The Basics

This mandatory standard requires that your DTM program provides feedback to those providers that participate in the program as needed in order to improve quality of care and to coordinate the care delivered to participating consumers.  That feedback might take the form of practice profile information or communication to providers about specific performance issues.

Management Tips

Your governing policy and procedure or program description for this standard should provide members of your staff with criteria for providing feedback to participating providers.  Your policy may provide for a variety of methodologies of communicating with providers, including letters, reports, with a consumer drug therapy management record.

URAC Accreditation Tips

This is a mandatory standard.

For the desktop review, you should submit the applicable policy and procedure, as well as samples of the feedback that you provide to participating providers via complaint logs, criteria, or practice profile reports.

The on-site reviewer will interview clinical staff about they provide feedback to participating providers.  In addition, he/she will examine reports to providers and/or consumer records for evidence of contacts with providers, particularly in urgent situations.

The Basics

URAC requires that your DTM program's disclosures of program evaluation, required by the previous standards, include these components:

• a description of the program evaluation methodology;
• a description of the strengths and limitations of that methodology; and
• any available external validation of that methodology.

In other words, the standard merely puts meat on the bones of the previous standard, describing what elements should be in the reports you provide to prospective and current purchasers when they request your program evaluation documentation.

Management Tips

The requirements of the standard can be incorporated into the policies and procedures submitted for the previous two standards.

URAC Accreditation Tips

The basic requirement that you describe your program evaluation methodology is mandatory; the other elements (strengths and limitations and external validation) are Leading Indicators, and are therefore optional.

The desktop review submission should include both policy and procedure describing a year staff should handle requests for performance evaluation reports and sample reports provided to current and prospective purchasers.

The on-site reviewer will examine data and information that you provide to purchasers.  In addition, he/she will interview staff members to assess their understanding of the process.

The Basics

This short, mandatory standard simply requires that your organization, upon request from current and prospective purchasers, reports the results of the program evaluation described in the previous standard.  Naturally, the program will have to be careful that all privacy laws are protected in that reporting process.  Your organization no doubt has a policy and procedure that describes how you receive such requests from current and prospective purchasers and which reports you will provide upon request.  Be sure you're familiar with your organization's policy on this subject.

Management Tips

Management's job here is to make sure that you have a policy and procedure that clearly describes to your employees how they will respond to a request from a current or prospective purchaser for outcomes data.  That policy and procedure should include a sample template of information provided to the purchaser.

URAC Accreditation Tips

This is a mandatory standard.

The program description or policy and procedure describing the release of outcomes measurement and program evaluation information to prospective and current purchasers will be all that you need to submit for the desktop review.

The on-site reviewer will examine randomly selected reports you provide to clients and potential purchasers.  In addition, the reviewer will interview staff members to make sure that they are trained on how to respond to such a request.

The Basics

This standard sets forth very specific requirements of your DTM program's periodic program evaluation process.  This process must be a detailed cost/benefit analysis.

First, the evaluation process must address projected clinical and health-related outcomes using, at least, the following performance measures:

• previous clinical and health-related outcomes;
• clinical and health-related outcomes for current purchasers;
• projected clinical outcomes for current or prospective purchasers; and
• how lab values and health screening data will be used in conjunction with self-reported data.

Second, the evaluation process must assess the financial benefits of the program using, at least, the following performance measures:

• previous financial outcomes;
• previous financial outcomes for current purchaser; and
• projected financial outcomes for new or prospective purchasers.

Third, the program evaluation must assess the impact of the program using other outcomes of the program in addition to those clinical and financial outcomes described above.

Management Tips

Your program evaluation documentation should be very explicit in outlining the clinical, financial, and other outcomes used.  As these measures relate to individual consumers, your program evaluation should involve a baseline assessment for those consumers against which you can compare subsequent health outcomes.  Possible metrics that you can use regarding financial outcomes could include claim costs, costs extrapolated from risk categories and health metrics, or Quality Adjusted Life Years, or the cost of employee recruitment and retention.

URAC Accreditation Tips

The 13 elements of the standard range from Leading Indicator to Mandatory.

For the desktop review, you should submit your evaluation methodology, which should include a detailed description of your outcome measurements.  In addition, you should submit sample quality management committee meeting minutes demonstrating that the committee has evaluated the outcomes.

The on-site reviewer will interview staff members about the outcomes measurement processes for the program evaluation.  In addition, the reviewer will want to see reports to clients or purchasers, meeting minutes, and even marketing materials for potential clients.

The Basics

This standard requires that your DTM program have a quality measurement process.  It must be read in conjunction with the quality management standards in the PHARM Core module. Those standards outline in detail URAC's requirements of the organization's quality management program.  If you are involved in quality management of the DTM program, you will need to know about those requirements.

Management Tips

The quality management program description that is used to meet the QM standards in the PHARM Core module will need to specifically address the quality measurement within the DTM program.  Make sure not only that the program description addresses DTM, but also its implementation within the DTM program is fully documented.

URAC Accreditation Tips

This standard is weighted 3.

All you need to submit for the desktop review is the quality management program description and or the drug therapy management program description, whichever describes the quality measurement program.

During the on-site review, your program leadership will give a presentation describing the quality management program, including your quality improvement projects, particularly as it relates to drug therapy management, to the on-site reviewer.

The Basics

This standard requires your program to spell out in a policy and procedure how it provides information to consumers who might benefit from other resources that might be available to them both from the purchaser and/or the external health-care system.  Naturally, this applies only in those cases where your program has been contracted to provide this kind of coordination service.  Check your program's documentation to be sure you are familiar with whether and how your organization provides this kind of referral information.

An example of this kind of coordination might be if you refer a consumer to specialty programs offered by the purchaser or to targeted services offered by a community health organization.

Management Tips

You will need a policy and procedure explicitly addressing this issue.  That policy and procedure should provide clear instruction to staff, including scripts where appropriate, on when and how such referrals must be made.  In addition, staff must be trained in how to document those referrals for each consumer where appropriate.

URAC Accreditation Tips

Both elements of the standard are mandatory.

For the desktop review, submit the required policy and procedure as well as any templates and scripts guiding staff members on how to conduct these referrals.

The key to the on-site review is that your staff members who might make such referrals be well-trained in how to do so consistent with your organization's policies.

The Basics

This standard spells out the requirement that your organization clearly communicate to consumers their rights and responsibilities.  Minimum requirements include the right to:

• know about your program's philosophy;
• have personal health information handled in compliance with the law;
• know the identity of the DTM program staff member with whom the consumer is dealing, including the right to talk to a supervisor;
• receive current information about program;
• receive information about significant program changes;
• decline participation at any point along the way.

In addition, the consumer must be advised of his/her responsibility to:

• submit appropriate forms required for program participation;
• provide accurate information;
• notify their treating physician of their participation in the DTM program.

This standard requires that all of this information be provided in some form to the consumer shortly after his/her enrollment.

Management Tips

In addition to the appropriate policy and procedural program description, you'll need to make sure that you have complete templates, scripts, letters, or Web content that provide all of this information regarding consumer rights and responsibilities.  As important is that you document how and when your staff provides this information to each consumer who participates in your program.

URAC Accreditation Tips

Nearly all of the elements of the standard are weighted 4, with the exception of the element regarding personal health information, which is mandatory.

Your desktop review submission should include sample templates, scripts, and other communications of rights and responsibilities.  In addition, he should submit sample documentation of how you document that your staff members have provided this information to consumers.

During the on-site review, the reviewer will examine randomly selected consumer records to make sure that each consumer has received his/her notification of rights and responsibilities.  In addition, if consent is applicable, the reviewer will be looking for documentation of that consent.

The Basics

This standard fleshes out the more general requirements regarding consumer communications that are spelled out in other standards in the PHARM Core module by more specifically requiring that your DTM program ensures that that communication system:

• provides program staff with the capability of receiving and returning phone calls;
• has clearly specified hours of operations that are communicated to consumers;
• operates within clear criteria for how to handle inbound and outbound calls;
• provides for documentation of performance evaluation.

This communication system must handle both ordinary and emergency situations.  In addition, the system must specifically address how your organization handles inbound calls that take place outside of your normal hours operation.  Make sure you are familiar with your organization's policies and procedures regarding this communication system.

Management Tips

The intent of this standard is to ensure that your program provides communications services that are appropriate to both your program and its participants.  Your job as a manager concerning this standard is to make sure that your documentation, both of policies and procedures and of processes, address every element of the standard.  Be sure that your logs of consumer communications are well kept, and that you evaluate your organization's communications system performance periodically.

URAC Accreditation Tips

The elements of the standard vary from a weight of three to mandatory.

The essential document to submit for purposes of the desktop review will be your program description or policy and procedure.

The on-site reviewer is likely to ask for a demonstration of how your communications system works, including how it tracks incoming and outgoing calls.  He/she is also likely to interview staff members involved in the operation of the communication system.  Finally, the on-site reviewer almost certainly will listen to any recorded voicemail messages, particularly those handling inbound calls outside of normal business hours.

The Basics

The intent of this standard is to make sure that your DTM program empowers consumers to make decisions regarding the course of the program.  The standard accomplishes this by requiring that your program spell out in policies and procedures mechanisms by which:

• your organization will make information available to consumers to help them with decision-making;
• those decision support tools are made available to the consumer; and
• your program engages consumers in empowered decision-making.

Your organization has some flexibility as to how it provides this information, including in person, by mail, telephonically, or online.  Make sure you are familiar with the particular blend of media your program uses.

Management Tips

Your documentation needs to be explicit about how your organization supports the empowerment of consumers in decision-making throughout the program.  Make sure that the applicable policy and procedure or program description is explicit regarding the requirements of all three elements of this standard.

URAC Accreditation Tips

Each of the three elements of the standard is weighted 3.

In addition to the applicable policy and procedure regarding consumer decision-making, you should submit for the desktop review examples of decision support tools that you provide consumers.

During the on-site review, in addition to staff interviews, the reviewer will conduct a review of your consumer decision-support instruments that you described in your policies and procedures.

The Basics

The standard supplements the previous standard's requirements for program integration by adding the requirement that your program coordinate communications, materials, and procedures with the purchaser's health and service offerings.  In other words, not only must your program be coordinated, but the distribution of your educational materials must be coordinated as well.

Management Tips

The policies and procedures that you used for the previous standard should simply be broad enough to include explicitly these requirements regarding consumer materials distribution and maintenance.

URAC Accreditation Tips

This standard is weighted 3.

In addition to the applicable policy and procedure, you should provide a sample of program materials that show evidence of being explicitly coordinated with your purchaser's specific program.

Again, the onset review will involve an examination of consumer materials plus an interview with staff members.