SNP 1 through 3 Training July 9, 11 and 16, 2013

2 SNP Training – SNP Structure & Process Measures 1 thru 3 Objectives of SNP Training Review NCQAs year-to-year approach to the project and reporting requirements for SNPs Describe the changes in the S&P measures for the 2013 SNP Assessment Explain how NCQA assesses plans performance with individual elements in the S&P Measures

3 SNP Training – SNP Structure & Process Measures 1 thru 3 Objectives of SNP Assessment Program Develop a robust and comprehensive assessment strategy Evaluate the quality of care SNPs provide Evaluate how SNPs address the special needs of their beneficiaries Provide data to CMS to allow plan-plan and year-year comparisons

4 SNP Training – SNP Structure & Process Measures 1 thru 3 SNP Assessment: How did we get here? Existing contract with CMS to develop measures focusing on vulnerable elderly Revised contract to address SNP assessment rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs focused on SNP-specific measures refined existing measures clarified requirements in SNP 1 thru refined measures and documentation requirements; focus on implementing interventions

5 SNP Training – SNP Structure & Process Measures 1 thru 3 Who Reports HEDIS measures – All SNP plan benefit packages with 30 or more members as of February 2012 Comprehensive Report (CMS website) S&P measures – All SNP plan benefit packages – Plans with zero enrollment as of April 2013 Comprehensive Report are exempt for certain elements

6 SNP Training – SNP Structure & Process Measures 1 thru 3 SNP Reporting Returning SNPs all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted. – SNP 1 A-G, SNP 2A-C, SNP 3-6 New SNPs all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time. – SNP 1 A-D, SNP 2A-C, SNP 4-6

7 SNP Training – SNP Structure & Process Measures 1 thru 3 Project Time Line – June 2013 through September Training for SNPs June & July Release S&P Measures in hardcopy and ISS Data Collection Tool October 15, S&P Measure submissions due to NCQA October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors June NCQA delivers SNP Assessment Report to CMS

Structure and Process Measures

SNP 1: Care Management and Coordination

10 SNP Training – SNP Structure & Process Measures 1 thru 3 Changes since 2012 Replaced elements of Complex Case Management with new ones for Care Management that assess whether SNPs have appropriate programs to coordinate services and help all members access needed resources Better align with CMS MOC requirements for assessment and care plans SNP 1- Care Mgmt. and Coordination

11 SNP Training – SNP Structure & Process Measures 1 thru 3 Changes continued Care Mgmt. and Coordination consists of Elements A: Care Management Program Description B: Population Description C: Care Management Process D: Individualized Care Plan E: Satisfaction with Care Management F: Analyzing Effectiveness/Identifying Opportunities G: Implementing Interventions and Follow-up Evaluation SNP 1- Care Mgmt. and Coordination

12 SNP Training – SNP Structure & Process Measures 1 thru 3 Definition - Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients functional health status, enhancing coordination of care, eliminating duplication of services and reducing the need for expensive medical services. SNP 1- Care Mgmt. and Coordination

13 SNP Training – SNP Structure & Process Measures 1 thru 3 Element A - Program Description The SNP has a description for its Care Mgmt. program that includes: 1.Evidence used to develop the program 2.Criteria for identifying members who are eligible for the program 3.Services offered to eligible members 4.Defined program goals Data source: documented process SNP 1- Care Mgmt. and Coordination

14 SNP Training – SNP Structure & Process Measures 1 thru 3 Care Mgmt. program focuses on member-specific activities and the coordination of services; it involves: – Comprehensive assessment of members condition – Determining benefits/resources – Developing and implementing a care plan that includes performance goals, monitoring and follow-up SNP 1- Care Mgmt. and Coordination

15 SNP Training – SNP Structure & Process Measures 1 thru 3 A SNP must have a Care Mgmt. Program Based on the subpopulations within its membership SNPs may have the following within a larger Care Mgmt. Program: – Complex case mgmt – Transitional case mgmt – High-risk/high utilization programs – Hospital case mgmt SNP 1- Care Mgmt. and Coordination

16 SNP Training – SNP Structure & Process Measures 1 thru 3 Factor 1 requires the SNP to describe the evidence it used to develop the program. – E.g., clinical practice guidelines; scientific evidence from clinical or technical literature or government research; or literature reviews for nonclinical aspects of the program like dealing with or promoting behavioral change. Program description must also detail the criteria SNP uses to identify eligible members for factor 2 SNP 1- Care Mgmt. and Coordination

17 SNP Training – SNP Structure & Process Measures 1 thru 3 SNPs description includes the services it provides to members. Org that stratifies members based on risk or level of need must include eligibility criteria, services to be provided and goals for each tier. Program description also needs to include goals that reflect specific objectives and targets. SNP 1- Care Mgmt. and Coordination

18 SNP Training – SNP Structure & Process Measures 1 thru 3 Element B – Population Assessment Annually SNP must: 1.Assess the characteristics and needs of member population and pertinent subpopulations 2.Review and update Care Mgmt. processes to address member needs 3.Review and update Care Mgmt. resources to address member needs Data source: Documented process SNP 1- Care Mgmt. and Coordination

19 SNP Training – SNP Structure & Process Measures 1 thru 3 Population assessment includes SNPs covered population not just members in specific programs like CCM Documentation must show how: – SNP considers specific member characteristics when designing and revising program e.g., Medicaid eligibility categories Nature and extent of carved out benefits Type of SNP Race/ethnicity and language preferences SNP 1- Care Mgmt. and Coordination

20 SNP Training – SNP Structure & Process Measures 1 thru 3 Population assessment procedures also need to include consideration of program characteristics and resources e.g., staffing ratios, clinical qualifications, job training, external resources and cultural competency SNPs documentation needs to be dated after 10/15/12 SNP 1- Care Mgmt. and Coordination

21 SNP Training – SNP Structure & Process Measures 1 thru 3 Element C - Care Mgmt. Assessment Process Includes all info for SNP to assess members needs and develop interventions for them A SNPs documentation must address all 8 factors It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality SNP 1- Care Mgmt. and Coordination Data sources: Documented process and reports or materials

22 SNP Training – SNP Structure & Process Measures 1 thru 3 SNPs evidence must include: Documentation of clinical history and meds – e.g., disease onset, inpatient stays, treatment history Initial assessment of: – health status & comorbidities – activities of daily living – mental health status and cognitive function both aspects are required SNP 1- Care Mgmt. and Coordination

23 SNP Training – SNP Structure & Process Measures 1 thru 3 Evaluation of: – cultural and linguistic needs review of language needs meets factor 5 – visual & hearing needs, preferences/limitations – caregiver resources e.g., family involvement in decision making – available benefits covered by SNP, carved out for supplemental services such as community behavioral health or national and community resources SNP 1- Care Mgmt. and Coordination

24 SNP Training – SNP Structure & Process Measures 1 thru 3 Element D - Individualized Care Plan SNP uses info from assessment e.g., HRAs and other sources to develop a comprehensive care plan Care plan includes info on actions or interventions and their duration a SNPs Interdisciplinary Care Team (ICT) takes to address members medical, BH, functional and support needs. SNP 1- Care Mgmt. and Coordination Data sources: Documented process and reports or materials

25 SNP Training – SNP Structure & Process Measures 1 thru 3 A SNPs documentation shows that the ICT develops a care plan for each member that includes: – prioritized goals that reflect members or caregivers preferences and involvement – self-management plan – schedule for follow-up/identify barriers – process to assess member progress SNP 1- Care Mgmt. and Coordination

26 SNP Training – SNP Structure & Process Measures 1 thru 3 Based on the members specific needs the care plan also identifies: – resources to be utilized and appropriate level of care CMs as members of the ICT often facilitate referrals to other providers as part of members benefits – planning for coordination of care including transitions and transfers identifying how and when ICTs follow up with a member after referral to a health resource – collaborative approaches to be used SNP 1- Care Mgmt. and Coordination

27 SNP Training – SNP Structure & Process Measures 1 thru 3 Element E - Satisfaction with Care Mgmt Intent is for SNP to obtain feedback on its Care Mgmt. program from a broad sample of members, not just those that contacted it SNP must submit a report showing it performed an evaluation of satisfaction by: 1)Obtaining feedback from members 2)Analyzing member complaints and inquiries SNP 1- Care Mgmt. and Coordination Data source: Reports

28 SNP Training – SNP Structure & Process Measures 1 thru 3 Factors 1 and 2 require SNPs to use: focus groups or satisfaction surveys that are specific to Care Mgmt program – e.g., assess satisfaction with--program staff, the usefulness of info received, members ability to adhere to recommendations. analysis of complaint and inquiry data after 10/15/12 to identify patterns or trends – quantitative and qualitative SNP 1- Care Mgmt. and Coordination

29 SNP Training – SNP Structure & Process Measures 1 thru 3 Factors 1 and 2 focus on satisfaction with the Care Mgmt. Program not satisfaction with the SNPs overall operations Reports with data obtained from CAHPS or general surveys will not meet the intent Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis SNP 1- Care Mgmt. and Coordination

30 SNP Training – SNP Structure & Process Measures 1 thru 3 Factor 2 is NA if SNP provides evidence (e.g., tracking mechanism) showing it did not receive any Care Mgmt. complaints and inquiries after 10/15/12 Factors 1 and 2 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report. SNP 1- Care Mgmt. and Coordination

31 SNP Training – SNP Structure & Process Measures 1 thru 3 Element F - Analyzing Effectiveness/ Identifying Opportunities The SNP measures the effectiveness of its Care Mgmt. program using three measures. For each measure, it: 1)Identifies a relevant process or outcome 2)Uses valid methods that provide quantitative results 3)Sets a performance goal 4)Clearly identifies measure specifications 5)Analyzes results 6)Identifies opportunities for improvement, if applicable SNP 1- Care Mgmt. and Coordination Data source: Reports

32 SNP Training – SNP Structure & Process Measures 1 thru 3 SNPs report must contain appropriate measures likely to have significant and demonstrable bearing on all or a subset of Care Mgmt. members –Outcomes based –Relevant to target population –Valid methodology Contains info on sampling (if used) and sample size calculation Measurement periods reflect the effects of seasonality –Denominator specific to Care Mgmt. population SNP 1- Care Mgmt. and Coordination

33 SNP Training – SNP Structure & Process Measures 1 thru 3 Report shows appropriate analysis – goes beyond simple reporting or data display –Comparison to goal or benchmark Measure must not have exceeded goal from outset –Quantitative and qualitative –Opportunities for improvement SNP can use 3 patient experience measures e.g., improved quality of life, pain management and health status May only use 1 satisfaction measure with Care Mgmt. program operations SNP 1- Care Mgmt. and Coordination

34 SNP Training – SNP Structure & Process Measures 1 thru 3 Scoring is based on an average for all 3 measures Analysis of measures must be SNP- specific. Org can present aggregate analysis if it breaks out data and results for individual SNPs SNP must have performed analyses of measures after 10/15/12 SNPs that submit Care Mgmt. worksheets also need to provide actual reports SNP 1- Care Mgmt. and Coordination

35 SNP Training – SNP Structure & Process Measures 1 thru 3 Factor 6 is NA if a plans documentation confirms it does not have any opportunities for improvement Factors 1 thru 6 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report. SNP 1- Care Mgmt. and Coordination

36 SNP Training – SNP Structure & Process Measures 1 thru 3 Examples of measures – HEDIS measures of effectiveness for chronic conditions e.g., controlling high blood pressure, persistence of beta blocker treatment after a heart attack – SF-36 or SF-12 results – Use of service measures for which consensus indicates improvement – e.g., reduced ED visits – Readmission rates – Ambulatory-care sensitive admissions SNP 1- Care Mgmt. and Coordination

37 SNP Training – SNP Structure & Process Measures 1 thru 3 Element G - Implementing Interventions and Follow-up Evaluation Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization: 1)Implements at least one intervention for each of the three opportunities identified in Element F to improve performance 2)Develops a plan for evaluation of the intervention and re-measurement SNP 1- Care Mgmt. and Coordination Data source: Documented process and Reports

38 SNP Training – SNP Structure & Process Measures 1 thru 3 Scoring is based on an average for all 3 measures Interventions must have been implemented after 10/15/12 A SNPs documentation needs to show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement. SNP 1- Care Mgmt. and Coordination

39 SNP Training – SNP Structure & Process Measures 1 thru 3 Factor 1 may be NA if no opportunities Factor 2, re-measurement, must be completed whether there are opportunities or not. SNPs that did not have any members at the start of the look-back period, per the CMS April 2013 Comprehensive Report receive an NA for factors 1 and 2. SNP 1- Care Mgmt. and Coordination

40 SNP Training – SNP Structure & Process Measures 1 thru 3 We contract with other entities (medical groups) to perform a number of the functions assessed by the Structure and Process measures. How should we demonstrate performance with these requirements? – Your organization needs to provide the appropriate evidence from these contracted entities to document their performance. In addition you should discuss the details of this documentation with a member of the SNP Team. Delegation

41 SNP Training – SNP Structure & Process Measures 1 thru 3 Only attach documentation to the survey tool that fulfills the requirements and contains direct evidence of performance Make sure your documentation shows that your SNP meets the intent of each factor/element Please provide context to the documents- roadmap/explanation of documentation About Documentation

42 SNP Training – SNP Structure & Process Measures 1 thru 3 Questions?

SNP 2: Improving Member Satisfaction

44 SNP Training – SNP Structure & Process Measures 1 thru 3 SNP 2 Elements A and B – Now applicable to both initial and returning SNPs SNP 2 Element C – Added new example for factor 2 that emphasizes continuing the intervention and then re-measuring if an organization does not meet its initial goal Summary of Changes for 2013

45 SNP Training – SNP Structure & Process Measures 1 thru 3 Who reports? – Initial and returning SNPs are responsible for reporting all of SNP 2. This includes Elements A, B and C – SNPs that did not have any members at the start of the look-back period will receive a score of NA for the measure Per the CMS April 2013 SNP Comprehensive Report SNP 2: Overview

46 SNP Training – SNP Structure & Process Measures 1 thru 3 Assessment of Member Satisfaction a SNP must supply BOTH a documented process and a report explaining how it performed the assessment and an analysis of member satisfaction data that shows it: – identified the appropriate population – selected appropriate samples from the affected population, (if used) – conducted an quantitative and qualitative analysis annually The SNP will receive credit for factor 2 if it collects data for its entire population SNP 2 Element A

47 SNP Training – SNP Structure & Process Measures 1 thru 3 A SNPs complaint and appeal data must relate to at least the four major categories – Quality of Care – Access – Attitude and Service – Billing and Financial It must submit a report that shows the quantitative and qualitative analyses were performed after 10/1/12. Complaint, grievance and appeal data or satisfaction survey data collected more than 12 months prior to the start of the look-back period--(4/15/12) will not meet the intent SNP 2 Element A

48 SNP Training – SNP Structure & Process Measures 1 thru 3 All SNP complaint/appeal data must be at the PBP level. The SNP should receive a score of: – 50% for data only identified as Medicare – 0% if data source is not specified at all SNPs must perform their own analysis of CAHPS results, not just attach a vendors report to meet the intent of Element A. SNP 2 Element A

49 SNP Training – SNP Structure & Process Measures 1 thru 3 If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis and found no complaints or appeals for its members SNP 2 Element A

50 SNP Training – SNP Structure & Process Measures 1 thru 3 The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans SNP 2 Element A

51 SNP Training – SNP Structure & Process Measures 1 thru 3 Opportunities for Improvement Element B requires a SNP to show: – How it identifies opportunities for improvement of member satisfaction (documented processes) – At least 2 opportunities for improvements based on its data and analysis for SNP 2A (reports) – It identified opportunities after 10/1/12. Analysis should indicate reasons for opportunities identified – May be lesser priorities SNP 2 Element B

52 SNP Training – SNP Structure & Process Measures 1 thru 3 Element B is NA if: – a SNPs analysis does not result in the identification of one or more opportunities for improvement. Reasons for no improvement opportunities may include: – no or very low enrollment – no trendable data available – very low number of complaints/appeals SNP 2 Element B

53 SNP Training – SNP Structure & Process Measures 1 thru 3 Improving Satisfaction Element C requires a SNP to show that it is actively working on implementing interventions and measuring their effectiveness. – Plans must provide BOTH documented processes and reports The interventions must relate to opportunities identified in SNP 2B Do not have to show improvement on interventions, but a SNP must show it measured intervention effectiveness. SNP 2 Element C

54 SNP Training – SNP Structure & Process Measures 1 thru 3 Timeframes – Interventions must be implemented within one year of the submission date (October 15, 2012 – October 15, 2013) – Analysis of intervention effectiveness or remeasurement for those that do not have opportunities must be performed within the look-back period (April 15, 2013 – October 15, 2013) SNP 2 Element C

55 SNP Training – SNP Structure & Process Measures 1 thru 3 When evaluating intervention effectiveness for factor 2 - SNPs must perform remeasurement against an original goal, or a targeted intermediate measurement of specific interventions SNP 2 Element C

56 SNP Training – SNP Structure & Process Measures 1 thru 3 If a SNP has no members as of the start of look-back period, then this element is NA. – Per the CMS April 2013 SNP Comprehensive Report Initial SNPs with no opportunities for improvement get an NA for factors 1-2 Returning SNPs with no opportunities for improvement get an NA for factor 1 only SNP 2 Element C

57 SNP Training – SNP Structure & Process Measures 1 thru 3 Polling Question

58 SNP Training – SNP Structure & Process Measures 1 thru 3 True or false. – For SNP 2 Element C, a returning SNP will be scored NA for factor 2 if the analysis of satisfaction data shows it does not have opportunities for improvement Polling Question

SNP 3: Clinical Quality Improvement

60 SNP Training – SNP Structure & Process Measures 1 thru 3 Methodology has been revised to calculate statistically significant improvement. The new methodology better addresses the small numbers issues related to low enrollments and denominators for many of the HEDIS measures and more accurately reflects year-to-year improvement without penalizing plans. SNPs that do not have 30 members as of the CMS February 2012 SNP Comprehensive Report are exempt from reporting this measure and receive a score of NA. SNP 3 Element A

61 SNP Training – SNP Structure & Process Measures 1 thru 3 What is statistical significance? – 0-59: At least a 6 percentage point change – 60-74: At least a 5 percentage point change – 75-84: At least a 4 percentage point change – 85-92: At least a 3 percentage point change – 93-96: At least a 2 percentage point change – 97-99: At least a 1 percentage point change This applies to measures where both higher and lower percentages are better SNP 3 Element A

62 SNP Training – SNP Structure & Process Measures 1 thru 3 Which SNPs must demonstrate clinical improvement? – Only returning SNPs will be scored – Initial SNPs and plans with <30 members (as of Feb 2012 CMS Comp. Report) are exempt Plans are not required to submit anything in ISS. NCQA will score this element internally. SNP 3 Element A

63 SNP Training – SNP Structure & Process Measures 1 thru 3 Questions?