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What is CORE?
CORE is a hands-on approach to improving processes by applying Quality Improvement (QI) methods and tools.  We chose to use it in our every day work of completing applications for enrolling and retaining children in insurance programs. CORE began in April 2005 in Fresno. Our partnering organizations who provide outreach, enrollment, retention and utilization efforts continue to work collaboratively on improvements. The goal is to facilitate utilization of health services among newly insured children. 

Our projects to achieve this goal include:

PROJECT 1: Design the process for incorporating a families’ self-identified health status of their child into the One-e-App application process, with minimal time impact to the certified application assistors (CAA) or the applicants. This health status evaluation is completed for all Medi-Cal, Healthy Families and Healthy Kids applications.
The CORE team tackled adding 13 questions into the One-e-App application process with minimal addition time for the families; the result was placing the questions during an electronic transmission process, since it was determined this was down time. Our certified application assistors find this survey information helps them discuss the health needs of the families’ children.  Since 2006, these questions are completed on new and renewal applications.  We are currently analyzing this data and conducting a CAA survey regarding the effectiveness of these questions.

PROJECT 2: Improve the utilization of health care services to all newly insured children within the Healthy Kids, Medi-Cal and Healthy Families programs through education of the CAAs and then the families in the use of the local and rural transit systems.
With One-e-App’s launch in Fresno, the number of enrollees into the health plans provided evidence that our project was successful.  However our CAAs were not seeing the utilization of these services.  A survey of the applicants showed transportation issues as the main reason families were not able to use services: the lack of transportation or knowledge of how to use the local transit system. This project resulted in a handbook prepared by the CORE team which provides assistance to both the CAA as well as the client in the use of the local transit system and other transportation services.  Our CORE team partnered with the Fresno County Office of Governments to provide input into their annual transit guide. For example, we were able to add all the clinics into the guide.   Each CAA and community-based organization was provided copies of the guide at no cost; we also received the guide on cd.  Our transportation resource information is beneficial to the CAAs and the families. 
   
PROJECT 3:  Improve the enrollment process by reducing the number of “already covered” recipients for Medi-Cal.
With the use of One-e-App, CAAs were enrolling families into Medi-Cal and Healthy Families at a high rate.  It was soon discovered that there was also a high volume of “already covered” Medi-Cal recipients; the CORE team decided to take the project on.  With involvement from Fresno County the group was able to identify additional resources available to the CAA, including a list of Eligibility Workers in Fresno County,   in order to help eliminate duplicate efforts with enrolling families.   The result of this project showed an 82% decrease in “already covered” applications in a year.  

PROJECT 4: Design a process for redirecting clients to the appropriate organization or CAA when seeking to apply or renew their health coverage.
Due to the Governor’s OERU budget cuts many of our community-based organizations were faced with cutting services and laying off certification application assistants.  This created an immediate need for the CAAs to design a process to help the organizations that no longer provided services to refer their families to other organizations that did. This project resulted in a flowchart of the process, a referral site list, an FAQ for the families and a letter of reassurance to the families letting them know that there was no change in their health coverage.  The CORE team has received many compliments on this project and positive feedback from the CAAs on its effectiveness.    

PROJECT 5:  Design a process for training new CAA’s in Medi-Cal, Healthy Families and Healthy Kids and the electronic application tool One-e-App.
With new CAAs coming from Sequoia Community Health Center, Marjorie Mason Center and Children’s Hospital Central California as well as a few veterans, we identified that there was no process in place for CAA training. Our new CAAs designed this process and Fresno HCAP designed a new CAA training curriculum based upon the needs of the CAAs.   We are in the process of implementing this with the first dry-run of the training and new CAAs being trained in May. 

PROJECT 6: Fresno County E & TA: Improve the in-take process for the Aged, Blind and Disabled in Medi-Cal by providing a timely determination of eligibility with improved customer service and a shorter wait time.
In 2007 we were asked by Fresno County Employment and Temporary Assistance (E&TA)to assist them with teaching CORE to their staff from the Aged, Blind, and Disabled Department.  The team had identified that there was a long wait time for their clients to work through the registration and in-take process; they wanted to be able to identify and address some of the causes for the long wait time.  The County drafted a flow chart of their existing process and concluded that they design a document which would allow them to time how much time it took for a client to work through the in-take process.  The County presented their results at a subsequent CORE meeting.  The result was a decrease in waiting time for their clients.   However the Hawthorne effect was observed.  They are currently working on placing their data into a run chart and plan to monitor periodically.

PROJECT 7: Ensure that the integration of One-e-App into the new expansion sites improves services to the clients and does not negatively impact the current operational flow.
With two new expansion sites, Valley Health Team (FQHC) and Catholic Charities (CBO),  Our CORE focus for was to ensure minimal disruption to their current operations flow.  Both organizations completed their own operational flow chart and after careful consideration were able to determine where best to place the One-e-App in-take process.  Both sites currently have CAAs who are preparing for One-e-App training.  We are using this same approach for all new One-e-App user organizations, including hospitals.

PROJECT 8: Design a process for on-going case management for families insured under Medi-Cal, Healthy Families and Healthy Kids.
This project was placed on hold due to the State OERU budget cuts which created uncertainty as to the ability of community-based organizations and clinics to continue application in-take.  We recently reactivated the case management project with new One-e-App expansion site participants as well as CORE veterans.   The CAAs felt the need was still extremely important to create a process for case management.  We created a flowchart and are in the early stages of implementation.  Our next step is to coordinate this case management activity of the CAAs with that in the schools, clinics and health plans.