Educational Activities for Providers...Educational Activities for Providers The Molina Mission 2...

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.



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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


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)



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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


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


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:


http://www.psgmolinahealthcare.com/

THANK YOU!

Q & A

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Educational Activities for Providers...Educational Activities for Providers The Molina Mission 2...

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