The Basics

this edition standard requires that your a disease management program implement P&Ps prescribing how your program communicates with treating providers in collaboration around the care of patients.  Those P&Ps must:

• describe when the program will refer patients' clinical questions to treating providers;
• define other circumstances under which the program staff will contact treating providers (both scheduled and unscheduled contact);
• provide information on providers' rights and responsibilities in relation to the disease management program.

Your organization has such a policy and procedure, so it is important that you familiarize yourself with that P&P in order to comply with the standard.

Management Tips

As is always the case when a standard specifically mentions "procedures", it will be insufficient that your program does the things mentioned in this standard.  Rather, you will need to have a policy and procedure that specifically addresses all three elements of this standard.  That P&P could specify several things:

• if it relies on patients to communicate to providers, how it will educate those patients in provider communications; or
• if it communicates with providers directly:
  • how it identifies the provider,
  • the circumstances under which it communicates not urgent information,
  • the circumstances under which it communicates urgent information, and
  • what to do if the patient has multiple treating providers.

Be specific -- anticipate and describe the types of questions that might be referred to providers and set forth, very specifically, what mechanisms (fax, letter, phone) will be used to contact providers.  A key test of the adequacy of the provider outreach is whether he/she is receiving enough information to identify the DM program and to access that program.

Even if your program relies primarily on consumers for communications with their treating providers, your P&P  must do must demonstrate your capacity to contact the treating provider in the event of an emergency.

Make sure you describe what providers' rights and responsibilities are, and how you convey them to the providers.  This is often overlooked by first-time applicants, particularly those that deal almost exclusively with consumers.

Beyond the development of the P&P lies the responsibility of developing a means of documenting interactions with patients and treating providers.  URAC expects that every communication with a provider regarding a specific patient be documented in that patient's record.

URAC Accreditation Tips

This standard carries a scoring weight of 4.

Documentation needed for the desktop review stage is simply a combination of the appropriate P&Ps and the staff training protocols. 

The onsite review will focus on staff interviews and any documentation of provider outreach to verify implementation of your P&Ps.