Who is PCP and responsibility of PCP

Primary Care Providers

Primary care providers (PCPs) are responsible for monitoring the care of their Tufts Medicare Preferred HMO members to provide quality and cost-efficient medical management.

The PCP must be able to provide integrated, accessible health care services and be accountable for addressing a large majority of personal health needs, developing a sustained partnership with members, and practicing in the context of the family and community.
The following list encompasses a common set of proficiencies for all PCPs:

? Training in a primary care discipline, or significant additional training in primary care subsequent to training in a non-primary care discipline

? Periodic assessment of the asymptomatic patient

? Screening for early disease detection

? Evaluation and management of acute illness

? Ongoing management of members with established chronic diseases

? Coordination of care among specialists, including acute hospital care and long-term care

? Assessment and either management or referral of members with more complex problems requiring the diagnostic and therapeutic tools of a specialist or other health care professional.


Note: Any provider designated as a PCP must devote a significant percent of his/her clinical time in a practice that encompasses the above list of proficiencies. This list is adapted from the Report on Primary Care from the Institute of Medicine, 1996.




Responsibilities

PCPs are responsible for providing or arranging the total care of their Tufts Medicare Preferred HMO members. This includes providing high-quality, cost-efficient medical care and/or management. The PCP’s role in successfully recognizing and addressing the member’s needs is key to the success and satisfaction of the member, the medical group and Tufts Medicare Preferred HMOPCP responsibilities include the following:

? Providing care in a manner consistent with recognized standards of health care and in a culturally-competent manner to all Tufts Medicare Preferred HMO members, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities. Successful medical service management and coordination ensures continuity of care and eliminates test and procedure duplication.

? Being accessible to members 24 hours a day, 7 days a week via direct contact or through PCP-arranged provider alternative, another Tufts Medicare Preferred HMO participating provider.

? Coordinating services that allow for continuity of care and integration of services, including:



Continuous patient care and quality review

An initial assessment of the member’s health care needs within 90 days of the member’s initial enrollment Systems to address barriers to the member’s compliance with the physician’s prescribed treatments or regimens Procedures to ensure that members are informed by providers of specific health care needs that require follow-up care and receive care/treatment as appropriate Training in self-care and other measures that members should take to promote their health.

? Arranging for the continuation of benefits in the event of plan contract termination, non-renewal, or insolvency through the end of the period for which the Tufts Medicare Preferred HMO member’s premium is paid or hospital discharge date by the following:



Honoring all open authorizations for care

Placing outbound calls to affected Tufts Medicare Preferred HMO members who are scheduled for services and undergoing treatment plans to coordinate continuation of care

Providing an opportunity for members undergoing a treatment plan to continue to see providers who are no longer in the  etwork due to the group insolvency