In 2002, Molina reviewed utilization of its outsourced nurse advice line and found that usage of Language Line Services by Spanish-speaking members (Latinos) was very low. Although 45 percent of the plan’s membership is Latino (primarily of Mexican origin) with a declared Spanish language preference, a Spanish interpreter had been requested in fewer than 2 percent of calls. This low utilization suggested a barrier for members in accessing nurse advice services.
Molina Healthcare was one of 10 grantees of the Hablamos Juntos project, sponsored by the Robert Wood Johnson Foundation (RWJF). The TeleSalud project was established in 2004 as a separate department within Molina Healthcare of California. It offered direct accessibility for medical interpretation services to address the health and language needs of the underserved, limited English proficient Latino population living in the Inland Empire region of Southern California. The project was conceived to provide Molina Healthcare’s members with service in their declared language of preference with 24-hour live and direct access to a registered nurse for advice and interpretation assistance.
Interpreter services are structured according to the Molina Healthcare Communication Model, in which bilingual registered nurses perform complex medical interpreting and education. The two-tiered model employs nonclinical staff to receive the intake calls and registered nurses to receive calls requiring interpretation, clinical assessment or intervention. Calls from Spanish-speaking members are answered in Spanish and routed to bilingual registered nurses for completion. If members find themselves in situations where no Spanish interpreter is available for a medical visit, emergency room or pharmacy encounter, Molina Healthcare’s nurses are also available to interpret, educate and assist. The model empowers members to call for such assistance directly and at no cost to themselves or their health care providers.
A centralized data system provides documentation capabilities and tracking for language needs. It is designed to support data security, integrity and confidentiality in compliance with the Health Insurance Portability and Accountability Act of 1996 requirements. All calls into the department are recorded as part of the Quality Improvement Program for monitoring purposes and coaching as indicated.
Registered nurses follow nationally recognized adult and pediatric protocols for nurse advice. The guidelines are based on scientifically valid and documented clinical principles and are appropriate for use by registered nurses. Physicians completely review the nurse advice protocol regularly and provide updates every six months.
The TeleSalud core staff includes an exchange operator who receives the call, the registered nurse providing interpretation services and advice, and management staff. The operators are responsible for live telephone access into the Clinical Telephone Services Department in accordance with defined policies and procedures. The registered nurses are licensed in the state in which clinical telephone nurse advice services are provided.
Responsibilities include but are not limited to:
Registered nurses must meet professional qualifications and minimum experience requirements. Bilingual fluency is also necessary. Interviews are conducted in Spanish by Molina Healthcare’s language coaches, and test interactions (i.e., simulated advice call) are conducted in Spanish.
Training includes a review of the California Healthcare Interpreter Standards, with a significant focus on confidentiality. Molina Healthcare tested bilingual dual-role staffs working in the clinical office setting and member services using the LISA tool presented by RWJF.
TeleSalud staffs complete orientation and training specific to their job functions, lasting up to 30 days, with an additional coaching and review period for RNs. Molina Healthcare also has established training program criteria using the California Healthcare Interpreting Association’s (CHIA) Healthcare Interpreting Guidelines published by The California Endowment. Language coaches conduct ongoing quality monitoring by simultaneously listening to calls and reviewing call recordings. Inter-rater reviews are regularly conducted as well as regular meetings of TeleSalud nurses to discuss issues surrounding how to express certain concepts in Spanish to speakers from different countries of origin.
Since initial implementation in April 2004, the TeleSalud program has grown tremendously, now serving Molina Healthcare members in nine states. Significant additions have been made to Molina Healthcare’s infrastructure. There has been a substantial increase in bilingual capacity for nurse advice services at Molina Healthcare. Teams have been organized in each state and oriented to the project history, vision and implementation plan. Policies, procedures and individualized workflows that clearly demonstrate how the project functions have resulted in replicable practices while serving specific needs.
Based on data collected during December 2004 through February 2005, Molina Healthcare’s TeleSalud program produced a cost-savings of $2,448 per month during the pilot phase, totaling an extrapolated annual cost-savings of $29,000. Expansion of the program to cover all of Molina’s members in all states yielded a savings ranging from $0.14 to $1.35 per member per year in calendar year 2005–2006, totaling more than $750,000 in cost-savings. The state with the greatest savings was California, where the greatest percentage of Spanish-speaking members resides.