You can get the name of a behavioral health specialist who will see you if you need one. You can also find a provider with our Find a Doctor tool or by viewing the provider directory. See your member handbook to learn more about your benefits. You don't need a referral from your primary care provider PCP to see a behavioral health specialist in your plan.
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There are some treatments and services your behavioral health specialist must ask Healthy Blue to approve before you can get them. For information about services that need preapproval, please see your member handbook. Sometimes knowing how to care for your health can be hard. Our case managers can help make it easier.
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Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. This call is a great chance to talk about what case management handles and if it could help you. Your case manager will work with you and your provider to set up a plan of care. Do you think you need case management services? We use data to find out if our Complex Case Management program could help you. We may call you about this program if you have:. As your child reaches adulthood his or her healthcare needs start to change.
By age 18, your young adult may want to find a primary care provider who treats adults. Healthy Blue is here to help, too.
Quality Management Requirements
As a Healthy Blue member, you have rights and responsibilities. They are listed in your member handbook. Do you want a printed version of your handbook? Sometimes, Healthy Blue needs to make choices about how we pay for care and services. This is called Utilization Management UM.
Quality Program - Provider Handbook
All UM choices are made from medical needs and current benefits we offer. We do this so you can be as healthy as possible. Some Healthy Blue services and benefits need prior approval. This means your provider must ask Healthy Blue to approve the services he or she wants you to have. The team decides if:. You or your provider can ask us to take another look at that care. Without some type of systematic approach, improvement work can become chaotic, ineffective, and unlikely to produce the outcomes desired. Some of these are covered in subsequent modules and include workflow mapping, audit and feedback, benchmarking, academic detailing, and best practices research.
Best practices research is a powerful but less well-known QI approach that you should make an effort to become very familiar with and comfortable using.
It can be used to identify the best process for activities such as managing lab test results, managing prescription refills, delivering adult immunizations, managing walk-ins, and caring for diabetic patients. The first step in best practices research is to clearly define the process you are seeking to improve and break it down into discrete elements or subprocesses.
The second step is to define what constitutes a best practice for each element or subprocess. The third step is to identify exemplars in the overall process or for each element or subprocess through peer nomination and confirmation through performance audit, or through chart audit reviews. The next step is to combine the methods used by exemplars into a best approach. Best practices research is an approach that can help you identify exemplar practices appropriate to spread.
Best practices research. Fam Med Feb, 35 2 Mold J, Peterson K. Primary care practice-based research networks: working at the interface between research and quality improvement. Search ahrq. Latest available findings on quality of and access to health care. Funding Opportunity Announcements. Practice Facilitation Handbook Module 4. Practice Facilitation Handbook. Module 1. Practice Facilitation as a Resource for Practice Improvement. Module 3. An Overview of the Facilitation Process. Module 4.
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Approaches to Quality Improvement. Module 7. Measuring and Benchmarking Clinical Performance. Module 9. Preparing and Presenting Performance Data. Tutvustus Sisukord Arvustused Goodreads'ist Offers a general resource in the field of behavioral health quality management, for students, payers and purchasers, administrators in managed care organizations, and public sector planners.
Contains sections on the changing context for quality management in behavioral health, tools for quality management, quality management in practice, and regulating bodies and their roles. This second edition is written in a way that is less technical and academically focused. The editor is affiliated with Adelphi University.
Annotation c. Book News, Inc. This handbook is designed as a general resource in the field of behavioral health quality management for a very diverse group of readers, including graduate and undergraduate students, payors, purchasers and administrators within managed care organizations, public sector service system planners and managers, applied health services researchers and program evaluators. This volume provides a comprehensive context for the development of quality management QM in health services - behavioral health in particular - as well as an overview of tools, techniques, and programs reflecting QM in practice.
It also offers perspectives on both internally- and externally-based QM activities.
Troy Sharon A. Sharfstein Anne M.