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 2007-2008 Quality Improvement Program activities focus on critical areas for improving the service to and health status of our membership based on ongoing measurement and analysis of our programs.

• 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 888-665-4621.

• The asthma program, " breathe with ease^sm ", that assists members with their understanding of asthma, provides general asthma education to all identified asthma members and a more intensive asthma program if the member requires a higher level of management. The improvements in the health of the members between 2006 and 2007 included:
  An increase in the use of the asthma action plan by members with persistent asthma
  Increased rate of use of appropriate asthma medications ages 5-56 years ( annual HEDIS rates)
  A decrease in ED use
• The diabetes program "Healthy Living with Diabetes^SM " focuses on increasing primary care practitioners' knowledge and use of the diabetes care standards. Physicians are notified of the A1C level and retinal exam status. For members, we encourage and guide diabetic member awareness about self-care and self-management of diabetes. The rate of A1C testing showed a gradual improvement but our rates for A1C control decreased (annual HEDIS rates). We monitor the rate of diabetic retinal exam testing and that rate showed some improvement.
• Increasing hypertension control and management among members who are 18 to 75 years of age is achieved by promoting appropriate and effective clinical therapy (annual HEDIS rates). The goals are to:
  Decrease the rate of hypertensive members who are receiving antihypertensive class medications (ACEI, ARB, BB, CCB) without thiazide-type diuretics.
  Increase the rate of hypertensive members who are receiving thiazide-type diuretics, either alone or in combination with other antihypertensive class therapy (ACEI, ARB, BB, CCB).
  Decrease the rate of hypertensive members not prescribed any type of antihypertensive medications.
  
  The physicians are sent member specific information and are asked if there is a contraindication to a thiazide- type diuretic. If there is, the explanation is accepted. Our results demonstrated improvements each quarter in the percentages of hypertensive members who were taking a thiazide-type diuretic.

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 new strategy was implemented in mid-2007 using a post-card reminder to the members at the time the letter is sent to their physician.

Other studies and programs include decreasing unnecessary ED visits, improving the physician/adolescent interaction during the well child visit and antibiotic use with upper respiratory infections. A major 2007-2008 initiative is the design and implementation of a complex case management program to manage and improve the health of members with special needs and the Medicare members. The programs are integrated with the Utilization and Case management programs, the Pharmacy management program 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
  JCAHO national patient safety goal ratings
• Molina is proud to report that the Diabetes Physician Recognition Program (DPRP), developed by the National Committee for Quality Assurance (NCQA) and the American Diabetes Association (ADA), awarded recognition to five of our contracted practitioners. Information about this recognition program is available on the NCQA website www.ncqa.org. The practitioners have demonstrated that they provide high quality care to patients with diabetes.
  Sadhana Kamath, MD (Lancaster)
  Jeereddi Prasad, MD (Pomona)
  Daryoosh Valamanesh, MD (Pomona)
  Takahiro Otsuka, MD (Pomona)
  Santosh Sinha, MD, (Los Angeles)
• We perform a 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. Improvements in safety programs were demonstrated by Ambulatory Surgery Centers implementing electronic Physician Order Entry Systems, hospitals keeping logs of sentinel events and having a Pharmacist assigned to the ICU to monitor medications, and Skilled Nursing Facilities creating a Safety or similar committee. 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.

1. Practitioner and Medicaid CAHPS 4.0H Adult Member Satisfaction Surveys
2. Focused Medical Record reviews
3. Beta-blocker treatment post-acute Myocardial Infarction (MI) study

• The practitioner surveys were redesigned to utilize the annual practitioner satisfaction survey questions about communication of member information to the PCP from various provider settings. The coordination of home health and DME services for direct members (not assigned to an IPA) when the member transitions from inpatient to the home setting question scored 25.5% for direct members. This is an area requiring significant improvement by the UM department for Molina members post-discharge. Education of the PCP office staff on Molina's UM department policies about notification of in-patient admissions and post-discharge care is planned using reminders at Joint Operations Meetings and practitioner site visits.
• The study on persistence of beta-blocker use for six months after an acute MI. showed some improvement, however it does not meet the 2007 NCQA Medicaid 90th percentile (annual HEDIS rates). We use inpatient authorization data to identify members and monitor pharmacy data at least quarterly to verify the prescription is filled.
• The data from the CAHPS 4.0H adult member satisfaction survey was added to the analysis. The score for the Coordination of Care section about the PCP knowing about care received from other doctors was favorable at 62.1%. The goal is 75.8%, so there is some area for improvement next year.

• Measurement and evaluation of geographic access (time and distance) to primary care physicians, key specialists, hospitals and other health care services. This includes comparing the gender, language and ethnicity of our members to that of our contracted practitioners. 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 of timely physician office telephone answer, urgent, routine and adult preventive care appointments exceeded the performance goal of 85%. Although the performance rate of 81.5% for timely well-child preventive care appointments did not achieve the 85% goal , the performance did improve. The rates for appropriate after-hour emergency instructions were 91% and for timely after-hour physician response to calls or pages was 80.1%. Both rates did not meet the established goals of 100% and 85% respectively but did improve from 2006.
• 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 2007 CAHPS Customer Service score was 60.3%, so improvement is needed.
• Educating new members with a "Welcome Call".

• Member grievances
• Financial viability
• Claims payment accuracy and timeliness
• Peer review of credentialing/recredentialing decisions
• Peer review of investigated quality of care issues and proposed corrective action plans

Annual or quarterly reviews are conducted and if the standards are not met, corrective actions are implemented until we can verify that delegated organization meets Molina's high standards.

• Contracted practitioners and providers participation in the planning and execution of clinical programs.
• Identifying legislative and benefit changes that enhance health promotion.
• Annual review of member and practitioner satisfaction surveys and identification of opportunities initiatives to improve satisfaction.
• Review of all sources of member satisfaction including, but not limited to, disenrollment information, complaints and appeals.

Annually we measure member satisfaction using the CAHPS® survey (Consumer Assessment of Healthcare Providers and Systems). The survey looks at key satisfaction drivers through the continuum of care, including health plan performance and the members' experiences in the physician office. The 2007 survey contained new or revised questions or composite.

• Modify the UM prior authorization requirements to decrease delays in appointments for specialty care
• Revise the pharmacy prior authorization list and change some prior auth drugs to step-therapy
• Expand the physician network to better serve the language spoken, ethnicity and cultural needs of our members
• Expand the Urgent Care Center network for access to after-hours care
• Improve the health status of our members through our disease management programs and the program for pregnant women
• Increase the bilingual capabilities of our after-hours nurse line and customer service staffs to improve communication about health care and service issues and needs. Expand physician office education about access to our multi-language and sign language translation service and encourage its use.
• Develop multi-disciplinary teams, including clinical experts, to analyze service and process improvement opportunities, determine actions for improvement, and evaluate results.

Molina Healthcare of California values the care, education and advice you provide to our members. Our Quality Improvement Program and local activities represent a collaborative effort between you and Molina to improve overall healthcare. We look forward to collaborating with you. Together, we can make a difference in the lives of our members. If you would like more information, or have suggestions for our Quality Improvement Program, please call 1-800-526-8196, Ext. 126137.

If you have any questions or would like additional information about HEDIS®, please call 1-800-526-6296, Ext. 127557. For the breathe with ease^sm pediatric and adult Asthma Disease Management Program or Healthy Living with Diabetes^SM , our adult diabetes disease management program, call Health Education at 1-800-526-8196, Ext. 127532. For more information or to refer a patient to motherhood matters^SM, our perinatal education program, call 1-877-665-4628.

*If you click on the link or icon above, you will leave the Molina website. These links are here for your ease, if you want to get more information on the topic. These sites are not approved by Molina. Molina cannot change anything on these sites. As always, check with your doctor before taking any advice.

return to the top