The Basics

This standard deals with coordination of services between the DM program, its clients, and other healthcare organizations and programs (including case management and pharmacy).  Specifically, it requires that your program have a written description of:

• how your staff members gain access to patients’ benefit information;
• how the program coordinates patient referrals (which may include working with the client and other providers to coordinate care);
• what staff members should do to manage patients with comorbidity;
• how staffers communicate with other healthcare entities in the event of the transfer of the patient or his/her termination from the DM program.

Management Tips

Be sure your P&Ps clearly spell out how members of your staff members:

• get a patient’s benefit information;
• work with the client and with other healthcare programs to coordinate the patient’s care;
• refer and/or manage the care of patients facing comorbidities; and
• handle transitions of care and terminations from the program.

URAC Accreditation Tips

All four elements of this standard carry a weight of 4.

For purposes of the desktop review, submit a P&P that meets the requirements outlined in “Management Tips.” 

The onsite review will include an interview of staff members asking:

• How do you access the patient’s benefit information?
• How do you find out whether a patient has a comorbid condition, and what do you do when you find out that he/she does have such a condition?
• What is the program’s policy about how you should handle referrals to other healthcare organizations or programs?