Dual Eligible Special Needs Plan Model of Care

SNP Model of Care The SNP (Special Needs Plan) Model of Care is the architecture for care management policy, procedures, and operational systems for members with both Medicare and Medicaid otherwise known as Dual Members. The MOC is expected to be a tool used by the MAO to improve patient outcomes of care. MAO is the Medicare Advantage Organization, i.e. Fidelis Care All coordinated care plans such as Special Needs Plans are based on a disease management model.

FCNY SNP Demographics Fidelis Care has two Special Needs Programs (SNP), both are for dual Medicare/Medicaid eligible members. The SNP Dual Advantage Flex plan is for members who receive their Medicaid benefits from the fee for service program and their Medicare benefits through Fidelis Advantage. The SNP Dual Advantage is for members who receive their Medicaid and Medicare from Fidelis managed care programs. The current gender mix is 60% female, 40% male. The age break-out of the current membership demonstrates a population that is 40% under the age of 65. This particular population contains members who are disabled and therefore require additional health care services and outreach such as transportation assistance or in-home personal care assistance. The Fidelis Care Special Needs Plan operates in over 16 counties in New York State. Geographical differences in the state impact service provision for the SNP membership. Access and availability differ widely between upstate and downstate counties. This difference is particularly evident in ancillary services such as non-emergent transportation and the variety of in-home supportive service availability. Fidelis Care is mindful of these differences and endeavors to maintain a broad panel of credentialed providers and vendors to serve the needs of the SNP membership.

Required Model of Care Elements Measureable goals Target population Staff structure and care management roles Interdisciplinary Care team Specialized Provider network Model of Care training Health Risk Assessment Individualized Care Plan Communication network Performance and health outcome measurement Care management for most vulnerable sub-population CMS requires all SNP Models of Care provide the structure for care management processes and systems that will enable the SNP to provide coordinated care for special needs individuals.

Required SNP MOC Goals Improve access to medical, mental health, and social services Improve access to affordable care Improve coordination of care through an identified point of contact Improve transitions of care across healthcare settings and providers Improve access to preventive health services Fidelis Care has developed measurable outcomes to determine when a program goal has been met. For goals which are not met as anticipated a Quality Improvement project is developed to assess barriers to success and determine new strategies for implementation.

Required SNP MOC Program Goals cont’d Assure appropriate utilization of services Assure cost-effective service delivery Improve beneficiary health outcomes Reduce hospitalizations and SNF placements Improve self-management and independence Improve mobility and functional status Improve pain management Improve self-reported quality of life Improve satisfaction with health status and health services received from Fidelis Care

STAFF STRUCTURE Administrative Enrollment Department processes member eligibility and enrollment. Claims Department adjudicates all claims for services. Member Services Department assists members with questions on Plan benefits, provider availability and service delivery. Member Complaints Department addresses and responds to all member complaints, grievances and appeals. QHCM Informatics/IT Department performs all data collection and analysis. Contract Management and Credentialing provides management of provider and vendor panels. Many departments throughout Fidelis are involved in making the SNP work. Administrative staff coordinate benefits, data collection and analysis for members, providers and the public.

STAFF STRUCTURE Clinical Case Management Department assists members in regaining optimum health or improved functional capability, in the least restrictive setting and in a timely and cost effective manner. Utilization Management Department facilitates member access to appropriate and health care services. Pharmacy Services Department advises on medication therapy management and pharmacy issues such as drug-drug or drug-disease interactions. Behavioral Health Case Management Department aids members with mental health concerns in accessing appropriate care and services within their community. Quality Management Department creates and oversees all quality improvement and performance improvement initiatives, as well as performing quarterly program evaluations. Network of Contracted Physicians and Allied Health Professionals to provide clinical care. Staff who provide Coordination of care delivery in a timely and cost-effective way as well as education in disease self-management and preventive care services.

STAFF STRUCTURE Administrative and Clinical Oversight License and competence verification are performed by the Human Resources Department during the initial hiring of the case managers, utilization managers, and other professional staff personnel. The new employee mentor program provides additional opportunities for training and supervision of skill level for a minimum of 90 days after employment. Review of encounter data for timeliness and appropriateness of service delivery is the function of the RN Utilization Management Supervisor using standardized clinical care criteria such as Milliman. Pharmacy claims and utilization data are reviewed by the pharmacy department interns and department director with the assistance of a contracted pharmacy benefit manager. Provider use of clinical practice guidelines is monitored by the utilization management department, the departmental medical directors and the Chief Medical Officer. On a quarterly basis Providers receive feedback on their Fidelis Care SNP members' compliance with HEDIS measures. HEDIS measures are based on nationally recognized practice guidelines. Moreover, the Fidelis Care website will provide links to clinical practice guidelines found at such sites as: U.S. Preventive Services Task Force, AHRQ National Guideline Clearing House. Staff that provide oversight of contracted and staff personnel.

Role of the Interdisciplinary Care Team Collaborate to develop and revise the individualized care plan for EACH beneficiary, Analyze and incorporate the results of the initial and annual health risk assessment into the care plan, Communicate with PCP, any specialists, and the member/responsible party to coordinate care plan delivery. The Interdisciplinary Care Team plays an integral role in the overall care management of the SNP member. The ICT meets weekly to develop, review and revise member care plans in order to maximize the achievement of quality care outcomes.

Interdisciplinary Care Team The interdisciplinary care team includes at a minimum a: Physician Registered Nurse Behavioral health expert Medical Social Worker Additional clinical specialists are included in the ICT as dictated by the member’s care plan requirements.

Specialized Provider Network Fidelis Care SNP maintains a network of over 29,000 medical practitioners within the network. The network includes geriatricians, cardiologists, surgeons, infectious disease/HIV specialists, mental health specialists, orthopedists, rheumatologists, and endocrinologists among other medical specialties. Board Certification is preferred. Additionally, the Plan contracts with other health care specialties such as nutritionists, dietitians, podiatrists, and dentists. Plan participating facilities include teaching hospitals, community hospitals, clinics and community health centers, in-patient mental health facilities, HIV clinics, community dialysis centers, wound care centers, laboratory and radiology service providers, Skilled Nursing Facilities, Sub-Acute facilities, and Rehab facilities. The Fidelis Care credentialing process of individual medical practitioners, facilities and other health care specialists and allied professionals is ongoing and up-to-date. Each contracted provider is re-credentialed every 3 years. Providers are encouraged to use evidence-based clinical guidelines in the diagnosis and treatment of Fidelis members.

Health Risk Assessment The HRA forms the foundation for the member’s individualized care plan and is included in the evaluation process performed by the Interdisciplinary Care Team. Assesses the member’s general health, medical history, current treatment regimen, functional ability, psychosocial, mental health and cognitive abilities and needs, available support systems and potential barriers to accessing care and services and achieving care goals. Each member receives an HRA within 90 days of enrolling in the plan and annually -- within one year of the last assessment, or as the member’s health status warrants. The member’s PCP and any other specialty care provider and the member and/or caregiver are provided with a copy of the care plan, the HRA and risk stratification. The HRA is performed by the Case Manager over the telephone with the member. If the member is unable to complete the telephone contact, the form is mailed to the member for self-completion and a SASE is provided to return the completed HRA to Fidelis.

Individualized Care Plan Individualized Care Plans are developed as a guide for care delivery in conjunction with the member/caregiver, primary care provider, appropriate specialists and other key community or institutional professionals. Care Plans include, but not limited to: Specific services and benefits to be utilized, including the appropriate level of care; Member preferences for care; Identification of measurable outcomes; Short and Long-term goals; Provision of educational materials and one-on-one education opportunities; Collaborative approaches to be used including community and family participation; Add-on benefits and services for the most vulnerable members; Coordination of Medicare and Medicaid benefits to maximize service delivery and increase cost-efficiency; Identification of and strategies to overcome potential barriers to achieving identified goals including, but not limited to financial, cultural, language or lack of family/community support; Planning for continuity of care, including transitions of care. It is with the Individualized Care Plan that the care needs of the SNP member are identified and coordinated. It is also how the Plan measures the outcomes of care.

Communication Network Fidelis Care maintains an interactive website through which members, providers and the public can receive information on Fidelis Care health plans, network providers, current health care initiatives and advice to maintain a healthy lifestyle Fidelis Care will also communicate with its members and providers: by telephone, by mail, via e-mail if available, via Fidelis Care website, by Provider/Member Newsletter, by secure file delivery via the internet, through video conferencing, and through face-to-face meetings as applicable. As a state-wide Plan, Fidelis Care maintains a network of regional offices throughout New York State which are available and accessible for the SNP membership to facilitate any face-to-face contact with the Case Manager or other Fidelis personnel should it be necessary.

Performance and Health Outcome Measurement The quality committee structure of Fidelis Care is designed to ensure that all activities pertaining to performance and the health outcomes of the SNP members, the quality of service delivery and appropriate utilization management are evaluated at multiple levels throughout the organization. The SNP Model of Care is evaluated annually making any necessary and appropriate changes. The evaluation includes review of the eleven elements which comprise the MOC including: review of plan goals; rates of attaining identified goal outcomes; identification of opportunities for improvement/modification going forward and development of new strategies to achieve goals; rate of performance of initial Health Risk Assessments as well as annual re- assessments; rate of hospitalizations, ER utilization, transitions to other care settings; identification and appropriate service delivery to most vulnerable subpopulation; effectiveness of training initiatives, rate of employee/vendor/provider participation. Changes to the Model of Care are incorporated into the Model of Care training. Members and providers are notified of changes to the MOC in the Fidelis Care Newsletters available both electronically and in print.

Care for the Most Vulnerable Sub- population Fidelis establishes clinical programs to assure that members with exceptional needs (i.e., the frail, near end-of-life, dementia needing supervision, etc.) receive recommended preventive care as well as the appropriate care for acute and chronic illnesses. These programs include activities to: Collaborate and coordinate with other health care and community organizations when needed; Provide in-home falls assessments; Make available a Licensed Social Worker to evaluate eligibility for additional entitlement programs and community services; Provide in-home supportive services such as personal care aide and housekeeper/chore worker; Make available Hospice care and services either in the home or in-patient; Assist with non-emergent transportation to medical/health care services appointments. Fidelis defines its most vulnerable sub-population as members with exceptional care needs beyond those of an already special needs population. Fidelis Care identifies its most vulnerable SNP members for additional case management interventions through reports run daily to identify high utilization patterns, risk for complications or transition of care setting, as well a through assessments, or referrals from Utilization Management personnel or practitioners.