This new position is needed due to the growth of membership and increase in requirements imposed by our Medi-Cal contract and by regulatory and accrediting agencies. Our membership has grown more than 60% in the last two years, and we expect to see a continued high level of new enrollees through the end of the year. With that growth, there are more members qualifying for programs including our Disease Management Programs for Diabetes and Pediatric Obesity. Our staff works directly with patients with these diagnoses and their families to improve their health status and reduce future Plan medical expenditures, for example by avoiding ER visits. The current staff supporting this program has reached her capacity; more staff is needed to counsel additional members. Also, CCHP is now responsible for providing mild to moderate mental health benefits and Applied Behavioral Analysis for Autism. These new benefits require new quality measurement and improvement work, requiring additional staff time. NCQA, our accrediting body, has implemented extensive new standards. To meet the standards, we need staff to: 1)Produce and distribute self management tools, 2)Perform usability testing on them, 3)Review and update when new evidence is available, at least every two years, 4)Assist members with the tools by email, phone, and mail, 5)Use data sources to identify members eligible for wellness activities, 6)Provide reminders for needed or missed care, 7)Provide incentives for use of tools and health assessments measure effectiveness of the incentive program, 8)Provide required quality measurement and improvement assistance to Claims, Pharmacy, Member Services, and Advice Nurse Unit regarding new web-based functionality they are required to add, and 9)Manage compliance with numerous Behavioral Health standards that had previously been carved out.
If this action is not approved and without additional staff, the Quality Management unit will not be able to meet the mandated requirements of the Health Plan.