1. San Diego Housing Federation Conference
October 13, 2016
San Diego Housing Federation Conference
Nora Faine, MD MPH
Medical Director, Molina Healthcare

2. Role of Healthcare What:
5 percent—accounts for nearly half of total spending on health care, while 20 percent accounts for four-fifths of total spending. This relatively small slice of the population incurs such high costs because most of these individuals have complex medical problems
Problems include common but difficult-to-manage chronic diseases like diabetes and heart failure, mental and behavioral health issues
Prevention of readmissions to acute care hospitals and psychiatric hospitals repeatedly could save millions if hospitals, doctors, and community health programs worked together to connect wraparound services
Better Care at Lower Cost: Is It Possible?, The Commonwealth Fund, November 2013.

3. Role of Healthcare How:
Have reliable policies and procedures to communicate with other clinicians, agencies, service providers etc. with access to community and social support resources
Coordination of care across settings to integrate services that are centered on the comprehensive needs of the individual
Coordination at transitions of care e.g. discharged patients need clear instructions on how to care for themselves at home, as well as help in scheduling and keeping follow-up appointments, sticking to a prescribed medication plan, and making necessary lifestyle changes
Effective strategies to end homelessness taking into account the individual’s health conditions and disability
All of these have the potential to decrease healthcare cost, decrease societal cost and most importantly increase the quality of life of impacted individuals

4. Healthcare Systems / SDHC
360 View
Person
Healthcare Systems / SDHC
Social Services
HHSA / Housing
EMS / Paramedics
Health Plans
211

5. We strive to be an exemplary organization:
Molina Healthcare - Who We Are
In 1980, the late Dr. C. David Molina, founded Molina Healthcare with a single clinic and a commitment to provide quality healthcare to those most in need and least able to afford it. This commitment to providing access to quality care continues to be our mission today, just as it has been for the last 30 years.
Mission Statement
Our mission is to provide quality health services to financially vulnerable families and individuals covered by government programs
Vision Statement
Molina Healthcare is an innovative national health care leader, providing quality care and accessible services in an efficient and caring manner
Core Values
We strive to be an exemplary organization:
We care about the people we serve and advocate on their behalf
We provide quality service and remove barriers to health services
We are health care innovators and embrace change quickly
We respect each other and value ethical business practices
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

6. Molina Health Care San Diego Enrollment Medi-Cal 212,700
Medicare and Duals
13,033
Marketplace
7,672
~2200 members in Complex Care Management
~300 members in monitoring Care Management

7. Molina Healthcare Services
Complex Case Managers
Community Connectors
Transitions of Care Coaches
Care Review Clinicians
Pharmacists
Behavioral Health Care Management
Quality Management

8. Molina Healthcare Services
Level 4
Imminent Risk
Level 3
Complex CM
Level 2
Case Management
Level 1
Health Management
Level 4
Imminent Risk
Level 3
Complex CM
Level 2
Case Management
Level 1
Health Management

9. Molina Healthcare Services
Care management is the core of the Molina model of care
Member centered and individualized
Offered based on risk assessment
Supported by an Interdisciplinary Care Team (ICT)
Guided by an integrated plan of care
Assures member receives all necessary covered benefits
Occurs across settings of care: home, hospital, skilled or custodial nursing facility as well as transitions between care setting
Includes:
Family, caregiver, support system
Functional, cognitive and behavioral health status and needs
Cultural & linguistic needs

10. Interdisciplinary Care Team (ICT)
Purpose
Assess needs, contribute to care plan, problem solve based on subject matter expertise, assure timely access to needed services and care
Core ICT
Member or Member’s representative,
Primary physician
Case Manager
Additional Members (as needed)
Family/caregiver, nursing home staff, specialty providers, behavioral health provider, etc.
Goal
Develop an Individualized Care Plan

11. Individualized Care Plan
Based on the results of the assessment and consultation with members of the Interdisciplinary Team
Includes coordination of medical and ancillary services, including but not limited to medical, long term services and supports (LTSS), behavioral health, substance use disorders, and social services
Reviewed on a quarterly basis, or more frequently if there is a change in condition or critical event.

12. Molina Healthcare Services
Transitions of Care Coaches
Engage members in the hospital with bedside visits
Facilitate pending discharges by contacting the assigned Molina Care Review Clinician RN
Assist with PCP or Specialist follow up appointments
Arrange transportation
Facilitate medication refills
Educate member on their diagnosis, treatment options, and medications
Provide community resources as needed
Remain engaged for 30 days post discharge

13. Molina Healthcare Services
Behavioral Health Care Management
Personal Service Coordinator (Medicare)
Link member to medical, behavioral health and other resources
Keep member independent in their home, decrease ED use
Quality Management
Monitor quality of services
Receive and track reports of sentinel events
Goal to build on current processes and work with providers to continually improve processes
Focus on quality measurements and data collection

14. Other Related Services
Cultural & Linguistic Services
Reduce barriers to accessing quality healthcare
Interpreter / Translation Services
Provider Services
Network adequacy and integrity
Provider training, tools and inquiries

15. Collaborative Opportunities
Leverage capabilities and assets
Decrease duplication of services
Increase effectiveness
Prevent unanticipated denials / delays
Create a collaborative approach to determine an individual’s appropriate level of care
Achieve seamless care coordination

16. Healthcare Systems / SDHC
360 View
Person
Healthcare Systems / SDHC
Social Services
HHSA / Housing
EMS / Paramedics
Health Plans
211
Right Care
Right Place
Right Time
Right Coordination

17. Q & A