT/COLONOSCOPY- Family history of familial polyposis coli or cancer family syndrome.
(22) NEEDLE SHARING- Intravenous drug users OVDU's).
(23) BACK EXERCISES - increased risk for low back injury due to past history, body configuration,
or type of activities.
(24) CHILDHOOD INiURY PREVENTION- Persons with children in home or automobile.
(25) FALLS IN ELDERLY- Persons with older adults in home.
(26) HEPATTCIS-B-Homosexually active men, IVDUs, recipients of some blood products, or
persons in health related jobs with frequent exposure to blood or blood products.
(27) PNEUMOC CAL VACCINE - Increased risk of a pneumococcal Infection (chronic cardiac or
pulmonary disease, sickle cell disease, nephrotic syndrome, Hodgkin's disease, asplenia,
diabetes mellitus, ETOHism, cirrhosis, multiple myeloma, renal disease, or conditions associated
with immunosuppression.
(28) INFLUENZA VACCIINE- Residents of chronic care facilities, patients with chronic
cardlopulmonary disease, metabolic diseases (including diabetes), hemoglobinopathies,
immunosuppression, or renal dysfunction.
(29) MMR VACCINE- Persons born after 1956 without evidence of immunity to measles (receipt of
live vaccine on or after first birthday, lab evidence of Immunity, or physician-diagnosed measle.
COUNSELING NOTES . Refer to Ba3ic Counseling on chart
(a) MET AND EXERCISE
• Fat, cholesterol, complex carbohydrates, Cber. Na. and Ca. Fe (for females)
• Caloric balance
Selection of exercise program
(b) SUBSTANCE USE
Tobacco cessation
ETOH/dtugs -limit ETON consumption;driving/other dangerous activities while under the influence;
treatment for abuse.
(c) D l RU Y PFXWN77ON
• Seat belts
• Smoke detectors
• Smoking near bedding or upholstery
Safety helmets
Violent behavior/firearTns -Age 19.39
Prevention of falls -Age 65 and over
Hot water heater temperature -Age 65 and over
(d) DENTAL HEALTH
Regular brushing, dossing, and dental visits
(e) SEXUAL PRACTICES
• STD's
• Partner selection
• Condoms
• Anal intercourse
• Unintended pregnancies and contraceptive option
.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A Periodic Health Evaluadon includes:
1. Basic medical history, review of systems, plus health risk appraisal to determine high risk categorie-
2. Basic age/sex determined physical examination plus risk group specific examinations.
I A limited age/sex determined group of screening tests' plus risk group specific screenting tests'.
4. Medical problem/diagnosis/symptom intervention plus counseling for reduction of high risk
Imhavior/llfestyle.
• All diagnostic screen tests chosen based on their scientifically assessed efficacy as screening tests.
Including assessment of their potential for false positive and false negavie results.
PREVENTIVE HEALTH GUIDELINES
TYPE OE SERVICE 19.39 YEARS 4@-64 YEARS 65 and OLDER
* q 1-3 Years * q 1-3 Years * Yearly
BASIC HISTORY Dietary Intake Dietary Intake Dietary Intake
Physical Activity Physical Activity Physical Activity
Tobacco/ETOH/Drug use Tobacco/ETOH/Drug Use Tobacco/ETOH/Drug Use
Sexual Practices Sexual Practices Prior Symptoms TIA
Functional Status
at home.
RISK GROUP HISTORY• Applies to all age groups; targeted at identification of risk group categories applying to
(See page 4) the individual patient, with subsequent examination. testing, and counseling directed
accordingly.
BASIC PE • Ht & Wt Ht& Wt Ht & Wt
Minimum recommended BP BP BP
guidelines Pap smear - After 3 annual Breast exam yearly Breast exam yearly
negatives, q 1-3 yrs. Pap smear-q 1-3 Yrs- Pap smear- at physician's
Clinical breast exam . at Digital rectal exam -at discretion (see Risk
physician's discretion. May physician's discretion. Group 20).
be prudent at earlier age in Digital rectal exam - at
certain persons (see Risk physician's discretion.
Group 3). Visual acuity
Hearing, hearing aids
RISK GROUP SPECIFIC Oral caviry(1) Oral caviry(1) Orsi cavity(1)
PE Thyroid palpation(2) Thyroid palpation(2) Thyroid palpation(2)
Skin exam(5) Skin exam(5) Skin ccam(5)
Clinical breast exam - (3) Ausculate carotids(6) Ausculate carotids(6)
Testicle exam(4)
BASIC DIAGNOSTIC Total chol.(nonfasting) - Total chol.(nonfasting) - Total chol.(nonfasting) -
TESTS q 5 yrs., more frequently if q 5 yrs., more frequently q 5 yrs., more frequently
previously elevated. if previously elevated. if previously elevated.
,Mammogram - q 1-2 yrs. Dipstick U/A - may he
ages 40-49, yearly ages 50 prudent over age 60.
or older. Mammogram - q 1.2 urs.
FOBT/Sig• ages 50 and until age 75, unless
older at physician's pathology detected.
discretion. May be Thyroid function tecta -
clinially prudent in may be prudent.
certain persons (see Risk especially for women
Group 19). FOBT/Sig- same as ages I
40-64.
*Applies only to the periodic PERIODIC IMALM EVALUATION(SEE PAGE S)
-cumbers In parenfheses-react to Risk Croup Cctegorfes (See Page 4)
1
PREVENTIVE HEALTH GUIDELINES
IM OF SERVICE 19.39 YEARS 40-64 YEARS 65 and OLDER
* q 1-3 Years * q 1-3 Years * Yearty i
RISK GROUP SPECffIC FBS(7) FBS(7) FBS(7)
DIAGNOSTIC TESTS Rubella(8) VDRL(9) PPD(15)
VDRL(9) U/A for bacteriuria(10) EKG(16)
U/A for bacteriuria(10) Chlamydia(11) FOBT/Sig(19)
Chlamydi2(l1) GC culture(12) Pap sme2r(20)
GC culture(12) HIV-counseling, testing(13) FOBT/Colonoscopy(21)
HIV-counseling, testing(13) He2ring(14)
Hearing(14) PPD(15)
PPD(15) EKG(16) j
EKG(16) FOBT/Sig(19) I
Mammogmm(17) FOBT/Colonoscopy(21)
Colonoscopy(18)
BASIC COUNSELING Diet/Exercise (a) Diet Exercise (a) Diet/Exercm (a)
See Counseling Notes, Substance Use (b) Substance Use (b) Substance Use (b) I
page 5. (a) thru (e) Injury Prevention (c) injury Prevention{c) Injury Prevention (c) +II,
Dental Health (d) Dental Health (d) Dental Health (d) I
Sexual Practice (e) Sexual Practices (e)
RISK GROUP Needle sharing(22) Needle sharing(22) Prevention of childhood
SPECIFIC COUNSELING Back exercise(23) Back exercise(23) injury(24)
Prevention childhood Prevention childhood
injury(24) injury(24)
Falls in elderly(25) Falls in elderly(25)
r BASIC U4MUNLZATION TD q 10 yrs. TD q 10 yrs. TD q 10 yrs. i
Influenza annually
Pneumococcal once
RISK GROUP Hep B(26) Hep B(26) Hep B(26)
SPECIFIC IMMUNIZATION Pneumococcal once(21 Pneumococcal once(27)
Influenza annually(28) Influenza annually(28)
,IMMR(29)
ALERTS -Depressive symptoms -Depressive symptoms -Depressive symptoms
-Physical abuse signs -Physical abuse signs -Physical abuse signs
-Suicide risk factors-recent -Suicide risk factors -Suicide risk factors
divorce, separation. -Abnormal bereavement -Abnormal bereavement
unemployment, -,Malignant skin lesions Malignant skin lesions
depression. ETOH/drug -Tooth decay, gingivitis, -Tooth decay, gingivitis.
use, illness, living alone loose teeth loose teeth
-Abnormal bereavement -Periph. arterial disease - -Changes in congnitive
-Malignant skin lesions age over 50, smokers, function
-Tooth decay, gingivitts diabetics -Medications that increase
risk of falls
-Periph. arterial disease .
age over 50, smokers.
diabetics
*Applies only to the perWic PERIODIC HEALTH EVALUAHON(SEE PAGE S)
Numbers In parenftmn4efef to Risk Group Cartegodes (See pogo 4)
2
PREVENTIVE HEALTH GUIDELINES
ryn Of SERVICE 19-39 YEARS 40-64 YEARS 65 and OLDER
* q 1-3 Years * q 1-3 Years * Yearty
OT13YR PRIMARY -Hemoglobin testing -Skin protection -Glaucoma tcsung
PREVENTIVE MEASURES depending on -ASA therapy-men with -Skin protection
dcscent(Caribbcan. GAD risk factors with -ASA therapy
Latin American. Asian. neither history of -Estrogen replacement
,Mediterranean, or African) GVother bleeding therapy
-Skin protection-increased problems. nor other risk
exposure to sunlight factors for bleeding or
cerebral hemorr.
-Estrogen replacement
therapy-perimenopausal
with increased risk of
osteoporosis and without
known contraindications
to therapy
5
*Applies only to the palodlc PEMDIC]MUM EVALUAMN(SEE PAGE S)
lumbers in pareMhes—refer to Risk Group CakKpies (See pogo 4)
3
RECOMMENDED SCHEDULE FOR EVALUATION AND IMMUNIZATION
OF INFANTS AND CHILDREN
2 weeks- Physical exam; PKU repeat
2 months - Physical exam; DPT #1; TOPV #1; Hib Titer #1
4 months- Physical exam; DPT #2; TOPV #2; Hib Titer #2
6 months - Physical exam; DPT #3; Hib Titer #3
9 months - Physical exam; hemoglobin or hematocrit; urinalysis
12 months - Physical exam; Tuberculosis skin test
15 months - Physical exam; MMR; Hib Titer #4
18 months - Physical exam; DPT #4, TOPV #3
2 years to 6 years - Yearly physical exam; Tuberculosis skin test yearly or every other year
5 years - Physical exam; DPT and TOPV booster
6 years and over- Physical exam every two years; MMR booster age 10 to 12 years
Hepatitis B vaccine at birth, 1 month, and 6 to 12 months OR three part vaccine series for
older children
Optional - Urinalysis every two years with physical exam
Hemoglobin or hematocrit in adolescence
Cholesterol in adolescence
AULA AMI(It REVIEW SHEET
PART 1 AND PART 2
Provider ID Reviewer ID Date of Review
AM1(1( from 111A Staff Group Initial Review Re-Review
MEMBER IDENTIFICATION
CRITERIA PART 1 Y=Yes, N = No Line
STRUCTURAL 1NTEGRIlY Total•
1. Sat
2. Datc of birth
3. home address
t. [tome or work phone#
5. Occupation
6. Employer
7. Marital status
8. 10 all pages
9. individual medical record or indkidual
sheet
10.Medical record or&tnized
PART 1
SCORE = I(#YES RESPONSES/10 INDICATORS)/# OFMEDICAL RECORDS]X 100
PART.2 MEDICAL PRACTICE
11.Completed problem list or
summary health maintenance exams
12.Current coed list or med note
13•Allergies and adverse reactions
14.Past coed history
15.Each entry dated
16.E-ich entry has provider's name,initials
17.Provider's profession each entry
18.Legible
19.Nisit exam coincides with CC
PART 2
SCORE = 1(# YES RESPONSES/9 INDICATORS)/#OF\fE•DICAL RE•CORDSI X 100
TOTAL SCORE = ((PART I SCORE_X.15) + (PART 2 SCORE—X.85)) _
1'LUTAIICII. A UM ALVILAV SIIL'L'T
PART 1 AND PARI. 2
Provider ID Revicwer 11) Date of Review
AA9RR from 111A Staff Croup Initial Review Re•lteview
MEXIllrK IDEN'1117ICATION
CRITERIA PART 1 Y=Yes N =No line
STRUCTURAL 1NTECR.1'IY Taal•
1.Sex
2.Date of birth
3.Clonic address
4.Home or one of parents pork
phone number
5.Employer of at least one parent
6.ID all pages
7.Indi%idual medical record or
indioidual sheet
S.Medical record organized
PART 1
SCORE = 1(#YES RESPONSES/$INDICATORS)/# OF.%IE•DICAL RE•COIUDS]X 100
PART 2 MEDICAL PRACTICE
9.Completed problem list or
summary health maintenance exams
10.Current med list or med note
11.Allergies and adverse reactions
12.Past med history
13• Lich entry dated
14.Each entry has prodder's name,initials
15. Provider's profession each entry
16. Legible
17.Visit exam coincides with CC
IS. Up-todate immunizations
documented
PART 2
SCORE = 1(# ITS RESPONSES/10)1# OF MEDICAL HE-CORDS)X 100
TOTAL SCORE - 1(PART 1 SCORE_X.15) t (PART 2 SCORE—X.85)1 =
•
HOSPITAL/CLINIC QUALITY INDICATORS
OIIALITY ASSESSMENT & IMPROVEMENT PLAN 1994
Ambulatory-Care-Administration
1. Ambulatory Care Patient Complaints.
2. Ambulatory Care Unusual Occurrences.
3. Summary of Waiting Time To Obtain Appointments in
Ambulatory Care Clinics.
Ambulatory care Nursing
1. Adult Patient Preparation - Allergy, chief complaint,
vital signs, second hand smoke exposure for Pediatric
patients, patient teaching, signature and..title from last
visit.
2. Noting Orders - Each intervention checked, signature and
title from last Doctor's orders noted.
3. Injections - documentation of consent, route, site, date,
time, signature and title.
4. PPD - Results documented within 48-72 hours, or attempt to
contact patient, results in millimeters, date, signature
and title.
5. Endoscopy - Preparation of patient for exam, presence of
referral -note, and X-Ray present for exam.
Central Suvvly
1. Biological and Chemical Indicators of the Sterilization
Process.
2. Prepared Instrument packs will meet standards for
cleanliness and content 100% of the time.
Clinical Laboratory
1. Improperly identified Specimen/Slips.
2. Number of Lab Response Delay to Blood Draw Requests.
3. Number of Contaminated Blood Cultures.
4. Number of Instances Receipt of STAT Delayed more than 10
minutes.
5. Number of Unspun Blood Specimens Maximum Received more
than 8 hours.
6. Percent of Quality Control results above 2SD not
investigated.
7. Correlation of Reference Lab Results.
1
HOSPITAL/CLINIC QUALITY INDICATORS
Education and Training Department
1. Inservice of new equipment.
2. Classes identified needs assessment are offered by
Education and Training Dept.
3. Compliance with mandatory annual Safety Review Program
(Skills Day) .
4. Compliance with mandatory biannual CPR proficiency
requirement.
Emergency Preparedness Committee
1. Implement The Hospital Emergency Incident Command System
(HEICS) .
Environmental Services
1. Improving Organizational Performance: Inspections by
Manager & Supervisor to initiate and maintain Improvement,
Leadership, and Planning.
2. Safety Management: Safety inspection includes routine
inspection of staff activities, to reduce the risk of
human injury.
3. Number of Employee Accidents: Documentation of employee
injuries, as part of the continuing education of all
personnel and specific job-related hazards.
4.A Infection Control Linens: (clean & soiled) Written
Procedures for Infection Surveillance: Supply an adequate
amount of clean linen for at least 3 complete bed changes
for the hospital's licensed bed capacity.
4.B Soiled Linen shall be handled, stored, and processed in a
manner that will prevent the spread of infection and will
assure the maintenance of clean linen.
5. Linen Replacement Cost: (lost, torn, worn, out-of-stock)
Consultation from Linen Company.
6. Bio-Hazard Waste: (Medical Waste Management Program) It
is handled according to applicable laws and regulations.
Equipment Management
1. Failure Analysis.
2. Customer Service Evaluations.
3
HOSPITAL/CLINIC QUALITY INDICATORS
NURSING
Generic Nursing Indicators
1. Crash Cart Readiness.
2. Accu Check Calibration Accuracy.
3. Refrigerator Temperature Checks. ----
4. Nursing Documentation of Admissions, Discharges, Care
Plans, and Nursing Care Record.
5. Unusual Occurrence
6. Medical. Record Completion
.B-Medical Unit
1. Leather Restraints.
2. Soft Safety Devices.
3. Peripherally Inserted Central Catheter.
4. Maintenance of Skin Integrity.
Critical Care
1. Central line care, assessment, documentation, and
physician notification.
Detention Facilities
1. Monitoring of inmate self-administration of medication
system.
2. Effectiveness of sick call triage.
3. Monitoring of intake screening process.
Emergency Room
1. Triage patient assessment.
2. Completeness of Emergency Room Nursing Form.
Family Care Unit
1. Respiratory Assessment of Pediatric Asthma Patients Aspect
of Care.
2. Respiratory Care of Post-Operative Patients.
3. Documentation of Education on The Post-Surgical TAH/BSO
Patient.
Geriatrics
1. Patient falls and effectiveness of preventive measures.
5
HOSPITAL/CLINIC QUALITY INDICATORS
Surgical Vnit
1. Management of Pain.
2. Wound Management.
3. Pre and Post Surgical Management.
4. Education of the -Surgical/Orthopedic Patient.
Patient ombudsperson
1. All patient complaints will be handled at the time that
they are identified.
2. Numbers and categories of complaints will be tracked for
patterns and opportunities for improving patient relations
and/or services.
Pharmacy
1. Controlled Substance Monitoring.
2. Controlled Substance Nursing Sheets.
3. PYXIS Discrepancy Reports.
4 . Inpatient_Dispensing Errors.
5. Outpatient Dispensing Errors.
6. Medi-Span Drug Interactions into computer.
7. Outpatient Counselling by Pharmacist for new
prescriptions.
(J6 HQAIND94.LST)
7
ATTACHMENT D
Contra Costa Health Plan .
Table Of Contents
Executive Summary
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
Services . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . C
Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E
Enrollment Process . . . . . . . . . . . . . . 0 . 00 . . . . . . . . . . . 0 . . . . II
Enrollment Procedure A
Disenrollment Procedure B
Enrollment/Disenrollment Reports/Audits . . . . . . . . . C
Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III
Professional Healthcare System (PHS) . . . . . . . . . . . . A
In-Plan Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
Claims Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV
Referrals . . . . . . . . . . 0 . . . . 000 . . . . . . . . . . . . . . . . . . . A
Authorizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
Adjudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E
Financial Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
Capitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
Claims Processing B
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
Auditing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
Complaint And Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI
Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
Input/Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
Follow-Up/Resolution C
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D
Charts
Flow Chart - CCHP Medi-Cal Processing.
Screens
Enroll Subscriber Screen.
Enroll Additional Members Screen.
Disenroll/Re-Enroll Member Screen.
Authorizations Screen.
Grievance Entry Program Screen.
Forms
Grievance Form.
Graphs
Grievance/Complaints Trends Graph.
Reports
Enrollment Reports - Medi-Cal Enrollment Comparison.
Medi-Cal Applications Monthly Sum.
Medi-Cal Monthly Disenrollment Sum.
Utilization/Claims - Suspended Claims.
Financial Reports - Quarterly Utilization.
Medi-Cal Crossover Summary.
Medi-Cal Non-Crossover Summary.
Total Medi-Cal Member Summary.
Medi-Cal Utilization.
Grievance Reports - Number Of Activities On Average.
Number Of Activities By Type.
• Number Of Activities By Method.
Completed Disenrollment/Cause.
Completed Emergency Disenroll.
Disenroll By Site And Type.
Number Of Disenroll/Two Months.
Board Of Supervisors #1.
Board Of Supervisors #IA.
Board Of Supervisors #2.
Data Dictionaries (Demographic/Utilization Files)
Data Dictionary Definition.
Data Dictionary - Subscribers.
Data Dictionary - Members. (partial)
Data -Dictionary - Member.Add.
Data Dictionary - Disenroll.
Data Dictionary - Encounter. (partial)
Data Dictionary - PH.Claims.
Data Dictionary - Physician.
Data Dictionary - Authorization.
Data Dictionary - Vendor.
Data Dictionary - Diagnosis.
Data Dictionary - Master.Claims. (partial)
Data Dictionary - Grievance.
Executive summary
This document provides an outline of the Contra Costa Health Plan,
including its philosophies, services, and operations. The focus of
this reference is on the interaction this organization has with its
Medi-Cal members. of course, these operations as they apply to non-
Medi-Cal members are similar.
I. introduction
A. Location - The Contra Costa Health Plan is a Health Maintenance
Organization operated by the Health Services Department of Contra
Costa County. The CCHP business office is located in Martinez, as
is Merrithew Memorial, the hospital it serves. The members of the
CCHP also have access to the HSD health clinics in Richmond,
Pittsburg, Concord, and Brentwood.
B. Population - Contra Costa County has approximately 65,000 Medi-
Cal eligible clients. 10,000 of these client are enrolled in the
CCHP. In addition, 15,000-20,000 Medi-Cal clients utilize the
hospital and health clinics on a fee-for-service basis. The CCHP
also has 10,000-11,000 members that are not Medi-Cal clients. The
Managed Care program is estimated to add an additional 50,000 Medi-
cal clients to the CCHP.
C. Services - The philosophy of the CCHP incorporates the practice
of preventative or managed health care, including a Primary Care
Physician, regular check-ups, wellness programs, Advice nurses, as
well as emergency services and more.
D. Information Systems - The CCHP currently employs 48 people to
assist in providing these services for the population it serves.
The success of operations can also be attributed to the information
systems, data processing expertise, and technology provided by the
Health Services Information Systems Department, without which the
number of clients served and the quality available would not be
possible. The HSD IS Department manages the information systems
used by the CCHP for all aspects of the members health care.
The primary systems implemented are the CCHP System, previously
referred to as the COMTEC system, and the Professional Healthcare
System (PHS) . The PHS system primarily contains information
regarding services received by members at the HSD Hospital and
clinics, and billing information. The CCHP System encompasses all
other operations and has access to the PHS information. The
Pharmaceutical Care Network (PCN) system is a private industry
system utilized by the CCHP which allows a patient to fill a
prescription at many non-HSD pharmacies. The HSD also operates its
own pharmacies which run on the PRX software. CCHP units use these
systems to research member inquiries, assist members with problem
resolution, various audits, reports, etc. Many demographic and
utilization files are accessible by these systems.
E. Processes - The major processes performed by the CCHP on a day
to day include the enrollment and disenrollment of members, the
utilization and authorization of the services available, the
processing of claims, financial reporting, and grievance reporting.
Many procedures are in-place that dictate the manner in which these
processes are performed, and to assure efficient and effective
monitoring of health care for CCHP members.
11, Barollment
A. 8nrollment process - To become a member of the CCHP, all clients
go through an enrollment process. The three Product Lines (groups)
served by the CCHP are Medi-Cal, MediCare, and Commercial
(employees of CCC and Individual policies) . Members that are both
Medi-Care and Medi-Cal clients are referred to as Crossovers.
Members that are only Medi-Cal clients are referred to as non-
crossovers. The Contra Costa County Basic Adult Care clients are
managed by the CCHP, but are not members. The enrollment process is
different for the various groups served. Two methods exist to
process Medi-Cal enrollees.
The first method for Medi-cal clients is to visit one of the five
Social Services Department locations. This department has a service
called Health Care Options. A representative explains the health
care options available to the client, including CCHP, fee-for-
service, and Kaiser. This application information is entered on-
line to the State Department Of Health.
The second method involves an employee of the CCHP, whose primary
responsibility is to solicit Medi-Cal users for enrollment. If the
client desires enrollment, this information is forwarded to the
State Department Of Health from the CCHP once a month. CCHP
Enrollment Unit clerks input the applicant data in the CCHP system,
including Medi-Cal number and demographic information, for each
applicant on a daily basis. Once a month a CCHP Data Unit clerk
inputs this demographic information into the Contra Costa County
Data Processing Unit's Sperry Univax system, which prepares the
data for the State. The CCC DP Unit is notified upon completion.
The CCC DP Unit transfers the data from Sperry Univax system to a
tape. This tape is then forwarded to the State by a CCHP Data Unit
clerk.
In either case, if the State approves the applicant, they update
their Cal-Med system. The State forwards the Cal-Med Renewal tape,
referred to as the PHP (Pre-Paid Health Plan) tape, to Contra Costa
County at the end of each month. This tape provides an automatic
means to enroll Medi-Cal clients into the CCHP system, and to
maintain records for all enrollees under the Medi-Cal program.
The automatic enrollment process rejects records that may need
special attention. These records can be adjusted and/or manually
enrolled if needed. All manual enrollments and re-enrollments are
performed by a CCHP Enrollment Unit clerk through the Enrollment
programs.
All information obtained in the enrollment process is stored in the
demographic files. The enrollment information is virtually the same
for each Product Line. This information includes the demographic
data of each member, as well as a status field indicating if the
member is currently enrolled, re-enrolled, disenrolled, or pending.
Each Medi-Cal applicant is entered in an applied (pending) status
until notification of the State's acceptance or . rejection is
received. While in this status services are available at Merrithew
Memorial Hospital or at the HSD clinics. However, the services are
not covered by the CCHP until approval.
Once the approval of the applicants) is confirmed, the demographic
files are updated to reflect this and the member is informed of the
full services available through the CCHP by a CCHP Member Services
Representative. This orientation includes a package of literature
which details the locations of each clinic, the services provided
at each clinic, the member's rights, pharmaceutical options, etc.
B. Disenrollment Process - There are three methods in which a
member may be disenrolled. Firstly, upon receipt of the PHP tape
from the State, members that the State has concluded as ineligible
are automatically disenrolled. If this occurs, the State and/or a
Social Services worker is responsible for notifying the member.
Secondly, the State may put a member in a Hold status. This means
that the State is reviewing the member's eligibility and may
declare the member ineligible in the near future. In this case a
Social Services worker will work with the State and the member to
determine eligibility. If ineligibility is determined or if the
status of Hold is unchanged over a two month period, the member is
automatically disenrolled by the CCHP system. When the State
indicates that a member's coverage is in a Hold status, a CCHP
Enrollment Unit clerk notifies the member and explains their rights
to apply and/or receive other health insurance, to assure continual
coverage. Thirdly, if a member no longer desires an enrollment into
the CCHP, they must complete the required forms through the Member
Services Unit. Members are then disenrolled in CCHP by an
Enrollment Unit clerk.
C. Reporting - Reports and audits generated monthly by the
Enrollment Unit include:
New Enrollees Programs - Detail of all new enrollees, screened and
verified. Information is used to complete monthly report which
verifies the number of enrollees by enroller.
Medi-Cal Monthly Summary - The names of new Medi-Cal enrollees are
verified against the corresponding months active Medi-Cal list.
Pending Listing - A listing of Medi-Cal members that the State has
put in a Hold status. Used to notify member of change in status and
to offer conversion rights.
Group Change/Conversion Listing - A listing of members, that have
changed group coverages in a given month. This information is used
to complete a monthly report.
Disenrollment Listing - A list of all disenrollments of a given
month. Names are screened and verified, then the information. is
used to complete a monthly report.
Membership Comparison - On a quarterly basis, data is retrieved
from membership and PHP tape files to compare names and confirm
current enrollment. Discrepancies are screened and identified. The
findings of this audit is formatted into a report to indicate
matching totals.
III. utilisation
A. PHS - The Professional Healthcare System (PHS) is used by the
Contra Costa County Health Services Department to complete patient
registrations, bill for services rendered, and confirm Medi-Cal
eligibility.
B.In-plan Services - The activities of all in-plan members that
take place at Merrithew Memorial Hospital and/or the
HSD clinics are tracked through the PHS computer system. A tape
containing this data is loaded onto the CCHP system once a month.
This information includes the dates and places that the members
where served, diagnosis, services received, and billing
information. This information is reviewed and posted to the
utilization files.
C. Reporting - All of this information is available for both
regularly scheduled reports and Ad hoc reports. These reports are
performed by both the CCHP and HSD IS staff. All regular reports
are scheduled on a calendar to insure that the they are executed at
the proper time. Ad hoc reports are run when needed or requested.
The programs, reports, and/or files incorporated in the utilization
process are Patcom Tape, Patcom Transaction Report, Post Patcom
Encounters, and Purged Posted Patcom Transactions. These reports
provide a means to effectively monitor the healthcare of all CCHP
members, which is the goal of our Managed HealthCare system.
IV. Claims Processinc
A. Referrals - When a service is required but not available at
Merrithew Memorial hospital or one of the HSD health clinics, a
patient may be referred to an out-of-plan provider. This process
starts with a recommendation from a doctor or Social worker. A
doctor, Social worker, or appointed nurse will then contact a CCHP
Medical Record Technician for a verbal authorization.
B. Authorizations - The Medical Record Technician confirms that the
patient meets certain criteria before issuing an authorization
number. This criteria includes confirmation that the service is
covered by the patients group plan and that the out-of-plan
provider has an agreement with the CCHP. The Medical Record
Technician inputs the information regarding the patient including
a General Ledger number, date of service, and payment amount, etc.
In addition, an authorization number, which is generated by the
Authorization program, is input into the CCHP system through the
Authorization program. Claims are input as suspended until they are
batched for payment.
If the patient is admitted to the out-of-plan provider, the Medical
Record Technician contacts the provider periodically to find out if
the patient is stable for transfer to Merrithew Memorial Hospital.
If this is confirmed, the information is forwarded to the Merrithew
Memorial doctor that made the original recommendation. The doctor
makes the decision to transfer the patient.
C. Claims Submission - The Vendor Claim forms (A/P) from the out-
of-plan provider are received in the CCHP Business office. This
process is initiated with the confirmation of the eligibility of
the patient by a CCHP staff reviewer
D. Adjudication - Vendor claims are then forwarded to one of the
CCHP Account clerks who matches the authorization numbers through
the CCHP systems Authorizations Inquire screen with the authorized
patients. Claims that are received that are not pre authorized are
forwarded to the Authorizations Unit. If the services represented
by these claims are covered by the patients plan, the information
regarding the claim is input, assigned an authorization number, and
returned to the Claims Unit for processing. If the services
represented by the claim are not covered by the plan, the claim is
denied. When a claim is denied, the Authorizations Unit sends out
a letter of denial to the vendor and the member, and notifies the
Claims Unit so that the denied suspended claim can be deleted.
These claims are batched bi-weekly.
E. Payments - After all current claims have been batched, the
information is electronically transferred to the Contra Costa
County Auditor/Controllers finance system. A hardcopy of the claims
is also forwarded so that they can be matched against each warrant
and microfilmed. The warrants are issued from the Auditor/
Controllers office to the out-of-plan provider.
V. Financial Reporting
A. Capitation - The amount of capitation that the CCHP receives
from the State each month is based on the amount of Medi-Cal
members enrolled. The Cal-Med Renewal tape received from the State
each month is a general representation of this. When the State
distributes the capitation, it is deposited directly into the CCHP
account. A summary is forwarded from the State to the County.
A Revenue And Usage report is generated monthly by the Health
Services Data Processing Unit for the CCHP pertaining to this Medi-
cal usage information. This report details the cost of care for the
enrolled Medi-Cal users at the hospital and HSD clinics for the
month. The CCHP Finance Department updates the General Ledger to
reflect a transfer of funds from the CCHP to the HSD based on this
report.
B. Claims Processing - The funds received as capitation are used to
pay any and all claims related to services received by the CCHP
members. These includes, claims from PCN received twice a month, as
well as out-of-plan service. The claims are received and processed
at the CCHP, but the funds are distributed from the County Finance
Department by the Auditor/Controller.
C. Reporting - Several report facilities are implemented for
reviewing and/or auditing Medi-Cal member activities. These include
the Revenue and Usage report, PHS Log and Aged Trial Balance, Medi-
Cal Fee for Services Inpatient, MediCare Fee for Service Outpatient
log, PHS Outpatient Bills, Information Center, Medi-Cal
Administration Cost File, and the PHS Medi-Cal Quarterly
Utilization report. These reports are generated by both the CCHP
Business Office staff, CCHP Financial Services staff and the Health
Services Information Systems Department.
D. Auditing - The Quarterly Utilization Cost report is generated
and forwarded to the State Department of Health representative who
is responsible for Medi-Cal in Contra Costa County. In addition,
the CCHP is audited approximately once a year by the State
regarding the cost of Medi-Cal members, the information accumulated
for the audit is derived from both the CCHP and PHS systems.
yI. Comiplaint and Grievance
A. Contact - The CCHP is very concerned about the satisfaction of
its members and problem trends associated with the service they
receive. As mandated by the State, the CCHP has a Grievance System
implemented to receive, track, resolve, follow-up, and report on
feedback from our members. In addition, this system provides an
option for disenrollment of Medi-Cal members, upon their request.
The CCHP Grievance System exceeds the requirements of the State
Department of Health Services, Health Care Finance Administration,
and Department Of Corporations. The feedback received from our
members might be a complaint, compliment, disenrollment, or just a
question. The Grievance System is the primary responsibility of
the Member Services Unit. 90% of the contacts between the Member
Services Unit and a CCHP member are handled over the telephone. The
other inquires are received by letters, or other means. The
majority of the calls are just to obtain information.
H. Input/Tracking - The CCHP system has a program referred to as
the Grievance Module which exists for these calls. The program
provides a means for the Member Services Representative to input
information on the member and the reason for the call. A Type Code
is input which represents the reason for the call. This code
categorizes the nature of the call to allow for the tracking of the
single complaint, as well as statistical reporting regarding a
group of like complaints. All calls are saved in files on the CCHP
system for future tracking and yearly auditing by regulating
agencies, including the State. All calls are also output onto
three-part Grievance Forms. One of these parts is always on file
for the yearly audits by the State or other regulating agency. The
other parts might be sent to the member or the site in which the
grievance derived, depending on the circumstances of the call.
C. Follow-up/Resolution - If the nature of the call is a complaint,
the Member Services sends a Grievance Form notification, detailing
the complaint, to the head of the unit in which the member is
complaining about. This complaint stays active until a response is
received. As mandated by the State, the CCHP has 30 days to
responded to the member regarding the grievance. The Member
Services Representative will follow-up on outstanding Grievance
Form notifications and communicate with the CCHP member until a
satisfactory resolution is achieved.
D. Reporting - The Grievance Module report facility currently
incorporates six report options to choose from. These include:
Number Of Activities - Amount of calls by a particular
representative, by grievance type, by particular method of inquire
receipt, within a specified time period.
Completed Medi-Cal Disenrollment For Cause - Listing of members who
disenrolled, and reason for disenrollment, for a particular
grievance, within a range of time, by site and zip code.
Completed Emergency Medi-Cal Disenrollments - Listing of emergency
disenrollments in the time period specified.
Completed Medi-Cal Disenrollments Within Two Months Of Date Of
Enrollment - Listing of amount of members who have disenrolled
within two months or enrollment, by Marketing Representative.
Advisory Boardi - A report listing the amount of grievances and
assistance calls, for each Product Line, related to access,
acceptability, quality of care, and enrollment issues, within a
specified time period. •
Advisory BoardiA - A report listing the amount of Medi-Cal
disenrollments, related to access, acceptability, quality of care,
and enrollments issues, a specified time period.
Advisory Board2 - Amount of complaints from each CCHP facility
regarding clinic waiting times, appointment waiting times, staff
attitude, and Urgent Care issues, within a specified time period.
Some of these reports are used internally for tracking and
improvement. Other reports are forwarded to the CCHP Advisory
Board, which is a group that is set-up by the Contra Costa Contra
Board Of Supervisors.
Charts
Grievances - Out-Plan - When a service in-Plan - When a CCHP member
A CCHP Mem- is not available at a CCHP visits any of the CCHP
ber Services clinic, a member will be facilities, activities of the
Rep. inputs, referred to an out-of-plan the visit are recorded in the
tracks, and provider. An authorisation Utilisation and data files.
attempts to number is obtained by a These files are transferred
resolve com- CCHP Medical Record by tape to the CCHP System
plaints. Technician. monthly.
Out-Of-Plan Authorizations - A CCHP CCHP rf-ancial Services -
Provider - Medical Record Technician Reports such as Revenue and
Forwards assigns the authorization Usage are run monthly from
bill to number and inputs all the PHS by the CCHP Finance Dep.
CCHP. appropriate member data in- This report details the
to Authorizations program, amount of Medi-Cal usage for
which updates the Aut- the month. This information
horizations data file.- is the basis for the amount
of funds transferred from the
CCHP account to the HSD.
Claims Processing - When a
claim is received from the Not-PraAuthorised Claims -
out-of-plan provider, the When a claim is received
CCHP Accounts clerk matches which is not preauthorized
the authorization number the information is reviewed
with the authorized member by an Authorization clerk.
list. The claim is entered If approved, the claim goes
as a Suspended claim until back to the CCHP Accounts
batched and electronically clerk. If not approved, the
transferred to the Auditor/ claim is denied.
Controllers office.
_T
Auditor/Controllers - Upon
receipt of the claim from
the CCHP Accounts clerk,
a check is issued to the
out-of-plan provider.
Contra Costa Health Plan Medi-Cal Processing
Contra Costa County Social CCSP Qedi-Cal Representative
Services - Application for contacts Medi-Cal Client
Medi-Cal. Health Care options regarding CCHP enrollment.
including CCHP are offered. Applicant is briefed on
available services.
CCHP Enrollment unit - Prepares
applicant data and forwards it
to the Contra:Costa County Data
Processing unit, then transfers
the tape to the State.
State Department of Health - Upon
approval, the state updates their Cal-Med
system and forwards the PHP tape to
Contra Costa County Health Services.
Contra Costa County CCEP System - Medi-
Cal members are automatically enrolled
when the PHP tape is loaded onto the CCHP
system. Demographic files such as the
Members and Subscribers are updated.
Reports - Many reports are
generated from the CCHP
system including Enrollment
Population reports and other
reports to track and audit
member activity.
Professional Healthcare System - The
CCHP system and PHS interface so that
eligibility of members is available to - <
hospital and clinic staff from the
CCHP System.
Enrollment Screens
HC111 E N R O L L S U B S C R I B E R
--------------------------------------------------------------------------------
SUBSCRIBER NUMBER PREVIOUS MEMBER NO.
I. LAST NAME FIRST & MI
2. ADDRESS
3. CITY STATE ZIP CODE
4. PHONE (HOME) H
(WORK/OTHER)
--------------------------------------------------------------------------------
5. GROUP
6. ENROLLMENT DATE ! 10. CUSTOMER A/Rf
7. CYCLE NUMBER ! REVENUE G/Lf
8. HOLD BILL? !
9. SOCIAL SEC# !
f '
1
--------------------------------------------------------------------------------
CHANGE FIELD F-FILE X=EXIT R=RETYPE
--------------------------------------------------------------------------------
HC112 E N R O L L A D D I T I O N A L M E M B E R S
--------------------------------------------------------------------------------
SUBSCRIBER MEMBER GROUP
I. LAST NAME FIRST & MI
2. BIRTHDATE
3. MEMBER'S PHONE NUMBER 11. FINANCIAL CLASS
4. SOC. SEC. # 12. PURGED DATE
5. MEDICAL RECORD# 13. PHYSICIAN
6. SEX (M/F) 14. BEGIN COVERAGE
7. RELATION CODE 15. PRIOR MEMBER#
8. MARITAL STATUS 16. CENTER
9. ETHNIC ORIGIN
10. PRI(P)-SEC S)
-----=------------- O T H E R C A R R I E R S -----------------------------
20. INS. CD. CONTRACT
GROUP NAME
INS. CD. CONTRACT
GROUP NAME
--------------------------------------------------------------------------------
CHANGE FIELD F=FILE X=EXIT R=RETYPE A=ADDITIONAL INFO.
------------------------------------------------------------------- ------
HC115 DISENROLL / RE-ENROLL MEMBERS
--------------------------------------------------------------------------------
SUBSCRIBER MEDICAL RECORD
GROUP
LAST NAME FIRST & MI
BIRTHDATE ENROLL STATUS
SOC. SEC. # BEGIN COVERAGE
SEX ( M/F )
1. DS/RE/TR/CX/RF/GC/DR (D/R/T/C/RF/G/DR) 2. EFFECT. DATE
3. DATE REQUESTED
4. DISENROLLMENT CODE AND REASON
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
PENDING? (Y/N) REASON
5. NEW GROUP#
--------------------------------------------------------------------------------
CHANGE FIELD F=FILE X=EXIT R=RETYPE
--------------------------------------------------------------------------------
Authorization Screen
HC441.1 INPATIENT AUTHORIZATIONS
--------------------------------------------------------------------------------
AUTHORIZATION NO. TYPE (I/L)
--------------------------------------------------------------------------------
1. SUBSCRIBER MR NAME
GROUP PLAN INSURANCE AGE SEX
2. P/C PHYS 5. LIABILITY (Y/N/S/V)
3. P/C CENTER 6. COB (W/A/0)
4. ATT. PROV
---------------------------------------------------------------------------------
7. ADMIT DATE ! 16. DIAGNOSIS
8. PERC. DAYS 50 75 90 !
9. EST. DISCH !
10. ACT. DISCH ! 17. EST. AMOUNT
11. HOSPITAL ! 18. G/L NUMBER
12. AUTHORIZER ! 19. REVIEW DATE
13. AUTH. DATE 13A. DAYS ! 20. NEWBORN DIS 21. DAYS
14. AUTH. TIME ! 22. BOARDER DAYS
15. BED TYPE ! 23. REMARKS
BED DAYS !
--------------------------------------------------------------------------------
CHANGE FIELD X = EXIT F = FILE R = REDISPLAY
--------------------------------------------------------------------------------
Grievance Screen
GRIEV.# 24472 MEMBER?(Y/N) 1. TYPE
--------------------------------------------------------------------------------
2. LAST NAME FIRST MEMBER#
MEDI-CAL,# GROUP
SOCIAL SECURITY# MEDICAL RECORD#
DATE OF ENROLLMENT BIRTH DATE
ENROLLER PREMIUM .
--------------------------------------------------------------------------------
3. STREET 4. PHONE
5. CITY 6. ZIP
--------------------------------------------------------------------------------
7. DATE RECEIVED
S. MEMBER SERVICE REP. 9. DATE OF INCIDENT
10.METHOD RECEIVED (MA-MAIL,PH-PHONE,WI-WALKIN,WC-WHITE COURTESY,FO-FORM)
ll.SITE 12.DATE REFERRED FOR REV.
13.DEPT. 14.DATE TO BE RETURNED
15.STAFF NAME 16.DATE RETURNED
17.GRIEVE-1 18.REV. BY1
19.GRIEVE-2 20.REV. BY2
21.DISENROLL REQUESTED? (YIN) 22.RESPONSE REQUESTED? (YIN)
--------------------------------------------------------------------------------
CHANGE FIELD X = EXIT F - FILE DEL = DELETE R = REDISPLAY
--------------------------------------------------------------------------------
*** Grievance Entry Program ***
ATTACHMENT E
CCHP CREDENTIALING/RECREDENTIALING GUIDELINES
I. PURPOSE-CCHP Credentialing Committee will credential all
licensed Providers who provide care to CCHP members
initially, and recredential or recertify every two years
thereafter .
II . GOALS--All out-of-plan providers currently serving CCHP
members will be credentialed by the end July, 1995. All new
contracted providers will have credentialing accomplished
prior to seeing CCHP members.
III . COMMITTEE RESPONSIBILITIES
Reviews qualifications of physician applicants and of
existing physician providers, and other licensed health
care providers for credentialing and recredentialing
according to NCAA requirements. Primary verification of
qualifications will be accomplished prior to review by
the Committee. In addition to the information obtained
during initial credentialing, the recredentialing process
includes review of data from member complaints, quality
reviews, utilization management , and member satisfaction
surveys.
IV. APPEALS PROCESS
If the Credentialing Committee denies an inital application,
or recredentialing, the provider is notified in writing the
reason for the denial , and given the opportunity to appeal the
decision if desired.
1 . The applicant meets with the Credentialing Committee
to provide any additional information. The
Committee will then notify provider of decision to
stay or overturn the denial within two weeks. The
provider is notified that a final appeal may be
made, if requested, to the Integrated Quality
Assurance Committee.
2. The IQAC reviews the application and review. Any
new information will be reviewed. Applicant has a
right to be represented by council . The decision
of the committee is final . The provider will be
notified within 4 weeks of the appeal review.
V. DELEGATION OF CREDENTIALING/RECREDENTIALING
CCHP Credentialing committee retains the authority to review
and approve delegated credentialing. Records must be
available to CCHP, and any auditing agency, upon request .
Regular reports, at least quarterly, from delegated sources
must be reviewed by the CCHP Credentiaiing Committee, and the
results forwarded at regular intervals to the CCHP Quality
Council .
VI . THRESHHOLD FOR INTERMITTANTLY USED PROVIDERS
CCHP will requi re, credential ing of providers who see at least
10 different members in a 12 month period.
VII. The Credentialing Committee reports to the CCHP Quality
Council . Guidelines are to be reviewed annually to ascertain
compliance with current regulations.
Preferred Physician o
Out Of Plan Credentialing Questionnaire �w ��•�
Contra Costa Health Plan �N
A division of Contra Costa Health Saviees Department t. p
595 Center Avenue,Suite 100
Martinez.California 94553
PLEA5E(3011t1PLE'fE #IIS'QUESTI:ONNAIRE AND RETURN AS SQON AS POSSJBLEitl igtus#tt�ns m4tst contain a,
ifa sa.on is Iica
� ble. lease tost
a. .
Groep prac#ices ati parme'ahtlu gold cornpletra aepttrats gpplu atron't'or rash provrder Howt:vrr,if'yi4n are dart of:sn IPAor'
er Medical Practitroner:(3rotrp thatltas an tsocnedtted Cr9deotasJ p�o�ratst forellsprofesttlonals.please arc l =a In
Goordinatorto contact Susanne Penio d 8 before,:comp[eting fhu que tioruoeire
SECTION I
Provider's Name
Last First Middle Suffix
Organization Name
Work Address
City State Zip Phone No.
Home Address
City State Zip Phone No.
License No. State of Licensure Field of License Expiration Date
Date of Birth mm/dd/yy Social Security No.(U.S.) Federal DEA No. Tax ID No.
Professional Schoo)(s)Attended: Year of Graduation
SECTION TI
List all practice activity for the past ten years.Please give locations and dates starting with current practice.Any missing dates
should be fully explained.
I
SECTION III.
Board Certification Date Specialty Board Eligibility Expiration Date
SECTION IV.
Education History—You may substitute your current C.V.or complete the following.In each case please give full name of
institute,address,year of graduation,degree and date.
Undergraduate:
Medical School:
Internship:
Residency-
Residency:
esidencyResidency:
Fellowship:
Other:
Foreign Medical School Graduate D Yes O No Date Certified No.
School
List any other states in which you have been or are licensed and/or practiced during previous 10 years.Please indicate any
restrictions or suspensions,etc.
State Dates License No. Status
SECTION V.
List Medical associations and society memberships:
2
SECTION VI.
List hospitals giving type of privilege,restrictions,etc:
SECTION VII.
List contracts/employment with other health care organizations such as HMO,PPO,IPAs,etc.
SECTION VIII.
List groups,practice affiliations,clinic or professional corporations,and any partnerships not mentioned elsewhere in
this questionnaire from which you receive any financial consideration and/or to which you might refer CCHP patients.
SECTION IX.
List ownership and investment interests or organizations from which you receive financial considerations(include all
health plans,health care provider organizations,health care services such as lab,pharmacy,etc.):
SECTION X.
List all Board Certifications or Eligibility:
SECTION XI.
Continuing Medical Education: On a separate sheet of paper,list all postgraduate activities for which you have
received credit in the past two years or submit a copy of report from authorized association to which you report your
Continuing Medical Education.
SECTION XII.
Give details of Professional Liability Insurance or attach copy policy:
Carrier: Cover:
Limitations: Term:
Renewal: No:
SECTION XIII.
List any judgements or settlements made against you in any professional liability cases or any cases pending,and any
out of court settlements during last ten years.
3
SECTION XIII.(Continued)
SECTION XIV.
List all insurance carriers during past ten years:
SECTION XV.
Check correct answer to following questions:
1. Have you ever been treated for alcoholism,substance abuse,or mentally illness? ❑ Yes ❑ No
2. Have you now or ever had any chronic physical defect or emotional impairment? O Yes ❑ No
3. Has your professional liability insurance ever had a premium increase,been denied,
canceled,not renewed? O Yes ❑ No
4. Has your medical license ever been revoked,suspended,or canceled? O Yes ❑ No
5. Has your permit to prescribe drugs ever been revoked or suspended? O Yes ❑ No
6. Has any hospital ever censured,restricted,suspended or revoked your priviliges? ❑ Yes ❑ No
7. Have you even been denied a medical license or certification by a specialty board? O Yes ❑ No
8. Have you even been convicted of a crime other than a minor traffic moving violation? O Yes ❑ No
9. Has your membership in any professional society or association even been canceled,
revoked,or censured? O Yes O No
10. To your knowledge,has any fee complaint ever been registered against you? O Yes O No
11. Has Medicare,Medicaid,PRO,or PSRO authorities ever brought documented charges
against you for alleged inappropriate fees or quality of care issues? ❑ Yes O No
12. Have any claim or suit for alleged malpractice ever been brought against you,or are you
aware of any circumstances that might lead to such a claim or suit? O Yes O No
4
SECTION XVI.
List any pending malpractice claims and any settled claims in the past ten years:
SECTION XVII.
Have you ever been denied membership an any hospital staff or denied advancement in medical staff status,or are any
such actions pending?If yes,please explain
SECTION XVIII.
Have you ever been convicted of a felony or pled guilty to any crime relating to your professional service?If yes,
please explain.
SECTION IXX.
Have you ever been denied certification,recertification,or has your eligibility status changed with respect to
certification or recertification by a specialty board?If yes,please explain:
SFCTION XX.
Give below three personal medical references. One may be a current professional colleague associated with your
practice,one should be practicing in your discipline outside of your own practice,and the third must be practicing
outside of your specialty discipline.
Name Address Phone No. Association
1 fully understand that any misrepresentations in,or omission from this application/credential questionnaire bearing on my qualifications
constitutes cause for denial of participation in the company system.All information submitted by me in this application is warranted to be
true and correct.
In making this application to the company system,l agree to abide by its rules,regulations,and policies as these may be promulgated from time
to time.1 am also familiar with the principles and standards which govern my specialty and profession,and 1 agree to be bound by those as
well.
I understand and agree that 1,as an applicant for the company system membership,have the burden of producing adequate information for the
proper evaluation and primary verification of my credentials,including professional competence,character,ethics,and other qualifications, and
am responsible for resolving any doubts about such qualifications.
Signature Dated
Please check where you have not completed a question preferring to send a copy document:
O Copy of current medical license,signed and dated O Copy of DEA certificate,signed and date
O Copy of Board Certification O Copy of malpractice insurance facesheet
O Curriculum Vitae O Other—Specify
5
Title Credentials Verification Form:
By applying or reapplying for membership in the company system,I: (please check all boxes below)
❑ do hereby signify my willingness to appear for an interview.
13 authorized the company system or its representatives to consult with administrators,members of the medical staff
of other hospitals or institutions which I have been associated with,and others,including past and present mal-
practice carriers who may have information regarding my credentials.
❑ authorize the company system to contract the personal professional references give above
O Consent to inspection by,and release to,the company all records and documents,including my own personal
medical records,that may be material to an evaluation of my professional competence as well as my moral and
ethical qualifications for membership.
❑ release from liability all representatives of the company for their acts performed in good faith and without malice
in connection with evaluating my application,credentials,and qualifications.
D release from liability all individuals and organizations who provide information to the company in good faith and
without malice concerning my professional competence,ethics,and character,AND
D hereby consent to release of such information.
Signature Dated
Please note that we will be verifying at source all information contained in this questionnaire.
Your questionnaire is treated as confidential in our system,and your social security number will only be used in
connection with the National Practitioner Data Bank querying system.
If you have any questions,please call Dr. Bill Burr at 313-6019 or Susanne Penfold at 313-6008.
Thanks you for completing and returning this questionnaire.
Return to: Bill Burr,MD,Medical Director
Contra Costa Health Plan
595 Center Avenue,Suite 100
Martinez,California 94553
r Please do not.umte below R. title
i 1
1
1 :I ns$ licat-on was revaewed-by:he Plan's CredenUahng 1✓ommittee and approved by the CCHP Medical 1
pp.
1 Director.*nth the following rtcoriamendaUons
1Appointment ui O Approved CCHP Provider; C11 deferred ❑ Not Recommended 1
1 1
i luith pnvinges>n
Mayor Category of Practice Medical or Surgical Subspecialty 1
1 Dated 1
Signed
1 CCHP Medical Director,Bill Burr,KD or Designee. 1
2194 6
ATTACHMENT F
MEMORANDUM OF UNDERSTANDING BETWEEN
CONTRA COSTA HEALTH PLAN
AND
MERRITHEW MEMORIAL HOSPITAL AND CLINICS
August 1994
BACKGROUND:
This Memorandum of Understanding between the Contra Costa Health Plan (CCHP) and
Merrithew Memorial Hospital and Clinics (MMH&C) sets out respective roles and
responsibilities in Quality Assurance, Credentialing, and Utilization Review. It is designed in
compliance with Federal (42CFR434.34) and California State Department of Health Services
regulations. These Federal and State regulations require that each Health Maintenance
Organization or Prepaid Health Plan which contracts with State Medicaid agencies has in place
an internal Quality Assurance system. Internal Quality Assurance programs(IQAPs)shall consist
of systematic activities, undertaken by the managed care organization itself, to monitor and
evaluate the cane delivered to enrollees according to predetermined objective standards, and to
effect improvements as needed.
CCHP has no direct control over the provider system of MMH&C. Further, the provider staff
are employees of the hospital and are governed according to the current bylaws of the MMH&C
Medical Staff, and report ultimately to the Contra Costa Board of Supervisors.
In order for CCHP to fulfill its legal obligation to be responsible for the quality of care provided
to its enrollees, this Memorandum of Understanding outlines the delegation by CCHP of certain
functions to MMH&C and the Medical Staff, while maintaining the required oversight functions
of these delegated activities.
DELEGATED ACTIVITIES:
1. Quality Assurance Plan for CCHP enrollees obtaining care at MMH&C
2. Credentialing of MMH&C provider staff and all MMH&C contracted providers
who provide care
3. Utilization Review and provider utilization data collection
The CCHP Quality Council shall receive quarterly a Quality Management activities report from
the Medical Quality Assurance Committee or more frequently as needed. This report shall
contain information regarding current Quality Management projects, problems identified, and
corrective action taken regarding the care provided to CCHP enrollees. When specific problems
are identified such as access, continuity of care, or other audit deficiencies, the Medical Staff
and MMH&C will take corrective action as soon as possible. Confidentiality is ensured due to
the legally protected nature of Quality Management activities, and the signed confidentiality
statements of all CCHP Quality Management and Utilization Management Committee members
and staff. According to the California Medical Board Regulations, Section 805, the revocation
or reduction of privileges of any medical provider, whether employed by or contracted with
MMH&C, shall result in the notification of the Medical Director of CCHP in a timely manner.
The delegation of credentialing of the Medical Staff and providers contracting with the hospital,
requires that CCHP retain the right to examine any credentials of providers caring for CCHP
enrollees. The credentialing process shall follow current NCOA guidelines for primary
verification, recredentialing, recertification, and use of the National Physicians' Data Bank and
the California Board of Medical Examiners. CCHP Quality Council shall receive regular
Memorandum of Understanding Between
Contra Costs Health Plan and
Merrithew Memorial Hospital and Clinics
August 1994
Page Two
Credentialing Committee minutes from the MMH&C Medical Staff.
Utilization Review will be conducted by the hospital Utilization Review Department, which will
refer out-of-plan authorization requests on Plan enrollees to the Authorization Unit of CCHP,
or to the Medical Director, whichever is appropriate.
Aggregated utilization data collected by MMH&C will be made available to the CCHP Medical
Director, who is a current member of the MMH&C Utilization Task Force. CCHP will share
its utilization data regarding provider activities with MMH&C for the purpose of improving
quality and cost-effectiveness.
This agreement shall remain in effect indefinitely, unless modified by joint written agreement
of CCHP, MMH&C, and the Medical Staff.
Executive Director Date
Contra Costa Health Plan
Executive Director Date
Merrithew Memorial Hospital & Clinics
President, Medical Staff Date
I-U:MOU
ATTAa-]�ENT G
Contra Costa County October 1987
QUALITY ASSURANCE COORDINATOR
DEFINITION:
Under direction, coordinates non-physician-quality assurance
activities for Merrithew Memorial Hospital and clinics; facilitates the
integration of hospital ancillary service quality assurance activities with
those of the medical staff; provides administrative staff assistance to the
Medical Quality Assurance Committee; performs related work as required.
DISTINGUISHING CHARACTERISTICS:
Quality Assurance Coordinator is a single position management
class which is located in the hospital and clinics division of the Health
Services Department and is identified as an administrative staff position
assigned to monitor and coordinate hospital quality assurance activities.
This class is distinguished from Utilization Review Coordinator in that
positions in the latter class perform clinically oriented chart reviews and
assist in the collection of physician quality assurance data.
This class reports to the Associate Hospital Executive Director -
Patient Care.
TYPICAL TASKS:
Receives and reviews incident reports and other information for
the purpose of monitoring quality assurance (QA) activities in the hospital
ancillary services; makes referrals for action; maintains a tracking system
of activities to insure hospital accreditation standards are met;
recommends what information, to whom, and how often QA data is reported;
prepares schedules and reports on QA problems and solutions for hospital
administration and the medical staff; attends meetings of the Medical
Quality Assurance Committee, collects data and prepares reports for them
and protects the confidentiality of committee proceedings; reviews the
minutes of ancillary department QA activities to monitor the resolution of
QA issues; assists physician and departmental QA committees develop
criteria for QA studies and appropriate QA monitors/screens; recommends
methodology and assists in the collection, analysis and presentation of
data for QA studies; serves as a resource person for other staff members
relative to QA issues; participates in the National Association of QA
professionals and the local Patient Care Assessment Council for the purpose
of staying informed on new developments; prepares a variety of reports and
correspondence.
MINIMUM QUALIFICATIONS:
License Required: Possession of a valid license as a Registered
Nurse in the State of California.
Experience: Three years of fulltime experience or its equivalent
as_ a Registered Nurse in an acute care hospital .
Substitution: Possession of a baccalaureate degree in nursing
from an accredited college or university may be substituted for six months
of the required experience.
KNOWLEDGE. SKILLS AND ABILITIES:
Knowledge of quality assurance principles and practices
applicable to hospitals and clinics; knowledge of acute care hospital
organization and the inter-relationships of various clinical and
diagnostics services; knowledge of medical staff organization including the
roles and responsibilities of physician committees; knowledge of medical
terminology, hospital routine and commonly used medical equipment;
knowledge of fundamental statistics and methods of graphic presentation;
ability to organize and conduct medically oriented quality assurance
studies; ability to gather, analyze and present data; ability to
communicate effectively verbally and in writing; ability to get along with
physicians, nurses and other health care professionals.
Class Code: VWSE
Contra Costa County September 1987
UTILIZATION REVIEW COORDINATOR
DEFINITION:
Under general supervision, coordinates assigned utilization
review activities in an acute care hospital ; identifies potential or
existing physician quality assurance issues and refers them to the
appropriate persons; provides administrative staff assistance to designated
physician committees; performs related work as required.
DISTINGUISHING CHARACTERISTICS:
Positions in this class are located in the Utilization Review
Office at Merrithew Memorial Hospital in the Health Services Department.
Incumbents perform clinically oriented medical chart reviews and other
administrative staff activities to meet the requirements of the Hospital
Utilization Review plan, State and Federal regulations, insurance company
requirements for reimbursement and facility accreditation standards.
Supervision is received from a Supervising Nurse.
TYPICAL TASKS:
Obtains medical records for in-patient admissions, scrutinizes
them to determine if required documentation is present and completes
patient review forms recording such examinations; continues chart reviews
during in-patient stay and discusses care changes with attending physicians
and others; documents changes in the level of care and initiates change of
status notifications to record non-acute status condition of patient or
changes in reimbursement sources; attends patient rounds to obtain further
patient care and discharge planning information; provides staff support to
various physician committees by attending and participating in such
meetings; consults with physicians regarding chart audit criteria and
performs both on-going and one time chart audits; gathers, organizes,
summarizes and displays audit information and prepares reports and
recommendations based thereon; identifies the need for and makes referrals
to other health care providers and tracks such referrals to assure that
needed follow-up occurs; answers questions from providers regarding
reimbursement, prior authorization and other documentation requirements;
teaches providers the documentation requirements of payor sources to
maximize reimbursement to the hospital ; keeps informed of patient disease
processes and treatment modalities through reading clinical literature.
MINIMUM QUALIFICATIONS:
License Required: Possession of a valid license as a Registered
Nurse in the State of Californi#.
Experience: Two years of fulltime experience or its equivalent
as a registered nurse in an acute care hospital , at least one of which was
on a medical/surgical ward or unit.
KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of payor source documentation requirements and
governmental regulations affecting reimbursement; knowledge of acute care
nursing principles, methods and commonly used procedures; knowledge of
common patient disease processes and the usual methods for treating them;
knowledge of medical terminology, hospital routine and commonly used
equipment; knowledge of acute hospital organization and the
interrelationships ofvarious clinical and diagnostic services; ability to
effectively evaluate the medical records of hospital admissions regarding
continuing stay necessity, appropriateness of setting, delivered care, use
of ancillary services and discharge plans; ability to assess and judge the
clinical performance of physicians and other health professionals; ability
to communicate documentation needs in an effective and tactful manner that
promotes cooperation; ability to teach co-workers what is needed and
required in the medical record for reimbursement and audit purposes;
ability to gather and analyze data and prepare reports and recommendations
based thereon; ability to get along with physicians, other health
providers, outside payor sources and the general public.
Class Code No. VWSD
Contra Costa County February 1989
UTILIZATION REVIEW SUPERVISOR
DEFINITION:
Under general direction, plans, organizes and supervises the
activities of utilization review staff at Merrithew Memorial Hospital;
develops policies and procedures for adherence to governmental and
accrediting agency standards; provides administrative staff assistance to
designated physician committees; performs the most complex assignments in
the unit; and does related work as required.
DISTINGUISHING CHARACTERISTICS:
This single-position class is distinguished by its responsibility
to implement and oversee the Utilization Review plan at' Merrithew Memorial
Hospital . It is distinguished from Nursing Program Manager in that
incumbents of the latter class are responsible for the management of
nursing services on one or more inpatient units or service.
This position reports to the Chief Finance Officer.
TYPICAL TASKS:
Supervises and trains subordinate Utilization Review Coordinators
in the methods and practices pertinent to their assignments; confers with
subordinates regarding disposition of problems; interviews, selects, hires,
orients, evaluates, counsels and recommends discipline of subordinate
staff; reviews and analyzes governmental and accrediting agency standards
governing admissions, treatment and continued stay of patients to develop
policies and procedures; analyzes individual patient records to determine
legitimacy of admission; reviews patient treatment plans to ensure
adherence to established criteria and standards; refers cases to
Utilization Review Committee for review and course of action when case
fails to meet criteria; assists review committee in planning and holding
federally inundated quality assurance reviews, periodic medical reviews and
professional reviews; serves as review committee liaison with other
hospital committees in development of policies and procedures; supervises
and coordinates activities of utilization review staff in maintenance of
policy and procedure manuals, files, records and correspondence; keeps
informed of patient disease processes and treatment modalities through
reading clinical literature.
MINIMUM QUALIFICATIONS:
License Required: Valid license as a Registered Nurse issued by
the State of California.
Education: Possession of a baccalaureate degree in nursing from
an accredited college or university.
Experience: Three years of full-time experience or its
equivalent as �a Registered Nurse in an acute care hospital , one year of
which was in the capacity of a Charge Nurse or Head Nurse-on a
medical/surgical unit.
Substitution: Two additional years as a Charge Nurse or Head
Nurse may be substituted for the baccalaureate degree.
KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of payor source documentation requirements and
governmental regulations affecting reimbursement; knowledge of acute care
nursing principles, methods and commonly used procedures; knowledge of
common patient disease processes and the usual methods for treating them;
knowledge of medical terminology, hospital routine and commonly used
equipment; knowledge of acute hospital organization and the
interrelationships of various clinical and diagnostic services; ability to
supervise subordinate staff; ability to effectively evaluate the medical
records of hospital admissions regarding continuing stay necessity,
appropriateness of setting, delivered care, use of ancillary services and
discharge plans; ability to assess and judge the clinical performance of
physicians and other health professionals; ability to communicate
documentation needs in an effective and tactful manner that promotes
cooperation; ability to teach co-workers what is needed and required in the
medical record for reimbursement and audit purposes; ability to gather and
analyze data and prepare reports and recommendations; ability to work
effectively with physicians, other health providers, outside payor sources
and the general public.
Class Code: VWHG
ATTACHMENT H
MERRITHEW MEMORIAL HOSPITAL & CLINICS
QUALITY ASSESSMENT& IMPROVEMENT PLAN
I. Organizational Mission
Merrithew Memorial Hospital and Clinics, the County
Hospital, and Health Centers in Contra Costa County
deliver high - quality, personalized, and comprehensive
health services to all who seek care. Prevention,
treatment, and continuity of care services are provided,
within available resources, in our facilities and through
collaboration with other public and private entities. in
our role as a teaching hospital, we provide innovative
leadership and teaching in the delivery of primary
services and in the training of family practice
physicians.
To fulfill the obligations referred to in the
organizational mission, Merrithew Memorial Hospital and
Clinics' governing body, medical and dental staff, and
hospital-wide departments and administration have
established the following Quality Assessment and
Improvement Program.
Every component and department of Merrithew Memorial
Hospital and Clinics assumes responsibility for quality
of services at it's respective level of functioning.
This responsibility is shared proportionately by doctors,
nurses, attendants, technologists, pharmacists, social
workers, dietary, environmental service personnel, the
clerical support staffs, and numerous others all of whom
comprise the working force of the hospital and it's
ambulatory care centers.
In January of 1992, we embarked on our organization-wide
effort of continuous quality improvement emanating from
top administration down to all employees. We are
adapting the philosophy and tools that will allow us to
continuously improve the quality of the services we
provide. It is our goal to become more customer oriented
and patient-centered, achieve greater aphacia-
efficiencies and improve the quality of our care. These
changes in our organization are reflected in this plan.
II. Organizational Service Values
Merrithew Memorial Hospital and Clinics have adopted the
following eight value statements.
1. Each employee is responsible for contributing
to the Hospital and Clinics mission.
2. We, honor compassion, integrity, and
resourcefulness.
3. We respect the values and cultures of our
patients, families, and employees.
4. We promote a team approach-that recognizes the
value of the individual.
5. We emphasize teaching and learning in
everything we do.
6. We continuously improve the quality of our
services.
7. We provide an environment that promotes the
safety, health and well being of patients,
employees, and visitors.
S. We advocate quality health care as a basic
right for all people.
These values represent an organizing principle for our
organization and guide the implementation and structure
of our quality improvement process.
In addition to these values, we recognize the importance
of the nine dimensions of quality which the Joint
Commission 'of Health Care Organizations (JCAHO) has
adopted: efficiency, appropriateness, availability,
timeliness, effectiveness, continuity, safety,
efficiency, and respect and caring with which test
procedures, treatments and services are provided. These
dimensions reflect important aspects of performance of
health care.
Departmental improvement activities, clinical indicators,
quality improvement teams, and actions will be aligned
with the Merrithew Memorial Hospital and Clinics mission
and value statements. In addition, the nine dimensions
of performance from JCAHO will be considered when
designing assessment and improvement plans.
III. Quality Management Lgadershin
The ultimate responsibility of quality patient care at
Merrithew Memorial Hospital and Clinics rests with the
governing body, Contra Costa County Board of Supervisors.
The responsibility for day-to-day governance and
implementation of quality assessment and improvement is
delegated through the Professional Affairs Committee to
the Chief Executive Officer and the medical staff. The
2
leadership of the organization has a number of important .
responsibilities . regarding quality assessment and
improvement, including:
1. Service planning and direction through
strategic and operational plan and
organizational policies which are consistent
with our mission and values.
2. Implementing and coordinating patient and
support services.
3. Improving organizational performance on a
system-wide basis.
4 . Setting priorities for performance improvement
throughout the organization.
The major decision making body leading the quality
improvement process is the Quality Council. The Quality
Council was formed in February, 1992, under the direction
of the Board of Supervisors. Membership includes
Hospital Administration, department managers, medical
staff, quality assurance representatives, and union
representatives. The Quality Council is co-chaired by
the CEO and the Quality Management Director. The Quality
Council oversees the hospital-wide quality improvement
planning, education, and quality improvement team
activities.- A strategic roll out plan is implemented and
updated bi-annually and reflects the various appropriate
activities as the organization progresses from an
awareness of quality improvement to total integration.
The Quality Council works to achieve an environment which
fosters cooperation and communication enabling our
employees, nurses, and doctors to fulfill our mission of
providing the highest quality of care to each patient.
A curriculum in quality improvement education has been
developed for both administrative and medical staff
leadership, as well as all employees, nurses, and
physicians in the hospital and clinics. The Quality
Council is responsible for the organizational
transformation which will allow quality improvement to
permeate every facet of our organization.
Department managers and medical staff department chairs
are responsible for the continuous, effective operation,
and constant improvement of their respective departments.
It is recognized that a major role for all leaders and
managers in the organization is performance improvement.
These responsibilities include, but are not limited to,
developing and implementing policies and procedures and
3
gathering and analyzing data to continuously improve
their services and processes in accordance with
principles of patient-centered care. where issues or
opportunities for improvement are complex and cross
service or department lines, issues are brought to the
Quality Council for cross departmental team formation.
' Hospital department and nursing quality assessment and
improvement reports are communicated in cost center
managers' monthly meetings. In addition, quarterly
reports prepared • through the Quality Management
Department are submitted to the Medical Quality Assurance
Committee, Medical Executive Committee, and to the
Professional Affairs Committee and the Contra Costa
Health Plan.
Medical staff quality assessment and improvement is
discussed monthly at Medical Quality Assurance committee
meetings. Not only do individual departments communicate
their results of clinical indicator monitoring and
performance improvement, but also cross- departmental
issues and concerns are addressed. The Medical Quality
Assurance Committee is also responsible for overseeing
surgical case, blood, and drug utilization evaluations in
addition to monitoring individual physician's
performance. Medical Quality Assurance Committee reports
on a monthly basis to the medical staff governing body,
the Medical Executive Committee, and quarterly to the
Professional Affairs Committee.
IV. Continuous Performance Based Assessment & Improvement
It is now well recognized that organization-wide
performance improvement is due to the planned and
systematic improvement of processes through a
collaborative effort between professional and
departmental services. At the heart of process
improvement is the ability to acquire information
regarding our processes and outcomes. All patient care
areas and organizational functions need to be included in
this performance measurement. The most important
processes which need to be measured on an ongoing basis
include those processes which: 1) affect a large volume
of patients; 2) have a serious risk if not well
performed or if the process or procedure is not
indicated; and 3) are problem prone. Continuous and
periodic monitoring are used to identify problems or
opportunities to improve care. The monitoring will have
objective criteria to identify problems in clinical
judgment, professional and technical skill, patient
results, and system problems that require assessment,
action, and the evaluation of the action. The findings
4
of ongoing monitoring and problem solving activities are
documented either in departmental minutes or regular
reports and are then reported to the Medical Quality
Assurance Committee or the hospital quality assurance
coordinator as appropriate. It is expected that as
medical and hospital components monitor their respective
activities, evidence impacting the others will be
discovered. Problem areas which cross departmental lines
will be referred to the Quality Council for consideration
of project team formation and to address system issues.
Ongoing data needs to be assessed to determine the
current level of performance and the stability of the
current processes. Likely, there will be many areas
which could be improved, but prioritization will occur
which is consistent with the hospital mission .and values.
The available data will be compared not only to previous
data to determine if the performance is stable and
acceptable, but will also be compared to other outside
data bases, including:
1. Datis
2. Tumor Registry
3. HCFA
4. OSHPD (Office of Statewide Health & Planning
Development)
5. CMRI (California Medical Review, Inc. )
6. CAP/AAB- (College of American Pathologist, American
Association of Bioanalyst)
7. State of California Maternal & Child Health database
S. JCAHO Indicator Monitoring System
This will allow us to compare ourselves to state of the
art, "benchmarked" measurements. We will also, if
appropriate, compare our data to best practices or
clinical pathways. Intensive assessment will be
undertaken for a variety of reasons including:
1. Single or sentinel events. There may be
occasions where a single negative occurrence
would trigger an intensive assessment and
improvement of a process because of unusually
high risk or harm associated with it.
2. Undesirable variation or a negative trend in
internally collected data.
3. Where performance varies significantly in a
negative fashion from other benchmarked data
sources. (ex. mortality or complication rates
from data bank source or variations in
treatment patterns in the tumor registry) .
5
4. Where we deviate from ' recognized standards
such as practice standards that have been
developed by major clinical organizations.
5. Where we simply wish to improve already good
performance.
6. As a reaction to patient complaints, patient
satisfaction surveys, or patient focus groups.
We strive to become more patient centered and
these sources -of information allow us to focus
on dimensions such as respect, caring, and
continuity of care.
The organizational leadership is responsible for setting
priorities and allocating resources for quality
improvement which is consistent with the hospital and
clinics mission and values and strategic plan in addition
to the JCAHO defined dimensions of care. The Quality
Council is responsible for assigning needed personnel for
quality improvement activities, creating informational
systems and data management process systems to provide
adequate information on process improvement and to
provide staff training.
Once an area has been determined in need of improvement,
then action may occur on a number of different levels.
If the process is complex or interdepartmental,
improvement would usually be accomplished through a
quality improvement team which would be chartered by the
Quality Council.
Once the Quality Council has decided to charter a quality
improvement team, the Quality Council will be responsible
for determining the mission, boundaries, members, leader,
quality coach, and available resources which the team has
to work with. The quality improvement team is to make
regular reports of their progress in process improvement
to the Quality Council. The quality improvement team is
responsible for clarifying the process, understanding the
causes of variation and selecting an intervention.
Usually a small pilot project would be undertaken and
studied to determine if the desired results were obtained
using a Plan, Do, Check, Act (Focus PDCA) cycle. This
cycle would be continued until the desired results are
obtained. It is then the responsibility of the involved
managers and Quality Council to implement the changes and
continue the monitoring to make sure that performance
improvement is maintained.
Quality improvement teams will be facilitated by a
quality coach. The quality coaches are selected in
6
conjunction with the Quality Council. We' have taken into
account the need for analytic and facilitation skills of
our quality coaches in addition to considering people
from different areas and levels of the organization.
Training of the quality coaches is an ongoing and
continual process. Course work emphasizes CQI tools and
facilitation and leadership skills.
We recognize, however, that much of the performance
improvement in our organization is done within
departments or with small intradepartmental teams. Many
issues and problems can be successfully dealt with by
making changes in policies or procedures. These changes
are documented in departmental minutes and communicated
through regular meetings to pertinent departments and
individuals.
occasionally an individual's performance may be at issue,
in which case education or further action directed by
medical staff by-laws or hospital procedure and -policies
would be necessary. Within the medical staff this may
result in a revision or change in clinical privileges
through the Medical Executive Committee and medical staff
by-laws. Competence of individuals who are not licensed
independent practitioners is determined in conjunction
with the department manager or director.
V. Medical Staff Quality Assessment and Improvement
Component
The medical staff bylaws and this quality assessment and
improvement plan serve as the primary document that
spells out the full range of accountability mechanisms.
A. Medical Staff oualitX Assurance Committee
The Medical Staff Quality Assurance Committee is
responsible for coordinating and integrating the medical
staff's quality assessment and improvement functions. It
is responsible for monitoring and evaluating the
effectiveness of process improvement activities within
the medical staff. It receives and synthesizes
information submitted by the Risk Management Committee,
Utilization Review Committee, and the various clinical
departments to determine what types of policy or process
improvement is indicated. In addition, it is responsible
for evaluating individual physician quality assurance
profiles during the reappointment process, or more often
if patterns of questionable or inappropriate care occur.
The profile elements reviewed include mortality and
morbidity case reviews, surgical case reviews, drug use
7
evaluations, transfusion monitoring, clinical pertinence
review, ' legibility, clinical indicator reports and
department meeting participation. Subsequent recommend-
dations are forwarded to appropriate department
chairperson and the Medical Executive Committee. Through
its minutes, and other means of communication, the
Medical Quality Assurance Committee submits findings and
recommendations of the medical staff and hospital quality
assessment activities to the Medical Executive Committee
and the Professional Affairs Committee of the Board of
Supervisors.
A. Medical staff Departments
The clinical departments routinely review morbidities,
mortalities, blood usage, surgical case review, clinical
indicators monitoring, infection control, : drug use
evaluation, and clinical pertinence. In addition, they
review cases, as appropriate, from other sources, such as
Risk Management, Utilization Review and hospital
department referrals. Clinical departments develop
indicators appropriate to their scope of patient care.
In addition, the department chairperson reviews and
recommends modification, as necessary, privileges of
department members on a biannual basis, using quality
assurance information accumulated in individual QA
physician profiles. Medical staff departments direct
performance improvement based on clinical indicators as
well as external data base sources.
C. Medical Executive Committee
The Medical Executive Committee receives, coordinates and
acts upon written reports and recommendations from MQAC,
departments, committees, and other assigned activity
groups. It is responsible for taking reasonable steps to
insure professionally ethical conduct and competent
clinical performance on the part of medical staff members
and pursues corrective action when warranted.
VI. Specialized Areas of Quality Assessment & Improvement
There are a number of areas that require special
attention because of the high risk nature of the process
or procedure. Many of these areas also include
"traditional" quality assurance activities.
A. surgical Review
The scope of surgical case review includes not only
indicators of patient outcome and appropriateness of the
procedure. In addition, it's recognized that appropriate
8
surgical intervention is dependent upon other factors
including laboratory, x-ray, and operating room and
nursing personnel. Ongoing monitoring occurs through
clinical indicators which may reveal sentinel events that
need intensive assessment or indicators which frequently
have normal levels of occurrence or "thresholds" where
first level screening is appropriate followed by trend
analysis. . Surgical and other invasive procedure
monitoring will include:
1. Selecting appropriate procedures
2. Preparing the patient for the procedure
3. Performing the procedure and monitoring the patient.
4. Providing post operative care.
In addition, all cases where there is significant tissue
discrepancy between the pre-op diagnosis and the
pathologic diagnosis will be referred to the involved
clinical department for review. Results of monitoring
will be distributed to appropriate departments and
process improvement will involve all the necessary
personnel from each of the involved disciplines.
B. Drug Utilisation Evaluation
Medication usage is one of our most important therapeutic
options in treating a wide variety of diseases. But if
not administered properly or to the appropriate patient,
it may pose- significant risks. Therefore, not only will
physicians prescribing and ordering be monitored, but in
addition, preparation and dispensing by the pharmacy,
administration by nursing, and the joint responsibility
of monitoring the medication effects on patients will be
assessed and improved where appropriate.
Medications to be considered include those that are used
in high volume or in high risk patients or medications
that are known to be risky in certain patient
populations, are costly or cause adverse drug reactions
frequently.
In addition, all adverse drug reactions are to be
reported and followed in the Pharmacy and Therapeutics
Committee in coordination with major clinical departments.
C. Blood Monitoring
Similar to drug utilization evaluation and surgical case
monitoring, . blood usage requires interdisciplinary
review. Concurrent review by the Pathology Department
with predetermined criteria allows for concurrent
ordering and appropriateness screening by the
9
pathologist. If there are questions regarding the
appropriateness of transfusion, the ordering physician is
called at that time to determine whether this transfusion
could be avoided. If there are still questions regarding
appropriateness of the transfusion after the discussion
between the ordering physician and the pathologist, the
case is referred to the involved department for further
. review.
In addition, the distribution, handling, dispensing, and
administration are monitored by appropriate departments
and both physicians and nursing are responsible for
monitoring the effects of the transfusion.
All blood transfusion reactions are reported to the
Pathology Department, thoroughly investigated, and where
appropriate, results of transfusion reactions reported
back to the ordering department.
Results of drug utilization, blood monitoring, and
surgical case review will be trended and, where possible,
compared to relational data banks to determine if there
is a need for improvement in our practice.
D. MOM Findings
The results of all autopsies are correlated with the
discharge diagnosis during department meetings. Where
there is significant discrepancy, further review is
accomplished. All unrecognized communicable diseases are
appropriately reported.
E. Utilization Review
The Utilization Review Committee reviews the appropriate-
ness, medical necessity, and efficiency of care provided
to patients at Merrithew Memorial Hospital and Clinics.
The Utilization Review Program is conducted in accordance
with the Utilization Review Plan, which is approved by
the Board of Supervisors, Administration, and the Medical
Staff. The Utilization Review Committee reports its
findings and recommendations to the Quality Management
Department,Medical Quality Assurance Committee, and
clinical departments, where appropriate, in addition to
the Chief Financial Officer.
F. Risk Management
The Risk Management Committee, meeting every other month,
is responsible for implementing systems for ongoing
screening of unexpected patient care management events.
This includes systems to monitor unusual occurrences,
10
clinical indicators, patient complaints, medical device
failures, and medical malpractice claims. Where
appropriate, individual cases and/or significant medical
risk trends are reported to individual clinical or
hospital departments. The Risk Management Committee
reports its findings to the Medical Quality Assurance
Committee. .
The Medical Risk Specialist, in conjunction with the
Quality Management Department, maintains the above
referenced patient care management systems and monitors'
them for hospital and clinic-wide trends which would
benefit from process or system improvement. Where
appropriate, recommendations are made to either
appropriate departments or the Quality Council for system
improvement.
VII. Hospital and Clinics Quality Assessment and Improvement
Component
The Hospital Executive Director shares responsibility for
the continuous improvement of its services with the
Hospital and Clinic's administrative and management
leadership. The hospital departments and inter-
disciplinary committees include: Nursing, Infection
Control, Interdisciplinary Psychiatric Committee,
Ambulatory Care, Cardiopulmonary, Clinical Lab,
Diagnostic . Imaging, Equipment Management, Facilities
Management, Medical Library, Medical Social Services,
Nutritional Services, Ombudsman, Pharmacy,
Rehabilitation, Safety and Employee Health. Individual
department managers are responsible for designing,
implementing, and reporting quality assessment and
improvement activities of their services in consultation
with the Quality Management Department. Results of
routine monitoring leads to incremental improvements of
services through the use of the JCAHO ten step model
and/or Focus PDCA cycle. Department and nurse managers
regularly report their QA and I activities to the cost
center managers' meeting in addition to the quarterly
reporting to the medical staff and Professional Affairs
Committee.
A. Infection Control
The Infection Control Committee establishes and directs
a hospital and clinic-wide infection control program and
formulates and implements infection reporting, analysis,
record-keeping criteria and procedures. The Infection
Control Coordinator evaluates data and is responsible for
initiating improvement projects which relate to infection
control areas, including TB screening, exposures and
11
protocols, immunizations, employee infections, blood
andbody fluid exposures and protocols and related work
restrictions.
B. pursing Quality Assessment and Improvement
Nursing Quality Assessment and Improvement is responsible
for regularly reviewing the quality and effectiveness of
nursing care. .They are responsible for identifying
problems, planning solutions and implementing change
where needed. Information is also used for evaluating
individual competency and performance. They encourage
collaboration between the clinics and the hospital to
solve problems and develop policies and procedures on
issues which they have in common.
C. Bafely Committee
The Safety Committee coordinates the Hospital and Clinics
environmental safety and risk management loss prevention
activities and is responsible for developing policies and
procedures to enhance the safety within the hospital, on
its grounds and in the outpatient facilities. It
provides safety-related information to be used in the
orientation of all new employees and in the continuation
of all current employees.
VIII. Interdisciplinary Quality Assessment and Improvement
Committees
A. Institutional Review Committee
The Institutional Review Committee approves or
disapproves all research activities concerning
the use of investigational drugs or devices
within the Hospital and Clinics. It insures
compliance with all federal informed consent
regulations and assures the protection of the
rights and welfare of all human subjects.
B. Critical Care Committee
The Critical Care Committee develops criteria
for a number of processes which occur within
the Critical Care Unit, including but not
limited to developing guidelines for providing
specialized patient care, developing
guidelines for admissions, discharge,
transferring and referring patients who
require services not provided, defining the
role of the resident staff and developing
guidelines for appropriate consultation and
12
orientation and education of both medical and -
* nursing staff.
C. Cancer Committee
Cancer Committee conducts and evaluates
hospital-wide oncology services .
Additionally, the committee oversees the tumor
registry. and insures that• full oncologic
services, including surgery, chemotherapy and
radiation therapy, as well as rehabilitation
and hospice care are available to all patients
in an effective and timely manner.
D. Ethics Committee
The Ethics Committee was developed to
anticipate and respond to ethical dilemmas
related to health care decisions. As part of
this role, it educates its members and plans
educational opportunities for the hospital and
ambulatory clinic staff. The Ethics Committee
is instrumental in developing policies and
patient care guidelines which provide
consultation for biomedical ethical issues on
behalf of patients, families and health team
members.
E. Perinatal . Morbidity, Mortality Committee
This committee reviews perinatal, morbidity,
and mortality cases on a twice-a-month basis
with reporting of findings to both the OB-GYN,
Pediatric, and Nursing departments. Where
opportunities for improvement arise, the
Perinatal Committee is instrumental in
performance improvement.
F. Quality Management Department
The purpose of the Quality Management
Department is the integration of quality
assessment and improvement information as it
relates to physician, nursing and hospital-
wide quality assessment and improvement
activities. The managers of activities from
Utilization Review, Quality Assurance, Risk
Management, Infection Control, Quality
Improvement, Medical Staff and Nursing Quality
Assurance all coordinate the organization-wide
quality management activities and provide
education and leadership to the medical staff
13
and hospital departments in the current
technology and quality assessment and
improvement tools and techniques. In
addition, they are responsible for helping to
manage the vast amount of quality assessment
and improvement information which is available
from the various clinical and hospital •
departments.
IX. Quality Management Information
Information is one of our most important resources in
enhancing and improving organizational performance. It
is realized that data is not the same as information. It
is the responsibility of the leadership and Quality
Management Department to turn data into information. The
leadership is responsible for assuring the timeliness,
accuracy and security of data collection. The leadership
is responsible for prioritizing which type of data and
information needs to be collected. Generally, priority
will be given to information which is necessary to
improve processes and services which are central to the
hospital and clinics mission and values and JCAHO nine
dimensions of care. As the organization as a whole and
individual departments determine what data is to be
collected, emphasis should be placed on areas where there
is known to be a high patient volume or are risk or
problem prone. Ongoing data will be collected which
relates to all of the processes described throughout this
plan. The frequency of data collection is determined by
factors including the frequency of the process outcome,
the significance of the event being monitored, the extent
to which our organizational performance is meeting both
our internal and external expectation, and the extent to
which our performance has been stable over a long period
of time.
Data is collected utilizing a variety of mechanisms and
individuals. A significant portion of the medical staff
clinical indicators are picked up through a case
management mechanism of UR/QA Coordinator's concurrently
reviewing patient medical records on the unit. This
allows for direct intervention at the time of a potential
occurrence and has the potential for both improving
patient care as it is occurring and proactive risk
management. Blood utilization, drug use evaluations,
infection control, utilization management, risk
management, and medical staff clinical indicators are all
collected concurrently, thus allowing for concurrent
process and patient outcome improvement. Surgical case
review, patient satisfaction survey results, and
comparative data and reference data base comparison are
14
generally done in a retrospective fashion. An important
aspect of data collection and analysis is the appropriate
use of statistical quality control techniques. All
personnel who are responsible for collecting and
analyzing data will be expected to have specialized
training in statistical quality control techniques in
addition to understanding the importance of collecting
unbiased data and insuring the security of this data.
Through the interdepartmental linkages of the Quality
Management Department and the Quality Council,
information from one system or department will be made
available to other departments where appropriate. This
allows us to link patient and non-patient care
information; to link internal and external data bases,
including Datis and OSHPD; and to link financial and
clinical data to determine appropriate levels of
staffing, patient volume or length of stay..- Aggregate
data is used by managers to make appropriate decisions
regarding their departments operations and performance
improvement activities.
The Quality Management Department will summarize the
activities and actions which have been taken as a result
of performance improvement of the clinical and hospital
departments. This will promote organizational wide.
understanding and coordination of performance improvement
activities. This data will allow departmental and
clinical managers to make more effective decisions in the
assessment and planning of future activities.
X. Human Resources
It is our expectation that all employees and clinicians
of the Merrithew Memorial Hospital and Clinics will be
involved in quality assessment and improvement. Each
staff member has a individual responsibility to
contribute to the hospital and clinics mission and for
their behavior to be consistent with our values. We
encourage our employees to help in the solution of
problems, be creative innovators, and to advocate
patient-centered care. In order to accomplish this,
staff-wide quality improvement education in the pre-
employment process will be systematically carried out.
Once the employee has been hired, quality improvement
will be a regular part of orientation and ongoing
education. Staff will be involved in quality improvement
activities, both at the department level and possibly in
quality improvement teams.
15
XI. Strategic Goals and Tactics
Biannually, the Quality Council will address the current
and future needs of the quality improvement program. It
is anticipated that these needs will change over time as
we gain the knowledge and skills in quality improvement
and methods and As health care reform changes the face of
health care delivery. As the face of medicine changes,
it is apparent that we need to assess the ability to
respond rapidly to unusual events or sudden changes in
the policy and direction of health care delivery.
XII.Confidentiality
All copies of minutes, reports, work sheets and other
data are stored in a manner insuring strict confiden-
tiality of peer review and patient records. A written
confidentiality policy detailing procedures for
maintenance and release of data and other quality
assessment and improvement-related information govern
release of such information. This policy specifies that
records numbers or identifiers be used in place of
patient names; and code numbers in place of physician or
other provider names when confidentiality is appropriate.
XIII.Annual Program Review
The structure, function and methods of the quality
assessment and improvement program are appraised annually
by the Quality Council, the Medical Quality Assurance
Committee, and the Quality Management Department to
assure the program is achieving its objectives and is
consistent with JCAHO and other external requirements.
XIV. Adoption
The quality assessment and improvement plan has been
reviewed and adopted by the Quality Management Department
Director, Medical Quality Assurance Committee
Chairperson, Medical Staff President, Executive Director
of Merrithew Memorial Hospital and Clinics and the Health
Services Director (Board of Supervisors designee .
16
Quality ManagemeAt Department' Date
Chairperson Date
Medical Quality Assurance Committee
President, Medical Staff Date
xecutiv Dir or Date
Merrithew Memorial flospital & Clinics
Health. Service Director Date /
(Board of Supervisors' Designee)
17
NERRITHEW MEMORIAL HOSPITAL i CLINICS
QUALITY ASSESSMENT i IMPROVEMENT PLAN
APPENDIX
Appendix A CQI Roll out Plan
Appendix B Medical Staff Clinical Indicator Monitoring Inventory
Appendix C Quality Indicators
18
Merrithew Memorial Hospital & Clinics
Biannual COI Roll-Out Plan
1994/1995 .
Through collaborative efforts of all members, the Quality
Council has developed the following strategic plan to further the
definition, planning and organization wide implementation of the
Continuous Quality 'Improvement (CQI) Program.
Building on goals that have already been obtained and
efforts currently underway, the overarching principles of this
strategic plan include:
Dessiminate educational efforts to all levels of
employees; reinforce what already has been learned.
Reinforce leadership commitment; model quality skills.
Provide leadership oversite to CQI projects through the
use of •chartered* teams. Commit resources to CQI
project teams.
Identify and eliminate barriers to implementation.
I . Formalize Integration of CQI into Operations
A. finalize mission/value statement (.ministration: 4/94)
B. develop vision statement (Aminietration: Snd)
C. develop policy that defines CQI and criteria necessary
for chartering projects
1 . all chartered projects will provide Quality
Council with an update and/or summary of team
activities (steering comittee, s/sd-onooiag)
2 . develop criteria for team member selection (steering
Coal ttaa:I/Rd-)/!4)
3 . develop guidelines for data collection and
analysis (steering Cosittee:1/9I-3/0I)
D, continue to develop Quality Coaches as resources for
CQI efforts (ongoing)
1 . develop job descriptions (co: coordinator, s/94-j/s4)
2 . define parameters/communicate capabilities and
roles of coaches (COS coordinator::/s4-2/sd)
E. dedicate resources to CQI teams including computer,
staff, time commitment (Administration: !/!1-ongoing)
F. re-evaluate existing monitoring functions and their
effectiveness in improving services to ensure readiness
for JCAHO (Aminiotration: s/gd-6/94)
G. develop departmental roll-out plans for CQI
implementation (oW/A&UAJ*eratiW/Iraa ff*"t I/11-10/11)
II. Educational Efforts
A. establish an educational foundation
1. orientation of new employees (AQoisistratim/owisty
Conseil+ I10I-ao00106) -
a.. two-part: 'administrative component (mission
-and values) and Introduction to CQI
b. CQI film of MMH to be incorporated into CQI
portion facilitated by Quality Coaches
2. education of all current employees
(AQalailtration/duality OMOCilr IM-4/01)
a. same as new employee orientation
b. to include all hospital and clinic employees,
including medical staff
B. provide specialized training for management/leadership
staff (stsartao Camaittsar Iff1-i/1s)
I . develop Cultural Diversity Training Program for
management and staff; focus on patient
populations; employee-to-employee relations
2 . coaching/mentoring courses to assist improvements
in managerial styles
3 . dealing with change in the work environment
C. reinforce continual learning (AQaiaiatration: I/94-oaooiso)
1 . monthly presentation at Cost Center Managers
meeting
2 . Quarterly articles in Heartbeat
3 . ongoing just-in-time training for COI tools
4 . follow-up training in 1994 to team building module
(Dy 10/04)
5. expand CQI library to include videos/self-
instructional materials
6. CQI presentations at Quarterly Medical Staff
meetings; every six months to Medical Executive
Committee
7 . ongoing CQI updates in departmental meetings
8. monthly education for managers through MEP
in. Reinforce Leadership Qmmitment (AQaintatration/ouality
Council/�lanaoar)
A. Communicate that quality is an important aspect of
performance
1 . include in annual employee performance evaluation
(5/94-629012g)
2 . foster an attitude of coaching and mentoring among
management and administrative staff
a. evaluate coaching and mentoring skills in
annual performance evaluations
•,.b.. encourage staff to mentor one another
3 . visible demonstrations of commitment
a. utilize and explain COI tools in staff
meetings
b. build time into schedules for meetings and
feedback
C. use fact based decision style
d. role model principles of employee empowerment
4 . insure all management staff have been offered CQI
training roy sibu
a. develop monitoring process of educational
activities and different levels of training
S. assess degree of readiness to participate in teams
a. repeat management survey; include all
employees to assess organizational readiness
for change (by 611-1)
6. move toward employee empowerment philosophy of
recognition and reward (e.g. PRIDE) (iiloaoiss)
e. Administrative Staff to work on diminishing identified
barriers to CQI implementation (see attached) .
QUALITY MMAGkMM IDEPARTMM
MZDICAL STAFF CLINICAL INDICATOR
1lNONITORING SNYENTORY '
�eoaRz, �aiNTai; �n� i�la� �tATi►L�" asiff��i'��leosm�n) .
�P�►xT,csrrrs
5101 Maternal Mortality
5001 Acute MI or CVA 5102 Transfers to XM
5002 Arrest-cardiac or 5103 Unplanned readmission
respiratory within 14 days
5003 Consent form-missing/not 5104 Cardiopulmonary arrest
signed/not timely and 5105 Transfusion Indications
surgery performed (C 1/94)
5004 Incorrect sponge, needle, 5106 Eclampsia
instrument count (OK if 5107 Postpartum return to
x-ray negative) delivery room or
5005 Injured or burned by operating room for
equipment management
5006 Retained foreign body 5106 Cesarean delivery for
5007 Unplanned inpatient fetal distress
admission 5209 Cesarean delivery for
5008 Unplanned return to failure to progress
surgery 5110 Fourth degree laceration
5009 Unplanned removal , rate 30-10% of total
repair/injury of organ or deliveries by provider
body part 5111 PP infection (C 4/93)
SO10 Wrong patient 5112 Premature NS > elective
5011 Wrong procedure C-section (A 12/93)
5012 Mortality 5113 DUE: (A 12/93 to be
5013 Unplanned ICU admission decided)
(D 4/93) 5114 Other (A 1/94)
5014 Surgical indications (A
4/93) IEORATAL 'Perinatal ICom)
5015 Transfusion indications
(A 4/93) 5201 Death: stillborn, fetal,
5016 Nosocomial infection for newborn (C 12/93)
Class I & II surgical 5202 Death: fetal after
procedures (C 12/93) admission (D 12/93)
5017 Blood loss > 1000 cc's (A 5203 Death: Neonatal to 28
4/93 , Ob/Gyn) (A 1/94, days (D 12/93)
Surg) 5204 Delivery of infant c2500
5018 Over scheduled surgical gm
time (>50$) (A 4/93, 5205 -Transfer of newborn to
Ob/Gyn only) NICU
5019 DUE: intraoperative DVT 5206 Apgar SS 0 5 minutes
prevention (A 12/93) 5207 Injury of newborn related
5020 Other (A 1/94) to delivery
5208 Transfusion indications
(A 4/93)
WUA1.1TI AANPA*&rAZN X i7LrAsL.L7=.V 1
AZDICAL STAFF CLINICAL INDICATOR
MONITORING nnmr TORY
S209 Nosocomial infections (A 5407 Post operative aphasia or
4/93) paralysis (C 12/93)
5210 DUE: blood gas use (A 5408 Ophthalmic injury
12/93) S409. Reintubation (C• 12/93)
5211 Other (A 1/94) 5410 Unplanned admission (C
5212 Infant with RDS following 12/93)
labor induction (A 1/.94) 5411 Unplanned ICU admission
secondary to anesthesia
TKRIULt SWICIM -%=A*TMZNT (D 12/93)
5412 Mortality
5301 Acute Mi (D 8/93) 5413 Transfusion indications
5302 Use of Swan-Ganz catheter (A 4/93)
(D 6/93) 5414 Score <4 on PAR arrival
5303 Unplanned ICU transfer (A 12/93)
5304 Mortality (A 4/93) 5415 Injured or burned by
5305 Surgical indications (A equipment (A 12/93)
4/93) 5416 Other (A 1/94)
5306 Transfusion indications
(A 4/93) "DIJI?A= ; Z$S70;NT
5307 Nosocomial infections (A
4/93) 5501 Readmission within 30
5308 DUE: infectious disease days (exclude neonates
screening in IVDU (A readmitted f or
12/93) hyperbilirubinemia)
5309 DUE: screening for 5502 Transfer from Family Care
complications of diabetes Unit to another hospital
physical exam (A 12/93) 5503 Clinical management
5310 DUE: DVT prophylaxis/low issues related to fluid
dose Heparin (A 12/93) and electrolytes; pain
5311 Other (A 1/94) control; bronchiolitis;
and the extreme premature
E"S OM1/' VARTNZNT infant
5504 Nosocomial infections
5401 Acute MI or CVA 5505 Mortality
5402 Arrest -cardiac or 5506 Surgical indications (A
respiratory (C 12/93) 4/93)
5403 Aspiration or R/0 5507 Transfusion indications
aspiration (C 12/93) (A 4/93)
5404 Dental injury (C 12/93) 5508 Other (A 1/94)
5405 Equipment malfunction,
failure, or disconnection SA,1XIMCB. iPR►RT'l�NT
(C 12/93)
54D6 Failure to regain 5601 Readmission within 30
consciousness days
(unarousable) , except for 5602 Mortality
planned ICU admission
QUALITY`lSAAlAG�7i'.1V"T ar:YAitT1'li:[V 1'
ANDICAL STAFF CLINICAL INDICATOR
•. 1KONITORING INVENTORY '
5603 Unplanned transfer to 5710 Timely a/or appropriate .
another service . ED intervention not done,
5604 'Use of arm Vor leg or inappropriate
restraints intervention done (A
5605 Fall resulting in injury 12/93)
5606 Nosocomial infection (A 5711 Other (A 1/94)
4/93)
5607 Surgical indications (A �Iat08TZ�.;; dZ9iq
4/93)
5608 Transfusion indications 5801 Acute MI or CVA
(A 4/93) 5802 Arrest-cardiac or
5609 Outpatient Polypharmacy respiratory
(8+ drugs) (A 12/93) 5803 Circulatory impairment
5610 Outpatient Admissions following a procedure
( prevention 4 5804 Contrast media reaction
communication) (A 12/93) 5805 Perforation - barium
S622 Other (A 1/94) enema (A 12/93)
5806 Pneumothorax - needle
0SR00= NWIMM,WWARThMNT lung biopsy (A 12/93)
5807 Seizure (A 12/93)
5701 Left without being seen 5808 Reading not corroborated
by physician by another Radiologist 1A
5702 X-ray misread by ER 12/93)
physician leading to 5809 Other (A 1/94)
morbidity (C 12/93)
5703 inappropriate transfers .',WOLOOY MPAITIMT
from other hospitals
5704 Cardiac / respiratory 5901 Correlation of frozen
arrest after arrival section and permanent
(excludes Code 3 diagnoses
arrivals) 5902 Review of malignant
5705 Unscheduled return to ER diagnosis by second
within 48 hours for pathologist
related complaint leading 5903 Correlation of external
to admission, surgery or diagnosis with in-house
MH Crisis Service diagnosis
referral 5904 Correlation of cervical
5706 Mortality (A 4/93) b i o p s 'i e s w i t h
5707 Nosocomial infections (A corresponding abnormal
4/93) Pap smears
5708 Surgical indications (A 5905 Correlation of fine
4/93) needle aspiration (FNA)
5709 Transfusion indications diagnoses with biopsy
(A 4/93) diagnoses
5906 Cytology review cases
5907 Other (A 1/94 )
JWDICAL STAFF CLINICAL INDICATOR
1K0IINIT0RING INVENTORY
Ion
��zcBl�►TR :�sp�►R�errr
6101 Transfers to Emergency
6001-Mortality Dept from clinic (C 1/94)
6002 Assault episode 6102 Transfer to Emergency
6003 Transfer to medical or Department from Detention
surgical service (D (C 12/93)
12/93) 6103 Other (C 1/94)
6004 AWOL 6104 Patient complaints (A
6005 Suicide Vor attempt; 12/93)
other self injury 6105 High utilization of
6006 Readmission within 30 services (A 12/93)
days 6106 Direct hospital
6007 Length of stay exceeding admissions from clinic (C
90 days (inpatient) 1/94)
6008 Length of stay exceeding 6107 Code 3 Detention
24 hours (crisis service) emergencies (A 12/93)
(D 1/94) 6108 Random case review by
6009 Injury of patient selected diagnosis (A
resulting from takedown, 12/93)
restraints or seclusion
6010 Code Blue-cardiac arrest
1:8IB„�TltIT
or respiratory arrest
6011 Agranulocytosis, jaundice 6201 Evaluation content does
secondary to medications not meet criteria (A
(D 12/93) 12/93)
6012 Neuroleptic malignant 6202 Medication administration
syndrome does not meet criteria (A
6013 Delirium tremens (D 12/93)
12/93) 6203 Admission orders not
6014 Non - response or complete (A 12/93)
deterioration after 60 6204 Admission physical exam
days treatment not present (A 12/93)
6015 10 lb. weight loss or 6205 Other (A 1/94)
gain in one month (C 6206 Length of stay exceeding
12/93) 24 hours (A 1/94)
6016 Secluded >24 hrs
requiring two consecutive
MD orders (A 12/93)
6017 DUE : ongoing
comprehensive medication
monitoring (10% of all
inpatient admissions) (A
12/93 )
6018 Other (A 1/94)
QUALITY MANAGDMNT DEPARZMNT
REDMAL STAFF CLINICAL SNDICATOR
MONITORING INVENTORY
OWMAL IMPARTMENT 6311 Prophylaxis hygiene-
geee also 5000) diet instructions has-
been completed dA 1/94)
6301 Health history is' 6312, Tx for initial complaint
adequate including was completed (A 1/94)
currency, date, and 6313 Broken/cancelled appts
initialed review by' the have been noted (A 2/94)
dentist (A 1/94) 6314 Pt was referred to e
6302 Quality & quantity of x- specialist , i f
rays is adequate (A 1/94) appropriate (A 1/94)
6303 Dx & tx plan is specified 6315 A physician was
in writing & work is consulted, : if necessary
planned in an acceptable (A 1/94)
sequence (A 1/94) 6316 Pt was placed on recall
6304 Any drug sensitivity is (A 1/94)
clearly noted & flagged
(A 1/94)
6305 Rx's given are clearly
documented (A 1/94)
6306 Symbolic charting is used
(A 1/94)
6307 All missing &/or non-
vital teeth -are charted
(A 1/94)
6308 Existence & condition of
any prosthesis is noted
(A 1/94)
6309 The following problems or
conditions are noted in
the dx:
A. paries
B. soft tissue
abnormalities
C. malocclusion
D. p e r i o d o n t a l
condition or
problems
E. oral hygiene level
F. defective contacts
& / o r marginal
overhangs
(A 1/94)
6310 The tx plan has been
followed (A 1/94 )
: HOSPITAL/CLINIC QUALITY INDICATORS
QUALITY ASSESSMENT & IMPROVEMENT PLAN 1994
Ambulatory Care-Administration
1. Ambulatory Care Patient Complaints.
2. Ambulatory Care Unusual Occurrences.
3. Summary of Waiting Time To Obtain Appointments in
Ambulatory Care 'Clinics.
Ambulatory Care Nursing
1. Adult Patient Preparation - Allergy, chief complaint,
vital signs, second hand smoke exposure for Pediatric
patients, patient teaching, signature and.-title from last
visit.
2. Noting Orders - Each intervention checked, signature and
title from last Doctor's orders noted.
3 . Injections - documentation of consent, route, site, date,
time, signature and title.
4. PPD - Results documented within 48-72 hours, or attempt to
contact patient, results in millimeters, date, signature
and title.
5. Endoscopy - Preparation of patient for exam, presence of
referral note, and X-Ray present for exam.
Central Supoly
1. Biological and Chemical Indicators of the Sterilization
Process.
2. Prepared Instrument packs will meet standards for
cleanliness and content 100% of the time.
Clinical Laboratory
1. Improperly identified Specimen/Slips.
2. Number of Lab Response Delay to Blood Draw Requests.
3. Number of Contaminated Blood Cultures.
4. Number of Instances Receipt of STAT Delayed more than 10
minutes.
5. Number of Unspun Blood Specimens Maximum Received more
than 8 hours.
6. Percent of Quality Control results above 2SD not
investigated.
7. Correlation of Reference Lab Results.
- 1
HOSPITAL/CLINIC QUALITY INDICATORS
8. Number of'-Prothrombin Time more than' 2SD more than 2
successive
9. Glucose and Electrolytes TAT.
10. CBC/UA TAT.
11. G.S. TAT.
12. Prothrombin Time TAT.
13. Cerebral Spinal Fluid TAT.
14. Reporting Errors (Category A) .
15. Number of send-out tests requested exceeding $35.00.
16. Number of Outpatients Not Registered.
17. Number of Incomplete Information on Outpatient
Requisition.
18. Number of ER and Inpatient specimens not physically
received by lab.
19. Equipment Preventive Maintenance by Lab Personnel.
Diagnostic Imaging
1. Repeat/Reject Analysis or X-rays.
2. Inpatient Barium Enema preparation.
3. Timeliness of getting an appointment.
4. Outpatient waiting times.
5. Patient consents (Outpatients) .
6. Inpatient imaging report timeliness.
7. MRI Referrals - All patients referred for MRI scans will
be screened for various medical conditions that might
negatively affect the exam threshold 100%.
S. Ultrasound patients appointment no-show at RHC. Threshold
20% no-show rate.
9. Clinic Diagnostic Imaging Reports - Monitor timeliness of
D.I. reports to Richmond Health Clinic.
2
HOSPITAL/CLINIC QUALITY INDICATORS
Education and Trainincr Department
1. Inservice of new equipment.
2. Classes identified needs assessment are offered by
Education and Training Dept.
3. Compliance with mandatory annual Safety Review Program
(Skills Day) .
4. Compliance with mandatory biannual CPR proficiency
requirement.
Emergency Preparedness Committee
1. Implement The Hospital Emergency Incident Command System
(HEICS) .
Environmental Services
1. Improving Organizational Performance: Inspections by
Manager & Supervisor to initiate and maintain Improvement,
Leadership, and Planning.
2. Safety Management: Safety inspection includes routine
inspection of staff activities, to reduce the risk of
human injury.
3. Number of Employee Accidents: Documentation of employee
injuries, as part of the continuing education of all
personnel and specific job-related hazards.
4.A Infection Control Linens: (clean & soiled) Written
Procedures for Infection Surveillance: Supply an adequate
amount of clean linen for at least 3 complete bed changes
for the hospital's licensed bed capacity.
4.B Soiled Linen shall be handled, stored, and processed in a
manner that will prevent the spread of infection and will
assure the maintenance of clean linen.
5. Linen Replacement Cost: (lost, torn, worn, out-of-stock)
Consultation from Linen Company.
6. Bio-Hazard Waste: (Medical Waste Management Program) It
is handled according to applicable laws and regulations.
Equipment Management
1. Failure Analysis.
2. Customer Service Evaluations.
3
HOSPITAL/CLINIC QUALITY -INDICATORS
3. Safety Medical Device Act Investigations.
4. Manufacturer Alerts.
infection Control Department
1. `Autopsy reports will be reviewed for communicable illness
not diagnosed prior to patient death.
2. Reportable illness among patients will be reported to the
Public Health Department--with particular emphasis on
Tuberculosis.
3. Employees will report exposure to blood and body fluids.
Exposures will be managed according to Infection Control
and hospital policy.
4. Employees exposed to communicable disease will be notified
and appropriate prophylaxis will be offered.
5. Patients who test positive for HIV will be notified in a
timely manner.
6. Targeted nosocomial surveillance will include patients
with intravenous central lines, Foley catheters,
ventilators, and specific surgical procedures.
Medical Library
1. Library "USER SATISFACTION SURVEY" - Nursing, Residents,
and allied health specialties.
Medical Social services
1. Inpatients on Medicare 65 years or older, or High Risk Dx
hospitalized 3+ days are given a social service
evaluation.
2. Mothers who deliver but have had no prenatal care are
given a Psychosocial assessment.
3. Psychosocial Assessment is completed on Med/Surg patients
using the NAP format.
4 . Assessment of Med/Surg patients will include documentation
of resources identified and referrals initiated during
inpatient stay.
5. Response to alcohol and drug abuse counseling referrals
will occur within 2 working days.
4
HOSPITAL/CLINIC QUALITY INDICATORS
NURSING
Generic Nursing Indicators
1. Crash Cart Readiness.
2. Accu Check Calibration Accuracy.
3. Refrigerator Temperature Checks.
4. Nursing Documentation of Admissions, Discharges, Care
Plans, and Nursing Care Record.
5. Unusual Occurrence
6. Medical Record Completion
B-Medical Unit
1. Leather Restraints.
2. Soft Safety Devices.
3. Peripherally Inserted Central Catheter.
4. Maintenance of Skin Integrity.
Critical Care
1. Central line care, assessment, documentation, and
physician notification.
Detention Facilities
1. Monitoring of inmate self-administration of medication
system.
2. Effectiveness of sick call triage.
3. Monitoring of intake screening process.
Emergency Room
1. Triage patient assessment.
2. Completeness of Emergency Room Nursing Form.
Family Care Unit
1. Respiratory Assessment of Pediatric Asthma Patients Aspect
of Care.
2. Respiratory Care of Post-Operative Patients.
3. Documentation of Education on The Post-Surgical TAH/BSO
Patient.
Geriatrics
1. Patient falls and effectiveness of preventive measures.
5
HOSPITAL/CLINIC QUALITY INDICATORS
2. Patient leave without permission and effectiveness of
preventive measures.
3. Use of stat team for patient with behavioral problems.
Inpatient Psychiatric Unit - I
1. Use of Seclusion including interventions and medications.
2. Use of Restraints (Leather) including interventions and -__._
medications.
Inpatient Psychiatric Unit - J
1. Use of Restraints (Leather) including interventions and
medications.
2. Use of Seclusion including interventions and medications.
3. Threatening Behavior Assessment and Intervention.
Mental Health Crisis Service
1. Discharge documentation.
2. Physicians Orders Noting and Nursing Documentation.
3. Nursing Intervention Notes.
4. Admission .Assessment documentation.
5. Use of leather restraints.
6. Advance Directives.
7. Emergency medication use and documentation.
Operating Room/PAR
1. Assessment and documentation of patient hemorrhage.
2. Use of side rails for safety of patient.
3. Completeness of surgical consent form.
4. Maintenance of Implant Log.
Perinatal Unit
1. Labor Progress Records.
2. Caesarean Section Readiness.
3. Respiratory Care Checklist.
4. Nursery Care of The Growing Premature Infant.
5. Infant Security.
6
HOSPITAL/CLINIC QUALITY INDICATORS
surgical Unit
1. Management of Pain.
2. Wound Management.
3. Pre and Post Surgical Management.
4. Education of the •Surgical/Orthopedic Patient.
Patient Ombudsperson
1. All patient complaints will be handled at the time that
they are identified.
2. Numbers and categories of complaints will be tracked for
patterns and opportunities for improving patient relations
and/or services.
Pharmacy
1. Controlled Substance Monitoring.
2. Controlled Substance Nursing Sheets.
3 . PYXIS Discrepancy Reports.
4. Inpatient. Dispensing Errors.
5. Outpatient Dispensing Errors.
6. Medi-Span Drug Interactions into computer.
7. Outpatient Counselling by Pharmacist for new
prescriptions.
(J6 HQAIND94.LST)
7
ATTACE MU I
SERVICE PROTOCOL
Unit: Advice Nurse #ANi
1. Service Strategy
What: Assist as needed with discharge planning, home health agency,
referrals, and equipment needs for patients hospitalized or discharged
from out-of-Plan facilities.
Group: All members
2. Service Standard
Advice Nurse will assist with needed services as soon as possible after notification
of pending discharge.
3. Service Audit
Director of Provider Affairs will review a random sample of utilization review work
sheets quarterly.
1 0:SP1
Date Originated: 1/8/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Advice Nurse #AN2
L Service Strategy
What: In an attempt to encourage continuity of care,the CCHP Advice Nurse
will contact all members who have been seen or hospitalized in an out-
of-Plan facility.
Group: All members
2. Service Standard
Advice Nurse will contact member asap after visit or discharge and assist with
obtaining follow-up care. If unable to contact by phone, the Advice Nurse will send
a letter.
3. Service Audit
Director of Provider Affairs will review a random sample of MD call slips for
compliance.
L20:SP2
Date Originated: 1/8-/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Authorization Unit #AU1
1. Service Strategy
What: Authorization letters are sent to eligible CCHP members who have
been referred to an out-0f--Plan provider.
Group: Eligible CCHP patients
2. Service Standard
Referring physician calls Authorization Unit to make referral. Authorization from
Medical Director/designee is obtained; eligibility is verified. Authorization letter is
completed and mailed to patient.
3. Service Audit
When the patient is seen, the out-of-Plan provider returns authorization letter, bill,
and records. The bills are paid by Claims Unit and records forwarded to chart for
physician review. If more services are needed, the provider is referred to referring
physician.
1.20:SP3
Date Originated: 1/16/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Authorization Unit #AU2
1. Service Strategy
What: To provide a timely response to member's request for out-of-Plan
authorization.
Group: All product lines
2. Service Standard
Follow up with member within two worldng days with an answer or a reason for
'non-response and estimate of time for resolution.
3. Service Audit
Business Services Manager will monitor by routine monthly inquiry. Quarterly review
of work sheets will be made and noted to ensure the timeliness of answers to
members' requests.
'Follow-up call within five working days
120:SP4
Date Originated: 1/29/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Authorization Unit #AU3
L Service Strategy
What: Assist members in finding alternate sources of care when request for
services are denied.
Group: All product lines
2. Service Standard
The Authorization Unit staff will work with Member Services and use other
resources to assist members in finding alternate sources for denied services.
Source information will be researched and provided to members within five working
days.
3. Service Audit
Business Services Manager will monitor process by making monthly inquiry.
Quarterly phone calls to members will be made to ensure needs are being met.
L20:05
Date Originated: 1/29/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Authorization #AU4
1. Service Strategy
What: Answer member questions on benefits and exclusions and assist
members with coverage information.
Group: All product lines
2. Service Standard
Authorization Unit staff will assist members, giving accurate coverage information
at time of inquiry. If answer is unclear, investigates and follows up with phone call
to member within two working days.
3. Service Audit
Business Services Manager will monitor by routine monthly inquiry. Quarterly review
of work sheets will determine if members' inquiries are being handled in a timely
manner.
L20:SP6
Date Originated: 1/29/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Maims #CI
1. Service Strategy
What: Reassure members with authorized out-of-Plan claims that CCH? is
responsible for payment and "not to worry."..
Group: All product lines
2. Service Standard
Claims Unit staff will:
Contact provider when member is being billed for CCHP
authorized/covered charges.
Contact member to let them know the provider has been contacted and
explain any difficulties which may exist, i.e., need EOMB, itemized statements, etc.
Check suspended claim if unpaid 30 days from suspend date. Contact provider to
inquire as to status of billing.
3. Service Audit
Business Services Manager will review Suspended Claims Report monthly to
ensure/evaluate effectiveness of process.
120:SP7
Date Originated: 1/29/90
Review: 3/1/91
3/92
SERVICE PROTOCOL
Unit: Claims RC2
L Service strategy
What: Assist providers in correcting billing errors after the same type of error
occurs more than once.
Group: All out-of-Plan providers
Z. Service Standard
Contact provider by telephone within two working days to discuss problems.
Send hard copy of examples with resolution. Visit provider and/or request they visit
CCHP to discuss problems with billing.
3. Service Audit
Business Services Manager will monitor process by making routine monthly inquiry.
Quarterly,at least one provider will be contacted to evaluate effectiveness of process.
1.20:SP8
Date Originated: 1/29/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Claims #C3
L Service Strategy
What: Return all claims inquiries from members.
Group: All product lines
2. Service Standard
Claims Unit staff will investigate and respond to members' claim inquiries within 24
hours.
The timely response must be made even when follow-up action must be taken.
Member to be notified of final outcome within one week.
3. Service Audit
Business Services Manager will process by making routine monthly inquiry.
There will be quarterly contact of two members to determine that member's inquiries
are being met in timely fashion.
I.20:SP9
Date Originated: 1/29/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Claims #C4
I. Service Stratea
What: Send letter to family of deceased Medicare member to offer help with
any out-of-Plan medical bills.
Group: SeniorHealth
2. Service Standard
Upon notification from Business Office or Member Services of death of a
SeniorHealth member, Claims Unit sends attached letter to family.
3. Service Audit
Quarterly in year one and annually thereafter,Business Services Manager will review
to confirm that Ietters are being sent.
L20:SP10
Date Originated: 4/11/90
Review: 4/91
3/92
SERVICE PROTOCOL
Unit: Enrollment #El
1. Service Strategy
What: Send all recertified BACs notification that coverage is extended so that
BACs are aware they are covered for necessary medical care.
Group: BAC ,
2. Service Standard
Application Analyst sends notification letter to all BACs who have been recertified
for three months coverage within 24 hours of recertification being entered in the
computer system.
3. Service Audit
Listing of BAC members is produced at the same time as the mailing labels. Listings
are retained by the Data Unit. Lead Specialist will review every two weeks and ask
if all the letters have been mailed within 24 hours.
L20:SP11
Date Originated: 1/31/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Enrollment #E3
I. Service Strategy
What: Approve payment extension for specified Health Partnership members
who have difficulty paying the fee.
Group: BAC Health Partnership
2. Service Standard
BAC/Health Partnership Specialist grants short extensions when circumstances have
changed since application or when required notifications were not received.
3. Service Audit
Specialist sends notice to each member granted an extension. A copy of the notice
is kept with the original application. Lead Specialist reviews files on a monthly basis.
L20:SP13
Date Originated: 1/11/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Enrollment *FA
1. Service Strategy
What: Verify eligibility inquiries from various sources to ensure correct
billing.
Group: All members
2. Service Standard
All enrollment staff answer eligibility inquiries as they are received, give an
immediate answer.
3. Service Audit
Evaluated only by direct observation. Lead Specialist observes staff answering
inquiries for the eligibility status of clientele.
L20:SP14
Date Originated: 2/16/94
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Enrollment #E5
L Service Strategy
What: Advise individuals about alternate sources for medical coverage and
available payment options.
Group: All members and non-members
2. Service Standard
All enrollment unit staff will respond immediately to inquiries about medical
coverage and payment options.
3. Service Audit
Evaluated by direct observation. Lead Specialist assists and observes staff in advising
individuals of their alternatives.
1.20:SP15
Date Originated: 12/18/89
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Enrollment #E6
L Service Strategy
What: Provide prepaid envelopes to members Wbo pay premiums to
demonstrate CC:HP's attention to its members and to encourage
payment in a timely manner.
Group: SeniorHealth, Commercial Groups, and Private Individuals
2. Service Standard
Office of Revenue Collection and Central Services include prepaid envelope for
mailing payment in all statement mailings to members.
3. Service Audit
Lead Specialist will call Office of Revenue Collections on occasion to inquire about
mail out.
L20:SP16
Date Originated: 2/26/90
Review: 3/91
3/92
SERVICE PROTOCOL
Unit: Marketing #Ml
L Service Strategy
What: Treatment of prospects/members when they visit the office.
Group: All visitors/prospects/members
2. Service Standard
Greet people in the lobby even if they are not your customer. Ask if they have been
helped. Direct them to the proper person. Ask if they would like any refreshment
(i.e. tea or coffee, etc.).
3. Service Audit
Observation and feedback from members
1.20:SP17
Date Originated: 1/8/90
Review: 3/92
SERVICE PROTOCOL
Unit: Marketing *M2
1. Service Strategy
What: Treat customers courteously and with respect when making sales
presentations.
Group: All potential non-BAC members
2. Service Standard
Account representatives will always be friendly and courteous when making
presentations. Will use client's name often, listen attentively to objections and
questions,_and show a caring attitude when overcoming objections.
3. Service Audit
A Number of service complaints/compliments will be monitored by the
Marketing Director.
B. Direct observations will be done by allmanagement and reported verbally to
the Marketing Director.
C. Marketing Director will accompany sales representatives on oils and will
monitor phone conversations.
D. All marketing staff will attend service training.
E. A quarterly service evaluation will be prepared for the Planning Director.
L20:SP1S
Date Originated: 2/16/90
Review: 3/92
SERVICE PROTOCOL
Unit: Marketing *M3
L Service Strategy
What: All staff will demonstrate prompt, courteous, and efficient telephone
manners.
Group: All phone callers
2. Service Standard
Answer phone before fourth ring; return all calls within 24 hours; return to person
on hold within 30 seconds; call back for fellow employee if he/she has not returned
by the time the caller was told he/she would be back. Be knowledgeable about all
products so callers' questions can be answered.
3. Service Audit
Marketing Director or designee will perform random weekly observations. A
quarterly report will be prepared for the Planning Director.
U0:SP19
Date Originated: 2/16/90
Review: 3/92
SERVICE PROTOCOL
Unit: Marketing #M4
L Service Strategy
What: The Commercial salesperson is to make calls on eidsting group
accounts under the following circumstances:
A To solve problems
B. To encourage renewals
C. To gather referrals
Group: Commercial group accounts
2. Service Standard
The Commercial salesperson will make calls on existing group accounts per the basic
criteria listed above.
We will ask that they exhibit good business judgement and time management.
3. Service Audit
The ongoing supervision of account relationships shall be a part of the Marketing
Director's responsibility. A quarterly report will be prepared for the P1
Director.
IZO:SP20
Date Originated:
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS1
1. Service Strategy
What: Sympathy cards are sent to the family when a member dies to show
concern for our members.
Group: All product lines
2. Service Standard
Member Services mail sympathy card within two worldng days of being notified of
the member's death and sends notice to CCHP Business Office and Claims Unit.
Claims Unit sends letter to family of deceased Medicare member (see Claims Unit
protocol).
As needed, family members will be advised of grief counseling services available in
the community or through the Health Plan for members.
3. Service Audit
Quarterly in year one and annually thereafter, Member Services Coordinator will
perform log review to confirm sympathy cards were sent. A quarterly service report
will be prepared for the Provider Affairs Director,with a copy to Planning Director.
L20:SP21
Date Originated: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #EMS2
1. Service Strategy
What: Replace lost, misplaced, stolen, or non-received ID cards and/or new
member packets so member is reassured and has necessary information
on how to use services.
Group: Non-BACs
2. Service Standard
Member Services Representative, within one working day of request, to review
request for eligibility, and accuracy of information, updates computer as necessary
and gives written request to Member Services Secretary. Member packet and/or
card(s) to be sent out within two days.
Marketing Representatives,Advice Nurses,and Business Services Clerks should pass
inquiries to Member Services to be screened as mentioned above.
3. Service Audit
Member Services Coordinator will review files quarterly to determine compliance
and send report to the Director of Provider Affairs with a copy to the Director of
Planning.
Ltd:SP22
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS3
1. Service Strategy
What: Explain reasons for denial of membership so that Plan is not put in
jeopardy,and applicant is provided with enough information to explain
reasonableness of Plan's medical review.
Group: Individual applicants
2. Service Standard
Member Services Coordinator reserves two hours weekly (2 p.m. to 4 p.m. Mondays)
to return telephone calls from applicants. Phone calls are returned within one week.
3. Service Audit
Calls will be logged. Quarterly, a service report will be sent to the Provider Affairs
Director, with a copy to Planning Director.
L20:SP23
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS5
L Service Strategy
What: Assist members in making appointments that are satisfactory to the
patient.
Group: All members
2. Service Standard
Upon member request, within two days, Member Services
Representative/Coordinator secures appointment for member. Whenever possible,
appointment should be timely, with correct provider and at convenient time and
location. -
3. Service Audit
Member Services Coordinator will monitor, as received, the clinic appointment
backlogs for any appointment difficulties. Member Services Representatives will
write up complaint forms for clinic management when appropriate appointments are
not available for members. Quarterly, service report summarizing such complaints
will be sent to Provider Affairs Director, with a copy to Planning Director.
I.20:SP24
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS6
L service Strategy
What: Give new members a tour of the clinic to acquaint members with clinic
services, layout, and protocols for obtaining and using services.
Group: All non-BACs
2. Service Standard
Upon request, Member Services Representative either gives clinic tour or arranges
with clinic personnel to conduct tour. Tour is given within two weeks of request.
3. Service Audit
Member Services Coordinator will schedule monthly tours of clinics and give
schedule to marketing staff. Member Services Coordinator will monitor monthly
need to increase tour schedule. A quarterly service report will be sent to the
Provider Affairs Director, with a copy to Planning Director.
1.20:SP25
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS7
1. Service Strategy
What: "Paid in Full"letters are sent to appropriate CCHP members who have
been hospitalized at Merrithew, to reassure them they have no
financial obligation for their inpatient stay..
Group: Non-BACs with no copays or deductibles
2. Service Standard
CCHP Receptionist logs details, Advice Nurse screens for appropriateness, and
Member Services Secretary prepares and dispatches letter within two weeks of
discharge to member (or in the case of a minor, the parent or guardian subscriber).
3. Service Audit
Quarterly, Member Services Coordinator will monitor files and send a service report
to the Provider Affairs Director, with a copy to Planning Director.
L20:SP26
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services *MS8
1. Service Strategy
What: Verify if individual is a member or a pending member so that
individual and providers ]mow if C� covers care.
Group: All members and pending members
2. Service Standard
Upon request of individual, out-of-Plan provider, or Merrithew provider, within one
day, Member Services Representative/Coordinator verifies coverage. If individual
is pending, Member Services resolves any outstanding issues to complete the
application:
3. Service Audit
Member Services Coordinator will monitor requests for membership verification and
prepare a quarterly service report for the Director of Provider Affairs, with a copy
to Planning Director.
1L20:SP27
Date Originated: 4/24/90
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS9
L Service Strategy
What: Assist members in selecting primary care physician so that services are
accessible and acceptable to the members, i.e. the physician is in a
convenient clinic location, and physician's background is fitted to a
member's needs and preferences.
Group: All members
2. Service Standard
Upon request by member or by staff to help resolve a problem, Member Services
Representative/Coordinator will offer suggestions to member about primary care
physicians.
3. Service Audit
Member Services Coordinator will evaluate by direct observation and document any
problems. The Coordinator will send a service report quarterly to the Director of
Provider Affairs, with a copy to Planning Director.
L20:SP28
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS10
1. Service Strategy
What: Answer members'questions on benefits and exclusions so members are
informed about their oaverage.
Group: All product lines
2. Service Standard
Upon request by members or CCHP staff, Member Services
Representative/Coordinator gives accurate information. Gives suggestions for
alternate means of obtaining service when requested service is not a covered benefit.
Answers questions the same day.
3. Service Audit
Member Services Coordinator willroutinely monitor phone calls to unit to determine
that members' needs are addressed. The Coordinator will send a service report
quarterly to the Provider Affairs Director, with a copy to Planning Director.
UO:SP29
Date Originated: 4/24/90
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS11
1. Service Strategy
What: Member Services will place phone ells to new members during the
first month of enrollment.
Group: AFDC
2. Service Standard
Beginning on the 10th of each month and weekly thereafter, Member Services
Representatives will receive printout of all AFDC members. Member Services
Representatives will contact each new member family.
A For AFDC group - the Member Services Representatives will verify
enrollment procedures as well as provide new member information. Member
Services Representatives will try and contact 20% of the families by phone
and will send report cards to those unable to contact.
3. Service Audit
A- Monthly, upon completion of AFDC calls, Member Services will notify
Marketing Director of:
1. total number of AFDC members listed
2. total number of AFDC members reached
3. breakdown of enrollment problems by problem area and enroller
B. Member Services Coordinator will review printout comments on a monthly
basis to ascertain problem areas for new members and to verify the number
of phone call attempts.
L.20:SP30
Revised: 9/12/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS12
1. Service Strategy
What: Request feedback on performance from members using Member
Services.
Group: All
2. Service Standard
Each month, the Member Services Coordinator will randomly select 25 cases from
each Member Services Representative's log and send a(torr Card to the member.
3. Service Audit
Monthly, the Member Services Coordinator will tabulate the results of returned
Rgport Cards into a report to be used as a feedback and evaluation device for each
Member Services Representative. A copy of the report and conclusions will be sent
to the Provider Affairs Director.
1.20:SP31
Date Originated: 2/26/90
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS13
I. Service Strategy
What: Send birthday cards to demonstrate a personal interest in our
members.
Group: SeniorHealth members, 1-6 year olds in the private individual, FKO,
and small group categories
2. Service Standard
Director of Provider Affairs Secretary (or designee) sends a birthday card to all the
above-mentioned members on their birthday.
3. Service Audit
Director of Provider Affairs Secretary will keep computer printout list of those sent
birthday cards, which will be reviewed whenever protocol reports are due.
L20:SP32
Date Originated: 7/24/91
Review: 3/92
SERVICE PROTOCOL
Unit: Member Services #MS14
1. Service Strategy
What: Provide flowers to members hospitalized at Merrithew to demonstrate
caring, concern, and CCHP's personal attention.
Group: Non-BAC members
2. Service Standard
Member Services screens admission list and orders flowers for delivery daily.
Members to receive flowers on first or second day of stay.
3. Service Audit
Member Services Coordinator will ask monthly if flowers have been delivered to
hospitalized members.
1.20:SP12
Date Originated: 10/91
Review: 3/92
SERVICE PROTOCOL
Unit: Provider Affairs #PAI
L Service Strategy
What: Out-of-Plan ongoing providers will be sent credentialing packet after
first service is given.
Group: All Contra Costa County Providers
2. Service Standard
A. Authorization Unit will notify Provider Affairs Secretary when an account is
passed for payment when it is for a new ongoing provider in the Plan's service
area.
B. Provider Affairs Secretary will send a credentialing packet.
3. Service Audit
Provider Affairs Secretary will maintain file to ensure credentials are up-to-date.
L20:SP33
Date Originated: 9/91
Review: 3/92
T0:
Susanne Penfold DATE: A4
FROM: Marie
Please note the following provider of services.
We expect this provider to be:
[] on going with just one of our members;
[] one time with one member; -
[] on going with more than one particular CCHP member.
[] please credential in the usual manner.
[] please send a rote of thanks to this out of area
provider who was very helpful in taking care of
(please give
patient's namb and date of service) .
Provider's name
Provider's practice/group name
Address
Specialty if known
SERVICE PROTOCOL
Unit: Provider Affairs #PA2
1. Service Strategy
What: Out-of-Plan providers and facilities will be contacted every six months
to clear up misunderstandings, explain new policies and procedures,
and enhance relations with these providers..
Group: Established providers and facilities who provide frequent services to
CCHP members. Three services and $3,000 in a six month time
period.
2. Service Standard
A Member Services staff will send a letter (copy attached) semi-annually to
inquire about various procedures(eligibility,authorizations,claims processing,
etc.) to clarify any misunderstandings, refer problems to the appropriate
person, and offer provider a personal visit.
B. Staff will call on provider if requested.
3. Service Audit
Provider Affairs Secretary will maintain schedule. A record will be kept of calls and
letters received. Questions will be responded to in writing and a copy kept on file.
A service report will be prepared as needed.
L20:SP34
Date Originated: 3/27/90
Review: 8/90, 1/91, 9/91, 3/92
SERVICE PROTOCOL
Unit: Provider Affairs #PA3
1. Service Strategy
What: Members who have visited an outpatient,out-of-Plan specialist will be
sent a report card to evaluate the services.
Group: Commercial
2. Service Standard
A Monthly,the Provider Affairs Secretary will request computer list of members
receiving out-of-Plan specialty treatment and will send a report card to the
member.
B. Provider Affairs Secretary will screen returned report cards and send those
needing followup to Member Services Coordinator.
C. Member Services Coordinator will send letter to providers where members
rated service as unacceptable.
3. Service Audit
A Statistical reports will be generated by provider on number of report cards
sent, number returned, ratings and followup, on an as needed basis.
L20:SP35
Date Originated: 9/91
Review: 3/92
gAQ.G�
September 19, 1991
Dear
As a Contra Costa Health Plan preferred provider, we want to do everything within
our power to make sure that doing business with us is efficient, friendly and as
problem-proof for you as possible. We feel that the best way to do this is for you to
let us know what we could improve.
Because most of our out-of-Plan providers use our authorization process, our eligibility
process and/or our claims process we would like to hear your opinions on how well
these processes work for you. If you have had any problems in dealing with these
or any other areas of the Health Plan, please call me or one of our member services
representatives at 510/313-6070.
Thank you for taking the time to help us improve our services to our members and to
you.
Sincerely,
Judith A. Sizemore
Member Services Coordinator
&Wimw.
JM.-SW
Asn.
ATTACHMENT J
CCHP WORKPLAN
1994-95
Action Lead Target Date Expected Outcomes
Date Completed
Submit Work Plan to Medical 9/94 Approved Work Plan
CCHP Advisory Board for Director
review and approval.
Hire QA/UM Coordinator Medical 11/94 Qualified and experienced leadership
Director
Obtain Board of Executive 10/94 Delegation of QA to the new
Supervisors Order of QA Director Integrated Quality Assurance
delegation Committee
Obtain signed letter of Executive 9/94
agreement with MMH&C Director
and Medical Staff
Form new committees with Medical 12/94 Required QA Committees and
appropriate policies Director membership established
QA
Coord.
Review existing QA QA 12/94 Necessary policies
policies,protocols, Coord. reviewed/developed
procedures
Develop or update QA and Medical W94 Ensure proper legal oversight by
delegation language for Director CCHP of out-of-plan providers
provider contracts Legal
Council
Continue Baby Tracking QA On- On-going ()Meet national immunization rate
program. Coord. going goal for children;and
Continue immunization. 2)Comply with Medical DHS
(GHAA monitoring). recommendations.
Pregnancy Monitoring QA 12/94 On-going Comply with DHS recommendation
Coord. for MediCal members
Develop continuity of care QA 12/94 Improve continuity process in out-
guidelines and monitoring Coord. patient clinics and comply with DHS
protocol audit recommendations.
Action Lead Target Date Expected Outcomes
Date Completed
Review and approve Cred. 12/95 On-Going Approval of delegated credentialing
MMH&C Med. Staff Comm. of MMH&C Medical Staff
credentialing QA
Coord.
Amb.Medical Records QA 12/94 On-Going 1)Revicw existing amb.care
Review Coord. providers and provide feedback,and
2)Review office records prior to
contracting with new out-of-plan
providers,and do facility inspection.
Monitor access to primary Prov. 9/94 On-Going Ensure access standards are being
care Relations met.
Coord.
First year Quality Council QA 8/95 Quality Council meeting will be at
meetings Coord. least bi-monthly.
Medical
Director
Provider Survey Prov. 8/95 On-Going Complete at least one provide survey
Relations with feedback to providers.
&QA
Coord.
Patient Satisfaction Survey QA 8/95 On-Going Complete at least one survey with
Member feedback to providers and staff.
Sat.
Member Survey Member 8/95 On-Going Complete at least one survey with
Sat. feedback to providers and staff.
QA
Coord.
Prepare at least 2 quarterly QA 8/95 On-Going Review and feedback to Quality
reports to Int.QAC Coord. Council
Prepare annual QAIP QA 8/95 On-Going Approval by all committees and
report Coord. Board of Supervisors
Ensure that PCP's have QA 2/95 All providers will be using consistent
CUP prevention Coord. preventive health care standards.
guidelines
Identify specific QA studies QA 1994-95 8/95 Be prepared for intensive QA work
for 1995-96 Workplan Council following artup year.
Prepare reports to quality QA 11/94 On-Going Assistance and support from CCHP
Council on Workplan Coord. staff,QA Council for QA Coord.
progress and problems
Credential all out-of-plan Cred. 3/95 On-Going All contracted providers credentialed
contracted providers Coord. and reviewed by Quality Council and
Medical Board.
Director
CCHP Audit of MIvtIiNC QA 12/94 On-Going Evaluation of Ambulatory Medical
Clinics Ambulatory Coord. Records against standards.
Medical Records
ATTACHMENT K
CONTRA COSTA HEALTH PLAN
Baby Traddng Program
GOAL:
To ensure all Contra Costa Health Plan babies receive periodic well-baby exams and
immunizations through 15 months of age, following periodic guidelines established
by Merrithew Memorial Hospital and Clinics pediatric department and CHDP. In
addition, this program will ensure at least one postpartum visit for mothers and
instructions regarding contraception.
POLICY & PROCEDURES:
1. Advice Nurse obtains all discharge summaries for CCHP newborns born at
Merrithew Memorial and all outside hospitals, e.g., Brookside. Once Advice Nurse
obtains names and demographic information of newborn, chart is compiled.
(See Addendum I for format and content.)
If Advice Nurse ascertains any high risk factors in discharge summary (see
Addendum 11 — High Risk), Advice Nurse refers infant and mother immediately to
our CCHP Targeted Case Management team. Advice Nurse then proceeds with
initial contact phone call.
2. CCHP Advice Nurse team assigns Advice Nurse member who will track and follow
infant throughout their first 15 months of life.
3. Advice Nurse's first action to engage mother in baby tracking program is via phone.
If mother is successfully reached by phone, Advice Nurse proceeds to interview and
complete Form 46BT(see attached). Baby tracking contact is completed with Advice
Nurse proactively making appointment for newborn two weeks after discharge. The
two-month appointment is also made at this time. The Advice Nurse also makes the
mother's follow-up postpartum appointment.
4. Advice Nurse interviews the mother, delivers basic newborn education, postpartum
education and ascertains if there are any problematic areas warranting further
discussion (see attached Interview Form). If Advice Nurse ascertains any problem
and risk factors (per Addendum II),appropriate action will be taken immediately per
Advice Nurse medical pediatric protocols.
5. Advice Nurse follows up each phone call with a congratulatory letter. If the Advice
Nurse attempts to reach mother three times without success, a letter is mailed (see
Addendum III). If within two weeks the Advice Nurse has not received a response,
Advice Nurse mails out a second letter. If Advice Nurse does not receive a response,
an attempt to access Global Appointments is investigated. After all aforementioned
measures are exhausted, the file is placed in tickler for next 15 months.
6. For those newborns engaged in program, Advice Nurse will continue to track their
compliance with appointments via phone calls. During these intermittent contacts,
Advice Nurse will continue to assess status of mother and infant. This system
continues until the infant is 15 months old and has completed the series of
immunizations. M-btp.jv
Addendum 11
POLICY & PROCEDURE FOR HIGH RISK INFANTS
Criteria for Neonatal Home Visit through
CCHP Case Management
1. Low birth weight (< 2500 gyms.)
2. Small for gestational age
3. Special Care Nursery patient
4. Known risk for nonphysiologic hyperbilirubinem'a
5. At-risk social assessment
6. Limited or no support
7. Maternal age under 17
8. Positive urine toxicology screen and discharged with mother
9. History of maternal mental illness or attempted suicide
10. Kinship placement
11. Congenital malformation/anomaly
12. Prematurity
13. Breast feeding
14. Weight loss > 8% at discharge
15. Poor feeding
16. Early discharge
17. Poor infant-parent attachment
18. Family history of suspected abuse/neglect
19. Primary care giver's medical, social, or mental condition of a nature to require
professional supervision and support to fulfill parental responsibilities, e.g., mental
illness, substance abuse, mental retardation, etc.
F29:btp.jv pg2
CCHP BABY TRACKING
BABY'S FULL NAME: URNk D.O.B.
ADDRESS: PHONE NO:
City Zip
PRIMARY M.D. CLINIC:
APPOINTMENT DATE: KFS REAPPOINT KEPT
Ist [ ] [ ] [ ]
2 months [ J [ ] [ ]
4 months [ J [ ] [ ]
6 months [ ] [ ] [ ]
9 months [ ] [ ] [ ]
12 months [ ] [ ] [ J
15 months [ ] [ J [ J
[ ] Advised re: 240 availability, number given, other concerns.
j ] Inst. s!sx illness.
j ] Inst. newborn care. feeding.
'MOWS NAME LT RUN# [ ] Letter Sent
[ ] Letter Returned
PRIMARY I.D. [] Referred to CHDP
[ ] Referred to TCM
j ] PP f01101A-up date kept reappoint
j ] Discussed birth control Method chosen
SIBLINGS NAMES AGES UP TO DATE/WELLNESS APPT. MADE
1.
2.
3.
4.
5�6 -
1
] At the end of 15 months. send a letter or call with praise, contragulations and a tee-shirt - suggested logo -
"I'm a well-baby and immunized
Contra Costa Health Plan"
j ] Ensure mom has yellow immunization card that is complete. If not, make arrangements for clinic staff to
complete and send to mom.
46:BT--SN:smp COWLETION DATE:
NEWBORN ENROLLMENT DATA
BABY'S INFO:
Name:
URN; —
SUBSCRIBER #
Male ( ] Female ( ] D.O.B.
Medi-Cal #
Address:
Phone:
Month to be disenrolled
MOTHER'S INFO-
Name:
URN:
SUBSCRIBER #:
Medi-Cal #:
t� i
BABY TRACKING NOTES
Mother URN
Baby URN DOB
Date
Mbtnirm
Date
BABY'S FULL NAME: dtda- n U URN# 51 D.O.B.
ADDRESS: I'Gt-r–� PHONE NO: -�o?rQ
City —Zip 9c�s5
PRIMARY M.D. w�'�.c – /e� CLI111'IC: `�; Z
APPOINTMENT DATE: KEPT REAPPOINT KEPT
1st_ 9/1 N [ t 11
2 months i X 9 3 [ ] [ ]
4 months y` 1 -K-,
6 months -0 [ ] [ ]
9 months 4U
12 months
15 months [ ] [ ] [ ]
(�] Advised re: 241 availability, number given, other concerns.
Q(j Inst. s/sx illness.
j� Inst. newborn care, feeding.
MOM'S NAME URN# a��/ 7�� �`� [�} Letter Sent
[ ] Letter Returned
PRIMARY M.D. Lt, Crk Referred to CHDP
[ ] Referred to TCM
PP follow-up //1 '10-3 date Lkept reappoint
j}Q Discussed birth control Method chosen ,er5 el-9 —71
SIBLINGS NAMES AGES UP TO DATE/WELLNESS APPT. MADE
1.
3.
4.
5.
6.
[ ] At the end of l5 months. send a letter or can with praise, congratulations and a tee-shirt - suggested logo -
"I'm a well-baby and immunized
Contra Costa Health Plan"
j ) Ensure mom has yellow immunization card that is complete. If not, make arrangements for clinic staff to
complete and send to mom.
46:BT--SN:smp COMPLETION DATE:
CONTRA COSTA COUNTY HEALTH SERVICES
MERRITHEW HOSPITAL
2500 ALHAMBRA AVENUE* IAL MEMRMARTINEZ,CALIFORNIA
DISCHARGE SUMMARY AND ORDERS
09 ZS 93
1. ADMISSION DATE: 9/z,( 9 3 .w =.. - mow
2 DISCHARGE DATE: a.;s
3. INITIAL COMPLAINT: BAKER
DANA
8/14/1976 510 .228
P 00284126-1 co
4. PRINCIPAL DISCHARGE DIAGNOSIS: KD tlART V
(Chief assn for patient's admission) '` PA 8 E R S a J•
PATIENT W.I,cxh.<Area wrist bo readabb on an 000ies
ATED SUMMARY- YES❑
onTe
Other Dx:
I
t
5. RES PERFORMED:.*.".. .
1 It�ic► I r•. • -Vie..\� �.�-1v�-�..•�.. �-`�,� .
8. SPITAL CC)URSE/TREATMENT/FINDINGS: (Include studies pending std ) SR•-c"1 V/Yq (�is fa/�Id
IS.� ld �n�ntp �•• t Ao.haSfv+.�SIC a n�I4-kd I
4135 rNo., stw-re. d-^ n►w�lutl�,�, it hid iv�at r�ncAertt�w. . �as�.i...•� €
5 �Hca�►.e. �b..w tnS� d�.. �-���-�oa 'F�.-�..,...,.:5.��..�L�.e. t`sSC' �t
'1't�co��.-e_ ��y.�•eto•� �vo '��;s.�. 'e`� 4n�a.-tP��.. Z.� - � p•-�c,,,�
7. CONDITION ON DISCHARGE:
S. INSTRUCTIONS TO PATIENT: (Include medications not being dispensed.)
Diet: LL �►►.
Other.
t
APPOINTMENT REQUEST FOR FOLLOW UP: CLINIC FPS-
ADDITIONAL APPOINTMENTS:
Doctor' WHEN?' `
MARTINEZ- RICHMOND O Pt nsURG O CONCORD❑ t3REwwooD❑ OTHER❑
%•DISCHARGE MEDICATION ORDER
(DISPENSED)
21
2
IV-IS Ct
PATIENT I.D.Imprint Area must be readable on all copes
• • t j4
• i F
L�6 P(JIu�ER J• {SIGNATURE) L
CONTRA COSTA COUNTY HEALTH SERVICES
ti MERRITHEW MEMORIAL HOSPITAL
2500 ALHAMBRA AVENUE a MARTINEZ,CALIFORNIA
DISCHARGE SUM ARY AND ORDERS '
p pr AND
ADMISSION DATE: ( xj( ! t 6 x371 :.
ZV .t yr z 1. _ •, -Y ►
2. DISCHARGE DATE: ,�s• '•.
T y2 r
3. INITIAL COMPLAINT: 8 EA A AST.*!G 1 R L
BIRTH ,A ��s.1'�5">l!s 8 x
�4.•.PRINCIPAL DISCHARGE DIAGNOSIS: y +• ���5
,fte.r(Chlef reason for patient's admission) �1€N� bri a0 poples
j Other Dx :: Te
,�=gIfAA ,tNALHtS?ORY:
#year olds G t P� Ab
PPD I` '�'C`+..�' GY.S�� '' VDRL HBsAg PPS,
�': O , .;; •c-:EDC• h� tBlood type.._
b: PROCEDURES PERFORMED: perinatal problems:
Il
VITAMIN K 1 MG IM -•.:: ;� � � � v
ERYTHROMYCIN OPHTHALMIC OINTMENT OU
NEWBORN SCREEN
6. HOSPITAL COURSE/TREATMENT/FINDINGS: (Include studies pending at(fadm ge)
APGARS , / LENGTH.b cm
1 minute 5 minutes IFHEAD CIRCUMFERENCE 3 cm
BIRTH WEIGHT 3165 O gm / Ibs
�} DISCHARGE WEIGHT gm
�7. CONDITION ON DISCHARGE:
INSTRUCTIONS TO PATIENT: (Include medications not being dispensed.)
Activity: Apply alcohol to the cord 3-4 times daily
Diet: Feed infant every 3-4 hours when hungry
Other. Watch for Jaundice (yellowing of the skin);return H it occurs
Call Advice Nurse If your baby has any problems with feeding,breathing, color or activity.
6• APPOINTMENT REQUEST FOR FOLLOW UP: CLINIC �� ADDITIONAL APPOINTMENTS:
f ' DoctorWHEN?.2-%6J
MARTINE� RICHMOND❑ Prl` SBURG 0 CONCORD 0 BRENTWOOD 0 OTHER 0 (SPECIFY)
;,
'K DISCHARGE MEDICATION ORDER
(DISPENSED)
10 IA' N0Y C6/4Z/6 >�
Ow • r * SV38Vd 0661 /98/6
-TS +,E900I0 9-966 bb500
05 sari-eaa pts ie3ilr►o
Aeve
PATIENT I.D.ImprMt Are,must be readable on a0 copies
C Tf 51
f6 LZ 6
• CNVA v
ON 1D (SKINATURE)
i
NEWBORN ENROLLMENT
B A Y'S,
MCI-
Name- 46
qCe( 5446
URN:
SUBSCRIBER #
Male Female j D.O.B. �?;z L
Med�•Cal #
Address: SYS- `P4 c,4 e c.e Z.E.
,44 z
-Phone:
Month to be disentolled /4 S
NIQTHER•S
Name: �a�e�, /t" peg,
URN. �y �o a-/
SUBSCRIBER #: 72-6"7.9
Medl-Cal ##` • 0 1'772. 0 -o -ti
s.��L
1
BABY TRACKING NOTES
Mother ��rt _ C�QJcx URN-0-7? ,.� Z� -
Baby ��ti_",-E��. l�/�.Cti URN fc1 e ? 6-—6 - DOB
Date
CONTRA COSTA 395 Center Avenue,Suite 100
Martinez,California 94553
HEALTH PLAN
A division of Contra Costa Aeakh Services —
Dear
Congratulations on the birth of your new baby. We have tried to call you
to discuss your health and your baby's health, but we have been unable
to reach you.
We recommend that your baby have check-ups and immunizations at 2, r
4, 6, and 15 months of age. The immunizations will protect your baby
against many serious illnesses and the check-ups are to monitor your
baby's growth and development. This will also help us to catch any
problems early on.
We also suggest that you have an exam about six weeks after delivery.
This exam is to make sure you have healed and for you to discuss family
planning.
We realize that it can be difficult to get appointments. The CCHP
Advice Nurses are here to assist you and to answer any questions 24-hours
every day.
Please call our special member's only numbers:
510-313-6800 or
800-621-0880
or Nancy at 313-6041. Remember to leave a phone number so that we
can return your call. t
Sincerely,
Advice Nurse ;
.,
1
CONTRA COSTA 595 Center Avenue,Suite 100
Martinez,California 94553
HEALTH PLAN
A division of Contra Costa Aeakh Services —
Dear
Congratulations on the birth of your new baby. We have tried to call you
to discuss your health and your baby's health, but we have been unable
to reach you.
We recommend that your baby have check-ups and immunizations at 2,
4, 6, and 15 months of age. The immunizations will protect your baby
against many serious illnesses and the check-ups are to monitor your
baby's growth and development. This will also help us to catch any
problems early on.
We also suggest that you have an exam about six weeks after delivery.
This exam is to make sure you have healed and for you to discuss family
planning.
We realize that it can be difficult to get appointments. The CCHP �t
Advice Nurses are here to assist you and to answer any questions 24-hours
every day.
Please call our special member's only numbers:
000.
510-313-6800 or
800-621-0880
or Nancy at 313-6041. Remember to leave a phone number so that we
can return your call.
Sincerely,
Advice Nurse
j
1
CONTRA COSTA
HEALTH PLAN
�&WA
Dear
Congratulations on the birth of your new baby! We at Contra Costa Health
Plan are very concerned that your baby get the best possible start in
life.We think well-baby exams and immunizations/baby shots are the best
ways to keep your baby healthy. We strongly recommend a check-up for
your baby at 7-14 days, 2 months,4 months, 6 months, and periodically
thereafter. The Contra Costa Health Plan Advice Nurse can assist you in
making these appointments.Anytime your baby is sick the Advice Nurse
can help you decide if your baby's symptoms need to be checked at one of
our health centers.
And while making appoinments for your baby, don't forget that your
health is important too.You should have a 6 week postpartum check-
up. At that time you can discuss ways to prevent unplanned pregnan-
cies.
The Advice Nurses are always available to assist you 24-hours a day.
1-800-621-0880
or
510-313-6800
Sincerely,
R
595 Center Avenue,Suite 100 Martinez,California 94553 510-313-6000
CONTRA COSTA
HEALTH PLAN
Dear
Congratulations on the birth of your new baby! We at Contra Costa Health
Plan are very concerned that your baby get the best possible start in
life.We think well-baby exams and immunizations/baby shots are the best
ways to keep your baby healthy. We strongly recommend a check-up for
your baby at 7-14 days, 2 months, 4 months, 6 months, and periodically
thereafter. The Contra Costa Health Plan Advice Nurse can assist you in
making these appointments. Anytime your baby is sick the Advice Nurse
can help you decide if your baby's symptoms need to be checked at one of
our health centers.
And while making appoinments for your baby, don't forget that your
health is important too.You should have a 6 week postpartum check-
up. At that time you can discuss ways to prevent unplanned pregnan-
cies.
The Advice Nurses are always available to assist you 24-hours a day.
1-800-621-0880
or
510-313-6800w
Sincerely,
_=�
J-d- v'
1
595 Center Avenue,Suite 100 Martinez,California 94553 510-313-6000
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Contra Costa County Health Services Department
'•� Public Health Division
•1 COMMUNICABLE DISEASE CONTROL
T �
597 Center Avenue, Suite 200A
Martinez, California 94553.4669
C-v (510) 313-6740
February 23, 1994
TO: Public Health Immunization Providers
FROM: Dottie Langthorn, PHN
Immunization Coordinator
SUBJECT: Extended Immunization Clinic Hours and Days
Beginning March 1, Public Health Immunization Clinics will be expanded in the following
sites:
Brentwood: 118 Oak Street (behind the Brentwood Health Center)
Every Wednesday from 3-5 pm
Pittsburg: 550 School Street
Daily from 2-4 pm
Concord: 2355 Stanwell Circle
Daily from 9-11 am
In Addition: Fridays from 24 pm
4th Friday from 2-6 pm
Richmond: 39th and Bissell
Mondays and Wednesdays from 2-4 pm
No appointment is needed.
Immunizations clinic fees remain unchanged from prior. We will continue to give state
supplied immunizations when a family is unable to pay.
CONTRA COSTA COUNTY HEALTH SERVICES
Beginning September 1, 1992
Referrals for Public Health Services, including public health nursing, can now be made
directly to specific programs.
PROGRAM SERVICE DFSCRIP'TION TELEPHONE
MI o Case management,severe medical 313-6100
California Children conditions: 0-21 years
Services (CCS) o Physical&Occupational Therapy for
neuromuscular conditions: 0-21 years
o CCS HIV Program: 0- 14 years
313-6141
N2 o Child Health Screening Clinics PUBLIC HEALTH
Clinical Services o Child Abuse Prevention CEN7ERS:
o Child Health Promotion Richmond-374-3111
o Family Planning/Pregnancy Testing Concord- 646-5275
o Geriatrics/Adult Health Pittsburg- 427-8034
o Health Care for the Homeless
o Employee/Occupational Health
o Contra Costa Health Plan Advice Nurse
(advice&authorization: 1-800-524-2247)
o School Based Health Care Admin- 313-6250
#3 o TB Clinics&Field Follow-up 313-6740
Communicable Disease o Acute Communicable Disease
o Refugee Services
o Sexually Transmitted Disease Services(STD)
o HIV/AIDS Test Counseling 313-6770
o Immunization Program
313-6767
k4 o Prenatal Care Richmond-374-3012
healthy Start Martinez-6464715
o Sudden infant Death Syndrome Pittsburg-427-8070
313-6254
p5 o Appointment assistance for wellness care 313-6150
Maternal & Child (medical and dental): 0-21 years
Ilenith (CIIDP) o Prenatal Care Guidance(assistance to
pregnant women)
o Child Injury Prevention Information
High Risk Infant o Assistance to developmentally at risk,delayed 313-6250
or low birth-weight child: 0-3 years
k6 o Skilled Nursing and rehabilitation services Richmond-374-3186
flume Health Agency to homebound patients Fax-374-3849
Concord- 646-5270
Fax-646-5269
Pittsburg-427-8043
Fax�27-8188
Admin- 313-6650
Fax-313-6659
N7 o Food Supplement for Pregnant or Brew: Feeding Richmnnd-374-3250
Women, Infant, and Women /;�_c37(,
Children o Food Supplement fo. Infant and
(�VIC) Nt:1Tit+,,n Ricks: 0 -
ATTACH�M L
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-�� - ATTACHMENT M
lndivfdua/ Programs and Large Groups
Evidence of Coverage
A Federa'ly Qualified Health Maintenance Organization
A D'W"m et Contra Com COYnt►ttieauh Services Dept-1 "t
f
CONT&4 COSTA
HEALTH PUN
TABLE OF CONTENTS
CONTRA COSTA HEALTH PLAN•AN OVERVIEW
L EXTENSIVE BENEFITS I
Doctor Visits and Outpatient Services. »..........»......».»»..„.•„»»»»�..»»..•..•
Hospital Services.---
Emergency
ervices.„».....Emergency and Urgently Needed Care......„„„......».„»»....„„»»..».....».„»»„...„»»»„.»..».»»..„••...........I
HealthInformation and Education.........„.„.....„.„. ...„.»»...»»»»»»».»....».„..............„...„..».......„....1
BenefitHighlights.»....„„.......„.».».„„...„„„».........»„»...».......„...»„...» »...».„,»...................................2
11. PERSONALIZED SERVICES«.....» _ 4
ChooseYour Own Physician.................».»».»...».»».....„.»»..„.........„.„.»...»..„.»...„.........»»..............„„...4
Advice Nurse at Your SenviCe..»»»».»......„........».„..».....».„...»..„.».»..».„..„.„»_„.....................»»„.........4
Member Satisfaction—Our Number One Priority..........................„..»»..„:»»....„.».„.............„.............4
ComplaintResolution Procedures...........................................................»..._...................„.........................4
Ill. ABOUT COSTS .........«.«..«..««..«....«.................«. .......».......«.............«.».«..«..........«............ 4
MonthlyPremiums...........................................................................................................................................4
BillPayment''Reimbursement Procedures..................................................................................................5
Renes+al Provisions for Individual Health Coverage................................................................................5
IV. ENROLLMENT/EFFECTIVE DATE OF COVERAGE ........................»...»..........................«.....„..... 5
GroupMembership .........................................................................................................................................5
Effective Date of Coverage (Groups)...........................................................................................................5
EligibleDependents.........................................................................................................................................5
Additionof Dependents .................................................................................................................................5
IneligiblePersons..............................................................................................................................................6
IndividualMembership....................................................................................................................................6
Effective Date of Coverage (Individual).......................................................................................................6
V. LIMITATIONS, EXCLUSIONS, AND REDUCTIONS IN BENEFITS...«..................«««.................. 6
Principal Limitation of Benefits......................................................................................................................6
Exclusions ...........................................................................................................................................................6
Reductionin Benefits.......................................................................................................................................7
Coordinationof Benefits.................................................................................................................................7
VI. TERMINATION OF MEMBERSHIP/CONTINUATION OF COVERAGE...».«».......................... 7
Lossof Benefits..........„..„..................................................................................................................................8
DependentsOnly ............................................................................................................................................8
Termination of Group Agreement....„..........................................................................................................8
GroupContinuation.........................................................................................................................................8
Conversion to Individual Plan Coverage.....................................................................................................8
Rightto Review.................................................................................................................................................8
V11. YOUR RIGHT TO MAKE DECISIONS ABOUT MEDICAL TREATMENT...____ 9, 10
VIII. PUBLIC POLICY.««».«««.«.....«...».....««....«..».«.«»....«.».««..........««....»...«..»»„.........».............. 10
IX. YOUR PREMIUM DOLLARS AT WORK..............».................................................«..........„....„.... I I
X. PLA! DIRECTORY............................................................................................................................ 12
Welcome!
ti►
iMEW If you're looking for a health plan that offers broad extensive coverage, afford-
able cost, and personalized service . . .we've got just the health plan for you.
%Ve're Contra Costa Health Plan, the first publicly sponsored,federally quali-
44 fied health maintenance organization (HMO) in the nation. And we've been
rr� providing quality health care services to residents of Contra Costa County
since 1974.
Contra Costa Health Plan features:
• Preventive care
• Convenient hours (Saturday & evenings at some locations) and local
P" facilities to serve you and your family
` Choice of your own family physician from among the largest group of
y•� family practice specialists in the county
C •
T 1 A variety of affordable plans to choose from
an
M�
I. COMPREHENSIVE BENEFITS significant disability.Some problems are
emergencies because they may be poien-
With Contra Costa Health Plan,you et com- tially life-threatening and others are consid-
g ered emergencies because if not treated
prehensive health benefits that help keep you promptly they might become more serious.
and your family healthy and feeling well.
Everything from physical check-ups to medi- If you are hospitalized at another facility, you
cal services for major health problems is may be moved to Merrithew Memorial
covered by the Plan. Hospital as soon as it is medically safe to do
Doctor Visits and Outpatient Services so.
As a member of Contra Costa Health Plan, Urgent care is medical treatment that re-
you receive routine medical care from your quires a visit to a health care provider within
own personal family physician or family nurse a few days.
practitioner.The centers are conveniently
located in Brentwood, Concord, Martinez, Within Contra Costa County
Pittsburg and Richmond, and are within easy Emergency and urgent care services are
reach from major highways.They are open available 24 hours a day, every day of the
weekdays and some offer evening and Satur- year at Merrithew Memorial Hospital in
day hours as well. (Refer to the Plan Direc- Martinez, and at other facilities as authorized
tory on page 11 for exact locations and by the Health Plan. If you have questions,
hours of services.) even after hours, call the 24 hour advice and
authorization service.
Hospital Services
Hospital services are provided at Merrithew Outside of Contra Costa County
Memorial Hospital in Martinez. A full range When outside the service area, medically
of ser,ices is available including obstetrics, necessary emergency medical services are
intensive and coronary care, specialty pro- covered at any time.The Plan should be
grams in geriatrics, and more. At Merrithew notified at the time of the service or as soon
Memorial Hospital, a special wing with semi- as possible after service. Urgently needed
private rooms is reserved exclusively for services are covered with prior authorization
members. Amenities include telephones and of Contra Costa Health Plan. Authorization
television in these rooms. can be obtained by calling the 24 hour
Occasionally, because of a special medical advice and authorization service.
service requirement, one of our physicians Health Information and Education
may refer a member to another location at Contra Costa Health Plan also provides
Merrithew, or to another hospital. preventive care for the early detection and
prompt treatment of illness. Education and
Emergency and Urgently Needed Care information about health problems and
Emergency and urgently needed care is health hazards are readily available at the
available 24 hours a day, seven days a week. plan's health centers. Also, a variety of health
Even when you are out of the service area education services is offered at no extra cost
you will be covered when authorized by to members, including classes in:
Contra Costa Health Plan. An emergency is
the sudden and unexpected start of an illness a Prenatal Education • Family Planning
or injury which requires the immediate O Stress and Relaxation
services of a physician to prevent death or a • Smoking Cessation • Living with Diabetes
0
With Contra Costa Health Plan, you get
comprehensive health benefits that help keep
you and your family healthy and feeling well.
Everything from physical check-ups to medi-
cal services for major health problems is
covered under the Plan. Following this sec-
tion is a summary of benefits covered by
Contra Costa Health Plan. All services are
provided at designated Plan facilities and at
non-plan facilities when authorized.by a
Contra Costa Health Plan physician. Some
plan options will require copayments . d
BENEFIT HIGHLIGHTS
HOSPITAL SERVICES'
• Inpatient Unlimited room and board, and all medically necessary services COVERED
• Outpatient Surgical room fee, radiation and chemotherapy treatment, and COVERED
acute renal dialysis
Diagnostic x-ray and laboratory services. including allergy testing COVERED
PHYSICIAN CARE' Office and hospital visits, surger,,vision and hearing testing, well- COVERED
bab% care, periodic health exams(including pap smear, mammograms,
and breast exam), immunizations and inoculations,and allergy serum
injections
PRESCRIPTION Prescription drugs obtained at Plan authorized pharmacies, including COVERED
DRUGS" birth control pills, insulin/needles and prenatal vitamins for pregnant
women
EMERGENCY Worldwide emergency care for acute illness or injury requiring COVERED
CARE' immediate medical attention
Ambulance and air ambulance service when required for an COVERED
emergency or approved by a Contra Costa Health Plan physician
MATERNITY CARE' All hospital and physician services relating to pregnancy and COVERED
(treated as any other interrupted pregnancy
medical condition)
Nursery care during mother's hospitalization;newborn is fully COVERED
covered from birth (must be formally enrolled within 30 days of birth
for continued coverage)
Prepared childbirth classes COVERED
Some plan options monde copayments for this wrvice,
All pian option have CotinsuranCe a do not corer Pre OPlronS.
Refer to vour contract or as&a Plan representative for details.
FAMILY Voluntary sterilization COVERED
PLANNING'
Prescription contraceptives and artificial insemination COVERED
THERAPY AND
COUNSELING SERVICES'
• Mental Health' Inpatient: up to 30 days per calendar year including physician COVERED
services
Outpatient: up to 20 visits per calendar year for short-term evaluation COVERED
and crisis intervention
• Alcohol and Inpatient or outpatient: diagnosis,medical treatment,crisis inter- COVERED
Drug Abuse' vention counseling and referral services. Inpatient treatment for
addiction is not covered
• Speech/ Provided for conditions which are expected to result in significant COVERED
Physical/ improvement within two months
Occupational`
SKILLED NURSING Up to 100 days per calendar year,limited to services for recovery COVERED
FACILITIES from an illness or injury(no copayment if within 90 days of
hospitalization)
HOME HEALTH Unlimited visits provided in the home when prescribed by a Health COVERED
CARE Plan physician, including diagnostic and treatment service and nursing
care
HOSPICE CARE Upon referral, either in-home or hospital unit COVERED
OTHER SERVICES Replaced blood and/or blood products COVERED
Organ transplants that are not considered experimental COVERED
Health education programs such as smoking cessation,stress and COVERED
and relaxation, nutrition information, living with diabetes, natural
childbirth, and more
Podiatry': upon referral of Health Plan physician (covered if certain COVERED
serious conditions are present)
Emergency Medical Advice: toll-free service 24 hours a day COVERED
Orthotic' & prosthetic devices COVERED
• Some plan options include copayments for this service.
•' All plan options have coinsurance or do not cover prescriptions.
Refer to your contract.or as1.a Plan representative for details.
referred to on-call staff. Please limit your after
11. PERSONALIZED SERVICES hours calls to urgent situations such as high
fever, injury,or persistent flu symptoms.
Choose your own doctor!
Member Satisfaction—Our Number
When you become a member of Contra One Priority!
Costa Health Plan, you will choose your own All of us at Contra Costa Health Plan share in
personal doctor from our staff of qualified the responsibility of providing you with the
family practice physicians. We have the best health care services possible. Our mem-
largest group of family practice specialists ber services representatives are ready to
and family nurse practitioners in the county. assist you with any questions or concerns
Our member services representative can you may have about Health Plan coverage,
help you make your selection by matching services and practices. Our representatives
you and your health needs with the most can be reached Monday through Friday
appropriate physician on our staff. 8 a.m. to 5 p.m., excluding holidays.
Your physician will work with you to see that Complaint Resolution Procedures
you get all the health care sem-ices you need, The staff of the Contra Costa Health Plan
including preventive care, hospitalization and share responsibility for assuring your satisfac-
referral to specialists as necessary. You can tion and we welcome your comments and
be assured that you and your family receive suggestions. If you have a problem obtaining
the personalized attention you need and health services or a complaint about care
deserve. you received, you are encouraged to call a
member services representative for assis-
Please note: tance. If any problem is not resolved to your
All benefits described in this brochure are covered satisfaction you may submit a written com-
by Contra Costa Health Plan only if thet are pre- plaint to the Plan for review and resolution.
scribed or directed bt a Contra Costa Health Plan
physician. Contra Costa Health Plan will not pay for Address your complaint to Member Services
services from non-plan doctors and hospitals unless Department, Contra Costa Health Pian, 593
they are authorized and approved by Contra Costa Center Avenue, Suite 100, Martinez, CA
Health Plan. 94553.
Advice Nurse At Your Service! Normally, all complaints are resolved within
%%'hen you have health related questions, a 30 days.
simple toll-free call to our advice nurse can
quickly answer your concerns. If an urgent
medical situation arises and you're not sure if fit. ABOUT COSTS
a visit to the doctor is necessary, or you have
questions about a medication or treatment, Contra Costa Health Plan gives you afford-
the Advice Nurse Service is your friendly able care plus service.There are a variety of
connection to us. Our advice nurses can plans to choose from.
even arrange urgent care appointments!
Monthly Premiums
The Advice Nurse Service is available to Please refer to the rate sheet for listings of
Contra Costa Health Plan members Monday current benefit plans and monthly rates.
through Friday, 8 a.m. to 9 p.m. and Saturday
• 9 a.m. to 1 p.m. After hours, weekends and
holidays, calls to the atiti ice nurse service are
0
For Groups groups of various sizes located within Contra
Your employer is responsible for prepayment Costa County.If Contra Costa Health Plan is
of the monthly premiums for Contra Costa part of your benefits package and if you
Health Plan coverage.You may be required meet the eligibility requirements established
to pay a portion of the charges;If to,you will by Contra Costa Health Plan for your group,
be notified by your employer. you may enrol yourself and any eligible
dependents.For up-to-date eligibility require-
For Individuals, For Kids Only ments, contact an account representative at
and On Your Own Contra Costa Health Plan or the Benefits
You will receive a monthly bill for your plan Manager where you work.
premium. Payment for each month of cover.
age must be received on or before the last Effective Date of Coverage(Group)
day of the preceding month. If you decide to join Contra Costa Health
Plan,you and your eligible dependents must
Siff Payment/Reimbursement Procedures apply for membership through the group
When a member receives authorized care within 30 days of becoming eligible to enroll.
from a non-plan provider, Contra Costa Coverage will be effective on the first of the
Health Plan will pay the bill. As a member, month following approval of request to join
you will never have to worry about compli- Contra Costa Health Plan. Persons not en.
cated claim forms and reimbursement proce- rolled when they are first eligible may enroll
dures. If you choose an option with copay- later during the group's annual `open enroll-
ments, you will be billed for your portion of ment period'.Your employer will announce
the out-of-plan services, Some providers such the open enrollment period dates and will
as PCN pharmacies will collect copayments inform you when your coverage takes effea
at point of services.
Eligible dependents are:
Renewal Provisions for Individual
Health Coverage • Lawful spouse
A subscriber renews coverage by making the • Unmarried dependent children through the
required monthly prepayment by the due age of 24 years. For children aged 19
date. The due date is the last day of the through 24, a dependency statement may
preceding month. The Medica! and Hospital be required to verify that the child is legally
Contract may be amended at any time by dependent in accordance with IRS require.
Contra Costa Health Plan upon at least 30 ments, (Dependents who are attending
days' notice.The monthly charges are subject school outside of Contra Costa County will
to such amendments. be covered for emergency and urgently
needed care only;follow-up visits and
The monthly charges may also be increased routine care are covered only at Plan
to cover taxes or licensing fees imposed on facilities.)
Contra Costa Health Plan by a government
entity upon the effective date of such taxes Addition of Dependents (Groups)
or fees. If you get married, have a child, adopt a
child, or gain a stepchild, after you enroll in
IV. ENROLLMENT/EFFECTIVE ! Contra Costa Health Plan, it is simple to
DATE OF COVERAGE ( make additions or add the new family mem-
Group Membership ber to your policy. All you have to do is
Group membership is mailable to employee submit a corrected enrollment form through
' A
your employer within 30 days of their be. V. LIMITATIONS, EXCLUSIONS AND
coming dependents. Newborn children are REDUCTION IN BENEFITS
covered under the polity from date of birth
as long as they are added to your coverage Principal Limitation of Benefits
within 30 days of birth. Dependents not • All health services are limited to Contra
enrolled when the subscriber was enrolled or Costa Health Plan designated centers and
when they were initially eligible may only be physicians except for emergency care
added during the group's annual open enroll- and other authorized service.
mens period.
• Emergency are within the service area at
Ineligible Persons non-plan facilities is limited to life-
If you and/or a family member is disenrolled threatening conditions.
for just cause,you and/or your dependents
may not be eligible to convert to Individual • Inpatient and outpatient physical, speech
Plan membership. Please call the Enrollment and occupational therapy services, and
Unit at Contra Costa Health Plan for more other rehabilitation services are provided
information. for conditions which are expected to result
in significant improvement within a period
Individual Membership of two (2) months, except at the discretion
To apply for membership as an individual of the Plan Medical Director.
rather than through a group, you must submit
•�• a completed medical questionnaire for to the event there are circumstances
-:-self and each eligible dependent you beyond Contra Costa Health Plan's control
wish to enroll and (b) a non-refundable such as war, riot, epidemic, or disaster
processing charge. affecting Health Plan personnel, the Plan
will take appropriate action (to the extent
The questionnaires) will be reviewed, and a possible) to refer members to other partici-
health screening medical exam may be pating providers.
requested. Applicants are responsible for the
medical examination fee and duplication of Exclusions
any medical records requested. You may be Contra Costa Health Plan does not cover:
asked to obtain your medical records.
• Care for conditions that state or local law
Effective Date of Coverage (individuals) requires be treated in a public facility
If you are interested in Individual Plan cover- (However, the Health Plan will reimburse
age, you may apply if you meet the eligibility for the costs of any covered benefits
requirements established by Contra Costa delivered at such public facilities.)
Health Plan (see Page 5). Individuals are
eligible for health benefits from the first of • Experimental medical, surgical, and other
the month following their acceptance and procedures including drugs where the
upon receipt of the first month's premium. safety and effectiveness of such have not
been proven effective
When you are accepted as a member you
will have a 6 month premium guarantee.You • Alternative therapies including, but not
will be enrolled for a minimum of 6 months limited to, acupuncture, biofeedback and
but your premium will not be raised during hypnotherapy, unless specifically autho-
rized by the Plan Medical Director
that time.
• All drugs and/or procedures to induce • Services not recognized as generally
fertilization or conception, except artificial accepted by the medical profession stan-
insemination dards as being safe and effective for use in
the treatment of the Condition in question
• Private room: unless ordered by a Contra
Costa Health Plan physician due to medic • Reversal of voluntary sterilization
Cal necessity
* Medication prescribed for the purpose of
• Cosmetic surgery and prescriptions for weight loss and dietary supplements
cosmetic use unless deemed medically (except for services specifically listed as
necessary by a Health Plan physician covered benefits in the member's contract)
• Custodial or domiciliary care Reduction in Benefits
If injury or illness is caused by any act or
• Non-medical personal and comfort items omission of a third party, services and other
benefits are furnished hereunder at prevailing
• Radial keratotomy rates. However, the member is not required
to pay any amount collected on account Of
• injectable prescription drugs (other than the injury or illness.
insulin) not administered in doctor's office
unless deemed medically necessary by the Coordination of Benefits
Plan Medical Director if you or your dependents are entitled to
benefits under additional health insurance,
• Conditions covered by Workers' Compen• Contra Costa Health Plan may choose to bill
sation or other insurance services all or some of your health care charges to
your other carrier.This is a customary pro-
• Supplies (including medications) or devices cess known as"coordination of benefits". If
not recognized by generally accepted this situation should arise,we will do every-
medical standards as being safe and effec• thing possible to minimize your involvement
Live for use in the treatment of the condi- and inconvenience.
tion in question, or that are considered VI.TERMINATION OF MEh1BfRSHiP/ `
experimental or investigative
CONTINUATION OF COVERAGE
• Care in a facility which specializes in the Coverage will be discontinued for a member
treatment of alcoholism, drug abuse, or and all enrolled dependents when the mem.
drug addiction ber ceases to be eligible for coverage.This
may occur when:
• Procedures or treatments to change char-
acteristics of the body to those of the • A member fraudulently or deceptively uses
opposite sex Contra Costa Health Plan services or
facilities or knowingly permits such fraud
• Dental care except for oral surgery inti- or deception by another
dental to fractures and tumors or
Congenital defect (except those members • A member fails to pay a premium or
with a dental plan) copayment (if required)owed by the
member to Contra Costa Health Plan
• Conventional or surgical orthodontics or
Orthognathics
• A member's group coverage terminates for any reason, the coverage of all members
because of premiums owed by the group enrolled through the group will end on the
to Contra Costa Health Plan date the group agreement terminates. Mem-
bers have the right to convert to Individual
• A member's group coverage terminates Plan membership Identical to level of the
because of termination of employment for group coverage.
reasons of gross misconduct
• A member puts fraudulant information on Group Continuation
the application form or medical question- An enrolled active employee and/or his/her
naire enrolled family members may be entitled to a
group continuation plan when coverage is
Loss of Benefits lost under the employer's group plan. If he or
Group benefits cease on the date group she qualifies,the benefits of the group con-
coverage terminates.There is no coverage tinuation plan are identical to the group plan
for continued hospitalization or treatment of andthecosts of coverage may not exceed
any condition, including pregnancy, beyond 102% of the applicable group premium rate.
the effective date of termination.Persons will An eligible employee (or his/her family
be charged for any services received after members) is entitled to elect this coverage
group coverage terminates subject to the provided an election is made within 60 days
right of the member or his or her dependents of notification of eligibility and the required
to convert to Individual Plan coverage. premium is paid. Your employer will help
determine if you or your family members
Individual benefits cease in the month the qualif.. ;or continuation of group coverage.
member fails to make payment of the re-
quired premium. There is no coverage for Conversion to Individual Plan Coverage
continued hospitalization or treatment of any Persons who are no longer eligible for group
ccoverage but who are entitled to convert to
condition, including pregnancy,beyond the
effective date of termination. Persons will be Individual Plan coverage may apply without a
charged non-member rates for any services medical evaluation for the Individual Plan at
received after delinquency of premium the same level as their group coverage,
within 31 days of eligibility. Individual Plan
payment and may be required to reapply for membership begins at the time group cover-
membership as described in Section Iv, p.6. age ends and must be continuous.
Dependents Only Right to Review
In the event of a divorce, a spouse loses If you allege that your coverage was can-
eligibility at the end of the month in which celed because of your health status or re.
the divorce is final. Children lose eligibility as
dependents at the end of the month in which quirements for health care service,you may
the child becomes ineligible for continuing request a review of the cancellation by the
coverage or ceases to meet an eligibility State Commissioner of Corporations and by
the Federal Health Care Financing Adminis•
requirement for dependency status.The
for conver-
sion
tration.
spouse and children may apply
to coverage under an Individual Plan If you have questions regarding benefits,
contract within 60 days of loss of eligibility. coverage, or membership, please call your
Termination pt Group Agreement
Member Services Department.The phone
number is in the Plan Directory.
If the group terminates its group agreement
0
EI
UR RIGHT TO MAKE DECISIONS
BOUT MEDICAL TREATMENT .
This section ertplains your rights to you want to happen if you cant care also gives them legal protec-
make health caro decisions and how i speak for yourseff.There are several ; tion when they follow your wishes.
You can plan what should be done I kinds of'advaria direc#ves'that
waren you ant speak for yourseff t you can use to say what you want What If 1 don't have anybody to
and who you want to speak for make decisions for me?
A federal law requires us to 1h*you YOU. You an use another kind of
this information.We hope this } ` advance directive to write down
information will help increase your One kind of advance directive your wishes about treatment This is
control over your medical treatment under California law lets you name often called aIving will"because
someone to make health care it takes effect while you are$611
%%%o decides about my treatment? : decisions when you can't This form alive but have become unable to
Your doctor will give you infonna. ' is called a Durable Power Orf speak for yourself.The California
tion acid advice about treatment Attorney For Health tare. Natural Death Act lets you sign a
You have the right to choose.You living will called a Declaration.
can say"Yes'to treatments you Who an fill out this forret Anyone 18 years or older and of
want You an say'No*to any You can if you are 18 years or older sound mind can sign one.
treatment you don't want-even if and of sound mind.You do not
the treatment might keep you alive need a lawyer to fill it out Men you sign a Declaration it tells
longer. your doctors that you don't want
Who can 1 name to make medical any treatment that would only
How do I know what i want? treatment decisions when I'm prolong your dying.All life-sustain-
Your doctor must tell you about unable to do so? ing treatment would be stopped if
your medical condition and about You an choose an adult relative or you were terminally ill and your
%%-hat different treatments can do for friend you trust as your`agent"to death was expected soon,or if you
you. Many treatments have"side speak for you when you're too sick were permanently unconscious.
effect-C.Your doctor must offer you to make your own decisions. You would still receive treatment to
information about serious problems keep you comfortable,however.
that the medial treatment is likely, Now does this person know what 1
to cause you. would want? The doctors must follow your
After you choose someone,talk to wishes about limiting treatment or
Oiten, more than one treatment that person about what you want. turn your are over to another
might help you-and people have You can also write down in the doctor who wilt.Your doctors are
different ideas about which is best. Durable Power Of Attorney For also legally protected when they
Your doctor can tell you which Health Care when you would or follow your wishes.
... tmerrt are available to you,but wouldn't want medial treatment
your doctor can't choose for you. Talk to your doctor about what you Are there other trying wills t can
The choice depends on what is : want and give your doctor a copy use?
important to you. of the form.Give another copy to Instead of using the Declaration in
the person named as your agent. the Natural Death Act,you can use
What if I'm too sick to decide? And take a copy with you when any of the available living will forms.
If you can't make treatment deci. you go into a hospital or other You can use a Durable Po%er Of
sions your doctor will ask your treatment facility. Attorney For Health Care form
closest available relative or friend to without naming an agent Or you
he.1p decide what is best for you. Sometimes treatment decisions are can just write down your wishes on
Most of the time,that works.But hard to make and it truly helps your a piece of paper.Your doctors and
sometimes everyone doesn't agree family and your doctors if they family can use what you write in
about++fiat to do.That's why it is know what you want.The Durable deciding about your treatment.But
helpful if you say to ad►ance what Power Of Attorney For Health living wills that don't meet the
requirements of the Natural Death wouldn't want particular Power of Attorney,a Living Will,
Act don't give as much legal kinds of treatment. or a Natural Death Act Declara-
protection for your doctors if a I s don Form,please give your
disagreement arises about follow- • If you don't have someone physician a copy and take a
ins your wishes. + you want to name to nuke copy when you check into a
decisions when you can't,you hospital or other health facility so
'K%at N 1 change my mind? can sign a Natural Death that it can be put in your medical
You can change or revoke any of Act Declaration.This Dada- ' record.
these documents at any time as ration says that you do not
long as you can communicate want lif"rolongingtreatment Please call your doctor or a
your wishes. N you are terminally in or member services representative
permanently unconscious, if you need more information on
Do i have to fill out one of Advance Directives.
these forms? How can I get more information
No, you don't have to fill out about advance directives? The information is also available
any of these forms if you Ask your doctor,nurse,or social in:Chinese, Korean,Japanese,
don't want to. You can just worker to get more information Tagalog,Vietnamese,Cambo-
talk with your doctors and ask for you.' dian, Hebrew, Russian,Arme-
them to write down what pian, Persian,and Spanish.
you've said in your medical important Information
chart. And you can talk with For Health Plan MembersVllt. PUBLIC POLICY
your family. But people will Advance Directives
be more [leer about your
treatment wishes if you write Contra Costa Health Plan shares Contra Costa Health Plan's
them clown. And your wishes your interest in preventive care, Advisory Board meets on the
are more likely to be followed and in maintaining good health, second Wednesday of the
if you arils them down. However,eventually every month at 5:30 p.m. in the confer-
famiiy must face the possibility of ence room at Merrithew Memo-
Will 1 still be treated if I serious illness in which important rial Hospital.Anyone desiring to
0^n't fill out these forms? decisions must be made. We effect public policy will be
ilutely. You will still get believe it is never too early to allowed to speak at The Advisory
medical treatment. %1'e just think about decisions that may Board meetings. For more
%.ant you to know that, if you be very important in the future, information about participating
become too sick to make and io discuss these topics with in establishing public policy call
decisions, someone else will family and friends. the Health Plan offices at (5 10)
have to make them for you. 313-6000.
Remember that: Contra Costa Health Plan com-
plies with California laws on From time to time there are
• A Durable Power Of Advance Directives.We do not openings on the Contra Costa
Attorney For Health Care condition the provision of care Health Plan's Advisory Board.
lets you name some- or discriminate against anyone Anyone interested in serving on
one to make treatment based on whether or not you the Advisory Board can call the
decisions for you.That have an Advance Directive.We Director of Planning at 510.313-
person can make most have policies to ensure that your 6004.
medical decisions-not just wishes about treatment will be
those about life-sustaining followed.
treatment-when you Copies of the forms mentioned
can't speak for yourself. in this section are available when
Besides naming an agent,you you are admitted to a hospital. if
can also use the form to say you have completed a Durable
when you would and
Q
Contra Costa Health Plan does not discriminate on the basis of sex, race,color, creed or national
origin or ancestry. Bilingual staff are provided to assist members. If you have questions about our
affirmative action policy, please contact a member services representative.
X.„YOUR PREM Z DOLLARS'AT WORK
In compliance with State legislation (AB2833)Contra Costa Health Plan must report to our Com-
mercial Group membership the ratio of premium costs to health services for the preceding fiscal
year (July 1, 1991—June 30, 1992).
We are pleased to report that the Health Plan paid back to you, our commercial product line
members 62% of the premium dollars collected in the form of medical services such as hospital
care, doctor visits, and pharmacy costs.The remaining 38% of your premium was utilized to pav
for such service benefits as the Advice Nurse Program, Member Services Representatives, various
wellness activities, and other administrative costs.
For our Commercial Groups with under 25 members and Individuals, 96% of the premiums
collected were returned to our members in medical care costs.
You can be assured that with Contra Costa Health Plan you are getting the best value for your
premium dollars.
BEST VALUE AROUND
Compare The Difference
Member Support Services and Administration Expenses
As Percent Of Medical Costs for groups under
28 members and individuals
10�
96%
50%
0%
Member support Meduatl
smie+e tu>a Expenses
AdmiWarntim Gets
Contra Costa Health Plan puts more of your
premium dollars into your health care.
Brentwood Health Center PitUburg Health Caner
118 Oak Street SSO School Stmt THE PLAN DIRECTORY
Hours: Hours: t a.m. to S P.M. Monday to
I a.m. to S P.M. Friday. Other Swwices;
Monday. Tuesday. Thursday, and
Friday. Appointments. . . . . . . . . . 427.9755 2NIW :
Wednesday 9 a.m. to 11.30 a.m. !member Services . . . . . . . 427.8165
Pediatrics: Preeaiptice Reftlh. . . . . . . 427.8024 Martinez . . . . . . . . . . . . . 370-5300
12.30 to 9.30 p.m. firmly practice. To Reach Your Dr. . . . . . . 427.8115 Pittsburg. . . . . . . . . . . . . 427-SOIS
Appointments . . . . . . . . . . 634.1102R4,Asooad . . . . . . . . . . . . 374-3088
Member Services . . . . . . . 427-8165 f MIMW Hulk-
41
To Reach Your Dr. . . . . . 634-1102
tu•rwoc Antioch 427.8664
Comcord . . . . . . . . . . . . . 646-5480
es Pittsburg. . . :. . . . . . . . . 427.8110
D Ricbmood . . . . . . . . . . . . 374.3261
t
Richmond Health Center Pleue sots
381h&Bissell 4The bourn of operation is this
directory are subject to change. Call the
Concord Health Center Hours: 8 a.m. to S p.m. Appointment Unit or your Health Center
3052 Willow Pass Road Monday to Friday for current information.
Hours: Appointments . . . . . . . . . . 374-3755 0 Additional clinics said urgent care
8 a.m. to S p.m. Monday and Friday. Member Services . . . . . . . 374.3228 cervica ars available evenings and
8 a.m. to 9 P.M. Tuesday through Prescription Refills . . . . . 374-3375 wakends at various times and locations.
Thursday. To Reach Your Dr. . . . . . . 374.3025 Call the Health Plan Advice Nurse or
Closed: Boon to 1 p.m.
aKM
Movn the Appointment Unit of your Health
''•
and 5 p.m. to 6 p.m. ��s Center for details of these extra hours.
4r 'a ♦Member Services and the Appointment
Appointments . . . . . . . . . . 646.4455 ,. ... Units arc available from 7 a.m. to 7 p.m.
Member Services . . . . . . . 313-6070 a•^.�
To Reach Your Dr. . . . . . . 646-5502 a• " •The toll-free 800 numbers are available
co%cota 't 6
CCHP AD:►IAISTRATION throughout the USA, including Hawaii,
' Mexico. Canada and the Virgin Islands.
1 . Advice Nurse. Authorizations,
S Urgent Can Appointments, 24 Hours,
! 7 Days a Weds
1-800-621-0890Martine: p
Martina Health Center From Central County . . . . . 313-6900 /
2500 Alhambra AvenuePiaaburb Seeoavo,
Business Office . . . . . . . . 313.6010 O Richmond Concord
Hours: 8 a.m. to 5 p.m. Monday to
Friday. 5.30 to 9 p.m. Monday Ctims Unit . . . . . . . . . . . 313-6030
dt Tuesday.
Fateeutive Director . . . . . . 313-6004
Appointments . . . . . . . . . . 646-6455
kND
Member Services . . . . . . . 313-6070 Fax . . . . . . . . . . . . . . . . 3134002
Prescription Refills . . . . . . 370.5240
To Reach Your Dt. . . . . . . 370-5000 Information . . . . . . . . . . . 3134000
�• aras�ra Marketing B Sala . . . . . . 31340
To obtain further copies of this director)
Member Services . . . 1.800-644.2247 and other Health Plan materials,ca11313.
6008.
Parenting Line . . :. . 1.900-621-0880
0 so
This Evidence of Coverage is only a summary of the Contra Costa Health Plan.
You should consult your contract for exact terms and conditions.The contract
is on rile and available for review. A copy will be furnished to you by Contra
Costa Health Plan upon request.
;
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,%ATel
e CONTRA COSTA
HE9LTH P Y
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Cenn Caws Real*N►n marAsenen suR
Dear Contra Costa Health Plan Member:
We are happy to welcome you to Contra Costa Health Plan. Your health and your
satisfaction with our service are our foremost concerns.
You have chosen a health plan that offers you high quality medical care and the
best value for your dollar. Once our members join Contra Costa Health Plan they
stay with us . . . the best testimony there is. We are committed to seeing that you
have the same positive experience as our other Contra Costa Health Plan
members.
To help you use your benefits and our services to the fullest, we have created this
member handbook. Our intent is to answer in easily understood terms as many
of your questions and concerns as possible, but if you are still puzzled about any
pan of your health plan,just call your Member Sen-ices Representative. They are
here to sere you.
Thank you for joining Contra Costa Health Plan. We want to be your health care
choice for long into the future.
LIP,
`
Milt Camhi Bobbi Baron Elissa Leidy
Bill Burr, M.D. I ffasqerJudith Louro
I Hamcnn Darlene Ktic{i
K��,.�
1acqueline.valentine, R.N., B.S.M., P.H.N.
f
Table Of Contents
Where To Get Health Care
OurHealth Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
HospitalServices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
InpatientCue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
AmbulanceService . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S
What If You Are Out Of The Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S
How To Make Appointments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S
Urgently Needed Care . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . S
How To Get Records . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . 6
The Treatment Of Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
What About Dependents Who Are Away At College . . . . . . . . . . . . . . . . . . . 6
Health Care Coverage
YourFamily Practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Seeing A Specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Special Cervices
Advice Nurses
Urgently Needed Appointments . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Emergency Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ParentingLine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Wellness Activities And Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Child Health and Disability Prevention Services (CHDP) . . . . . . . . . . . 11
Women's Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Maternity Care (Healthy Start Program) . . . . . . . . . . . . . . . . . . . . . 12
Health Education Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Shapers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
HealthSense Newsletter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Owner's Manual For Your Body . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medical Services To Kap You Well . . . . . . . . . . . . . . . . . . . . . . . 12
Special Coverage
Pharmacy
Health Center Pharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Telephone Prescription Refill Service . . . . . . . . . . . . . . . . . . . . . . . 14
Prescription Service: Contracting Pharmacies . . . . . . . . . . . . . . . . . . 14
If You Have Prescription Coinsurance . . . . . . . . . . . . . . . . . . . . . . . 14
If You Have Dental Care Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Are You Covered For Eyeglasses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Hearing Aid Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ChiropracticCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Medical Equipment And Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
About Your Membership
Contra Costa Health Plan Identification Card . . . . . . . . . . . . . . . . . . . . . . . 17
Clinic Card . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Pharmaceutical Care Network Cud (PCN Card) . . . . . . . . . . . . . . . . . . . . . 17
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Eligibility For Health Plan Coverage . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 18
Adding/Deleting Dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Loss of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Continuation of Group Coverage (COBRA) . . . . . . . . . . . . . . . . . . . . . . . . 18
Coordination Of Benefits With Other Insurance Companies . . . . . . . . . . . . . . 19
About BiIIing . . . . . . . . . . . 19
Major Exclusions And Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Martina:FWAY Pnctin
2500 Alhambra Ayataos
UArdoa=,Wifornia
Our Health Centers
Contra Costa Health Plan is a Health
Maintenance Organization (HMO). That means
that you come to our health centers and receive
your health care from the doctors and nurses
who are on our staff. 0
We have several convenient locations in �...
Contra Costa County where you receive your
medical care. Most of our members choose the
health center nearest their home or work but you
are welcome to make your appointments at any
one of our locations. Pittsburg Health Ceota
$50 Scbool Street
The phone numbers for each of the health PirS'ca'
tornia
centers are listed in the front of this booklet in
the Plan Directory. Call us if you would like us
to send a map and directory of the health center
you choose.
�i
ing � r
Richmond Health Caotsr
36th and Binell
Richmond,California
otber Health Cooter:an located at
116 Oak Street.Brentwood and
3032 Willow Pats Road in Concord
.3. _ .
Hospital Services
t
4.
r
.... .�yT
i�
AlurisMw MommW HoV41.2300 AIM06re,Manisa 91333
Inpatient Care and unexpected start of an illness or injury which
If you or a family member need to be requires the immediate services of a qualified
hospitalized you will go to Merrithew Memorial physician to prevent death or a significant
Hospital in Martinez. We know that you will be disability. Some problems are emergencies
satisfied with the care you receive from our because they may be potentially life threatening.
competent caring stiff. In a recent survey, 94% Others are considered emergencies because if
of all respondents said they were happy with the not treated promptly they might become
service they received while at Merrithew more serious.
Memorial Hospital. .
Like other emergency rooms, Merrithew
To make things even better, we have a Memorial Hospital treats patients with the most
special wing reserved with semiprivate rooms, severe medical problems first. 7be Health Plan
TVs, phones and other amenities just for our Advice Nurse will help you determine whether
Health Plan members. You will even get a visit you need to go to the hospital emergency
from one of our friendly staff and a special gift department. You can find the telephone number
to make your stay a little brighter. for the Advice Nurse in the Plan Directory in the
front of this booklet. In addition, you will find a
handy self-sticking label to attach directly on
Emergency Services your phone, listing the important numbers.
In a We threatening emergency, call
911 immediately. Of course, if you have a life threatening
emergency such as unusual or excessive
Emergency care is available 24 hours a day bleeding,broken bones, severe pain, poisoning,
.and is located new the lobby of Merrithew unconsciousness or choking, you would go to the
Memorial Host-_:1. An emergency is the sudden nearest emergency rogm. As soon as possible
.4_
you should all the medical authorization number appointments, it is important to plan ahead.
printed in the Plan Dirtaory and on your Contra Please give yourself plenty of advance time
Costa Health Plan Identification Card. when making routine health maintenance
appointments such as for immunizations,
Ambulance Service smears
examinations, routine doctor visits,pap
Ambulance service will be arranged far :mean:and the like, as there may be a waiting
g you period for these non-urgent appointments. You
if necessary when you all for emergency au- may be disappointed if you wait until the last
thorization or, in a true emergency, you may all minute to make such an appointment, especially
911 and an ambulance will be dispatched to take at unusually busy times (e.g., flu season). Back
you to a hospital. The ambulance crew will make to school, sports and camp physicals should
the decision on which hospital to use. particularly be made well in advance since most
Remember, ambulance services must be
other people want them at the same time of year
as you do.
authorized or be medically necessary in order to
be a covered benefit. Appointments for follow-up are that
your doctor requests should be made before
Khat If You Are Out Of leaving the health center. You may use the
appointment telephones located in the health
The Area? centers with direct lines to the appointment unit.
If you are sick or injured and need medial To make an appointment at the Brentwood
attention while you are out of Contra Costa Health Center, look in the Plan Directory for
County, go to the nearest medical facility. The the phone number.
Health Plan covers the cost of emergency and
urgently needed services only. Call the 24 hour Appointment phones are open from 7 a.m.
emergency medical number listed in the Plat to 7 p.m. Monday through Friday. The
Directory before you receive care, or as soon as appointment phone numbers are listed in the
possible afterward. If you don't receive prior Plan Directory. The best time to call for an
authorization you may be responsible for the cost appointment is between 7 a.m. and 8 a.m. or
of the care. after S p.m. when the lines are less busy.
If for some reason you can't kap your
appointment,please call as early as possible to
• cancel your appointment so that another member
•: may use the appointment time.
it is necessary to Ball for an a pomtmeat before comic j in.For
our bealtb centers to provide the most convenient care for all
our wetabets,the staff must be able to scbedule and plan for
escb patient's arrival.For this reason,members who drop in
for Pon-etnersency care am seen afta .patients wa
appoinatxnts and mom ur eat conditions. For your own
convenience,sad to avoid orlons wait,please nail before you
• visit your bealth anter.
_= Urgently Needed Care
When you get sick and need to sec the
'""Im of O`°"ad''AVPOWL" N UM w'r doctor, you can obtain advice and authorizations
How To Make by calling the 24-hour toll-free number listed in
the Plan Directory, on the emergency number
Appointments sticker, and on your Identification Card. You
can make urgent are appointments by calling
In your Plait Directory you can find the the same number during regular business hours.
phone number for appointments. When making
How To Get Your Records
So that you will have continuity of art, it
is important to have the records pa *ft to
your prior health care transferred to the Contra
Costa Health Plan health anter what you will
be getting your medical treatment.When you
arrive for your first appointment,or even before,
visit the Medical Records Departmmt at your
health anter so they an assist you in completing
a form for transferring your medial records
from your previous doctors.
a
� , •;.;�, .ate
What About Dependents
•,�,. Who Are Away At College
' The Health Plan does not cover the cost of
non-emergency health services outside of our
normal service area. If you have a child away at
college, you will find that most college campuses
have student health centers for treating minor
ailments. Usually these services are performed at
little or no cost to the student. For true
The Treatment Of Minors emergencies, all Contra Com Health Plan
members including college students am covered
When a child under the age of 18 years wherever they are. However, any follow-up or
needs medical treatment, it is imperative that a ongoing are for a chronic condition would have
parent or legal guardian accompany the child. It to be treated at our fi Ities.
is illegal for any medial are b be given to a
minor without the proper adult giving consent. If
you foresee a time when you may not be able to
accompany your child to a health center, it
would be wise for you to complete an authoriza-
tion form available at the registration desk at all
of our health centers. Having an authorization
form on file will give your permission for a
neighbor or family member to authorize health
care for your chili in your.abompe.
}
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COVIEILXGVj
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As a member of Contra Costa Health Plan Health Plan health center most convenient for
you will have all the health care you need. We you it's easy to choose your doctor.
cover you when you're sick and we encourage
preventive care to keep you well. Since choosing a Primary Care Provider is
such an important decision, our Member Serv-
Some of the services covered are: ices Representatives are available to discuss your
needs and assist you in selecting the best pro-
Hospital and emergency services vider for you. Since most of our doctors are
Physician care including: Office and Family Practice Specialists, it is usually best if
hospital visits, surgery, vision exams and all members of your family choose the same
hewing tests, well baby care, doctor. We have both men and women doctors,
immunizations, inoculations, allergy some of whom speak a language in addition to
treatment, sick leave and disability English. Look in the Plan Directory at the front
verification of this booklet for your Member Services phone
•Maternity care number. It is important for you to be comfort-
•Skilled Nursing facilities (limited) able and develop a long term relationship with
Premarital testing your family doctor. If for any reason you should
Home health care upon referral prefer to change to another Plan doctor, we will
Non-experimental organ transplants be glad to assist you.
Podiatry care
Diagnosis and treatment of alcohol and drug You will visit your Primary Care Provider
abuse (limited) at one of our health centers. To call your doctor
Physical examinations look in the Plan Directory in the front pocket of
Blood transfusions (limited) this booklet.
Each Health Plan option has a slightly
different benefit coverage. If you are unsure Seeing A Specialist
about the coverage you have, refer to your Evi- If it becomes necessary for you to see a
dente of Coverage, your Contra Costa Health specialist, yaw pricey Care provider will
Plan contract or call Member Services. recommend one for you. Most specialty clinics
are held at the local health centers on certain
days and sometimes you may be asked to see a
Your Family Practitioner specialist at Merrithew Memorial Hospital.
Contra Costa Health Plan has a Family Occasionally you may be referred to a specialist
Practice philosophy. Ibis means you have the that is not on the staff of Contra Costa Health
benefit of choosing a family doctor from our Plan. Your Family Doctor will make those
large list of specialists in family medicine. These arrangements for you. However, if you set a
highly qualified Primary Care Physicians get to specialist without an authorization from one of
know you and your medical history. They guide our doctors or nurses you will be responsible for
you through the tests and checkups you need to the cost.
keep you healthy, and they take care of you and
your family through colds, flu, childhood dis- 'There is no additional cost when you must
eases or minor injuries that happen to all of us. sec a specialist that is authorized by your doctor.
In addition to our family physicians and
under their direct supervision, family nurse
practitioners also give routine care. These highly
trained and skilled professionals extend the reach
of the doctors and ensure that you get all the
personal :-tention you need.
Once you have selected the Contra Costa
-a-
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i
,
SFSPEC�IXL 'RVICES
r
1
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1}
1
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t
1
1
s Advice Nurses
i V-' �
•" '� The Advice Nurse Service for Contra Costa
Health Flan members is your friendly connection
to us . . .someone with the medical information
.•t �j you need that you can reach with just a phone
call. The Advice Nurse can help you get medical
are without delay, or help you treat the ailment
at home. You will find the Advice Nurse phone
number in the Plan Direaory.
AIR-_ 4
Jorq.rbblrnrmi.Arlen Nrai D:r«ro, The Advice Nurse can help with such
matters as:
Urgently Needed Appointments
The Advice Nurse can make a same day
appointment for you if you are faced with an
urgent need for medical attention. To ensure an
available appointment, it is best to call as early
in the morning as possible.
Emergency Visits
A call to the Advice Nurse can help you
a ,•.+ determine whether you need to go to the hospital
emergency department, what to do before you go
and what to tell the emergency staff once you
arrive at the emergency room.
Community Resources
Our Advice Nurse staff are specially trained
to be able to recommend health-related
organiza-tions in the County to give you specialized help
if you need it.
e .•
3 Your Advice Nurse is k just a hone call
r away. They are ready to Wto you . . .to give
• helpful accurate and timely information
whenever you need it. This is a 24 hour a day
0 service. Look for the phone number in the
Plan Directory.
. to-
-
Parenting Line ,Selection of a Health center
When you join Contra Costa Health Plan Selection of a Primary Care Doctor
you can take advantage of our Parenting Line Explanation of your coverage
which is staffed by knowledgeable health care Requests for new or replacement
professionals. The focus of the Parenting Line is identification or pharmacy cards
education . . .for parents and children. When Investigation and resolution of complaints
you call the Parenting Line you can get and grievances(a response to your concerns
information on childhood and adolescent will be made within 30 days)
development, health and behavior including: Information about all Health Plan services
i When to know when your baby's eying Health Center tours and orientation
means something serious You can reach your Member Services
Nutritional, sleep time and potty training Representative by calling the phone number
tips for parents of young children in the Plan Directory or by using the White
i What immunizations are necessary to Courtesy Telephone in any of the five
protect your child's health health centers.
What to do for common childhood
illnesses
How to best deal with behavioral
problems such as the "terrible twos" or
teenage conflict. Wellness Activities And
The Parenting Line is open from 10 a.m. to Programs
S p.m. on Monday through Friday and from 9 By choosing to join Contra Costa Health
a.m. to 1 p.m. on Saturday. The Plan Directory Pte, you have selected to receive your
has the phone number for the Parenting Line. pre through a feder-
ally qualified state
�[ "•' licensed Health
Maintenance
• t$ Organization -
i (HMO). Contra
Costa Health Plan
s ' takes the concept
+ of health
:r• _. maintenance very
"r ; seriously. We
provide our
members with
many options
Out NSIOU M"*W spa set[ aimed at keeping
them healthy and fit through
Member Services Prevention, early detection, and health and
fitness promotion.
We are especially interested in keeping our
members informed, happy with their Some of the programs available to assist
membership and satisfied with their treatment. you in maintaining your good health are:
When questions or concerns arise, your Member
Services Representative is your very own Child Health and Disability Prevention
personal expert. Services (CHDP)
CHDP is available to all members under 21
Your Member Services Representative can years of age. This program includes physical
assist yoC in the following ways:. examinations and immunizations to encourage
-11 .
young members to establish a pattern of wellness management, smoking cessation, weight
care, to detect health problems early and to treat reduction and more.
them before they become serious.
Shapers
Women's Health Care Nutrition and diet classes for children and
Contra Costa Health Plan has complete teens are held for our members who need help in
services for women of all ages including pap these areas.
smears, mammograms, birth control services and
instruction, sterilization, maternity care, prenatal HealthSaae Newsletter
vitamins, Healthy Stan Program, prenatal and Each quarter you will receive an informa-
postnatal programs as well as regular checkups tive newsletter from Contra Costa Health Plan.
and physicals. We hope you will tike the time to read the
articles on health and wellness, nutrition, fitness,
N
prevention and self care.
as
'Alb. Itr t Each edition also has important messages
from the Health Plan to keep you informed of
moo what changes have been made, what is coming
up in the future, how to use our health care
system and much more.
s E Also included in most issues are articles that
introduce the Health Plan staff so when you call
_ or come in, you will be able to put a face to the
•� voice on the phone or the signature on the letter.
Owner's Manual For Your Body
,�- '� ,: , „_:• This special prevention program helps our
members form a partnership with ;:Mir-doctors to
keep them healthy and fit. It includes a booklet
customized for your age and gender which lists
l►taternit� Care (Health. Start Program) the tests and health practices for you, and a
g handy wallet card which helps you keep track of
The Healthy Start Program is a your progress. You can get an Owner's Manual
comprehensive prenatal/postnatal program by asking your doctor or from the Health Plan
covering health education, dieticians, doctor receptionist in our offices at 595 Center Avenue,
visits, public health nursing, medical social Suite 100, Martinez.
workers, financial counseling, vitamins, and
practically everything for the mother and child. For more information about Healthy Start,CFIDP,
When you arrive for your first prenatal appoint- Shapen,Halth Education Clam or owner':Manual,
ment you will be enrolled in this program to co- gait your Ma+ber Swvias Repmentadv&
ordinate your prenatal care.
Health Education Classes Medical Services To Keep You Well
Health education classes are available for Among the medical services we provide in
individuals or for small groups of members at our commitment to your wellness care are:
Conte Costa Health Plan's health centers. These annual physical examinations from your primary
classes provide information, consultation and care provider; back to school, sports and camp
education on illness, injury prevention, health physicals for children and tans; regular
maintenance and disease management. immunizations;-diagnostic tests as needed;
vaccinations and some immunizations for out of
There are classgs in nutrition, family country travel; hearing exams; and eye exams
'planning, stress management, diabetes including tests for glaucoma.
-12-
SPECIAL COVERAGE
Pharmacy
Contra Costa Health Plan has several plans • To read your prescription label:
available each with slightly varying benefit
packages and eligibility requirements. Your plan
may or may not have all the benefits listed in this '0- .,
section. If you have questions about which a"on
benefits
"o-
benefits are featured in your plan option, please '"�'�'a" • �'°'°" °i"' •� ^"�"0''`
consult your Evidence of Coverage Brochure, Date er.+:•� w�To.�
your Health Plan Contract, or call your Member
Services Representative phone number listed ina','aL,w•+.� `':f
the Plan Directory. a"," •»•,�•••' :�In :::NAW
11�hu�ll�n,�nmp
Prescription Service: Contracting Pharmacies
_z2 Contra Costa Health Plan also has
agreements with local pharmacies for
prescriptions that cannot be obtained from the
Health Center pharmacies and for members who
see their family doctor at the Concord or
Brentwood Health Centers. Members with
Pharmacy coverage will receive a
Pharmaceutical Care Network (PCN) card
which can be used to obtain authorised
prescriptions from our contracted prarmacies.
For your convenience there is a toll-free number
for local participating pharmacies on the back of
your PCN card.
Health Center Pharmacies
Contra Costa Health Plan has easy to locate If You Have Prescription Coinsurance
pharmacies in the Richmond, Pittsburg and Some Contra Costa Health Plan options
Martinez Health Centers. Prescriptions can be require you to pay a percentage of your
filled at those locations. prescription costs. If you have your prescription
filled at a Health Center pharmacy, Contra Costa
Telephone Prescription Refill Service Health Plan will bill you separately for the
If there are refills remaining on the pre- portion not covered by your benefit package.
scription label and the prescription date is leas
than 6 months old, you may phone in refill If you have your prescription filled at a
requests for prescriptions that have been filled at PCN participating pharmacy, you will be
a pharmacy located in a Health Plan Center. required to pay your coinsurance when you pick
up your prescription.
• Have your prescription container near you
when you call. If you are outside the PCN network area or
• Be prepared to give your name, drug name, Plan pharmacy am, the Plan may reimburse you
number of refills remaining, prescription for the Cost of your prescription. You will need
number and your telephone number. to send a Copy of the prescription and your
• Pick up your refills after 1 p.m. the receipt to the Health Plan Claims Unit. The Plan
following work day. Allow 2 working will not cover the cost of prescriptions filled at
days if you call on a weekend or holiday. non-contracting pharmacies within the PCN
network area or Health Center Pharmacy areas.
- 14-
Plan's optical Provider List. You will be given a
copy of the Optical Provider List by the Contra Costa Health Plan eye doctor who gives you
your vision exam,or your Member Services
Representative can send you one.
You an make a vision exam appointment
by calling the Appointment phone number listed
in the Plan Direcwry.
Hearing Aid Benefit
•k For members whose plan contains a hearing
' � `' i :•� aid benefit the Contra Costa Health Plan has
audiology clinics at the three major Health
Centers. You will need to be referred by your
Primary Care Physician to the audiology clinic
If You Have Dental Care for a hearing test. A hearing aid ordered through
Coverage our audiology clinic is a covered benefit but is
not a covered benefit if you purchase it outside
If your benefit package includes dental care, the Health Plan.
you will visit your dentist at one of our major
health centers . . . Martinez, Richmond, or Chiropractic Care
Pittsburg. The dental appointment phone number If your benefit package includes
is listed in the Plan Directory in the front pocket
of this booklet. Chiropractic care you can receive up to 2 visit
a month for manipulation of your spine but
For tre,pwasional urgent dental problem generally you must be referred by your Primary
such as a toothache, a broken or loose tooth Care Provider and have the approval of the
or injury to the mouth and teeth, there are
Contra Costa Health Plan Medical Director.
emergency dental appointments available Medical Equipment and
Monday through Friday at each Dental Health
Center. Because these appointments fill up Supplies
fast, it is advisable to call at 8 o'clock in the
morning to be sure of receiving an appropriate Upon the authorisation of your health care
appointment time. provider, the following medical supplies and
equipment may be covered. Contact the
Authorization Unit listed in the Plan Director)
Are You Covered For if you are unsure of your coverage.
Eyeglasses? i Durable Medical Equipment (DME) such
Health Plan members under most plan as wheelchairs, crutches, and other
options are covered for eye exams (refraction). non-medical supply items
The optometry clinics where you can obtain your -e prosthetic devices like braces and artificial
eye exam are located at the major Health
Centers: Pittsburg, Martinez and Richmond. If limbs
you have your vision examination in our system Bandages, diabetic supplies, and other
your cost is covered in full. If you go to a disposable supplies, as medically necessary
private optometrist without a referral you will be
responsible for the cost of the exam. Preacriptiom,Dental care,Ereslasm,Hearing Aids.
Chiropractic Care, Durable Medical Equipment and
If your benefit plan includes an eyeglass Supplies art all covered Medi-Cal benefit•with no cgmy-
menu- See your Evidence of Coverage brocburc for lbs
benefit, take your prescription for eyeglasses to level of coverage.
one of the opticians on Contra Costa Health
•ts=
ABOUT YpUR
�� MEMBERggIP
Card for use at Contra Costa Health Plan facili-
ties. This is the card you use whenever you use
Contra Costa Health Plan medical services. The
card can be reissued by the receptionist at any
a Plan facility if it is lost, misplaced or needs to be
i corrected or updated.
The most important information on the
Clinic Card is your Medical Record Number.
Please have your Medical Record Number ready
when you call for an appointment or call an
Advice Nurse. You will also find a sample
Clinic Card in the back of this booklet, and
• directions on where on it to find your Medical
Record Numba.
Pharmaceutical Care
Contra Costa Health Plan members Network Card (PCN Card)
represent a wide variety of commmity residents. If your membership includes a pharmacy
In order to serve the needs of such a varied benefit, you will also be issued a PCN card.
membership, and to conform with Government You will use your PCN card when you fill
regulations, we offer several benefit packages, authorized prescriptions at pharmacies outside of
each with different eligibility requirements. the Contra Costa Health Plan facilities. On the
Your plan option may have all of the features back of the card is a toll-free number to call to
mentioned, or only some of them.If you are find the participating pharmacy nearest you.
unsure of yowAbenefits, please rek to your
Evidence of Coverage booklet, your Health Plan Copayments
contract, or call Member Services. A copayment is a fee that is paid, if your
coverage requires it, on such medical services
as doctor visits, mental health appointments,
Contra Costa Health Plan hospital and emergency room services. If you
Identification Card visit one of Contra Costa Health Plan's medical
facilities you will be billed separately for the
Shortly after the first of the month in which amount of your copayments. If you ever need to
your membership begins, you will receive a have care outside our system or use out-of-
Please
Health Plan Identification Card. county emergency medical services, you will be
Please carry it with you at all times because you responsible for the copayment at the time you
will need it for your first visit to one of our receive medical care.
health centers or the hospital. Yoe will also show
it if you ever need emergency, urgent, or Coinsurance
care at a medical facility that is not part
of Contra Costa Health Plan. You should carry If your benefit package includes a
your Identification Card with you at all times coinsurance payment on pharmacy, you pay a
because it contains vital information and percentage of the cost of your prescriptions.
telephone numbers. But you can be seen at our When you have your prescriptions filled at
Plan facilities without it. In the back of this Martinez, Richmond, or Pittsburg Health
brochure is a sample card and directions on how Centers you will be billed for the amount of the
to read the information on it. coinsurance. If you take your prescription to ere
of our contracted pharmacies, you will pay the
Clinic Card coinsurance when you pick up your medications
You will be given a plastic embossed Clinic .
-'17-
Marketing Representative within 30 days when
Eligibility For Health Plan any of the following circumstances occur.
Coverage
Contra Costa Health Plan is open only to 1. The birth of a child
3• The adoption of a child
residents of Contra Costa County. Applicants to
3. A marriage
our Commercial individual, family and children
only pians must pass a medical screening before 4. A marriage that adds stepchildren
they can become members. If you have any S. A divorce
questions about qualifying for Health Plan
coverage, or if you want to make sun that you You will find the number in the Plan Directory
are still eligible, your Marketing Representatives in the front of this bookies.
will answer your questions.
If you know someone who would like to Loss Of Eligibility
join Contra Costa Health Plan, call the If you wish to continue your Contra Costa
Marketing Department listed in the Plan Health Plan membership when you leave your
Directory at the front of this booklet. present employment or when you are no longer
eligible through a state or federally sponsored
program, please contact the Contra Costa
+ej;• •: Health Plan Marketing Department to ensure
continuous membership.
If you lose your eligibility you can request
continuation of health benefits through a
program where you pay the premium directly.
,I� + For more information about your conversion
righu, please contact the Marketing Department.
The phone number to reach Mark&j;jDgjs listed in
the Plan Directory at the front of this booklet.
Continuation of Group
Coverage (COBRA)
_ Under certain circumstances, you and
:� ..
eligible family members may be entitlesd to
continue coverage in Contra Costa Health Plan
for a specified length of time if you have been a
Adding/Deleting member of an employee group and lose
coverage. Contact your employer or former
Dependents employer for details.
Each Health Plan option has separate rules
for adding dependents into the Health Plan.
Coverage for new family members is not
automatic. It is important to understand the open �--
periods in which you will be allowed to add a
dependent to your coverage. Newborns are
generally covered for the stay in the hospital
associated with their delivery.
There is usually a limited amount of time to
add dependents onto your Plan. Please call your
Coordination Of Benefits Major Exclusions and
IN"ith Other Insurance Limitations
Companies Some services are not covered by Contra )
Costa Health Plan because they are excluded by
If you or your dependents are entitled to government regulations. They may be covered
benefits under additional health insurance, under some other specially funded program
Contra Costa Health Plan may choose to bill however. Check your Contract. Evidence of
all or some of your health care charges to Coverage or call Member Services for a full
your other carrier. This is a customary pro- description of exclusions and limitations that
cess known as "coordination of benefits." If apply to your coverage.
this situation should arise, we will do every-
thing possible to minimize your involvement Among the services that Contra Costa
and inconvenience. Health Plan does not cover are:
About Billing Care for conditions that state or local law
Health Plan members who are requires be treated in a public facility
responsible for paying premiums will get a Experimental medical, surgical and other
premium statement on or about the 10th of procedures including drugs where the
the month for the next month's coverage. safety and effectiveness of such have not
Remember that Contra Costa Health Plan is a been proven
PRE-PAID health pian and premiums must Custodial or domiciliary care
be paid before the first of the month. v Conditions covered by Workers'
Compensation or other insurance
If you receive a bill for services that you v Cosmetic surgery and prescriptions for
feet should be covered by the Health Plan, cosmetic purposes unless they are considered
or if you have made a payment to an out-of- medically necessary
Plan provider and feel that the Health Plan Most over-the-counter medications
should reimburse you, call the Contra Costa 1
Health Plan Claims Unit. The phone number
is found in the front of this booklet in the
Plan Director)'.
If you have coverage that requires
copayments, you will be billed for your Meet Our
portion of the cost of the services or
prescriptions you obtain at one of the Health hev► Medica(
Plan's facilities. If you use one of our Director
authorized pharmacies or are referred to a SOME of our
physician outside our system by your Primary
merribm ha%r had the
Care Provider, you will be responsible for pleasure of jrt4k true
-,r ,r rte►► Medicall Dve;tv!.$,ll
paying the copayment at the point of service. f Burr..!o Dr.out?Comes
Remember, if you use a pharmacy that is not w us after spend,nj; 1:
in our network or go to a doctor that is not years as Medica!D,rc;tur
authorized, you may be responsible for the of(iruup Health%*unh-
entire bill. Ncst.anon•profitsurf
model 11%10
Dr Burr has p►acn xJ
pnnun care.intema:
a.::�.•• ►r r, rned:;mc.and t'anuf%
Failure to pay eopa%menta and.'or coinsurance mai nfd« pr,;::;r cur 0%%:f=u•er•
Jeopardize your Hr,".h Plan a+emberslup. Nc,a rsp.:,au� ,mcresud
to rrrmo:m;j+rctcn;i%c
• h1d1:h care
t9 Dr Hu"ulllK';O-
authou,n�the%led,;a'
Index
Access to health ars 3. 10 Emergency services 4. 10 Orientation 11
AddingtDeteting depeadeats 18 Equipment 15 Other insurance 19
Adoption of child 18 Exclusions 19 Out of Contra Costa
Advice Nurse S, 10, 17 Experimental procedures 19 Health Plan area S.6. 8
Ambulance service S Eye exam 15 Out of play are S,6. 8
Appointments S Eyeglasses 15 Owner's Manual For
Audiology 15 Family Nurse Practitioners 8 Your Body 12
Authorization S Family planning 12 Pap smear 12
Authorization for minors 6 Family practice 8 Parenting line 11
Back to school exams 11 Family practice specialists 8 PCN 14. 17
Billing S. 17. 19 Female health 12 Pharmaceutical Care
Birth 12, 18 Fitness 11, 12 Network(PCN) 14, 17
Birth control 12 Follow-up care appointments S Pharmacy 14, 17
Braces 15 Glass" is Pharmacy refill 14
Cancelling appoiatmeats S Grievances 11 Physicals 12. 18
Child Health di Disability Group coverage 18 Pittsburg Health Center 3
Preventive Services Health Center pharmacies 14 Planning ahead for
(CHDP) 11 Health Centers 3, 11 appointments 5
Children away at eoth%e 6 Health coverage 11 Postnatal 12
Children under age 18; 6, 11. Health education 11. 12 Prenstal 12
12. 15 Health maintenance 11 Prescriptions 14, 17
Chiropractic care 15 Health Plan ID card S, 11. 17 Prescription billing 14, 17
Choosing a doctor S. 11 HealthSense newsletter 12 Prescription refill 14
Claims 19 Healthy Stat 12 Prevention 11, 12
CliniecarAJ7. Hearing 15 Primary can physicians 8
COBRA 18 Hearing aid 15 Primary are providers 8
Coinsurance 14. 17. 19 Hearing exam 15 Prosthetic devices 15
Community resources 10 Hospital service 4 Reimbursement 14, 17
Complaints I I How to make appointments S Re-marriage 18
Contact lenses 15 ID Cad S, ll, 17 Richmond Health Center 3
Coordination of benefits 19 Inpatient care 4 Routine health care, exams 8
Copayments 11. 19 Limitations 19 School physicals 11
Cosmetic surgery 19 Loss of eligibility 18 Selection of a health center I l
Courtesy phones (white) 11 Mammograms 12 Shapers 12
Crutches IS Marketing Department 18 Skilled Nursing Facility 8
Custodial can 19 Marriage 18 Smoking cessation 12
Definition of emergency 4 Martinez Family Practice 3 Special referrals 8
Deleting dependents 18 Maternity 12 Sports physicals 12
Dental appointments 15 Medical equipment 15 Step children 18
Dental coverage 1S Medical Record Number 17 Sterilization 12
Dentist 15 Medical records 6, 17 Tours 11
Dependents 11, 18 Medical screening 18 Traveling out of area S
Discontinuing coverage 18 Medical supplies 15 Treatment of minors 6. 11
Disenrollment 18 Member Services 11 Urgent Care S. 10
Divorce 18 Membership issues 17, 18, 19 Vision 1S
DME IS Merrithew.Dr. Edwin 7 Weight reduction 12
Doctors 8 Merrithew Memorial Hosp.4 Well baby are 11. 12
Domiciliary are 19 Minors 6, 11. 12. 18 Wellness program 11, 12
Durable medical equipment 13 Newsletter 12 Wheelchairs 15
Education 11, 12 Nonemergency are 3. 11 White Courtesy Telephones 11
Eligibility 18 Nutrition 11, 12 Women's health can 12
Emergency medical advice 4. Obstetrical care 12 Workers'compensation 19
10 Optical 13
Emergency room 4 Optometry 15
When ill my!'CN card QU�Sfi6w w arrive?
Your PCN card will be mailed to you during
the first month dyour enrollment.
t 1, What do I do KI need service at a PCN
A. nsNV
pharmacy and do not have my card'
eYou may CU your prescriptions at any PCN
• Pharmacy without a PCN card,although it is
AbouU our much easier and faster for you and the
J pharmacist if you have your card with you.
PCWhen Wur hen you present yoauthorized presaip.
1; , tion,your pharreuicrst must have your PCN
Pharmacy identification number to fill the prescription.
r ;l Your pharmacist an find that number in
Coverage =eves ways:
r+►. ■ It is an your PCN identification cud
IS It is an your Health Plan identification
card
N You can call a PCN representative at
1-800.777-0Q74 or a Health Plan Mexrmber
Khat is PCN" Service Representative at 313.6070
PCN (Pharmaceutical Care Network) is a during regular business hours Monday
network of independent and chain pharma- through Friday from 8 a.m.to S p.m.
cies you can use if you are authorized to go except holidays. )
outside the Health Centers which have on.
site pharmacies (Martinez. Pittsburg, and If you do not have either your PCN or
Richmond).Although most pharmacies in Health Plan identification card,you should
California are pan of the PCN network,you fill your prescriptions at a PCN Ournmacy
can locate the participating pharmacy most only during regular business hours Monday
convenient to you by calling PCN's toll-free through Friday.
number 1-800-777.0074.
If your cards are lost.all PCN at 1-800-
Do ail Health Plan members get PCN 777-0074 for a new PCN card and all
Identification cards' Member Services at 313-6070 for a new
No,only members with pharmaceutical Health Plan identification card.
coverage will receive PCN cards. Private
pay and commercial group members will Do I need my PCN card to rill a
receive a single family cud that can be used Prescription at my Health Center
by all eligible family members.All other pharmacy'
CCHP group members with pharmacy No. If you fill your prescription at one of the
coverage will receive individual PCN cards. Health Center pharmacies you will not need
to use your PCN card.
Can I ret a replacement card or an extra
card? When will I nerd to use a PCN
Yes, you car-get replacement of extra cards pharmacy'
by calling PCN at 1.800-777-0074 Monday You will be directed to use a participating .
through Friday 8 a.m.to S p.m. except pharmacy when tlmc CCHP pharmacy at the
holidays. Pittsburg Health Center.Richmond Health
Center or Merrithew Memorial Hospital
does not carry the medications that you
need. Members using the Brentwood and
Concord Health Centers where there are no
tan-site pharmacy services can use a PCN Contra Costa Rea1ri fba idestirkatiera Cara
pharmacy if the Martinez or Pittsburg Health corner : `
Center Pharmacy is not convenient. You rEAUXA,,W
n►ay d w use a PCN pharmacy when you are � ---------
Y1J1 ati IMO.
out of the area and have a prescription to be VAML $*tor vos '
filled
Dol-104W
f trcx w.soo tom. 6
'"'ho do I notify if I change my name, Caper.do•no.tt ora *0%
address or telephone number' •�+�«••*�•••+••��
Anytime you have a change of status.please t t km�,,s N.mc a ,,,�to No.
call your Health Plan Member Services
Re esentative who will make thea r 2• 1fe d&"h: x �C"VV No.
Pr PF s. Caprom gads s, Fhvrr wwicat
ate adjustments for your account. Grow No.ad to
IftWhat medicines will I have to a for.' FO#we •e:•eteai Can Kate et
Generally.the Health Platt covers medicines
that legally require a prescription to dis. COWMA�*A
pease.With a few exceptions,most Over- a„ "�
the-counter (OTC)medications, even when 806619 NAM 3
written on a prescription form,are not j a I$.a 4
covered. Be sure to ask your pharmacist if 1 Opp o0„�► e
you have any questions about which medi- 2
cines wilJ be covered by your Health Plan S
membership. t. Membefs Name 2. "Sub COOW No.
2. P CN group No. t. t'.opr codes
1'1'hen will 1 have to Pay' S. SubmiWA No.
Your PCN pharmacist will require that.your Contra Coma Health Plan Clinic Card
pay for all non-covered medicines and for I
any copayment at the time you pick up your DOs )OWN
F a ass ssa5.5sis ontoprescriptions. At the Heath Center pharma-
cies,you will be billed for any copayments 3 OOOOo0000 lanoo0ov4 S
due or any non-covered mediations your 'i Ingote'R''W SAM A
receive.
I. Your taw Name 4. borne Phone
• 2. Yaur Fmp Name S. MW at Recad No.
J S- one or&nh & %i avy Ma►hh Ce"er
Call A nedmil y"Wed Nukk s,1.. wAm orlmumm
PCN at 1-R(10-7774W4 A dwom of a.$Us%servim oepimem
mith any prvblents
r
Monday to Friday
Samtosp-m
(excluding hdidaycl .
Scheduling Your
First Appolintment
As soon as possible after joining, you
should make an appointment for a
check-up. This will allow you to get to
know your doctor and your doctor will
get to know your history.
Please call the appointment number
in the Plan Directory to schedule a
convenient time for your check-up.
Brentwood Realth Ceuta Richmond Realth Gator
'i 1 Oak Saw 3"&Bissell ]PLAN DIRECTORY
vatwood.CA 94313 Richmond,CA 9490
Hours: i A.M. b 5 p.m. Houtz: t a.m. In 5 p.m.
Idonday.Tuesday.Tbutsday, A Friday. Monday to Friday
Ved. t a.m. to 11:30 a.m.Peds. Only Thursday Evenings:5:30 p.m.10 9 p.m. Please note:
and 12:30 to 1:30 p.m. family pracdce. 4Tlse bourn of operation m this
Appointments. . . . . ... . . 374.3755 dumtory ars subject to ebaage. Call the
Appointments. .. . . . . . . . 634.1102 Member Servioae . . . .. .. $74.3228 Appointment Unit or your Healib Doter
Member Servion . . . . . . . 427.8165 Pnecription Refills . . . . . 374.3373 br euanat informasiaa.
To Reach Your Dr. . . . . . . 634.1102 To Reach Your Doctor. . . . 374.3023
4 Call the Health Plan Adria Nww for
Concord Bealth Canter CC.HP AD11M'LTRATION Urgent can and Saturday appointments.
3052 Willow Pan Road 4 Member Savioas and the Appointment
Concord. CA 94519 Advice Norse, Autlorindoas, Units we available from 7 a.m.m 7 p.m.
Urgent Care and Saturday
Hours: Appointments 4 The coli-free 800 numbers an ovaLlable
1 a.m. to S p.m. Monday and Friday. throughout the USA (including Hawaii)
S a.m. to 9 p.m. Tuesday-Thursday. 24 Hours 7 Days/Week 1-800.621-0810 Mexico.Cahuda, and the Virgin Islands.
A From Central County . . . 313.6100
Closed: Now to I p.m. and 0Plem tamember to an the new
5 P.M. to 6 P.M. Business Offica . . . . . . . . 313.6010 Members' Only Advice Nurse and
Appointment telepbone numbers.
Appointments . . . . . . . . . . 646-4455 Claims Unit . . . . . . . . . . . 313.6030
Member Services . . . . . . . 313-0070 *If you ever experience any problems
To Reacb Your Doctor. . . . 646-5502 Executive Director . . . . . . 313-0004 with any of the telepboae numbers listed
in this Directory a soy other Plan
Information . . . . . . . . . . . 313-M materials, please call the Receptionist at
313-M for assistance.
Martinet Health Center Marketing do Sales . . . . . . 313.6060
2500 Alhambra Avenue 4 To obtain Anther copies of this
Martinez, CA 94533 Member Services . . . 1-8004".2247 story and other Hath pyc
k From Central County . , . 313.6070 materials, call 3134001.
Scours: 1 a.m. to S P.M. and S P.M. to
9 p.m. Monday to Friday Parenting Line . . . . . I-100-021-0880
Saturdays. 11:30 a.m. to 8 p.m. If you need belp reaching your Doctor October 1994
call 1-800.621-0880.
Appointments . . . . . . . . . . 646-4455
Member Services . . . . . . . 3134070 Other Services:
Prescription Refills . . . . . . 370.3240
To Reach Your Doctor. . . . 370.5000 DSIII M�r<u►a
Martinez . . . . . . . . . . . 370-5300 0 A��
Pittsburg . . . . . . .. . . . . . . . 427-8011 O Richmond Concord"�eun arearwood
IRtubur:Health Center Richmond . . . . . . . . . . . . 374-3081
550 Scbool Street
Pituburg.CA 94565 dental Health- ,r✓"
Hours: 8 a.m. to S p.m. Mooday Friday Antioch . . . . . . . . . . . . . 427.8664
Caward . . . . . . . . . . . . . 646.5480
Wednesday Evening:3:30 p.m.lot p.m. Pittsburg . . . . . . . . . . . . . 4274130
Richmond . . . . . . . . . . . . 374-3261
Appointments . . . . . . . . . . 427.8755
Member Services . . . . . . . 427-8165 Older Adults Clinics-
Prescr!ptioa Refills. . . . 427-8024
To Reacb Your Doctor. 627-8113 Concord . . . . . . . ... . . . 646-S535 - SC:D
El Cerrito . . . . . . . . . . . . 374-3629
Antioch . . . . . . . . . . . . . 427-1775
i
We're Always Here
For You
We know you will be satisfied with your membership in Contra Costa Health
Plan. We are here to serve you, so if we don't meet your expectations, use
the Plan Director- to call us. We want the opportunity to take care of your
health needs for long into the future.
-zo-
Health Services Department
`� ate; OFFICE OF THE DIRECTOR
•:„./' AjrA4n inistrative Offices
n; :• 20 Allen Street
Martinez,Calilornia 1.4553
�► _ 1�1 -'�":o (415) 646--4157
c6'
POLICY ON
t`ONFIDENTIALITY OF PATIENT INFORMATION
A. The policy applies to all Health Services Department employees whether or
not their duties involve patient contact or use of confidential information.
S. The policy includes all information regarding patients whether or not the
information comes from a confidential record or simply from observation of a
patient at the facility.
C. Violation of this policy may be serious and disciplinary action for viola-
tions will be considered on the basis of facts in each instance.
sjm
(3/88)
A-345 5/86 Contra Costa County
Contra Costa County Policy 4 215
Realth Services Department MARCH 1988
(Replaces Policy ,7517)
POLICY ON CONFIDENTIALITY OF PATIENT INFORMATION
I. PURPOSE
To establish a Department-wide policy that expresses the Hcalth Serv-
ices• Department's commitment toward protecting patients' right to con-
fidentiality and to provide references for educating Health Services
employees in these rights.
II. REFERENCES
Welfare and' Institutions Code 5530 - (Mental Health)
Code of Federal Regulations 42, Subpart A, Section 2.1 (Drug Abuse)
Code of Federal Regulations 42, Subpart B, Section 2.2 (Alcohol Abuse)
Civil Code, Part 2.6 of Division 1, commencing with Section 56 (General
Patient
California Health and Safety Code, Sections 25250-25258 (General
Patient
Evidence Code, 1040 (Venereal Disease)
California Administrative Code, Title 17, Section 2636(b) (Venereal
Disease
Tarasoff vs. Regents of University of California (1976) 17 CAL. 3d 425
Accreditation Manual for Hospitals, 1983 Edition
Health Department Policy on Public Release of Patient Information
III. POLICY
While individuals are patients/clients of the Health Services Depart-
ment, it is each employee's obligation to contribute to the provision of
care in an environment which protects the right to privacy. As a
general guideline, all observations and/or communications regarding
patients, in the absence of appropriate authority to release that infor-
mation, should be safeguarded as "CONFIDENTIAL." Particular caution
shall be exercised in protecting the confidentiality of Contra Costa
Health Plan members who may be fellow employees, and alcohol, drug abuse
and mental health patients who are particularly protected under the law.
IV. AUTHORITY/RESPONSIBILITY
Each employee is responsible to hold information confidential by noc
discussing or revealing any information regarding patients, including
their presence at Contra Costa County Health Services, without proper
authorization.
Contra Costa County Policy #217
Health Services Department MARCH 1988
(Replaces Policy #517)
Employees with access to more detailed information have an additional
responsibility to be aware of confidentiality and to conduct themselves
in a manner which reflects their responsibility to release information
only when appropriate and in accordance with their duties.
Licensed personnel are also expected to adhere to the applicable State
licensing regulations relative to the protection of patient confiden-
tiality.
Prevailing legal considerations that effect the use of health infor-
mation require additional measures to withhold or release information in
the areas of mental health, drug and/or alcohol buse and venereal
disease. Employees whose duties fall within the-e areas should consult
with the appropriate supervisor/manager for guidance and should review
the pertinent references cited herein.
Supervisors are responsible for providing their employees with guidance
related to confidentiality and for keeping staff advised of prevailing
legal considerations which may apply.
V. PROCEDURE
Upon initial appointment to the Health Services Department, the Employee
Services Office will give each employee a copy of this policy. Annually
thereafter, each employee will be given a copy of this policy by his/her
supervisor. The Department may periodically mandate orientation on con-
fidentiality in order to reinforce its importance, clarify any
questions, and ensure optimum compliance.
Violations of confidentiality are considered to be serious. The
Department may consider action against an employee who violates the
policy and, in addition, the employee may be subject to action against
his/her license (if applicable) or liable to legal penalties.
Hark Finucan
Health tier-vices Director
CONTACT PERSON: Chief Medical Records Administrator
Revision Date: :larch 1988
Rescission Date: 'larch 1991
(Review Annually)
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ATTACHMENT' Q
Contra Costa County
Health Services Department
Report of Ad Hoc Committee on Access Standards
The Ad Hoc Committee consisting of seven physicians, the Department Chief Financial Officer,
the Director of Quality Management, and the Contra Costa Health Plan Director of Provider
Affairs, developed the following access standards for Medi-Cal patients.
The standards set forth are expected to be the minimum acceptable standards for providing
access. It is recommended that an acceptable level of compliance is meeting the standard, on
average, 90% of the time (e.g. 90%a of the time, routine appointments should be available within
six weeks; and 90% of the patients served shall live within 15 miles of the site of that routine
appointment).
1,33:POC
POINTS OF ACCESS - PRIMARY CARE
(Primary Care Defined As: Family Practice, Pediatrics, OB/GYN, Internal Medicine)
TIME DISTANCE
Appointments
Wait to Make Appointment 10 minutes
Primary Care FOR ALL APPOINTMENTS:
(Primary Care and Specialty):
Patient sees provider within 45
minutes from time of
appointment
Routine Appointment New Patient 6 weeks 15 miles
Prenatal Appointment 2 weeks 15 miles
F/U - Routine Appointment 6 weeks 15 miles
Established Patient
F/U - Urgent Appointment 2 weeks or less 15 miles
Urgent Care within 24-36 hours 15 miles
Telephone Advice/Triage 5 minutes
BASIC RULES:
1. Routine primary and specialty care appointments to be available within 6 weeks.
2. Urgent primary and specialty care appointments to be available within 2 weeks.
1.33:POC
POINTS OF ACCESS - ANCILLARIES
TIME
Lab
Drop-in Sees provider 20 minutes
from time of arrival
Scheduled 1 week; sees provider 20 minutes
from time of appointment
Imaging Services
Drop-in 20 minutes from time of arrival
Scheduled 3 weeks; 20 minutes
from time of appointment
Cardiopulmonary
Drop-in 20 minutes from time of arrival
Scheduled 3 weeks; 20 minutes
from time of appointment
until patient sees provider
Pharmacy 30 minutes
Therapy Services
PT 2 weeks
OT 2 weeks
Speech/Audiology 4 weeks
L33:POC
POINTS OF ACCESS - SPECIALTY CARE
Specialist/Consultant
Urgent 2 weeks or less
Non-urgent 6 weeks
Telephone Advice/Triage 5 minutes
BASIC RULES:
1. Routine primary and specialty care appointments to be available within 6 weeks.
2. Urgent primary and specialty care appointments to be available within 2 weeks.
133:POC 5/17/94
POINTS OF ACCESS - EMERGENCY ROOM
TIME
Triage Patient seen within 5 minutes of arrival
Level I Immediately
Level II 2 hours
Level III 4 hours
"Level IV" Refer for short or
long-term appointment
133:POC
- ATTACHMENT R — q
_= CONTRA COSTA - 545 Center Avenue,Suite 100
�=
HEALTH PLAN Martinez,ctliW2 94553ss3
FAX(510)313-- 002
• A divftion q f Caws Costo E nkh Savkes
CONTINUED
QUALITY IMPROVEMENT
PLAN
ADVICE NURSE PROGRAM
1994
i
8
AMRWIX CAR PLUS_SERVICE
t
Advice Nurse CQI Plan
TABLE OF CONTENTS
Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Vision Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Policy & Procedure Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Purpose/Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scope of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Important Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
CQI Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Problem Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Communication of Information / Findings . . . . . . . . . . . . . . . . . . . . . .
Program Annual Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CQIPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Standards & Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Consistent Advice Per Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Length of Client Wait on Hold . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Client Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Indicator Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Step Monitoring & Evaluation Process . . . . . . . . . . . . . . . . . . . . 15
Monitoring Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Survey/Satisfaction - Report Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Utilization Review Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ssz:CQI
CONTINUED QUALITY.IMPROVEMENT
CONTRA COSTA HEALTH PLAN -- ADVICE NURSE PROGRAM
MISSION STATEMENT
-----------------
To provide 24-hour access for all clients served to timely,
consistent, and informative advice.
To develop and maintain systems in the Department to
promote members, staff, consultants, employers and
vendors optimal satisfaction with the Advice Nurse Services.
To establish an harmonious Department while maintaining
the Department in the most cost effective manner.
To provide ongoing education pertinent to clients' and
nurses' needs.
2
VISION STATEMENT
Advice Nurse provides triage and liaison for clients and members that are served by Contra
Costa Health Plan ("CCHP").
1. Increased accessibility/decreased waiting times for clients phoning for advice.
2. Improved access to Advice Nurse and Urgent Care appointments. .
3. Improved quality of care using protocols from the Joint Peer Review / Continued Quality
Improvement Committee.
4. Improved communication and interaction among all staff and clients.
S. Improved patient satisfaction.
6. Decrease cost of quality health care by appropriate use of services.
3
CCHP Advice Nurse - Continued Quality Improvement
Policy & Procedure Manual
rob,.rih Example of a Department CQI Program roky No.
PURPOSE / OBJECTIVE
o To assure that patient rare is at an acceptable level of quality and delivered in an
efficient, safe, and cost effective manner.
o To identify and resolve problems.
o To identify and pursue opportunities to improve patient care.
RESPONSIBILITIES
The Advice Nurse Manager and CCHP Medical Director are responsible for assuring that the
quality, safety, and appropriateness of patient care services provided within the Department are
monitored and evaluated on a regular basis and that appropriate actions, based on findings, are
documented. Staff will participate in Continued Quality Improvement activities.
SCOPE OF CARE
Types of Patients Served:
Conditions and Diagnosis Treated:
Treatment / Activities / Services Provided:
Tunes of Practitioners Providing Care
Sites Where Care is Provided
Times When Care is Provided
4
Policy & Procedure Manual
V"cy Ttk Poky No.
CON77NUED QUALITY IMPROVEMENT ACTIVTI7ES:
Activity: Frequency:
1. Monitoring & Evaluation Ongoing
o See attached 10 Step Monitoring &
Evaluation Process (Indicator Table 1)
o See CQI Monitoring Agenda that defines indicators .
(Indicator Table 2)
2. Standards/Policies & Procedures Development and Review Annual Review &
Develop as needed
3. Problem Identification (Standards) Ongoing
4. Performance Appraisal ' Annually p e r
o Compliance with CQI process used in performance person
evaluation
S. Credentialing Annually or as
needed
6. Continuing Education / Inservice Education / Training As needed
7. Department Resource / Utilization Ongoing or as
o No shows needed
o Telephone surveys
8. Risk Management
o Employee Injury Reports Every 6 months
o Environmental Survey Deferred
9. Study (Focused) As needed
6
CCHP Advice Nurse - Continued Quality Improvement
Policy & Procedure Manual
Toney Tik: laity No.
PROBLEM IDENTIFICATION METHODS
Problems are identified in a variety of ways. The following, although not
all inclusive, is representative:
o Department meetings
o Client questionnaire/survey
o Staff/MD/Management input/suggestions
o Evaluation/Audit (Accreditation and Licensing)
o Member Complaints via CCHP Provider Relations Department
DATA SOURCES
The following are some of the data sources which may be utilized:
o Centramax Data Files -
Electronic medical information will be stored by magnetic tape for
the length of time prescribed by law (HCFA requirement)
currently 10 years.
o Client questionnaires/surveys
o Medical records
o Department logs
o Utilization management
C9MNIUNICATION OF INFORMATION / FINWINGS
o A quarterly report is prepared by the Department and is submitted
to the CCHP Continued Quality Assurance Committee.
January to March (First Quarter) due May 10th
April to June (Second Quarter) due August 10th
July to September (Third Quarter) due November 10th
October to December (Fourth Quarter) due February 10th
7
CCHP Advice Nurse - Continued Quality Improvement
Policy & Procedure Manual
ram Tide: Poky No.
o Staff will be informed of results of Continued Quality Improvement Activities through
staff meetings, or posting of results in staff work area, etc.
o Problems with individual members will be communicated to the primary care
provider, if appropriate.
o Findings affecting physician, staff, other departments, or committees will be
communicated to that person, manager, department, or committee.
o Reports will be kept by the Department.
o All reports will be maintained in a confidential manner. Access to CQI findings will
be restricted to qualified individuals.
PROGRAM ANNUAL EVALUATION
The objective, scope, organization, and effectiveness will be evaluated annually during the
4th Quarter and revised as necessary (see attached Program Evaluation Form).
PROGRAM PLANNING
The Continued Quality Improvement monitors for the following year will be determined by
February 10th of each year. We will recommend quality improvement monitors for
approval by the Quality Improvement Committee.
Approved by:
Date Approved:
Date Revised:
Date Reviewed:
8
CCHP Advice Nurse Program
Continued Quality Improvement Plan
1
I. RESPONSIBILITY
The Advice Nurse Manager in conjunction with the Medical Director will be responsible for
promoting efficient and high quality care through the development, implementation, and
ongoing review of a Department monitoring and evaluation program. Staff will participate
in CQI Activities;
II. SCOPE OF CARE
Department description to include a general statement regarding:
Types of clients served
Advice and disposition
Treatment/acdvities/service provided
Types of practitioners providing care
Sites where care is provided
Times when care is provided
111. MAJOR CLINICAL FUNCTIONS / IMPORTANT ASPECTS OF CARE
List: The most frequent presenting client complaint (high volume)
The most frequent presenting client complaint with the potential for negative outcome
(high risk)
The presenting client complaint with the natural tendency to have problems develop
(problem prone)
IV. INDICATORS AND DATA COLLECTION
See attached Monitoring Agenda
Indicator Table I
V. EVALUATION
Data collected is evaluated monthly or as otherwise indicated by the Advice Nurse
Department and documented in the Department's CQI Minutes.
V. continued ...
Causes of problems and methods to improve care/services are identified (see Standards).
Data is analyzed for possible trends and patterns.
As part of this process, the CQI data/reports will be reviewed by the CQI Committee, a
minimum of quarterly and the review, discussion, actions, etc., are documented in their
Minutes,
VI. CORRECTIVE ACTION AND FOLLOW-UP
Action appropriate to the cause will be taken to resolve identified problems.
Opportunities to improve care are addressed.
Corrective actions might include: education, system modifications, as well as individual
counseling.
If the action needed exceeds the Department authority, recommendations are made to the
CCHP Advice Nurse Continued Quality Improvement Committee.
The effectiveness of actions taken and documentation of improvements made are reviewed as
indicated in the Department. Where possible, baseline data will be used to measure
improvement.
Identified problems will be monitored until acceptable performance is achieved.
VII. COMMLM, CATION IREPORTING
Results of Continued Quality Improvement Monitoring will be submitted to the CCHP
Continued Quality Improvement Committee in according with the CCHP Advice Nurse CQI
Plan.
Approved by:
Date Approved:
Date Revised:
Date Reviewed:
10
CQI STANDARDS & MONITORING
STANDARD 1 DOCUMENTATION
Documentation varies among advice nurses. Documentation per protocol needs to be
improved. All calls must be documented as to advice given or services that were assisted
by advice nurse (i.e. earlier appointment, prescription refills). Audits will be done on an
individual staff basis and appropriate action (training, reminder) will be implemented.
STANI3ARD 1 MONITORING
o Is it legible
o Does it include: date
time
primary care provider
clinic site
telephone number
medical record number
date of birth
o Is signature legible
o Disposition
STANDARD 2 CONSISTENT ADVICE PER PROTOCOL
All clients will receive the same advice from all advice nurses. The advice will be given at
the leve] of the client's understanding and specific needs (Le. education, cultural diversity).
Consistency will be evaluated by using a specific audit too] designed for specific
triage/advice categories. Return calls to clients will also be made in order to assess clients'
understanding of advice.
Standard 2 MONITORING
o Problem stated
o Signed
C Protocol used/documented
o Patient educatiom'Urgent Care pm/ appropriate disposition of
12
STANDARD 3 LENGTH OF CLIENT WATT ON HOLD
Client waiting time is a concern. Advice nerds to be given in a timely manner. Many
clients have followed the advice given and are calling back as instructed for urgent care
appointments. The length of each call on hold is being monitored by computer. Two hour
time blocks on each day of the week will be evaluated to isolate peak times. The peak times
will then be evaluated by length of advice calls. The lengthy calls will be audited as to their
content (i.e. client education, long waits for appointment search). Call backs will be
encouraged during off peak times.
Standard 3 MONTITORING
o Time of call
o Establishes peak hours
o Evaluate staff structure / patterns
- 13
STANDARD 4 CLIENT SATISFACTION
Client satisfaction is a priority of the CCHP Advice Nurse Program. A client satisfaction
survey will be sent to clients in order to measure client services. The survey will be
monitored ongoing for client concerns and suggestions. See sample of survey/report card on
page 17.
Standard a MONITORING
o Response on mail-out survey
14
Advice Nurse CQI and Performance Report INDICATOR TABLE 1
10 STEP MONITORING AND EVALUATION PROCESS
1. Assign responsibility
2. Delineate scope of care (delivery)
3. Identify important aspects of care (delivery)
4. Identify indicators - establish criteria for each indicator
5. Establish thresholds for evaluation
6. Collect and organize data
7. Evaluate care
8. Take actions to solve problems
9. Assess actions plus document (Documentation improvement)
10. Communicate information
15
Advice Nurse CQI and Performance Report INDICATOR TABLE 2
INDICATOR GOAL ACTU ACTION
I. Triage / advice appropriate per 99%
protocol
2. On hold less than 10 minutes 90%
3. Emergency line answered in less 90%
than 60 seconds
4. Satisfaction by patient survey 959
good/excellent
5. Protocol available for primary 90 c7
patient complaint
6. Follow up protocol compliance in 99%
response to all patients complaints
16
Advice Nurse CQI and Performance Report SURVEY/SATISFACTION
The following is the Advice Nurse Report Card Send to a random selection of clients on a
routine basis:
Recentl\ you contacted the Advice Nurse Service. Please tell us. hoA
did ue score with you?
Contra Plan
' ADVICE '
t.RTFC T RADE
A+ B C D F
SERVING THE CUSTOMER E..: -n A.crs A ,crspe Arra r PMT
Fnencr%� � i
HC
Pl \/(llic:l
Pi;r7r,c
O!1!c!
i
SOL\ ING PROBLEM'S
CFf,iln:, throigi:
� SG.'r5,'1117� Ilee[r
Oi lier
AV ER.•�GE ADVICE
N'L'RSE SERVICE GRADE
WHICH OF THESE STATEMENTS BEST DESCRIBES YOUR
EXPERIENCE WITH THE ADVICE NURSE SERVICE?
SELECT ONE
] l was satisfied with the Advice Nurse Services staff.
I was satisfied but m\ problem was not resolved.
J I was not complete!` satisfied. howe\er, m) problem was
resolved.
] 1 was not satisfied with the Advice Nurse Services staff.
N12\ \ke co,:act \o:. ,f ue need more informatior7? ] Yes ] No
17
UTILIZATION REVIEW
Staff Com tency:
Competency of Advice Nurse staff to deliver appropriate advice per protocol shall be
documented annually.
1. Audit of protocol/documentation utilization
2. Return demonstration of triage protocol for Advice Nurse as defined in the Advice
Nurse Standards
3. Inservice/Educational binder
4. Roster Qualifications
S. Nursing Competencies
6. Change of shift report to maintain continuity and quality of care
7. Maintaining computer literacy
8. Maintain CPR
18
Patient Care and Organizational Problems:
1. Interdisciplinary Quality Assurance Committee Referral
2. Patient Satisfaction Report Card
3. Patient Satisfaction Report Card Log
4. Statement of Concern log with follow up and log of patient/staff complaints with
follow up
5. Urgent Care Delays and Lack of Access Delays
6. Patient Education
7. Monthly Advice Nurse Meetings
8. Liaison for patient / primary care provider communication
9. Physicians fail to follow up e.g. not returning patient's call
10. Frequently canceled clinics without prior notification
11. Inappropriate use of Advice Nurse Service
19
Nursing Documentation:
Reflects the nursing process, the implementation of patient care, patient/family teaching, and
disposition.
Monthly peer charts shall be audited and specified 'problem charts' shall be referred to the
Advice Nurse Program Quality Assurance.
1. Advice Nurse Documentation
2. Form MR 258 will be appropriately filled out
20
Summary / Action Plan:
1. Implement peer auditing, packets collated, and audit tools distributed during next QA
meeting. Target: September.
2. Documentation will reflect standardized care with all pertinent patient information,
with all key components of nursing process reflected. Target: September.
21
Client & Vendor Satisfaction:
1. Easy access
2. User friendly
I Appropriate vendor utilization, e.g. E.R. authorization
4. Follow up on all client report card surveys, including written resolution
5. Appropriate client / vendor disposition.
52:cqi
22
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ImCONTRA COSTA
am HEALTH PLAN
Dear Contra Costa Health Plan Member:
�4
Recently you were referred to —
We want to know what you thought about the services X80
given by this health care provider. Your opinions are very
important to Contra Costa Health Plan. The best way to
keep our members satisfied is for you to let us know
what you like and what we can improve. �.
Please take a moment to answer the questions on the
back of this card. Then fold it over so our address is showing on the outside and tape or staple it
closed.
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Please answer these questions about the health care provider to whom you
were referred.
I thought: °Q °t°4
1. The system for making appointments ♦o P� Je° �o
with the outside provider was O O O O
2. The quality of the services I received was O O O O
3. The helpfulness of the office staff was O ❑ O O
4. The convenience and attractiveness of
the office was O O O ❑
Other comments:
May we share your rating with the Provider? O Yes ❑ No
Thank you for taking your time to help us serve you better.
Judith A Louro.Director of Member Services
. sy
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NO POSTAGE
NECESSARY
F MAUM
IN THE
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BUSINESS REPLY MAIL
FIRST CLASS PERMIT NO. 59 MARTINEZ, CA
Postage Will Be Paid ev Addressee
Contra Costa Health Plan
595 Center Avenue Suite 100
Martinez Caldomia 94553.9880
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Attachment S
Patient Bill of Rights and Responsibilities
As a member of Contra Costa Health Plan, you are entitled to considerate and respectful care,
regardless of your race, religion, education, sex, cultural background, or financial status.
You have the right to know the name of the physician who has primary responsibility for your
care. You are also entitled to receive information from your physician about your illness,
treatment, and your prospects for recovery in terms that you can understand. You are entitled
and encouraged to participate actively in decisions regarding your medical care and receive
reasonable responses to any reasonable requests you may have. To the extent permitted by law,
this includes the right to refuse treatment.
To enable you to give informed consent, you are entitled to receive as much information about
your proposed treatment as you may need. Except in emergencies, this information shall include
a description of the procedure, the significant risks, alternative treatments, and the risks involved
in each.
You may refuse to participate in any treatment which is experimental; and you will not be
involved in an experimental study without your full understanding and permission.
You are entitled to privacy concerning your medical care; facts and information about
consultations, examinations and treatments are confidential. Your written permission must be
obtained before any medical records can be made available to anyone not directly concerned with
your care.
You have the right to know about the continuing health care you may require. This includes
notification in advance of the time and location of appointments as well as the physician
providing the care. You are entitled to examine and receive an explanation of your bills
regardless of the source of payment.
Just as our staff has responsibilities to you as a patient, you also have responsibilities that will
help us provide high quality medical care for you.
As a CCHP member we ask that you provide complete and accurate information about your
present medical complaint, past illnesses, medications, and other matters related to your health.
In the event that you are incapacitated, all your rights as a CCHP member apply to the person
who may have legal responsibility to make decisions regarding medical care on your behalf.
page two
We also ask that you follow the treatment plan recommended by your practitioner. To ensure
your health and safety, please follow established policies. We also ask that you be considerate
of the rights of other patients by helping control noise and, when hospitalized, the number of
your visitors.
For a conflict of values: Sometimes problems arise because different people have different
viewpoints about health care issues. An example would be that some people have religious
beliefs that affect the health care decisions that they make. When one person's viewpoint or
values clashes with that of another this is called a values conflict.
Values conflicts can occur between family members, between a patient or family and physician,
or between members of the health care team. For example, a patient may wish to refuse a
treatment because of religious beliefs, but the nurse or physician may believe it is their duty to
give the treatment to help the patient recover.
As with other types of problems, the best place to start is with your health care team. Talking
over your views and differences with the nurse or physician may be all that is needed to resolve
the issue. But if this does not take care of your concern, the social worker, nursing manager,
patient ombudsperson, or your physician's department chief may be able to help you and your
health care team reach a solution.
Hospital Ethics Committee: If a conflict of values still persists, you can ask a member of your
health care team to refer your case to the Hospital's Ethics Committee.
Made up of nurses, physicians, social workers, and others, the Ethics Committee discusses all
sides of a values conflict and helps you and your health care team come to an agreement about
what to do. The Ethics Committee may give you and your health care team recommendations
to think about. None of the Committee's recommendations are binding; decisions are still up
to you and your physician.
Your Resources: Because Contra Costa Health Plan and Merrithew Memorial Hospital and
Clinics are committed to the highest standards of quality for your health care, we have provided
you and your family with several resources for resolving different kinds of problems. For help
and advice if you have a problem during your hospital stay, use the list of phone numbers in the
information given to you when admitted or ask your nurse how to contact the person who can
best help you resolve your particular concern. Call your member services representatives for
assistance with any other concerns you have about other Contra Costa Health Plan services.
54:CCHPRR 8/94
ATTACHMENT T
CXxTIRA CXOS'I'A CX7gA N HEALTH SERVICES
PA'T'IENT ACCESS 70 MEDICAL RECORDS
Beginning January 1, 1983, patients in California will be able to have direct access to
their medical record information, either by inspection, obtaining copies, or receiving a
summary of their care. A new law, AB610, describes the conditions and limitations for
obtaining such access. The following information is furnished to help you answer ques-
tions you may have regarding this process. Should you need further assistance, please
call the Medical Pecord Department at the clinic or Hospital where you received treatment.
WHAT RECORDS ARE COVERED BY THE NEW LAW?
Basically, the new law permits access to any medical record in the possession of any
health care provider. The term "health care provider" applies to almost every licensed
health care facility or health care professional in the state. For example, it could be
an acute care hospital, an outpatient clinic, a skilled nursing facility, physician, a
chiropractor, or a licensed social worker.
HOW DO I REQiJFST ACCESS?
All requests must be in writing, no telephone requests can be accepted. Your written
request should give as nuch information as possible to help the health care provider
identify your record in the event that there are other patients with a name similar to
yours. The following information is needed:
. full name (including any ether name you may use)
. date of birth
. approximate date of treatment
when requesting copies, you should also indicate which parts of the record you want.
Requests for hospital records should be addressed to the Medical Record Department.
'WAT IS MEANT BY "INSPECTION" AND 11SMIARY"?
Inspection means that you can co to the hospital or the office to review the actual
record. This may be done during scheduled business hours only (usually 8 am to 4 rm
Monday through Friday) . 'There is no right of inspection at odd hours or on weekends or
holidays. You should call the provider and make an appointment for such review. the
health care provider has the option of providing a summary of -our care when he feels
it is more appropriate instead of permitting inspection or providing copies.
AM I TEE ONLY ONE WHO CAN NAVE THIS ACCESS IMER 'INF NEW LAW?
An adult patient is the only one with access to the record, unless there is a conserva-
torship of the person, in which case the conservator has the right of access as the
patients' representative. If the patient is a minor, the parent or guardian has access
unless the minor had the right of consent to the treatment given, in which case the minor
patient has the right of access.
ARE THERE ANY LIMITATIONS?
The law describes certain types of information which are not considered to be part of
the medical record e.a., information regarding another patient or a collection of infor-
mation about many patients. The health care provider can deny your request for psychi-
atric records if the provider believes that there may be significant adverse consequences
of such disclosure. If access is denied on this basis, you may then name a licensed
physician, social worker, or clinical psychologist to inspect the record and/or obtain
copies. The provider may alsc deny access to the parent or guardian when it is believed
that such disclosure will have a detrimental effect on the treatment relationship with
the minor patient. Federal regulations place scrme additional limitations on access to
alcohol and drug abuse records.
1-245 (Side 1) 3/83
WAT Was. IT COST ME? '
The new law allows the health care provider to recover the costs involved in furnishing
access. There will be an initial charge for clerical services necessary to make the
record available for either inspection or copying. If copies are requested, there will
be an additional charge, not to exceed twenty-five cents ($0.25) each or fifty cents
($0.50) each if the original record is on microfilm. Since most medical records are
lengthy, you may want to consider just what your actual needs are and limit your request
for copies to those specific items, rather than requesting the entire record. The pro-
vider may also charge for the time spent in preparing a summary alternative.
DO I HAVE 'ICS PAY IN ADVANCE?
Yes. The law makes access conditional upon the pre-payment of allowable charges and
most health care providers will expect to be paid prior to inspection or copying. If
you have requested copies, the provider will usually send you a statement of expected
charges before making the copies so that you will have an opportunity to change your
request if the charge is greater than anticipated.
HOW SOON WILL I HAVE ACCESS?
The law specifies that inspection must be permitted within five working days and copies
must be available within fifteen days after a valid written request is receive by the
provider. If the provider chooses to furnish the summary alternative, it must be avail-
able within ten working days but this time may be extended to thirty days if the record
is lengthy or if you have been discharged from the hospital within the previous ten days.
If this extension is necessary, you will be notified. A request is not considered valid
until the information furnished is adequate to identify the record properly and payment
is made for requested copies.
ARE THERE OTHER WAYS I CAN OBTAIN D7MIATION FRCM MY MEDICAL RECORD?
Yes. Physicians and hospitals ordinarily furnish information necessary to continue your
care when it is requested by another physician or hospital. If your insurance company,
school, employer, or other third party needs information from your record, it is usually
better to let them request it directly as they can be more precise about what they need.
Any charges for information furnished in this way are usually paid by the third party
who has requested the information. Such requests will require a valid written consent
from you to release the information. Your authorization for its release should include
in addition to the information furnished for your own access, the following:
• name of the provider of health care that may disclose the medical
information
• name of person or agency to receive the information
• uses for which it is being released
• specific limitations you want to place on the release
• a date when the authorization will expire
. your signature.
You have a right to request a copy of the authorization. There are special requirements
relating to the release of information from psychiatric, alcohol and drug abuse records
or venereal disease records. If your records contain any of these diagnoses, the author
ization must specifically state that this information is to be released. venereal
disease diagnoses and/or treatment records will only be released to the patient, the
patient's attorney or another treating professional.
1
r
ATTACHMENT U
Dear Health Plan Member:
Since your satisfaction is our number one concern, we are genuinely interested in finding out what
we can do to make things better for you. In order to improve and expand our services, we need your
input.
Your answers to the enclosed questionnaire will enable us to provide you with even better services
in the future. Please take a few minutes now to complete the survey and return it to us by February
19, 1994. No postage is necessary. Your response will, of course, be held in the strictest confidence.
We look forward to hearing from you soon.
Thank you for helping us help you.
Sincerel -
Este cuestionario esta disponible en espanol.Si su lengua es el espanol por
favor flame a Romelia Watkins al telefono(510)313-6070 y ella le mandara a
usted una Copia.
Milton S. Camhi
Executive Director
Wiff CONTRA COSTA BULK RATE
QAWEV� HEALTH PLAN U.S. POSTAGE
595 Center Avenue, Suite 100 PAID
Martinez, California 94553 MARTINEZ, CA
PERMIT NO. 43
1
Plieai
Contra Costa Health Plan
Member Satisfaction Survey
The Contra Costa Health Plan is dedicated to providing our members with
Affordable Care Plus Service.
Please help us pinpoint where we can improve our services by filling out this
brief questionnaire . . .
Fold with this side out when complete
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY MAIL
FIRST CLASS PERMIT NO. 59 MARTINEZ, CA
Postage Will Be Paid By Addressee
CONTRA COSTA
HEALTH PLAN
595 Center Avenue, Suite 100
Martinez, California 94553
1 2 3 4 5
PLEASE MAIL WITH THIS SIDE OUT
VeryVery
Milling System Services: des ='; Toy. 'Satisfied ]Satisfied Dissatisfied ]Dissatisfied
Have you been billed for _
copayments?
If yes, how satisfied were - '
you with the billing `11 : 212
procedure? 1 2 3 4
If yes, how satisfied were
you with the billing form? t. 1 2 3 4 213
If you were very satisfied or very dissatisfied with our billing forms or procedures, please tell us why:
214
215
216
.:^—..— ..•: -�....�. —.� ..r.. 5r r. -....� _ �}.� _�.r-ter,•• _ ^Y.' `� — -,. _
Overall Satisfaction
Overall, how satisfied have you been with Contra Costa Health Plan?
❑ Very Satisfied ❑ Satisfied ❑ Dissatisfied ❑ Very Dissatisfied 217
Do you plan to stay enrolled in Contra Costa Health Plan?
❑ Definitely will ❑ Probably will ❑ Probably will not O Definitely will not 218
Additional Comments:
What is the one most important thing that you think Contra Costa Health Plan should do to improve its 219
services?
220
And what are some of the little things we can do that might make a big difference? 221
222
Tease Tell Us About Yourself. . .
223
1. In what city do you live? 224
2. Please indicate which age group you are in:
❑ 21 & under ❑ 22-35 ❑ 36-50 ❑ 51-64 ❑ 65 & over 225
3. Please indicate whether you are ❑ Male ❑ Female 226
4. How long have you been a member of Contra Costa Health Plan?
❑ Less than 6 months ❑ 6 months to 11 months ❑ 1-2 years ❑ More than 2 years 227
S. Optional (for statistical purposes only) Please indicate your race/ethnic background
❑ White (not Hispanic) ❑ Hispanic ❑ African/American ❑ Asian ❑ Other 228
6. ❑ Check here if you would like to be included in discussions on health care. -
Thank you for your assistance. Please return this questionnaire by February 21, 1994. If you have any other concerns or
recommendations, feel free to call our Member Services staff directly at 313-6070 or 1-800-644-2247.
If member services were available on weekends mitely Probably ftobably :definitely
or in the early evening, would you use them: - 'Yes NOS =< '` ?Alo sIo
on weekends? 1 2 3 4 170
in the evenings? 1 2 3 4 1171
If you were very satisfied or very dissatisfied with any of the Contra Costa Health Plan special services,
please explain below:
172
173
174
� ....._ :._ ...__ .... - -. ,. ....-,.._. .:'--;-.cr�r...,n... �;.,,,,�..,,._...,.._..,.r._s.: yrs•.._ �..
Contra Costa Health Plan .MarketingDepartment
Please tell us how satisfied you were with Contra Costa Health Plan's sales presentations and materials.
Were the sales presentations and written materials:
(Please circle your answer)
Sales Presentation Written Materials
Accurate Yes No Yes No 205
Complete Yes I No Yes I No 206
Clear/Understandable Yes No Yes No 207
If you were very satisfied or very dissatisfied with the sales presentations or written materials, please explain
below. Tell us which materials were not satisfactory. 208
209
210
H. Copayments
If you have copayments for any of your Contra Costa Health Plan services, please tell us how
satisfied you are with the copayment billing system.
Very Very
Billing System Services: Yes No Satisfied Satisfied Dissatisfied Dissatisfied
Have you paid a copayment I
directly to a provider(e.g. I
pharmacy)? I
If yes, how satisfied were I
you with the handling of 1 2 3 4 211
your copayment?
I
USED Very Very
Non-County Services: Yes No Satisfied Satisfied Dissatisfied Dissatisfied
X-ray(which facility?) I 1 2 3 4 152
I
Optical care (which provider?) I 1 2 3 4
Emergency Room I 1 2 3 4
(which facility?) I
Pharmacy services (name & I 1 2 3 4
155
location of pharmacy) I
Inpatient care (which hospital?) I 1 2 3 4
Physician (which one?) I 1 2 3 4
Psychological or psychiatric I 1 2 3 4
services (which one?) I
Other service (which one?) I
1 2 3 4 159
If you were either very satisfied or very dissatisfied with any of the services you received in a non-county 160
facility, please explain below
161
162
F. Contra Costa Health Plan Special Services
Please indicate which of the special Contra Costa Health Plan services you have used and then circle how
satisfied you were.
USED Very Very
Health Plan Special Services: Yes No Satisfied Satisfied Dissatisfied Dissatisfied
Advice Nurse. . .
• Ease of Getting Through 1 2 3 4 163
• Advice Received �11
1 2 3 4
000ll
Member Services . I
• Ease of Getting Through ( 1 2 3 4
• Guidance Given ( 1 2 3 4
• Resolution of Your Problem 1 2 3 4
• Hours of Operation I 1 2 3 4 169
USED Very Very
E.R.Services: Yes- No Satisfied Satisfied Dissatisfied Dissatisfied
Emergency Room at
Merrithew . . .
• Overall Service 1 1 2 3 4 136
• Medical Care 1 2 3 4 137
•If yes, how many times in the last year did you use the Emergency Room at Merrithew Memorial Hospital? 138-
139
Have you been seen in the Emergency Room in the past year because the wait to get a health plan appoint-
ment was too long? 0 Yes ❑ No 1ao
If yes, how many times? ❑ Once 0 Twice 0 3 or more times 141
D. Merrithew Memorial Hospital And Health Centers Staff
Please indicate how satisfied you are with the hospital and health centers staff(circle one answer for each category):
Very Very
staff: Satisfied Satisfied Dissatisfied Dissatisfied
Reception/registration or other 1 2 3 4
142
clerical staff
Physicians 1 2 3 4
Nurses 1 2 3 4 144
Nurse Practitioners 1 2 3 4
Other staff(specify) 1 2 3 4 146
If you were either very satisfied or very dissatisfied with any of the services or staff at Merrithew Memorial
Hospital or Health Centers, please explain: 147
148
149
E. Non-County Facilities And Services
While a member of Contra Costa Health Plan have you been referred to and/or used private services that are not
operated by the County (not part of Merrithew Memorial Hospital or Health Centers)? O Yes 0 No 150
USED Very Very
Non-County Services: Yes No Satisfied Satisfied Dissatisfied Dissatisfied
Dental Care (which dentist?) 1 2 3 4 1 5 1
3. How long do you usually have to wait to get a non-urgent medical appointment?
❑ Same Day ❑ 1-2 Days ❑ 3-5 Days ❑ 6-10 Days ❑ 11-14 Days ❑ 2 Weeks or more 118
4. At your health center how long do you usually wait, after your scheduled appointment time, to see your
physician?
❑ Less than 10 minutes ❑ 10-19 minutes ❑ 20-29 minutes ❑ 30-60 minutes ❑ More than 1 hour i 19
5. If they were available at your health center, would you use evening hours of service for routine 120
care? ❑ Yes 0 No For urgent care? ❑ Yes ❑ No 121
If yes, which evenings would be most convenient? (Check two.) 122
❑ Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ Friday
6. If they were available at your health center would you use Saturday hours of service for 123
routine care? ❑ Yes ❑ No For urgent care? ❑ Yes ❑ No 124
B. Ancillary Services
Please indicate below which of the services you have used and then circle how satisfied you were with each of
those services.
USED Very Very
Ancillary Services: Yes No Satisfied Satisfied Dissatisfied Dissatisfied
Laboratory Services 1 2 3 4 125
Pharmacy Services 1 2 3 4
Dental Services 1 2 3 4
X-Ray Services 1 2 3 4 128
Tell us which Health Center you mostly used to receive these ancillary services: 129
C. Inpatient And Emergency Room Services
Please indicate if you have used Inpatient or Emergency Room services at Merrithew Memorial Hospital
(County Hospital) and then circle how satisfied you were with each of those services.
USED Very Very
Inpatient Service Yes* No Satisfied Satisfied Dissatisfied Dissatisfied
Inpatient Hospital stay at
Merrithew . . .
• Overall Service 1 2 3 4 130
• Medical Care 1 2 3 4 131
* If yes, please give month and year of admission 1132
35
Please Tell Us About Your Visits To Our Health Centers
(Please check one answer)
1. Which one of our health centers do you normally visit for your medical care?
❑ Brentwood ❑ Concord 0 Martinez ❑ Pittsburg ❑ Richmond O Martinez Specialty Clinics tos
O Other, Specify
2. At the health center you normally use
how satisfied are you with:
. . . How Satisfied Are You?
Very Dis- Very Dis-
Satisfied Satisfied satisfied satisfied
a. The system for making appointments 1 2 3 4 106
b. The time it takes between calling for an 1 2 3 4
appointment and actually seeing the
doctor
c. Your wait in the health center to see your 1 2 3 4
doctor
d. The convenience of the location 1 2 3 4
e. Comfort and attractiveness of the health center 1 2 3 4 Ito
f. The center's cleanliness 1 2 3 4
t
g. The quality of medical care provided by 1 2 3 4
physicians and other health care
professionals
h. The helpfulness of the clerical support staff 1 2 3 4
(i.e., receptionist)
i. The explanations given by physicians and other 1 2 3 4
health care professionals about your health
condition and treatment
professional PP
The rofessional a earance of the staff 1 2 3 4
k. The helpfulness of the nurse 1 2 3 4
I. Overall satisfaction with your health center 1 2 3 4 1
Go on to#3
ATTACH V
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TO BOARD OF SUPERVISORS ATTACFRO ]
Mark Finucane, t.�Jl ll�
"' Health Services Director �C+�wt,r,
C Ata
DATE: c"" ^J
Establishment of Contra Costa Health Plan Integrated
SUBJECT: Quality Assessment Committee As Part of Contra Costa Health
Plan's Quality Management Plan
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND APO JUSTIFICATION
I. RECOMMENDED ACTION
1. ESTABLISH the Contra Costa Health Plan Integrated
Quality Assessment Committee and DELEGATE the Board of
Supervisors' quality management functions to that
body.
2. APPOINT the Contra Costa Health Plan Medical Director
as the individual responsible and accountable for the
operation of Contra Costa Health Plan's Quality
Management Plan.
3. AUTHORIZE that Contra Costa Health Plan's Quality
Management Plan is to cover health care provided to
Contra Costa Health Plan members, including all Health
Services Department services and all authorized out-
of-plan care.
4. INCLUDE quality assessment, utilization management,
risk management, continuous quality improvement and
continuous quality management monitoring functions in
Contra Costa Health Plan's Quality Management Plan.
5. MEMBERSHIP: The Integrated Quality Assessment
Committee will consist of at least seven members:
Contra Costa Health Plan Executive Director
Contra Costa Health Plan Medical Director
Merrithew Memorial Hospital 6 Clinics Medical Staff President
Merrithew Memorial Hospital & Clinics Executive Director
Member of the Board of Supervisors
Community Provider
Public Health Division Representative
6. The Medical Director of Contra Costa Health Plan will
review and approve all quality management documents
before they are forwarded by the Integrated Quality
Assessment Committee to the Board of Supervisors for
their review and approval.
CONTINUED ON ATTACHMENT; X YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S):
ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER
VOTE OF SIJPE 7V I SORS
1 HEREBY CERTIFY THAT THIS IS A TRUE
_ UNANtW:)US (ABSENT ) AND CORRECT COPY OF AN ACTION TARN
AyES� NJES.. AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHDWN.
Milt Camhi, CCHP Executive Director
cc: ATTESTED
PHIL BATCHELOR CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
Page Two
II. FINANCIAL IMPACT
Expenses of the Contra Costa Health Plan Quality Management Plan
will be paid by member premiums.
III. REASONS FOR RECOMMENDATION/BACKGROUND
Both the State Department of Health Services and the State
Department of Corporations require that Contra Costa Health Plan
establish an internal Quality Management Plan for its members.
The State Department of Health Services requires that all Medi-
cal Prepaid Health Plan (PHP) contractors have an approved
Quality Assessment and Improvement Plan (QAIP) . This plan must
include all services for Contra Costa Health Plan members
including those provided by all divisions of the Health Services
Department and all authorized out-of-plan care. The Department
of Corporations also requires that to move forward with Medi-Cal
managed care, including establishing the Local Initiative, that
Contra Costa Health Plan must have a Quality Management Plan.
The establishment of the Contra Costa Health Plan Integrated
Quality Assessment Committee and the appointment of the Contra
Costa Health Plan Medical Director as the individual responsible
and accountable for Contra Costa Health Plan Quality Management
will provide the mechanisms the state requires for an approvable
Quality Assessment and Improvement Plan.
Attachment X
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