educational activities for providers...educational activities for providers the molina mission 2...
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Four Points Sheraton, Caguas May 19th, 2015
Windham Gardens – Palmas del Mar, Humacao May 20th, 2015
Ponce Golf & Casino Hilton, Ponce May 21st, 2015
Educational Activities for
Providers
The Molina Mission
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Vision Statement – Molina Healthcare is an innovative healthcare leader providing quality care and accessible services in an efficient and caring manner.
Mission Statement – Our mission is to provide quality health services to financially vulnerable families and individuals covered by government programs.
Core Values – We strive to be an exemplary organization: 1. We care about the people we serve and advocate on their behalf
2. We provide quality service and remove barriers to health services
3. We are healthcare innovators and embrace change quickly
4. We respect each other and value ethical business practices
5. We are careful in the management of our financial resources and serve as prudent stewards of the public’s funds.
This is the Molina Way
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Quality Improvement Program
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Quality Improvement
Clinical Quality
•Member Education
•Clinical Programs
•Clinical Guidelines
•Providers Education
•Providers Audits
•HEDIS
Quality Compliance
• CAHPS
• ECHO
• Quality of Care Issues, Adverse & Never Events
• Performance Improvement Projects
• Quality Incentives
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• Breast Cancer Screening
• Cervical Cancer Screening
• Cholesterol Management
• Diabetes Care Management
• Access to Preventive Care Visits
• Timeliness in Pre-Natal Care
• Asthma Management
• Follow-Up care for children prescribed ADHD medication
• Antidepressant medication management
• Initiation of drug or alcohol abuse treatment
• Follow up after hospitalization for mental health
Performance Measures (HEDIS)
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• Improving Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screening Rates;
• Improvement in Behavioral Health Inpatient to Outpatient Transitions of Care;
• Arteriovenous (AV) Fistula Usage Improvement;
• Primary Care Physician and Behavioral Health Collaborative Care Project.
Performance Improvement Projects (PIPs)
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CARE MANAGEMENT
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• Integration is defined as the combining and coordinating of separate parts or elements into a unified whole;
• The goal of integrated care management is to eliminate fragmentation of care;
• Molina Care Management staff are responsible for coordinating medical, behavioral, and long-term support services throughout the member’s continuum of care incorporating his/her preferences;
• The Case Manager is responsible for coordinating communication and service delivery with the member, the member’s family or caregivers, treating physicians, therapists, counselors, social workers, and other practitioners involved in the member’s plan of care.
Integrated Care Management
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• Provide continuity of care and full integration of medical, behavioral health and social support;
• Utilize an Interdisciplinary Team (ICT) to coordinate care management integrating all treatment plans and services into one complete care plan maintained in CCA (Clinical Care Advance);
• Create a highly individualized care plan based on the member’s goals and preferences;
• Supporting the concept of member self-determination of his/her treatment plan and his/her selection of the individuals that will participate in their care;
• Provide a single point of contact;
• Maintaining members in the least restrictive environment.
Integrated Care Management
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Tools
• Assessments
• Care Plans
• Interdisciplinary Care
Team (ICT) and meetings
• Clinical Care Advanced
(CCA)
Goals
• Care Coordination
• Care Continuity
• Transition of Care
• Access to least
restrictive setting
Integrated Care Management
CORE PROGRAMS ELEMENTS
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• To identify the member’s care needs, the Care Management staff conducts the ASES approved Health Screening tools to all members referred to Case Management. This will allow assigning the member a risk level to determine their Case Management needs.
Molina Healthcare of Puerto Rico utilizes the following assessment tools: Telephonic Initial Health Risk Screening (HRS) Face-to-Face Comprehensive Needs Assessment (FCNA) Telephonic Comprehensive Needs Assessment (TCNA)
Integrated Care Management
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Disease Management
Molina Healthcare of Puerto Rico members that are included in our Disease Management program are:
Asthma (adults and children) Diabetes Type 1 & 2 Congestive Heart Failure (CHF) Hypertension Obesity Chronic Renal Disease Stages 1 & 2 Depression
After performing a TCNA/CAN to the member or authorized care giver, educational interventions will be provided based on the identified needs.
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• After performing the TCNA/FCNA or any condition-specific assessments available in CCA, and based in the member condition and identified needs, the Case Manager will develop an individualized care plan (ICP) taking into consideration the member’s main concerns;
• We will advocate for the member’s care in coordination with PCP, Specialist and any other provider that can help us improve the member’s quality of care;
• Complying with member’s desire, we will include any key person in the discussion of their ICP to be part of the ICT, as well;
• Utilization of motivational interviewing techniques when working with the member to encourage him/her to participate actively in their care;
• Our goal is to promote to the member empowerment for self management to take control of their own health care.
Complex Case Management
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Behavioral Health encompasses Mental Health Care and Substance Abuse Treatment and is often utilized to represent one or both within the scope of care. Molina focuses on the whole person for care management. Mental health and substance abuse disorders must be considered together with the medical care needs in order to bring the best care and outcomes to our members.
What additional resources does the care management staff have available? Health Wise Knowledge Database – located in CCA
Molina Corporate Health Care Services Guideposts
Molina Corporate Behavioral Health Team have created a Diagnostic Specific Quick Reference Guides (ORGs) to assist in: Symptoms identification;
Interventions Case Manager can utilize to assist the member;
Example of Care Plan per diagnosis.
Behavioral Health and Integrated Care Management
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Pre-Natal and Post Partum Program
• This program provides our members with professional clinicians that perform assessments based on the clinical guidelines for this population;
• We emphasized the importance of Pre-Natal Care, nutrition, going to all OB/GYN appointments; taking pre-natal meds, following up with required testing depending on gestational age;
• Behavioral Health Member’s is assessed to ensure a Holistic Care approach;
• We follow our members from pre-natal to partum care to asses and identify post-partum depression or any other needs, i.e., smoking cessation.
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Special Coverage Conditions
Persistent Persistent
HIV / AIDS Hemophilia
Rheumatoid Arthritis Leprosy
ESRD (if not transplanted) Autism (Under 21 years old)
Scleroderma Aplastic Anemia
ALS Multiple Sclerosis
Cystic Fibrosis Tuberculosis
Lupus CKD III, IV & V
Non-Persistent
Obstetric (Pregnancy)
Cancer
Special Needs Children*
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• Molina Healthcare of Puerto Rico has a group of specialized team that receives, evaluates and determines, in joint effort with our Medical Directors, each request we received for SCR in less than 72 hours;
• Every member that qualify for SCR is referred to Care Management to establish, with PCP and specialist, an ICP based on the member needs and concerns;
• We have Operational Guidelines based on ASES requirements.
Special Coverage Registration
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From the date the condition was diagnosed:
Condition Supporting Clinical Information
Anemia
Hematological Assessment including: Neutrophil count all < 500/mm3 Platelet < 20,000/mm3 Reticulocyte < 1%
Aspiration and/or biopsy of bone marrow results Certification of diagnosis by hematology oncology
Rheumatoid Arthritis
Certification of diagnosis by Rheumatologist and at least 4 of the following:
Morning numbness periarticular (over 1 hour) for over 6 weeks;
Swelling of soft tissue in > 3 joints for more than 6 weeks;
Symmetric arthritis for at least 6 weeks; Subcutaneous nodules; Positive Rheumatoid Factor test
Laboratory Test – ESR, ANA Test, CRP, RA Factor Evidence of Treatment with DMARDS Medicine
Autism
Certification of diagnosis from a Neurologist and Psychiatrist Evidence of Tests – M-CHAT and “Ages and Stages”
Special Coverage Registration From the date the condition was diagnosed:
Condition Supporting Clinical Information
Cancer
Certification of diagnosis with staging by hematologist / oncologist Treatment plan including start and completion dates Biopsy results Diagnostic Studies (CT, MRI, PET Scan, etc.)
Skin Cancer Carcinoma in SITU Positive Biopsy
Skin Cancer
Melanoma invasive or squamous cell carcinoma with evidence of metastasis Positive pathology or biopsy Diagnostic Studies (CT, MRI, PET Scan, etc.) Certification by dermatologist or medical oncologist / hematologist
Chronic Renal Disease
Glomerular filtration (GFR)
Level 1 - > 90 GFR Level 2 - 60-89 GFR Level 3 – 30-59 GFR
Level 4 – 15-29 GFR Level 5 - < 15 GFR
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• Referrals Source Special Coverage Registration
Auto-Referral
CAM Team
PCP and/or Specialist
Intra-Hospital Auditors
Nurse Advice Line
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Members Services
Pre Authorizations Nurse Advice Case
Management
1-877-335-3305 787-522-8281
(TTY)
787-999-4572 1-888-558-5501 1-855-378-3641
(Fax)
787-999-6209 1-888-620-1515 787-522-8281
(TTY)
787-999-6341 1-844-633-8350
Contact Information
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Providers Services Pharmacy
Authorizations Behavioral
Health Authorizations
Behavioral Health Crisis
Line
787-9994572 1-888-558-5501
1-888-558-5501 1-844-606-7171
(Fax)
1-855-580-2880 1-844-226-1440
(Fax)
787-999-6206 1-866-233-8333
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Behavioral Health Contact Information
FHC 787-622-9797
1-855-822-5111 (Call Center)
For Behavioral Health Inpatient Coordination and Partial Hospitalization Contact: 787-622-9797, Ext. 2022
FHC Clinics
FHC Clinic – Humacao Centro Comercial
Humacao Edif. 10-A
Ave. Fort Martelo Humacao, PR 787-248-1302
FHC Clinic – Cidra Calle Román Baldorioty
de Castro #12 Cidra, PR
787-247-9542
FHC Clinic – Yauco Calle Comercio #55
Yauco, PR 787-246-5248
INSPIRA – Caguas Consolidated Mall
Local B-5 Ave. José Gautier Benítez
Caguas, PR 787-704-0705
School of Medicine Parque Industrial
Reparada Ponce By Pass
Ponce, PR 787-842-3274
Important Contact Information
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Members ID Card
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HEALTHCARE SERVICES
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Molina Medical Management Model
HCS Care Access & Monitoring (Nurses/SW/ Support Staff)
HCS Care Management Model (Nurses/SW/
Support Staff)
Medical Affairs (MDs)
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Medical Affairs – Medical Director’s Role
• Approving/denying medial service requests (peer to peers)
• Inpatient rounds
• Appeals, grievance, medical claims review decisions
Medical Decision Making
• Interdisciplinary Care Teams (peer to peers)
• Day to day problem solving for HCS teams Care Management
Support
• Interface with State Regulators
• Interface with Legislators
• Interface with Hospitals/ Large Provider Groups Leader Interfacing
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• Review provider and member requests for services
• 24 hour TAT for urgent requests (most plans)
• 14 days for non urgent requests (most plans)- 5 bus day goal
Prior Authorization
• Compare medical status to clinical criteria sets
• Prepare and discuss members in a facility at rounds with MDs
• Coordinate safe discharges for members
Concurrent Review (Inpt
Review)
• Review member appeals for denied services
• Review claims that did not pay for authorization reasons
Member Appeals/Medical
Claims Review
Care Access and Monitoring (CAM) Role
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Healthcare Services at Molina consists of four teams
Our teams must work together in an integrated approach to provide quality care and excellent customer service to our members and providers
Care Access and Monitoring Care Management Central Programs Member / Medical Appeals
Healthcare Services
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Why is it Important to do Utilization Review?
• Stewards of Public Resources
• Required by State/Federal Contract
• Redirect Potential Waste to Provide Increased Services and Resources to More Members
• Company Mission
Molina Care Access & Monitoring/Utilization Review Philosophy
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Molina seeks to provide the right care, at the right time, and in the right setting for Molina Members
We do this by:
• Directing members to participating providers that have been credentialed to meet Molina standards;
• Assuring services are covered benefits;
• Ensuring a Molina Medical Director does not approve requested services that are deemed to be experimental and investigational;
• Applying evidence-based clinical decision support criteria (like InterQual) to determine the medical necessity or appropriateness of services that are often over-utilized.
Molina Care Access & Monitoring/Utilization Review Philosophy
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Molina Care Access & Monitoring Utilization Review Philosophy
Right Care Right Time
Right Setting
Utilizing Participating
Providers
Ensuring Services are
Covered
Evidence Based
Criteria
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Medical Necessity Criteria
GHP Guidelines
MCG
InterQual
Hayes
UptoDate
ODG
Apollo
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1st Criteria
Last Criteria
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Escalating to MD Review
Not Meeting Medical Necessity Criteria
Medical Necessity Criteria is Unavailable or Non Existent
Secondary Review is Indicated by Criteria or Policy
Member Refusing Conservative Treatment
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Prior Authorization / Pre-Service Review Guide
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Prior Authorization Request Form & Pregnancy Notification Form
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• Current (up to 6 months) adequate patient history related to the requested services;
• Relevant physical examination that addresses the problem;
• Relevant lab or radiology results to support the request (including previous MRI, CT Lab or X-Ray report/results);
• Relevant specialty consultation notes;
• Any other information or data specific to the request.
Information to Support Authorization Decision Making
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The urgent / expedited service request designation should only be used if the treatment is required to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain maximum function.
Requests outside of this definition will be handled as routine/non-urgent.
Request Categories
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www.psgmolinahealthcare.com
Providers May Utilize Molina Healthcare eWeb at:
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THANK YOU!
Q & A
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