The Basics

The DM program’s process for conducting individual consumer assessments must, under this standard:

• Specify the assessment tools and approaches the program uses for each clinical condition;
• Provides for consistent documentation of assessment results;
• Allows for adjustment of stratification level based upon the results of the assessment;
• Requires at least annual reassessment; and
• Is based on evidence.

Management Tips

The assessment described in this standard must be interactive with the program participant, not drawn from claims data.  In addition, your documentation must be able to show a connection between the assessment approach and the underlying evidence.  This is true for each condition in your program.

URAC Accreditation Tips

All five of the elements are weighted 4.

The essential documentation to submit to URAC is the P&P that describes the assessment process, how it relates to stratification, and how stratification relates to interventions.  A flow chart describing the process would be most helpful.

The onsite review involves a case file review to test the adequacy of the documentation of the assessment process, as well as a demonstration of the assessment process.  In addition, the reviewer will conduct staff interviews which likely will include questions such as:

• How would you describe the relationship between individual assessment and stratification [for a particular condition]?
• Once a person is assigned to a particular level, how does that assignment affect what interventions that person receives?
• How do you know when to reassess a program participant?  How is that assessment conducted?