1. Quality Improvement Program: Special Needs Plans
Marsha Davenport, MD MPH CAPT, USPHS
October 29, 2010
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

2. Quality Improvement Program Special Needs Plans (SNPs)
Overview
Background
Quality Improvement Program
Special Needs Plans (SNPs)
Future Directions
Summary
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

3. BACKGROUND
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

4. To describe the current Quality Improvement (QI) Program
Purpose
To describe the current Quality Improvement (QI) Program
To discuss quality indicators for Special Needs Plans (SNP)
To provide an update on future directions for the QI Program
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

5. Contains multiple dimensions
Defining Quality
Complex
Contains multiple dimensions
May have different meanings depending on the context
Focus is on quality for the Medicare Advantage Organizations (MAOs)
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

6. Institute of Medicine (IOM)Definition of Quality
“ Degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge”
For individuals and populations
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

7. Quality for Medicare Advantage (MA)
Determining what quality looks like for MAOs and SNPs
Quality has some unique features for the Special Needs Plans (SNPs) .
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

8. Chronic Condition SNP (C-SNP) Dual Eligible SNP (DE-SNP)
SNP Types
Chronic Condition SNP (C-SNP)
Dual Eligible SNP (DE-SNP)
Institutional SNP (I-SNP)
Spend a few minutes describing the number of SNPs refer to the fact that they saw Jon’s slide today on 66 percent of our SNPs are DE-SNPs
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

9. Chronic alcohol and other drug dependence Autoimmune disorders Cancer
Conditions for C-SNPs
Chronic alcohol and other drug dependence
Autoimmune disorders
Cancer
Cardiovascular disorders
Chronic heart failure
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

10. Conditions for C-SNPs (cont’d)
Dementia
Diabetes mellitus
End-stage liver disease
End-stage renal disease requiring dialysis
Severe hematologic disorders
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

11. Conditions for C-SNPs (cont’d)
HIV/AIDs
Chronic lung disorders
Chronic and disabling mental health conditions
Neurological disorders
Stroke
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

12. Quality is Multidimensional
SNP
Provider Network
Patient
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

13. Assessed through specific methods and/or tools
SNP Quality
Assessed through specific methods and/or tools
Goal is to improve the health outcomes for the patient
Methods for measuring quality may be
Qualitative
Quantitative
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

14. SNP Quality: Qualitative Tools
Quality Improvement (QI) Program Plan
Care Coordination Plan
Model of Care
Quality Improvement Projects (QIPs)
Chronic Care Improvement Program (CCIPs)
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

15. SNP Quality: Quantitative Tools
HEDIS
CAHPS
HOS
Structure and Process Measures
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

16. QUALITY IMPROVEMENT PROGRAM
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

17. Quality Improvement (QI) Program
QI Program Plan
Chronic Care Improvement Program (CCIP)
Quality Improvement Projects (QIPs)
Performance Measures
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

18. Quality Improvement (QI) Program
QI Program Plan (cont’d)
Health Information System
Program Review
Remedial Actions
Model of Care for SNPs
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

19. Target population and method of identifying eligible enrollees
CCIP Indicators
Target population and method of identifying eligible enrollees
Method for enrolling participants and particpation rates
CCIP designed to improve health
Data sources used to identify need for CCIP
Will describe elements in more detail and discuss the elements that are used now and the weights
Under present system, weights for all indicators are 15 percent except for the data sources which is 10 percent
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

20. CCIP Indicators (cont’d)
Intervention
Program monitoring and delegation oversight
Outcomes measures
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

21. Topic focus and relevance to the Medicare population
QIP Indicators
Target population
Topic focus and relevance to the Medicare population
QI indicators, data sourc and collection methodology
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

22. QIP Indicators (cont’d)
Participation
Results
Interventions
Indicators at 10 percent (participation); 15 percent (Results; QI indicators , data source and collection methodology) All other indicators are weighted at 20 percent.
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

23. Model of Care Elements Care Management Plan Model of Care elements
Description of SNP-specific Target Population
Measureable Goals
Staff Structure and Care Management Roles
Describe the elements and how they might be implemented
MOC is the tool that makes SNPs truly different from the rest of MA and FFS
Describe how we can make better use of this tool
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

24. MOC Elements (cont’d) Interdisciplinary care team (ICT)
Provider network having specialized expertise and use of clinical practice guidelines and protocols
MOC training for personnel and provider network
Health risk assessment
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

25. MOC Elements (cont’d) Individualized care plan Communication network
Care management for the most vulnerable subpopulations
Performance and health outcome measurement
Describe that we currently have a pilot project to evaluate the MOC that will be completed by the end of the year. We plan to expand this pilot study to include a larger number of SNPs beginning in early 2011 (APC contract).
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

26. Measuring Quality 26 Outcomes Structure Quality Process
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law. 26

27. Structure and Process Measures
Complex case management
Improving member satisfaction
Clinical quality improvements
Describe these elements and how why we want all plans to complete all 6 this year. Also, why we are not introducing new measures this year.
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

28. Structure and Process Measures (cont’d)
Care transitions
Institutional SNP relationship with facility
Coordination of Medicare and Medicaid coverage
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

29. Code of Federal Regulations (CFR)
QI Program Resources
Code of Federal Regulations (CFR)
Central Office and Regional Office Staff
CMS website
Medicare Managed Manual
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

30. FUTURE DIRECTIONS
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

31. QI Program Enhancements
Provide more training on the QI Program Tools
Expand the technical assistance (TA) available
Use a preventive intervention for plans
Use early and often
On-going
Use TA as a preventive intervention refers to not waiting until a SNP has to be on a corrective action plan (CAP) to provide TA but provide in an on-going support
Provide early and often means that when a SNP is new to the MA program, there will be TA provided within the first few months of their program and avaialble as needed
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

32. QI Program Enhancements
Conduct annual audits of the QIPs and CCIPs
Provide a list of clinical and non-clinical topics for the QIPs
Provide a list of clinical topics for CCIPs
Improve methods for reporting the QIPs and CCIPs
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

33. QI Program Enhancements
Revise and update all tools
Provide templates for these tools
Set higher standards and benchmarks
Provide training on existing and new tools as they are developed
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

34. Expand QI Program Resources
Develop better SNP website page and on-line resources and update regularly
Update Medicare Managed Care Manual Chapter 5: Quality
Update and provide QI Program Guidance
Outreach materials for plans and other communication tools
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

35. Increasing need to have clinical and health outcomes measures
Summary
Must continue to emphasize the importance of developing a strong QI Program
Increasing need to have clinical and health outcomes measures
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

36. Summary
Future efforts will focus on multidimensional aspects of quality improvement leading to better health outcomes for our patients
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

37. Contact Information
Marsha Davenport, MD, MPH Medical Officer and Acting Director Division of Medicare Advantage Operations (DMAO) Phone: Thank you!
MAY CONTAIN INFORMATION THAT IS NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.