1. Special Needs Plan (SNP) Model of Care Annual Provider Training

2. Objectives
Provide an overview of Elderplan’s Special Needs Plans care structure for its members
Understand the Care Management goals for its members
Identify key Roles and departments that support the Model of Care at Elderplan
Understand the role of an interdisciplinary care team for Elderplan’s Special Needs Plans members
Throughout this training, you will receive an overview of Elderplan's special needs care structure for its members; understand members care management goals; identify the role of certain employees within the organization, and understand the role of a team that handles a member's care - also known as the Interdisciplinary care team.

3. Introduction
So let’s begin!

4. Introduction
The Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage Special Needs Plans (SNPs) to have a Model of Care (MOC)
CMS.gov
Elderplan is required to submit the following to CMS:
Model of Care plan information
Initial and annual training for providers

5. Introduction
The MOC is designed using the eleven elements below but focused on meeting the clinical and non-clinical needs of the target population
MOC Elements
SNP-specific Target Population
Goals and Objectives
Key Structure and Staffing
Coordinated Interdisciplinary Care Team (ICT)
Provider Network and Clinical Practice Guidelines and Protocols
Training for Personnel and Provider Networks
Health Risk Assessment
Individualized Care Plan
Communication Network
Care Management for the Most Vulnerable Subpopulations
Outcome Measurements
What is the Model of Care?
The Model of Care – also referred to MOC - is designed using the eleven elements on your screen with a focus on meeting the clinical and non-clinical needs of the target population. In this training, we will provide you information on each element of Model of Care.

6. Description of SNP TARGET population
In this section we will discuss the Description of SNP Target Population.
Description of SNP TARGET population

7. Description of SNP TARGET population
Elderplan Special Needs Program
Description of SNP TARGET population
Two (2) Dual-SNPs (D-SNP):
Elderplan for Medicaid Beneficiaries (002)
Elderplan Plus Long Term Care (007)
One (1) Institutionalized-SNP (I-SNP):
Elderplan for Nursing Home Residents (003)
As of July 2014, Elderplan offers four special needs plans.
Three of the special needs plans are for persons with dual coverage (Medicare and Medicaid) and one is for people who are institutionalized – otherwise known as Nursing Home Residents.

8. Eligibility Requirements
Description of SNP TARGET population
Eligibility Requirements
D-SNP
I-SNP
Qualify for both Medicare and Medicaid
Must reside in an I-SNP nursing home for greater than 90 days at time of enrollment
Live in our geographic service area
Entitled to Medicare Part A
Enrolled in Medicare Part B
Do not have End Stage Renal Disease (ESRD)*
To better understand the target population - all of Elderplan’s Special Needs Plans require that enrollees must meet the following requirements:
Live in its service area;
Entitled to Medicare Part A;
Enrolled in Medicare Part B; and
Must not have End Stage Renal Disease at the time of enrollment – which means newly enrolled to any plan in Elderplan.
The additional requirement for D-SNP enrollees is that they must qualify for both Medicare and Medicaid.
The additional requirement for I-SNP enrollees is that they must reside in a nursing home for more than 90 days at the time of enrollment.
With a few exceptions: e.g., if the member developed ESRD when they were already a member of a plan that we offer

9. Now – what are the goals and objectives of this care structure?

10. Specific Care Management Goals for D-SNP
Goals and Objectives
Specific Care Management Goals for D-SNP
MOC Aspects of Care:
Access to essential services, affordable care and health services
Coordination of care
Transitional Care across settings, providers and health services
Appropriate utilization of services
Improving health outcomes
The MOC goals must be stated in measurable terms and should cover at minimum the following aspects of care:
Access to essential services such as medical, mental, social, affordable care and preventative health services
Coordination of care through an identified point of contact
Coordination in Transitions of care across settings, providers and health services
Appropriate utilization of services
Improving health outcomes

11. I-SNP D-SNP Goals and Objectives
Initial health risk assessment - 90 days of enrollment
Interdisciplinary Care Team (ICT) with a Care Manager
Meet care needs of dual eligible members
Access to preventive health services and chronic disease management
Care transitions support
No racial or cultural disparities
Improve health outcomes
Coordination of Medicare and Medicaid benefits
Initial health risk assessment - 30 days of enrollment
Interdisciplinary Care Team (ICT) - Physician and Nurse Practitioner
Meet care needs of institutional members
Ensure preventive health measures and utilization of services
Care transitions support
No racial or cultural disparities
Improve health outcomes
Collaborate with participating nursing facilities
The Specific Care management Goals for both D-SNP and I-SNP members varies in some aspects.
The Initial health risk assessment is required within 90 days of enrollment for D-SNP members and, at a minimum, annually each year while I-SNP members are required to complete the assessment within 30 days of enrollment to the plan.
Each member is assigned to an Interdisciplinary Care Team (ICT) with a designated Care Manager as point of contact for D-SNP members while the physician and/or nurse practitioner is the point of contact for I-SNP members.
Establish and maintain a network of providers with expertise in medical, social and behavioral health management of frail and/or chronically ill and disabled members in both plans.
Access to preventive health services and management of chronic disease for D-SNP members. The I-SNP plan ensures preventive health measures for residents and monitor care to ensure appropriate utilization of services.
Similarly in both plans, each
Provide support during care transitions across healthcare settings
Eliminate barriers resulting from racial or cultural disparities
Improve health outcomes across the population
Furthermore, the Coordination of both Medicare and Medicaid benefits for D-SNP members and a collaborative approach with participating nursing facilities.

12. Goals and Objectives
Quality Improvement Committee (QIC) and subcommittee structure is the reporting vehicle for goals and outcomes.
Every quarter the QIC develops recommendations such as:
Process changes
Corrective actions
Training for staff and/or providers
Changes to MOCs
The Quality Improvement Committee is the reporting vehicle for goals and outcomes. Every quarter they convene and develop recommendations such as process changes, corrective actions, training and any changes to the current Model of Care.

13. KEY STRUCTURE AND STAFFING
Now, what is Elderplan’s internal key structure and staffing?
KEY STRUCTURE AND STAFFING

14. Key Structure and Staffing
Administrative Functions for both D-SNP and I-SNP
Enrollment and Member Operations
Sales and Marketing
Member Services
Claims
Network Operations
Regulatory Compliance
Appeals & Grievances
Clinical Functions for both D-SNP and I-SNP
Quality Management
Coordinated Care
Clinical Services
To better understand the internal key structure and staffing of Elderplan's Model of Care, there are two functions that have the greatest impact for both D-SNP and I-SNP members - Administrative and Clinical. The departments listed on your screen play major roles in providing various services to our SNP members.

15. COORDINATED INTERDISCIPLINARY CARE TEAM
Another part of a SNP member’s Model of Care is the role of the coordinated Interdisciplinary Care Team.
COORDINATED INTERDISCIPLINARY CARE TEAM

16. Behavioral and/or Mental Health specialists are added as necessary
Coordinated Interdisciplinary Care Team (ICT)
D-SNP
I-SNP
Elderplan Clinical Team:
RN/LPN Care Managers,
SW Care Managers,
Chief Medical Officer & Physician Advisors
Social service roles:
Social workers
Public health professionals
Behavioral and/or Mental Health specialists are added as necessary
The PCP, and at times other professional providers of care, is considered part of the ICT
Elderplan Clinical Team:
Medical Officer,
VP of Clinical Operations,
Director, ISNP Clinical Services,
Care Managers
Pharmacy Manager and
Practitioners-Nurse Practitioner, PA, Medical Doctor
Long term care facility staff:
Medical Director
Director of Nursing
Director of Social Services
As needed:
Facility Physical or Occupational Therapist,
specialty physicians,
psychiatrists,
pastoral care, and
hospitalists
Both D-SNP and I-SNP members will have an Elderplan Clinical Team (consisting of various roles) participating in the ICT as indicated on your screen.
In addition to the Elderplan Clinical Team, D-SNP members ICT will include social service roles, Behavioral and/or Mental Health specialists, the PCP and/or other professional providers involved in the member's care. As for I-SNP members, certain long term care facility staff would be part of the ICT.

17. Beneficiary Participation
Coordinated Interdisciplinary Care Team (ICT)
Beneficiary Participation
D-SNP
Member receives a “Welcome Letter” with assigned Care Manager
Member and/or caregiver encouraged to inform the plan of new or changed condition
Care Manager communicates with member to discuss the program and Individualized Care Plan
I-SNP
Member/designated representative receives “Welcome Letter” with assigned Nurse Practitioner
Member or designee is invited to attend facility based team meetings, as necessary
The beneficiary may also participate in an ICT meeting.
Members in a D-SNP communicate their condition through their care manager who is the liaison for coordination of care. After an initial assessment, each member receives a “Welcome Letter” that introduces the assigned Care Manager.
The Member and/or caregiver are encouraged to make contact at any point, in particular whenever new or changed conditions arise (physical, psychosocial or environmental)
The Care Manager reaches out to the member at scheduled intervals to discuss the program and to develop an individualized Care Plan based on member needs
For I-SNP members - upon enrollment, the member/designated representative receives welcome information that includes the name of assigned Nurse Practitioner (NP) with his/her contact information and acts as liaison between member and facility staff.
The Member or designee is invited to attend facility based team meetings, as necessary (e.g., when there are significant changes in treatment plan or clinical conditions)

18. ICT Operations and Communications
Coordinated Interdisciplinary Care Team (ICT)
ICT Operations and Communications
Care Management Software System
Member assessments
Care plan & Care transitions
Claims
Pharmacy data
Monthly Meeting
Coordinated Care Department and other departments
Issues relating to delivery of care model
Service issues or complaints
D-SNP
Weekly staff meetings to discuss caseloads
Ad-hoc meetings when there is a significant change to a member condition or needs
I-SNP
Long term facility maintains clinical records
ICT members can access the member’s clinical record
Monthly meetings at facility or conference call to discuss member issues and/or concerns
All member assessments, care plan, care transitions, claims and pharmacy data are maintained in a software system
Monthly meetings with the Coordinated Care Department and other departments discuss issues relating to delivery of care model including enrollment, disenrollment, service issues or complaints
For D-SNPs - There are weekly staff meetings to discuss caseloads, processes and select member discussions.
When a significant change to member condition, care needs, social, financial or environmental issues are identified, additional participants (e.g., member, caregiver, physician, pharmacist, home health providers) may attend
Finally, I-SNPs long term care facility maintains the clinical record for the member.
The ICT team can access the member's clinical record as necessary.
Each month the ICT meet at facility or via conference call to review particular member issues involving such concerns such as unplanned hospital admissions, palliative and/or end-of-life referrals or updates, and quality or access issues

19. PROVIDER NETWORK AND CLINICAL PRACTICE GUIDELINES AND PROTOCOLS

20. Provider Network and clinical Practice Guidelines and Protocols
Clinical Practice Guidelines & Protocols
1. Licensing/Competency of Network Facilities and Providers
2. Coordination Among ICT, Network and Beneficiary to deliver services
3. Use Evidence-Based Clinical Practice Guidelines and Nationally Recognized Protocols for both D-SNP and I-SNP

21. Provider Network and clinical Practice Guidelines and Protocols
The Credentialing Subcommittee is responsible for ensuring that all participating providers, facilities and vendors are actively licensed and competent
Subcommittee consists of participating physicians of various specialties, with Chief Medical Officer, QM, Network Operations, and Credentialing Supervisor
Meets monthly for oversight of the Elderplan network
Recommendations are reviewed to ensure that all applicable licensures and certifications are active without restrictions from any governing or professional bodies, in compliance with CMS regulatory credentialing standards
Licensing/Competency of Network Facilities and Providers

22. Provider Network and clinical Practice Guidelines and Protocols
The Board Certification expiration is reviewed on a yearly basis
Credentialing database is maintained in CACTUS
Full Re-credentialing occurs on a three-year cycle, however, if need arises, providers will be evaluated at any point in the cycle, i.e., when the Plan becomes aware of poor outcome from a regulatory survey or adverse events
Substantiated concern or sanction with providers results in actions such as corrective action plan from provider/vendor or recommendation of termination or non-renewal from participation with the Plan
Licensing/Competency of Network Facilities and Providers

23. Provider Network and clinical Practice Guidelines and Protocols
D-SNP
The Plan’s Care Manager is the gatekeeper for coordination of services among providers and beneficiaries.
Acts as liaison between the PCP and ICT;
Updates and distributes revised Care Plan, as necessary;
Documents activities in the electronic care management software and communicates (telephonically or electronically) to providers Elderplan and member/caregiver
During ICT meetings, shares reports on hospitalizations, skilled services and any provider access issues
Encourages/supports the member in conversations with his/her PCP
Coordination among ICT, Network and Beneficiary to deliver services

24. Provider Network and clinical Practice Guidelines and Protocols
I-SNP
The Plan’s Care Manager is the gatekeeper for coordination of services among providers and beneficiaries.
Acts as liaison between the PCP , NP and ICT;
Documents activities in the electronic care management software and communicates (telephonically or electronically) to providers Elderplan and member/caregiver
During ICT meetings, shares reports on hospitalizations, skilled services and any provider access issues
Encourages/supports the member in conversations with his/her PCP
Coordination among ICT, Network and Beneficiary to deliver services

25. Provider Network and clinical Practice Guidelines and Protocols
I-SNP
The PCP is electronically notified of member admissions and discharges to/from acute and subacute settings to facilitate post discharge follow-up and reconciliation of medication and treatment plan
During acute and subacute episodes, care coordination across settings is facilitated by the Transitional Care RN in collaboration with the Care Manager and facility designee
Coordination among ICT, Network and Beneficiary to deliver services

26. Provider Network and clinical Practice Guidelines and Protocols
The Clinical Practice Subcommittee
Evaluates and adopts clinical practice guidelines applicable to the needs of the Plan’s membership; these guidelines are then posted on the Plan’s Provider Website along with news articles and updates in the Provider Magazine
The Pharmacy and Therapeutics Subcommittee
Offers valuable guidance on formulary development/maintenance and opportunities for enhancing member experience with the Plan
Use Evidence-Based Clinical Practice Guidelines and Nationally Recognized Protocols for both D-SNP and I-SNP

27. Provider Network and clinical Practice Guidelines and Protocols
Clinical Practice Committee
Utilize several additional tools/techniques to evaluate the use of evidence based clinical practice guidelines
Annual Medical Record Review for high volume PCPs and specialists with a substantiated quality-of-care concern in the past year
Pharmacy data to identify potential care gaps or potential adverse events and compliance issues
Identify real and potential gaps in care and generates notice to physician and member while sending quarterly reports to the Plan for review
Use Evidence-Based Clinical Practice Guidelines and Nationally Recognized Protocols for both D-SNP and I-SNP

28. Provider Network and clinical Practice Guidelines and Protocols
Clinical Practice Committee
PCPs (and assigned NP, in the case of the I-SNP) also receive monthly reports that identify gaps or opportunities for compliance with those clinical evidence based practice guidelines used in HEDIS such as diabetes care, hypertension, cholesterol management and preventive care
For I-SNP only: NPs and their collaborating physicians sign agreement citing source of clinical evidence based practice guidelines available to them for use in their clinical practice, as well as review select member records to ensure compliance with guidelines in the treatment of enrolled members
Use Evidence-Based Clinical Practice Guidelines and Nationally Recognized Protocols for both D-SNP and I-SNP

29. Provider Network
The Provider network for both D-SNP and I-SNP plans contains sufficient number of services and facilities for the member's holistic care.
D-SNP
Board Certified specialists - Such as Geriatrics, Cardiology, Neurology, Endocrine, Orthopedics, Nephrology, Pulmonology, and Behavioral Health
Facilities - Including Inpatient Acute Hospitals, Rehabilitation and Psychiatric facilities and Subacute Nursing Facilities
Qualified physicians and/or NPs to make home visits
Community based services such as Radiology, Laboratory, Certified Home Health Agencies, Licensed Home Health Care Agencies, Transportation and DME vendors

30. Provider Network I-SNP
Identifies and evaluates potential long term care facilities for participation in this I-SNP
Facility must meet Plan’s P&P for credentialing standards for participation in the network
Evaluates provider adequacy with sufficient number of professionals to provide services directly on the premises of the long term care facility such as: 
Board Certified specialists - Geriatrics, Cardiology, Neurology, Nephrology, Pulmonology, Endocrinology, Orthopedics, Behavioral Health
Clinicians - Nurse Practitioners, Physical Therapists, Occupational Therapists, Respiratory Therapists
Inpatient facilities - Acute Hospitals and Rehabilitation and Psychiatric

31. Provider Network Non-Par Providers
An inventory of non-par providers to whom Clinical Services has authorized in the past is reviewed to identify providers to fill gaps
Non-Par Providers

32. TRAINING FOR PERSONNEL AND PROVIDER NETWORKS

33. Training for Personnel and Provider Networks
New Employee Training – Clinical Operating Areas
Observe processes
Enhance plan/member/provider interaction
Mentored
Monitor activity
Provide direction and feedback
Weekly Meeting
Provide updated and feedback
Regulation or Policy
Monthly Meetings
Stay in compliance with all new and revised policies via and PPM
Policies
Training and education is available for Elderplan staff. An employee can access policies and procedures on the Model of Care in the Policy & Procedure Manager.
Training for new employees of the clinical operating areas cover a variety of topics, including similarities & differences between the various SNP product offerings (and MOCs) and how to use the Plan's case management database:
After initial orientation, newly hired staff are mentored by more experienced staff members as they observe processes and experience how to utilize communication mechanisms to enhance Plan/member/provider interaction and tracking.
On a weekly basis, the Care Team Supervisor meets with each employee to monitor activity and provide direction and feedback
Monthly meetings with staff provide updates and feedback on any service, regulation or policy affecting the delivery of the SNP model of care (the departments maintain minutes of these meetings)
All employees are required to read new and revised policies and receive notifications of any staff-related information.
The PPM allows us to track compliance
Employees who are not compliant will be counseled by immediate supervisors and required to complete the task to avoid further disciplinary action

34. Training for Personnel and Provider Networks
Provider representatives distribute provider education materials, which include information on the MOC for the SNPs
As for providers, provider representatives distribute education materials for information on Elderplan's Model of Care.

35. HEALTH RISK ASSESSMENT

36. Introduction
In this section, you will learn how and when we capture information about the member's health history through health risk assessments.
Important Note:
Care managers administer D-SNP / C-SNP assessments for Elderplan Medicaid Beneficiaries on an annual basis (telephonically).
Members in the Elderplan Plus Long Term care Plan are assessed in the home on a bi-annual basis using the UAS NY tool.

37. Health Risk Assessment (HRA)
D-SNP / C-SNP
All members enrolled in Elderplan Plus Long Term Care program (007) will be assessed using a NYSDOH Approved Assessment, which is the Uniform Assessment System for NY (UAS-NY). This comprehensive assessment includes the following domains: social, functional, medical, behavioral, wellness and prevention domains, caregiver status and capabilities, as well as the member’s preferences, strengths and goals.
All members enrolled in Elderplan for Medicaid Beneficiaries (002) will be assessed using a revised version of the Uniform Assessment System for NY (UAS-NY). This assessment is electronically programmed, thus upon completion becomes a part of each member’s clinical record within the Plan’s care management software system. This comprehensive assessment contains all necessary domains as outlined in the requirements: medical, functional, cognitive, psychosocial and mental health needs of each SNP members

38. Health Risk Assessment (HRA)
D-SNP / C-SNP
All members enrolled in C-SNP Diabetes Care will be assessed using two comprehensive assessment: one of them is specific to the Diabetic needs of the member and contains all necessary domains as outlined in the requirements: medical, functional, cognitive, psychosocial and mental health needs of each SNP members
UAS-NY identifies more detailed clinical information and specific /instrumental ADL assistance required. This assessment is:
Completed by a clinical professional member of the care team either face-to-face, depending on product requirements
Re-administered at six-month intervals

39. Health Risk Assessment (HRA)
I- SNP
Naylor Risk of Acute Hospitalization tool includes questions to identify medical, psychosocial, functional and cognitive needs. Is completed by NP and repeated at the anniversary date
Monthly monitoring tool, a health risk assessment developed by the plan to identify changes in condition and determine risk level
MDS assessment tool - Plan receives a copy quarterly and annually
Completed by registered professional nurse at the facility (face to face and medical chart review)
All outcomes are captured and entered into the Plan's case management database for the Plan’s review and use in updating care plan

40. Health Risk Assessment (HRA)
Personal who Review, Analyze and Stratify health Care Needs.
Clinical Services, IT, and Quality Management departments analyze assessment data and set benchmarks for different SNP types
Member-level data is reviewed by the ICT
Plan-level data is reviewed in collaboration with Health Economics department
For I-SNP only: Director of Clinical Services analyzes and presents Plan- and member-level data from the ongoing assessments to the ICT and the management team
Data is also reviewed by subcommittees of the Quality Improvement Committee consisting of clinical providers, pharmacists and Quality Specialists

41. Health Risk Assessment (HRA)
Communication Mechanism(s)
The ICT team is responsible for the development, implementation and oversight of an individualized Care Plan for each Member based on the assessment of medical, environmental, social and cognitive needs of the Member.
The Care Plan is maintained in the case management system and is formulated based on Member health care needs and desired outcomes identified through telephonic initial assessment with the Member or Member’s Designee or Representative using the internally modified assessment tool and/or regular contact between the Care/Case Manager and Member, the PCP or other Service Providers.

42. Health Risk Assessment (HRA)
Communication Mechanism(s)
This allows Elderplan to review Member progress and evaluate whether Member care and treatment goals are met or unmet and if changes are necessary to support Member’s health outcomes.
The team utilizes various evidence based clinical and functional assessments that address the unique medical, behavioral, cognitive, and social needs of Members who are dually eligible. Findings from the assessments are documented in both the case management and utilization management systems and used to update the Care Plan and maintain open communication with the Member regarding findings and the options for treatment and care.
The Member and Primary Care Physician receive a copy of the individualized Care Plan along with instructions on how to contact the Member’s Care/Case Manager as needed.

43. Health Risk Assessment (HRA)
Communication Mechanism(s)
Once the care plan is finalized, it is shared with the member, as well as the PCP and ICT members (including NP). Care Plan is maintained electronically in the Plan's case management database
Certain key responses allow the Plan’s databases to trigger electronic referrals for clinical intervention, such as disease or wellness education, to the appropriate care teams
I-SNP

44. INDIVIDUALIZED CARE PLAN

45. Introduction
Our members will have an individualized care plan that begins with input from:
Member and/or caregiver
Physician
Enrollment Nurse (develops the plan for MAP)
The Care Manager plays a major role in the individualized care plan. Select the markers on the screen to find out more about how the individual care plan works in D-SNP / C-SNP and I-SNP

46. D-SNP / C-SNP Individualized Care Plan
Developing the Member's Care Plan. The Care Manager does the following activities:
Reviews assessments and other data
Contacts the member telephonically to gather additional information
Reviews applicable clinical guidelines and criteria embedded in the Plan's case management database and Disease Monitor software
Member's answers and identification of preferences on the UAS-NY and/or D-SNP / C-SNP assessment will help Care Managers identify problems, set goals and generate interventions that will address Member concerns and priorities.
Member participates in the identification of interventions geared to addressing gaps (e.g., caregiver support and environmental or social issues)

47. D-SNP / C-SNP Individualized Care Plan
For members who require and receive personal care services administered and provided through the health plan, additional tools are used to determine the extent of the personal care needs (For MAP members only)
Develops goals and identifies the appropriate interventions (e.g., home visiting physicians, telehealth monitoring, palliative care)
Encourages PCP participation and solicits information when clinical concerns are identified
Consults with other ICT members during care plan development

48. D-SNP / C-SNP Complete Care Plan
Once the Care Plan is complete, it is:
Sent to the PCP via mail or fax and to the member
Stored in the secure Plan's case management database, where it is accessible and can be updated by ICT
A valuable tool during care transitions (available to the Transitional Care RN for use in facilitating communication of key elements of the plan)
Evaluated and updated on a semi-annual basis or when a significant change in condition or status is identified

49. D-SNP / C-SNP Complete Care Plan
Monthly inpatient admissions data, claims analysis, and other data triggers are used to revise Care Plan as necessary
Care Plan activity is monitored by the team supervisors and department management to ensure timeliness of updates, progress towards goals, and frequency/type of interventions.

50. I- SNP Individualized Care Plan
Upon effective date of enrollment, the member is assigned to a designated NP who is on-site at the long term care facility.
NP has access to the member’s facility record, and along with initial risk assessment tools, MDS information and a full history and physical
The Individualized Care Plan includes:
The Care Manager working closely with the assigned NP to develop Care Plan goals and interventions
PCP participation when clinical concerns are identified
The member or representative is encouraged to be part of this development and voice preferences for clinical and social interventions

51. I- SNP Individualized Care Plan cont’d
Monthly inpatient admissions data, claims analysis, and other data triggers are used to revise Care Plan as necessary
Care Plan activity monitoring by the Director of Clinical Services to ensure timeliness of updates, progress towards goals, and frequency/type of interventions
Data secured in the Plan's case management database
Quarterly evaluations and updates when a significant change in condition or status is identified

52. COMMUNICATION NETWORK

53. Communication Network for Both D-DNP and I-SNP
ICT team’s primary source of communication with members/caregivers and providers is telephonic
Member Services tracks and trends all incoming calls, call abandonment rates, and wait times
All incoming calls are recorded for quality control
SNP member/caregiver calls are forwarded to the appropriate Care Management Team or handled directly by the Member Service Representative
Communication network for providers includes designated call center, secure web-portal, Plan website, and face-to-face meetings with Provider Reps

54. Communication Network for Both D-DNP and I-SNP
The Plan provides additional resources in the form of print and electronic materials for both Members and Providers
I-SNP only: Nurse Practitioner (NP) provides members and family with access to his/her designated cell phone and encourages them to contact him/her with concerns and questions
Communicates with regulatory agencies in the resolution of inquires and complaints, such as through the CMS Complaint Tracking Modules, to ensure timely and adequate outcomes to member and provider concerns and issues

55. Communication Network for Both D-DNP and I-SNP
The Quality Improvement Committee (QIC) has responsibility for identification and implementation of process changes or enhancements relating to communication activities
The Customer Service Subcommittee reports on volume, trends, and responsiveness with member calls
The A&G Subcommittee tracks and trends member complaints relating to access to plan and/or providers

56. CARE MANAGEMENT FOR MOST VULNERABLE POPULATIONS

57. Care Management for the most Vulnerable Subpopulations
The Plan first utilizes assessment tools obtained both initially and at reassessment
Performs analysis of claims to identify potential for repeated hospitalizations, presence of chronic diseases, and triggers for psychosocial or significant change of condition issues.
Reports and Indicators that identify vulnerable members:
Hospital admission and readmission reports
Pharmacy utilization reports
Clinical data to identify members who may benefit from Palliative and/or Hospice care coordination
The Plan first utilizes assessment tools obtained both initially and at reassessment times to identify populations who are more vulnerable for medical/psychosocial complications.
Performs analysis of claims and other data to identify potential for repeated hospitalizations, presence of chronic diseases, and triggers for psychosocial or significant change of condition issues, to identify members who may benefit from more aggressive intervention by the ICT members
Utilizes a number of reports and indicators that further identify most vulnerable members for example:
Frequent hospital admission and readmission reports
Pharmacy utilization reports that identify members with high risk medications, poor compliance & adherence, and potential adverse reactions
Clinical data to identify those members with potentially life-threatening disease progression who may benefit from Palliative and or Hospice care coordination

58. PERFORMANCE AND HEALTH OUTCOME MEASUREMENTS

59. Performance and Health Outcome Measurements
The Quality Management Department assist in all aspects of data collection and analysis
HEDIS data and Part C&D reporting requirements are audited annually.
Data Collection & Analysis
Oversight of evaluation and monitoring activities include the AVP of Clinical Services, Director of Coordinated Care, Director of Pharmacy Services, Director of Informatics, Director of Member Services and AVP of Network Operations
Evaluation & Monitoring
Chaired by the Chief Medical Officer and co-chaired by the Director of Quality Management
Follows all CMS requirements in development and participation in quality activities and reporting
Quality Improvement Committee
The Quality Management department’s Director and staff, including QM Coordinators and Specialists, assist in all aspects of data collection and analysis.
For example:
HEDIS data, along with Part C & D reporting requirements, are audited annually by external certified consultants.
Other key personnel responsible for oversight of evaluation and monitoring activities, include the various roles on your screen.
All data is shared with the Quality Improvement Committee (QIC)
The QIC is chaired by the Chief Medical Officer for the Plan, and co-chaired by the Director of Quality Management
The Committee follows all CMS requirements in its development and participation in quality activities and reporting

60. Performance and Health Outcome Measurements
All data analysis and standard reporting is used in the Annual Plan Quality Improvement Evaluation/Workplan, and along is presented to the Board of Directors for their review and approval
Annual Plan Quality Improvement Evaluation/Workplan
Plan performance is shared across the plan and key Providers
The plan educates its network and membership on performance measures through newsletters and on Elderplan’s website
Performance & Education
All data analysis and standard reporting is used in the Annual Plan Quality Improvement Evaluation/Workplan, and along with recommendations for program improvements, is presented to the Board of Directors for their review and approval
The key elements reflecting Plan performance are shared across the Plan and with key Providers
The Plan educates its network and membership with updates regarding performance measures and/or changes in the MOC for the SNP via the Member/Provider Newsletters, WebPages and updates to Provider Manuals
High-volume physicians receive reports on individual performance against expectations and benchmarks

61. Data Sources Performance and Health Outcome Measurements
Annual surveys
Case & Disease Management
Departmental Data
Utilization Reporting & Analysis
Membership Data
Claims
Encounters
Authorization
Pharmacy
Hospital admissions
Readmissions
Care Plan Development
Intervention Reports
Access to Services
HEDIS, NCQA & CAHPS
Structure and Process Measures
Call Center Activity
Network Access and Availability
Appeals & Grievance trends and rates
Data sources
Membership data, claims, encounters, authorizations and pharmacy data are stored in the data warehouse and form the foundation for utilization reporting and analysis
Data from the Plan’s case management database on case and disease management is used to report outcome measures including hospital admissions, readmissions, care plan development and progress towards goals, intervention reports, and access to services
Data from annual surveys, such as HEDIS and NCQA Structure and Process Measures, are analyzed
Other departmental data
Call Center Activity, including time-to-answer, abandonment rate, and language-line activity
Network Access and Availability
Appeals and Grievance trends and rates
Disenrollment Rate and Trends
Utilization of Services for Acute & Subacute Level of Care
And Safe Care Transitions including Readmission Rates

62. Thank You
Thank you for completing the MOC training. Now that you have reviewed the Model of care training that outlines the basic Model of Care requirements for our providers please confirm that you have read and understood the material provided by completing the attached attestation.

63. MODEL OF CARE TRAINING ATTESTATION
Provider/Group Name: __________________________________________________________________ Address: _____________________________________________________________________________ NPI: ___________________________________________ TIN: ___________________________________________ License: _______________________________ PCP Specialist Multi-Specialty Group IPA The Centers for Medicare & Medicaid Services (CMS) regulations require that health plans provide their Special Needs Plan provider network with information on their basic Model of Care. This applies to our Dual-Eligible Special Needs Plan (D-SNP) members who are eligible for both Medicare and Medicaid The SNP MOC module covers metrics designed to improve Members’ access to medical, social, and mental health services and transitions of care across health care settings. All personnel/entities that are part of Elderplan’s provider network must receive this annual training Once you have reviewed the Model of care training that outlines the basic Model of Care requirements for our providers please confirm that you have read and understood the material provided by completing this attestation. I, _______________________________ (Name of the Provider/Administrator) Hereby attest that All employees (including Board Members, Directors, and Temporary employees) and the employees of downstream entities have completed D-SNP Model of Care training.