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 2008-2009 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 1-888-665-4621.

• The asthma program, " breathe with ease^sm ", assists members with their understanding of asthma, provides asthma education based on severity of asthma. The improvements in the health of the members between 2008 and 2009 included:
  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 practitioners and member knowledge of the diabetes care standards and awareness about self-management of diabetes. Neither the rate of A1C testing nor the rate of diabetic retinal exam testing showed any significant change from 2008-2009(annual HEDIS rates). 
• 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). Using antihypertensive class medications and to decrease the rate of hypertensive members not prescribed any type of antihypertensive medications. Our results demonstrated improvements in the percentages of hypertensive members who were taking a thiazide-type diuretic.
• Improving Appropriate Treatment for Children (under age 19) with Upper Respiratory Infection (URI) was achieved by participation in a small group collaborative with the goal of promoting appropriate antibiotic prescribing based on the AWARE (Alliance Working for Antibiotic Resistance Education ) URI clinical practice guidelines. Our 2009 HEDIS rates demonstrated improvement in appropriate treatment in all counties annual HEDIS rates.

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 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 ED visits:

DHCS statewide ED collaborative is a quality improvement project developed to decrease the rate of ED visits among Medi-Cal managed care member ages 1 to 19 years using the emergency room for avoidable visits.  Due to concerns about H1N1 influenza infection in quarters 1 and 3 2009, a decrease in ER visit was not realized. The increase in Avoidable ED visits /K between January and May 2009 reflected seasonal trends and a delayed flu season. The increase in September 2009 ED visits was due to increased concerns about H1N1 infection.

The Case Management (CM) Initiative identifies members of all ages with 3 or more avoidable visits within the past 4 months. CM conducts initial assessment with the member to determine reason(s) for the ED visit. The member is enrolled in the CM program to provide ongoing management to prevent unnecessary ED visits and the PCP is notified when the member is enrolled. Repeat offenders are reviewed to determine best approach to engage the member in CM.

The Regional Center Client (RCC) Preventive Care QI Project identifies and tracks RC members who use the ED for avoidable visits or access preventive care with a specialist rather than their PCP. We alert PCPs about their members that used the ED or specialist for non-emergent health problems. We also notify the members to visit their PCP for preventive care. By year end 2009, there was a statistically significant improvement in members using their PCP for preventive care.

One of the goals of the URI Collaborative Project was to decrease the inappropriate use of the ED for upper respiratory infections. Notification letters are sent to providers about their members who had an avoidable ED visit for a URI diagnosis. The goal of 5% improvement was realized in all counties between Q 3 2007 and Q 4 2009.

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 Diabetes Physician Recognition Program (DPRP), developed by the National Committee for Quality Assurance (NCQA) and the American Diabetes Association (ADA), awarded recognition to six 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.
  Lynda K. Fisher, M.D. (Los Angeles)
  Jeereddi Prasad, M.D. (Pomona)
  Daryoosh Valamanesh, MD (Pomona)
  Takahiro Otsuka, MD (Pomona)
  Santosh Sinha, MD, (Los Angeles)
  Francine R. Kaufman, M.D. (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. 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, adult preventive care and after-hour physician response time, exceeding the performance goal. The performance rates for timely 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 2009 CAHPS Customer Service score was 79.6%, an improvement from 2008. Educating new members with a “Welcome Call”.

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:

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