GVHP'S Team Approach To Health Care

GVHP is a health care delivery system. GVHP owns and operates several GVHP Family Health Centers. This is one part of our unique delivery system. What are the other parts?

Let's learn what a GVHP Family Health Center is. A GVHP Family Health Centeris much like any physician office. There are doctors, physician assistants, nurse practitioners, and nurses. But there is more! There are x-ray technicians. There is pharmacy staff. Your GVHP Family Health Center is there for you!

GVHP calls its physicians, nurse practitioners, and physician assistants "PRACTITIONERS". We will use this special word in the handbook.

Who's On Your Team?

Family Health Center Physician

Family Health Center physicians are specialists in family medicine. The doctors complete a residency program. This gives them training in key medical areas. They train in pediatrics. This is about learning about children, their development and illnesses. They train in obstetrics. This is learning about pregnancy, labor, delivery and after-birth. They train in gynecology. This is about learning about diseases relating to women. Their training includes internal medicine. This is the study of the internal workings of the body. They train in community medicine and surgery.

Physician Assistants and Nurse Practitioners

Physician assistants (PAs) and nurse Practitioners (NPs) are other types of medical professionals. We often call them mid-level Practitioners. The PA and NP work under the supervision of a Family Health Center physician. Both receive post-graduate training in medical and clinical sciences. PAs and NPs must meet specific educational requirements and strict licensing standards. They must also be board-certified. Just like a family physician, this happens every six (6) years. They are able to diagnose and treat most medical problems. They can write prescriptions and do health assessments and exams.

WHEN YOU VISIT YOUR GVHP FAMILY HEALTH CENTER, YOU WILL MOST LIKELY SEE BOTH A PHYSICIAN AND A PHYSICIAN ASSISTANT (PA) OR NURSE PRACTITIONER (NP). WHO YOU SEE DEPENDS ON YOUR PREFERENCE AND YOUR MEDICAL NEEDS.

There are other health care professionals on your team. These professionals also are trained and licensed in their special health care area. They work in support of your “primary” health care needs. These professionals include . . .

Nursing Staff

Registered nurses (RNs) are part of GVHP’s nursing staff. Licensed Practical Nurses (LPNs) and Medical Assistants (MAs) are also part of this staff. Each must complete a specific educational and training program. Their training allows them to take medical histories. They also can monitor your blood pressure and draw blood samples. They receive training on giving immunizations and allergy injections. They assist during routine examinations. Nursing staff can answer your medical questions over the phone. Nurses will suggest possible home care when appropriate. They are trained to assess your symptoms. They help make the right appointments for your needs.

Specialty Care Nurse

GVHP has a team of specialty care nurses. These nurses work on your behalf. The Specialty Care Nurse contacts you when you are in the hospital. She or he helps organize your care. She or he also arranges any special needs after you leave the hospital. The Specialty Care Nurse helps you understand your condition. This includes talking to you about treatment options and your doctors’ recommendations. Finally, Specialty Care Nurses provide case management services for members with more complex medical conditions. Case Management services are arranged for you by your Family Health Center Team. If at any time you believe you would benefit from case management services, contact your GVHP Family Health Center or Customer Service at 616-949-2410 or 800-335-1977.

Registered Pharmacist

GVHP operates its own pharmacies. GVHP pharmacies are staffed by registered pharmacists. The registered pharmacist supervises pharmaceutical and drug services at GVHP Family Health Centers. In addition, he or she works closely with your GVHP Family Health Center team. He or she is there to answer questions about your medication. All GVHP pharmacists are licensed by the State of Michigan.

Your GVHP Family Health Center team also has other staff working to help you with your Family Health Center appointment or referral needs. They strive to make this happen in a smooth and orderly manner. This staff includes . . .

Patient Care Coordinator

The Patient Care Coordinator is your advocate at the GVHP Family Health Center. She or he works to support your service needs. She or he is usually the first person you meet when you go the GVHP Family Health Center. The Patient Care Coordinator schedules your appointments. She or he helps you understand your health professionals' instructions. She or he can also answer many questions you may have. She or he can also help with any concern you may have about your health care or services.

Specialty Care Coordinator

The Specialty Care Coordinator helps you when you need a referral. If you and your GVHP Family Health Center Practitioner decide you need to see a specialist, she or he arranges your physician appointments outside of your GVHP Family Health Center. She or he also schedules tests, procedures and surgeries. She or he can answer any questions you have about bills. Finally, the Specialty Care Coordinator answers questions about non-covered services. Non-covered services are services that are not covered under your GVHP MIChild Certificate of Coverage.

SO . . . . What does this all mean? You get the best possible and most complete health care. We also are about quality care and service. The team approach helps us do this. We make sure the right person is doing the right thing. At the right time and place.

REMEMBER YOU are part of the team!

Making Decisions About Your Health Care

GVHP believes your health care decisions are a shared responsibility. Who shares this responsibility? You, your family and health care professionals! Health care professionals must tell you about your health status. This includes giving you information about your medical condition and treatment options. You, tell us about your health history and medical needs. If you want, your family can be included. They can give us other information to help us in treating you.

If you ask for a treatment or service that is unusual or rare, we might need to do some research. You or your Health Care Practitioner can request an opinion from our Vice President of Medical Affairs (VPMA). The VPMA will look into your request. He or she will then recommend the best treatment option for you. What something costs is not as important as you getting better. The VPMA will recommend the type of care or plan that is proven to be the best way to help you get better. (See also Requests for "Special Services:" The GVHP Medical Opinion Process.)

When you picked GVHP, most likely you had to choose a new doctor. We will work with you to make sure your care is transferred without a problem. We will work with you to choose where you go and who provides your care. This happens based on your needs and our experience of where you can receive the best care. Your GVHP Family Health Center team and you make the decision.

We want you to be part of the decision process. To do this, your GVHP Family Health Center team needs your attention. The more informed and involved you are in your own care, the better the care.

GVHP providers are committed to good communication with our members. They promise to:

1. Listen to you carefully
2. Care about what you think
3. Explain things well to you
4. Treat you with respect
5. Understand your health concerns
6. Speak to you in terms you can understand
7. Encourage you to ask questions
8. Spend enough time with you

Your time is valuable to us. We know you are busy. We want to help you make the most of your visits. You can do this by preparing ahead of time for your visit. To help make the most of your next visit, we have put together a list of things to do prior to your visit.

1. Get ready for your office visit. Write down what you want to tell your provider. For example, is anything unusual or abnormal? When did it start? What remedies have you tried?
2. Write down what you want your GVHP Family Health Center practitioner to do. For example, do you want pain relief? Tests? A referral? A prescription? Do you need help in figuring out what is wrong? Or, do you need reassurance about symptoms?
3. When you go to your appointment, pull out your “list” and share it!
4. Make sure your Practitioner is clear about what you said.
5. If a medical term or word is used that you do not understand, ask what it means.
6. When your health care practitioner says the “best option is . . .” Listen. Then, ask why? If you do not agree, tell your GVHP Family Health Center practitioner. Ask if there are other options.
7. Ask specific questions. For example, “How long will it take to heal?” “What are the side effects?” or “How will this affect my daily activities?”

If you are unhappy with your care for any reason, tell your GVHP Practitioner. He or she wants you to be satisfied. Changes cannot be made unless you are honest about what is bothering you. Get more out of your health care. Be involved! Be an active team member!

Understand that everything you need for care may not be covered. If you do not agree, it is your right to appeal through our grievance/appeal process.

Confidentality & Release of Information to Us

As a GVHP member, you have rights. One is the right to confidentiality. Confidentiality means your medical information is kept private. This information cannot be given out without your permission. We take confidentiality seriously. When you join GVHP, you agree to let us have access to your medical information. You also agree to let us use your medical information for certain business functions. This use is strictly limited.

So, what does this mean? It means you allow your GVHP Family Health Center team to review your medical information. We use this information to give or arrange your care. You also allow GVHP to show your records to state and federal agencies. Regulatory groups review us. They make sure we meet standard requirements. We also use your medical information to pay claims.

GVHP keeps all information confidential. We have strict rules. We will not release this information without your permission. GVHP Notice of Privacy Practices explains these rules.

You can look at your medical records during business hours. To receive a copy of your records, you need to fill out a form. This is a Release of Information form. There might be a cost for copying your medical records.

Please Note:
Children under 18 years of age have certain rights to confidentiality. These rights come from state or federal laws. This means, in some cases, we are not able to share information. Even with parents and guardians. Your child needs to sign Release of Information if they want you to receive this information. What information is protected? Information on behavioral health, sexual activity or abuse and physical abuse situations are protected.

Your Grand Valley Health Plan Membership Card

Your membership or ID card is a key to medical services. It identifies you as a GVHP member.

Always carry your membership card. Present this card whenever you receive services. Don’t have your card yet? Simply call your Customer Service Team at 616-949-2410 or 800-335-1977. We will verify your eligibility. We will check on the status of your card. Misplace or lose your card? Information on the front is incorrect? Simply call Customer Service at 616-949-2410 or 800-335-1977. GVHP will send you a new card. It takes approximately 10 business days to receive a new card.

There are two sides to your card. The front of the card gives information about your Health Center. This includes the phone number used to reach your GVHP Family Health Centeror access after hours care. Below is a sample id card:

Grand Valley Health Plan Grand Valley Family Health Center(1) Phone Number: (2) GVHP Membership Card Member: (3) ID#: (4) Group#: (5)

Contents of the Front of Your Card:

1. GVHP Family Health Center: This is the name of your GVHP Family Health Center.
2. Phone Number: This is the telephone number of your GVHP Family Health Center. Call this number 24 hours a day. 7 days a week.
3. Member: This is the name of the cardholder.
4. ID #: This is your individual identification number.
5. Coverage Code: This number identifies the group you belong to.

The Back of Your Card

The back of your card tells you what to do in case of an emergency. Below is the back of your card:

Your Rights And Responsibilities

As a GVHP member, you have certain rights and responsibilities. These fall under the Grand Valley Health Plan Member Bill of Rights and Responsibilities.

Your Rights

• The right to receive information about GVHP. Our services. Our Practitioners and providers (including any incentive plans). And our member rights and responsibilities.
• The right to have timely and appropriate medical care. Delivered in the appropriate setting.
• The right to be satisfied with your choice of GVHP Family Health Centers. To have a choice within your health plan of Practitioners and providers who meet high standards of professional training and experience.
• The right to be cared for by health care professionals who are accountable for the quality and confidentiality of the services they provide and for the satisfaction of their patients.
• The right to participate with your Practitioners and Health Care Team in decision making about your health care.
• The right to candidly discuss appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
• The right to voice complaints or appeals about GVHP or the health care provided.
• The right to be treated with respect and dignity, and have your right to privacy maintained.
• The right to make recommendations regarding Grand Valley Health Plan’s members’ rights and responsibilities policies.
• The right to have all GVHP Staff and affiliated providers to comply with all requirements concerning your rights.

Your Responsibilities

• The responsibility to hear how to use your GVHP Family Health Center.
• The responsibility to call your primary GVHP Family Health Center to get approval for any service.
• The responsibility to ask questions, when you think it is necessary, about your agreed upon treatment plan. And then follow your treatment plan and the instructions you were given.
• The responsibility to ask questions to understand your health problems, participate in developing an agreed upon treatment plan and then follow your treatment plan and the instructions you were given.
• The responsibility to be open and honest with your health care team. Supply information to the best of your ability that GVHP and our Practitioners or providers need in order to provide you with care.
• The responsibility to understand your health problems and to participate with your health care team in developing agreed upon treatment goals to the best of your ability.

Fraud and Abuse

Grand Valley Health Plan is working to stop medical fraud and abuse. What is fraud and abuse? Fraud is deception of facts. This could result in payment for services that should not occur. As a result, unnecessary costs occur. Below are some examples:

• A member shares their ID card with a non-member.
• A member does not provide correct information.
• A member and/or health care provider overstates the member's illness.
• A member forges a prescription. Or obtains medication to resell it.
• A health care provider bills for services not provided.
• A health care provider charges twice for the same service.

Reporting Fraud and Abuse:

Health care fraud and abuse makes health care costs increase. If you suspect fraud or abuse, contact Grand Valley Health Plan. Call Customer Service at 616-949-2410 or 800-335-1977. Or call our Fraud and Abuse Hotline at 1-866-203-7456. The hotline is available 24 hours a day. 7 days a week. Your call can remain anonymous. You can also write to us at: Grand Valley Health Plan, 829 Forest Hills Ave, Grand Rapids, MI 49546.

Medication Safety

Understanding your medications is important. The use of both prescription and over-the-counter medications requires careful attention. This is true if you are at home or in the hospital.

These tips may help you make the most of your medication:

• Follow all of your physician's instructions. Read and follow any directions or warnings. If you have questions, ask. Do this before leaving the doctor’s office or hospital.
• When you speak to your physician or pharmacist, ask questions. You need to feel confident. Be sure to tell him or her about any allergies you have. If your medication looks different, don’t take it. Ask about it immediately.
• If you see more than one doctor, be sure that each one is aware of all of your medicines. If you have more than one doctor prescribing the same medicine, let them know immediately.
• At the pharmacy, check the label on the bottle or package. If it is not the same as before, ask why. Were you given the correct medicine? Make sure that you can read the instructions easily. If not, ask the pharmacist for a label that’s easier to read
• Keep track of your medication with a chart listing the name, how much to take, when to take it, the doctor who prescribed it, and special directions such as “take with meals.” If you need help, ask your GVHP Family Health Center.
• Use a pill "reminder" case that has slots for each day of the week. You can buy these at the GVHP pharmacies. Or at other drug stores.
• You may experience side effects when you start a new medicine. Or after you have been taking it for some time. Call your physician immediately if you have itching, swelling, dizziness, or any other ill effects.
• Don't stop taking your medication unless your doctor says to do so.
• If you skip a dose of medicine, don’t assume it’s safe to double the next dose. Check with your physician or pharmacist. Find out what to do before this happens—then add that information to your medication chart.
• If you mistakenly take an extra dose of medicine, call your physician or the Poison Control Center. Be prepared to tell them what medicine you took.
• When taking a prescription medicine, consult your physician before taking any other medicine. Some over-the-counter medicines may interfere with prescription medicines. Others may be safe.
• Remember that alcohol and medicine don't mix.
• In the hospital, ask questions about what medicines they are giving you. If the color or shape of the pill changes, ask questions before taking it.