SNP Model of Care Provider Training

Transcription

1 SNP Model of Care Provider Training

2 The Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans (SNPs) to have a Model of Care (MOC) All information about the program must be available for submission to CMS or for review during monitoring visits. CMS also requires all SNPs to conduct initial and annual training that reviews the major elements of the MOC for providers.

3 The MOC is designed using the eleven elements below but focused on meeting the clinical and non-clinical needs of the target population MOC Elements 1. SNP-specific Target Population 2. Goals and Objectives 3. Key Structure and Staffing 4. Coordinated Interdisciplinary Care Team (ICT) 5. Provider Network and Clinical Practice Guidelines and Protocols 6. Training for Personnel and Provider Networks 7. Health Risk Assessment 8. Individualized Care Plan 9. Communication Network 10. Care Management for the Most Vulnerable Subpopulations 11. Outcome Measurements

4

5 3 Dual-SNPs: Elderplan for Medicaid Beneficiaries (002) Elderplan Plus Long Term Care (007) Elderplan Medicaid Advantage (008) 1 Institutionalized-SNP: Elderplan for Nursing Home Residents (003)

6 D-SNP Live in our geographic service area Entitled to Medicare Part A Enrolled in Medicare Part B Do not have End Stage Renal Disease (ESRD)* Qualify for both Medicare and Medicaid I-SNP Live in our geographic service area Are entitled to Medicare Part A Are enrolled in Medicare Part B Do not have End Stage Renal Disease (ESRD)* Must reside in an I-SNP nursing home for greater than 90 days at time of enrollment * With a few exceptions: e.g., if the member developed ESRD when they were already a member of a plan that we offer

7

8 The MOC goals must be stated in measurable terms and should cover at minimum the following 7 aspects of care: 1. Access to essential services such as medical, mental, and social 2. Access to affordable care 3. Coordination of care through an identified point of contact 4. Coordination in Transitions of care across settings, providers and health services 5. Access to preventative health services 6. Appropriate utilization of services 7. Improving health outcomes

9 D-SNP Initial health risk assessment within 90 days of enrollment and, at a minimum, annually each year Each member is assigned to an Interdisciplinary Care Team (ICT) with a designated Care Manager as point of contact Establish and maintain a network of providers with expertise in medical, social and behavioral health management of frail and/or chronically ill and disabled dual eligible members Access to preventive health services and management of chronic disease Provide support during care transitions across healthcare settings Eliminate barriers resulting from racial or cultural disparities Improve health outcomes across the population Coordination of both Medicare and Medicaid benefits I-SNP Initial health risk assessment and complete physical assessment within 30 days of enrollment Assign each member to an Interdisciplinary Care Team (ICT) led by collaborating Physician and Nurse Practitioner Establish and maintain a network of providers with expertise in medical, social and behavioral health management of frail and/or chronically ill and disabled institutional members Ensure preventive health measures for residents and monitor care to ensure appropriate utilization of services Provide support during care transitions across healthcare settings Eliminate barriers resulting from racial or cultural disparities health outcomes across the population Collaborate with participating nursing facilities

10 Quality Improvement Committee (QIC) and subcommittee structure is the reporting vehicle for goals and outcomes Every quarter the QIC develops recommendations such as: process changes, corrective actions, training for providers, and changes to MOCs

11

12 Enrollment and Member Operations Sales and Marketing Member Services Claims Network Operations Regulatory Compliance Appeals and Grievances

13 Quality Management Coordinated Care Clinical Services

14

15 ICT consists of : D-SNP Elderplan Clinical Team: RN/LPN Care Managers, SW Care Managers, Chief Medical Officer and Physician Advisors; Registered Pharmacist Social service roles: Social workers Public health professionals Behavioral and/or Mental Health specialists are added as necessary The PCP, and at times other professional providers of care, is considered part of the ICT I-SNP Elderplan Clinical Team: Medical Officer, VP of Clinical Operations, Director, ISNP Clinical Services, Care Managers Pharmacy Manager and Practitioners-Nurse Practitioner, PA, Medical Doctor Long term care facility staff: Medical Director, Director of Nursing, Director of Social Services As needed: Facility Physical or Occupational Therapist, specialty physicians, psychiatrists, pastoral care, and hospitalists

16 D-SNP I-SNP After initial assessment, the member receives a Welcome Letter that introduces the assigned Care Manager, who is the liaison for coordination of care Member and/or caregiver are encouraged to make contact at any point, in particular whenever new or changed conditions arise (physical, psychosocial or environmental) Care Manager reaches out to the member at scheduled intervals to discuss the program and to develop an individualized Care Plan based on member needs Upon enrollment, the member/designated representative receives welcome information, including name of assigned Nurse Practitioner (NP) and his/her contact information the NP acts as liaison between member and facility staff Member or designee is invited to attend facility based team meetings, as necessary (e.g., when there are significant changes in treatment plan or clinical conditions)

17 All member assessments, care plan, care transitions, claims and pharmacy data is maintained in McKesson s CCMS software system Monthly meetings with Coordinated Care Department and other department discuss issues relating to delivery of care model including enrollment, disenrollment, service issues or complaints; meeting minutes are distributed to attendees D-SNP Weekly staff meetings to discuss caseloads, processes and select member discussions. When a significant change to member condition, care needs, social, financial or environmental issues are identified, additional participants (e.g., member, caregiver, physician, pharmacist, home health providers) may attend I-SNP The long term care facility maintains the clinical record for the member ICT members can access the member s clinical record as necessary. Each month the ICT meet at facility or via conference call to review particular member issues involving such concerns as unplanned hospital admissions, palliative and/or end-oflife referrals or updates, quality or access issues

18

19 D-SNP Ensures that network contains a sufficient number of: Board Certified specialists such as Geriatrics, Cardiology, Neurology, Endocrine, Orthopedics, Nephrology, Pulmonology, and Behavioral Health Facilities, including Inpatient Acute Hospitals, Rehabilitation and Psychiatric facilities and Subacute Nursing Facilities Qualified physicians and/or NPs to make home visits Community based services such as Radiology, Laboratory, Certified Home Health Agencies, Licensed Home Health Care Agencies, Transportation and DME vendors I-SNP Identifies and evaluates potential long term care facilities for participation in this I-SNP Facility must meet Plan s P&P for credentialing standards for participation in the network Evaluates provider adequacy with sufficient number of professionals to provide services directly on the premises of the long term care facility such as: Board Certified specialists - Geriatrics, Cardiology, Neurology, Nephrology, Pulmonology, Endocrinology, Orthopedics, Behavioral Health Clinicians - Nurse Practitioners, Physical Therapists, Occupational Therapists, Respiratory Therapists Inpatient facilities - Acute Hospitals and Rehabilitation and Psychiatric Also an inventory of non-par providers to whom Clinical Services has authorized in the past is reviewed to identify providers to fill gaps

20 The Credentialing Subcommittee is responsible for ensuring that all participating providers, facilities and vendors are actively licensed and competent. Subcommittee consists of participating physicians of various specialties, with Chief Medical Officer, QM, Network Operations, and Credentialing Supervisor Meets monthly for oversight of the Elderplan network Recommendations are reviewed to ensure that all applicable licensures and certifications are active without restrictions from any governing or professional bodies, in compliance with CMS regulatory credentialing standards The Board Certification expiration is reviewed on monthly basis Credentialing database is maintained in CACTUS Full Re-credentialing occurs on a three-year cycle, however, if need arises, providers will be evaluated at any point in the cycle, i.e., when the Plan becomes aware of poor outcome from a regulatory survey or adverse events - Substantiated concern or sanction with providers results in actions such as corrective action plan from provider/vendor or recommendation of termination or non-renewal from participation with the Plan

21 D-SNP The Plan s Care Manager is the gatekeeper for coordination of services among providers and beneficiaries. Acts as liaison between the PCP and ICT; Updates and distributes revised Care Plan, as necessary; Documents activities in the electronic care management software and communicates (telephonically or electronically) to providers Elderplan and member/caregiver During ICT meetings, shares reports on hospitalizations, skilled services and any provider access issues Encourages/supports the member in conversations with his/her PCP I-SNP The Plan s Care Manager is the gatekeeper for coordination of services among providers and beneficiaries. Acts as liaison between the PCP, NP and ICT; Documents activities in the electronic care management software and communicates (telephonically or electronically) to providers Elderplan and member/caregiver During ICT meetings, shares reports on hospitalizations, skilled services and any provider access issues Encourages/supports the member in conversations with his/her PCP The Practitioner-Nurse Practioner, PA, Medical Doctor in collaboration with Director of Clinical Services for ISNP, coordinate all facility based services needs and/or specialty / ancillary services necessary the development of the Care Plan. Works closely with the PCP to ensure delivery of all necessary clinical care The PCP is electronically notified of member admissions and discharges to/from acute and subacute settings to facilitate post discharge follow-up and reconciliation of medication and treatment plan During acute and subacute episodes, care coordination across settings is facilitated by the Transitional Care RN in collaboration with the Care Manager and facility designee

22 The Clinical Practice Subcommittee evaluates and adopts clinical practice guidelines applicable to the needs of the Plan s membership; these guidelines are then posted on the Plan s Provider Website along with news articles and updates in the Provider Magazine The Pharmacy and Therapeutics Subcommittee offers valuable guidance on formulary development/maintenance and opportunities for enhancing member experience with the Plan. Utilize several additional tools/techniques to evaluate the use of evidence based clinical practice guidelines Annual Medical Record Review for high volume PCPs and specialists with a substantiated quality-of-care concern in the past year Pharmacy data to identify potential care gaps or potential adverse events and compliance issues Identify real and potential gaps in care and generates notice to physician and member while sending quarterly reports to the Plan for review PCPs (and assigned NP, in the case of the I-SNP) also receive monthly reports that identify gaps or opportunities for compliance with those clinical evidence based practice guidelines used in HEDIS such as diabetes care, hypertension, cholesterol management and preventive care For I-SNP only: NPs and their collaborating physicians sign agreement citing source of clinical evidence based practice guidelines available to them for use in their clinical practice, as well as review select member records to ensure compliance with guidelines in the treatment of enrolled members

23

24 Provider representatives distribute provider education materials, which include information on the MOC for the SNPs

25

26 The HRA tools are use to identify the specialized needs of the SNP s beneficiaries; including medical, psychosocial, functional and cognitive needs. Also the HRA includes Medical and Mental hystory D-SNP HSF is self-reported health risk assessment tool that identifies key medical, psychosocial, ADL and cognitive issues. Is Re-administered annually Based on information collected, a risk score is generated using key elements of the Probability of Repeated Admission (PRA) and the Frailty Risk Assessment (FRA) SAAM identifies more detailed clinical information and specific /instrumental ADL assistance required Completed by a clinical professional member of the care team either face-toface or telephonically, depending on product requirements Re-administered at six-month intervals I-SNP Naylor Risk of Acute Hospitalization tool includes questions to identify medical, psychosocial, functional and cognitive needs. Is completed by NP and repeated at the anniversary date Monthly monitoring tool, a health risk assessment developed by the plan to identify changes in condition and determine risk level MDS assessment tool - Plan receives a copy quarterly and annually Completed by registered professional nurse at the facility (face to face and medical chart review) All outcomes are captured and entered into CCMS for the Plan s review and use in updating care plan

27 Clinical Services, IT, and Quality Management departments analyze assessment data and set benchmarks for different SNP types Member-level data is reviewed by the ICT Plan-level data is reviewed in collaboration with Health Economics department For I-SNP only: Director of Clinical Services analyzes and presents Plan- and memberlevel data from the ongoing assessments to the ICT and the management team Data is also reviewed by subcommittees of the Quality Improvement Committee consisting of clinical providers, pharmacists and Quality Specialists

28 D-SNP: Based on the self-reported HSF assessment data, the following is system-generated: Member letter that summarizes self-reported health information and provides recommendations for self-care A letter to PCP that introduces the member, reports the HSF outcome and recommends whether the member should be scheduled with face-to-face PCP encounter as a matter of routine or with more urgency I-SNP: Once the care plan is finalized, it is shared with the member, as well as the PCP and ICT members (including NP). Care Plan is maintained electronically in CCMS Certain key responses allow the Plan s databases to trigger electronic referrals for clinical intervention, such as disease or wellness education, to the appropriate care teams

29

30 With input from member and/or caregiver and physician, an Enrollment RN develops the initial care plan As first step in creation of plan, uses outcomes of HSF and SAAM Member participates in the identification of interventions geared to addressing gaps (e.g., caregiver support and environmental or social issues) For members who require and receive personal care services administered and provided through the health plan, additional tools are used to determine the extent of the personal care needs Care plan is scanned into the CCMS system and reviewed by the ICT Team Supervisor, who assigns the member to a Care Manager The Care Manager does the following activities: Reviews assessments and other data Contacts the member telephonically to gather additional information Reviews applicable clinical guidelines and criteria embedded in the CCMS and Disease Monitor software Develops goals and identifies the appropriate interventions (e.g., home visiting physicians, telehealth monitoring, palliative care) Encourages PCP participation and solicits information when clinical concerns are identified Consults with other ICT members during care plan development

31 Once the Care Plan is complete, it is: Sent to the PCP via mail or fax Stored in the secure CCMS software, where it is accessible and can be updated by ICT A valuable tool during care transitions (available to the Transitional Care RN for use in facilitating communication of key elements of the plan) Evaluated and updated on a semi-annual basis or when a significant change in condition or status is identified Monthly inpatient admissions data, claims analysis, and other data triggers are used to revise Care Plan as necessary Care Plan activity is monitored by the team supervisors and department management to ensure timeliness of updates, progress towards goals, and frequency/type of interventions

32 Upon effective date of enrollment, the member is assigned to a designated NP who is on-site at the long term care facility NP has access to the member s facility record, and along with initial risk assessment tools, MDS information and a full history and physical The Care Manager works closely with the assigned NP to develop Care Plan goals and interventions PCP participation is vital especially when clinical concerns are identified The member or representative is encouraged to be part of this development and voice preferences for clinical and social interventions Monthly inpatient admissions data, claims analysis, and other data triggers are used to revise Care Plan as necessary Care Plan activity is monitored by the Director of Clinical Services to ensure timeliness of updates, progress towards goals, and frequency/type of interventions Stored in the secure CCMS software Evaluated and updated on a quarterly basis or when a significant change in condition or status is identified

33

34 ICT team s primary source of communication with members/caregivers and providers is telephonic Member Services tracks and trends all incoming calls, call abandonment rates, and wait times All incoming calls are recorded for quality control SNP member/caregiver calls are forwarded to the appropriate Care Management Team or handled directly by the Member Service Representative Communication network for providers includes designated call center, secure webportal, Plan website, and face-to-face meetings with Provider Reps The Plan provides additional resources in the form of print and electronic materials for both Members and Providers I-SNP only: Nurse Practitioner (NP) provides members and family with access to his/her designated cell phone and encourages them to contact him/her with concerns and questions

35 Communicates with regulatory agencies in the resolution of inquires and complaints, such as through the CMS Complaint Tracking Modules, to ensure timely and adequate outcomes to member and provider concerns and issues The Quality Improvement Committee (QIC) has responsibility for identification and implementation of process changes or enhancements relating to communication activities The Customer Service Subcommittee reports on volume, trends, and responsiveness with member calls The A&G Subcommittee tracks and trends member complaints relating to access to plan and/or providers

36

37 The Plan first utilizes assessment tools obtained both initially and at reassessment times to identify populations who are more vulnerable for medical/psychosocial complications. Performs analysis of claims and other data to identify potential for repeated hospitalizations, presence of chronic diseases, and triggers for psychosocial or significant change of condition issues, to identify members who may benefit from more aggressive intervention by the ICT members Utilizes a number of reports and indicators that further identify most vulnerable members Frequent hospital admission and readmission reports Pharmacy utilization reports that identify members with high risk medications, poor compliance and adherence, and potential adverse reactions Clinical data to identify those members with potentially life-threatening disease progression who may benefit from Palliative and or Hospice care coordination

38

39 The Quality Management department s Director and staff, including QM Coordinators and Specialists, assist in all aspects of data collection and analysis HEDIS data, along with Part C & D reporting requirements, are audited annually by external certified consultants. Plan also contracts with CMS-certified vendors for HOS and CAHPS annual collection Other key personnel responsible for oversight of evaluation and monitoring activities, include the AVP of Clinical Services, the Director of Coordinated Care, the Director of Pharmacy Services, Director of Informatics, Director of Member Services and the AVP of Network Operations All data is shared with the Quality Improvement Committee (QIC) The QIC is chaired by the Chief Medical Officer for the Plan, and co-chaired by the Director of Quality Management The Committee follows all CMS requirements in its development and participation in quality activities and reporting

40 All data analysis and standard reporting is used in the Annual Plan Quality Improvement Evaluation/Workplan, and along with recommendations for program improvements, is presented to the Board of Directors for their review and approval The key elements reflecting Plan performance are shared across the Plan and with key Providers The Plan educates its network and membership with updates regarding performance measures and/or changes in the MOC for the SNP via the Member/Provider Newsletters, WebPages and updates to Provider Manuals High-volume physicians receive reports on individual performance against expectations and benchmarks

41 Data sources Membership data, claims, encounters, authorizations and pharmacy data are stored in the data warehouse and form the foundation for utilization reporting and analysis Data from CCMS software on case and disease management is used to report outcome measures including hospital admissions, readmissions, care plan development and progress towards goals, intervention reports, and access to services Data from annual surveys, such as HEDIS and NCQA Structure and Process Measures, are analyzed Other departmental data Call Center Activity, including time-to-answer, abandonment rate, and languageline activity Network Access and Availability Appeals and Grievance trends and rates/1000 Disenrollment Rate and Trends Utilization of Services including Admits/1000 for Acute & Subacute Level of Care Safe Care Transitions including Readmission Rates

42 Implementation and Accountability

43 QIC Subcommittee Quality Indicator Accountability Subcommittee Composition (staff and department represented) Appeals and Grievances Complaints Appeals IRE Overturns Chairperson: Director, Appeals and Grievances Co-Chair: VP, Medical Management Committee Members: Manager, NPO; Supervisor, Customer Service; Par Reconsiderations Supervisor; Quality Management Coordinator; Manager of Review Operations, Medical Management; Compliance Coordinator. Clinical Practice Credentialing Target Population-Demographic and Clinical Characteristics of the Population Evidence Based Guidelines Evaluation of Performance of: HEDIS CAHPS/HOS Chronic Care Improvement Project Quality Improvement Project Structure and Process Model of Care Network Adequacy Chairperson: Chief Medical Officer Co-Chair: Director of Quality Management Committee Members: Plan Physicians - Five (5) with three (3) required for quorum; Director of Medical Management; Director, NPO Ad Hoc Members: Operational Staff (as needed) Chairperson: Chief Medical Officer Co-Chair: Director, NPO Committee Members: Physicians (8); Credentialing Supervisor, NPO; Director of Quality Management; Quality Management Coordinator

44 QIC Subcommittee Customer Service Pharmacy and Therapeutics Utilization Review Quality Indicator Accountability Call answer timeliness Call abandonment Language line activity Membership Disenrollment Rate and Trends High Risk Medication among the Elderly Medication Adherence Generic Dispensing Rate Medication Therapy Management Utilization Drug Utilization Reviews Utilization of Services including Admits / 1000 for Acute and Subacute Level of Care Frequency of Services Relative Resource Uses for Hypertensive Members Safe Care Transitions including Readmission Rates Subcommittee Composition (staff and department represented) Chairperson: Director of Customer Service Co-Chair: Director of Credentialing and Contracting, NPO Committee Members: Project Manager, Sales & Marketing; Director of Sales; Quality Management Coordinator; Customer Service Supervisor; Supervisor, Care Management; Supervisor, Appeals and Grievances; Supervisor of Sales Administration; Claims Manager; Director, Product Management; Enrollment Manager, HomeFirst Ad Hoc Members: Elderplan Member Representative(s) Chairperson: Plan Pharmacist Co-Chairperson: Chief Medical Officer Committee Members: Practicing Physicians; Pharmacist; Director of Medical Management; Quality Management Coordinator; Ad Hoc Members: Director of Provider Services Chairperson: Assistant Vice President of Clinical Services Committee Members: Manager of Coordinated Care; Manager of Review Operations, Medical Management; Informatics Representative; Claims Representative; Provider Services Manager; Quality Management Coordinator; Population Health Coordinator; Manager of Advantage Operations Ad Hoc Members: Chief Medical Officer; AVP, Medical Management; VP

45 Measurable Goals and Performance and Health Outcome Measurement Sample of Reports Used for Performance and Health Outcome Measurement Report Frequency Primary Use Related to MOC A&G Committee Dashboard Monthly Identify trends and areas for improvement in member dissatisfaction (complaints, appeals) Assessment Data Bi-monthly Ensure 100% completion of assessment within 30 days Clinical Practice: Gaps-In- Care Report Quarterly Identify member gaps in preventive care Frequent Flier Report Monthly Identify vulnerable members (for discussion at ICT meeting) Lab Utilization Ad hoc Identifies non-par lab utilization Pharmacy & Therapeutics Committee Reporting Procedure Frequency Report (Part C & D Reporting) Quarterly Yearly Identify vulnerable members (medication adherence, high-risk medication); Formulary design/changes (generic dispensing rate, tier/non-formulary exceptions requested and approved) Utilization of services by members Re-Admissions Report Monthly Identify vulnerable members (for discussion at ICT meeting)