Common use of ER Quality Initiative Program Clause in Contracts

ER Quality Initiative Program. 12.4.1 The Contractor shall develop an Emergency Room (ER) Quality Initiative Program, implementing efficient and timely monitoring of Enrollees’ use of the emergency room, including whether such use was justified by a legitimate Medical Emergency. 12.4.2 The ER Quality Initiative Program shall be designed to identify high users of Emergency Services for non-emergency situations and to allow for early interventions in order to ensure appropriate utilization of services and resources. 12.4.3 The ER Quality Initiative Program shall specify all strategies to be used by the Contractor to address high users of inappropriate Emergency Services and include, at a minimum, the following components: 12.4.3.1 Description of system(s) for tracking, monitoring and reporting high users of ER services for non-emergency situations; 12.4.3.2 Criteria for defining non-emergency situations; 12.4.3.3 Educational component to inform: (1) Enrollees about the proper use of ER services and how to access ER services; and (2) PCPs about identifying high users or potential high users of ER services and reporting to the Contractor; 12.4.3.4 Protocols for identifying high users of inappropriate ER services and referring them to Case Management for needs assessment and identification of other more appropriate services and resources; 12.4.3.5 Process for coordinating with and referring to MBHO upon identification of the need for behavioral health services and interventions based upon a needs assessment. 12.4.3.6 Quarterly reporting on ER services utilization; and 12.4.3.7 Process for monitoring and evaluating program effectiveness, identifying issues and modifying the ER Quality Initiative Program as necessary to improve service utilization. 12.4.4 The Contractor shall submit its ER Quality Initiative Program to ASES as part of its QAPI program.