Coventry Health Care of Florida. Special Needs Plan (SNP) Model of Care Annual Training

Transcription

1 Coventry Health Care of Florida Special Needs Plan (SNP) Model of Care Annual Training 1

2 Course Overview The Centers for Medicare and Medicaid (CMS) require all contracted medical providers to receive basic training about the Special Needs Plans (SNP) Model of Care. The SNP Model of Care is the plan for delivering coordinated care and case management to special needs members. This course will describe how Coventry and its contracted providers can work together to successfully deliver the SNP Model of Care. 2

3 Learning Objectives After the training, attendees will be able to: Describe the basic components of the Coventry SNP Model of Care. Explain how Coventry case management programs work and how contracted providers will work with the programs. Describe the essential role of contracted providers in delivering the SNP Model of Care. 3

4 What are Special Needs Plans? Medicare Advantage Special Needs Plans (SNPs) are designed for specific groups of members with special health care needs. Medicare SNPs are specially designed to have the following features: Enrollment limited to Medicare beneficiaries within the target SNP population. The benefit plan custom designed to meet the needs of the designated population. Additional election periods during which SNP members may change their Medicare coverage. 4

5 What are SNPs? (cont d) There are three types of Medicare SNPs: Individuals Dually Eligible for Medicare and Medicaid benefits and services Individuals with Chronic Conditions Individuals who are Institutionalized or eligible for nursing home care Coventry has 5 Dual Eligible Special Needs Plans 5

6 What is the SNP Model of Care? The SNP Model of Care is the plan for delivering case management services for Medicare Advantage members with special needs. 6

7 What is the SNP Model of Care? Model of Care elements 1.SNP-Specific Target Population 2.Measurable Goals 3.Staff Structure and Care Management Roles 4.Interdisciplinary Care Team (ICT) 5.Provider Network with Expertise and Use of Clinical Practice Guidelines 6.Model of Care Training for Provider Network 7.Health Risk Assessment 8.Individualized Care Plan (ICP) 9.Communication Network 10.Care Management of the Most Vulnerable Subpopulations 11.Performance and Health Outcome Measures 7

8 Model of Care Element: SNP-Specific Target Population 74% of Coventry SNP members are over age 65 years and 57% are female and 43% male Type of Dual SNP 36% are Full Medicaid recipients 71% are Qualified Medicare Beneficiaries (QMB) 17% are Specified Low Income Medicare Beneficiaries (SLMB) 8

9 Model of Care Element: SNP-Specific Target Population Conditions ranked by prevalence Diabetes Behavioral Health CHF Coronary Artery Disease Conditions ranked by cost Renal Failure Pharmacy Malignancies AIDS/HIV 9

10 Model of Care Element: Measurable Goals Coventry s mission is to optimize the health and well being its aging, vulnerable and chronically ill members. Examples of measurable goals: To ensure care is coordinated across specialty, multi-setting care continuum through a central point of access 100% of Coventry SNP members will be enrolled in case management. To provide a seamless transition across health care settings, Coventry has initiated a Transition of Care Program that is geared towards the prevention of readmissions. 10

11 Model of Care Element: Staff Structure and Care Management Roles Coventry recognizes the needs of the SNP membership and provides the appropriate staff to perform the functions needed to support this population. Clinical staff include Nurse Case Mangers, Medical Directors, Social Workers, Behavioral Health specialists and Pharmacists. Administrative staff include Administrative Assistants, Enrollment Specialists, Customer Service Reps, Grievance and Appeals Investigators. 11

12 Model of Care Element: Interdisciplinary Care Team (ICT) The Coventry ICT is assigned to each SNP member. The composition of the ICT is determined by the needs of the individual member. The ICT uses Health Risk Assessments (HRA) findings, medical history and current clinical diagnostics and assessments to continually modify the member s Individualized Care Plan (ICP) so that it reflects the member s most current condition and needs. After each ICT, the member s Case Manager updates the member s ICP and is responsible for facilitating completion of the member s goals. 12

13 Model of Care Element: Interdisciplinary Care Team (ICT) Sample ICT composition The Coventry SNP Medical Director SNP Case Managers SNP Social worker The plan s delegated behavioral health provider Coventry s pharmacist The beneficiaries PCP (if applicable) The beneficiary and/or their designated advocate or caregiver (if possible) 13

14 Coventry SNP Interdisciplinary Team Home Health Coventry SNP Management Team Primary Care Provider Coventry Vendors Member & Case Manager Specialists Pharmacists Family/Caregiver Social Services 14

15 Model of Care Element: Provider Network with Expertise and Use of Clinical Practice Guidelines All major specialties and services are represented on the Coventry panel of participating providers. A geo-access evaluation is performed annually to assure SNP members have access to providers necessary for rendering needed care. All Coventry Health Care providers are expected to practice evidence-based medicine. Coventry s Provider Portals contain clinical practice guidelines for reference. 15

16 Model of Care Element: Model of Care Training for Provider Network Coventry providers will have access to MOC training annually via DirectProvider.com. Yearly attestation of completion is required and can also be done through the site. Coventry staff are also trained annually either on-site and/or via teleconferences. 16

17 Model of Care Element: Health Risk Assessment (HRA) Every SNP member is evaluated at least twice annually with a comprehensive telephonic or faceto-face Health Risk Assessment. Results of this HRA are available to the provider via the SNP Management Department. 17

18 Model of Care Element: Individualized Care Plan (ICP) Results of the HRA are combined with laboratory, pharmacy, emergency department and hospital claims data to generate an Individualized Care Plan (ICP) for each member. The Interdisciplinary Care Team finalized the ICP with input from PCPs, specialists, members and their caregivers and/or families. The ICP is the initial and ongoing mechanism of evaluating the member s current health status and formulating an action plan to address care needs in conjunction with the ICT and member. Members are then placed into case management and triaged to any appropriate Coventry Disease Management programs. 18

19 Model of Care Element: Communication Network CMS requires ongoing communication between the member, provider and the Health Plan for all SNP members. Communication with providers and members occurs in a variety of ways Telephonic outreach by Case Managers and Social Workers Educational and informational mailings Blast Faxes Care Plan web portal Coventry Provider Portal 19

20 Model of Care Element: Care Management of the Most Vulnerable Subpopulations Coventry s SNP population is tiered based on the member s current health status and needs Tier 3 contains the most vulnerable members including those at risk of unplanned transitions of care. Tier 3 members are generally enrolled in several Coventry Disease Management programs. Tier 1 contains the most stable SNP members. 20

21 Model of Care Element: Performance & Health Outcome Measures Coventry conducts a Quality Improvement program to monitor health outcomes and implementation of the Model of Care by: Collecting SNP specific HEDIS measures Meeting NCQA SNP Structure and Process standards Conducting a Quality Improvement Project (QIP) annually that focuses on improving a clinical or service aspect that is relevant to the SNP population (for example Fall Prevention) Providing a Chronic Care Improvement Program (CCIP) for chronic disease that identifies eligible members, intervenes to improve disease management and evaluates program effectiveness Collecting data to evaluate if SNP program goals are met 21

22 What are the SNP Model of Care Goals for our Coventry members? The SNP Model of Care Goals for our members fall into six categories: 1. Improve Access to medical, mental health, social services, affordable care and preventative health services 2. Improved Coordination of Care through an identified point of contact 3. Improved Transition of Care across health care settings and practitioners 4. Assure Appropriate Utilization of services 5. Assure Cost-Effective service delivery 6. Improve Beneficiary Health Outcomes 22

23 Coventry SNP Model of Care (cont d) Members receive follow up, referral, education Member is re-assessed at least annually Case Managers and PCPs work closely together to monitor the Individualized Care Plan Coventry will disseminate evidence-based clinical guidelines and will conduct studies: To measure benefits to member and Coventry To monitor quality of care To evaluate the Model of Care 23

24 Coordination of Services Coventry Health Care considers its SNP management program to be an important and effective model that enhances the member s access to care, improves quality of care, and ensures the continuity of beneficial services, including medical, behavioral health, social, dental, and pharmacy services. 24

25 Coventry SNP Management Program Inpatient Census Enrollment Initial Health Screening Monthly Risk Stratification Member Self Referral Community Referral Physician Specialist Referral Case Management: Health Risk Assessment (HRA) UM Case Management/ Care Transitions Program Disease Management Community Services End of Life/Palliative Care Behavioral Health Emergency Department Utilization Management 25

26 Coventry Case Management Programs: Inpatient Care Management & Care Transitions Inpatient Care Management Coventry clinical staff coordinate with providers to assist members in the hospital or in a skilled nursing facility to access care at the most appropriate level Care Transitions The SNP Case Managers and Social Workers ensure members have appropriate follow-up care after a hospitalization The goal is to prevent hospital re-admissions 26

27 Coventry Case Management Programs: Disease Management Disease Management Helps members with Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD)/Asthma, End Stage Renal Disease (ESRD), Diabetes, Falls and Fractures, and Hypertension. Provides education to members about their disease, self-management/self-care, medication and nutrition. 27

28 What Coventry Case Management can do to help Providers Determine member s personal goals and needs Coordinate care Identify problems/anticipate crises Educate members about their health conditions and medications Coach members to manage according to the provider s plan of care Prepare members/caregivers for their provider visit Refer members to community resources 28

29 What Coventry Case Management can do to help Providers Manage the process of care transitions Identify problems that could cause transitions Where possible prevent unplanned transitions Coordinate Medicare and Medicaid benefits for members Identify and assisting members with changes in their Medicaid eligibility 29

30 Working with our Providers Coventry s Provider partners are an invaluable part of the SNP Management Team. Coventry s SNP Model of Care offers an opportunity for us to work together for the benefit of our member, your patient, by Enhanced communication Focusing on each individual member s special needs Delivering case management programs to assist with the patient s non-medical needs Supporting your plan of care 30

31 Your role as the Provider Communicate with Coventry SNP Case Managers, members of the Interdisciplinary Care Team (ICT), members and caregivers Collaborate with Coventry on the Individualized Care Plan (ICP) Review and respond to patient-specific communication Maintain ICP in member s medical record Participate in ICT 31

32 Model of Care Key Elements: Table of Responsibility 32

33 Coventry Contacts for SNP Model of Care Yisel De Llano, MS Health Services Director SNP Program Lissette Gomez Administrative Assistant SNP Program Mary R Mailloux, MD, MMM, FACEP Medical Director SNP Program