Healthy Way Los Angeles

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Jul 30, 2012 (4 years and 11 months ago)

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1

COUNTY OF LOS ANGELES

DEPARTMENT
OF HEALTH SERVICES



HEALTHY WAY LA

INFRASTRUCTURE COMPONENTS AND
WORKFLOW





Introduction


Pre
-
enrollment and enrollment activities for
Health
y

Way LA (
HWLA
)

have been
underway
at participating Department of Health Servic
es (DHS) ambulatory care
facilities
since September

1, 2007

(participating
Public Private Partner (
PPP
)

facilities
commence
d

HWLA operations
in
March, 20
08)
.
HWLA clinics are being scheduled at
several facilities to provide care to new HWLA members.
Othe
r new HWLA members
are being seen in existing clinic sessions.
Discussions are continuing with the State to
finalize the HWLA funding contract. Final changes and upgrades are being made to

basic

supporting
Information Technology (
IT
)

applications to ensu
re efficient
information processing and support

for the HWLA program. The Member Services
function is assisting facilities with HWLA materials and letters, follow
-
up calls to
potential members, the member call line, membership card and packet fulfillment,

and
medical home assignment changes.

The Nurse Advice Line for HWLA members has
been implemented.


This Operations
Workflow document

is designed to provide reference information
regarding HWLA program
infrastructure
components and workflows as the HWLA
P
rogram

is fully deployed.




HWLA Program Structure


The HWLA
P
rogram consists of four major
infrastructure
operational components
.
These components

are integrated in the HWLA
P
rogram

to provide comprehensive
achievement of the
Coverage Initiative (
CI
)

g
oals and objectives as stated in the CI
contract with the State of California
. The components

are
:



1.

HWLA Administrative unit


2.

Member Services (part of
the DHS Office of Managed Care)


3.

DHS Disease Management Program,
and

4.

DHS
ambulatory care
and PPP provi
ders.



These major components will be supported by the appropriate DHS departments and
resources (Office of Ambulatory Care,
Information Systems (
IS
)
,
Revenue Management,

2

etc.) i
n the delivery of

CI services. The role and services of these four HWLA
ope
rational components are described below.


HWLA Administration.
The County of Los Angeles’ Department of Health Services
(DHS) is developing and staffing an administrative unit to
implement,
administer
,
facilitate

and manage support services for
the Coun
ty
CI, named Healthy Way LA. This
administrative unit will
implement, facilitate and
manage the State CI contract, develop
and administer contracts with the PPPs for HWLA services, and define the business
requirements for Information Systems support, to b
e provided by
the DHS

IS function.

In addition, the administrative unit will report HWLA program performance to the State.
Over the life of the CI, it is expected that changes in process and care delivery will occur,
necessitating on
-
going involvement by

the administrative unit in designing and
implementing these changes. Finally, the administrative unit will, from time to time,
implement various County, State and Federal initiatives (such as the flu vaccine program
for HWLA patients) aimed at the County

s indigent patients that are

HWLA members.


Member Services.

As a unit of the Office of Managed Care, Member Services is already
providing the types of services currently offered to managed care patients that will be
important to HWLA patients. Member S
ervices provide
s

the following services to
HWLA members:




Mailing of membership card and membership packet to enrollees who have
completed enrollment and met all CI eligibility requirements. The
membership packet contains descriptions of HWLA member servi
ces and
instructions regarding how to access and use the services offered with the
program
.



A Nurse Advice Line service 24 hours per day, 7 days per week

(through
Vendor contract).



A member calls

line to answer questions and
provide

instructions regarding
the program
.



Changing a medical home for an HWLA patient who desires to receive care at
another facility
.



Periodic
mailings of
information brochures and letters/notices to members
.



Member support by providing facilities with marketing and information piece
s
(posters, brochures,
and banners, etc.)
.



A personalized pre
-
enrollment letter for each patient identified as being
potentially eligible for HWLA inviting them to visit their medical home to
become aware of HWLA services and commence the enrollment proces
s
.



Various other services for HWLA members and potentially eligible patients as
may be defined during the CI period.


Disease Management Program.
The DHS operates a nationally recognized disease
management program
(DMP)
that will be made available to HWLA

members. This
service will be delivered at selected facilities for HWLA patients accepted into the
program
. These services will be provided by

DMP clinicians.

This program is a key
component of the CI’s primary goal of implementing improved health stat
us through

3

preventive and planned interventions based on patient health data. The DMP also has
developed specific protocols for managing the care of

HWLA patients who exhibit
dyslipidemia

or hypertension
.


Provider Facilities and Caregivers.
The most imp
ortant component in the HWLA
program is, of course, the caregivers in the DHS and PPP facilities who provide the
HWLA members with actual care services. In most cases, care that is being delivered
now to these patients will continue to be delivered. The
HWLA program, however, is
designed to provide specific additional preventive services and improved access to
specialty care services in order to transition the existing episodic interventions sought by
these patients in
urgent care (
UC
)

and
emergency depar
tment (
ED
)

settings (and some
admissions to hospital)
to regular clinic visits, and thus help the patient more effectively
manage his/her disease. The resulting goal is improved health status. Research and
clinical study data support this approach, and t
he DHS and PPP facilities can deliver the
results using the HWLA program tools and supporting functions.





Pre
-
enrollment Workflow


Analysis of the DHS electronic data repository (EDR)
, which contains records of all
visits to DHS and PPP facilities
,

has

produced a list of unique patient records and
assigned a unique identification number to each of these patients. T
he application of
HWLA eligibility criteria
(
uninsured, at or below 133 1/3% Federal poverty level, met
citizenship requirement,
at least
tw
o

visit
s

to a DHS or PPP facility during the past year,
and between 19 and 64 years of age)
to patients assigned a unique identifier, have
identified patients who appear to be eligible for HWLA membership. The
full set of
eligibility criteria appear in th
e various HWLA
brochures and materials available from
Member Services.

These

potential members, if they can subsequently and successfully
document

identity,
citizenship

or legal residency for at least five (5) years

and in
co
me
level

during the enrollment
process
, become full members of HWLA

and receive the
additional services and preventive care provided by the program.


When the

Unique Identifier (UID) and HWLA
Potential
Eligibility Selection (
P
ES)

programs identify a
potentially eligible
candidate for me
mbership in HWLA, the patient’s
record is included in the HWLA operational
data store (ODS). The H
WLA ODS
becomes the electronic data base supporting HWLA operations. IT has nearly completed
the development and testing of programs that will permit a dail
y “refresh” of the HWLA
ODS so that this data base wi
ll always be up to date.

Applications to date of the UID
-
PES software processing has evaluated visit records from March of 2006 to the present
time (January of 2008 when daily refresh of the ODS will co
mmence).




When a patient is identified by the above described process as potentially eligib
le
(
identity,
citizenship and income verification

remain to be
done during enrollment) s/he

is

sent a pre
-
enrollment letter by Member Services.

PPPs also have th
e option to mail the
pre
-
enrollment letter themselves.

Each facility receives a list of the
ir

patients who have
been sent a pre
-
enrollment letter
.


The

pre
-
enrollment
letter
describes the

incremental


4

benefits of being a member of HWLA
,

and restates the el
igibility criter
ia to obtain these
added healthcare
benefits.


Per
iod
ically, each facility sends

a follow
-
up pre
-
enrollment letter to

patients

who have
not responded to the first letter.
Facilities are responsible for

follow
-
up with their
respective pot
e
ntial members directly, either by mail or phone call
s
. If a facility requests,
Member Services will mail the follow
-
up

pre
-
enrollment letter, and
may also assist the
facility with placing

follow
-
up calls to potential mem
bers
.



The

pre
-
enrollment workflo
w procedure is as follows:


1.

IT executes
UID run to merge records and

assign UID number
-
daily
.

2.

IT/Planning executes
potential
eligibility selection

(PES)

run to assign
medical home and refresh HWLA ODS
-
daily
.

3.

IT/Planning g
enerate
s

mailing list for
pre
-
enrol
lment letters to
new additions
to the “
potentially
eligible” group
.

4.

IT forwards mailing list through
the Patient Management System (
PMS
)

and
OMC/Member Services to mailing fulfillment vendor
.

(Alternatively, for
PPPs who chose to mail their own pre
-
enrollm
ent letters OMC/Member
Services would distribute the letters in bulk to the PPP medical home).

5.

Member Services forwards mailing list to each facility
(on the facility follow
-
up spreadsheet)
for their patients (
potentially eligible patients who have that
fa
cility as his/her

medical home)
.

6.

Mailing
fulfillment vendor

or PPP medical home

mails pre
-
enrollment letters
to new
“potentially eligible” patients
.


7.

Member Services sends list of “became ineligible” patients
to each
facility

(for DHS facilities, Member S
ervices enters “702” in financial class field)
.


8.

Facility removes patient from

facility follow
-
up
tracking
spread
sheet at
facility
, and stops follow
-
up activity for that patient
.

9.

Facility schedules and executes f
ollow
-
up activities using facility follow
-
up

spread
sheet:

a.

Follow
-
up letter

(to pre
-
enrollment letter)
.

b.

Reminder letter
.

c.

Follow
-
up call
.

d.

Remov
e from follow
-
up (code on facility follow
-
up spread
sheet)
.

10.

Patient responds to follow
-
up
?

a.

Yes, go to “
Eligibility Verification
” workflow description
.

b.

No, enter

702 in Affinity record

(DHS facilities)
,
and in facility
follow
-
up spread
s
heet, and stop follow
-
up activity for that
patient
.



Eligibility Verification


When a patient enters a
PPP
facility
,

his/her
HWLA status

needs to be determined.
Several situation
s will be encountered
:



5

1.

The patient arrives wit
h a pre
-
enrollment letter, or is responding to a follow
-
up call or letter.

The registration staff will then reference the list of
potentially eligible HWLA members from the sheet sent to them by the DHS
HWLA
Office.
If no appointment exists, the fact that the patient has a pre
-
enrollment letter addressed to him or her

qualifies that patient to be considered
for

the enrollment process.

The patient is asked if he/she is a citizen or legal
resident

for at least
five (5) years, between the age of 19
-
64
, has proof of
identity, and will attest to having no income or can verify with documents that
they have an income level less than 133

1/3
% of the Federal poverty level

(FPL)

(and qualifies under
the PPP program,
ATP

(with no liability), or GR).
If eligibility can be verified by answers to these questions,

and the patient is
interested in becoming a member of HWLA, he/she

should enter the
enrollment process.


2.

The

patient arrives and inquires about HWLA (heard about

it from a friend,
saw a poster,
is approached by a
n

HWLA Health Education Assistant

(HEA)
,
etc.).
This patient will be asked several questions
(see Situation #1 above)
to
det
ermine if he or she should be considered for

the

HWLA

enrollment
process. If an
swers to the questions verify eligibility,

and the patient is still
interested, he/she

should enter the enrollment process.

3.

The

patient arrives, gets registered and financially screene
d, but has not asked
about HWLA, and
cannot be found on the list of
pati
ent
s

who are

potentially
eligible for HWLA. This would likely be a first visit for this patient.

If the
results of the financial screen qualify the patient for
PPP,
ATP

(no liability)
,
a
nd/or GR, the patient should answer the three queries from Situatio
n #1
above to verify eligibility. If eligible

and interested
, the patient should
commence the enrollment process
.

4.

The

patient arrives who has started the enrollment process, but not completed
it. Th
is

patient

should
refer
red

to t
he
facility’s
HWLA enroll
ment process. If
patient

do not have an appointment,
s/he

should

inform the registrar that
is

returning to complete enrollment and be referred
directly to that

process.


See enrollment process below for all patients referred
.


Enrollment

1.

The potent
ial mem
ber’s file is requested i
n
the DHS SecureWeb application
using
her
/h
is

name and
/or

Eligibility
Number (the number on the pre
-
enrollment letter)
.
First visit patients may not be
in the HWLA ODS

until the
they have been billed to AIA
, so they may not appear

after the PPP bills AIA
for the patient visit
.
For patients who are not in the SecureWeb system, the
enrollment clerk should keep copies of all documents and then hold them until
the PPP has billed AIA and the names are uploaded in the SecureWeb
.

Dependi
ng on how frequently the PPP bills AIA this can take at least a month
if not longer.

Thus for returning patients who express an interest in HWLA,
and have all their documents with them on that visit, can complete enrollment
on that visit.


6

2.

When the

patient

is identified in ODS via

the
SecureWeb
request, information
and

documents requir
ed for enrollment
(
the SecureWeb
structures the
document scanning to avoid missing required items)
can be scanned

into the
ODS. If all requirements are met, and the appropria
te attestations are signed,
the patient is provided with a temporary

membership “card” letter. This
temporary “card”
s
erves as the patient’s

HWLA membership card

until a
membership packet and official
membership
card are mailed to the patient
.
Citizen
shi
p/le
gal residency, identity, inc
ome verification

and the attestation
form

d
ocuments are scanned into
WebSphere

and stored for later audits, as
necessary.

3.

Patient enrollment documents should be regarded as Personal Health
Information, and stored in secure l
ocations, indexed for access,
under the DHS
HIPAA policy. When
the SecureWeb
audits indicate a near
-
zero error rate in
scanning operations, these documents may be returned to the patient, or
destroyed. Each facility has accumulated sets of these document
s and
is

holding them for future scanning. As the UID
-
PES process becomes
operational and is refreshing the ODS daily, facility management should
attempt to scan these files, as patients will likely be in
the SecureWeb
as a
result of the refresh process.



4.

If the patient’s birth certificate has been obtaine
d from “vital records”
(California born only)
, it will already be in a file at the facility. Thus, the
birth certificate file must be checked at each enrollment. If the birth
certificate
(or verificati
on number)
exists in the facility file (
CA Born Index
),
the patient will not have to go home and find it and make a second trip to the
facility to complete enrollment.

A procedure has been documented by the
Citizenship and Identity work group to acquire o
ut of state birth certificates.


The facility enrollment workflow procedure is as follows:


1.

Sit down with patient and review documents
.

2.

Call up patient in WebSphere
.

3.

If patient has commenced enrollment on a previous date, pull patient’s paper
enrollment fi
le and go to step 6
.


4.

Display application/attestation form and print
.

5.

Fill out application/
attestation form with patient
.

6.

Review required forms and make copies
.

7.

If all forms required (driver’s license, green card, birth certificate, income
documents, etc.)

are available in attestable form, the enrollment can be
deemed complete; if this is the case, go to
next step
; if not, go to step

11
.

8.

Obtain patient’s signature on application/attestation form
.

9.

Sign application/attestation form
.

10.

Go to step

15
.


11.

Instruct p
atient regarding additional documents required to complete HWLA
enrollment
.

12.

Document this status on follow
-
up call list for the patient
.


7

13.

Provide patient with a form noting the additional documents required for
completing enrollment
-
see Attachment B
.

14.

End pa
rtial enrollment session with patient, indication when you will follow
-
up, or when patient agrees to return with required additional documents
.

15.

Provide temporary letter membership “card” to patient
.

16.

Scan documents and

application/attestation form
.

17.

File pap
er document file for the new member in a secure and clearly indexed
location

consistent with the DHS HIPAA policy
.

18.

When advised, return document file to patient, or destroy

consistent with the
DHS HIPAA policy
.





Enrollment
-
PPP Facilities


The enrollment

procedure for the PPPs is identical to that followed at the DHS facilities,
except that the online application is called “Secure Web” (a secure access portal on the
internet for WebSphere).


When enrollment has been completed, a file will be generated wit
hin 48 hours to notify
the Office of Managed Care to validate the enrollment of the patient in HWLA, and
notify the Fulfillment Vendor to mail the patient’s membership card and membership
information packet and manual.



Health Screen
, Health Education,

an
d Health Management Plan


New enrollees will be scheduled
with a facility nurse and/or primary care physician
for a
health screen/assessment, and the development of a personal health management plan.
This plan will be constructed to take full advantage of

HWLA benefits and services, and
will serve as a guide for delivering these services to the patient. The patient’s primary
care provider/team will
follow, execute, and update this plan for the duration
of the
program, using new protocols

and DMP resources

as

necessary to meet the goals of
the
HWLA

member’s health management plan
. The patient’s primary care provider/team
will manage all specialty referrals using the DHS Web Referral System

(“RPS”)
.


The facility’s
Health Education Assistant (
HEA
) or equiva
lent

will, based on the nurse’s
health assessment, provide appropriate health education, and supervise the patient’s
participation in and compliance with specifically assigned health improvement programs
(smo
king cessation, preventive care plans
, etc.).


T
he health management plan should be integrated with the patient’s encounter screens so
the provider is equipped with a seamless assessment, examination, documentation,
ordering, and results reporting record.



Appointment/
Encount
er


8


Each time the patient

enters a DHS facility, a financial screen and address
verification/update is routinely accomplished in
in the information system at the PPPs
. If
the patient is a HWLA patient and requests a change in medical home assignment, that
request is referred to M
ember Services for resolution using existing procedures.

Any of
these changes will be automatically updated in ODS within 24 hours.



Preventive Care

Services


A key goal of the
Coverage Initiative

is to enhance and intensify preventive care
measures and
activities to reduce the frequency of urgent and emergent care episodes. To
achieve that goal, the HWLA program will routinely report to the State performance in
the following preventive activities:


1.

Percentage

of all enrollees receiving initial risk asse
ssment
.

2.

Percentage

of all adults receiving annual hypertension
screening
.

3.

Percentage

of all women receiving annual PAP smear
.

4.

P
ercentage of women 49 years of age receiving annual mammogram
.

5.

P
ercentage of men over 40 and women over 50 taking daily aspirin
.

6.

P
ercentage of enrollees receiving annual flu vaccine
.

7.

N
umber of enrollees receiving tobacco use screening and intervention
.

8.

P
ercentage of men over 35 and women over 45 receiving cholesterol
screening
.

9.

“O
thers” for patients with specific chronic conditions
(e.g., diabetics will
receive annual retinal exams, hemoglobin A1c testing, LDL
-
cholesterol
testing, foot exams, and diet counseling)
.


These “preventive care” services are expected to be included in each patient’s health
management plan, and monitored for

compliance with scheduled provision.



Nurse Advice Line


As part of the CI goal to reduce unnecessary visits to the emergency departments HWLA,
through the DHS Office of Managed Care, is offering a nurse advice line (NAL) as part
of the HWLA benefits and

services. Patients will be able to call the NAL anytime of the
day or night, seven days a week, to ask questions and get advice regarding suspected and
real illness
. Patients needing provider visits will be scheduled for next day appointments
at their r
espective medical homes. Calls received by the NAL on Fridays and Saturdays
will be resolved over the phone, or the patient will be directed to the appropriate
ambulatory care center urgent care location.


Appointments and patient information for each cal
l will be faxed to the patient’s medical
home for review and action by facility providers.



9



Specialty
Care
Services


Each DHS and PPP Facility has been equ
ipped with online connections
t
o the DHS
specialty care R
eferral
Processing System (
RPS
)
. As part
of the HWLA program, when
an HWLA patient is input to the RPS for purposes of effecting a r
eferral, the RPS will
display the

preferred specialty site for that patient and service. This will enab
le the PPPs
to direct HWLA patients to

specialty car
e provide
rs in the appropriate hospital or CHC.



HWLA
Performance Reporting


In addition to the preventive care performance measures listed above that will be reported
periodically to the State, there are a number of other performance measures that will be
routine
ly measured and reported to assess the success and effectiveness of the HWLA
program and its underlying
assumptions.


The performance measurement and reporting system is still being designed and will be
added to this
document

when completed.



Frequently A
sked Questions

Document


Have been posted on the HWLA Website and is updated in an on
-
going basis
.

This
Website is located in the Department of Health Services Office of Ambulatory Care and

is

easily access by clicking on the HWLA site located on the left

hand
side menu

and
then

clicking on “HWLA Updates”.








HWLA Operations Workflow

6/23/08