Slide1 l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 91

Care Management through Special Needs Plans PowerPoint PPT Presentation


  • 282 Views
  • Updated On :
  • Presentation posted in: General

Care Management through Special Needs Plans. Special Needs Individuals. As of January 1, 2010, all SNP enrollees must qualify as: Dually eligible for Medicare and Medicaid benefits and services or Institutionalized or institutional equivalent residing in the community or

Download Presentation

Care Management through Special Needs Plans

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Care Management through Special Needs Plans

SNP Model of Care and Quality Improvement Program - May 2009


Special Needs Individuals

As of January 1, 2010, all SNP enrollees must qualify as:

  • Dually eligible for Medicare and Medicaid benefits and services

    or

  • Institutionalized or institutional equivalent residing in the community

    or

  • Having certain CMS-approved severe or disabling chronic conditions

SNP Model of Care and Quality Improvement Program - May 2009


SNP Model of Care

The SNP Model of Care is the architecture for care management policy, procedures, and operational systems.

SNP Model of Care and Quality Improvement Program - May 2009


SNP Model of Care

Gradual evolution of SNP Model of

Care in legislation and CMS guidance:

MMA of 2003Established SNPs

2007 Call LetterEstablished network of specialized providers, use of clinical practice guidelines, goals, staff structure and roles, & communication network

SNP Model of Care and Quality Improvement Program - May 2009


SNP Model of Care

2008 Call LetterEstablished training for providers

MIPPA of 2008Mandated health risk assessment, care plan, interdisciplinary care team for beneficiaries, &evaluation of care effectiveness

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care Elements

1)Measurable Goals

2)Staff Structure & Care Management Roles

3)Interdisciplinary Care Team

4)Provider Network Having Special Expertise and Use of Clinical Practice Guidelines

5)Model of Care Training

6)Health Risk Assessment

7)Individualized Care Plan

8)Communication Network

9)Performance & Health Outcome Measurement

SNP Model of Care and Quality Improvement Program - May 2009


CMS Oversight

  • MAO has a written care management plan that describes the model of care

  • MAO documents implementation of care management plan for CMS review during surveillance activities and audits

  • MAO complies with SNP-specific reporting requirements

SNP Model of Care and Quality Improvement Program - May 2009


SNP

Model of Care

Goals

SNP Model of Care and Quality Improvement Program - May 2009


SNP MOC Goals

  • Improve access to medical, mental health, and social services

  • Improve access to affordable care

  • Improve coordination of care through an identified point of contact

  • Improve transitions of care across healthcare settings and providers

  • Improve access to preventive health services

SNP Model of Care and Quality Improvement Program - May 2009


SNP MOC Goals

  • Assure appropriate utilization of services

  • Assure cost-effective service delivery

  • Improve beneficiary health outcomes

    • Reduce hospitalizations and SNF placements

    • Improve self-management and independence

    • Improve mobility and functional status

    • Improve pain management

    • Improve quality of life as self-reported

    • Improve satisfaction with health status and health services

SNP Model of Care and Quality Improvement Program - May 2009


SNP MOC Goals

The written care management plan should address:

  • MOC goals are written as measurable outcomes

  • How the MAO will know that MOC goals are met

  • What actions the MAO will take if MOC goals are not met

SNP Model of Care and Quality Improvement Program - May 2009


Staff Structure

and Care Management Roles

SNP Model of Care and Quality Improvement Program - May 2009


Care Management Staff

  • Plan administrative staff (employed or contracted)

  • Provider network (employed or contracted)

  • Interdisciplinary care team (employed or contracted)

  • Management staff (employed or contracted)

SNP Model of Care and Quality Improvement Program - May 2009


Care Management Roles

CMS believes MAOs have 3 essential care management roles:

  • Administer and coordinate benefits, plan information, and data collection and analysis

  • Manage thedelivery of services and benefits

  • Oversee administrative and clinical performance

SNP Model of Care and Quality Improvement Program - May 2009


Administrative Roles

MAO has administrative staff (employed or contracted) to:

1)Process enrollment

2)Verify eligibility for special needs plan

3)Process claims

4)Process and facilitate resolution of grievances and provider complaints

5)Communicate plan information

SNP Model of Care and Quality Improvement Program - May 2009


Administrative Roles

6)Collect, analyze, report, and act on performance and health outcome data

  • Conduct quality improvement activities

  • Review and analyze utilization data

  • Survey beneficiaries and providers, and analyze results

  • Report to CMS and States

SNP Model of Care and Quality Improvement Program - May 2009


Service Delivery Roles

MAO has service delivery staff (employed or contracted) to perform care management functions:

  • Advocate, inform, and educate beneficiaries

  • Identify and facilitate access to community resources

  • Triage care needs

  • Facilitates health risk assessment

  • Authorize or facilitate access to services

  • Obtains consultation and diagnostic reports

SNP Model of Care and Quality Improvement Program - May 2009


Service Delivery Roles

MAO has service delivery staff (employed or contracted) to perform assessment, diagnosis, and treatment functions:

  • Medical andmental healthcare (parity)

  • Social services (community-based)

  • Education on health risks and care

SNP Model of Care and Quality Improvement Program - May 2009


Service Delivery Roles

MAO has service delivery staff (employed or contracted) to perform healthcare information management functions:

  • Assure maintenance and sharing of records and reports

  • Assure HIPAA compliance

  • Maintains paper-based and/or electronic information systems

SNP Model of Care and Quality Improvement Program - May 2009


MAO Oversight Roles

MAO has management staff (employed or contracted) to monitor care management functions:

  • Administrative functions

    • Monitor MOC implementation

    • Assure licensure and competency

    • Assure statutory/regulatory compliance

    • Monitor contractual services

    • Evaluate MOC effectiveness

SNP Model of Care and Quality Improvement Program - May 2009


MAO Oversight Roles

2) Clinical Functions

  • Monitors interdisciplinary care team

  • Assures timely and appropriate delivery of services

  • Assures providers use clinical practice guidelines

  • Assures seamless transitions and timely follow-up

  • Conducts chart and/or pharmacy reviews

SNP Model of Care and Quality Improvement Program - May 2009


Interdisciplinary Care Team

SNP Model of Care and Quality Improvement Program - May 2009


MIPPA Mandate

  • The MAO must assign EACH beneficiary to an interdisciplinary care team

  • The MAO may design a team comprised of employed or contracted practitioners

SNP Model of Care and Quality Improvement Program - May 2009


Role of the Team

  • Analyze and incorporate the resultsof the initial and annual health risk assessment into the care plan

  • Collaborate to develop and annually update an individualized care plan for EACH beneficiary

  • Manage the medical, cognitive, psychosocial, and functional needs of beneficiaries

  • Communicate to coordinate care plan

SNP Model of Care and Quality Improvement Program - May 2009


Composition of the Team

The interdisciplinary care team should minimally include:

  • Medical expert

  • Mental health and/or behavioral health expert

  • Social services expert

SNP Model of Care and Quality Improvement Program - May 2009


Composition of the Team

Other care team members may include:

  • Pharmacist

  • Nursing professional

  • Restorative therapist

  • Nutrition specialist

  • Medical specialist

  • Pastoral specialist

  • Health educator

  • Disease management specialist

SNP Model of Care and Quality Improvement Program - May 2009


Composition of the Team

MIPPA of 2008 mandates participation of beneficiary and/or caregiver whenever feasible.

  • Document process for having beneficiary/caregiver on team in the care management written plan

  • Document beneficiary/caregiver participation when it occurs

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network Having Specialized Expertise

and

Use of Clinical Practice Guidelines

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network

Network Facilities:

  • Acute care facility

  • Laboratory

  • Radiography/imaging facility

  • Long-term care facility

  • Rehab facility

  • Specialty outpatient clinics

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network

Providers with specialized expertise:

  • Medical specialists (cardiology, psychiatry, neurologists, surgeons, etc.)

  • Behavioral specialists (drug counselor, clinical psychologist, etc.)

  • Nursing professionals

  • Allied health professionals

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network

MAOs must coordinate care and assure that providers:

  • Collaborate with the interdisciplinary care team

  • Provide clinical consultation

  • Assist with developing and updatingcare plans

  • Provide pharmacotherapy consultation

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network

CMS expects MAOs to:

  • Prioritize contracting with board-certified providers

  • Monitor network providers to assure they use nationally recognized clinical practice guidelines when available

  • Assure that network providers are licensed and competent through a formal credentialing review

SNP Model of Care and Quality Improvement Program - May 2009


Provider Network

CMS expects MAOs to:

  • Document the process for linking beneficiaries to services

  • Coordinate the maintenance and sharing of beneficiary health care information among providers, the interdisciplinary care team, and the MAO.

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care

Training for Plan Personnel and Provider Network

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care Training

MAOs must conduct and document training on SNP Model of Care for all employed and contracted personnel:

  • Initial and annual training

  • Methodology may be:

    • Face-to-face

    • Interactive (web-based, audio/video conference)

    • Self-study (printed materials, electronic media)

SNP Model of Care and Quality Improvement Program - May 2009


Health Risk

Assessment

SNP Model of Care and Quality Improvement Program - May 2009


Health Risk Assessment

MIPPA of 2008 mandated that MAOs conduct initial and annual health risk assessments for EACH beneficiary.

  • Assess the medical, psychosocial, cognitive, and functional needs of special needs individuals

  • Use the results to develop the individualized care plan

SNP Model of Care and Quality Improvement Program - May 2009


Initial Health Risk Assessment

  • Conducted within 90 days of enrollment

  • Comprehensive assessment of medical, psychosocial, cognitive, and functional needs

  • Includes medical and mental health history

  • May be face-to-face, telephonic, electronic, or paper-based

SNP Model of Care and Quality Improvement Program - May 2009


Annual Health Risk Reassessment

  • Conducted within one year of last health risk assessment

  • Comprehensive reassessment of medical, psychosocial, cognitive, and functional needs

  • Includes changes in health status since last assessment

  • May be face-to-face, telephonic, electronic, or paper-based

SNP Model of Care and Quality Improvement Program - May 2009


Health Risk Assessment Tool

MAOs may use a health risk assessment tool that is:

  • Commercial or plan-developed

  • Paper-based or electronic

SNP Model of Care and Quality Improvement Program - May 2009


Health Risk Assessment Tool

MAOs should:

  • Use a standardized tool for all beneficiaries

  • Determine the effectiveness of the tool to identify beneficiary needs

  • Stratifythe identified risks to develop the care plan

SNP Model of Care and Quality Improvement Program - May 2009


Analysis of Risks

  • Clinically knowledgeable personnel should analyze health risk assessments and reassessments, and stratify health needs for care planning.

  • Results should be communicated to beneficiaries, interdisciplinary care team, and pertinent providers.

SNP Model of Care and Quality Improvement Program - May 2009


Individualized

Care Plan for

Each Beneficiary

SNP Model of Care and Quality Improvement Program - May 2009


Individualized Care Plan

  • Developed for each beneficiary by the respective interdisciplinary care team

  • Involve beneficiaries and/or caregivers whenever feasible

  • Reviewed and revised annually or when health status changes

SNP Model of Care and Quality Improvement Program - May 2009


Individualized Care Plan

The individualized care plan should include:

  • Goal and objectives

  • Specific services and benefits to be provided

  • Measurable outcomes

SNP Model of Care and Quality Improvement Program - May 2009


Individualized Care Plan

  • Communicated to beneficiary, caregiver, and providers

  • Maintain care plan records to assure access by all stakeholders

  • Maintain records per HIPAA and professional standards

SNP Model of Care and Quality Improvement Program - May 2009


Communication

Network

SNP Model of Care and Quality Improvement Program - May 2009


Communication Network

  • Develop and document a structure for communication among plan personnel, providers, interdisciplinary care team, and beneficiaries

  • May include low or high level technology

SNP Model of Care and Quality Improvement Program - May 2009


Communication Network

  • Develop and document a process to maintain records of communication among stakeholders that complies with HIPAA and privacy laws

  • Monitor and evaluate the effectiveness of the communication network

SNP Model of Care and Quality Improvement Program - May 2009


Most Vulnerable Beneficiaries

SNP Model of Care and Quality Improvement Program - May 2009


Most Vulnerable

CMS recognizes SNP beneficiaries will include vulnerable individuals:

  • Frail individuals

  • Disabled individuals

  • Beneficiaries developing end-stage renal disease after enrollment

  • Beneficiaries near the end-of-life

  • Beneficiaries having multiple or complex chronic conditions

SNP Model of Care and Quality Improvement Program - May 2009


Most Vulnerable

MAOs must document in written care management plan how to:

  • Identify their most vulnerable beneficiaries’ special needs

  • Address the needs of the most vulnerable through add-on benefits and services

SNP Model of Care and Quality Improvement Program - May 2009


Performance

and

Health Outcome

Measurement

SNP Model of Care and Quality Improvement Program - May 2009


MIPPA Mandate

MIPPA mandated special requirements for SNP quality reporting:

  • Collect, analyze and report data to measure health outcomes and indices of quality

  • Evaluate the effectiveness of the care management plan to assure an evidence-based model of care

SNP Model of Care and Quality Improvement Program - May 2009


Data Collection & Analysis

MAOs document their methods to collect and analyze data:

  • Internal quality specialists implement and evaluate a quality improvement program

  • External consultants implement and evaluate a quality improvement program

  • Data are collected and analyzed using:

    • Electronic software

    • Manual techniques

SNP Model of Care and Quality Improvement Program - May 2009


Data Collection & Analysis

MAOs must collect data on beneficiary health outcomes such as:

  • Reduced hospitalizations and SNF placements

  • Improved self-management and independence

  • Improved mobility and functional status

  • Improved pain management

  • Improved quality of life as self-reported

  • Improved satisfaction with health status and health services

SNP Model of Care and Quality Improvement Program - May 2009


Data Collection & Analysis

MAOs must collect data on quality indices such as:

  • Improved access to medical, mental health, and social services

  • Improved access to affordable care

  • Improved coordination of care through a single point of care management

  • Improved transition of care across settings and providers

  • Improved access to preventive health services

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care Evaluation

MAOs may collect data on model of care structure or processessuch as:

  • Improved service delivery through a competent provider network having specialized expertise

  • Improved coordination of care through use of an individualized care plan

  • Improved coordination of care through management by an interdisciplinary care team

  • Improved utilization of services through identification and stratification of health risks

  • Improved coordination of care through effective communication among providers, beneficiaries, and interdisciplinary care team

SNP Model of Care and Quality Improvement Program - May 2009


Performance Measurement

In the care management plan, MAOs must document:

  • How they will involve beneficiaries, providers, and the interdisciplinary care team in performance improvement

  • How they will communicate performance measurement results to stakeholders

  • How they will maintain records of improvement activities

SNP Model of Care and Quality Improvement Program - May 2009


Performance Measurement

In the care management plan, MAOs must document how they will take actions based on results of performance measurement such as:

  • Change policies or procedures

  • Change staffing patterns or personnel

  • Change network providers or facilities

  • Change systems of operation

  • Communicate results internally and externally

SNP Model of Care and Quality Improvement Program - May 2009


Quality

Improvement

Program

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

Gradual evolution of the quality improvement program:

MMA of 2005Mandated the CCIP, QIP, participation of stakeholders, CMS reporting tools, health information system, & self-evaluation of quality program

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

Gradual evolution of the quality improvement program:

MIPPA of 2008Collect, analyze, and report data measuring health outcomes and indices of quality pertaining to special needs individuals

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

Gradual evolution of the quality improvement program:

CMS Rules, 2008Measure model of care effectiveness, and make data available to CMS as requested

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

For each plan, MAOs must:

  • Have a quality improvement program

  • Encourage providers to participate in the program

SNP Model of Care and Quality Improvement Program - May 2009


Chronic Care Improvement Program

For each plan, MAOs must:

  • Conduct a chronic care improvement program (CCIP)

  • Have methods to identify beneficiaries with multiple or severe chronic conditions who would benefit from CCIP

  • Have mechanism to monitor beneficiaries in CCIPs

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Projects

For each plan, MAOs must conduct quality improvement projects (QIP) on clinical or non-clinical areas that involve:

  • measuring performance

  • system interventions including clinical practice guidelines

  • projects to improve performance

  • mechanisms for systematic and periodic follow-up on the effect of the intervention

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Projects

For each project, MAOs must assess performance using quality indicators that are:

  • objective, clearly defined, based on clinical knowledge or health research

  • outcome measures such as changes in health status, functional status, and beneficiary satisfaction

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Projects

For the selected indicators, MAOs must:

  • perform systematic ongoing collection, and analysis of valid and reliable data

  • achieve demonstrable improvement from interventions

  • report status and results of projects to CMS as requested

SNP Model of Care and Quality Improvement Program - May 2009


Health Information

For each plan, MAOs must have a health information system to:

  • collect, analyze, and integrate data to conduct the quality improvement program

  • ensure data is reliable and complete

  • maintain health information for CMS review as requested

  • conduct annual review of effectiveness of the quality improvement program

  • take action to correct problems revealed in complaints and quality improvement activities

SNP Model of Care and Quality Improvement Program - May 2009


SNP-specific Requirements

MAOs offering SNPs must:

  • Collect, analyze, and report data that measure health outcomes and quality indices pertaining to its targeted special needs population (i.e., dual-eligible, institutional, chronic condition) at the plan level

SNP Model of Care and Quality Improvement Program - May 2009


SNP-specific Requirements

  • measure the effectiveness of the model of care through data on

    • improvement in access to care

    • improvement in beneficiary health status

    • staff implementation of model of care

    • comprehensive health risk assessment

    • implementation of individualized care plan

    • providernetwork of specialized expertise

    • use of evidence-based practices

    • use of communication system

SNP Model of Care and Quality Improvement Program - May 2009


SNP-specific Requirements

  • maintain quality improvement data for CMS review

    • enable beneficiaries to compare health coverage options

    • enable CMS to monitor the effectiveness of the model of care

SNP Model of Care and Quality Improvement Program - May 2009


Reporting Requirements

MAOs offering SNPs have the following participation &/or reporting requirements

  • HEDIS measures

  • Structure and process measures

  • CAPHS survey (beneficiary survey)

  • HOS survey (beneficiary survey)

  • Part C Reporting Elements

  • Medication Therapy Management measures

  • CCIP and QIP

SNP Model of Care and Quality Improvement Program - May 2009


Collection of

Model of Care &

Quality Improvement Program Data

SNP Model of Care and Quality Improvement Program - May 2009


MOC and QIP Modules

  • CMS will develop HPMS modules to collect model of care and quality improvement program data on a continuous basis

  • Contractor will analyze initial data and use information to develop the modules

SNP Model of Care and Quality Improvement Program - May 2009


CMS Notification

CMS Notification to MAOs Offering SNPs: Collection of Model of Care and Quality Improvement Program Data

SNP Model of Care and Quality Improvement Program - May 2009


Memo Instructions

  • SNP submission type codes

  • Instructions for completing Appendix A and B

  • Naming conventions

  • Submission via e-mail to contractor

  • CMS contact persons

SNP Model of Care and Quality Improvement Program - May 2009


Naming Conventions

SNP

Submission

Type

Codes

SNP Model of Care and Quality Improvement Program - May 2009


Naming Conventions

Use the following file naming convention for the SNP attestation worksheet:

Hxxxx_snp_attest_<SNP submission type code>.xls

Example:

H0000_snp_attest_IN-E.xls

SNP Model of Care and Quality Improvement Program - May 2009


Naming Conventions

Use the following file naming conventions for each file containing supporting material:

  • Hxxxx_snp_support_<SNP submission type code>.ext (template in Appendix B)

  • Hxxxx_snp_support_risktool_<SNP submission type code>.ext (if applicable)

  • Example:H0000_snp_support_IN-E.pdf (template in Appendix B)

SNP Model of Care and Quality Improvement Program - May 2009


Naming Conventions

For each contract number, package the SNP attestation worksheets and supporting materials for all applicable SNP submission types in a single .zip file.

SNP Model of Care and Quality Improvement Program - May 2009


Naming Conventions

Use the following file naming convention for each contract number submission:

  • Hxxxx_snp_reporting.zip

  • Example:H0000_snp_reporting.zip

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care

  • Open the spreadsheet and review the instructions in the first tab.

  • Prepare one Excel file for each contract # and each SNP type under that contract #.

  • Failure to follow the instructions will result in rejection of the submission.

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care

SNP Attestation Worksheet Instructions for the Model of Care

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care

  • Enter contract number, SNP type, and SNP subtype.

  • Respond “Yes” or “No” to the attestations.

  • DO NOT paste text into the spreadsheet.

SNP Model of Care and Quality Improvement Program - May 2009


Model of Care

Contract #

SNP Type

SNP Subtype

Yes or No

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

  • Insert your contract name, contract number, and SNP type.

  • In 1b, provide a narrative description of your overall quality improvement program.

  • In 2b through 12b, provide a description and examples of data collected, analyzed, and reported on specific measures.

SNP Model of Care and Quality Improvement Program - May 2009


Quality Improvement Program

Insert contract name, #, and SNP type

1b. Provide a narrative description of your quality improvement program

In 2b through 12b, provide a description and examples of data collected, analyzed, and reported on specific measures.

SNP Model of Care and Quality Improvement Program - May 2009


Submission

Send each contract number submission via e-mail to

Fu Associates, Ltd. at [email protected]

with the subject line entitled “Hxxxx SNP Submission”.

SNP Model of Care and Quality Improvement Program - May 2009


  • Login