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 2015-2016 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 Improvement 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 Molina breathe with easesm asthma program
- The Molina Healthy Living with Diabetessm program
- The Chronic Obstructive Pulmonary Disease (COPD) program
- The Heart-Healthy Living Cardiovascular program
- Motherhood matterssm pregnancy program to support and educate members and to provide special care to those with high risk pregnancy
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 Health Management Newsletters with information about health promotion
- Asthma, COPD, Heart Disease, and Diabetes Health Management Programs
- Motherhood Matters Pregnancy Program to encourage prenatal and postpartum care
- Member incentives for selected measures – Mammograms, Adolescent Well Visits, Diabetic Retinal Exam, Blood Pressure and Postpartum
- Communication with PCPs about the results of Focused Studies for Asthma, Diabetes, Hypertension and Cholesterol
- Collaborate with provider clinics on PDSA (Plan, Do, Study, Act) interventions and PIPs (Performance Improvement Projects).
To improve our HEDIS rates, Plan, Do, Study, Act (PDSAs) and Performance Improvement Projects (PIPs) were conducted by the Quality Improvement Department for several measures. Molina has participated in the following collaboratives by DHCS: Diabetes, Hypertension, Immunizations and Postpartum. In addition, for Sacramento County, Molina participates in the National Governors Association Collaborative that focuses on improving Tdap and influenza immunization rates in pregnant women, improving immunization rates in children under the age of two, and launching the fully populating the California Immunization Registry (CAIR).
The Health Care Services Department addresses the needs of hospitalized members regarding care transitions with the goal of promoting their health, supporting and maintaining them in the community, encouraging self-care on the part of the member over time and reducing inpatient readmissions.
The Patient Safety Program identifies appropriate safety projects and error avoidance for Molina members in collaboration with our network providers. MHC continues to support safe personal health practices for our members through our on-going monitoring of aspects of patient safety, pharmaceutical management programs and continuous education.
- Molina also monitors nationally recognized quality index ratings for facilities from:
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. Information about this recognition program is available on the NCQA website www.ncqa.org.
- In 2015, we performed a patient safety survey of our contracted hospitals, and skilled nursing facilities (SNFs) to evaluate key aspects of 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:
- Practices to Prevent Errors
- Safety Problems
- Doctors, Nurses & Hospital Staff
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. Results of the annual appointment access survey demonstrated several performance gaps. Molina network primary care providers (Pediatrics and General practice) met the Routine/non-urgent Care appointments compliance goal, while Internal Medicine and Family Practice providers did not meet the compliance goal. For Urgent Care appointments without prior authorizations, all primary care provider types did not meet the compliance goal. And for Urgent Care appointment with prior authorizations only Family Practice and Pediatric providers met the compliance goal. For After Hours, primary care providers did not meet the compliance goal for appropriate after-hour emergency instruction, but did meet the compliance goal for timely physician response to after hour phone calls/pages.
- Evaluating Molina Healthcare Member Services telephone access, including the bi-lingual 24/7 Nurse Advice Line. Telephone access and Customer Support Center satisfaction scores are strong predictors of member satisfaction with their health plan. Molina’s 2016 CAHPS Customer Service Summary score increased (83.5%) from the 2015 rate (83.4%).
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:
- Practitioner Satisfaction Survey
- Medicaid 2016 CAHPS 5.0H Adult Member Satisfaction Survey
The annual practitioner satisfaction survey questions are used to determine satisfaction with Molina, coordination of home health and DME services and inpatient to the home setting for members. For 2015, direct providers and IPA based providers were combined in to one survey. For 2016, slight survey modifications were made to separate this in to two surveys – one for direct providers and a second for IPA based providers. Moving forward, this should allow us to have a better understanding of the satisfaction of various provider types.
The 2016 overall satisfaction rate of the Provider Satisfaction Survey were 85.3% (IPA Based Providers), and 79.7% (Direct Providers). Provider satisfaction rate for the Coordination of Care Composite showed were 36.2% (IPA Based Providers), and 37.9% (Direct Providers) in 2016. Actions taken by Provider Services department included provider education on Timely Access to Healthcare standards and ongoing efforts to contact existing providers to verify information and complete missing data fields. Actions taken by the Health Care Services department included continued monitoring of new initiatives that were previously launched to help with coordination of home health and DME services, trained staff and developed internal UM call center to assist with provider questions and hired additional staff with Long Term Services and Supports experience to bolster coordination of care.
- The 2016 Coordination of Care Composite rate for directly contracted providers was 37.9% and showed an improvement from the previous year while the IPA rate was lower at 36.2% and did not surpass the rate from the previous year.
- The data from the CAHPS 5.0H member satisfaction survey was added to the analysis. The score for the Coordination of Care Composite, specifically the question about the member’s PCP knowing about care received from other doctors was 80.0% in 2016.
Oversight of IPA delegated activities, both credentialing and utilization management is conducted to confirm the adequacy of and access to their practitioner networks and if the correct processes are used during utilization management. Other monitors are:
- 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.
Molina's interface with practitioners, providers, members and state agencies to implement programs includes:
- 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 and initiatives to improve satisfaction.
- Review of all sources of member satisfaction including, but not limited to, disenrollment information, complaints and appeals.
Molina Healthcare measures member satisfaction using the CAHPS® survey (Consumer Assessment of Healthcare Providers and Systems) annually. The survey measures key satisfaction drivers through the continuum of care, including health plan performance and the members' experiences in the physician office.
Based on the comparison of our annual CAHPS® results, Molina has many ongoing initiatives to address opportunities where response rates indicate our members are not satisfied. In 2016, Molina members from all lines of business enrolled in the health plan were surveyed. It is Molina’s goal to create a significant impact on increasing member satisfaction through quality improvement activities. Examples of some of our activities to improve scores and satisfaction include:
- Developed and implemented workshop trainings focused on enhancing communication between providers, appropriate staff, and members.
- Increased provider education and literature on behavioral awareness and its significant impact on member’s perception of the provider and health plan.
- Enhanced collaborative efforts with provider groups to integrate practice facilitation and improve clinic workflows and overall patient satisfaction.
- Deployment Community Outreach campaign established to improve members knowledge on health plan benefits, total perception and experience.
- Expanding project to identify and resolve data exchange issues in a timely manner ensuring prescription fulfillment orders.
- Modified our Health Care Services prior authorization requirements to decrease delays in appointments for specialty care.
- Increased the communication and transfer of data between the Health Care Services and Health management programs to better coordinated care with the member, physician and Molina.
- Revised the pharmacy prior authorization drug list and changed some prior auth drugs to step-therapy.
- Monitored our Drug Formulary and compared it with formularies of other plans to identify enhancements and/or additions, while promoting the best clinical practice.
- Focused on expanding our physician network to improve the match with member languages spoken, ethnicity and cultural needs.
- Increased the multi-language capabilities of our after-hours Nurse Advice Line and Customer Support Center staffs to improve communication about health care and service issues and needs.
- Expanded physician office education about access to our multi-language and sign language translation service and encourage its use.
- Developed multi-disciplinary teams, including clinical experts, to analyze service and process improvement opportunities, determine actions for improvement, and evaluate results.
- Reminded member and physicians about the dangers of smoking and stop smoking programs available through Molina or the community.
- Increased the scope of our Member Services internal training programs.
- Improved the readability, layout, font size and relevance of member materials.
- Used our Provider Satisfaction Survey results to identify suggestions for improvement.
- Increased communications through provider outreach, provider office management meetings and support.
- Determined that our greatest opportunity to improve these scores is through “access to care” timeliness initiatives.
- Conducted semi-annual POMMS with PCP office staff and at least annual JOMS with IPA partners to update them on new Molina programs and services.
- Provided Eportal trainings with the office staff to expedite claims submission.
- Mailed a brochure of “Top Ten” tips and hints to assist members in navigating their health care benefit.
Molina Healthcare of California values the care, education and advice you provide to our members. Our Quality Improvement Program and local activities represent a coordinated 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, CAHPS, or HEDIS® please call 1-800-526-8196, Ext. 126137. For the breathe with easesm pediatric and adult Asthma Health Management Program or Healthy Living with DiabetesSM , our adult diabetes Health Management program, call Health Management at 1-866-891-2320. For more information or to refer a patient to motherhood mattersSM, our perinatal education program, call 1-866-891-2320.
*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. Printed copies of information posted on our website are available upon request.
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