Cardinal Innovations operates a high functioning clinical system by using various management tools available in a managed care system. We ensure a high-quality, financially viable network that provides the services needed by our members in the least restrictive settings possible. Additionally, we monitor the care provided through prior and continuing authorizations, as well as retrospective reviews of care. We continually monitor and assess the performance of our network and expect high marks from the perspective of our members, providers, stakeholders and regulators. Finally, we use high-intensity management strategies for our high-risk members to increase the likelihood of a positive outcome.
Specifically, we use the following tools to ensure a high-quality, highly accessible system of care.
Access Call Center
Cardinal Innovations maintains a 24/7/365 Access Call Center (1-800-939-5911) through which individuals, families, community stakeholders and others can speak directly with a qualified staff person to inquire about services; be connected to services (emergently, urgently, or routinely); and inquire about community resources. Appointments with many of our providers can be made anytime, day or night, through this access line. Cardinal Innovations contracts with providers in every county to ensure emergent access for individuals within two hours, urgent access within 48 hours and routine access within 14 days. In addition, Cardinal Innovations contracts with Comprehensive Community Clinics (see below) in each county to offer same-day access to assessments during business days each week.
The 1915(b) Waiver allows Cardinal Innovations to use a closed network of providers, allowing us to specifically tailor the service system to fit the unique needs of each community in which we are the payer.
Cardinal Innovations verifies the credentials of each licensed provider prior to permitting them to provide services. Doing so ensures each provider has the proper education, experience and licensure for the services provided.
Utilization Management and Clinical System Monitoring
Cardinal Innovations uses several clinical tools to assure that high-quality funded services are used appropriately. These tools include prior authorization (PA), tracking of under/over use, and both quantitative and qualitative measurements of clinical quality. It is vital that Cardinal Innovations members receive care that is medically necessary, in the right amount, for the right duration, and in the least restrictive setting.
The Utilization Management (UM) Department is the focal point for managing member care. UM Care Managers are responsible for the majority of member care management activities, and for initiating the use of additional tools (such as care coordination) when necessary to ensure high quality care and positive member outcomes. The UM Department must look at aggregate data as well as individual data to complete its functions. The following UM monitoring and management tools help ensure these goals are met.
Prior authorization (PA) means that Cardinal Innovations requires submission of a Treatment Authorization Request (TAR), before a service is provided so that medical necessity can be adequately assessed. PA is required in the following kinds of instances:
Over/Under Utilization Tracking
Cardinal Innovations reviews claims data and compares it to expected norms. The goal is to identify instances when services are used too little to be effective, or too often. These indicators reflect the need for a different level of care or that low-quality care has been provided. Also, Cardinal Innovations reviews coding to ensure providers are not over- or under-coding for specific services. Examples of over/under utilization data include the following:
Quantitative Clinical Data Monitoring
Quantitative claims, authorizations, and other data can be a proxy indicator of clinical quality. Cardinal Innovations reviews certain types of data to assess provider quality and member safety. These types of data include the following:
Qualitative Clinical Data Monitoring
Certain aspects of clinical quality can only be obtained by manually reviewing the medical records of our members. Cardinal Innovations gathers these data through two types of reviews: Quality Management (QM) and Utilization Management (UM).
In 2014-2015, Cardinal Innovations UM department is continually using greater data-based management solutions with the goal of reducing prior authorization management strategies and redistributing clinical care management resources towards targeted retrospective reviews of care (UR) in our more established network areas. The following are priorities for this transition:
High Risk Monitoring
Cardinal Innovations uses various data-driven and manual referral processes to select high-risk cases and/or cases with poor outcomes to be reviewed thoroughly by clinical staff.
For more information on high-risk and special populations, see the Special Populations section below.
Quality Management and Performance Monitoring
In addition to reviewing individual members care through care management, Cardinal Innovations assesses the function of our clinical system more globally through the following tools:
The Quality Management Department conducts on-going monitoring reviews according to the NC DHHS Provider Monitoring Review Process using standardized review tools. Monitoring Reviews occur according to timeframes outlined by NC DHHS Provider Monitoring Process. Providers are required to meet an 85% threshold during a review. Providers who do not meet the required threshold are subject to more frequent monitoring reviews.
Quality Improvement Activities (QIAs) represent a requirement by the National Committee for Quality Assurance (NCQA) to identify three clinical areas of improvement and two service opportunities. Our CQI committee selects the QIAs from review and prioritization of identified areas of opportunity and monitors incremental improvement to achieve better outcomes.
Clinical Initiative Tracking
In 2014, Cardinal Innovations developed its Clinical Initiative Tracking System, which allows a wide variety of initiatives, intended to improve the quality of life and care for our members, to be monitored by our Clinical Management Team (CMT). New clinical initiatives can be submitted by any Cardinal Innovations staff member for review and if accepted as an initiative, a system is in place to track progress. As of early 2015, Cardinal Innovations has over 40 clinical initiatives in planning, implementation or monitoring phases.
Cardinal Innovations defines a "clinical initiative" as any new activity or significant expansion of an existing activity that is primarily intended to improve the lives of consumers. Examples may include the development and implementation of a new service, the use of a new evidence based practice, or new collaboratives intended to address member needs. Typically, a clinical initiative will address one or more of the following aspects of the clinical system of care:
The Importance of Data-Based Decision-Making
As is evident throughout this Managed Care Tools section, care is managed most effectively through the following means:
In an effort to improve these efforts, Cardinal Innovations is depending on data-based decision-making more than ever. To further the success of these strategies, Cardinal Innovations has partnered with the Jordan Institute for Families at the UNC School of Social Work for the following initiative:
Accountable Behavioral Care (ABC) Project - The purpose of the ABC Project is to enhance the capacity of Cardinal Innovations and its service providers to manage the care of the people they serve. The project includes activities that will add value to the work of Cardinal Innovations leadership team, staff, providers, community stakeholders and consumers. This project is administered by the Jordan Institute for Families at UNC-Chapel Hill. The ABC Project's four primary goals are to
The Jordan Institute has completed most of the activities to address initiative goals. They used different activities to complete goals such as Data Summits, webinars on business practices for providers, a series of community dialogues in the Five County Community Operations Center (COC), and a survey with Cardinal Innovations staff. The community dialogues are currently being conducted in the Five County COC.
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