Quality Improvement Program: Special Needs Plans Marsha Davenport, MD MPH CAPT, USPHS October 29, 2010 MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Quality Improvement Program Special Needs Plans (SNPs) Overview Background Quality Improvement Program Special Needs Plans (SNPs) Future Directions Summary MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
BACKGROUND MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
To describe the current Quality Improvement (QI) Program Purpose To describe the current Quality Improvement (QI) Program To discuss quality indicators for Special Needs Plans (SNP) To provide an update on future directions for the QI Program MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Contains multiple dimensions Defining Quality Complex Contains multiple dimensions May have different meanings depending on the context Focus is on quality for the Medicare Advantage Organizations (MAOs) MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Institute of Medicine (IOM)Definition of Quality “ Degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge” For individuals and populations MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Quality for Medicare Advantage (MA) Determining what quality looks like for MAOs and SNPs Quality has some unique features for the Special Needs Plans (SNPs) . MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Chronic Condition SNP (C-SNP) Dual Eligible SNP (DE-SNP) SNP Types Chronic Condition SNP (C-SNP) Dual Eligible SNP (DE-SNP) Institutional SNP (I-SNP) Spend a few minutes describing the number of SNPs refer to the fact that they saw Jon’s slide today on 66 percent of our SNPs are DE-SNPs MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Chronic alcohol and other drug dependence Autoimmune disorders Cancer Conditions for C-SNPs Chronic alcohol and other drug dependence Autoimmune disorders Cancer Cardiovascular disorders Chronic heart failure MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Conditions for C-SNPs (cont’d) Dementia Diabetes mellitus End-stage liver disease End-stage renal disease requiring dialysis Severe hematologic disorders MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Conditions for C-SNPs (cont’d) HIV/AIDs Chronic lung disorders Chronic and disabling mental health conditions Neurological disorders Stroke MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Quality is Multidimensional SNP Provider Network Patient MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Assessed through specific methods and/or tools SNP Quality Assessed through specific methods and/or tools Goal is to improve the health outcomes for the patient Methods for measuring quality may be Qualitative Quantitative MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SNP Quality: Qualitative Tools Quality Improvement (QI) Program Plan Care Coordination Plan Model of Care Quality Improvement Projects (QIPs) Chronic Care Improvement Program (CCIPs) MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
SNP Quality: Quantitative Tools HEDIS CAHPS HOS Structure and Process Measures MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
QUALITY IMPROVEMENT PROGRAM MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Quality Improvement (QI) Program QI Program Plan Chronic Care Improvement Program (CCIP) Quality Improvement Projects (QIPs) Performance Measures MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Quality Improvement (QI) Program QI Program Plan (cont’d) Health Information System Program Review Remedial Actions Model of Care for SNPs MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Target population and method of identifying eligible enrollees CCIP Indicators Target population and method of identifying eligible enrollees Method for enrolling participants and particpation rates CCIP designed to improve health Data sources used to identify need for CCIP Will describe elements in more detail and discuss the elements that are used now and the weights Under present system, weights for all indicators are 15 percent except for the data sources which is 10 percent MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
CCIP Indicators (cont’d) Intervention Program monitoring and delegation oversight Outcomes measures MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Topic focus and relevance to the Medicare population QIP Indicators Target population Topic focus and relevance to the Medicare population QI indicators, data sourc and collection methodology MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
QIP Indicators (cont’d) Participation Results Interventions Indicators at 10 percent (participation); 15 percent (Results; QI indicators , data source and collection methodology) All other indicators are weighted at 20 percent. MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Model of Care Elements Care Management Plan Model of Care elements Description of SNP-specific Target Population Measureable Goals Staff Structure and Care Management Roles Describe the elements and how they might be implemented MOC is the tool that makes SNPs truly different from the rest of MA and FFS Describe how we can make better use of this tool MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
MOC Elements (cont’d) Interdisciplinary care team (ICT) Provider network having specialized expertise and use of clinical practice guidelines and protocols MOC training for personnel and provider network Health risk assessment MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
MOC Elements (cont’d) Individualized care plan Communication network Care management for the most vulnerable subpopulations Performance and health outcome measurement Describe that we currently have a pilot project to evaluate the MOC that will be completed by the end of the year. We plan to expand this pilot study to include a larger number of SNPs beginning in early 2011 (APC contract). MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Measuring Quality 26 Outcomes Structure Quality Process MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law. 26
Structure and Process Measures Complex case management Improving member satisfaction Clinical quality improvements Describe these elements and how why we want all plans to complete all 6 this year. Also, why we are not introducing new measures this year. MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Structure and Process Measures (cont’d) Care transitions Institutional SNP relationship with facility Coordination of Medicare and Medicaid coverage MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Code of Federal Regulations (CFR) QI Program Resources Code of Federal Regulations (CFR) Central Office and Regional Office Staff CMS website Medicare Managed Manual MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
FUTURE DIRECTIONS MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
QI Program Enhancements Provide more training on the QI Program Tools Expand the technical assistance (TA) available Use a preventive intervention for plans Use early and often On-going Use TA as a preventive intervention refers to not waiting until a SNP has to be on a corrective action plan (CAP) to provide TA but provide in an on-going support Provide early and often means that when a SNP is new to the MA program, there will be TA provided within the first few months of their program and avaialble as needed MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
QI Program Enhancements Conduct annual audits of the QIPs and CCIPs Provide a list of clinical and non-clinical topics for the QIPs Provide a list of clinical topics for CCIPs Improve methods for reporting the QIPs and CCIPs MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
QI Program Enhancements Revise and update all tools Provide templates for these tools Set higher standards and benchmarks Provide training on existing and new tools as they are developed MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Expand QI Program Resources Develop better SNP website page and on-line resources and update regularly Update Medicare Managed Care Manual Chapter 5: Quality Update and provide QI Program Guidance Outreach materials for plans and other communication tools MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Increasing need to have clinical and health outcomes measures Summary Must continue to emphasize the importance of developing a strong QI Program Increasing need to have clinical and health outcomes measures MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Summary Future efforts will focus on multidimensional aspects of quality improvement leading to better health outcomes for our patients MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
Contact Information Marsha Davenport, MD, MPH Medical Officer and Acting Director Division of Medicare Advantage Operations (DMAO) Phone: 410-786-0230 Email: marsha.davenport@cms.hhs.gov Thank you! MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.