SNP Surveyor Reminder Call October 3, 2013

Review of Changes and Clarifications in the S&P Measures

3 SNP: Surveyor Reminder Session Element A - Program Description The SNP has a description for its Care Mgmt. program that includes: Evidence used to develop the program Criteria for identifying members who are eligible for the program Services offered to eligible members Defined program goals SNP 1- Care Mgmt. and Coordination

4 SNP: Surveyor Reminder Session SNP 1 – Element A CCM – The org coordinates services for members with complex conditions & helps them access resources – Received credit for evidence that it enrolled and maintained all members Care Mgmt. – The org has appropriate programs to coordinate services and help all members access resources – May have over- arching Care Mgmt. program and other programs for various sub-populations

5 SNP: Surveyor Reminder Session A SNP’s documentation that shows it continues to follow the traditional member identification mechanisms for CCM e.g., analyzes data and accepts referrals from various sources only, does not meet the intent of this element. The SNP must have modified its documentation to show it has a Care Mgmt. program for all members SNP 1 – Element A

6 SNP: Surveyor Reminder Session Coordination of care and managing members’ conditions are constants for Care Mgmt. along with: – Comprehensive assessment of member – Determination of benefits or resources needed – An individualized care plan for each member with performance goals, monitoring and follow-up SNP 1 – Element A

7 SNP: Surveyor Reminder Session Factors 1 and 2 require a documented process that describes: – how SNP used specific clinical practice guidelines to develop its program – the criteria SNP uses to identify eligible members for specific programs within Care Mgmt If SNP uses risks or level of need to stratify members, then it must provide the eligibility criteria, services and goals for each program. SNP 1- Element A

8 SNP: Surveyor Reminder Session Documented processes are required e.g., – Care Mgmt Program Descriptions – Policies and Procedures (may be supplemented with reports or materials) – MOC – but it must contain descriptions of actual processes that specifically state what, how, when and who performs the required activities SNP 1- Element A

9 SNP: Surveyor Reminder Session Element B – Population Assessment Annually SNP must: – Assess the characteristics and needs of member population and pertinent subpopulations – Review and update Care Mgmt. processes to address member needs – Review and update Care Mgmt. resources to address member needs SNP 1- Care Mgmt. and Coordination

10 SNP: Surveyor Reminder Session Factor 1 requires a SNP’s population assessment to include all members, not just those in specific programs like CCM Although the stem indicates that it needs to perform the assessment annually, the SNP only needs to provide P&Ps showing it has a systematic process for the assessment -- not actual evidence of implementation SNP 1- Element B

11 SNP: Surveyor Reminder Session In addition to examples in S&P measures, member characteristics for factor 1 can include things like: – Demographic info on age/gender – Most prevalent diseases – HCC Groupings & comorbid conditions – Top Medicaid primary diagnoses – Risk scores – Highest number/percentage of meds prescribed SNP 1- Element B

12 SNP: Surveyor Reminder Session Factor 3 requires a SNP’s documentation to show it considers program characteristics and resources such as staffing ratios, clinical qualifications, job training, external resources and cultural competency when it reviews and updates resources Documented processes are required – E.g., program description, P&Ps or MOC that contains descriptions of actual processes SNP 1- Element B

13 SNP: Surveyor Reminder Session Element E - Satisfaction with Care Mgmt SNP must submit a report showing it performed an evaluation of satisfaction by: – Obtaining feedback from members and – Analyzing member complaints and inquiries Factor 1 requires SNP to obtain feedback on its Care Mgmt. program from a broad sample of members. This sample can include members in Care Mgmt program or other programs within it. SNP 1- Care Mgmt. and Coordination

14 SNP: Surveyor Reminder Session Element F - Analyzing Effectiveness/ Identifying Opportunities The SNP measures the effectiveness of its Care Mgmt. program using three measures. For each measure, it: –Identifies a relevant process or outcome –Uses valid methods that provide quantitative results –Sets a performance goal –Clearly identifies measure specifications –Analyzes results –Identifies opportunities for improvement, if applicable SNP 1- Care Mgmt. and Coordination

15 SNP: Surveyor Reminder Session SNP must provide reports that contain appropriate measures (along with any worksheet it submits) All three measures must: – Have a significant and demonstrable bearing on all Care Mgmt. members or a subpopulation – Involve relevant outcomes or processes – Show the use of a valid methodology Contain info on sampling (if used) and sample size calculation Denominator specific to Care Mgmt. population SNP 1- Element F

16 SNP: Surveyor Reminder Session SNP’s report must include: Comparison to goal or benchmark for each measure – Measure cannot have exceeded goal from outset A quantitative and a qualitative analysis that goes beyond simple reporting or data display SNP-specific analyses of measures. Orgs that present aggregate analysis also need to provide data and results for each individual SNP in it SNP 1- Element F

17 SNP: Surveyor Reminder Session Element G - Implementing Interventions and Follow-up Evaluation Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization: –Implements at least one intervention for each of the three opportunities identified in Element F to improve performance –Develops a plan for evaluation of the intervention and re-measurement SNP 1- Care Mgmt. and Coordination

18 SNP: Surveyor Reminder Session Interventions for factor 1 must have been implemented after 10/15/12 Factor 1 may be NA if no opportunities Factor 2, re-measurement, must be completed whether there are opportunities or not. SNP 1- Element G

19 SNP: Surveyor Reminder Session SNP 1C – Org can provide documented process OR CM Assessment form OR screenshots of assessment system that address factors 1 thru 8 SNP 1E – factor 1 requires a SNP to evaluate feedback from members obtained from focus groups or satisfaction surveys; AND factor 2 requires an evaluation of complaints and inquiries. Survey Reminders

20 SNP: Surveyor Reminder Session SNP 1F – measures may contain small denominators; surveyors still need to assess them SNP 1F – may present 1 satisfaction measure with CM measure and other patient experience measures SNP 1F – Orgs may use SF-8, SF-12 or SF- 36 for a physical and BH measure SNP 1F and 1G – report required; SNP can summarize or supplement with workbook Survey Reminders

21 SNP: Surveyor Reminder Session Elements A and C For this year’s submissions, SNP can use its 2012 CAHPS data to meet Element A and its 2013 CAHPS data to address Element C. However the intervention for factor 1 of Element C must have been implemented within the look-back period. SNP 2 – Improving Member Satisfaction

22 SNP: Surveyor Reminder Session 2A – analysis member satisfaction data must contain: – Complaints aka grievances AND appeals in required categories; or – SNP’s evaluation of CAHPs results (report from CAHPs vendor alone IS NOT acceptable); or – Other satisfaction survey results (assessing SNP’s operations) Survey Reminders

23 SNP: Surveyor Reminder Session Elements A, B and C New Care Setting For 2013, outpatient surgery depts. and ambulatory surgery centers were added to the list of care settings for planned transitions and SNPs need to include them in their documentation. However SNPs that do not require prior auth or have a process for identifying them need to state this in their P&Ps. These plans also need to provide examples as indicated in the explanations from other care settings. SNP 4 – Care Transitions

24 SNP: Surveyor Reminder Session Element E – Analyzing Transitions New for 2013: Factor 3—implementing interventions – The SNP must implement at least one intervention from the opportunities identified in factor 2. – Do not have to show improvement or effectiveness of the intervention – SNPs can use their existing CMS QIP related to reducing hospital readmissions SNP 4 – Care Transitions

25 SNP: Surveyor Reminder Session SNP 4 – job descriptions are not acceptable documentation SNP 4A and 4B – documentation for factor 3 of 4A and factors 1 thru 3 of 4B must contain timeframes for activities SNP 4A, 4B and 4C – institutional SNP members residing in facilities may not have as many transitions as members in other types of SNPs Survey Reminders

26 SNP: Surveyor Reminder Session SNP 4C – a SNPs’ analysis that does not meet factor 1 and 3 but has a detailed description of sampling method can receive credit for factors 2 and 4. Also remember to score factors 2 and 4 “yes” for a SNP that uses its entire universe of transitions from 10/15/12 to 6/30/13. SNP 4E – the analysis of ER visits and inpatient admits for factor 2 must include all hospitals Survey Reminders

27 SNP: Surveyor Reminder Session SNP 4E – a few orgs have SNP only plans that meet the requirement for contract- level reporting of all MA HEDIS measures (>1,000 members). These SNPs can use HEDIS 2013 data for ER and inpatient visits in their analysis for factor 2. Documentation for SNP 4F must be based on the patient-based analysis submitted for factor 1 of SNP 4E Survey Reminders

28 SNP: Surveyor Reminder Session SNP 6A – Orgs can submit an EOC that contains required info to meet factors 1 thru 3 but a Summary of Benefits must be accompanied by a report SNP 6E – SNPs’ analysis of network adequacy must include practitioners AND providers that accept members’ Medicare AND Medicaid benefits Survey Reminders

29 SNP: Surveyor Reminder Session S&P measures and Data Sources by Element (in Surveyor Resource Guide--SRG) detail when documentation in more than 1 data source is required or optional All analyses must contain SNP specific data Several elements in S&P measures require “annual” analysis but refer to the grid (in SRG) for info on timeframes. Explanations in the S&P measures also contain provisions for sampling. Survey Reminders

30 SNP: Surveyor Reminder Session If you cannot open a document in your assigned survey tool, that document must still be reviewed--so contact the SNP Team for help immediately! Surveyors conducting primary entity reviews need to review the documentation in the primary tool AND all PBP-level documentation in each subsidiary tool Survey Reminders

31 SNP: Surveyor Reminder Session Outstanding Issues Form

32 SNP: Surveyor Reminder Session Be sure to fill out the org’s information as it appears on your assignment sheet One table for each element – check appropriate box (Issue, No Issue, or NA) Check the issue type(s), more than one can be used Surveyor copies appropriate text the org has not met from S&P measures in ISS Completing the OIF

33 SNP: Surveyor Reminder Session Surveyor enters a detailed description of the issue on the form and in the ISS support text box – explains the specific reasons why the SNP has not met an element/factor – explains what the SNP needs to provide to resolve this – only references documentation in the required data source(s) Completing the OIF & Support Text Box

34 SNP: Surveyor Reminder Session Ensure that it is clear which factors are not met in an element Make sure to identify and record all of the issues in an element For Primary/subsidiary submissions, only elements that are reported at the subsidiary level should be filled out on the subsidiary OIF. Primary OIFs should be filled out in their entirety. Use language that is appropriate in the NCQA Writing Style Guidelines (Surveyor Resource Guide) OIF Reminders

35 SNP: Surveyor Reminder Session Similar to prior years, surveyors will be assigned multiple tools from the same org to maintain consistency across them Review your tools carefully to ascertain if they contain the same documentation and if not, determine which portions serve as direct evidence of performance Same/similar documentation needs to receive same or similar scores Survey Process Reminders

36 SNP: Surveyor Reminder Session Use the resources the SNP Team provides to verify info during survey CMS April 2013 Comprehensive Report for: – SNPs without members – also contains info on service areas and number of members that may help you determine if documentation is SNP-specific SNP Plans by Type for: – SNP Type, plan name and contract name – percentage of dual-eligible members Survey Process Reminders

37 SNP: Surveyor Reminder Session Carefully evaluate all documentation a SNP provided Resolve all issues that arise with the SNP Team Use the NCQA Style Guide to explain scores < 100% or NA and factors not met Remove the org’s comments from the support text boxes Never use scoring overrides Survey Process Reminders

38 SNP: Surveyor Reminder Session Weekly calls will be scheduled again to discuss any questions you have or issues you encounter Notify the SNP Team ASAP if circumstances come up that prevent you from completing your assigned surveys Be sure to use the resources available on the surveyor webpage: Survey Process Reminders

39 SNP: Surveyor Reminder Session S&P Tool Submissions due—Oct st batch assignments sent by 10/18 – Full-time = 5 tools/batch – Part-time = 2-3 tools/batch Weekly batches until mid-December (approximately) Primary Entity reviews—please review all tools and then notify NCQA of completion Surveyor Timeline

40 SNP: Surveyor Reminder Session Questions?

41 SNP: Surveyor Reminder Session Contacts Brett Kay Assistant Vice President, SNP Assessment Casandra Monroe Assistant Director, SNP Assessment Sandra Jones Assistant Director, SNP Assessment Anthony Davis Accreditation Manager, SNP Assessment 202 –

42 SNP: Surveyor Reminder Session Contacts Priyanka Oberoi Accreditation Manager, SNP Assessment Nidhi Dalwadi Accreditation Manager, SNP Assessment Ling Chen Accreditation Manager, SNP Assessment Delia Ponce Coordinator, SNP Assessment