Cultural, Ethnic, and Religious Reference Manual for Healthcare Providers

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Human resources a. Material resources a. Financial resources a. Donations a. Medical consumables b. Other in-kind. Logistical operational support a. Technical 5. Economic 6. Safety and security plan a. SOPs 1 activities of daily living 2 warden system 3 vehicle safety 4 office safety 5 residential safety Communications plan Staff health emergency plan a. Clinical case definitions Case management guidelines Rapid response team to investigate Specimen collection protocol to follow Reference lab to identify Patients to isolate Contact tracing.

Used with permission. It cannot do complete justice to the complexity of these two important functions. However, it is informed by our failures in managing them. Document 6. Before going to the field, it is helpful to be familiar with planning precursors such as context analysis, stakeholder analysis, SWOT analysis, and force field analysis.

It is also helpful to be familiar with planning tools such as problem trees, objectives trees, project maps, logframes, and workplans. There is a fair amount of homework to do. Clear and concise overviews of project planning exist in the bibliography of many relief organizations. Certain planning steps have particular boundary conditions or sensitivities for an organization.

Management guru Peter Drucker considers this situation the most dangerous for a manager. It may be useful when your organization does not stipulate one. Tools 6. The use of a logframe may not improve the quality of services described in a proposal. However, it will improve funding prospects with a serious donor. Health personnel tend to focus on the service end of a project rather than the procurement end. They should pay attention to medical logistics. Amateurs discuss strategy, but professionals discuss logistics.

Tool 6. T4 may be useful for abstracting project details prior to embarking on monitoring and evaluation visits. T5 may be useful when considering remote management. T6 [1] D Health care providers play key roles in many disaster relief operations. Epidemiological justifications exist for clinical skills in pediatrics, obstetrics, emergency medicine, internal medicine, infectious diseases, tropical medicine, surgery, rehabilitation medicine, and psychiatry.

Unfortunately, clinicians from donor countries practicing in international settings tend to have inflated notions of their own importance. Field conditions with limited resources place predictable constraints on specialist clinicians. Multi-disciplinary generalists generally prove to be more useful. Staff selection is a critical and under-examined issue in disaster management.

Medical coordinators are frequently called upon to advise or approve the selection of health personnel for their teams. This action requires understanding multiple dimensions of performance in disaster medicine. T6 provides a quantitative approach to assessing the criterion-referenced qualifications. This schema identifies benchmarks for health technical qualifications, field experience, language competence, and peer awards. Additional exploration of criterion-referenced qualifications in disaster medicine appears in Prehospital and Disaster Medicine [1]. Staff selection is the beginning of human resource management responsibilities for medical coordinators.

Briefing, tasking, supervising, updating, evaluating, debriefing, and discharging staff are all additional important duties. This aspect of management is woefully addressed by many organizations which thereby endanger their programs, their beneficiaries, as well as their staff. Medical coordinators must recognize an untenable position when they are hired with the responsibility, but without the authority, to fulfill their management duties. Accessible advice and ongoing support from their human resources department are critical. Hersey P. Blanchard, K. Leadership and the one minute manager. Disaster Planning Types 1.

Strategic 2. Preparedness 3. Operations a. Security b. Communications c. Transport d. Staff health e. Beneficiary programs 4. Contingency 5. Evaluation Planning precursors 1. Planning steps 1. Assumptions and Constraints 3. Monitoring and Evaluation Plan Reports Schedule SOPs Disaster History B. Sociopolitical and Cultural Context on health status, health care services, and interventions C. Security Situation D. Resources and Capacities Available E.

Roles and Influence of Major Stakeholders e. Disaster Expected Evolution lessons learned from past experience H. Reason for Agency Assistance. Mission 1. Goals 2. Beneficiaries 3. Geographic location 4. Timeframe B. Vision of End State C. Boundary Conditions 1. Key decisions 2. Antigoals unwanted outcomes III. Assumptions 1. Security and socioeconomic assumptions 2. Epidemiological assumptions 3.

Health resource assumptions 4. Donor assumptions B. Principles 1. Comprehensive approach involving PPRR a. Integrated approach involving prepared community 3. Build on existing platforms and investments 4. Coordinate and leverage resources with other donors and private sector 5.

Focus on high yield activities in high risk areas B. Strategy 1. Population targeted 2. Subsector goods and services provided 3. Objectives e. Prepare for epidemics 2. Prevent and control vaccine-preventable illnesses 3. Prevent and control vector-borne illnesses 4. Intensify disease surveillance system D. Expected Results 1. Implementation Plan B. Monitoring and Evaluation C. Outputs B. Impacts and Outcomes 1. Sustainability D. Organization Executive Officers B. Project External Advisory Panel C. Project Leadership Team D.

Field Supervisors E. Field Staff IX. Resource Management 1. Human resources 2. Material resources 3. Financial resources B. Other POA Deliverables 1. Operations research C. Incident Reports D. Unexpected Consequences X. Stakeholder analysis organization, community, population a. Force field analysis forces at play. Feasibility Analysis 1.

Technical 2. Administrative 3. Political 4. Economic 5. Developmental 6. Impact positive and negative. Logframe structure and completion sequence: Project Description 1. Goal 2. Objectives 3.

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Components 4. Indicators Indicators milestones per activity scheduled. Overall, a logframe is a matrix, a logic, and a grammar. It can be cumbersome for the uninitiated. Many organizations, including WHO, use a simplified form of logframe to facilitate field use. This simplified approach may rely on predetermined indicator libraries, activity lists by subsector, and activity-based budgets. Project Purpose:. Target Groups:. Project key contacts:.

Is there an access problem due to insecurity? Insightful stakeholder mapping and experienced access negotiators are keys to the process. Is there a direct life-saving action? Preparedness, early recovery, R2D, and resilience actions do not qualify. Can the action be implemented without risking the lives of those undertaking the work on the ground? What is the source of the needs assessment in a remotely managed action? Implementing partner must specify what sources of information were used to estimate needs.

Management staff must always have updated information on field level implementation. Are the monitoring arrangements adapted for remote management? When managers cannot go to field sites, it may be possible for some beneficiaries to travel to a sub-office location. Is there a mechanism of direct contact between program managers and beneficiaries or other local stakeholders? Are third party monitors engaged? If so, they must be external to the conflict. Debriefing between iNGO and local partner 2. Complaint boxes 5. Broadcasts about planned activities generally not feasible in conflicted areas 6.

Photos or videos of commodity distribution or service delivery 7. Web-based remote monitoring via geo-tagged photos posted online or sent by email 8. GPS shipment tracking barcoding of shipment, scanning at dispatch and receipt 9. Remote sensing Voucher reconciliation Peer monitoring triangulation thru discussion with organizations working in the same area Crowd sourcing via SMS, internet, Facebook. Donini, A. From face-to-face to face-to-screen: Remote management, effectiveness and accountability of humanitarian action in insecure environments.

Field assignments in disaster impact and needs assessment, disaster relief site operations, mass casualty incident management, or disaster response project management. Military active duty in peacekeeping or humanitarian assistance operations Field assignments in disaster preparedness, project identification, monitoring and evaluation, education, and research Section Total. Peer Awards in Disaster-Related Activities Military medicine in combat operations UN field assignments Red Cross field assignments Governmental organizations, military medicine in peacekeeping or humanitarian assistance operations Non-governmental organizations Academic and trade associations Section Total.

Grand Total. Medical coordinators should possess the technical competence to render an informed opinion, the administrative authority to mobilize resources, and the organizational responsibility for outcomes. Such is not always the case. If an organization is represented by someone lacking competence, authority, or responsibility, then the organization should be encouraged to send someone who has it. Health cluster coordination is the application of medical coordination skills to an interagency cluster context.

This application requires specialized tools and training. Medical Coordinator Work Products Document 7. Document 7. There is much overlap with the Medical Handover Checklist Document 7. Not all the work product need be produced by the medical coordinators. Some of it may exist in-country before the current disaster.

However all of it will need to be applied in the context of the disaster. This documentation contributes to a reference archive critical to the effectiveness of the medical coordinator. Health Cluster Principles of Coordination Document 7. T1 , Meeting Process Tool 7. T2 It is essential that host health authorities lead the process, and that it embraces local providers and NGOs.

Local culture, practices, and beliefs must inform decisions made about health programs. One must beware of the insidious cycle of foreign. Medical coordination meetings are an opportunity for the Ministry of Health and medical coordinators to develop consensus on health sector priorities, practices, and accountability. Meeting agenda and process are characterized in Tools 7. T1 and 7. At those meetings, principles of engagement are an excellent way to begin substantive discussions.

These principles typically acknowledge humanitarian values, group commitment to international best practices, and ascendancy of the host country. An example is presented in Document 7. The document specifics are less important in many ways than the process of developing a consensus around them. The process evidences the ability of medical coordinators to develop a consensus on non-controversial areas.

A fundamental problem in health sector coordination occurs when medical coordinators cannot reach consensus early in a relief operation. Reference 1. Demonstrated ability for leadership and independent decision-making Demonstrated management skills Strong negotiation and inter-personal skills Willingness and ability to work in hardship environments Readily available for deployment in emergency situations Cultural and gender sensitivity Success in developing partnerships Expertise in English with proficiency in another official UN language.

Provide health leadership in emergency and crisis preparedness, response, and recovery Prevent and reduce excess mortality and morbidity Ensure evidence-based actions, gap filling, and sound coordination Enhance accountability, predictability, and effectiveness of humanitarian health actions.

Clinical Medicine 1. Standardization of case management a. Authority to work in [country] is conferred by the Government of [country] through the Ministry of Health. Participants agree to conform to health policies and procedures established by statute of the Government of [country] and regulation of the Ministry of Health. Participants agree to support minimum standards of humanitarian assistance as disseminated by the Sphere Project. Participants agree to adhere to the Code of Conduct as disseminated by the Sphere Project.

Participants agree to undertake health activities relying on organizational competence to serve local needs with [lead agency] acting to encourage and coordinate multi-party involvement. Meeting agendas are intended to support and complement interactions currently underway between participants and [country] health authorities. Meeting discussions are intended to be interactive, field-oriented, and practical.

The approach to health issues will involve disseminating information, examining problems, appraising options, developing consensus, making decisions, and implementing remedies. Meeting minutes will be written by [lead agency] and disseminated to focal points among participant organizations and [country] health authorities to evidence ongoing transparency and professionalism among colleagues in humanitarian health assistance. Tool 7. Guidance Notes These annexes contain compilations of frequently used reference information.

This information has helped us analyze field data, generate REA and health situation reports, and answer countless questions from our colleagues. Selected comments follow below. Humanitarian Programs Annex 8. Security Sector Annex 8. Health Sector Annex 8. Tropical Medicine Annex 8. It briefly overviews pathophysiology, differential diagnosis, and management keys.

The accompanying tables provide disease-specific profiles which identify the disease vector and host, clinical presentation, diagnostic lab tests, clinical epidemiology, and therapy. Table 1 on Vector-Borne and Zoonotic Diseases is organized by vector. For detailed information on these and other communicable diseases, please refer to references cited in Section 1. Communicable Disease Control Annex 8. These diseases are: diarrhea, influenza, malaria, measles, meningitis, and viral hemorrhagic fever. Acronyms Annex 8. Save lives Alleviate suffering Reduce economic and social impact of disaster Maintain peace and security Uphold law and order host government Support vulnerable groups Implement durable solutions UNHCR a.

Common Service Areas 1. Security and Demobilization 4. Logistics 5. Site Planning 6. Water and Sanitation 7. Food Aid 8. Agriculture 9. Non-food Aid household support Health Rehabilitation Education and Training Economic Recovery and Community Development Durable Solutions B.

Gender 3. Themes Per Donor Grants Guidelines 1. Artisanal Production 2. Cash Distribution 4. Cash for Work 5. Children 6. Conflict Resolution 7. Gender Relations 8. Host Communities Host Government IDPs Information Systems Infrastructure Rehabilitation Market Rehabilitation Protection Mainstreaming Returnees Intervene early Support, not undermine, community coping strategies Prevent communities from migrating Avoid establishing large refugee camps Establish a health information system Ensure resources provided do not further divide communities Focus on disease prevention.

Work through existing structures and institutions 9. Insist that women control the distribution of relief supplies Ensure open communication and coordination B. Implementation Principles 1. Address identified needs in underserved areas Encourage local participation Integrate beneficiaries into program planning Collaborate with all stakeholders Coordinate with all implementing partners Plan comprehensive approaches Develop community-based programs Make inter-sectoral linkages sector-wide approaches Use existing resources Leverage outside resources of donors and private sector Build on existing platforms Apply international best practices Target vulnerable populations Focus on high impact activities Ensure equitable access to services Provide assistance acceptable to beneficiaries Implement with cultural sensitivity Reduce the local burden of disease Enhance capacities Reduce vulnerabilities Alleviate poverty Avoid dependency Foster sustainable development Support governmental priorities Operate cost-effectively, transparently, and accountably.

Transition to early recovery D. Restore productive assets supply side interventions a. Adopt systems approach a. Phase in assistance to beneficiaries a. Ensure responsible resource management a. Scale up coverage of priority health interventions 5. Address bottlenecks of the disrupted health system otherwise temporary solutions become permanent 6. Protect essential public health infrastructures 7. Build capacity of local authorities with focus on sustainable systems a.

Provide incentives for host government 9. Support host country non-beneficiary population Find new partners in the development community Use health Sustainable Development Goals as targets for recovery activities Seek opportunities and develop mechanisms for transition and phase out. Programmatic constraints a. Transparency 2. Frontline responders 3. Cash-based programming 4. Management cost reductions 5. Joint and impartial needs assessments 6. Proactive legislation and policy not reactive 2. Clear non-overlapping mandates 3. Funding commitment to comprehensive disaster management 4.

Vertical and horizontal linkages in policy implementation 5. Socioeconomic 1. Environmental impact of population growth 2. Poverty alleviation and economic diversification programs 5. Inclusiveness thru use of gender disaggregated data 6. Indigenous knowledge and contribution to DRR 7. Re insurance mechanisms D. Institutional 1. Leadership training programs Transparent resource management Open redundant communication channels. Hazard zoning Hazard and structural mitigation Remote sensing and early warning systems Preventive maintenance.

Streamlined work flows Robust information management and information sharing MEAL programs Accountability frameworks Inter-agency coordination Partnership development. Focus on those countries with significant need for assistance and with adequate or better commitment to ruling justly, promoting economic freedom, and investing in people. Adopt inclusive approach Integrate gender equality into all work Build partnerships Harness science, technology, and innovation Address unique challenges in crises and conflict-affected communities Serve as thought leader Be accountable.

International cooperation to protect lives and health 2.

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Timely and sustained high-level political leadership to the disease 3. Rapid response to the first signs of accelerated disease transmission 7. Actions based on the best available science. Community interventions a. Fistula Hospital, Addis Ababa, Ethiopia d. Behrhorst Clinic, Guatemala Self-replicating centers of excellence a.

Fistula Hospital, Addis Ababa, Ethiopia. Inter-agency Standing Committee. Global Cluster Leads as of June January US Homeland Security Council. National strategy for pandemic influenza. War crimes Article 8 a. Unimpeded Access to Beneficiaries 1. Humanitarian assistance 4. Family reunification 5. Information dissemination. Law Enforcement perpetrators of violence are arrested, charged, and tried in a civil court of law. Direct trauma Diseases of overcrowding and displacement Outbreaks of preventable and controlled diseases Untreated chronic illnesses Excess mortality in affected population.

Annex 8. Rapid epidemiological assessment minimum essential data sets Inter-agency health coordination Standardized case management Environmental health minimum standards Epidemic preparedness and response Disease surveillance surveillance case definitions, data flow, and analysis Special surveys cluster sample surveys Health policy and personnel planning Immunization programs EPI Medical logistics. Prehospital care Primary, preventive, and basic services a.

Core functions World Health Assembly Res Water and Sanitation 4. Maternal and Child Health, Family Planning 5. Immunization 6. Prevention of Endemic Disease 7. Treatment of Common Disease and Injury 8. Essential Drugs B. Growth Monitoring 2. Oral Rehydration Therapy 3. Breast Feeding 4. Immunization 5. Behavioral health services are interdisciplinary and multidisciplinary: a customer may need one or multiple types of behavioral health providers, and the exchange of information among these providers is essential.

Mental health and substance abuse benefits cover the continuum of care from the least restrictive outpatient levels of care to the most restrictive inpatient levels of care. Cigna-HealthSpring's behavioral health providers' responsibilities include but are not limited to:. When requesting Prior Authorization for specific services or billing for services provided, behavioral health providers must use the current DSM multi-axial classification system and document a complete diagnosis.

The provision of behavioral health services requires progress note documentation that corresponds with day of treatment, the development of a treatment plan, outcome of treatment and the discharge plan as applicable for each customer in treatment. Continuity of Care is essential to maintain customer stability.

Behavioral health practitioners and PCPs, as applicable, are required to:. This coordination assures promotion of the delivery of services in a quality-oriented, timely, clinically appropriate, and cost-effective manner for the customers. For requests for behavioral health services that require authorization, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. Cigna-HealthSpring's Health Services Department coordinates health care services to ensure appropriate utilization of health care resources.

Cigna-HealthSpring in no way rewards or incentivizes, either financially or otherwise, practitioners, Utilization Reviewers, clinical care managers, physician advisers or other individuals involved in conducting Utilization Review, for issuing denials of coverage or service, or inappropriately restricting care. Prior Authorization should be received at least seven 7 days in advance of the admission, procedure, or service.

The customer may also request services on their own. Requests for Prior Authorization are processed as expeditiously as the enrollee's health condition requires. Cigna-HealthSpring accepts Prior Authorization requests via our confidential fax lines and portal 24 hours per day, 7 days per week. Requests must include all pertinent clinical information.

Prior Authorization is a determination of medical necessity and is not a guarantee of claims payment. Claim reimbursement may be impacted by various factors including eligibility, participating status, and benefits at the time the service is rendered. Please listen carefully to the prompts to make the appropriate selection. The presence or absence of a service or procedure on the list does not determine coverage or benefits.

Log in to HSConnect or contact customer service to verify benefits, coverage, and customer eligibility. The Prior Authorization Department, under the direction of licensed nurses, clinical pharmacists, and medical directors, documents and evaluates requests for authorization, including:. For customers who go to an emergency room for treatment, an attempt should be made in advance to contact the PCP unless it is not medically feasible due to a serious condition that warrants immediate treatment.

If a customer appears at an emergency room for care which is non-emergent, the PCP should be contacted for direction. The customer may be financially responsible for payment if the care rendered is non-emergent. Cigna-HealthSpring also utilizes urgent care facilities to treat conditions that are non-emergent but require immediate treatment. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity including severe pain such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:.

Prior Authorization is not required for an Emergency Medical Condition. An expedited request can be requested when you as a physician believe that waiting for a decision under the routine time frame could place the customer's life, health, or ability to regain maximum function in serious jeopardy. Expedited requests will be determined within 72 hours or as soon as the customer's health requires.

An expedited request may not be requested for cases in which the only issue involves a claim for payment for services that the customer has already received. A routine or standard Prior Authorization request will be determined as expeditiously as the health condition requires, but no later than 14 calendar days after receipt of the request. Approval: Once the Precertification Department receives the request for authorization, we will review the request using nationally recognized industry standards or local Coverage Determination criteria.

If the request for authorization is approved, Cigna-HealthSpring will assign an authorization number and enter the information in our medical management system. This authorization number can be used to reference the admission, service or procedure. Approval notification is provided to the customer and the provider. The Medical Director, in making the decision, may suggest alternative covered services to the requesting provider. If the Medical Director makes a determination to deny or limit an admission, procedure, service or extension of stay, Cigna-HealthSpring notifies the facility or providers office of the denial.

Such notice is issued to the provider and the customer, when applicable, documenting the original request that was denied and the alternative approved service, along with the process for appeal. Cigna HealthSpring in no way rewards or incentivizes, either financially or otherwise, clinical practitioners, utilization staff customers, clinical care managers, physician advisers or other individuals involved in conducting reviews, for issuing denials of coverage or service or inappropriately restricting care.

The only scenarios in which retrospective requests can be accepted are:. Cigna-HealthSpring requires notification of home health services prior to commencement of such services. Timely receipt of clinical information supports the clinical review process. Failure to comply with notification timelines or failure to provide timely clinical documentation to support the need for home health services or continuation of home health services could result in an adverse determination.

Cigna-HealthSpring's nurses, utilize CMS guidelines and nationally accepted, evidence-based review criteria to conduct medical necessity review of services. A Cigna-HealthSpring Medical Director reviews all home health services that do not meet medical necessity criteria and issues a determination. If the Cigna-HealthSpring Medical Director deems that the services do not meet medical necessity criteria, the Medical Director will issue an adverse determination a denial.

The Prior Authorization Nurse or designee will notify the provider and customer verbally and in writing of the adverse determination via notice of denial. This notice will be sent by fax to the HHA. The agency is responsible for ensuring the customer, authorized representative or POA signs the notice within the specified time frame. If the agency believes continued home health care is required, a request for additional services must be submitted prior to the expiration of the existing authorization. Concurrent Review is the process of initial assessment and continual reassessment of the medical necessity and appropriateness of inpatient care during an acute care hospital admission, rehabilitation admission or skilled nursing facility or other inpatient admission in order to ensure:.

Emergent or urgent admission notification must be received within twenty-four 24 hours of admission or next business day, whichever is later, even when the admission was prescheduled. If the customer's condition is unstable and the facility is unable to determine coverage information, Cigna-HealthSpring requests notification as soon as it is determined, including an explanation of the extenuating circumstances.

Timely receipt of clinical information supports the care coordination process to evaluate and communicate vital information to hospital professionals and discharge planners. Failure to comply with notification timelines or failure to provide timely clinical documentation to support admission or continued stay could result in an adverse determination. Cigna-HealthSpring's Health Services department complies with individual facility contract requirements for Concurrent Review decisions and timeframes.

Cigna-HealthSpring's nurses, utilizing CMS guidelines and nationally accepted, evidence-based review criteria, will conduct medical necessity review. Cigna-HealthSpring is responsible for final authorization. Cigna-HealthSpring's preferred method for Concurrent Review is a live dialogue between our Concurrent Review nursing staff and the facility's UM staff within 24 hours of notification or on the last covered day. If clinical information is not received within 72 hours of admission or last covered day, the case will be reviewed for medical necessity with the information Cigna-HealthSpring has available.

If it is not feasible for the facility to contact Cigna-HealthSpring via phone, facilities may fax the customer's clinical information within 24 hours of notification to:. Concurrent Review Fax Numbers. To obtain prior authorization, please contact naviHealth by faxing your request to or by calling Following an initial determination, the Concurrent Review nurse will request additional updates from the facility on a case-by-case basis.

Cigna-HealthSpring will render a determination within 24 hours of receipt of complete clinical information.

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Cigna-HealthSpring's nurse will make every attempt to collaborate with the facility's utilization or case management staff and request additional clinical information in order to provide a determination. Clinical update information should be received 24 hours prior to the next review date. The Concurrent Review nurse or designee will notify the provider s e.

For customers receiving hospital care and for those who transfer to a Skilled Nursing Facility or Acute Inpatient Rehabilitation Care, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. Cigna-HealthSpring will also issue a notice of denial if a customer who is already receiving care in an Acute Inpatient Rehabilitation Facility has been determined to no longer require further treatment at that level of care.

This document will include information on the customer's or their representative's right to file an expedited appeal, as well as instructions on how to do so if the customer or customer's physician does not believe the denial is appropriate. The log will indicate if the confinement is approved, denied or pended if additional clinical information is necessary.

For pre-service requests, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. The Health Services Department will review all readmissions occurring within 31 days following discharge from the same facility, according to established processes, to assure services are medically reasonable and necessary, with the goal of high quality cost effective health care services for health plan customers.

If admissions are determined to be related; they may follow the established processes to combine the two confinements. All ACCMs are expected to perform at the height of their license. They understand Cigna-HealthSpring plan benefits and utilize good clinical judgment to ensure the best outcome for the customer. Utilization Review is performed utilizing evidence- based guidelines, well-established clinical decision-making support tools and collaborating with Primary Care Physicians PCP , attending physicians, and Cigna-HealthSpring Medical Directors.

The ACCM effectively manages all transitions of care through accurate discharge planning and collaboration with facility personnel to prevent unplanned transitions and readmissions via interventions such as:. Discharge planning is a critical component of the process that begins with an early assessment of the customer's potential discharge care needs in order to facilitate transition from the acute setting to the next level of care. Cigna-HealthSpring's ACCM staff will coordinate with the facility discharge planning team to assist in establishing a safe and effective discharge plan.

The Cigna-HealthSpring ACCM nurse will facilitate the communication for all needed authorizations for services, equipment, and skilled services upon discharge. In designated contracted facilities, Cigna-HealthSpring also employs ACCMs to assist with the process, review the inpatient medical record, and complete face-to-face customer interviews to identify customers at risk for readmission, in need of post-discharge complex care coordination and to aid the transition of care process. This process is completed in collaboration with the facility discharge planning and acute care management team customers and other Cigna-HealthSpring staff.

When permissible by facility agreement, the ACCM also completes the Concurrent Review process onsite at assigned hospitals. The role of the ACCM onsite reviewer then also includes the day-to-day functions of the Concurrent Review process at the assigned hospital by conducting timely and consistent reviews and discussing with a Cigna-HealthSpring medical director as appropriate. The reviewer monitors the utilization of inpatient customer confinement at the assigned hospitals by gathering clinical information in accordance with hospital rules and contracting requirements including timelines for decision-making.

All clinical information is evaluated utilizing nationally accepted review criteria. The ACCM onsite reviewer will identify discharge-planning needs and be proactively involved by interacting with attending physicians and hospital case managers in an effort to facilitate appropriate and timely discharge. The onsite reviewer will follow the policies and procedures consistent with the guidelines set forth by Cigna-HealthSpring Health Services Department and the facility.

Cigna-HealthSpring has an on-call nurse available to providers who can be reached between the hours of 5p. Monday through Friday, and 24 hours a day on weekends and holidays to assist with the authorization process for customers being discharged. The on-call cellular telephone number is For the convenience of our providers and customers; Cigna-HealthSpring accepts requests via facsimile fax during and after normal business hours. Cigna-HealthSpring Utilization Management staff however does not monitor and retrieve faxed documentation routinely after normal business hours.

In these circumstances, after business hours, the time of receipt for non-urgent requests is considered the next business day. The Utilization Management staff is authorized to render an administrative denial decision to participating providers based only on contractual terms, benefits, or eligibility. Every effort is made to obtain all necessary information, including pertinent clinical information and original documentation from the treating provider to allow the Medical Director to make appropriate determinations. The Medical Director, in making the initial decision, may suggest an alternative Covered Service to the requesting provider.

If the Medical Director makes a determination to deny or limit an admission, procedure, service, or extension of stay, Cigna-HealthSpring notifies the facility or provider's office of the denial of service. Cigna-HealthSpring employees are not compensated for denial of services. The PCP or attending physician may contact the Medical Director by telephone to discuss adverse determinations. Cigna-HealthSpring complies with CMS requirements for written notifications to customers, including rights to appeal and grievances. Cigna-HealthSpring has published and actively maintains a detailed set of program objectives available upon request in our case management program description.

These objectives are clearly stated, measurable, and have associated internal and external benchmarks against which progress is assessed and evaluated throughout the year. Plan demographic and epidemiologic data, and survey data are used to select program objectives, activities, and evaluations. Cigna-HealthSpring has multiple programs in place to promote continuity and coordination of care, remove barriers to care, prevent complications and improve customer quality of life.

It is important to note that Cigna-HealthSpring treats disease management as a component of the case management continuum, as opposed to a separate and distinct activity. In so doing, we are able to seamlessly manage cases across the care continuum using integrated staffing, content, data resources, risk identification algorithms, and computer applications. Cigna-HealthSpring employs a segmented and individualized case management approach that focuses on identifying, prioritizing, and triaging cases effectively and efficiently.

Our aim is to assess the needs of individual customers, to secure their agreement to participate, and to match the scope and intensity of our services to their needs. Results from health risk assessment surveys, eligibility data, retrospective claims data, and diagnostic values are combined using proprietary rules, and used to identify and stratify customers for case management intervention.

Personalized case management is combined with medical necessity review, ongoing delivery of care monitoring, and continuous quality improvement activities to manage target customer groups. Customers are discharged from active case management under specific circumstances which many include stabilization of symptoms or a plateau in disease processes, the completed course of therapy, customer specific goals obtained; or the customer has been referred to Hospice.

A customer's case may be re-initiated based on the identification of a transition in care, a change in risk score, or through a referral to case management. Customers that may benefit from case management are identified in multiplies ways, including but not limited to: Utilization Management activities, predictive modeling, and direct referrals from a provider. In addition, our customers have access to information regarding the program via a brochure and website and may self-refer. Our case management staff contacts customers by telephone or in a face-to-face encounter.

The customer has the right to opt out of the program. Once enrolled, an assessment is completed with the customer and a plan of care with goals, interventions, and needs is established. Cigna-HealthSpring offers customers access to a contracted network of facilities, primary care and specialty care physicians, mental health, and alcohol and substance abuse specialists, as well an ancillary care network. A toll-free Customer Service telephone number is provided, and customers with questions are asked to reach out to the plan.

Customers also have access to a series of web-based provider materials. The website allows customers to search the provider directory for doctors, facilities, and pharmacies. Our case management staff will work with you and your staff to meet the unique needs of each customer. Case managers work with customers and providers to schedule and prepare for customer visits, to make sure that identified care gaps are addressed and prescriptions are filled, and to mitigate any non-clinical barriers to care.

In cases where provider referrals are necessitated, case managers work closely with customers to identify appropriate providers, schedule visits, and secure transportation. The plan also has a provider incentive program that supports case management objectives and which incentivizes providers to coordinate closely with the customer and plan on specified quality measures. Active participation in the care management of our customer is required to ensure proper care coordination and care management. Our case management program includes initiatives specific to this population and our case managers provide support to resolve the special needs of this population.

As a provider, your participation is key in the coordination of care plan management, and in identifying care needs for our Special Needs program customers. Our Summary of Benefits available on our website defines the SNP benefits for your state and the case management staff can assist with identifying resources and providing support to assure coordination. Cigna-HealthSpring provides multiple communication channels to customers.

The plan maintains a full- service inbound call program that allows customers to inquire about all aspects of their relationship with the plan.


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Outbound customer services and care management calls are also made regularly to customers to encourage them to participate in clinical programs and assessment activities provided as part of their health care benefit. In addition to telephonic touch points, the plan regularly sends educational materials to customers in response to identified care gaps and changes in health status. Customers also have access to web-based materials, where they can learn more about their benefits, explore additional benefits, search the provider directory, find a pharmacy, query the formulary, and identify the time and location of sales sessions.

Cigna-HealthSpring continually monitors the program, and makes changes as needed to its structure, content, methods, and staffing. Changes to the program are made under two conditions: 1 changes must benefit customers; and 2 changes must be in compliance with applicable regulations and guidance. Changes to the program are accompanied by policy and procedure revisions and staff training as required.

It is reviewed and updated annually in collaboration with the Quality Improvement Department. Cigna-HealthSpring is committed to preserving the confidentiality of its customers and practitioners. Written policies and procedures are in place to ensure the confidentiality of customer information. Patient data gathered during the case management process are available for the purposes of review only and are maintained in a confidential manner. Employees receive confidentiality training that includes appropriate storage and disposal of confidential information.

Employees also sign a confidentiality agreement at the time of their initial company orientation. In addition, customers undergoing active treatment for a chronic or acute medical condition will have access to the exiting provider through the current period of active treatment or a maximum of 90 calendar days, whichever is shorter.

Customers in their second or third trimester of pregnancy have access to the exiting provider through the postpartum period. Cigna-HealthSpring is not responsible for the health care services provided by the terminated provider following the date of termination under such circumstances. Cigna-HealthSpring also recognizes that new customers join our health plan and may have already begun treatment with a provider who is not in Cigna-HealthSpring's network.

Under these circumstances, Cigna-HealthSpring will work to coordinate care with the provider by identifying the course of treatment already ordered and offering the customer a transition period of up to 90 calendar days to complete the current course of treatment. For additional information about continuity of care or to request authorization for such services, please review our Health Services section of this manual for contact information for Case Management Services.

The BFCC-QIO contactors will focus on conducting quality of care reviews, discharge and termination of service appeals, and other areas of required review. Special Needs Plans SNPs are designed for specific groups of customers with special health care needs. Only customers meeting the following criteria may join the SNP plan. The MOC is an evidenced-based care management program which facilitates the early and on-going assessments, the identification of health risks and major changes in the health status of SNP customers. SNP population — provides a description of the unique characteristics of our overall and most vulnerable SNP customers.

The wide range of services is targeted to help our SNP customers achieve their optimal health and improve the connection to care. These benefits and services are provided to ensure appropriate care coordination and care management. Cigna-HealthSpring also utilizes risk stratification methodology to identify our most vulnerable SNP customers. The risk stratification process includes input from the provider, customer, and data analysis.

The goal is to identify interventions, care coordination and care transitions needs, barriers to care, education, early detection, and symptom management. Your Participation is needed at the ICT meetings. Additionally, care transitions, whether planned or unplanned, are monitored, and PCPs are informed accordingly. Implementation of the SNP Model of Care is supported through feedback from you, as well as systems and information sharing between the health plan, health care providers and the customer.

The customer and assigned PCP will receive a copy of the customer's care plan. The Primary Care Physician PCP is the customer's primary point of entry into the health care delivery system for all outpatient Specialist care. Your Network Operations representative can provide additional details regarding the preferred method of communication in your area. The Specialist is also required to communicate to the PCP via consultation reports any significant findings, recommendations for treatment and the need for any ongoing care.

All referrals must be obtained prior to services being rendered. No retro-authorizations of referrals will be accepted. It is also absolutely essential that customers are directed to Participating Providers only. In order to ensure this, please refer to our online directory or contact Customer Service for assistance.

Remember: An authorization number does not guarantee payment — services must be a covered benefit. To verify benefits before providing services, call If a customer is in an active course of treatment with a Specialist at the time of enrollment, Cigna-HealthSpring will evaluate requests for continuity of care. For further details, please refer to the Continuity of Care section in Health Services.

Please note: A Specialist may not refer the patient directly to another Specialist. If a customer has a preference, the PCP should accommodate this request if possible. Customers may only self-refer to:. Customers may be assessed a co-payment or coinsurance for some visits depending on coverage limits. This flexibility allows data entry at any time and records the transaction for the referring specialist to verify that a referral is on file prior to the date of the visit.

The PCP has the responsibility of notifying the customer that the referral is approved and documenting the communication in the medical record. For those PCPs who do not have web access, a request for a referral may be obtained by calling Our hours of operation are Monday through Friday a.

PCPs that are having difficulty locating a Participating Provider for specialty care are encouraged to go to www. A referral is not a guarantee of payment. Payment is subject to eligibility on the date of service, plan benefits, limitations and exclusions under the benefit plan. A PCP is responsible for ensuring a customer has a referral prior to the appointment with the specialist.

Claims will be denied if a Specialist sees a customer without a referral when the health plan requires a referral. Cigna-HealthSpring is unable to make exceptions to this requirement. Instructions for a Specialist to Obtain Referrals The Specialist can obtain referrals directly for the customer to another Specialist with the following limits:. Note: If all elements within the limits above cannot be met, the Specialist must defer back to the PCP for further services.

The Specialist may obtain referrals via HSConnect or fax. Specialist should use the fax method if the referral is not needed within forty-eight 48 hours. If the referral is needed in less than forty- eight 48 hours, the Specialist must use either the telephone referral process or HSConnect. Requests are not accepted via fax for membership in the Delaware, Maryland, Pennsylvania, and Washington, DC service areas. Detailed information regarding Part D drugs, their utilization management requirements prior authorization, step therapy, quantity limits , non-extended day supply limitations, any plan year negative changes, and most recent plan formularies is available here.

Cigna-HealthSpring utilizes the United States Pharmacopeia USP classification system to develop Part D drug formularies that include drug categories and classes covering a variety of disease states. Each category must include at least two drugs, unless only one drug is available for a particular category or class. The Part D utilization management is available here. Prior Authorization PA For a select group of drugs, Cigna-HealthSpring requires the customer or their physician to get approval for certain prescription drugs before the customer is able to have the prescription covered at their pharmacy.

All medications on the list are ones for which the AGS Expert Panel strongly recommends avoiding use of the medication in older adults. Due to these safety concerns, Cigna-HealthSpring requires Prior Authorization for these medications in all customers aged 65 and older to confirm that the benefits outweigh the risks, and that safer alternatives cannot be used. Quantity Limits QL For a select group of drugs, Cigna-HealthSpring limits the amount of the drug that will be covered without prior approval.

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A coverage determination CD is any decision that is made by or on behalf of a Part D plan sponsor regarding payment or benefits to which a customer believes he or she is entitled. For the provider call center, please call: 7 a. CST to 8 p. Any call received after 8 p. CST will be routed to a voicemail box and processed daily. To ensure timely review of a CD and that the prescriber is aware of what Cigna-HealthSpring requires for the most commonly requested drugs, drug-specific CD forms are available here or by requesting a faxed copy when calling For standard requests, the provider will receive the outcome of a coverage determination by fax no later than seventy-two 72 hours after the initial request receipt or receipt of the supporting statement, and for urgent requests, the provider will receive the outcome notification no later than twenty-four 24 hours after the initial request receipt or receipt of the supporting statement.

For a standard Part D appeal, Cigna-HealthSpring will provide a decision and written notice no later than seven 7 calendar days from the date the request received. If the request is regarding payment for a prescription drug the customer already received, an expedited appeal is not permitted. Cigna-HealthSpring provides access to more than 64, network pharmacies throughout the country. This extensive network gives our customers — your patients — convenient access to many pharmacies in their area to choose for their unique pharmacy needs.

Options range from large chain pharmacies to locally owned, independent retail pharmacies. Long-term care, home infusion, mail order, home delivery pharmacy options are available, as well. Preferred Pharmacy Network We also deepened our partnership with a large number of the pharmacies in our existing network to form a preferred pharmacy network to offer lower copays on most prescriptions. Our preferred network of pharmacies includes over 32, retail pharmacies across the United States. Large national and regional chains in the preferred pharmacy network include Walmart, Walgreens, and many of the most commonly used grocery store pharmacies.

There are also numerous local and independent pharmacies options in the preferred pharmacy network. A more detailed list of preferred pharmacies is available here along with the full listing of the provider directories by region , which include network pharmacy providers.

Preferred pharmacies are identified using a grey shaded box in the provider directories. Customers can choose to use a pharmacy in either the standard or preferred network according to their needs, but only preferred pharmacies can offer savings on prescription costs.

This can often result in significant total savings over the course of a year, especially for customers that take multiple prescription medications. The Narcotic Case Management Program is designed to identify patterns of inappropriate opioid utilization with the goal to enhance patient safety through improved medication use. Monthly reports are generated using an algorithm that identifies customers at risk of potential opioid overutilization based on the number of prescribers, pharmacies, and calculated morphine milligram equivalent MME per day. Any individual with cancer or on hospice care is excluded from the program.

The Cigna-HealthSpring clinical staff review claims data of all identified customers who meet the established criteria and determine whether further investigation with prescribers is warranted. If clinical staff is able to engage with prescribers, then action will be taken based on an agreed upon plan. In the most severe cases, clinical staff may collaborate with the prescriber s to implement customer-specific limitations to assist with control of inappropriate utilization or overutilization of opioid medications.

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UC Library's Cultural, Ethnic and Religious Awareness Resources for Nurses

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