INSTITUTIONAL SPECIAL NEEDS PROGRAM Best Practices in Care Coordination and Care Transitions Beth Ann Martucci, DNP, CRNP Director of Clinical Operations January 13, 2014

Institutionalized Medicare beneficiary who resides or is expected to reside in a Cigna-HealthSpring contracted skilled nursing facility for 90 days or longer. I-SNP membership: –Largely female, cognitively impaired, in fair to poor health due to multiple chronic illnesses, low income and over the age of 81. –Top 5 admitting diagnoses: pneumonia, respiratory failure, UTI, CHF, altered mental status Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 2 TARGET POPULATION

Total # of institutional-based members: 1,256 Total # of Cigna-HealthSpring contracted facilities: 42 I-SNP Nurse Practitioner Case Managers: 24 Dedicated I-SNP Care Coordination Team: 4 Care Coordinators I-SNP RN Case Manager: 1 (pilot program completed in December 2013) Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 3 I-SNP PROGRAM SNAPSHOT

The clinical team provides integrated health care management with a strong primary and preventive care focus to treat acute and chronic conditions. –All I-SNP members receive a comprehensive history and physical exam and care plan within 30 days of enrollment and comprehensive visits at least once a month, thereafter. Care coordination and care transitions support is provided to all members, as needed. Nurse Practitioners (NPs) utilize a risk assessment tool that rates each member’s medical condition on a scale of 1-5: Level 1-HOT, Level 2 and 3- WARM, Level 4 and 5-COLD –Risk score dictates the NP’s visit schedule –Average NP visits per day – 8 –Risk score framework used at each visit and tracked over time via encounter data Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 4 RISK ASSESSMENT TOOL

The Cigna-HealthSpring NP, PCP and the member’s caregiver are to be notified of every acute care transition. Prior to the member’s transition, the SNF completes a checklist/packet that includes: the member’s comprehensive history and physical notes, the most recent comprehensive or episodic note, consult notes, the medication list, and advanced directives. Upon return to the SNF, the NP must see the member within 1 business day. A comprehensive visit is performed; discharge summary is reviewed and signed; medication reconciliation is performed and a call is placed to the caregiver and PCP. If the NP is unable to reach the caregiver, a postcard note is sent to the caregiver with the NP’s contact information. During the weekly plan-level Interdisciplinary Care Team (ICT) call, the dedicated NP assigned to the hospitalized member updates the ICT on the member’s status and transition plan. 5 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna CARE TRANSITIONS PROCESS

Daily Hospitalization Report –Used to track transitions over time. Updated by the NP when a transition occurs. Unplanned Transition Audit Tool –Completed by the NP Senior Clinician on each member that has had an unplanned transition and reviewed monthly with SNF administration team. 6 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna MONITORING CARE TRANSITIONS

Plan-level Interdisciplinary Care Team (ICT): Medical Director from each market, Nurse Practitioners, pharmacist from each market, RN Case Managers. Daily NP management call to discuss happenings at the facility level. Weekly conference call with the plan-level ICT to discuss HOT, skilled and hospitalized members. Also review care plans for at risk members. Care Plan Conferences with NP, facility staff and member/caregiver, as appropriate. Weekly meetings with the Care Coordination team to improve processes/efficiencies, improve level of customer service and communication. Monthly mandatory NP meetings – case presentations, educational in- services including best-practices/evidence based practices. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 7 IMPROVING OUTCOMES

Measurable outcomes are monitored by measuring, reporting, and base-lining/goal-setting or benchmarking to standards for the following activities: –Completion of a comprehensive history and physical with the ICP within 30 days of enrollment and annually thereafter. –Completion of a monthly comprehensive visit on all members. –Care coordination (arranging for authorizations, appointments and transportation within turn around time: Immediate: same day; Urgent: 2 days; Standard:14 days. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 8 MONITORING PROGRAM PERFORMANCE

–NP notification prior to un-planned discharge from the SNF to an acute setting –Re-admissions to an acute setting within 30 days –HEDIS measures These clinical and service operations metrics are measured and reported to Cigna-HealthSpring’s executive management team monthly in a Key Performance Metrics report. The Market Manager and Chief Operating Officer take direct responsibility for ensuring remediation plans are fulfilled. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna 9 MONITORING PROGRAM PERFORMANCE - CONTINUED

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