SNP Training – Topic 3: Structure & Process Measures 1 through 3

1. March 12, 19, 25 and April 23, 2009 SNP Training – Topic 3: Structure & Process Measures 1 through 3

2. Objective of S&P Measures Training • Describe the SNP assessment project NCQA is executing on behalf of CMS • Explain the intent of the S&P Measures • Determine what type of documentation to provide • Demonstrate how NCQA will survey the measures.

3. Objectives of SNP Assessment Program • Develop a robust and comprehensive assessment strategy • Evaluate the quality of care SNPs provide • Evaluate how SNPs address the special needs of their beneficiaries • Provide data to CMS to allow plan-plan and year-year comparisons

4. SNP Assessment: How did we get here? • Existing contract with CMS to develop measures focusing on vulnerable elderly • Revised contract to address SNP assessment • 1st year—rapid turnaround, adapted existing NCQA measures and processes from voluntary Accreditation programs • 2nd year—focus on SNP-specific measures • 3rd year—Refine measures; identify new SNP-specific measures, where appropriate

5. Three-Year Strategy

6. Who Reports • HEDIS measures • All SNP plan benefit packages with 30+ members as of February 2008 Comprehensive Report (CMS website) • S&P measures • All SNP plan benefit packages • Plans with no enrollment exempt from certain elements

7. What to Report • S&P measures • Cohort I—All SNPs operational as of January 1, 2007 and renewed in 2009. • S&P measures 4-7 (SNP 2:C & 3:B) • Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009 • All S&P measures (SNP 1-6) • Do not report SNP 7 (SNP 2:C & 3:B)

8. Project Time Line – Phase II • March 4 - Release final S&P measures • March 30 - Release ISS Data Collection Tool • S & P Measures • April - Release IDSS Data Collection Tool • HEDIS Measures • June 30 - HEDIS submissions and S&P measures submissions due to NCQA • October 30 - NCQA delivers SNP Assessment Report to CMS

9. SNP Structure and Process Measures Brett Kay, Director, SNP AssessmentCasandra Monroe, Assistant Director, SNP Assessment

10. SNP Assessment Process • Phased Approach • Defining and assessing desirable structural characteristics • Assessing processes • Assessing outcomes • Two main components • HEDIS Measures-focus on clinical performance • Structure & Process measures-focus on structural characteristics and systems

11. S&P Measures • Three Measures; adapted from existing accreditation standards • SNP 1: Complex Case Management • Elements A-G • SNP 2: Improving Member Satisfaction • Elements A, B • SNP 3: Clinical Quality Improvements • Element A

12. Components of the S&P Measures • Standard statement: a statement about acceptable performance or results • Intent statement: A sentence that describes the importance of the S&P measure • Element: The component of the measure that is scored and provides details about performance expectations. NCQA evaluates each element within the measure to determine the degree to which the SNP has met the requirements within the S&P measure.

13. Components of an S&P Measure • Factor: An item within an element that is scored (e.g., an element may require an organization to demonstrate that a specific document includes 4 items. Each item is a factor). • Scoring: The level of performance the organization must demonstrate to receive a specific percentage on each element (100%, 80%, 50%, 20%, 0%) • Data source: Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA defines 4 types of data sources:

14. Data Source Types • Documented Processes: Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization • Reports: Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports of analysis; system output giving information; minutes; and other documentation of actions that the organization has taken • Materials: Prepared materials or content that the organization provides to its members and practitioners, including written communication, Web sites, scripts, brochures, review and clinical guidelines • Records or Files: Actual records or files, such as denial, appeal or credentialing flies that show direct evidence of action or compliance with an element---NCQA does not require file review for phase two.

15. Components of an S&P Measure • Scope of Review: The extent of the organization’s services evaluated during an NCQA survey. • Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element • Explanation: Guidance for demonstrating performance against the element • Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

16. SNP 1: Complex Case Management

17. SNP 1: Complex Case Management • The organization helps members with multiple or complex conditions to obtain access to care and services and coordinates their care NCQA Definition: Complex Case Management The systematic coordination & assessment of care & services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources & who need help navigating the system to facilitate appropriate delivery of care & services

18. SNP 1: Element A • Identifying Members for Case Management • Looking for evidence plans are culling from the applicable data sources to find members eligible for CM • Data Sources • claims or encounter data • hospital discharge data • pharmacy data • laboratory results • data collected through the UM process, if applicable Note: NCQA looking to collect information on eligibility criteria used by plans for CM and data on % of members enrolled in CM.

19. SNP 1: Element A FAQs • What type of information is NCQA looking for? • Documented processes or reports that demonstrate the SNP is using various data sources to identify eligible members for CM • What if a plan automatically enrolls all members in CM? • Plans that auto-enroll and maintain all members in CM can provide evidence of this and receive 100% for this element • What if CCM is part of larger DM program? • SNPs must have a CCM program. This program may be part of a broader DM program, but the SNP must demonstrate that it meets the requirements for CCM.

20. SNP 1: Element A Examples Documentation describes how the organization uses the specified data sources to determine if a member is eligible and may: • Feed information from these data sources into to a predictive modeling system • Describe the member identification process flow and include resources case managers use such as: discharge reports; reports showing multiple admissions; hospital history; reports on past and present treatment; lab reports; reports from ancillary and/or behavioral health providers; information on the member’s prognosis; cost and utilization data; catastrophic pharmacy claims; disability claims; and aggregate claims exceeding certain thresholds.

21. SNP 1: Element B • Access to Case Management: Plan is open to referrals from other sources to consider members for CM • Health information line referral • DM program referral • Discharge planner referral • UM referral, if applicable • Member self-referral • Practitioner referral • Other referrals (must specify what these are)

22. SNP 1: Element B FAQs • What type of information is NCQA looking for? • Documented processes, reports or materials that demonstrate the SNP allows referrals from multiple sources • Does a SNP have to enroll every member referred for CM? • No. Plans do not have to enroll every member referral, but must consider them • Health information line referral is not required for Medicare, do the SNPs have to have this? • This factor may be scored “NA,” but if a SNP has an HIL, it must accept referrals

23. SNP 1: Element B Examples Documentation may include: • A policy for the case management referral process that identifies which persons or entities refer members for services • A description which indicates how the organization uses the data sources to confirm case management referrals are appropriate for: members need for long-term monitoring, interventions and support • A flowchart detailing the steps of the case management process and persons used as referral resources within it

24. SNP 1: Element C • Case Management Systems • Conduct assessment and management • evidence-based clinical guidelines or algorithms • Scripts or protocols with EBG meet the intent • Automatic documentation of contacts • the staff member who made contact • the date and time when the organization acted on the case or interacted with the member • Automated prompts for follow-up, as required by the case management plan

25. SNP 1: Element C FAQs • What type of guidelines should be used for Factor 1? • Any evidence-based guidelines are acceptable. They must provide documentation of clinical evidence used to develop the CM system. • Scripts or other prompts that have an evidence base satisfy this factor • What about frail members or those where there are not available or appropriate guidelines? • For frail members, plans are not required to use guidelines that may not be appropriate

26. SNP 1: Element C • Documentation for Factor 1 may include: • Online scripts and checklists that allow case managers to obtain information on interventions in evidence-based care plan by physician, any care gaps or mitigating circumstances and assess the member’s compliance with the care plan • Screen shots supplemented with policies or descriptions that specify how the case manager performs the assessment activities • Flow charts that include descriptions of assessment process activities and the clinical evidence used in the process • Documentation for Factors 2 and 3 must include: • Screen shots from electronic case management systems that capture the date, time, user ID, action by the case manager along with reminders and follow-up due dates; policies or usage instructions accompany these screen shots

27. SNP 1: Element D • Frequency of Member Identification • Systematically identify members • At least monthly • given the dynamic nature of clinical data, an organization that uses these data with greater frequency has the greatest opportunity to identify members who may benefit most from CM programs

28. SNP 1: Element D FAQs • What if a plan automatically enrolls all members in CM? • Plans that auto-enroll and maintain all members in CM can receive 100% for this element(if they provide appropriate documentation)--also applies to SNP 1A, 1B and 1E Factor 2 • What type of information is NCQA looking for? • Documented processes or reports that demonstrate the frequency with which SNPs systematically identify eligible members for CM

29. SNP 1: Element E • Providing Members With InformationDoes the SNP give members written and verbal information on: • How to use the services • How members become eligible to participate • How to opt in or opt out

30. SNP 1: Element E • What type of data sources is NCQA looking for? • To demonstrate performance on this element, the SNP must provide: • Documented processes that describe the process for notifying members; and • Materials provided to members • In some states, SNPs are required to provide CM to all members, so “opt out” should not apply • Factor 3 is “NA” if the organization is required by states or others to provide case management to all members

31. SNP 1: Element F • Case Management Process • Member’s right to decline participation or disenroll • Health status • Clinical history and meds • Activities of daily living • Mental health status and cognitive function • Life planning activities • Cultural and linguistic needs, preferences or limitations

32. SNP 1: Element F (cont. …) • Case Management Process Requires • Caregiver resources • Available benefits • Case management plan with long- and short-term goals • Barriers • Follow-up schedule • Self-management plan (needs to be documented) • Assessing progress

33. SNP 1: Element F FAQs • Can Plans use screen shots from a computerized questionnaire or case management system to show compliance with this element? • Yes, provided the screen shots display the fields with the relevant questions related to the factors

34. SNP 1: Element F Examples Evidence that addresses requirements in each of the fourteen factors may consist of: • Policies and procedures which delineate the case manager’s actions and documentation requirements during the initial assessment, care plan implementation and follow-up activities. These policies must be supplemented with questionnaires, or call scripts the call managers uses for care plan implementation, evaluation and follow-up activities. • Screen shots supplemented by instructions or policies and documentation guidelines the case manager uses during initial assessment, care plan implementation, evaluation and follow-up activities. • Printer friendly versions from an electronic case management system that detail timing, status, results of initial assessment, care plan implementation, evaluation and follow-up activities the case manager performs.

35. SNP 1: Element G • Informing and Educating Practitioners • Instructions on how to use CM services • How the organization works with a practitioner’s patients in the program

36. SNP 1: Element G FAQs • What type of information is NCQA looking for? • To demonstrate performance on this element, the organization must provide: • Documented processes that describe its process for notifying practitioners; and • Materials provided to practitioners • Examples of materials include: • Provider manuals • Training brochures • information on Organization’s Website

37. SNP 2: Improving Member Satisfaction

38. SNP 2: Element A • Assessment of Member Satisfaction • Identify the appropriate population • Draw appropriate samples from the affected population, if a sample is used • Collect valid data *Plans with no enrollment as of the start of the look-back period are exempt from this element

39. SNP 2: Element A FAQs • Does the member satisfaction apply only to the SNP’s case management program? • SNPs must assess member satisfaction across its entire operations, not just its CM program. • Can SNPs use self-reported data from members, such as member satisfaction with practitioner availability or other existing surveys? • SNPs may use self-reported data to satisfy this element. • SNPs can use CAHPS data they have analyzed to satisfy this element in place of analyzing complaints and appeals

40. SNP 2: Element A FAQs • If we do not pull a sample and analyze member satisfaction data for our entire SNP population will NCQA score Factor 2 NA? • NCQA scores Factor 2 “Yes” when an organization analyzes member satisfaction data for its entire SNP population • How recent must the data be for this element? • Data must be collected no more than 12 months prior to the look back period

41. SNP 2: Element B • Opportunities for Improvement • Plans must review their data and determine how best to improve • Identify opportunities * Plans with no enrollment as of the start of the look-back period are exempt from this element

42. SNP 2: Element B FAQs • What if no opportunities for improvement are identified? • If no opportunities are identified in the SNP’s analysis, and NCQA surveyors agree with this conclusion, the element is scored “NA.” • Do SNPs have to show improvement based on the opportunities identified? • Plans undergoing the SNP Evaluation for the first time in 2009 are not required to demonstrate they have taken action on the identified opportunities • Plans that completed the SNP Evaluation in 2008 must provide evidence of actions taken and a plan to evaluate its actions

43. SNP 3: Clinical Quality Improvements

44. SNP 3: Element A • The organization measures quality of clinical care to improve that care • Organization selects 3 measures to assess performance and identify clinical improvements that are likely to have an impact on the membership • Plans must demonstrate that each of the 3 clinical issues is relevant to its membership. *Plans with no enrollment as of the start of the look-back period are exempt from this element

45. SNP 3: Element A FAQs • Can a SNP use HEDIS measures to identify relevant clinical improvements? • SNPs may use HEDIS measures to satisfy this element • Do SNPs have to show actual clinical improvements for this phase? • Plans undergoing the SNP Evaluation for the first time in 2009 are not required to identify opportunities or demonstrate they have taken action to show improvement • Plans that completed the SNP Evaluation in 2008 must demonstrate they identified opportunities and decided which ones to pursue.

46. SNP 3: Element A FAQs • Can a SNP submit service-oriented performance measures and meet SNP 3A? • No, measures for this element must involve improvements in the quality of clinical care • Should a SNP use a particular format for its documentation? • The ISS Survey tool contains a supplemental worksheet plans can use to demonstrate performance

47. General FAQs • Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within that this timeframe? • The look-back period is the three-month period prior to survey submission—March 31, 2009 to June 30, 2009. All documentation must be current as of the look-back period but it could have been developed before that time. • For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.

48. General FAQs • We contract with other entities (medical groups) to perform a number of the functions assessed by the Structure and Process measures. How should we demonstrate performance with these requirements? • Your organization needs to provide the appropriate evidence from these contracted entities to documenting their performance. In addition you should discuss the details of this documentation with a member of the SNP Team.

49. Additional Resources

50. Additional Resources • NCQA SNP Web page www.ncqa.org/snp.aspx • FAQs (HEDIS) • Training descriptions & schedule • S&P measures • NCQA Policy Clarification Support (PCS) http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp • HEDIS Audit information http://www.ncqa.org/tabid/204/Default.aspx