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Service Delivery Innovation Profile

24-Hour, Bilingual Nurse Line Provides Advice and Interpreter Services for Plan Members, Leading to Wiser Decisions and Cost Savings


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Snapshot

Summary

Molina Healthcare, a Medicaid managed care organization serving medically underserved individuals who depend on government assistance, instituted a 24-hour bilingual advice line to address the health and language needs of its low-income, Spanish-speaking members. Known as TeleSalud, the advice line provides callers with direct access to a registered nurse who can address their health and interpreter needs in their preferred language. The bilingual nurse advice line has significantly increased the number of calls coming from Spanish-speaking members and has helped members to make wiser choices, leading to fewer emergency department visits and significant cost savings.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on advice line use and caller satisfaction, pre- and post-implementation comparisons of the percentage of Spanish-speaking callers to the advice line, anecdotal reports from staff, post-implementation data comparing ED use between those with and without access to the line, and estimates of the cost savings generated due to these reductions in ED visits.
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Developing Organizations

Molina Healthcare
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Use By Other Organizations

Molina Healthcare now offers its bilingual nurse advice line services to three outside organizations.

Date First Implemented

2004
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Non-english speaking/limited english proficiencyend pp

Problem Addressed

Molina Healthcare's existing nurse advice line did not adequately meet the needs of its Spanish-speaking members.
  • Few calls from Spanish-speaking members: Approximately 65 percent of Molina's members identified themselves as Latino, with 45 percent preferring to communicate in Spanish. Yet, less than 2 percent of calls to Molina's advice line came from Spanish-speaking members.
  • Turned off by automated services: Due in part to cultural differences, those who speak Spanish are more likely than English-speaking individuals to hang up when they reach the type of automated telephone services historically used by Molina.
  • Language barriers for Spanish-speaking callers: Although many nurse advice lines are available to health plan members and patients throughout the nation, few, if any, have traditionally required their operators and nurses to be bilingual.

What They Did

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Description of the Innovative Activity

To address the health and language needs of underserved members with limited English proficiency, Molina Healthcare instituted a 24-hour, bilingual nurse advice line. Known as TeleSalud, this program enables Molina's members to directly access a bilingual registered nurse (RN) who can address their health and interpreter needs in their preferred language. Key program elements are described below:
  • Linguistically appropriate marketing: Molina distributes identification cards with the toll-free TeleSalud phone number to all Spanish-speaking members. New members receive marketing materials written at a fifth-grade reading level.
    • Health booklet: The program has expanded member education through the distribution of a health booklet to all Molina member households. Printed in English and Spanish, this booklet provides basic care instructions for common health issues and has the TeleSalud phone number on every page.
    • Calls after discharge and emergency department (ED) visits: The organization promotes the availability of its 24-hour nurse advice line during followup telephone calls made to all members discharged from the hospital or seen in the ED.
  • Bilingual, two-tiered staff: Operators who speak both English and Spanish answer all calls, and route those requiring interpreting, clinical assessment, or intervention to an RN. Spanish-speaking callers requiring such assistance are routed to one of eight bilingual RNs who staff the line. Patients who prefer a different language can be connected to a separate language line for assistance.
  • On-demand services: The line provides callers with timely access to RNs able to provide medical advice and, if necessary, direct them to the most appropriate level of health care. Nurses also provide interpreter services to members during health care encounters. For example, if members find themselves in situations in which no Spanish interpreter is available during a medical appointment, ED visit, or pharmacy encounter, they can call TeleSalud to gain immediate access to a nurse who will interpret, educate, and assist them.
  • Followup support: RNs follow up with any member who calls for medical advice, with calls being placed the day after the initial call. During these conversations, nurses check to make sure that the patient's issues have been resolved, and also make referrals, provide education, and help schedule appointments as appropriate.
  • Ongoing quality monitoring and improvement: The compliance administrator and call center management conduct ongoing quality monitoring by listening to live patient calls and call recordings. In addition, interrater reviews are conducted on a regular basis, and nurses perform monthly peer reviews and self-assessments. This information serves as the basis for discussions with RNs regarding their member encounters.

Context of the Innovation

Molina Healthcare, a Medicaid managed care organization, covers approximately 1.6 million medically underserved individuals in California, Michigan, Missouri, Nevada, New Mexico, Ohio, Texas, Utah, Washington, and Wisconsin. In 2002, Molina reviewed usage patterns for its outsourced nurse advice line and found that few Spanish-speaking members called the service. This finding suggested that these members were experiencing barriers in accessing advice services, prompting Molina to revamp the program. Molina is now one of only a few health plans that owns and self-operates a nurse advice line, and Molina's program is believed to be the only advice line in the country that requires all operators to be fluent in both English and Spanish. As of July 2011, it currently has 30 bilingual operators and 8 of its 26 nurses are bilingual. The program was developed in collaboration with the Robert Wood Johnson Foundation Hablamos Juntos initiative.

Did It Work?

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Results

The bilingual nurse advice line has significantly increased the number of calls coming from Spanish-speaking members and has helped members to make wiser choices, leading to fewer ED visits and significant cost savings.
  • More Spanish-speaking callers: The nurse advice line currently receives between 27,000 and 28,000 calls per month. Approximately 60 percent of these calls come from Spanish-speaking members, compared with 2 percent with the old advice line. Following the mailing of a bilingual health booklet that lists the advice line number, call volume increased 9.5 percent.
  • Wiser choices, fewer ED visits, and significant cost savings: Staff members report that patients who call the nurse advice line often avoid going to costly EDs or urgent care centers, and health plan data backs up this claim. For example, annual ED usage among Spanish-speaking patients who had access to TeleSalud during 2004 averaged 191 visits per 1,000 members, well below the 217 visits per 1,000 Spanish-speaking members for those without access to the line (during this initial pilot test, Molina members in two counties had access to the revamped advice line, while members in other counties having access to the traditional line).1 Based on a 3-month analysis, project staff estimate that these wiser choices saved the health plan approximately $2,500 per month.2 Since that time, the program has continued to generate cost savings. For example, the program generated estimated cost savings of $1.5 million in 2009, and is expected to yield even greater savings ($1.7 million) in 2010.
  • High satisfaction: A survey found that 99 percent of those who called the nurse advice line reported being satisfied with the services received.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on advice line use and caller satisfaction, pre- and post-implementation comparisons of the percentage of Spanish-speaking callers to the advice line, anecdotal reports from staff, post-implementation data comparing ED use between those with and without access to the line, and estimates of the cost savings generated due to these reductions in ED visits.

How They Did It

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Planning and Development Process

Key steps in the planning and development process are described below:
  • Joining collaborative network: Molina obtained a grant from the foundation as part of its Hablamos Juntos initiative, which served communities with fast-growing Latino populations by focusing on the development of affordable models for providing innovative language and interpreter services.
  • Hiring staff: Molina hired RNs and operators fluent in both English and Spanish. Molina initially tested applicants' abilities to fulfill this role by using the foundation's Language and Interpreters Skills Assessment (also known as LISA) tool.3 Molina currently uses Berlitz for all language testing.
  • Training staff: All staff must review the California Healthcare Interpreter Standards, with a particular emphasis on standards related to confidentiality. All staff complete orientation and training specific to their role, which can last up to 30 days. RNs receive additional coaching and performance reviews and are also required to earn continuing education credits on relevant health care subjects each year.
  • Pilot testing and expansion: Through Hablamos Juntos, Molina initially tested the service in the California counties of Riverside and San Bernardino, which have large, growing Latino populations. This successful pilot convinced Molina's leaders to expand the service to all states where Molina operates.

Resources Used and Skills Needed

  • Staffing: TeleSalud staff consists of 30 nonclinical, bilingual operators, 26 RNs (8 of whom speak both English and Spanish), and management.
  • Costs: Data on program costs are unavailable. The bilingual advice service has become a revenue-generating unit for Molina, as the program is now offered on a contractual basis to other organizations. As of July 2011, the program continues to expand and generate revenue.
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Funding Sources

Robert Wood Johnson Foundation
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Adoption Considerations

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Getting Started with This Innovation

  • Ensure high-quality staff from the outset: Hiring culturally competent staff is crucial to successfully getting this type of program off the ground. Interview applicants thoroughly to gain confidence in their abilities, and ensure that all newly hired RNs and operators have appropriate qualifications and adequate experience.
  • Start small and then roll out: The program initially began in two counties, and then expanded to other areas once proved to be effective.

Sustaining This Innovation

  • Clearly delineate and continually review responsibilities: Policies, procedures, and individual workflows should be developed and periodically reviewed to ensure that they clearly lay out program-related functions and responsibilities, thus making replicability and expansion easier.
  • Develop systems for quality monitoring and improvement: Consider using side-by-side dual listening to calls, reviews of call recordings, and regular meetings with RNs to obtain feedback and provide opportunities to discuss issues.
  • Obtain URAC accreditation: Receiving and maintaining URAC accreditation is a valuable tool for providing members with the highest quality of care, based on sound standards and measurable outcomes. (URAC is an organization that accredits different types of health care organizations and programs.)
  • Promote program value: The need for the Molina Nurse Advice program will continue to increase in response to a growing lower-income population. Would-be adopters will need to promote the cost effective nature of the program and its role in reducing health disparities.

Use By Other Organizations

Molina Healthcare now offers its bilingual nurse advice line services to three outside organizations.

More Information

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Contact the Innovator

Marianne E. Czapla, RN
Vice President, Consolidated Plan Solutions
Molina Healthcare
200 Oceangate, Suite 100
Long Beach, CA 90802-4317
Phone: (562) 435-3666
Fax: (562) 499-6165
E-mail: marianne.czapla@molinahealthcare.com

Innovator Disclosures

Ms. Czapla has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 Alliance of Community Health Plans Foundation. Making the Business Case for Culturally and Linguistically Appropriate Services in Health Care: Case Studies from the Field. 2007. Available at: http://minorityhealth.hhs.gov/Assets/pdf/Checked/CLAS.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Robert Wood Johnson Foundation. Molina Healthcare's TeleSalud Program: Providing Direct Access to Language Services. September 2008. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=34027
3 Hablamos Juntos. Language and Interpreters Skills Assessment - L&ISA Pilot Project. September 30, 2005. Available at: http://www.hablamosjuntos.org/resource_guide_portal/pdf/11LISA_Profile_Final.pdf
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Original publication: August 05, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 16, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.