Special Needs Plan Model of Care 101

Transcription

1 Special Needs Plan Model of Care 101

2 What is a Special Needs Plan? First of all it s a Medicare MA-PD, typically an HMO Consists of Medicare enrollees who meet special eligibility requirements In our case members need to be dually enrolled with Medicare and Full Medicaid benefits

3 What is a Model of Care? A living and evolving program that meets the specialized needs of the SNP enrollees through the use of interdisciplinary care teams and the development of care plans that connect the enrollee to the right service at the right time Typically connects the member with the touch points of the Medical Home Model with measurable outcomes

4 Who is the target population Medicare enrollees who live in the service area and are Fully Dual Eligible for both Medicare and Medicaid Compared to the overall Medicare population, Dual Eligibles tend to have a higher utilization of both medical and pharmacy services due to their poor health and higher levels of health impairments Also, the percentage of Dual Eligibles who qualify for Medicare because of disability rather than age is much higher when compared to the overall Medicare population Within that specific target population, the most vulnerable subpopulation receives special services

5 Vulnerable sub populations: Frail Members Reduced physical capacity and increased risk of developing a disability Depends on others for the activities of daily living or the risk of becoming dependent ATRIO determines these members from the HRA Shopping and meal preparation Cleaning your home Showering or dressing Getting up/down or in/out of chairs and bed Eating and/or Drinking

6 Vulnerable sub populations: Members with Multiple Chronic Conditions Identified through claims reports Members with three or more of the following chronic conditions: Diabetes Congestive Heart Failure COPD Asthma Dementia Major Depression End Stage Renal Disease

7 Vulnerable sub populations: Members with End Stage Renal Disease Members with ESRD are identified by comparing claims run and CMS Monthly Membership Report

8 Vulnerable sub populations: Members Near the End of Life: Weekly CMS Transaction Reply Report identifies members on Hospice whom a medical provider has determined near end of life

9 What makes ATRIO unique? We have found that working with ATRIO affiliated Medicaid health plans and their provider networks to coordinate Medicare and Medicaid benefits is ideal: This provides easier access to healthcare and better communications between the providers offering varying levels of care Working with our nurse case managers helps to ensure the beneficiaries are linked into the correct service at the correct time

10 Who are the ATRIO Affiliated Medicaid Health Plans? Cascade Comprehensive Care (CCC) Serving Medicaid members in Klamath county ATRIO currently has have as of approximately 635 SNPs also enrolled with CCC DCIPA Serving Medicaid Members in Douglas county ATRIO currently has have approximately 1,345 SNPs also enrolled with DCIPA Marion Polk Community Health Plan (MPCHP) Serving Medicaid members in Marion and Polk counties. ATRIO currently has have approximately 3,175 SNPs also enrolled with MPCHP

11 MOC Program Overview Our nurse case managers are the hub working.

12 to connect vulnerable enrollees to the right services at the right time.

13 Step 1: Who are we doing this for? Let s run some reports Using the following data sources, the SNP Model of Care is designed to identify members that would benefit from specialized outreach services : GuidingCare A monthly report from GuidingCare is produced using medical claims and pharmacy claims data. Evidence-based algorithms are applied to identify members stratified as High Risk. Intelligenz Comorbid Conditions Report A monthly inhouse report used to identify members with the multiple chronic conditions. Examples include: asthma, congestive heart failure, chronic obstructive pulmonary disease, dementia, diabetes mellitus, end-stage renal disease, and major depression.

14 Step 1 continued Health Risk Assessment HRA s are mailed to SNP members upon initial enrollment, then annually or upon a change in health status As HRAs are received by the health plan, they are scored and stratified based on member responses. Members with scores of 30 or above are considered High Risk. Members identified as frail are automatically considered High Risk The HRA is possibly one of the major pieces of information that helps the nurse case manager develop an Interdisciplinary Care Team and Plan of Care for the member Transitions of Care A daily record of members experiencing a transition of care such as a discharge from the hospital to a skilled nursing facility CMS Reports Using the daily CMS Transaction Reply Report (TRR), a list of members identified with ESRD or Hospice status codes

15 Steps 2 and 3: Now who s going to benefit and where do we go from here Step 2: Members selected from the above data sources are identified as Potential SNP Model of Care Participants and are assigned to a Nurse Case Manager on a daily basis Step 3: The Nurse Case Manager reviews relevant member information and develops a draft Initial Care Plan

16 Steps 4 and 5: Let s first ask the enrollee what they think Step 4: The Nurse Case Manager contacts the member by telephone to introduce the SNP Model of Care Program, discuss possible resources the member may find to be helpful for their specific needs and answer general questions the member may have Step 5: The member is asked if they would like to participate in the SNP Model of Care Program. If the member declines, ATRIO respectfully honors the member s wishes. If the member agrees to participate in the program, the Nurse Case Manager informs the member that a Plan of Care will be drafted for their review. The Plan of Care will be sent to the member, along with general information about the SNP Model of Care Program and the Nurse Case Manager s contact information

17 Steps 6 and 7: Get buy-in and Create a Care Plan Step 6: Using information gathered from the phone call with the member and other available resources, the Nurse Case Manager develops the Initial Plan of Care Step 7: The Plan of Care is sent to relevant members of the Interdisciplinary Care Team (ICT) for review and approval

18 Steps 8 and 9: One last review then act!!! STEP 8: The Initial Plan of Care approved by the ICT is sent to the member and the member s primary care provider (PCP) who is also a member of the ICT.for review and feedback STEP 9: The Plan of Care approved by the member and PCP is implemented and monitored for progress by the member and relevant ICT

19 So, tell us more about the ICT Nurse case managers are responsible for forming an ICT for each participating SNP member considering the individual needs and appropriate specialists. The goal is to include members into the ICT who can best deliver coordinated care to the member. ATRIO has established a panel of specialists which includes a pharmacist, behavioral health clinician, and plan medical directors from which the nurse case manager can select for the member s ICT. In addition, the nurse will include each member and member s primary care provider. The ICT for any given individual SNP member can include specialists not on the panel like clergy members, care takers, member friends, etc. however; at minimum, each ICT will have a nurse case manager, primary care provider and member. Providers participate by reviewing the plan of care and returning revisions to the nurse case manager.

20 What is the responsibility of the ICT Completing the preliminary Plan of Care Sending the Plan of Care to the member and Provider Working with the provider to revise the Plan of Care as appropriate Participate in ICT Rounds

21 Still more about the ICT On a monthly basis the plan will hold meetings called ICT Rounds with various members of the pool of ICT participants This is a meeting where select complex cases are evaluated by the ICT Rounds team Goals for ICT Rounds will be to discover best practices that are driving the Model of Care toward meeting goals as well as identifying potential hurdles preventing the best possible health outcomes for the SNP population

22 So what goes into creating a Plan of Care? Care plans are created for each targeted SNP member The care plans are developed and stored in Guiding Care by the nurse case manager with input from the ICT Primarily driven by the HRA, the care plans are also generated through the nurse case manager s review of medical and pharmacy claims data, appeals and grievances as well as from the Health Opportunities module in Guiding Care In developing the care plan the nurse case manager works with the member, the member s providers and other members of the ICT to develop: Member health goals Create interventions Establish time frames And to help track when goals are met

23 Measurable Goals: How do we know this is working? Monitor claims data to ensure 85% of SNP members had one or more of an identified preventive services in 2012 At least 95% of SNP members will have an identified primary care provider Achieve an overall score of 50% or better for the Special Needs Plans Structure & Process Measure 4: Care Transitions pertaining to 2012 dates of service Decrease in the total number of Emergency Department Visits/1,000 Member Months (per HEDIS guidelines) in 2012 compared to 2011

24 Measureable Goals: continued Show an improvement in members diagnosed with diabetes 10% improvement in the number of member having controlled blood sugar. 10% improvement in the number of members getting an annual diabetic eye exam Improve high blood pressure control for members diagnosed with hypertension 10% improvement in the number of members having adequate blood pressure control

25 How do we ensure this Model works: The Carrot or the Stick The SNP Program Manager, Director of Quality Assurance and the Medical Director coordinate the clinical and operational functions of the Model of Care The SNP Program Manager reports to the Quality Assurance Committee on the performance of the Model of Care and makes recommendations when goals are not being met The Quality Assurance Committee has ultimate oversight of the Model of Care and will make decisions on recommended changes or actions to help bring goals back into alignment

26 The Quality Assurance Committee will typically recommend actions that: Improve access to essential services such as medical, mental health, and social services Improve access to affordable care Improve coordination of care through an identified point of contact (e.g., gatekeeper) Improve seamless transitions of care across healthcare settings, providers, and health services Improve access to preventive health services Assure appropriate utilization of services Improve beneficiary health outcomes

27 Well, who else helps out? Customer Service Ensures that members know and understand their benefits and is the front line in the appeals and grievance process. Credentialing and Contracting managers Ensure that we have a full network of providers who can offer coordinated care for our members. Enrollment staff Ensure that the member is set up correctly in our payment systems so that they can easily access services with out any delay in care. Pharmacists and the Part D Team Review various reports and programs to ensure that the pharmacy benefit and formulary are set up in a way to optimize member s health. Claims Processor Ensures that providers get paid correctly. Compliance Officer Ensures all programs and staff are carrying out our contractual duties in alignment with CMS and State regulations and standards.

28 Questions? Thank You!