1. 2019 Model of Care Training Special Needs Plan (SNP) Cal MediConnect (CMC)

2. Special Needs Program (sNP) Model of Care (MOC)
The Medicare Act of 2003 established a Medicare Advantage coordinated care plan that is designed to provide targeted care to individuals with special needs.

3. What is the Model of Care?
The Model of Care (MOC) is the comprehensive plan for delivering our integrated care management program for members with special needs

4. Elements of the SNP Model of Care (MOC)
Description of the Special Needs Population with benefits designed to meet the population’s specific needs
Care Coordination
Health Risk Assessment (HRA)
Individualized Care Plan (ICP)
Interdisciplinary Care Team (ICT)
Case Management (CM)
Care Transition (CT)
Provider Network with Specialist that meet the population’s specific clinical needs
MOC Quality Measurement and Performance Improvement

5. OVERALL Goals of the Model of Care
Improve Access
Improve access to medical and behavioral and social services
Improve access to affordable care, long-term supports and services (LTSS for CMC) and preventive health services
Improve Coordination
Improve coordination of care through an identified point of contact
Improve transitions of care across health care settings, provider and health services
Assure appropriate utilization of services
Improve Health Status
Improve member health outcomes

6. Types of Moc SNPS
D-SNP-Dual Special Needs Plan: for members that are dually eligible for Medicare and Medicaid known as the Cal MediConnect (CMC)
C-SNP-Chronic Special Needs Plan: for members with chronic and disabling disorders such as:
Diabetes
Chronic Heart Failure
Cardiovascular Disorders: Cardiac Arrhythmias
Coronary Artery Disease
Peripheral Vascular Disease
Chronic Venous Thromboembolic Disorder
ESRD
I-SNP- Institutional Special Needs Plan: Individuals that live at a facility such as custodial at skilled nursing facility.

7. Most Vulnerable Population
Populations at greatest risk are identified on multiple hospital admissions, high pharmacy utilization, high cost, or combination of medical, psychosocial, cognitive and functional challenges
SNPs are identified in order to direct resources towards those with increased need for care management services:
Complex and multiple chronic conditions–members with multiple chronic diagnoses that require increased assistance with disease management and navigating health care systems
Disabled–members unable to perform key functional activities (walking, eating, toileting) independently such as those with amputation and/or blindness due to diabetes
Frail–may include the elderly over 85 years and/or diagnoses such as osteoporosis, rheumatoid arthritis, COPD, CHF
Dementia–members at risk due to moderate/severe memory loss or forgetfulness
End-of-life–members with terminal diagnosis such as end-stage cancers, heart or lung disease

8. MOC: Cal Medi-Connect (CMC)
Eligibility rules can vary from state to state.
General eligibility guidelines are that members are eligible for Medicare and Medicaid and have no private insurance
CMC members have full Medicare and Medicaid rights and benefits
The Medicare and Medicaid benefits are integrated as one benefit

9. MOC- Benefits to meet specialized needs
Disease Management–whole person approach to wellness with comprehensive online and written educational and interactive health materials
Medication Therapy Management–a pharmacist reviews medication profile quarterly and communicates with Member and doctor regarding issues such as duplications, interactions, gaps in treatment, adherence issues
Transportation –the number of medically related trips up to unlimited may be under the health plan or Medicaid benefit and vary according to the specific SNP/CMC and region
Additional benefits vary by region and type of SNP/CMC but may include Dental, Vision, Podiatry, Gym membership, Hearing Aides or lower costs for items such as Diabetic Monitoring supplies, Cardiac Rehabilitation

10. MOC- Language/Communication needs
SNP/CMC members may have greater incidence of limited English proficiency, health literacy issues and disabilities that affect communication with negative impact on health outcomes. Services to meet these needs include;
Office interpretation services–in-person and sign-language with minimum of days notice
Health Literacy–training materials and in-person training available
Cultural Engagement –training materials and in-person training available
Translation of vital documents
711 relay number for hearing impaired

11. MOC- Communication Systems
Integrated communication systems are necessary to implement the SNP/CMC care coordination requirements:
An Electronic Medical Management System for documentation of care management, care planning, input from the interdisciplinary team, transitions, assessments and authorizations
A Customer Call Center to assist with enrollment, eligibility and coordination of benefit questions and able to meet individual communication needs (language or hearing impairment)
A secure Provider Portal to communicate HRA results and new Member information to SNP/CMC delegated medical groups
A Member Portal for access to online health education, interactive programs and the ability to create a personal health record
Member and Provider Communications such as member and provider newsletters and educational outreach may be distributed by mail, phone, fax or online
Staff Training

12. CMS MOC Requirements
CMS requires all SNP and CMC members to have the following:

13. MOC Division of responsibilities-plan/group
Health Plan
THIPA
Diagnosis Verification(C-SNP)
Review & Act on Trigger Reports
Health Risk Assessment (HRA) and Care Plan (Initial & Annual)*
Provide CM, Interdisciplinary Care & Care Transitions (CT)*
Provide Weekly Trigger Reports
Submit Care Transitions (CT) Reports Quarterly*
Provide Tools & Resources
For those in Care Management, Update Care Plan*

14. The 4 elements of snp model of care

15. Health risk assessment (hra) tool
Health Plan completes the Health Risk Assessment
HRA assesses the medical, cognitive, functional, psychosocial and mental health of each beneficiary
The HRA may be completed face-to-face, telephonic, or paper-based by mail
Initial HRA is completed within 90 days of enrollment and at least annually thereafter

16. Health risk assessment (hra) tool (Continue)
Member is reassessed as needed when there is a change in health status
Answers to the HRA are used to:
develop and/or update the members’ Individualized Care Plan (ICP)
stratify member into risk categories for care coordination
Member is provided with a copy of the ICP and encouraged to visit the PCP
Provider is given a copy of the ICP and the answers to the HRA

17. Individualized care plan (ICP) What is a care plan?
Case Management Society of America defines a Care Plan as:
“A comprehensive plan that includes a statement of problems/needs determined upon assessment; strategies to address the problems/needs; measurable goals to demonstrate resolution based upon the problem/need, timeframe, the resources available, and the desires/motivation of the client/family.”

18. Individualized care plan (ICP)
An initial ICP is developed upon completion of the HRA
Essential components of the ICP include:
Member focused problem identification, goals and objectives
Healthcare preferences
Specific services tailored to the member as needed
Identification of goals met/not met

19. ICP- Building individualized care plans

20. Icp- building individualized care plans
Individualized care plans include, but are not limited to, the following:
Establishing member prioritized goals: what is important TO the member and FOR the member
Identifying resources that might benefit the member, including recommendations for the appropriate level of care
Planning for continuity of care, including assisting the member in making the transition from one care setting to another.
Collaborative approaches to health and care management which can including the PCP, family or member representative.
Established timeframes for ongoing evaluation of member’s goals

21. Icp- Identifying individualized care problems
Medical conditions not being well managed
Ineffective pain management
Cognitive deficits (dementia, brain injury)
Unable to meet financial obligations (rent, utilities, food)
Unsafe housing, lack of social support
Lack of knowledge to self-manage health
Lack of caregiver or family support
Communication needs: language or sensory deficits
Cultural or other beliefs interfere with prescribed treatment

22. ICP-Individualized care plans problems

23. Icp-Individualized Care Plan
ICP is reviewed and updated at least annually or when a member health status changes
ICP updates and modifications are communicated to member and/or caregivers and providers, and other stakeholders as necessary
ICP is maintained and stored to assure access by all care providers
Records of the ICP are stored per HIPAA and professional standards

24. Icp-member centered goals
Measurable goals provide a clear description for the member and care manager on how and when the goals have been achieved, member behavior and improvement in health outcomes.
Goals and outcomes reflect member behaviors and responses expected as a result of nursing interventions. Write a goal or outcome to reflect a member's specific behavior, not to reflect the care manager’s goals or interventions.
Each goal should address only one behavior or response. The outcome should be measurable and evidence-based.
Goals can be short term or long term.

25. Icp-member centered goals

26. Interdisciplinary Care Team (ICT)
ICT facilitates care management, assessment, care planning, authorization of services and care transitions
Composition of ICT is dependent on the members medical and psychosocial needs as determined by the HRA and ICP. It typically includes Case Managers, Social Workers, Pharmacists, Medical Directors and treating Physicians
Members and caregivers are encouraged to participate
The ICTs are aligned with the delegated delivery system. PCPs and specialty physicians are active participants
Each member of the ICT has specific defined roles and responsibilities based on their expertise

27. Ict- membership
The Care Manager leads and determines ICT membership with the member and can include:

28. ICT – Interdisciplinary Care Team
The Interdisciplinary Care Team is developed based on member needs/requests and facilitate:
Access to appropriate and person-centered care
Multidisciplinary approach to support Integrated Care Management
Development of a comprehensive plan of care
Communication regarding individualized care plan

29. ICT –Regular Meetings
ICT meetings are conducted at least annually and more frequently based on the member’s needs. They can be in the form of:
Virtual/Conference calls
In-person meetings (Grand Rounds)
In member facility care conference

30. ICT –Member Centered
The member should attend or be kept informed of ICT meeting outcomes and identify preferences for ICT members.

31. Ict- must be documented

32. Cm- what is care management
Care Management (CM) is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet the Member and their caregiver’s comprehensive health needs through communication and available resources to promote member safety, quality of care and cost- effective outcomes.
THIPA Care Management:
Inpatient Care Management: Manages members hospitalized and supports successful discharge planning (DCP)
Skilled Nursing Facility Care Management: Manages members receiving care in a skilled nursing facility and supports successful DCP
Ambulatory Care Management: Manages members in the ambulatory setting to support, timely appropriate care, focused on improved quality of care with optimal health outcomes across the continuum

33. Care Transition (CT)
Care Transition is: Movement of a member from one care setting to another as the member’s health status changes
Within 1 day of notification of an admission to a hospital, a copy of the most current ICP is faxed to the hospital
Within 1 day of discharge from a hospital to a skilled nursing facility, the discharge orders/care plan are faxed to the skilled nursing facility
When the member is being transitioned to the usual setting of care (typically the home), the Case Manager will discuss the discharge plan with the member and/or caregiver. This will be followed within 2 business days with a phone call to ensure the member is familiar with the appropriate self management tools and to assist with scheduling a follow up appointment with the Primary Care Physician
The Primary Care Physician will be notified by fax within 3 business days of all care transition episodes

34. Care transitions
THIPA’s Expectation
Care Transitions documentation must include:
Members contacted (or attempts made) within five business days post-notification of discharge from one setting to another
Notification to PCP within five business days of discharge
Ensure follow-up services and appointments are scheduled and performed within 5 business days of transition
Care is provided by appropriate persons
Care plan transferred between settings before, during, after transition of care
Member coaching occurred
Members of the ICT and members/caregivers have access to the plan of care
Review and analyze available data to ensure improvement in the member’s health status

35. Use of clinical practice guidelines (cpgs)
Use evidence-based nationally approved CPGs for making UM decisions
Compliance with approved guidelines is monitored through:
An annual review of utilization decisions
The member appeals process
HEDIS reporting

36. Provider network
THIPA has a specialized network of providers to meet the needs of SNP members including but not limited to:
Internist, geriatrician, endocrinologist, cardiologist, oncologist, pulmonologist
General and subspecialty surgeons
Behavioral Health Providers
Ancillary health providers such as physical, speech, occupational therapists
Tertiary care physicians