From the Medical Director

for Quality and

Care  Improvement

Dear Colleagues,

The GHC-SCW Quality Improvement (QI) program is dedicated to improving the quality of clinical care, service and safety provided to all of our members. Each year, we review our QI program efforts, prepare our annual report of the previous year and develop a work plan for the year ahead. The work plan includes information about our processes, goals and project outcomes as they relate to member care and services.

As we evaluate the QI program, we refine goals and priorities based on how performance measures compare against national benchmarks, best practices, internal benchmarks and our members' and Providers' needs. Improvement efforts primarily focus on clinical quality, behavioral health, service quality, patient safety and member experience.

I invite you to view our 2014 QI Annual Report and see the work going into furthering our continuous improvement journey. We remain committed to quality improvements that prioritize Triple Aim - "Better Care, Better Health and Lower Costs" - and focus our efforts in 2015 on patient experience and diabetes care improvements.

You can also access the report and plan when you visit www.ghcscw.com and select "Quality," located in the bottom footer section of the page under "About GHC-SCW." Printed copies can be requested by calling the GHC-SCW Quality Management department at (608) 828-4820.

Sincerely,

Jeff Huebner, MD

Medical Director for Quality and Care Improvement

1. Standards of Medical Care in Diabetes - 2014; including the executive summary
2. ACC/AHA Guideline on the Treatment of Blood Cholesterol - 2013
3. Screening Pelvic Exam in Adult Women; ACP - 2014

Access the approved Clinical Practice Guidelines on our website. 

• Living Well with Diabetes helps patients learn how to better understand their condition, self-manage diabetes through education, nutrition, physical activity, medication regimens and appointments with Dietitians and Certified Diabetes Educators.
• Asthma Disease Management works with members' Primary Care Providers and the Asthma Educator to provide the tools and knowledge needed to take control of asthma.
• Heart and Vascular Disease Management assists members' Primary Care Providers in educating patients on ways to control cholesterol, blood pressure and other risk factors associated with heart and vascular disease.

• Valid GHC-SCW health care coverage for their medical/behavioral health services; and
• A chronic disease diagnosis of two to three co-morbidities (CHF, COPD, diabetes, CA, depression/AODA) and/or multiple hospital admissions and/or emergency room visits within six months; or
• A catastrophic event and/or the complexity of services  

Utilization Management

Member Rights and Responsibilities

The right to:

1. Receive information about GHC-SCW, its services and its providers, including the right to receive a copy of the GHC-SCW Patient Rights and Responsibilities.
2. Be treated with dignity and respect in a confidential manner.
3. Participate with your providers in making decisions about your health care.
4. Participate in a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
5. Voice complaints about the service and care you receive without penalty or disenrollment.
6. Receive notification and a rationale when case management services are changed or no longer needed.
7. Receive a certificate outlining the coverage to which you and/or your family members are entitled, and to whom the benefits are paid.
8. Ask questions regarding your medical plan coverage, the preauthorization process or claims payment.
9. Submit complaints about appeals about GHC-SCW or the care we provide.
10. Select a Primary Care Provider and to request a new provider without indicating a reason.
11. Receive a full explanation of any charges billed to you as a result of care.
12. Participate in the governance of GHC-SCW. Each member must be at least 18 years of age to be a voting member of the Cooperative and is encouraged to actively participate in its operation.
13. Make recommendations regarding the organization's member rights and responsibilities.
14. Receive informed consent, as required by law, prior to procedures or treatments. To the extent permitted by law, it is your right to refuse the recommended treatment and be informed of the consequences of this decision.
15. Receive confidential treatment of all communications and records concerning your care, except as otherwise provided by law.
16. View and receive a copy of your health records and x-rays upon receipt of written authorization.
17. Receive a copy of the GHC-SCW Notice of Privacy Practices.

Responsibilities

The responsibility to:

1. Be considerate of others.
2. Observe safety and smoking regulations in all GHC-SCW facilities.
3. Treat GHC-SCW employees with consideration and respect.
4. Provide accurate and complete health care information.
5. Use facilities and equipment properly.
6. Read and understand your coverage.
7. Be on time for appointments and inform the clinic in advance when appointments cannot be kept.
8. Follow plans and instructions for care as agreed to with your provider.
9. Understand your health problems and participate in developing mutually-agreed-upon treatment goals.
10. Pay your financial obligations under the benefit plan.
11. Know and confirm your benefits before receiving treatment.
12. Obtain preauthorization for services indicated in your certificate.
13. Notify GHC-SCW of changes in your address, phone number or family status.
     

To review GHC-SCW Member Rights and Responsibilities, or view other documents related to member privacy such as the Notice of Privacy Practices, visit www.ghcscw.com and select "Privacy" in the black bar at the bottom of any page. Contact the GHC-SCW Privacy Officer at (608) 662-4899 or (800) 605-4327 or email jcoleman@ghcscw.comfor more information.

Recent Changes

Changes from September 2014 - April 2015

Additions