Information requirements _____ 12 Role of demand and capacity in supporting cancer care delivery _____ 14 . You can refer Tasmanians to specialist outpatient services. It will take your concerns into account when considering the most appropriate arrangements. Question: Part 1 refer to pages 370 and 371 answer to the following (10 pts) Outline (list)managed care requirements for patient referrals. Finding more information and committee details, 1.1 Governance for managing medicines safely and effectively, 1.2 Assessing and reviewing a person's medicines support needs, 1.3 Joint working between health and social care, 1.4 Sharing information about a person's medicines, 1.5 Ensuring that records are accurate and up to date, 1.7 Supporting people to take their medicines, 1.8 Giving medicines to people without their knowledge (covert administration), 1.10 Transporting, storing and disposing of medicines, NICE's guideline on managing medicines in care homes, Health and Social Care Information Centre's guide to confidentiality in health and social care, NICE guideline on medicines optimisation on sharing information about medicines when a person is transferred from one care setting to another, The Health and Social Care Act 2008 [Regulated Activities] Regulations 2014, The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, recommendation 1.9.10 on supplying medicines administration records, self-management plans in the NICE guideline on medicines optimisation, recommendations 1.6.4 and 1.6.5 on raising concerns or seeking advice, Mental Capacity Act 2005: Code of Practice. Medicaid Managed Care requires patients be seen by their PCP for a referral to a specialist. This includes details of all support for prescribed and over-the-counter medicines, such as: reminding a person to take their medicine. (VIII.C.2) Expert Answer Ans 1.a)Effects of Upcoding:- Effects of upcoding include higher medical costs for tax payers and the insured.it can have negative health ramifications for patients.it pouts false information on their medical records and can affect their future abili Start with an assessment of current referral processes to determine how well you manage referrals today. You should be given a copy of the completed checklist. Disclaimer. Kinn's Chapter 12: Health Insurance Essentials Flashcards PDF THE MANAGED CARE ANSWER GUIDE - RWJBarnabas Health ensuring that the patient is appropriately covered (if applicable). Inall cases, the overall need, and interactions between needs, will be taken into account, together with evidence from risk assessments, in deciding whether NHS continuing healthcare should be provided. Any support that enables a person to manage their medicines. PDF Managed Care Specialty Referrals and Authorization 2 0 obj Find out more about the children and young people's continuing care national framework on GOV.UK. the care worker is trained and assessed as competent (see also the section on training and competency). 1.4.3 Follow the advice in the NICE guideline on medicines optimisation on sharing information about medicines when a person is transferred from one care setting to another. 1.3.4 Health professionals should provide ongoing advice and support about a person's medicines and check if any changes or extra support may be helpful, for example, by checking if: the person's medicines regimen can be simplified, information about time-sensitive medicines has been shared, the formulation of a medicine can be changed, support can be provided for problems with medicines adherence. Specialist advice on how to help some users with specific moving and handling needs will also be useful. Bookshelf Let us know if this is OK. Well use a cookie to save your choice. The assessment should be person-centred and, where possible, involve the service user or their family in decisions about how their needs are met. Moving and handling in health and social care, Coding health and social care RIDDOR reports, Scotland NHS manual handling passport scheme, MHRA Device Bulletin DB 2006(06) Safe Use of Bed Rails, Safety alert - Vertical lifting platforms or lifts for people with impaired mobility, Scottish Manual Handling Passport Scheme (August 2014), Safety alert risk of death or serious harm by falling from hoists, commitment to introducing precautions to reduce that risk, a statement of clear roles and responsibilities, an explanation of what is expected from individual employees, arrangements for training and providing / maintaining equipment, a commitment to supporting people who have been injured in connection with their work, avoiding those manual handling tasks that could result in injury, where reasonably practicable, assessing the risks from moving and handling that cannot be avoided, putting measures in place to reduce the risk, where reasonably practicable, follow appropriate systems of work and use the equipment provided, co-operate with their employer and let them know of any problems, take reasonable care to ensure that their actions do not put themselves or others at risk, a statement of the organisation's commitment to managing the risks associated with moving and handling people and loads, details of who is responsible for doing what, details of your risk assessment and action planning processes, a commitment to introduce measures to reduce the risk, arrangements for providing and maintaining handling equipment, details of your systems for monitoring compliance with the policy and for regular review, information for staff on reporting pain and injuries, assisting in carrying out daily activities (such as bathing) with individuals who will have specific needs. This includes medicines supplied in monitored dosage systems. Care Quality Commission - CQC b. Before The remaining 23 states do not use comprehensive managed care to cover dual-eligible individuals but may coordinate care using other strategies (Figure 2, No managed care tab). This is to ensure that it is clear who is responsible and accountable for the decisions being made, and which providers will deliver each aspect of medicines support. For example: e-RS contains several search methods (for example using clinical terms) to find appropriate services and identify referral criteria. The Health and Care Act 2022 revoked Schedule 3 and amended Section 74 of the Care Act 2014 on 1 July 2022. . D|OA3$ GL@#6 } & <> Local health communities should come together to: The role of e-RS in the stages of referral management, Referral management - Lessons for success, treat patients as individuals with needs and concerns at very uncertain times of their lives, recognise the management of referrals as a clinical skill, maintain professional autonomy and responsibility for patients and their referrals, deliver financial savings but not at any price, Develop and maintain own professional skills, knowledge and experience, Use external resources and knowledge bases to check referral criteria or alternative treatment options, Arrange peer review by colleagues (for example within a referring practice or a clinical commissioning group), Seek advice and guidance from more qualified clinician, Request formal assessment/triage by a specialist clinician, Encourage rejection of inappropriate referrals by provider clinicians (for example consultants and AHPs), see what services are available in the community, note responses from advice and guidance requests, update knowledge based on advice in service details or links to external guidance, local and national referral forms - that check referral criteria have been met, should be aimed at determining the correct clinical pathway for the patient, where the referrer is unsure or where the options are complex, should provide added clinical value to the referral pathway, should minimise lengthening of referral to treatment times and be provided for specialties where proven benefits are likely, must be carried out by clinicians who are authorised and suitably skilled to be able to deviate from agreed protocols, based on individual patient needs, if required, should, wherever possible, involve a personal interaction between the provider clinician and the patient or their referring clinician, should take place at a pre-arranged time that the patient is aware of, should address the concerns and uncertainties of patients, prevent unnecessary and expensive referral management schemes, support education and training of referrers, promote benefits of effective referral management tools (for example e-RS), ensure adequate local (community) service provision is available as an alternative to hospital services via e-RS, promote patient choice and professional autonomy/responsibility for referrals, make provision for peer review and advice/guidance, maintain professional skills and education, support and understand patients rights to choice, be prepared to ask for advice from colleagues, meet regularly with colleagues to discuss referrals, audit referral outcomes and learn from feedback, ensure that all services are directly bookable on e-RS with adequate appointment capacity to match demand, ensure that the e-RS directory of service entries is accurate and contain appropriate information to support referrers, encourage all clinicians to review referrals on line and provide feedback where appropriate, empower clinicians to reject clinically inappropriate referrals, accept all clinically appropriate referrals, ensure that clinicians are involved at all stages of planning a referral management scheme, develop education, training and support groups, seek feedback from patients on their experiences of the referral process, make efficiency savings for the NHS - but not at the expense of quality. This is different from fully insured plans, in which the employer contracts with an insurance company to cover the employees and dependents. To help teams get the most from A&G services, weve developed a series of short guides which set out practical advice and information. Clipboard, Search History, and several other advanced features are temporarily unavailable. Generic assessments to consider the overall needs of the setting, looking at: the type and frequency of moving and handling tasks, what moving and handling would be required in emergencies such as fire evacuations or residents' falls. sharing sensitive information, make sure youre on a federal Identify what is needed to reduce the risk for all the tasks identified: to include appropriate techniques and training, equipment and accessories required for each task, number of staff needed etc. These concerns may include: the person declining to take their medicine, medicines not being taken in accordance with the prescriber's instructions, possible adverse effects (including falls after changes to medicines; see the NICE guideline on falls in older people), possible misuse or diversion of medicines, the person's mental capacity to make decisions about their medicines. For most people, there's an initial checklist assessment, which is used to decide if you need a full assessment. There should be recognition of the potential need for psychological and emotional support, as well as of the importance of meeting fundamental needs such as nutrition and pain management. This review will consider whether your existing care and supportpackage meets your assessed needs. Through better enabled communication, A&G provides GPs with access to consultant advice on investigations, interventions and potential referrals. other agencies, for example, when care is shared or the person moves between care settings. A "managed care" plan can be defined as an integrated system that manages health care services for an enrolled population rather than simply providing or paying for them. Some staff may have to adopt and hold awkward postures as part of their work, for example, nursing staff, sonographers and theatre staff. Moving and handling risk assessments help identify where injuries could occur and what to do to prevent them. Back to Health professionals include, but are not limited to, GPs, pharmacists, hospital consultants, community nurses, specialist nurses and mental health professionals. NHS-funded nursing care is available irrespective of who is funding the rest of the care home fees. Nursing questions and answers. Ramsbottom-Lucier M, Pregler J, Gomez AG. 1.1.2 Ensure that factors such as physical or learning disabilities, sight, speech or hearing problems and difficulties with reading, understanding or speaking English are addressed so that the patient is able to participate as fully as possible in consultations and care. 1.5.12 Give the patient both oral and written information. 1.5.2 Maximise patient participation in communication by, for example: maintaining eye contact with the patient (if culturally appropriate), positioning yourself at the same level as the patient. Nursing. 1.3.8 Respect and support the patient in their choice of treatment, or if they decide to decline treatment. Record this information in the provider's care plan. 1.4.6 Give the patient (and their family members and/or carers if appropriate) information about what to do and who to contact in different situations, such as 'out of hours' or in an emergency. NICE guideline [NG67] If the ICB decides you're eligible, but takes longer than 28 days to decide this and the delay is unjustifiable, they should refund any care costs from the 29th day until the date of their decision. 1.7.10 Supplying pharmacists and dispensing doctors must supply a patient information leaflet for each medicine supplied, in line with The Human Medicines Regulations 2012. Integrated care boards, known as ICBs (the NHS organisations thatcommission local health services), must assess you for NHS continuing healthcare if it seems that you may need it. 1.5.18 Advise the patient where they might find reliable high-quality information and support after consultations, from sources such as national and local support groups, networks and information services. Health professionals working in primary and secondary care have an important role in advising and supporting care workers and other social care practitioners. 1.5.28 Ensure that patient-education programmes: have specific aims and learning objectives, meet the needs of the patient (taking into account cultural, linguistic, cognitive and literacy considerations). 1.3.2 General practices should record details of the person's medicines support and who to contact about their medicines (the person or a named contact) in their medical record, when notified that a person is receiving medicines support from a social care provider. Solved 1- Outline (list)managed care requirements for - Chegg changes to the person's physical or mental health. The team will look at all your care needs and relate them to: Your eligibility for NHS continuing healthcare depends on your assessed needs, and not on any particular diagnosis or condition. Patients have needs other than the treatment of their specific health conditions. 1.10.1 Agree with the person and/or their family members or carers who will be responsible for transporting medicines to or from the person's home. Patients have needs other than the treatment of their specific health conditions. Delegation and referral. 1.9.7 Supplying pharmacists and dispensing doctors should supply medicines in their original packaging. NHS continuing healthcare - Social care and support guide PDF Introduction: What you will Find in This Module - Centers for Medicare Initiate a referral. This question was created from D. Submitting Claims to Third-Party Payers 1. This platform hosts a range of tools and resources to support local health systems implement A&G services. Change my preferences 1.4.1 When social care providers have responsibilities for medicines support, they should have robust processes for communicating and sharing information about a person's medicines that take account of the person's expectations for confidentiality. Lin CT, Albertson G, Price D, Swaney R, Anderson S, Anderson RJ. 1.9.1 Social care providers should agree with the person and/or their family members or carers who will be responsible for ordering medicines, and record this information in the provider's care plan. Below are theresponsibilities of different organisations involved in developing a referral management plan. Referring clinicians should accept feedback and referral outcomes as a positive learning experience. The .gov means its official. Enhancements include: More information, including training materials and details of awareness sessions, are available on the NHS Digital website. Regular meetings, as agreed upon by the MCP and MHP to review the referral and care coordination process and to monito member engagement and utilization. These should ensure that records are: accessible, in line with the person's expectations for confidentiality. Accessibility They require consumers to pick a primary care physician (PCP) who will supervise their treatment under these plans. 1.9.3 When social care providers are responsible for ordering a person's medicines they should not delegate this task to the supplying pharmacist (or another provider), unless this has been requested and agreed with the person and/or their family members or carers. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. This may involve the patient seeing the same healthcare professional throughout a single episode of care, or ensuring continuity within a healthcare team. In Referral Circle: Professionals within the Primary Care Physicians circle of specialist: Emerson Hospital then Mass General Hospital. These services should be made available on e-RS to provide referrers with an easy way of identifying what is available locally. Describe the electronic claim form. Patients should be referred to secondary care if other coagulopathies co-exist, or if the INR is unstable or if they fulfil any of the criteria described in the referral guidelines. How to refer a patient to another doctor | The Jotform Blog and transmitted securely. Patients' values, beliefs and circumstances all influence their expectations of, their needs for and their use of services. Patients wish to be seen as an individual within the healthcare system. NHS services and treatments - NHS The following guidance is based on the best available evidence. Page last reviewed: 25 March 2021 4. Visit the Beacon website or call the free helpline on 0345 548 0300. Fusce dui lectus, congue ve, View answer & additonal benefits from the subscription, Explore recently answered questions from the same subject. 1.10.4 When social care providers are responsible for storing a person's medicines, they should have robust processes to ensure there is safe access to medicines, particularly for controlled drugs (for more information see NICE's guideline on controlled drugs). People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care. Would you like email updates of new search results? The utilization review committee reviews individual cases to ensure the medical care services are medically necessary. 1.5.11 Give the patient information, and the support they need to make use of the information, in order to promote their active participation in care and self-management. I'm OK with analytics cookies. Redirection should be considered as an alternative to rejection where the referral is appropriate, but where a more suitable clinic or service exists. <> 1.4.3 Ensure clear and timely exchange of patient information: between healthcare professionals (particularly at the point of any transitions in care). Nam lacinia pulvinar tortor nec facilisis. what the user of the care service is able/unable to do independently, the extent of the individual's ability to support their own weight and any other relevant factors, for example pain, disability, spasm, fatigue, tissue viability or tendency to fall, the extent to which the individual can participate in/co-operate with transfers, whether the individual needs assistance to reposition themselves/sit up when in their bed/chair and how this will be achieved, eg provision of an electric profiling bed, the specific equipment needed including bariatric where necessary and, if applicable, type of bed, bath and chair, as well as specific handling equipment, type of hoist and sling; sling size and attachments, the assistance needed for different types of transfer, including the number of staff needed although hoists can be operated by one person, hoisting tasks often require two staff to ensure safe transfer, the arrangements for reducing the risk and for dealing with falls, if the individual is at risk, ergonomists with experience in health and social care, organisations such as the National Back Exchange or Chartered Society for Physiotherapists, Ensure that your assessor is suitably trained and competent. Properly positioned, the helper may prevent a fall or allow a controlled slide. Section 2: Making Appropriate Referrals: The Referral Decision Process Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. The person or organisation responsible for implementing a recommendation is clearly stated, except when it is not possible to specify. not discuss the patient in their presence without involving them in the discussion. Further information is available on the National Elective Care Transformation Programmes Community of Practice site. About advice and guidance and points to consider - NHS Digital 1.5.14 Explore the patient's preferences about the level and type of information they want. 1.1.5 Avoid making assumptions about the patient based on their appearance or other personal characteristics. affect their ability to manage their own care and make decisions about self-management and lifestyle choices. The MDT should usually include both health and social care professionals who are already involved in your care. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. If the person needs medicines support include the following information in the provider's care plan: how consent for decisions about medicines will be sought, details of who to contact about their medicines (the person or a named contact), who will be responsible for providing medicines support, particularly when it is agreed that more than one care provider is involved. When and how to refer patients to a fellow physician | PatientPop Donec a, molestie consequat, ultrices ac magna. doi: 10.1046/j.1525-1497.1999.00262.x. hV[8+~y 8YUH0iROpj&b;$\V*2>|> DEXSX@a(1"s1AyLQ#@ a #Ib b$cq '`5 &H%JwxM] 1.3.5 When specific skills are needed to give a medicine (for example, using a percutaneous endoscopic gastrostomy [PEG] tube), health professionals should only delegate the task of giving the medicine to a care worker when: there is local agreement between health and social care that this support will be provided by a care worker, the person (or their family member or carer if they have lasting power of attorney) has given their consent, the responsibilities of each person are agreed and recorded. Individuals may become upset or agitated when being moved. Services within managed care plans are usually delivered by providers who are under contract to, or employed by the plan. An example of a person-based manual handling risk assessment can be found in the All Wales NHS manual handling passport scheme and Scotland NHS manual handling passport scheme. 1- Outline (list)managed care requirements for patient referrals. A&G services improve the interface between primary and secondary care. informing the person's supplying pharmacy, if this is needed and agreed with the person and/or their family members or carers. The recommendations in this guideline assume that the responsibilities for providing medicines support have been agreed between the relevant NHS and local authority commissioners. No, it is not possible to top up NHScontinuinghealthcare packages, like you can with local authority care packages. Nam lacinia pulvina, ur laoreet. This varies for different people depending on their specific needs. The https:// ensures that you are connecting to the The content of this policy will depend on the responsibilities of the social care provider, but it is likely to include processes for: assessing a person's medicines support needs, supporting people to take their medicines, including 'when required', time-sensitive and over-the-counter medicines, joint working with other health and social care providers, sharing information about a person's medicines, ensuring that records are accurate and up to date, managing concerns about medicines, including medicines-related safeguarding incidents, giving medicines to people without their knowledge (covert administration), transporting, storing and disposing of medicines. Weve put some small files called cookies on your device to make our site work. Managed care - Wikipedia $.' Patient demographic information full name date of birth name of parent or carer (if applicable) address telephone number (s) email address alternative contact details preferred method of communication Medicare number These are to: Any referral management plan should include the following 6 steps to support referrers: e-RS can support all the six stages of referral management listed above. Making a referral for support | Safe and Equal The term 'medicines support' is defined as any support that enables a person to manage their medicines. If you don't get a referral first, the plan may not pay for the services. 15. 1.6.6 Health and social care practitioners should encourage and support people and/or their family members or carers to raise any concerns about their medicines. 3 0 obj The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). Differentiate between fraud and abuse MEDA140 6 2015 IX.C. 0 1.5.1 When social care providers have responsibilities for medicines support, they should have robust processes for recording a person's current medicines. who is responsible for their clinical care and treatment, the roles and responsibilities of the different members of the healthcare team. To be eligible for NHS continuing healthcare, you must be assessed by a team of healthcare professionals (a multidisciplinary team). Moving and handling in health and social care: What you need to do - HSE Combatting Patient Leakage by Directing Physician Referrals - Mintz medicinesrelated staff training and assessment of competency. 1.5.7 Use open-ended questions to encourage discussion. Advice and Guidance (A&G) services are a key part of the National Elective Care Recovery and Transformation Programmes work. Managed care plans require that you obtain a referral and/or authorization prior to seeking specialty services. Answer any questions the patient may have about these. 1.1.6 Take into account the requirements of the Equality Act 2010 and make sure services are equally accessible to, and supportive of, all people using adult NHS services. See also NICE's guideline on multimorbidity. These insurance plans require patients to select a PCP and the P.CP must manage their healthcare. 1.4.2 For patients who use a number of different services (for example, services in both primary and secondary care, or attending different clinics in a hospital), ensure effective coordination and prioritisation of care to minimise the impact on the patient.

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