Special Needs Plans. Model of Care and Quality Improvement Program Training May 27, 2009
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1 Special Needs Plans Model of Care and Quality Improvement Program Training May 27, 2009 Judy Sutcliffe Technical Advisor Division of Special Programs
2 Care Management through Special Needs Plans SNP Model of Care and Quality Improvement Program - May
3 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
4 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
5 SNP Model of Care Gradual evolution of SNP Model of Care in legislation and CMS guidance: MMA of 2003 Established SNPs 2007 Call Letter Established 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
6 SNP Model of Care 2008 Call Letter Established training for providers MIPPA of 2008 Mandated health risk assessment, care plan, interdisciplinary care team for beneficiaries, & evaluation of care effectiveness SNP Model of Care and Quality Improvement Program - May
7 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
8 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
9 SNP Model of Care Goals SNP Model of Care and Quality Improvement Program - May
10 SNP MOC Goals 1) Improve access to medical, mental health, and social services 2) Improve access to affordable care 3) Improve coordination of care through an identified point of contact 4) Improve transitions of care across healthcare settings and providers 5) Improve access to preventive health services SNP Model of Care and Quality Improvement Program - May
11 SNP MOC Goals 6) Assure appropriate utilization of services 7) Assure cost-effective service delivery 8) Improve beneficiary health outcomes a) Reduce hospitalizations and SNF placements b) Improve self-management and independence c) Improve mobility and functional status d) Improve pain management e) Improve quality of life as self-reported f) Improve satisfaction with health status and health services SNP Model of Care and Quality Improvement Program - May
12 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
13 Staff Structure and Care Management Roles SNP Model of Care and Quality Improvement Program - May
14 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
15 Care Management Roles CMS believes MAOs have 3 essential care management roles: Administer and coordinate benefits, plan information, and data collection and analysis Manage the delivery of services and benefits Oversee administrative and clinical performance SNP Model of Care and Quality Improvement Program - May
16 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
17 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
18 Service Delivery Roles MAO has service delivery staff (employed or contracted) to perform care management functions: 1) Advocate, inform, and educate beneficiaries 2) Identify and facilitate access to community resources 3) Triage care needs 4) Facilitates health risk assessment 5) Authorize or facilitate access to services 6) Obtains consultation and diagnostic reports SNP Model of Care and Quality Improvement Program - May
19 Service Delivery Roles MAO has service delivery staff (employed or contracted) to perform assessment, diagnosis, and treatment functions: 1) Medical and mental health care (parity) 2) Social services (community-based) 3) Education on health risks and care SNP Model of Care and Quality Improvement Program - May
20 Service Delivery Roles MAO has service delivery staff (employed or contracted) to perform healthcare information management functions: 1) Assure maintenance and sharing of records and reports 2) Assure HIPAA compliance 3) Maintains paper-based and/or electronic information systems SNP Model of Care and Quality Improvement Program - May
21 MAO Oversight Roles MAO has management staff (employed or contracted) to monitor care management functions: 1) Administrative functions a) Monitor MOC implementation b) Assure licensure and competency c) Assure statutory/regulatory compliance d) Monitor contractual services e) Evaluate MOC effectiveness SNP Model of Care and Quality Improvement Program - May
22 MAO Oversight Roles 2) Clinical Functions a) Monitors interdisciplinary care team b) Assures timely and appropriate delivery of services c) Assures providers use clinical practice guidelines d) Assures seamless transitions and timely follow-up e) Conducts chart and/or pharmacy reviews SNP Model of Care and Quality Improvement Program - May
23 Interdisciplinary Care Team SNP Model of Care and Quality Improvement Program - May
24 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
25 Role of the Team Analyze and incorporate the results of 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
26 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
27 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
28 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
29 Provider Network Having Specialized Expertise and Use of Clinical Practice Guidelines SNP Model of Care and Quality Improvement Program - May
30 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
31 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
32 Provider Network MAOs must coordinate care and assure that providers: Collaborate with the interdisciplinary care team Provide clinical consultation Assist with developing and updating care plans Provide pharmacotherapy consultation SNP Model of Care and Quality Improvement Program - May
33 Provider Network CMS expects MAOs to: Prioritize contracting with boardcertified 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
34 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
35 Model of Care Training for Plan Personnel and Provider Network SNP Model of Care and Quality Improvement Program - May
36 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
37 Health Risk Assessment SNP Model of Care and Quality Improvement Program - May
38 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
39 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
40 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
41 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
42 Health Risk Assessment Tool MAOs should: Use a standardized tool for all beneficiaries Determine the effectiveness of the tool to identify beneficiary needs Stratify the identified risks to develop the care plan SNP Model of Care and Quality Improvement Program - May
43 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
44 Individualized Care Plan for Each Beneficiary SNP Model of Care and Quality Improvement Program - May
45 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
46 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
47 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
48 Communication Network SNP Model of Care and Quality Improvement Program - May
49 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
50 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
51 Most Vulnerable Beneficiaries SNP Model of Care and Quality Improvement Program - May
52 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
53 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
54 Performance and Health Outcome Measurement SNP Model of Care and Quality Improvement Program - May
55 MIPPA Mandate MIPPA mandated special requirements for SNP quality reporting: 1) Collect, analyze and report data to measure health outcomes and indices of quality 2) Evaluate the effectiveness of the care management plan to assure an evidencebased model of care SNP Model of Care and Quality Improvement Program - May
56 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
57 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
58 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
59 Model of Care Evaluation MAOs may collect data on model of care structure or processes such 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
60 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
61 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
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