GUILDNET HEALTH ADVANTAGE MODEL OF CARE

Transcription

1 GUILDNET HEALTH ADVANTAGE MODEL OF CARE Introduction: GuildNet Health Advantage is a dual eligible SNP. The plan provides a rich benefit package to beneficiaries eligible for Medicare and full Medicaid that consists of most services covered by Original Medicare, and many services covered by the Medicaid fee-for-service program. In addition, some extra services like expanded vision care and wellness benefits are covered. The goal of the plan is to help dually eligible individuals achieve optimal health outcomes through a coordinated care program that incorporates risk identification, wellness initiatives, utilization management, disease management and care coordination. A. Structure GuildNet has a contract with CMS to operate a dual eligible SNP, under which GuildNet covers Medicare benefits for GuildNet Gold enrollees. GuildNet also holds a contract with the New York State Department of Health for a Medicaid Advantage plan. This contract allows GuildNet to offer Medicaid benefits to GuildNet Gold members. Together, these two contracts allow GuildNet to offer an integrated dual eligible SNP, with a benefit package that consists of most of the services that members used to get from Original Medicare, and many of the services that the member used to get from Medicaid fee-for-service. GuildNet Health Advantage is a zero cost share plan. There is no Part C plan premium, and members have no deductibles or co-pays for medical services. All members are eligible for the low income subsidy and pay small co-pays for covered prescription drugs. GuildNet has entered into a contractual arrangement with Emblem Health (GHI and HIP) to provide certain Medicare related administrative functions for the plan, including utilization management, payment of claims, and processing of enrollments. GuildNet has also contracted with Emblem for the GHI Medicare Advantage Choice PPO Provider Network and PBM services. The GHI Medicare Choice PPO Provider Network consists of physicians, nurse practitioners, physical therapists, occupational therapists, optometrists, mental health providers, certified home care agencies, hospitals and skilled nursing facilities for Medicare covered stays, and other ancillary providers. Emblem Health has administrative staff that credentials providers. Its Credentialing Committee, made up of doctors and management staff, approves providers for participation in the network upon joining and every three (3) years thereafter. It should be noted that for Medicare services, members have a point of service option. They are able to access out-of-network providers without cost-sharing. Referrals are not needed for any service accessed through the GHI Medicare Choice PPO Provider Network. However, some limited services do require authorization. Authorization is not required for doctor visits or for preventive health services. Administrative functions related to Medicaid (e.g. utilization management and claims payment for Medicaid only covered services), Call Center operations, and marketing/enrollment are performed by GuildNet. GuildNet also manages and credentials providers for Medicaid only services such as transportation and Private Duty Nursing and delegates management and credentialing of dental services to HealthPlex. Medicaid only covered services must be obtained from in-network providers and while a referral is not needed, all services require prior authorization. Page 1

2 GuildNet Marketing Representatives, who are insurance agents licensed by the New York State Department of Insurance, meet with potential enrollees to discuss the plan, providing all required disclosures, including information about the provider network and covered benefits. If the person is interested in joining the plan, the Marketing Representative asks the beneficiary complete and sign the plan s Medicare Advantage and Medicaid Advantage enrollment forms. GuildNet s Intake Department verifies Medicaid eligibility and sends the request to the New York City Human Resources Administration (HRA) or identified LDSS contractor (the local agency that administers Medicaid) for processing and approval. Once the enrollment is approved by HRA/LDSS, the request is sent to CMS. When CMS approves the enrollment, EmblemHealth notifies GuildNet electronically. GuildNet s Transition Team (consisting of Registered Nurses and support staff) contacts the member (Outbound Enrollment Verification call) and confirms their understanding of the program and continued interest in enrollment. A Member Services Representative (MSR) is assigned to make a welcome call to orient the new member to the plan and to make an appointment to conduct the telephonic Health Risk Assessment if it is not conducted at the time of welcome call. The plan may also include a Health Risk Assessment in the welcome packet to be completed by mail. The member s primary point of contact with the plan is determined by the results of the member s Health Risk Assessment and/or review of available claims data. Based on the results of the Health Risk Assessment and/or claims data, members are assigned to a GuildNet staff member with skills appropriate to the member s health care status. Members can always contact GuildNet Member Service Representatives by calling the plan s toll free number. An MSR will triage the call to the appropriate party. Completed Health Risk Assessments are reviewed by GuildNet staff. Based on the results, members are assigned to one of the plan s three (3) Special Needs units : a. Wellness Unit. Primary Point of Contact: GuildNet MSR. Members assigned to the Wellness unit are those that do not have an identified chronic illness or disability and are those who are primarily self-managing. These members are provided with health and wellness information, coordination of screening and preventive services, and recommendations for physician checkups and community supports. b. Disease Management (DM) Unit. Primary Point of Contact: Case Aide (a staff member with experience in health education and/or care coordination). Members assigned to the DM unit are those identified as having a chronic disease(s). This includes members with HIV/AIDS, a mental health diagnosis, chemical dependency, and other chronic and disabling conditions. Members with HIV/AIDS or mental health issues are assigned to a Case Aide who coordinates services for the member and when appropriate, refers the member to other case management services such as COBRA Case Management program, community based services, or a mental health provider. Members with other chronic diseases are assigned to a Case Aide, who coordinates services based on members clinical needs according to established protocols. These protocols are developed based on evidencebased practices and guidelines from established professional organizations such as the American Heart Association, National Institutes of Health, American Diabetes Association and AIDS Institute, and approved by the GuildNet Medical Director. c. Case Management Unit. Primary Point of Contact: Nurse Case Manager (NCM). Members assigned to the Case Management Unit have multiple chronic illnesses, multiple and/or frequent hospitalizations/emergency room visits, polypharmacy/medication Page 2

3 adherence concerns, and/or significant social service concerns interfering with their medical management, all of which warrant acute, intermittent case management. NCMs are responsible for coordinating care and communicating with the members of the Interdisciplinary Care Team (ICT) as warranted. In addition to the functions described above, a primary function of the NCM/ICT is to prepare and manage members through transitions of care across settings, assuring appropriate follow up with the PCP and other providers such as mental health providers upon hospital discharge, and medication reconciliation. Members in this group are considered the most vulnerable. Designated RN staff provides oversight of the activities of the GuildNet Special Needs units including supervision of staff, participation in care plan development and coordination with other members of the ICT as warranted. For those members receiving case management, the ICT includes at least the member, the member s family or informal caregiver as required, NCM, the PCP, a Social Worker, a Mental Health Liaison, and if the member receives paraprofessional services, the member s Home Health Aide or Personal Care Aide. Other providers and community support representatives may be included on the ICT as necessary to meet the member s needs. Most ICT meetings are informal, and are conducted through electronic or verbal communication facilitated by the NCM. The NCM communicates and collects clinical and psychosocial information from ICT members through the electronic medical record, by phone, fax, or by encrypted . Information collected from ICT members is documented by the NCM in the electronic health record. (Note: All records are maintained in accordance with HIPAA and Medicare record retention requirements). As appropriate, the NCM will share information collected with ICT members via the same mechanisms. Collection of and sharing of information among ICT members happens annually, at which time a re-evaluation of the member s health risks through the Health Risk Assessment takes place. It also takes place upon changes in the member s condition including discharge from the hospital. When it is necessary, the NCM may convene an in-person meeting with the member, their family and caregivers, and other members of the ICT. Many GuildNet Health Advantage members are expected to have Personal Care Aides or Home Health Aides, obtained through Medicaid fee-for-service. Additionally most members are expected to utilize non-emergency medical transportation, which is covered by the plan, to get to and from appointments. Personal Care Aides and Home Health Aides assist the member with self-management and activities of daily living, and they provide the NCM with direct insight into the member s health status and conditions in the home on a regular basis. Many members may require Personal Emergency Response Systems (PERS). These devices help the plan to monitor members when they are alone in their homes, and facilitate independent living. Referrals for PERS are made to Medicaid fee-for-service providers. Claims for covered services provided to members are processed by claims processors (clerical staff) at either EmblemHealth for Medicare and Medicaid-covered services or Relay Health for Medicaid only services. The GuildNet Quality Assurance and Performance Improvement department (QAPI) is responsible for developing and implementing the Quality Improvement Plan, managing grievances, collecting, analyzing and acting on performance and health outcome data, including provider adherence to clinical practice guidelines, conducting Quality Improvement (QI) activities including a CCIP and QIPs, reviewing and analyzing utilization data, and leading the evaluation of the effectiveness of GuildNet s Health Advantage Model of Care. The QAPI department also conducts quality audits to evaluate Page 3

4 coordination of care, participation of the ICT in the care planning process, and the appropriateness of services included in the plan of care. The Staff Development department is responsible for training GuildNet staff on clinical protocols, the Health Risk Assessment tool, Disease Management/Case Management protocols and standards, the Model of Care, and other operational processes. The Medicare Services department provides guidance to GuildNet staff on regulatory issues related to Medicare, Medicaid, and GuildNet Health Advantage, serves as liaison between the plan and regulatory agencies, and is responsible for oversight of delegated entities. The department is also responsible for enrollment reconciliation, reviewing and approving Part C and D reports, preparing and analyzing internal management reports including utilization data, and for conducting compliance and fraud, waste and abuse audits. B. Health Risk Assessment GuildNet Health Advantage conducts a Health Risk Assessment (HRA) for each member within 90 days of enrollment and annually thereafter. It may be conducted more frequently if there is a change in the member s medical condition. The HRA collects a baseline of the member s medical history, select clinical issues, diagnoses, functional status, psychosocial issues, and cognitive status. The HRA also evaluates potential health risks that may be amenable to intervention, such as tobacco use, obesity, and decreased medication adherence. The information collected using the HRA is the basis for development of the plan of care, including the identification of member-specific problems and goals. The HRA is the primary but not the sole means for identifying member needs, and stratifying the member for placement in one of the three Special Needs Units (Wellness, Disease Management or Case Management). It is also the basis for developing the care plan for individual members. The HRA is conducted telephonically by an MSR during the welcome/orientation call or at a later date (within 90 days of enrollment) if preferred by the member. After 3 unsuccessful attempts to contact the member via telephone, the plan mails an HRA and a self addressed return envelope to the member. Completing the HRA is voluntary. In those cases where the plan is unable to obtain a completed HRA from a member, the plan will assess the members needs via claims analysis. Each HRA will be reviewed by an RN who will approve the assignment of the member to the appropriate Special Needs Unit. C. Eligibility and Enrollment: To enroll in GuildNet Health Advantage, individuals must meet the following criteria: Age 18 or older Have full Medicaid coverage or full Medicaid coverage with Qualified Medicare Beneficiary(QMB) eligibility; A resident of Brooklyn, Queens, Manhattan, the Bronx, Nassau and Suffolk counties; Have Medicare Part A & B, or C ; and Otherwise not ineligible to enroll in the Medicaid Advantage Plan Page 4

5 Enrollment into GuildNet Health Advantage is a voluntary process. Members can disenroll at any time. D. Interdisciplinary Care Team All members will have their plan of care developed by an Interdisciplinary Care Team (ICT). For each member the ICT will be determined by the Special Needs Unit the member is assigned to and also by the identified health risks of the member. The Interdisciplinary Care Team (ICT) may include all or some of the following: the MSR, Case Aide, and NCM and includes at least the member, the member s family or informal caregiver as required, the PCP, a Social Worker, a Mental Health Liaison, and the member s Home Health Aide or Personal Care Aide if the member is receiving such services. Specialists and other providers are involved in the ICT based on the member s health condition(s) and the results of the health risk assessments. For members receiving Case Management, the NCM is the member s primary contact for the plan and is the facilitator of the member s health care, the involvement of the ICT, and the member s plan of care. Case Management may take several forms. For members who are independent and self-managing their chronic illnesses, the Case Management may be intermittent during transitions of care or the initiation of a new medication or treatment regimen. Some members however will need more continuous Case Management due to challenges with adherence to treatment regimens or the labile nature of their illness(s). The NCM is responsible for ongoing evaluation of member s health risks through telephone contact with the member and through monitoring the results of the assessments which may be completed by other providers of care, such as a certified home health agency or PCP. The NCM shares health risk information with members of the ICT through the electronic health record when members of the ICT are part of the organization or parent organization. In all other cases, the NCM shares information with the ICT verbally or in writing. ICT members also provide information to the NCM regarding services and interventions that should be put in place to meet the member s needs. With input from the ICT, the NCM documents the plan of care. The NCM arranges the delivery of covered benefits identified in the plan of care and also coordinates non-plan services required by the member. The member s PCP works closely with the NCM in identifying the member s acute and chronic needs, and the services necessary to support those needs. Communication between the PCP and the NCM occurs as changes in condition take place or needs are identified, and when the plan of care is evaluated. The Social Worker (SW), who may be an employee, a contracted provider, or a representative of a community-based organization, assesses and identifies the member s needs as they relate to eligibility for entitlement programs, social and community services, housing, and psychosocial supports. The SW also assesses caregiver ability to participate in the plan of care. The SW provides feedback to the NCM on identified needs and recommends services and linkages to support identified needs for inclusion in the plan of care. In addition, the SW assists the member with accessing State and Federal social programs, and provides support to the member and the family/caregivers in coping with chronic illness. The Social Worker communicates with the NCM via phone, in person conferences and through the member s electronic health record. Page 5

6 The Mental Health Liaison, who works for the GuildNet parent organization, assesses mental health needs upon request from NCM or member, plan s identification of psychiatric diagnosis or medications, and as needed upon change in member s condition. The Mental Health Liaison identifies the need for mental health services and intervention, and defines those needs and services for inclusion in the plan of care. The Mental Health Liaison reviews the health risk assessments. He/she also collaborates with mental health providers when such services are needed, defines goals and outcomes, and provides information back to the RN/MSR/Case Aide/NCM telephonically. For those members who are receiving Case Management, the MSR provides support to the ICT by assisting with member communication. The MSRs respond to members requests for information, assist members with selecting providers, coordinate service placement with vendors, assist with translations, enter authorizations for Medicaid only-covered services, and disseminate written communication across ICT members. The Case Aide (CA) is responsible for the management and coordination of the member s care plan in the DM unit. The CA is responsible for completing additional condition-specific assessments to determine the member s knowledge of their disease process and to work on developing goals and outcomes for improvement in member self-management. The CA follows protocols developed by clinicians, based on standards of community practice and evidence-based guidelines. The CA will be the primary contact for the member who is responsible for developing the care plan and seeking input from the member and other ICT members as warranted. Additionally the CA will have regular ongoing coaching sessions with the member to discuss their progress towards goals and to assess their needs for additional services and to coordinate their care with the PCP and other service providers. All Case Aides will be supervised by an RN. Other specialists and ancillary providers give input into the member s plan of care, when the NCM/ CA or ICT members identify a specialized need that they believe is better supported with the outside resources. E. Plan of Care Once enrollment is processed, and approval obtained from both CMS and LDSS (or contractor), a GuildNet MSR makes a welcome call within 1 month of enrollment. If the member is amenable, the MSR conducts the Health Risk Assessment (HRA) at the time of the welcome call; otherwise a telephonic appointment is made with the member to conduct the HRA at another time within 90 days of enrollment. During the welcome call if the HRA cannot be completed, the MSR will inquire if the member requires any services/assistance in the interim. The assessment of the member includes identification of care preferences and the ability of family to provide support. Upon completion of telephonic or mail assessment, the member s assigned MSR/CA/NCM works with the member and ICT, as appropriate, to develop the plan of care. This care plan is put in place to meet the medical, psychosocial, and care needs identified by the member, through the information gathered during the welcome call, the HRA and claims information. Enrollees in the Disease Management/Case Management Units will have a more comprehensive care planning process than those members in the Wellness Unit. Information about accessing mental health providers, chemical dependency programs, family planning services, other medical specialists, HIV/AIDS care management programs and clinical specialists will be provided and included in the care plan. If the presence or history of mental health diagnoses is identified then referral for further assessment by a Mental Health Liaison is made. Page 6

7 If warranted, based on results of the HRA, the Social Worker conducts a psychosocial assessment of the member. The results of the psychosocial assessment are stored in the electronic health record and are reviewed by the MSR/CA and/or RN/NCM. Services identified are added to the member s plan of care. If appropriate, a Mental Health Liaison reviews the member s response to the HRA and conducts a telephonic assessment of the enrollee to determine if mental health services are needed. The Mental Health Liaison and the MSR/CA and RN/NCM discuss the results of the assessment, along with goals and outcomes for the member, and the primary contact updates the initial plan of care. The plan of care which is developed by the primary member contact (MSR, CA, NCM) in collaboration with other ICT members, includes services that address the member s health risks/needs as identified by the HRA, through assessment calls to the member, and through other health information identified by the ICT or others (including family and other providers.) The plan includes both covered and non-covered benefits that may be coordinated by the plan. For covered benefits, the plan of care includes the type of service, frequency, and duration of services that have been authorized, put in place, or recommended for the member. It also includes non-covered benefits that the plan coordinates for the member such as Vision Rehabilitation services and Telephone Reassurance. The member s care plan is reviewed and may be updated/ amended if there is a change in the member s condition or there is a change in caregiver status. Changes in condition may be identified through conversations or clinical notes from a provider, analysis of utilization data, and/or member/caregiver report. The plan of care includes the goals that the team has established with the input from the member for the period covered by the plan of care. A copy of the plan of care is mailed to the member s Primary Care Provider by support staff. F. Care Management Members requiring Case Management include those with multiple chronic illnesses, multiple and/or frequent hospitalizations/emergency room visits as well as those with difficulties adhering to their medication or therapeutic regimen. Additional Case Management services are offered to people with HIV/AIDS, mental illness and chemical dependency either directly or through a contract with agencies with an expertise in Case Management of these areas. Case Management includes development and monitoring of the member s plan of care, coordination of services and communication, and ongoing assessment of the member s health status. Through telephone communication with the member, family, or Personal Care Aide/Home Health Aide, and through verbal and written reports from the ICT and other providers, the NCM monitors the member s progress towards goals identified in the plan of care. The NCM routinely updates the member s electronic health record with information regarding the member s health status and with documentation of communication with ICT members and other providers. NCMs contact their assigned members at a minimum of quarterly to discuss care issues. The NCM goes through a formal list of questions with the member to evaluate changes in health status or needs, to identify and resolve problems, and to identify the need for additional and/or change in current services. During that call, among other things, the NCM asks the member if they have noticed changes in their health, if they have started new medications, if there have been changes in the member s home, or if they have fallen. The NCM also reviews the member s current services to determine if services have been received in accordance with the member s plan of care. The NCM discusses appointments Page 7

8 that the member had since the last telephonic assessment, as well as upcoming appointments. Information gathered from the quarterly call is used to coordinate care, update the member s plan of care, and to ensure that the member is receiving the services they need to address their health needs. The NCM communicates with providers to facilitate transitions of care. When transitions of care, (hospitalization or skilled nursing facility admission or discharge, provision of certified home care services) occur, the NCM communicates health care status information with the admitting facility/program and EmblemHealth s utilization management (UM) staff as appropriate, to whom GuildNet has delegated certain UM functions. The NCM maintains regular contact throughout the admission/ provision of services, and participates in discharge planning processes with the providers of care, UM staff and the ICT. Information obtained through this contact is entered into the member s electronic health record by the NCM. Upon discharge from inpatient care, the NCM requests written and/or verbal information about the course of the member s stay and ensures that ICT members are updated as needed. The NCM maintains both verbal and written reports in the electronic medical record. The NCM also provides ongoing education to members regarding management of their health conditions. The NCM may work with providers of in-home care (Certified Home Care Agencies and Licensed Home Care Agencies), Case Aides or family members on ways to help the member with selfmanagement. G. Provider Network GuildNet Health Advantage offers its members a point of service option for Medicare covered services. Medicare covered services are available to members through a contract that the plan has with one of the largest health plans in New York City (Emblem Health). This network is called the GHI Medicare Choice PPO Provider Network and it is comprised of physicians and other providers, including nurse practitioners, physical therapists, occupational therapists, speech therapists, mental health professionals (psychiatrists, social workers, psychologists), hospitals, ancillary providers and specialty clinics (e.g. dialysis, lithotripsy, endoscopy.) Ancillary services include home infusion, DME, prosthetics, orthotics, diabetic supplies, and diabetic shoes. The network also offers an extensive choice of specialists, including geriatricians, nephrologists, pain management specialists, endocrinologists, rheumatologists, and HIV specialists who can act as PCPs. Among the extensive number of mental health practitioners in the network, members have access to our parent organization s onsite mental health clinic which is staffed with experienced social workers, psychologists and psychiatrists. Members always have the option of selecting an out of network provider at no additional cost sharing. GuildNet Health Advantage has a closed network for Medicaid only covered services. These services are available to members through the GuildNet Network and include services to support the chronically ill. Services that can be obtained through this network include private duty nursing and non-emergency medical transportation. To facilitate the care of the GuildNet Health Advantage membership, the GHI Medicare Choice PPO Provider Network and the GuildNet Services Network both include providers who have ADAaccessible offices. There are also physicians, dentists, medical suppliers, and prosthetic suppliers who make home visits participating in the plan s network. Page 8

9 GuildNet has delegated credentialing of providers in the GHI Medicare Choice PPO Provider Network to EmblemHealth. GuildNet maintains accountability for the credentialing of providers in the GHI Medicare Choice PPO Provider Network, with GuildNet s Medicare Services department performing delegation oversight, including auditing, of Emblem s credentialing policies and practices. Credentialing staff at Emblem Health review provider applications and verify the provider s license, DEA Certificate, work history, malpractice insurance, and professional claims liability history. They also verify that the provider is not on the Medicare opt-out list, and verify that the provider does not have any Medicare or Medicaid sanctions against them. In addition, site visits of provider offices/facilities are conducted. The results of the credentialing review/process are compiled and presented to the Medical Director in those cases where there have been no adverse findings, or otherwise to the Credentialing Committee, for approval to participate in the network. Providers are credentialed for a three (3) year period. Providers are available to members only after they have gone through the credentialing process and been approved for participation. GuildNet s Provider Relations staff manages the credentialing of providers in the GuildNet Network. Working with a vendor, licenses, certifications, insurances, and sanctions are verified. All provider applications and credentials must be approved by the Senior Vice President of Provider Relations before the provider is made available to members. All providers are recredentialed within three (3) years. GuildNet assures that providers use evidence based clinical practice guidelines and nationally recognized protocols. In addition, medical providers in the GHI Medicare Choice PPO provider network are required to comply with professional medical standards of practice, GHI Medicare Choice PPO s practice guidelines, and all applicable federal, state, and local laws. Providers are notified of their obligation through the Provider Manual and plan s website. Medical record audits are conducted by EmblemHealth to ensure provider compliance and utilization management guidelines and clinical criteria incorporate evidence based clinical practices. H. Communication Network The MSR/CA/NCM are the focal point for communication. This includes communicating with the ICT members, other providers and support staff, as well as for documenting clinical conversations and Case Management/service coordination activities in the electronic health record. Most communication with the member occurs telephonically. Communication with the ICT may be telephonic, but it may also be done by fax, encrypted or through the use of the electronic health record. Although ongoing day-to-day communication with members and providers is facilitated by the MSR/ CA/NCM, communication with members and providers is supported by MSRs and other plan staff. MSRs staff the Call Center and receive calls from members regarding benefits, provider selection, and problems. They communicate by phone with providers and members to coordinate the delivery of services to members, and fax or mail plan information as necessary. GuildNet Health Advantage has an electronic health record which includes information about member s health risk assessment, health information, the plan of care, correspondence, and Case Management activities related to the member, including records of communication with the member, their providers, and among ICT members. This record is available electronically to ICT members who Page 9

10 are employed by the plan or parent organization, and by hard copy to all participating and supporting members of the ICT. It is used as an instrument to facilitate the exchange of information during the care planning and Case Management processes. The ICT develops the plan of care through telephonic and electronic communications as described in the Plan of Care section. In addition to telephone, and the electronic health record, the NCM may facilitate an onsite meeting which can include the member, the member s family, and members of the ICT. The same is true for case conferences, though most often, case conferences are telephonic. If a member is homebound when a meeting is necessary, an advocate member of the ICT will participate from the member s residence to assure member/caregiver input is received and acknowledged. A copy of the member s current plan of care and a historic record of past care plans are saved in the electronic health record. The GuildNet Health Advantage Website has all the required plan information and is available to members, providers, and the public. Maintained by the Medicare Services department, it contains the Summary of Benefits, Evidence of Coverage, Provider and Pharmacy Directory, Formulary, Provider Manual, and other important plan information. The website also includes an online provider, pharmacy and drug look-up search tools. In addition, it contains training information specifically for providers including Model of Care training, and Fraud Waste and Abuse training. By reviewing the website, members and providers can obtain information on how to enroll and disenroll from the plan, benefits, how to access services in and out of the provider network, obtain authorization, and how to file a grievance and appeal among other things. I. Model of Care Training Staff is trained on the Model of Care in person by GuildNet s Staff Development department which reports to the Vice President of Quality Assurance. This training occurs annually and staff is required to take a post training test to demonstrate their understanding. The training describes the regulatory requirements, the role of the MSR, Case Aide, NCM, and the ICT, the use of the HRA as a health risk assessment tool, and the model s goals and measurements. Sign-in sheets and the results of testing are tracked and kept on file by Staff Development. If training is not completed by a staff member or if test results indicate a lack of understanding, Staff Development notifies the staff member s supervisor who works with Staff Development to ensure training is completed and staff obtains the necessary knowledge. Reports on the status of training are made to the Compliance Committee by the Vice President of Quality Assurance. Model of Care training for providers is posted on the GuildNet website. It is updated annually. As with the training for employees, the provider training describes the regulatory requirements and the specifics of GuildNet Health Advantage s Model of Care. GuildNet s Staff Development department, which is responsible for most organizational trainings, develops the content of Model of Care training, with input from clinical staff and management. Medicare Services has oversight for ensuring that the training reflects current regulatory requirements. Page 10

11 J. Model of Care Oversight and Evaluation On a quarterly basis, GuildNet Health Advantage reviews the progress that has been made toward meeting the goals of its Model of Care. This is done through the Model of Care Oversight Committee which is made up of NCM Supervisors and Directors, the Assistant Vice Presidents of Case Management, the Senior Vice President of GuildNet, the Vice President of Quality Assurance, the Senior Executive Vice President of GuildNet, the Senior Vice President of Provider Relations, and the staff of the Medicare Services department. The Committee reviews each goal of its Model of Care and monitors the corresponding performance measures which are compiled by the Medicare Services department with the assistance of the QAPI department. If an area of non-performance is identified, the Committee may assign a work group to look at the issue, or may suggest changes to current processes. Such changes are presented to the Committee for approval. On an annual basis, the Committee formally reviews its Model of Care and evaluates its effectiveness by analyzing performance measures established for each goal. Based on the analysis and review, the Committee may decide to undertake quality initiatives to improve performance with regard to meeting one or more of its goals, may revise its measures, may revise operations/business practices or care management practices, and/or make changes to the provider network to meet Model of Care goals. The results of this meeting are documented and presented to the GuildNet Quality Assurance and Performance Improvement Committee, which includes providers, by the Vice President of Quality Assurance. Results are subsequently reported up to the GuildNet Board of Directors through the Regulatory Committee, which is a subcommittee of the GuildNet Board of Directors. K. Model of Care Goals: GuildNet Health Advantage s Model of Care has the following goals: A. Improve access to medical, mental health, social services, and other services as needed by our members, demonstrated by: a. A provider network that includes a full range of routine and specialty providers and services; b. Enhanced access to providers through a point of service benefit design that does not require preauthorization for many services; and c. Monitoring and enforcement of 85% compliance by network provides with access and availability standards set by the plan. B. Improve access to affordable care as required by our members demonstrated by: a. A benefit design that includes no or low plan premium, deductible and co-payments; b. Medicaid recertification assistance available from Medicaid Eligibility specialist and Social Work services; and c. Monitor and maintain the disenrollment rate related to failure to maintain Medicaid eligibility at or below 5%. C. Improve coordination of care through an identified point of contact, demonstrated by: a. Stratification model based on a health risk assessment that triages members into a unit with an identified point of contact : Case Management (Nurse Case Manager), Disease Management (Case Aide) and Wellness (Member Service Representative); b. The point of contact facilitates the development/implementation of care plan and/or coordination of services; and Page 11

12 c. 80% of record reviews show staff adherence to standards of care coordination and stratification protocols. D. Improve transitions of care across settings and providers for members who are case managed, demonstrated by: a. 80% of record reviews show staff adherence to the transition protocol. E. Improve access to preventive health services, demonstrated by : a. A benefit design that includes coverage of preventive health services without authorization or member cost-sharing; b. 80% of members diagnosed with HIV/AIDS have a check-up visit with an HIV/AIDS specialist within 6 months of enrollment; and c. A 10% increase in the rate of members receiving preventive health services of glaucoma screening, colorectal screening and screening for untreated depression. F. Assure appropriate and cost-effective utilization of services, demonstrated by: a. The use of member s family, informal caregiver(s) and/or community supports in the member s plan of care; b. 80% of members see a mental health provider within 7 days and 30 days of discharge from a facility where the member had a psychiatric diagnosis as the reason for admission; and c. 85% of members have an annual PCP visit. G. Improve beneficiary health outcomes, demonstrated by: a. A benefit design to promote improved self-management and independence and prevent further deterioration and dependence, as appropriate, that includes multiple services and pathways to provide member teaching and rehabilitation, including cardiac rehabilitation, SNF rehabilitation and sub acute care, diabetic training, nutritionist services, in-home skilled nursing and rehabilitation services, outpatient rehabilitation and other services; b. An initiative to decrease the rate of falls for the most vulnerable population, defined as those with multiple chronic illnesses requiring Case Management. This is measured by a 10% decrease (27.5 PTMPM baseline) in rate of falls and a 10% (17.0 PTMPM baseline) decrease in rate of falls with injury. Page 12