Educational Activities for Providers Four Points Sheraton, Caguas - - PowerPoint PPT Presentation

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Educational Activities for Providers Four Points Sheraton, Caguas - - PowerPoint PPT Presentation

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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

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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

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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)

Educational Activities for Providers

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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)

Educational Activities for Providers

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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

  • ther practitioners involved in the member’s

plan of care.

Integrated Care Management

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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.

Educational Activities for Providers

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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*

Educational Activities for Providers

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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
  • ver 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

Educational Activities for Providers

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  • Referrals Source
  • Special Coverage Registration
  • Auto-Referral
  • CAM Team
  • PCP and/or Specialist
  • Intra-Hospital Auditors
  • Nurse Advice Line

Integrated Care Management

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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

Educational Activities for Providers

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

Educational Activities for Providers

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Members ID Card

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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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

Educational Activities for Providers

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Medical Necessity Criteria

GHP Guidelines

MCG

InterQual

Hayes

UptoDate ODG

Apollo Educational Activities for Providers

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

Educational Activities for Providers

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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

Educational Activities for Providers

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www.psgmolinahealthcare.com

Providers May Utilize Molina Healthcare eWeb at:

Educational Activities for Providers

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THANK YOU! Q & A

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