Transcript Patient centered medical home Oklahomans are counting on us….

Patient centered
medical home
Overview of Quality Compliance
following implementation of the Patient
Centered Medical Home
Oklahomans are counting on us….
Quality Assurance and
Quality Improvement
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The Compliance area of the Quality Assurance and Quality
Improvement Department was charged with the task of
developing a systematic process to educate and evaluate
medical providers who opted to become a Medical Home.
There are three levels of complexity and expectation
within the Medical Home concept. These are referred to as
“Tier Levels”.
Onsite educational reviews began in February 2009 to
assess provider implementation of the Medical Home.
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Medical Home and
Contract Compliance
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The Quality Assurance Department formulated an
educational “tool” that combines contract requirements
with Medical Home processes.
2009 was determined to be a year for educational
opportunities with SoonerCare providers.
A Compliance Analyst and Compliance Nurse team
together to visit providers in their office.
Medical Home audits will begin in January 2010.
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The 2009 Review Process
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It is the goal of the Quality Assurance department that each provider receive
individual education about Medical Home during 2009. There are some rural
providers who will be educated telephonically.
There are currently three teams performing medical and administrative
provider educational reviews.
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Team 1: Ann Flores, RN and Kevin Jones
Team 2: Patrice Calvin, RN and Cynthia Brown
Team 3: (As needed) – Beverly Rupert, RN and Kara Jennings, RN
The Quality Assurance Nurse Educator (RN) follows up with a telephone call
to the provider’s office when appropriate.
The Compliance Analyst provides hands on assistance with provider office
staff, taking them to the OHCA website and showing them the tools that are
available.
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Key Medical Home
Concepts
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Self Management Plans
Formulation of a Medical Home Agreement between the
provider and the member
Referral and Laboratory tracking systems
Care Coordination of members transitioning from an
inpatient to outpatient status.
Mental Health and Substance abuse evaluation with a
direct referral to the OHCA Behavioral Health
Department
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Audit Database Statistics
As of 8/31/2009
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732 Active providers
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395 Completed audits (54% complete)
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337 Remaining audits Sep thru Dec (46%).
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Approx 140 (19% of all audits) will be completed by phone.
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Audit Database Statistics
A review of the number of audits performed shows
the following:
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About 226 providers were audited in 2007
About 275 providers were audited in 2008
About 732 providers will be audited in 2009 (592 in
person)
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Key findings from
education reviews
Most common issues to be addressed
are:
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Problem list
Medications/Allergies
Referrals
Medical Home Agreements
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