Special Needs Plans Model of Care and Quality Improvement Program Training May 27, 2009 Judy Sutcliffe Technical Advisor Division of Special Programs

SNP Model of Care and Quality Improvement Program - May Care Management through Special Needs Plans

SNP Model of Care and Quality Improvement Program - May 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 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 SNP Model of Care Gradual evolution of SNP Model of Care in legislation and CMS guidance: MMA of 2003Established SNPs 2007 Call LetterEstablished 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 SNP Model of Care 2008 Call LetterEstablished training for providers MIPPA of 2008Mandated health risk assessment, care plan, interdisciplinary care team for beneficiaries, & evaluation of care effectiveness

SNP Model of Care and Quality Improvement Program - May 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 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 SNP Model of Care Goals

SNP Model of Care and Quality Improvement Program - May 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 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 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 Staff Structure and Care Management Roles

SNP Model of Care and Quality Improvement Program - May 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 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 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 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 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 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 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 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 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 Interdisciplinary Care Team

SNP Model of Care and Quality Improvement Program - May 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 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 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 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 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 Provider Network Having Specialized Expertise and Use of Clinical Practice Guidelines

SNP Model of Care and Quality Improvement Program - May 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 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 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 Provider Network CMS expects MAOs to: Prioritize contracting with board- certified 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 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 Model of Care Training for Plan Personnel and Provider Network

SNP Model of Care and Quality Improvement Program - May 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 Health Risk Assessment

SNP Model of Care and Quality Improvement Program - May 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 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 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 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 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 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 Individualized Care Plan for Each Beneficiary

SNP Model of Care and Quality Improvement Program - May 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 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 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 Communication Network

SNP Model of Care and Quality Improvement Program - May Develop and document a structure for communication among plan personnel, providers, interdisciplinary care team, and beneficiaries May include low or high level technology Communication Network

SNP Model of Care and Quality Improvement Program - May 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 Communication Network

SNP Model of Care and Quality Improvement Program - May Most Vulnerable Beneficiaries

SNP Model of Care and Quality Improvement Program - May 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 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 Performance and Health Outcome Measurement

SNP Model of Care and Quality Improvement Program - May 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 evidence- based model of care

SNP Model of Care and Quality Improvement Program - May 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 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 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 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 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 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 Quality Improvement Program

SNP Model of Care and Quality Improvement Program - May Quality Improvement Program Gradual evolution of the quality improvement program: MMA of 2005Mandated the CCIP, QIP, participation of stakeholders, CMS reporting tools, health information system, & self-evaluation of quality program

SNP Model of Care and Quality Improvement Program - May Quality Improvement Program Gradual evolution of the quality improvement program: MIPPA of 2008Collect, analyze, and report data measuring health outcomes and indices of quality pertaining to special needs individuals

SNP Model of Care and Quality Improvement Program - May Quality Improvement Program Gradual evolution of the quality improvement program: CMS Rules, 2008Measure model of care effectiveness, and make data available to CMS as requested

SNP Model of Care and Quality Improvement Program - May Quality Improvement Program For each plan, MAOs must: 1)Have a quality improvement program 2)Encourage providers to participate in the program

SNP Model of Care and Quality Improvement Program - May Chronic Care Improvement Program For each plan, MAOs must: 1)Conduct a chronic care improvement program (CCIP) 2)Have methods to identify beneficiaries with multiple or severe chronic conditions who would benefit from CCIP 3)Have mechanism to monitor beneficiaries in CCIPs

SNP Model of Care and Quality Improvement Program - May Quality Improvement Projects For each plan, MAOs must conduct quality improvement projects (QIP) on clinical or non-clinical areas that involve: 1)measuring performance 2)system interventions including clinical practice guidelines 3)projects to improve performance 4)mechanisms for systematic and periodic follow- up on the effect of the intervention

SNP Model of Care and Quality Improvement Program - May Quality Improvement Projects For each project, MAOs must assess performance using quality indicators that are: 1)objective, clearly defined, based on clinical knowledge or health research 2)outcome measures such as changes in health status, functional status, and beneficiary satisfaction

SNP Model of Care and Quality Improvement Program - May Quality Improvement Projects For the selected indicators, MAOs must: 1)perform systematic ongoing collection, and analysis of valid and reliable data 2)achieve demonstrable improvement from interventions 3)report status and results of projects to CMS as requested

SNP Model of Care and Quality Improvement Program - May Health Information For each plan, MAOs must have a health information system to: 1)collect, analyze, and integrate data to conduct the quality improvement program 2)ensure data is reliable and complete 3)maintain health information for CMS review as requested 4)conduct annual review of effectiveness of the quality improvement program 5)take action to correct problems revealed in complaints and quality improvement activities

SNP Model of Care and Quality Improvement Program - May SNP-specific Requirements MAOs offering SNPs must: 1)Collect, analyze, and report data that measure health outcomes and quality indices pertaining to its targeted special needs population (i.e., dual-eligible, institutional, chronic condition) at the plan level

SNP Model of Care and Quality Improvement Program - May SNP-specific Requirements 2)measure the effectiveness of the model of care through data on a)improvement in access to care b)improvement in beneficiary health status c)staff implementation of model of care d)comprehensive health risk assessment e)implementation of individualized care plan f)provider network of specialized expertise g)use of evidence-based practices h)use of communication system

SNP Model of Care and Quality Improvement Program - May SNP-specific Requirements 3)maintain quality improvement data for CMS review a)enable beneficiaries to compare health coverage options b)enable CMS to monitor the effectiveness of the model of care

SNP Model of Care and Quality Improvement Program - May Reporting Requirements MAOs offering SNPs have the following participation &/or reporting requirements 1)HEDIS measures 2)Structure and process measures 3)CAPHS survey (beneficiary survey) 4)HOS survey (beneficiary survey) 5)Part C Reporting Elements 6)Medication Therapy Management measures 7)CCIP and QIP

Collection of Model of Care & Quality Improvement Program Data SNP Model of Care and Quality Improvement Program - May

MOC and QIP Modules CMS will develop HPMS modules to collect model of care and quality improvement program data on a continuous basis Contractor will analyze initial data and use information to develop the modules SNP Model of Care and Quality Improvement Program - May

CMS Notification SNP Model of Care and Quality Improvement Program - May

Memo Instructions SNP submission type codes Instructions for completing Appendix A and B Naming conventions Submission via to contractor CMS contact persons SNP Model of Care and Quality Improvement Program - May

Naming Conventions SNP Model of Care and Quality Improvement Program - May SNP Submission Type Codes

Naming Conventions Use the following file naming convention for the SNP attestation worksheet: Hxxxx_snp_attest_.xls Example: H0000_snp_attest_IN-E.xls SNP Model of Care and Quality Improvement Program - May

Naming Conventions Use the following file naming conventions for each file containing supporting material: Hxxxx_snp_support_.ext (template in Appendix B) Hxxxx_snp_support_risktool_.ext (if applicable) Example:H0000_snp_support_IN- E.pdf (template in Appendix B) SNP Model of Care and Quality Improvement Program - May

Naming Conventions For each contract number, package the SNP attestation worksheets and supporting materials for all applicable SNP submission types in a single.zip file. SNP Model of Care and Quality Improvement Program - May

Naming Conventions Use the following file naming convention for each contract number submission: Hxxxx_snp_reporting.zip Example: H0000_snp_reporting.zip SNP Model of Care and Quality Improvement Program - May

Model of Care 1.Open the spreadsheet and review the instructions in the first tab. 2.Prepare one Excel file for each contract # and each SNP type under that contract #. 3.Failure to follow the instructions will result in rejection of the submission. SNP Model of Care and Quality Improvement Program - May

Model of Care SNP Model of Care and Quality Improvement Program - May SNP Attestation Worksheet Instructions for the Model of Care

Model of Care 1.Enter contract number, SNP type, and SNP subtype. 2.Respond “Yes” or “No” to the attestations. 3.DO NOT paste text into the spreadsheet. SNP Model of Care and Quality Improvement Program - May

Model of Care SNP Model of Care and Quality Improvement Program - May

Quality Improvement Program 1.Insert your contract name, contract number, and SNP type. 2.In 1b, provide a narrative description of your overall quality improvement program. 3.In 2b through 12b, provide a description and examples of data collected, analyzed, and reported on specific measures. SNP Model of Care and Quality Improvement Program - May

Quality Improvement Program SNP Model of Care and Quality Improvement Program - May Insert contract name, #, and SNP type 1b. Provide a narrative description of your quality improvement program In 2b through 12b, provide a description and examples of data collected, analyzed, and reported on specific measures.

Submission Send each contract number submission via to Fu Associates, Ltd. at with the subject line entitled “Hxxxx SNP Submission”. SNP Model of Care and Quality Improvement Program - May