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July 9, 11 and 16, 2013. SNP 1 through 3 Training. Objectives of SNP Training. Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs Describe the changes in the S&P measures for the 2013 SNP Assessment

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SNP 1 through 3 Training


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    Presentation Transcript
    1. July 9, 11 and 16, 2013 SNP 1 through 3 Training

    2. Objectives of SNP Training • Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs • Describe the changes in the S&P measures for the 2013 SNP Assessment • Explain how NCQA assesses plans’ performance with individual elements in the S&P 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 2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs 2009 - focused on SNP-specific measures 2010 - refined existing measures 2011 - clarified requirements in SNP 1 thru 6 2012 - refined measures and documentation requirements; focus on implementing interventions

    5. Who Reports • HEDIS measures • All SNP plan benefit packages with 30 or more members as of February 2012 Comprehensive Report (CMS website) • S&P measures • All SNP plan benefit packages • Plans with zero enrollment as of April 2013 Comprehensive Report are exempt for certain elements

    6. SNP Reporting • Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted. • SNP 1 A-G, SNP 2A-C, SNP 3-6 • New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time. • SNP 1 A-D, SNP 2A-C, SNP 4-6

    7. Project Time Line – 2013-2014 • June 2013 through September 2013- Training for SNPs • June & July 2013 - Release S&P Measures in hardcopy and ISS Data Collection Tool • October 15, 2013 - S&P Measure submissions due to NCQA • October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors • June 2014 - NCQA delivers SNP Assessment Report to CMS

    8. Structure and Process Measures

    9. SNP 1: Care Management and Coordination

    10. SNP 1- Care Mgmt. and Coordination Changes since 2012 • Replaced elements of Complex Case Management with new ones for Care Management that assess whether SNPs have appropriate programs to coordinate services and help all members access needed resources • Better align with CMS MOC requirements for assessment and care plans

    11. SNP 1- Care Mgmt. and Coordination Changes continued Care Mgmt. and Coordination consists of Elements A: Care Management Program Description B: Population Description C: Care Management Process D: Individualized Care Plan E: Satisfaction with Care Management F: Analyzing Effectiveness/Identifying Opportunities G: Implementing Interventions and Follow-up Evaluation

    12. SNP 1- Care Mgmt. and Coordination Definition - Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing coordination of care, eliminating duplication of services and reducing the need for expensive medical services. 

    13. SNP 1- Care Mgmt. and Coordination Element A - Program Description The SNP has a description for its Care Mgmt. program that includes: • Evidence used to develop the program • Criteria for identifying members who are eligible for the program • Services offered to eligible members • Defined program goals Data source: documented process

    14. SNP 1- Care Mgmt. and Coordination • Care Mgmt. program focuses on member-specific activities and the coordination of services; it involves: • Comprehensive assessment of member’s condition • Determining benefits/resources • Developing and implementing a care plan that includes performance goals, monitoring and follow-up

    15. SNP 1- Care Mgmt. and Coordination A SNP must have a Care Mgmt. Program • Based on the subpopulations within its membership SNPs may have the following within a larger Care Mgmt. Program: • Complex case mgmt • Transitional case mgmt • High-risk/high utilization programs • Hospital case mgmt

    16. SNP 1- Care Mgmt. and Coordination • Factor 1 requires the SNP to describe the evidence it used to develop the program. • E.g., clinical practice guidelines; scientific evidence from clinical or technical literature or government research; or literature reviews for nonclinical aspects of the program like dealing with or promoting behavioral change. • Program description must also detail the criteria SNP uses to identify eligible members for factor 2

    17. SNP 1- Care Mgmt. and Coordination • SNP’s description includes the services it provides to members. • Org that stratifies members based on risk or level of need must include eligibility criteria, services to be provided and goals for each tier. • Program description also needs to include goals that reflect specific objectives and targets.

    18. SNP 1- Care Mgmt. and Coordination Element B – Population Assessment • Annually SNP must: • Assess the characteristics and needs of member population and pertinent subpopulations • Review and update Care Mgmt. processes to address member needs • Review and update Care Mgmt. resources to address member needs Data source: Documented process

    19. SNP 1- Care Mgmt. and Coordination • Population assessment includes SNP’s covered population not just members in specific programs like CCM • Documentation must show how: • SNP considers specific member characteristics when designing and revising program e.g., • Medicaid eligibility categories • Nature and extent of carved out benefits • Type of SNP • Race/ethnicity and language preferences

    20. SNP 1- Care Mgmt. and Coordination • Population assessment procedures also need to include consideration of program characteristics and resources e.g., staffing ratios, clinical qualifications, job training, external resources and cultural competency • SNP’s documentation needs to be dated after 10/15/12

    21. SNP 1- Care Mgmt. and Coordination Element C - Care Mgmt. Assessment Process • Includes all info for SNP to assess members’ needs and develop interventions for them • A SNP’s documentation must address all 8 factors • It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality Data sources: Documented process and reports or materials

    22. SNP 1- Care Mgmt. and Coordination SNP’s evidence must include: • Documentation of clinical history and meds • e.g., disease onset, inpatient stays, treatment history • Initial assessment of: • health status & comorbidities • activities of daily living • mental health status and cognitive function • both aspects are required

    23. SNP 1- Care Mgmt. and Coordination • Evaluation of: • cultural and linguistic needs • review of language needs meets factor 5 • visual & hearing needs, preferences/limitations • caregiver resources • e.g., family involvement in decision making • available benefits • covered by SNP, carved out for supplemental services such as community behavioral health or national and community resources

    24. SNP 1- Care Mgmt. and Coordination Element D - Individualized Care Plan • SNP uses info from assessment e.g., HRAs and other sources to develop a comprehensive care plan • Care plan includes info on actions or interventions and their duration a SNP’s Interdisciplinary Care Team (ICT) takes to address members’ medical, BH, functional and support needs. Data sources: Documented process and reports or materials

    25. SNP 1- Care Mgmt. and Coordination • A SNP’s documentation shows that the ICT develops a care plan for each member that includes: • prioritized goals that reflect member’s or caregiver’s preferences and involvement • self-management plan • schedule for follow-up/identify barriers • process to assess member progress

    26. SNP 1- Care Mgmt. and Coordination • Based on the member’s specific needs the care plan also identifies: • resources to be utilized and appropriate level of care • CMs as members of the ICT often facilitate referrals to other providers as part of member’s benefits • planning for coordination of care including transitions and transfers • identifying how and when ICTs follow up with a member after referral to a health resource • collaborative approaches to be used

    27. SNP 1- Care Mgmt. and Coordination Element E - Satisfaction with Care Mgmt Intent is for SNP to obtain feedback on its Care Mgmt. program from a broad sample of members, not just those that contacted it • SNP must submit a report showing it performed an evaluation of satisfaction by: • Obtaining feedback from members • Analyzing member complaints and inquiries Data source: Reports

    28. SNP 1- Care Mgmt. and Coordination Factors 1 and 2 require SNPs to use: • focus groups or satisfaction surveys that are specific to Care Mgmt program • e.g., assess satisfaction with--program staff, the usefulness of info received, member’s ability to adhere to recommendations. • analysis of complaint and inquiry data after 10/15/12 to identify patterns or trends • quantitative and qualitative

    29. SNP 1- Care Mgmt. and Coordination • Factors 1 and 2 focus on satisfaction with the Care Mgmt. Program not satisfaction with the SNP’s overall operations • Reports with data obtained from CAHPS or general surveys will not meet the intent • Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis

    30. SNP 1- Care Mgmt. and Coordination • Factor 2 is NA if SNP provides evidence (e.g., tracking mechanism) showing it did not receive any Care Mgmt. complaints and inquiries after 10/15/12 • Factors 1 and 2 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report.

    31. SNP 1- Care Mgmt. and Coordination Element F - Analyzing Effectiveness/Identifying Opportunities • The SNP measures the effectiveness of its Care Mgmt. program using three measures. For each measure, it: • Identifies a relevant process or outcome • Uses valid methods that provide quantitative results • Sets a performance goal • Clearly identifies measure specifications • Analyzes results • Identifies opportunities for improvement, if applicable Data source: Reports

    32. SNP 1- Care Mgmt. and Coordination SNP’s report must contain appropriate measures likely to have significant and demonstrable bearing on all or a subset of Care Mgmt. members • Outcomes based • Relevant to target population • Valid methodology • Contains info on sampling (if used) and sample size calculation • Measurement periods reflect the effects of seasonality • Denominator specific to Care Mgmt. population

    33. SNP 1- Care Mgmt. and Coordination Report shows appropriate analysis – goes beyond simple reporting or data display • Comparison to goal or benchmark • Measure must not have exceeded goal from outset • Quantitative and qualitative • Opportunities for improvement • SNP can use 3 patient experience measures • e.g., improved quality of life, pain management and health status • May only use 1 satisfaction measure with Care Mgmt. program operations

    34. SNP 1- Care Mgmt. and Coordination • Scoring is based on an average for all 3 measures • Analysis of measures must be SNP-specific. Org can present aggregate analysis if it breaks out data and results for individual SNPs • SNP must have performed analyses of measures after 10/15/12 • SNPs that submit Care Mgmt. worksheets also need to provide actual reports

    35. SNP 1- Care Mgmt. and Coordination • Factor 6 is NA if a plan’s documentation confirms it does not have any opportunities for improvement • Factors 1 thru 6 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report.

    36. SNP 1- Care Mgmt. and Coordination • Examples of measures • HEDIS measures of effectiveness for chronic conditions • e.g., controlling high blood pressure, persistence of beta blocker treatment after a heart attack • SF-36 or SF-12 results • Use of service measures for which consensus indicates improvement – e.g., reduced ED visits • Readmission rates • Ambulatory-care sensitive admissions

    37. SNP 1- Care Mgmt. and Coordination Element G - Implementing Interventions and Follow-up Evaluation • Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization: • Implements at least one intervention for each of the three opportunities identified in Element F to improve performance • Develops a plan for evaluation of the intervention and re-measurement Data source: Documented process and Reports

    38. SNP 1- Care Mgmt. and Coordination • Scoring is based on an average for all 3 measures • Interventions must have been implemented after 10/15/12 • A SNP’s documentation needs to show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement.

    39. SNP 1- Care Mgmt. and Coordination • Factor 1 may be NA if no opportunities • Factor 2, re-measurement, must be completed whether there are opportunities or not. • SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report receive an NA for factors 1 and 2.

    40. Delegation • 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 document their performance. In addition you should discuss the details of this documentation with a member of the SNP Team.

    41. About Documentation • Only attach documentation to the survey tool that fulfills the requirements and contains direct evidence of performance • Make sure your documentation shows that your SNP meets the intent of each factor/element • Please provide context to the documents-roadmap/explanation of documentation

    42. Questions?

    43. SNP 2: Improving Member Satisfaction

    44. Summary of Changes for 2013 • SNP 2 Elements A and B • Now applicable to both initial and returning SNPs • SNP 2 Element C • Added new example for factor 2 that emphasizes continuing the intervention and then re-measuring if an organization does not meet its initial goal

    45. SNP 2: Overview • Who reports? • Initial and returning SNPs are responsible for reporting all of SNP 2. This includes Elements A, B and C • SNPs that did not have any members at the start of the look-back period will receive a score of NA for the measure • Per the CMS April 2013 SNP Comprehensive Report

    46. SNP 2 Element A Assessment of Member Satisfaction • a SNP must supply BOTH a documented process and a report explaining how it performed the assessment and an analysis of member satisfaction data that shows it: • identified the appropriate population • selected appropriate samples from the affected population, (if used) • conducted an quantitative and qualitativeanalysis annually • The SNP will receive credit for factor 2 if it collects data for its entire population

    47. SNP 2 Element A • A SNP’s complaint and appeal data must relate to at least the four major categories • Quality of Care • Access • Attitude and Service • Billing and Financial • It must submit a report that shows the quantitative and qualitative analyses were performed after 10/1/12. • Complaint, grievance and appeal data or satisfaction survey data collected more than 12 months prior to the start of the look-back period--(4/15/12) will not meet the intent

    48. SNP 2 Element A • All SNP complaint/appeal data must be at the PBP level. The SNP should receive a score of: • 50% for data only identified as “Medicare” • 0% if data source is not specified at all • SNPs must perform their own analysis of CAHPS results, not just attach a vendor’s report to meet the intent of Element A.

    49. SNP 2 Element A • If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis and found no complaints or appeals for its members

    50. SNP 2 Element A • The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans