California's Quality Improvement Program

Molina Healthcare of California Partner Plan, Inc. annually assesses its Quality Improvement Program (QIP) to provide the structure and key processes that enable us to plan and implement our care and service goals. The QIP is an evolving program that is responsive to the changing needs of our members and the advances and changes in clinical practice. The 2009-2010 Quality Improvement Program activities focused on critical areas for improving the service to and health status of our membership based on ongoing measurement and analysis of our programs.

Data and expert opinion sources help guide the direction of the QI program and include:

• Data generated from our claims and encounters to analyze inpatient/outpatient diagnoses, HEDIS data, ethnicity prevalence, and other indicators.
• Clinical Practice Guidelines (CPGs) based on scientific evidence, review of the medical literature, or appropriately established authority, as cited. The recommendations do not favor any particular treatment based solely on cost considerations.
• Preventive Care Guidelines (PHGs) targeted to all age groups and disseminated by national and specialty organizations. They focus on improving members' access to preventive health services and encourage practitioners to promote routine screenings. We monitor the preventive health delivery through annual HEDIS rates and quarterly missed services reports sent to the primary care physicians.

Our Clinical Quality Management Committee, whose members are contracted network practitioners and MHC's medical directors, annually reviews and adopts the CPGs and PHGs. The Clinical Practice Guidelines are available on the Molina Healthcare of California Provider Website as are the Preventive Care Guidelines. Printed copies of the CPGs and PHGs are available upon request. For a copy, please call 1-888-665-4621.

We have on-going programs associated with major, high-risk, acute and chronic illnesses that address member needs, health deficits and health care disparities by assisting members with their understanding of the disease and providing education based on severity of the disease.

The breathe with ease^sm asthma program
The Healthy Living with Diabetes^sm program
The Chronic Obstructive Pulmonary Disease (COPD) program
The Heart-Healthy Living Cardiovascular program
Motherhood matters^sm pregnancy program to support and educate members and to provide special care to those with high risk pregnancy.

Some of the positive effects of these programs and our ongoing QI activities are observed through improvements in member health, as demonstrated in our annual HEDIS rates between 2009 and 2010:

Increased rate of breast cancer screening for women 40 to 69 years of age (annual HEDIS rates).
Decreased Emergency Room (ER) use for avoidable visits, i.e. inappropriate ER visits.
Although the rate of HbA1C testing increased from 2009 to 2010, other comprehensive diabetes care such as HbA1 control, eye exam, dilated retinal exam, LDL-C screening, and monitoring for nephropathy need improvements (annual HEDIS rates).  The diabetes program “Healthy Living with Diabetes^sm” focuses on increasing practitioners and member knowledge of the diabetes care standards and awareness about self-management of diabetes.
Increased hypertension control and management among members 18 to 75 years of age was achieved by promoting appropriate and effective clinical therapy (annual HEDIS rates) using antihypertensive class medications. 
Even though the rates for timeliness of prenatal and postpartum visits increased without statistical significance from 2009 to 2010, there is a strong need to improve and emphasis receiving timely prenatal and postpartum visits (annual HEDIS rates).

To improve our HEDIS® rates by meeting or exceeding the NCQA national 75th percentile performance benchmark, we are implementing these interventions and initiatives:

Welcome calls to new members to encourage Initial Health Assessments

Practitioner, Member and Disease Management Newsletters with information about health promotion

Asthma, COPD, Heart Disease, and Diabetes Disease Management Programs

Motherhood Matters Pregnancy Program to encourage prenatal and postpartum care

Member incentives for selected measures – Mammograms, Adolescent Well Visits, and Diabetic Retinal Exams

Communication with PCPs about the results of Focused Studies for Asthma, Diabetes, Hypertension and Upper Respiratory Infection

For our Asthma, Diabetes, Hypertension and URI clinical studies we increased early member identification efforts and notification to their physician about any need for increased management and use a quarterly reminder system to send the information to the physicians. A post-card reminder to call for an appointment with their PCP is also sent to the members at the time the letter is sent to their physician.   

There are ongoing studies and programs to decrease unnecessary Emergency Room (ER) visits:

The DHCS ER Collaborative is a statewide mandated quality improvement project developed to reduce the ER utilization rates among Medi-Cal managed care members age 1 and older who use the emergency room for avoidable visits.  The increase of ER visits particularly observed in quarters 1 to 3 in 2009 may have been affected by the public concerns for the H1N1 flu, member growth, and shift in membership.  There were significant interventions implemented, but these appeared to be offset by the flu activities that continued until late 2009, further increasing avoidable ER visits and overall ER utilization rates.  The impact of continuously implemented interventions are long-term effects, which is observed in quarters 1 through 2, 2010, resulting in decreased rates of avoidable ER visits.
The Case Management (CM) Initiative identifies members of all ages with 3 or more avoidable visits within the past 4 months. CM conducts initial assessments with the members to determine reason(s) for the ER visit. The member is enrolled in the CM program to provide ongoing management to prevent unnecessary ER visits and the PCP is notified when the member is enrolled. Repeat ER users are reviewed to determine the best approaches to engage the member in CM.
The Regional Center Client (RCC) Preventive Care QI Project identifies and tracks RC members who use the ER for avoidable visits or access preventive care with a specialist rather than their PCP. We alert PCPs about their members that used the ER or specialist for non-emergent health problems. We also notify the members to visit their PCP for preventive care. There was a statistically significant improvement in members using their PCP for preventive care in 2009, but there is no statistically significant increase seen in 2010.
The URI Clinical Study has a goal to decrease the inappropriate use of the ER for upper respiratory infections. Notification letters are sent to providers about their members who had an avoidable ER visit for a URI diagnosis.  The 2009 rates failed to meet the 5% improvement goals; however, showed a statistically significant improvement (decrease) in the Q1-Q2 2010 rate when compared to the 2009 rate. The Q1-Q2 2010 rate exceeded the 5% improvement goal.

Another major initiative is the refinement of the Complex Case Management Program to improve the health of members with multiple conditions, special needs or who are Medicare members. The program is integrated with the Utilization and Case Management programs, Disease Management, the Pharmacy Management programs and the Health Education program.

The Patient Safety Program identifies appropriate safety projects and error avoidance for Molina members in collaboration with their primary care providers. MHC continues to support safe personal health practices for our members through our infant car seat safety program, pharmaceutical management and disease management programs and education delivered through member newsletter articles.
• Molina also monitors nationally recognized quality index ratings for facilities from:
  Leapfrog Group
  Calhospital.org
  The Joint Commission national patient safety goal ratings
• Molina is proud to report that the Physician Recognition Program, developed by the National Committee for Quality Assurance (NCQA), awarded recognition to sixteen of our contracted practitioners.  NCQA Physician Recognition Programs are designed to assess key quality performance measures in recognition of physicians and other clinicians who provide excellent care to their patients. Below is the list of Molina participating practitioners who demonstrated that they meet important stan dards of care.  Information about this recognition program is available on the NCQA website www.ncqa.org.
  
  NCQA Diabetes Recognition Program: practitioners who demonstrated high quality care to patients with diabetes.

• NCQA Heart/Stroke Recognition Program: practitioners who demonstrated high quality care to patients with Cardiovascular Diseases and stroke.

• NCQA Physician Practice Connection-Patient Centered Medical Home: recognizes physician practices functioning as medical homes by using systematic, patient-centered and coordinated care management processes.

• We perform a patient safety survey once a year of our contracted hospitals, skilled nursing facilities (SNFs) and Ambulatory Surgical Centers (ASCs) to evaluate patient safety. Survey results revealed that all of our contracted organizations’ missions include patient safety as a priority. The overall Patient Safety Survey results showed strength in:
Patient Safety Structure and Strategy, Patient Safety Training, Communication.
Reporting Frequency and Recording and Tracking.


The area identified in need of improvement was the electronic Physician Order Entry System.  Specific electronic systems such as this require significant time and resources to implement fully.

Confirming that our members have access and availability of care and service is based on:

Measurement and evaluation of member geographic access (time and distance) and gender, language and ethnicity to primary care physicians, key specialists, hospitals and other health care services. Because of the diverse ethnicities of the California population, identifying an adequate network of practitioners with the identical characteristics is an ongoing challenge.

Evaluating appointment access and availability of after-hours care. The statewide results for the Access Survey showed outstanding performance in timely physician office telephone answer, urgent care, adult preventive care appointments and timely physician response to after-hour urgent issues, exceeding the performance goal. The performance rates for timely routine/non-routine and well-child preventive care appointments, and appropriate after-hour emergency instructions demonstrated the need for improvements.

Evaluating Molina Healthcare Member Services telephone access, including the bi-lingual 24/7 Nurse Advice Line.  Telephone access and customer service satisfaction scores are strong predictors of member satisfaction with their health plan. Molina's 2010 CAHPS Customer Service score was 80.66%, an improvement from 2009. Educating new members with a “Welcome Call” is an important Member Services initiative.

Continuity and coordination of care is part of improving and maintaining our member’s health and we evaluate this through ongoing analysis of data from:

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