Integrating Member Information

It’s been way too long since my last post.  A combination of writer’s block and lots of deadlines conspired to prevent blog entries.  I apologize to those of you who’ve been periodically looking here for new information. 

I write the entries myself—unless the entry notes that it’s been written by someone else—and sometimes I just can’t keep up with my editorial calendar. 

Anyhow, enough of that.

Integrating member information is an element in the Disease Management Standard for NCQA’s Health Plan Accreditation program.  Questions have arisen about just what NCQA expects for such integration, given that the areas involved are ones that are frequently delegated. 

Just to recap, QI 8I, Integrating Member Information, requires that the health plan integrate information between a health information line, a disease management program, a case management program, and a utilization management program to facilitate access to member health information for continuity of care. 

Even when one or more of these functions are delegated, NCQA expects the integration of member information to occur.  This integration can be quite a challenge without delegation!

What you need to think about is whether the current systems and processes will allow staff performing each of these different functions to have access to member information when needed.  Consider for example:

·        If a member in the asthma disease management program called the health information line to get advice on what to do for a bee sting that seemed to be getting worse, would the staff at the health information line know that the member had asthma and was in the asthma disease management program?

·        If a member in a complex case management program were hospitalized, would the complex case management staff know of the hospitalization?  How long would it take for them to find out?

I could go on, but you get the idea.  Come up with a series of scenarios for how members could utilize the services provided by each of the four components mentioned above, and see if your current systems and processes would allow staff to have access information about the member’s involvement with the other program(s). 

Despite the fact that NCQA does not typically look at documentation prepared by delegates, except for the file review standards, this may be an element where delegate-prepared reports will be needed to demonstrate that the integration is, in fact, happening.