Eligibility Process Improvement Center

Transcription

1 Eligibility Process Improvement Center

2 Health Care Coverage Solutions at Work Too often, children and adults who are eligible for Medicaid or the State Children s Health Insurance Program (SCHIP) remain uninsured because of procedural problems within the application and renewal processes. As a result, they are left uninsured, risking both their physical and financial health. In addition, health care providers pay the price of unreimbursed medical bills. The Southern Institute on Children and Families established the Eligibility Process Improvement Center which utilizes collaborative learning to help government agencies, health care purchasers and health care providers find solutions that work. The Eligibility Process Improvement Center also provides For many, the collaborative learning experience shattered the myth that individuals cannot make a difference. No matter their position in the hierarchy, participants discovered that they can encourage and even instigate institutional and procedural changes that make the system perform better for families and revitalize the work lives of individuals. consulting services. The collaborative learning technique has proven to be an effective tool in finding the best ways to solve procedural breakdowns and improve system efficiencies and effectiveness. The Eligibility Process Improvement Center adopted this technique and applied its principles to the Medicaid and SCHIP eligibility systems to maximize the efficiency and accuracy of getting eligible individuals and families on Medicaid and SCHIP, and keeping ineligible individuals and families off of these public health care coverage programs. 2 The Movement Toward Quality Improvement The Movement Toward Quality Improvement 3

3 Public trust is diminished and the eligibility system loses credibility when eligible persons are denied coverage and ineligible persons are provided coverage. OUR CLIENTS State agencies are required to maintain health coverage for eligible people and need to streamline work for overburdened staff. Managed care providers and insurers seek to reduce "churning" to allow for the provision of continuous health care. Cycling on and off eligibility rolls results in sporadic health care coverage and increased administrative costs. Health care providers, such as hospitals and community health centers, want to reduce the number of uninsured to help quell health disadvantages and the rippling financial impact of treating patients without health insurance or any other means of payment. The Eligibility Process Improvement Center offers its services through a Collaborative or on a consulting basis. 4 The Movement Toward Quality Improvement The Movement Toward Quality Improvement 5

4 Southern Institute eligibility process improvement initiatives have had a significant impact on Georgia as far as bringing the right people to the table and cultivating relationships across state agencies. The development of these interagency relationships has been critical to the improvements that have SYNERGY T hrough a dynamic and powerful 10-month commitment, known as the Eligibility Process Improvement Collaborative, staff and Collaborative faculty can help your organization achieve its goals by providing public eligibility agencies, managed care organizations, hospitals and insurers with the skills, practical experience and individual attention necessary to make changes that lead to rapid and measurable improvements. The Eligibility Process Improvement Collaborative brings together dynamic teams made up of staff from a single organization or multiple organizations. These dedicated professionals and staff from government agencies and health care professionals work individually and collectively to share ideas and know-how on single or multiple eligibility process topics. ELIGIBILITY PROCESS IMPROVEMENT COLLABORATIVE GETS RESULTS The Eligibility Process Improvement Collaborative gets results by placing an emphasis on shared learning and measuring successes. Only by reviewing outcomes over time can improvements to effectiveness and efficiency be judiciously developed and implemented. Iowa tested an automated referral system to days from the date of walk-in application reduce the incidence of Medicaid cases being as opposed to days from request for been made in Georgia. denied or closed without consistently being appointment to completion under the old system. referred to SCHIP for eligibility determination. The Fran Ellington, Director of Recipient and Delaware tested a Verification Checklist to automated referral system increased referrals from Third Party Services, Georgia Department assist staff in reducing the over- or underverifying of Community Health Medicaid to SCHIP by an average of 191 percent. of eligibility requirements for children Nassau County, New York re-engineered its and families applying for or renewing their Community Medicaid application process to make Medicaid or SCHIP coverage. The Verification it more user-friendly. Testing of the new process Checklist was successful and was implemented was successful and when implemented, the statewide along with a training module. new procedure for the acceptance and review The Verification Checklist was adapted by of applications resulted in the elimination of a collaborative members for use in Los Angeles backlog of 7,500 applications. Approximately and San Bernardino Counties in California, as 2,800 cases are processed per month and well as Cuyahoga County in Ohio. applications are being processed in approximately 6 The Movement Toward Quality Improvement The Movement Toward Quality Improvement 7

5 Learning, Action and Support Eligibility Process Improvement Center A 10-month structured and proven collaborative experience resulting in Medicaid and SCHIP Eligibility Process Improvements Pre-Work General information, schedules and activities to be completed Learning Session 1 2 1/2 days of instruction in Plan-Do-Study-Act (PDSA) and quality improvement methodology The ability to work incrementally and benefit from the experience of others, both inside and outside your organization, leads to problem solving that saves time and money. From start to finish, the Eligibility Process Improvement Center assures that your team derives the greatest benefit. Interactive sessions, known as Learning Sessions, bring the teams, faculty and staff together to determine where improvements can take place and Action Period 1 Applying new skills in the work environment, with technical support Learning Session 2 2 1/2 days of advanced instruction utilizing real-world data from Action Period 1 Action Period 2 Applying enhanced skills in the work environment, with technical support Learning Session 3 2 1/2 days refining skills in data analysis and in rollout of systemwide improvements how these improvements will be executed and measured to ensure quality. These two and one half day Learning Sessions are held three times during the Collaborative year. They utilize the Plan-Do-Study-Act (PDSA) approach to effectively solve problems. 1 This widely recognized process for continual improvement involves the following steps: Multi-Team Collaboration, Technical Support and Web Site Access The Eligibility Process Improvement Center Collaborative is adapted from the Breakthrough Series Collaborative model developed by the Institute for Healthcare Improvement. Plan Develop a plan for improving the quality of a process Do Execute the plan, first on a small scale Study Evaluate feedback to confirm or adjust the plan Act Adopt the plan, adapt the plan or abandon the plan 1 Gerald J. Langley, Kevin N. Nolan, Thomas W. Nolan, Clifford L. Norman and Lloyd P. Provost, The Improvement Guide, (San Francisco, CA: Jossey-Bass, 1996), Action Periods augment the Learning Sessions by giving teams an opportunity to apply their new knowledge and skills on the job. Fellow Collaborative team members come together regularly during the Action Periods via conference calls and an interactive Web site to receive guidance and technical assistance from the Eligibility Process Improvement Center staff and Collaborative faculty. With consistent support, teams test strategies and collect data. The results are analyzed and refined during the Action Periods and in subsequent Learning Sessions. Ultimately, the strategies can lead to significantly improved processes and results. 8 The Movement Toward Quality Improvement The Movement Toward Quality Improvement 9

6 Consulting Services Eligibility Process Improvement Center staff from the Southern Institute on Children and Families are available to provide on-site consultation and technical assistance to Collaborative teams, as well as individual organizations. The areas of expertise include: Technical assistance on eligibility process improvement General consultation on process improvement General consultation on Medicaid and SCHIP policy About Us The Southern Institute on Children and Families, a respected national leader in improving access to health coverage for lower-income children and adults, established the Eligibility Process Improvement Center as a strategic business center focused on improving Medicaid and SCHIP eligibility processes. The Eligibility Process Improvement Center grew out of the Southern Institute s cutting edge research on eligibility policies and procedures and its many years of experience directing national initiatives for the Robert Wood Johnson Foundation, such as Contact Us Eligibility Process Improvement Center Southern Institute on Children and Families 500 Taylor Street, Suite 202 Columbia, SC Phone: Fax: info@thesoutherninstitute.org Supporting Families After Welfare Reform and Covering Kids & Families. These initiatives help improve the processes public agencies use to enroll and retain eligible children and adults. 10 The Movement Toward Quality Improvement The Movement Toward Quality Improvement 11

7 The Eligibility Process Improvement Center opens up your mind to a new way of thinking so that you can reexamine the processes that you follow every single day in a new light. That s what I think teams get out of this that their minds are opened up to a kind of kaleidoscopic approach where everything shifts just a little and you have a new way of doing things that s a little more helpful or a little bit closer to your goal. Penny Lane, Writer/Researcher, MAXIMUS,The Center for Health Literacy It s changed the way I approach my work. Now I look at things as much more achievable and doable because I ve narrowed the scope, broken it down to smaller steps and looked at doing projects in shorter time increments. Rebecca Pasternik-Ikard, Director, SoonerCare and Care Management, Oklahoma Health Care Authority Eligibility Process Improvement Center Southern Institute on Children and Families 500 Taylor Street, Suite 202 Columbia, SC Phone: Fax: info@thesoutherninstitute.org