Educational Activities for Providers Four Points Sheraton, Caguas May 19 th , 2015 Windham Gardens – Palmas del Mar, Humacao May 20 th , 2015 Ponce Golf & Casino Hilton, Ponce May 21 st , 2015
The Molina Mission 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: We care about the people we serve and advocate on their behalf 1. We provide quality service and remove barriers to health services 2. We are healthcare innovators and embrace change quickly 3. We respect each other and value ethical business practices 4. We are careful in the management of our financial resources and serve as prudent 5. stewards of the public’s funds. This is the Molina Way 2
Quality Improvement Program 3
Quality Improvement Quality Clinical Quality Compliance • Member Education • CAHPS • Clinical Programs • ECHO • Clinical Guidelines • Quality of Care Issues, Adverse & Never Events • Providers Education • Performance Improvement • Providers Audits Projects • HEDIS • Quality Incentives Educational Activities for Providers 4
Performance Measures (HEDIS) • Breast Cancer Screening • Follow-Up care for children prescribed ADHD medication • Cervical Cancer Screening • Antidepressant medication • Cholesterol Management management • Diabetes Care Management • Initiation of drug or alcohol abuse treatment • Access to Preventive Care Visits • Follow up after hospitalization for • Timeliness in Pre-Natal Care mental health • Asthma Management Educational Activities for Providers 5
Performance Improvement Projects (PIPs) • 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. Educational Activities for Providers 6
CARE MANAGEMENT 7
Integrated Care Management • 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. Educational Activities for Providers 8
Integrated Care Management • 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. Educational Activities for Providers 9
Integrated Care Management CORE PROGRAMS ELEMENTS Tools Goals • Care Coordination • Assessments • • Care Plans Care Continuity • Interdisciplinary Care • Transition of Care Team (ICT) and meetings • Access to least • Clinical Care Advanced restrictive setting (CCA) Educational Activities for Providers 10
Integrated Care Management • 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) Educational Activities for Providers 11
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. Educational Activities for Providers 12
Complex Case Management • 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. Educational Activities for Providers 13
Behavioral Health and Integrated Care Management 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. Educational Activities for Providers 14
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. Educational Activities for Providers 15
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* Educational Activities for Providers 16
Special Coverage Registration • 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. Educational Activities for Providers 17
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