All language subtitles for D1-002-Calopt-Main English subtitles

Hi everyone.

My name is Kelly when I'm

with Cal Optima, um, in the

case management department.

And then I have Judy

Riley with me and

she's the manager in UN

can you guys, oh, you guys

can see, see my screen.

Okay.

Just want to make sure.

Nope.

Yes.

Okay.

Okay.

Um, so I'll go ahead

and go to the agenda.

So first we are going

to go over Cal Optima

members profile.

Uh, we'll talk about

case management.

I here at Cal Optima, I'll

discuss about the beast,

the breast and cervical

cancer treatment program,

which is called the BCC

TP and case management.

Uh, how we develop an

individualized care plan

for the members, uh, how to

get help and a successful.

So who are our members?

As I mentioned earlier, we

have 808, 2001 membership

in Cal Optima between the,

our membership it's between

these program, which is

Medi-Cal OneCare connect,

OneCare, and program up on

to sift care for the elderly,

which we call it pace.

Uh, the majority of our member

is a med is medical members.

And, uh, these members

age ranges from zero

to 65 and above, as you

can see the breakdown

here to the left-hand

side, uh, the language

here, um, our threshold

languages is listed here.

We have mainly 59% of English,

um, a great percentage of

fancy speaker and Vietnamese.

And then of course,

everything else.

And these are the categories

that, um, our Medi-Cal members

are in mainly in the, uh,

temporary assistance for needy

family, which has caused.

Okay.

So what is case management?

Um, case managers in

our department here?

Um, it is a process that

we compete in assessment.

Um, we evaluate the member's

condition, determined their

benefit, um, availability

and their resources.

And of course we develop

an individualized care

plan, which we call an

ICP here with goals and

monitoring and follow.

Um, we also do something,

um, or manage the

interdisciplinary care team

meeting, where we have a

team of medical director,

um, case manager, social

worker, PCC, or personal care

coordinator, um, you know,

pharmacy and behavioral health

in these kind of meetings.

We also facilitate

coordination of care among

the members provider.

Um, and also we

ensure referrals and

linkage to community

resources and agents.

So our goal here, uh, for case

management is to help a member

regain optimum health and

improve functional capability

in the right setting, in

a cost effective manner.

Okay.

So the breast and cervical

cancer treatment program

and case management.

So here at Cal Optima,

we are a health plan.

Um, we also have a

health network called

Cal Optima community.

Now.

And under the, that network,

we have a team of, like I

mentioned, a registered nurse

case manager, a personal care

coordinator, a social worker

and stuff, and that they

can assist with your care.

So here we ensure,

um, you know, timely

coordination of care.

We assess that we

refer, um, member who

are receiving services

under the species CTP.

Which we support in creating

an individualized care pan.

Uh, we also assist member

to prioritize their needs.

Um, we facilitate

access to the breast and

cervical cancer services.

Uh, we coach the member in

navigating the healthcare

system and we link them

with breast center pro

cancer, community resources.

And of course promoting

self-sufficiency in the

end of case management, we

would like our members to

be independent and they are

able to advocate for them.

So the individualized

care plan for the BCC

TP member, uh, we create

actionable care plan.

Um, you know, we use smart

goals where, you know,

we work with the member.

So it's developed with the

member and the case manager.

We make sure it's

attainable for them.

And we outline what care plan

tasks or, um, that needs to

be performed by the minute.

Or the case manager.

I know an example of this

is, you know, a member who

has breast cancer, who is,

you know, wanting to get

a referral to see their

oncologist or, and we would

have to, uh, you know, assist

the member and kind of educate

them, you know, talk to

their primary care physician.

Um, and then we'll work

with our internal department

to get their referral so

that the member can be

seen in a timely manner,

some consideration that.

We can, uh, we

consider our cultural

differences languages.

And like I mentioned, we have

through threshold languages,

uh, health literacy,

and alternate format.

So how can somebody get help?

Uh, what they can do is

they can contact, uh,

CalOptima customer service.

Um, they can request for a

case manager to be assigned.

If a member has already been

with a case manager before

they can always request

that case manager, um, call

that case manager and have

them, um, request for their

case to be open again.

What happened is that customer

service would do the intake.

Then they would send.

And I, um, they were sent

an internal referral to our

case management department

triage, and we would

assign a case manager.

And then from there we

would contact the member

and outreach and assist

the member in the needs.

So here I have a

success story for you.

It is Mrs.

H she's um, 37

year old female.

She is effective with

the BCCP program.

Uh, since September 1st,

2021, she was nearly diagnosed

with cervical cancer.

She was referred to the

CalOptima case management on

September 22nd of 21, and she

was assigned a case manager.

Um, the case manager, you

know, did her assessment

came over with go, she,

uh, follow up with,

um, the member monthly.

She reminds the member

of her appointment and

how important it is to

keep her appointments.

She helped, uh, the

member with referrals.

Um, she worked with the

provider's office to

facilitate any health

education, or any care that

the member needs, um, and

also to follow a treatment.

Um, she did receive a cone

biopsy, which was performed

in November of 2021.

And following a

positive COVID test.

She had her hysterectomy,

which was performed on

February 26th of this year.

Um, she got her to

surgical treatment and

she's recovering well.

Um, she is now independent and

able to do things on her own.

Um, the case manager, you

know, helped her navigate

through the system.

So as you can see here,

um, you know, there are

many aspects of case

manager, what we can do.

Um, but in the end we would

like for, you know, all of our

members to be, uh, you know,

advocating for themselves

and to be successful.

Um, I will pass it

on to Judy for you.

M

Judy, thank you

so much, Kelly.

Thank you so much, Judy.

Okay.

No problem.

Um, so Kelly, if

you can navigate for

me, I appreciate it.

Thank you.

Um, so as Kelly said, I'm

the manager of utilization.

Uh, for the prior

authorization part

of that department,

we have two do areas.

We have the prior

authorization, which is

basically the outpatient.

And then we have concurrent

review that follows

the patients while

they're in the hospital.

Um, so with, with Kelly's

example, um, that member

would, when she, if she had

stayed as an inpatient in the

hospital for her hysterectomy,

she would have been followed

by our con current reviewed.

Um, but for the prior

authorization part of this,

um, what we do is we evaluate

for the medical necessity,

appropriateness efficiency,

um, for the procedures for

members in our case, this

is the Medi-Cal and Medicare

guidelines that we follow.

Um, it's also called

utilization review an example.

Would be, um, the surgery

that was scheduled for Ms.

Say that would come to

the department, it would

be reviewed against the

guidelines with the provider's

notes, the diagnosis,

and it would meet the,

um, the guidelines and it

would be approved by the

utilization management

department for either

inpatient stay depending

on what the guidelines

suggest or as an outcome.

Uh, next slide, please.

There are services that

require authorization,

uh, here at CalOptima.

We, um, publish that on

our external website,

which is where the link

is, but there are also some

services that we do not

require an authorization at.

Lot of these are

for, um, routine.

Testing, uh, things such

as for the, um, cervical

tests, we do not require,

um, authorizations

for a well-woman exam

for the pap smear.

That kind of thing.

We do not require an

authorization for mammograms,

as long as it's done at one

of our contracted facilities,

um, for prior authorization.

I've put here that these

are the usual expected,

um, timelines from getting

the referral sent to,

um, CalOptima to when the

member and the provider

should expect a decision.

Um, we are working

on expanding.

Uh, provide a portal for

our, um, CCN members,

our network members.

Um, so a lot of the requests

that are coming in via our

portal may all to approve

and the provider will

get an instant decision.

Um, for urgents.

Um, these urgent submissions

are reviewed within 72 hours.

Um, for a routine referrals,

it is usually five days from

receipt of the information

needed to make the decision.

So if the PCP or whoever

is making the referral

sense, everything with

their request, we can get

that done within five days.

Otherwise we would have

to take a little longer

asking for the additional.

Uh, the rest retrospective

services, there's the services

that have already been,

um, provided to the member.

Um, these requests will come

in and we have 30 days from

the time of receipt, um,

to make a decision on the

retroactive services next.

Um, For the, um,

breast cancer, cervical

cancer members, we work

closely with the case

management department.

Um, if we get a referral

in, for a member for a

consult for possible,

um, Counsel diagnosis.

Um, the members seen

by the PCP, they have

a positive pap smear.

Um, they have something that's

showing strange on the, uh,

the mammograms on x-rays.

Um, the prior authorization

department will also send

an internal referral to the

case management department.

If this member is not

currently under case

management, just to give them,

uh, an idea that this member.

Code or does have a

cancer diagnosis and to

follow up with a member.

So working with case

management and prior

authorization, um, we try to

make sure that these members

get the care that they need,

that, um, they are treated

respectfully and timely.